Divine Rehabilitation and Nursing at Toledo

Based on personnel record review, staff interview, and policy review, the facility failed to ensure employed State Tested Nursing Aides (STNA) were properly licensed with the State of Ohio. This had the ability to affect all 77 residents. The facility census was 77.

Findings included:

Review of STNA #200's personnel file revealed a hire date of 10/10/24. The STNA file contained a copy of STNA's Nursing Assistant Registration from the State of Washington which expired on 10/23/24.

A search on the State of Ohio Nurse Aide Registry website revealed STNA #200 had no current nor expired licensure.

Review of STNA #200's clock in/out report revealed eight hour shifts were worked on 10/10/24, 10/11/24, 10/12/24, 10/13/24, 10/14/24, 10/19/24, 10/21/24, 10/22/24, 10/25/24, 10/26/24, 10/28/24, 10/29/24, 11/04/24, and 11/05/24. A four hour shift was completed on 10/16/24.

Interview with the Administrator on 11/07/24 at 12:55 P.M., verified STNA #200 was hired and caring for residents without being certified with the State of Ohio Nurse Aide Registry and has an expired out of state certificate.

Review of the facility policy titled Required Training, Certification and Continuing Education of Nurse Aides undated revealed this facility will employ nurse aides that have successfully completed a State approved nurse aide training or competency evaluation program (NATCEP) and are awaiting certification results. They may be employed as a full-time and permanent but must provide documentation of certification within 4 months of their hire date. Facility will verify certification through the appropriate state's nurse aide registry. If an individual has not successfully completed a NATCEP at the time of employment, that individual may only function as a nurse aide if the individual has been verified to be currently enrolled in a State approved nurse aide training or competency evaluation program (NATCEP) and is a permanent employee in his/her first four months of employment in the facility.

Based on medical record review, facility policy review, facility investigation, and staff interviews, the facility failed to report a resident elopement to the state agency as required. This affected one resident (Resident #3) of three residents reviewed for wandering and elopement risk. The facility census was 68. Findings include: Review of the medical record for Resident #3 revealed an admission date of 07/31/24, diagnoses included chronic obstructive pulmonary disease, heart disease, hypertension, dementia and type II diabetes mellitus. Review of the admission Minimum Data Set (MDS) assessment dated 07/31/24 revealed Resident #3 was cognitively impaired and independently mobile with supervision for mobility required. Review of the hospital history and physical for Resident #3 completed on 07/03/24 and timed 8:35 A.M. revealed Resident #3 was brought to the hospital per emergency services from home due to increase wandering, frequent falls and family concern for safety. According to family, Resident #3 was insistent people were trying to get into the house causing Resident #3 to wander outside the home. The family was concerned Resident #3 would wander outside and get lost as Resident #3 had previously been found five miles from the home. Resident #3's family unable to continue to care for the resident at home. Resident #3 arrived at the facility on 07/31/24 at 7:45 P.M. by stretcher and was accompanied by two emergency medical service personnel. Resident #3 was alert and oriented to person and can walk independently. Review of the nursing admission assessment completed 07/31/24 at 10:56 P.M. revealed Resident #3 was confused, with aggressive behaviors and was independently mobile. Review of the elopement assessment dated 08/02/24 at 1:56 A.M. revealed Resident #3 was identified at risk for elopement due to cognitive impairment with a diagnosis of dementia, ambulated independently, and verbally expressed desire to go home. Review of the progress note dated 08/02/24 and timed 8:20 P.M. revealed a wander bracelet was placed on Resident #3's left leg. Review of the progress note dated 08/03/24 and timed 2:54 P.M. written by Registered Nurses (RN) #336 stated Resident #3 went outside the building through the back, fire safety door, Wanderguard did alarm. Resident #3 was escorted back into the building by staff that saw Resident #3 walking outside. The Director of Nursing (DON), physician, and family were notified. Resident #3 was assessed with no injuries noted. Review of the care plan dated 08/19/24 revealed Resident #3 was an elopement risk, and a wanderer related to attempts to leave the facility unattended and impaired safety awareness. Interventions included for staff to redirect resident from wandering, offer diversion and structured activities, identify patterns of wandering, monitor fatigue, and monitor the resident's location. Review of the facility investigation dated 08/05/24 regarding Resident #3's elopement on 08/03/25 stated Resident #3 was found walking outside of the building in the parking lot by a staff nurse, was brought back into the facility, assessed and the Wanderguard monitor was checked. Interview on 10/01/24 at 1:55 P.M. with RN #336 verified Resident #3 had gotten outside the building on 08/03/24 at roughly 11:45 A.M. and another staff member brought Resident #3 back into the building. RN #336 stated she was assigned to work both the 400 hall and 500 hall (Memory Care) and at the time of Resident #3 exited the building she was not in Memory Care and was unaware of Resident #3 getting outside until someone called. Interview on 10/02/24 at 1:30 P.M. with Licensed Practical Nurse (LPN) #235 revealed on 08/03/24 sometime between 11:00 A.M. and 12:00 P.M. LPN #235 went outside for break and when driving car from the front parking lot to the back parking lot, LPN #235 saw someone walking toward the front of the building from the back of the building. The person was walking in the grass to the left side of the car, as LPN #235 drove down the driveway to the rear parking lot, LPN #235 stated she did not think anything about it as there are people frequently walking in that area. LPN #235 stated she went to the back parking lot, parked the car and was finishing a phone conversation at which time LPN #235 again noticed the same man walking in the grass, walking back around the building toward the back parking lot. LPN #235 stated she had never seen this person before and wondered what he was doing and while watching noticed a wander guard. LPN #235 stated she called into the facility as she did not recognize Resident #3, and the unit manager came out and assisted to bring Resident #3 back into the building. LPN #235 verified no one was with Resident #3 and Resident #3 was not within eyesight the entire time during the episode that took between three and five minutes. LPN #235 also denied hearing an alarm sounding as Resident #3 had a wander guard on the left lower extremity. Interview on 10/02/24 at 2:45 P.M. with the DON verified she had been notified on 08/03/24 at 11:54 A.M. by a Unit Manager, that no longer works at the facility, that Resident #3 had gotten outside the building on 08/03/24 and at the time of the notification the Unit Manager was working on getting statements and providing staff education for those on duty. The DON at the time of the interview revealed the staff statements were unable to be found. Review of self-reported incidents revealed no self-reported incident related to the Resident #3's elopement. Interview on 10/02/24 at 2:50 P.M. with the Administrator verified no self-reported incident was submitted to the state agency as required. Review of the undated facility policy titled, Elopements and Wandering ResidentsBased on medical record review, facility policy review, facility investigation, and staff interviews, the facility failed to report a resident elopement to the state agency as required. This affected one resident (Resident #3) of three residents reviewed for wandering and elopement risk. The facility census was 68.

Findings include:

Review of the medical record for Resident #3 revealed an admission date of 07/31/24, diagnoses included chronic obstructive pulmonary disease, heart disease, hypertension, dementia and type II diabetes mellitus.

Review of the admission Minimum Data Set (MDS) assessment dated 07/31/24 revealed Resident #3 was cognitively impaired and independently mobile with supervision for mobility required.

Review of the hospital history and physical for Resident #3 completed on 07/03/24 and timed 8:35 A.M. revealed Resident #3 was brought to the hospital per emergency services from home due to increase wandering, frequent falls and family concern for safety. According to family, Resident #3 was insistent people were trying to get into the house causing Resident #3 to wander outside the home. The family was concerned Resident #3 would wander outside and get lost as Resident #3 had previously been found five miles from the home. Resident #3's family unable to continue to care for the resident at home.

Resident #3 arrived at the facility on 07/31/24 at 7:45 P.M. by stretcher and was accompanied by two emergency medical service personnel. Resident #3 was alert and oriented to person and can walk independently.

Review of the nursing admission assessment completed 07/31/24 at 10:56 P.M. revealed Resident #3 was confused, with aggressive behaviors and was independently mobile.

Review of the elopement assessment dated 08/02/24 at 1:56 A.M. revealed Resident #3 was identified at risk for elopement due to cognitive impairment with a diagnosis of dementia, ambulated independently, and verbally expressed desire to go home.

Review of the progress note dated 08/02/24 and timed 8:20 P.M. revealed a wander bracelet was placed on Resident #3's left leg.

Review of the progress note dated 08/03/24 and timed 2:54 P.M. written by Registered Nurses (RN) #336 stated Resident #3 went outside the building through the back, fire safety door, Wanderguard did alarm. Resident #3 was escorted back into the building by staff that saw Resident #3 walking outside. The Director of Nursing (DON), physician, and family were notified. Resident #3 was assessed with no injuries noted.

Review of the care plan dated 08/19/24 revealed Resident #3 was an elopement risk, and a wanderer related to attempts to leave the facility unattended and impaired safety awareness. Interventions included for staff to redirect resident from wandering, offer diversion and structured activities, identify patterns of wandering, monitor fatigue, and monitor the resident's location.

Review of the facility investigation dated 08/05/24 regarding Resident #3's elopement on 08/03/25 stated Resident #3 was found walking outside of the building in the parking lot by a staff nurse, was brought back into the facility, assessed and the Wanderguard monitor was checked.

Interview on 10/01/24 at 1:55 P.M. with RN #336 verified Resident #3 had gotten outside the building on 08/03/24 at roughly 11:45 A.M. and another staff member brought Resident #3 back into the building. RN #336 stated she was assigned to work both the 400 hall and 500 hall (Memory Care) and at the time of Resident #3 exited the building she was not in Memory Care and was unaware of Resident #3 getting outside until someone called.

Interview on 10/02/24 at 1:30 P.M. with Licensed Practical Nurse (LPN) #235 revealed on 08/03/24 sometime between 11:00 A.M. and 12:00 P.M. LPN #235 went outside for break and when driving car from the front parking lot to the back parking lot, LPN #235 saw someone walking toward the front of the building from the back of the building. The person was walking in the grass to the left side of the car, as LPN #235 drove down the driveway to the rear parking lot, LPN #235 stated she did not think anything about it as there are people frequently walking in that area. LPN #235 stated she went to the back parking lot, parked the car and was finishing a phone conversation at which time LPN #235 again noticed the same man walking in the grass, walking back around the building toward the back parking lot. LPN #235 stated she had never seen this person before and wondered what he was doing and while watching noticed a wander guard. LPN #235 stated she called into the facility as she did not recognize Resident #3, and the unit manager came out and assisted to bring Resident #3 back into the building. LPN #235 verified no one was with Resident #3 and Resident #3 was not within eyesight the entire time during the episode that took between three and five minutes. LPN #235 also denied hearing an alarm sounding as Resident #3 had a wander guard on the left lower extremity.

Interview on 10/02/24 at 2:45 P.M. with the DON verified she had been notified on 08/03/24 at 11:54 A.M. by a Unit Manager, that no longer works at the facility, that Resident #3 had gotten outside the building on 08/03/24 and at the time of the notification the Unit Manager was working on getting statements and providing staff education for those on duty. The DON at the time of the interview revealed the staff statements were unable to be found.

Review of self-reported incidents revealed no self-reported incident related to the Resident #3's elopement.

Interview on 10/02/24 at 2:50 P.M. with the Administrator verified no self-reported incident was submitted to the state agency as required.

Review of the undated facility policy titled, Elopements and Wandering Residents

Based on staff interviews, review of the medical record, and review of the facility investigation, the facility failed to ensure a complete and thorough investigation was conducted for a resident elopement. This affected one resident (Resident #3) of three residents reviewed for wandering and elopement risk. The facility census was 68.

Findings include:

Review of the medical record for Resident #3 revealed an admission date of 07/31/24, diagnoses included chronic obstructive pulmonary disease, heart disease, hypertension, dementia and type II diabetes mellitus.

Review of the admission Minimum Data Set (MDS) assessment dated 07/31/24 revealed Resident #3 was cognitively impaired, and independently mobile with supervision for mobility required.

Review of the hospital history and physical for Resident #3 completed on 07/03/24 and timed 8:35 A.M. revealed Resident #3 was brought to the hospital per emergency services from home due to increase wandering, frequent falls and family concern for safety. According to family Resident #3 was insistent people were trying to get into the house causing Resident #3 to wander outside the home. The family was concerned Resident #3 would wander outside and get lost as Resident #3 had previously been found five miles from the home. Resident #3's family unable to continue to care for the resident at home.

Resident #3 arrived at the facility on 07/31/24 at 7:45 P.M. by stretcher and was accompanied by two emergency medical service personnel. Resident #3 was alert and oriented to person, can walk independently and can follow simple commence.

Review of the nursing admission assessment completed 07/31/24 at 10:56 P.M. revealed Resident #3 was confused, with aggressive behaviors and was independently mobile.

Review of the elopement assessment dated 08/02/24 at 1:56 A.M. revealed Resident #3 was identified at risk for elopement due to cognitive impairment with a diagnosis of dementia, ambulated independently, and verbally expressed desire to go home.

Review of the care plan dated 08/19/24 indicated Resident #3 was an elopement risk, and a wanderer related to attempts to leave the facility unattended and impaired safety awareness. Interventions included for staff to redirect resident from wandering, offer diversion and structured activities, identify patterns of wandering, monitor fatigue, and monitor the resident's location.

Review of the progress note dated 08/02/24 and timed 8:20 P.M. a wander bracelet was placed on Resident #3's left leg.

Review of the progress note dated 08/03/24 and timed 2:54 P.M. written by Registered Nurses (RN) #336 stated Resident #3 went outside the building through the back, fire safety door, Wanderguard did alarm. Resident #3 was escorted back into the building by staff that saw Resident #3 walking outside. The director of nursing, physician and family were notified. Resident #3 was assessed with no injuries noted.

Interview on 10/01/24 at 1:55 P.M. with RN #336 verified Resident #3 had gotten outside the building on 08/03/24 at roughly 11:45 A.M. and another staff member brought Resident #3 back into the building. RN #336 stated she was assigned to work both the 400 hall and 500 hall (Memory Care) and at the time of Resident #3 exited the building RN #336 was not in Memory Care and was unaware of Resident #3 getting outside until someone called.

Review of the staffing for 08/03/24 for the Memory Care unit revealed the one aide assigned to the unit called off and another aide came in at 10:30 A.M. to cover. One nurse (RN #336) was assigned to both the Memory Care and the 400 hall.

Interview on 10/02/24 at 1:30 P.M. with Licensed Practical Nurse (LPN) #235 revealed on 08/03/24 sometime between 11:00 A.M. and 12:00 P.M. LPN #235 went outside for break and when driving car from the front parking lot to the back parking lot, LPN #235 saw someone walking toward the front of the building from the back of the building. The person was walking in the grass to the left side of the car, as LPN #235 drove down the driveway to the rear parking lot, LPN #235 stated she did not think anything about it as there are people frequently walking in that area. LPN #235 stated she went to the back parking lot, parked the car and was finishing a phone conversation at which time LPN #235 again noticed the same man scene walking in the grass, walking back around the building toward the back parking lot. LPN #235 stated she had never seen this person before and wondered what he was doing and while watching noticed a wander guard. LPN #235 stated she called into the facility as she did not recognize Resident #3, and the unit manager came out and assisted to bring Resident #3 back into the building. LPN #235 verified no one was with Resident #3 and Resident #3 was not within eyesight the entire time during the episode that took between three and five minutes. LPN #235 also denied hearing an alarm sounding which LPN #235 thought was odd because Resident #3 had a Wanderguard on the left lower extremity. LPN #235 verified there was no further discussion with anyone about what happened. LPN #235 stated that this is first time anyone has asked her anything about the incident.

Interview on 10/02/24 at 4:58 P.M. with State Tested Nursing Assistant (STNA) #262 verified she came in to assist in Memory Care on 08/03/24 due to a call off, remembered being the only person in unit providing care. STNA #262 stated the nurse was back and forth between memory care and another unit. STNA #262 stated she received a phone call later in the day inquiring about Resident #3 eloping and revealed she had no knowledge of a resident eloping and further verified no knowledge of a door alarming.

Review of the facility investigation dated 08/05/24 regarding Resident #3's elopement on 08/03/25 stated Resident #3 was found walking outside of the building in the parking lot by a staff nurse, was brought back into the facility, assessed and the wander guard monitor was checked. The investigation contained no staff interviews regarding the incident and no indication of when Resident #3 was last seen prior to the elopement.

Interview 10/02/24 at 2:45 P.M. with the Director of Nursing (DON) verified she had been notified on 08/03/24 at 11:54 A.M. by a Unit Manager, that no longer works at the facility, that Resident #3 had gotten outside the building on 08/03/24 and at the time of the notification the Unit Manager was working on getting statements and providing staff education on elopement for those on duty. The DON at the time of the interview revealed the staff statements were unable to be found.

Interview on 10/02/24 at 2:50 P.M. with the Administrator revealed knowledge of Resident #3 eloping, however, was unable to provide any specifics related to the incident or the investigation.

This deficiency represents non-compliance investigated under Compliant Number OH00157187.

Based on record review, resident interview, staff interview, and policy review, the facility failed to timely assist dependent residents with showers. This affected three of three residents (#8, #57, #22) reviewed for showers. The facility census was 68.

Findings included:

1. Review of Resident #8's medical record revealed an admission date of 03/28/24. Diagnoses included dementia, diabetes mellitus, urinary retention, and panic disorder.

Review of Resident #8's five-day Minimum Data Set (MDS) assessment dated 07/24/24 revealed she had low cognitive function. The resident was dependent on staff for showers and toileting.

Review of Resident #8's care plan revealed she had a self-care deficit related to dementia.

Review of Resident #8's medical record revealed she was scheduled to have showers every Tuesday and Friday on first shift.

Review of Resident #8's electronic medical record dated September 2024 revealed the resident received a shower on 09/06/24 and 09/17/24. A bed bath was received on 09/10/24 and 09/20/24. This indicated that Resident #8 failed to receive a shower or bath on 09/03/24, 09/13/24, 09/24/24, and 09/27/24.

Review of Resident #8's nurses notes revealed there was no documentation regarding why the showers were not given.

Resident #8 was not able to be interviewed due to her cognitive decline.

2. Review of Resident #57's medical record revealed an admission date of 04/29/23. Diagnoses included morbid obesity, congestive heart failure, lymphedema, epilepsy, and chronic kidney disease.

Review of Resident #57's quarterly MDS assessment dated 07/05/24 revealed the resident had intact cognition. The resident was dependent on staff for showers and bathing.

Review of Resident #57's care plan revealed she had an activity of daily living self-care deficit and required extensive assistance with bathing and showering.

Review of Resident #57's medical record revealed she was scheduled for showers/baths on the evening shift every Monday and Thursday.

Review of Resident #57's electronic medical record dated September 2024 revealed the resident received a bed bath on 09/02/24 and 09/05/24. The resident refused bathes on 09/12/24, 09/14/24, and 09/16/24. This resulted in Resident #57 not being offered nor receiving a bath on 09/09/24, 09/19/24, 09/23/24, 09/26/24, and 09/30/24.

Review of Resident #57's nurses notes revealed there was no documentation regarding why the showers were not given.

Interview with Resident #57 on 10/01/24 at 7:56 A.M. revealed only one bed bath was received in the previous month. She stated that she was unable to shower or get the bath supplies by herself and required assistance. At times she had to wait until family visited to receive bathing care.

3. Review of the medical record for Resident #22 revealed an admission date of 10/04/21, diagnoses include heart failure, anemia, morbid obesity hypertension and type II diabetes mellitus.

Review of the quarterly MDS assessment completed on 07/14/24 revealed Resident #22 was cognitively intact, and was dependent on staff for showers, dressing and personal hygiene.

Review of the care plan dated 10/22/21 revealed Resident #22 had an activities of daily living self-care deficit related to shortness of breath, weakness, activity intolerance, fatigue and limited mobility. Resident #22 requested showers. Interventions included total dependence for transfers with use of mechanical lift, one to two staff extensive assistance for showering twice weekly and for a bed bath to be provided when a shower cannot be.

Review of the bathing record indicated Resident #22 was to have a shower or bed bath if shower unable to be provided on the day shift each Wednesday and Saturday. Review of the bathing record with a look back period of thirty days from 09/28/24 revealed Resident #22 received a shower on 09/11/24, 09/18/24 and 09/28/24. This resulted in Resident #22 not being offered nor receiving a shower or bath on 09/04/24, 09/07/24, 09/14/24, 09/21/24, and 09/25/24.

Review of the nurses progress notes from 09/02/24 to 09/30/24 revealed Resident #22 had not refused a shower or bed bath and contained no documentation related to why showers were not provided.

Interview on 09/30/24 at 11:00 A.M. with Resident #22 revealed showers are preferred as the resident likes to be clean. Resident #22 verified showers are hit and miss and further verified bed baths are also not provided in place of the missing shower.

Interviews with Licensed Practical Nurse (LPN) #281 and State Tested Nursing Aides (STNA) #202 and #286 on 10/01/24 between 3:23 P.M. and 3:35 P.M. and on 10/02/24 between 10:10 A.M. and 10:25 A.M. with LPN #281 and #273 revealed showers were not being completed timely. Reasons included a lack of staff or staff not willing to do the work.

Interview with the Director of Nursing (DON) on 10/01/24 at 2:38 P.M. verified Residents #8, #22, and #57's showers and bathes were failed to be given timely. She stated showers are completed approximately 40% of the time. The showers were to be documented in the electronic medical record.

Review of the facility policy titled, Resident Showers

Based on record review, resident interview, staff interview, and policy review, the facility failed to complete weekly skin assessments per physician order. This affected two residents (#8, #57) of three residents reviewed for skin assessments. The facility census was 68.

Findings included:

1. Review of Resident #8's medical record revealed an admission date of 03/28/24. Diagnoses included dementia, diabetes mellitus, urinary retention, and panic disorder.

Review of Resident #8's five-day Minimum Data Set (MDS) assessment dated 07/24/24 revealed she had a low cognitive function. The resident was dependent on staff for showers and toileting.

Review of Resident #8's care plan revealed she had the potential/actual impairment to skin integrity related to fragile skin and had a self-care deficit. Interventions included the resident required skin inspections to observe for redness, open areas, scratches, cuts, bruises, and report changes to the nurse.

Review of Resident #8's Weekly Skin Observation Sheets dated August 2024 and September 2024 revealed the resident received skin checks on 08/13/24, 08/21/24, and 08/29/24. No skin checks were performed in September 2024.

Review of Resident #8's nurses notes revealed the record was silent of documentation regarding why the skin checks were not received.

2. Review of Resident #57's medical record revealed an admission date of 04/29/23. Diagnoses included morbid obesity, congestive heart failure, lymphedema, epilepsy, and chronic kidney disease.

Review of Resident #57's quarterly MDS assessment dated 07/05/24 revealed the resident had intact cognition. The resident was dependent on staff for showers and bathing.

Review of Resident #57's care plan revealed the resident required skin inspections every shift and as needed. Staff were to observe for redness, open areas, scratches, cuts, bruises, and report any changes to the nurse.

Review of Resident #57's electronic medical record revealed a physician's order dated 09/11/24 to complete skin observation assessment under assessment tab every Thursday evening shift.

Review of Resident #57's medical record revealed the resident was scheduled for showers/bathes on the evening shift every Monday and Thursday.

Review of Resident #57's Skin Observation Sheets dated August 2024 and September 2024 revealed the resident received skin checks on 08/17/24 and 09/01/24.

Review of Resident #57's nurses notes revealed there was no documentation regarding why the weekly skin checks were not performed.

Interview with Licensed Practical Nurse (LPN) #281 on 10/01/24 at 3:23 P.M. and on 10/02/24 between 10:10 A.M. and 10:25 A.M. with LPNs #281 and #273 verified skin assessments were not being completed timely.

Interview with the Director of Nursing (DON) on 10/01/24 at 2:38 P.M. verified Residents #8 and #57's skin evaluations were failed to be given timely. She stated all Weekly Skin Observation forms were to be completed in the electronic medical record.

Review of the facility policy titled, Skin Assessment

Based on review of the medical record, staff interview, and review of the facility policy, the facility failed to conduct timely fall reviews for three residents (#5, #70 and #71) and further failed to complete a quarterly fall assessment for a resident identified as a high fall risk (Resident #62). This affected four (#5, #70, #62 and #71) of four residents reviewed for falls. The facility census was 68. Findings include: 1. Review of the medical record for Resident #70 revealed an admission date of 08/30/24. Diagnoses included dementia, chronic obstructive pulmonary disease, type II diabetes mellitus and metabolic encephalopathy. Review of the quarterly Minimum Data Set (MDS) assessment revealed low cognitive function. Resident #70 required the extensive assistance of staff for transfers, toilet hygiene, and mobility. Review of the progress note dated 09/05/24 and timed 5:34 P.M. revealed Resident #70 was observed sitting on the floor with the wheelchair next to him while holding a tissue to the forehead. A laceration was observed with a moderate amount of serous drainage. Review of the post fall evaluation completed 09/13/24 at 10:46 P.M. revealed Resident #70 experienced a fall on 09/05/24, had one to two falls in the last 90 days, was a high risk for falls, had a history of falls. 2. Review of the medical record for Resident #71 revealed an admission date of 09/06/24 with a diagnosis of dementia. Resident #71 had low cognitive function. Review of the post fall evaluation dated 09/27/24 and timed 10:51 A.M. revealed Resident #71 experienced a fall on 09/14/24 at 12:00 P.M. with no injuries. 3. Review of Resident #5's medical record revealed an admission date of 09/05/24. Diagnoses included metabolic encephalopathy, dementia, chronic obstructive pulmonary disease, and malnutrition. Review of Resident #5's MDS assessment dated 09/08/24 revealed low cognitive function. The resident required substantial assistance rolling left to right and toileting. Supervision was required when going from sit to lying, lying to sitting, and walking 10 to 50 feet. Review of Resident #5's Fall Risk Evaluation dated 09/14/24 revealed the resident was at high risk for falls. Review of Resident #5's care plan revealed she was at a high risk for falls related to confusion, deconditioning, gait/balance problems, and recent falls. Interventions included to follow the facility fall protocol and review information on past falls and attempt to determine the cause of falls. Record possible root causes and remove any potential causes. Review of Resident #5's progress note revealed on 09/06/24 at 1:20 A.M. the resident was found yelling for help and was seen on the floor next to her bed with the wheelchair at the foot of the bed. Review of Resident #5's progress note dated 09/06/24 at 7:56 P.M. revealed the resident was found on the floor near her bed and stated she was making her bed before she fell. Review of Resident #5's medical record revealed post fall Internal Disciplinary Team (IDT) notes failed to be completed within 72 hours. The notes were dated 09/16/24 and 09/17/24 which reviewed the falls from 09/06/24. 4. Review of the medical record for Resident #62 revealed an admission date of 08/07/19, diagnoses included chronic kidney disease and dementia. Review of the MDS assessment dated 09/19/24 revealed Resident #62 had moderate cognitive impairment, had no functional impairments and utilized a wheelchair. Resident #62 required the assistance of staff for mobility. Review of the care plan dated 08/08/19 revealed Resident #62 was a risk for falls related to weakness, bowel and bladder incontinence and impaired cognition. Interventions included observation for fatigue or unsteadiness, encourage the use of appropriate footwear and provide assistive devices as needed. Additional interventions added 01/03/24 included frequent checks, complete fall risk assessment per facility protocol, keep call light within reach and utilize two wheeled walker. Review of the fall risk assessments revealed a quarterly assessment was completed on 02/06/24 and two post fall risk assessments were completed on 06/01/24 and 06/16/24. Interview with the Director of Nursing on 10/03/24 at 3:34 P.M. verified post fall evaluations are required to be completed within 72 hours of a fall and fall risk assessments are to be completed at least quarterly. The DON also verified that the 72 hour Fall Evaluations for Residents #5, #70 and #71 failed to be completed timely and further verified Resident #62 was past due for a quarterly fall risk assessment as the last fall risk assessment was completed on 06/16/24. Review of the undated facility policy titled, Fall Prevention ProgramBased on review of the medical record, staff interview, and review of the facility policy, the facility failed to conduct timely fall reviews for three residents (#5, #70 and #71) and further failed to complete a quarterly fall assessment for a resident identified as a high fall risk (Resident #62). This affected four (#5, #70, #62 and #71) of four residents reviewed for falls. The facility census was 68.

Findings include:

1. Review of the medical record for Resident #70 revealed an admission date of 08/30/24. Diagnoses included dementia, chronic obstructive pulmonary disease, type II diabetes mellitus and metabolic encephalopathy.

Review of the quarterly Minimum Data Set (MDS) assessment revealed low cognitive function. Resident #70 required the extensive assistance of staff for transfers, toilet hygiene, and mobility.

Review of the progress note dated 09/05/24 and timed 5:34 P.M. revealed Resident #70 was observed sitting on the floor with the wheelchair next to him while holding a tissue to the forehead. A laceration was observed with a moderate amount of serous drainage.

Review of the post fall evaluation completed 09/13/24 at 10:46 P.M. revealed Resident #70 experienced a fall on 09/05/24, had one to two falls in the last 90 days, was a high risk for falls, had a history of falls.

2. Review of the medical record for Resident #71 revealed an admission date of 09/06/24 with a diagnosis of dementia. Resident #71 had low cognitive function.

Review of the post fall evaluation dated 09/27/24 and timed 10:51 A.M. revealed Resident #71 experienced a fall on 09/14/24 at 12:00 P.M. with no injuries.

3. Review of Resident #5's medical record revealed an admission date of 09/05/24. Diagnoses included metabolic encephalopathy, dementia, chronic obstructive pulmonary disease, and malnutrition.

Review of Resident #5's MDS assessment dated 09/08/24 revealed low cognitive function. The resident required substantial assistance rolling left to right and toileting. Supervision was required when going from sit to lying, lying to sitting, and walking 10 to 50 feet.

Review of Resident #5's Fall Risk Evaluation dated 09/14/24 revealed the resident was at high risk for falls.

Review of Resident #5's care plan revealed she was at a high risk for falls related to confusion, deconditioning, gait/balance problems, and recent falls. Interventions included to follow the facility fall protocol and review information on past falls and attempt to determine the cause of falls. Record possible root causes and remove any potential causes.

Review of Resident #5's progress note revealed on 09/06/24 at 1:20 A.M. the resident was found yelling for help and was seen on the floor next to her bed with the wheelchair at the foot of the bed.

Review of Resident #5's progress note dated 09/06/24 at 7:56 P.M. revealed the resident was found on the floor near her bed and stated she was making her bed before she fell.

Review of Resident #5's medical record revealed post fall Internal Disciplinary Team (IDT) notes failed to be completed within 72 hours. The notes were dated 09/16/24 and 09/17/24 which reviewed the falls from 09/06/24.

4. Review of the medical record for Resident #62 revealed an admission date of 08/07/19, diagnoses included chronic kidney disease and dementia.

Review of the MDS assessment dated 09/19/24 revealed Resident #62 had moderate cognitive impairment, had no functional impairments and utilized a wheelchair. Resident #62 required the assistance of staff for mobility.

Review of the care plan dated 08/08/19 revealed Resident #62 was a risk for falls related to weakness, bowel and bladder incontinence and impaired cognition. Interventions included observation for fatigue or unsteadiness, encourage the use of appropriate footwear and provide assistive devices as needed. Additional interventions added 01/03/24 included frequent checks, complete fall risk assessment per facility protocol, keep call light within reach and utilize two wheeled walker.

Review of the fall risk assessments revealed a quarterly assessment was completed on 02/06/24 and two post fall risk assessments were completed on 06/01/24 and 06/16/24.

Interview with the Director of Nursing on 10/03/24 at 3:34 P.M. verified post fall evaluations are required to be completed within 72 hours of a fall and fall risk assessments are to be completed at least quarterly. The DON also verified that the 72 hour Fall Evaluations for Residents #5, #70 and #71 failed to be completed timely and further verified Resident #62 was past due for a quarterly fall risk assessment as the last fall risk assessment was completed on 06/16/24.

Review of the undated facility policy titled, Fall Prevention Program

Based on observation, staff interview, record review, review of facility policy, and review of manufacturer's instruction for use the facility failed to ensure insulin pens were primed prior to administration resulting in a significant medication error. This affected two residents (Resident #42 and #38) of three residents observed for insulin administration. The facility census was 68. Findings include: 1. Review of the medical record for Resident #42 revealed an admission date of 10/14/22 with diagnoses including dementia, anxiety, and type II diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment revealed Resident #42 was cognitively intact and received insulin injections. Review of physician orders for Resident #42 revealed an order for insulin Lispro, 100 units per milliliter per sliding scale before meals and at bedtime. The sliding scale included two units of insulin to be administered using a pen injector for a blood sugar of 151 to 200, four units for a blood sugar of 201 to 250, six units for a blood sugar of 251 to 300, eight units for a blood sugar between 301 and 350, and 10 units for a blood sugar between 351 and 400. Observation on 09/30/24 at 11:18 A.M. of RN #208 preparing to administer Lispro insulin to Resident #42. RN #208 removed the cap from the insulin pen, inverted the pen, inspected the tip, attached the needle cap, and dialed the pen to four units. RN #208 opened the alcohol pad, cleaned the right lower quadrant of Resident #42's stomach, placed the injector pen against the skin of Resident #42 and pressed the dose button. RN #208 did not prime the insulin pen prior to administration. 2. Review of the medical record for Resident #38 revealed an admission date of 10/15/20, diagnoses included hypertension, type II diabetes mellitus, and hypothyroidism. Review of the quarterly MDS assessment dated 07/07/24 revealed Resident #38 was cognitively intact. Review of the physician order dated 01/09/24 revealed Resident #38 was ordered blood sugars before meals and at bedtime with coverage using Insulin Aspart per Novolog Flex Pen 100 units per milliliter (u/ml) per sliding scale. The sliding scale included two units of insulin to be administered using a Flex Pen for a blood sugar of 151 to 200, four units for a blood sugar of 201 to 250, six units for a blood sugar of 251 to 300, eight units for a blood sugar between 301 and 350, and 10 units for a blood sugar between 351 and 400. Observation on 09/30/24 at 11:31 A.M. revealed RN #208 preparing to administer insulin to Resident #38. RN #208 verified the order and the dose of insulin, turned the dose selector on the pen to display four. RN #208 pulled up Resident #38's sleeve, opened the alcohol pad, cleansed the lateral left arm, waited a few seconds to allow the alcohol to dry and then placed the injector pen against the skin of the of Resident #38's left arm and pressed the dose button. RN #208 did not prime the insulin pen prior to administration of insulin. Interview on 09/30/24 at 11:35 A.M. with RN #208 revealed RN #208 was unaware of the need to prime insulin pens prior to use. Interview on 10/01/24 at 10:00 A.M. with the Director of Nursing (DON) verified insulin pens require priming after the needle is applied and before dialing the prescribed dose into the pen for administration to a resident. The DON verified nurses are provided education upon hire on medication administration including the use of insulin pens. Review of the manufacturer's instructions for use for the Novolog Flex Pen revealed after the needle is in place, prime the needle before taking the injection. To prime the needle, dial the pen to two units, and holding the pen with the needle pointing upward, press the push button until insulin appears at the tip of the needle. Once the priming is complete, make sure the dose selector is set at zero and then dial the number of units needed to inject. Review of the Lispro Kwik Pen instructions for use dated July 2023 revealed priming the pen before each injection removes the air from the needle and cartridge that may collect during normal use and ensures the pen is working correctly. Also, if the pen is not primed before each injection the resident may get too much or too little insulin. Review of the undated facility policy titled, Administration and Documentation of MedicationsBased on observation, staff interview, record review, review of facility policy, and review of manufacturer's instruction for use the facility failed to ensure insulin pens were primed prior to administration resulting in a significant medication error. This affected two residents (Resident #42 and #38) of three residents observed for insulin administration. The facility census was 68.

Findings include:

1. Review of the medical record for Resident #42 revealed an admission date of 10/14/22 with diagnoses including dementia, anxiety, and type II diabetes mellitus.

Review of the quarterly Minimum Data Set (MDS) assessment revealed Resident #42 was cognitively intact and received insulin injections.

Review of physician orders for Resident #42 revealed an order for insulin Lispro, 100 units per milliliter per sliding scale before meals and at bedtime. The sliding scale included two units of insulin to be administered using a pen injector for a blood sugar of 151 to 200, four units for a blood sugar of 201 to 250, six units for a blood sugar of 251 to 300, eight units for a blood sugar between 301 and 350, and 10 units for a blood sugar between 351 and 400.

Observation on 09/30/24 at 11:18 A.M. of RN #208 preparing to administer Lispro insulin to Resident #42. RN #208 removed the cap from the insulin pen, inverted the pen, inspected the tip, attached the needle cap, and dialed the pen to four units. RN #208 opened the alcohol pad, cleaned the right lower quadrant of Resident #42's stomach, placed the injector pen against the skin of Resident #42 and pressed the dose button. RN #208 did not prime the insulin pen prior to administration.

2. Review of the medical record for Resident #38 revealed an admission date of 10/15/20, diagnoses included hypertension, type II diabetes mellitus, and hypothyroidism.

Review of the quarterly MDS assessment dated 07/07/24 revealed Resident #38 was cognitively intact.

Review of the physician order dated 01/09/24 revealed Resident #38 was ordered blood sugars before meals and at bedtime with coverage using Insulin Aspart per Novolog Flex Pen 100 units per milliliter (u/ml) per sliding scale. The sliding scale included two units of insulin to be administered using a Flex Pen for a blood sugar of 151 to 200, four units for a blood sugar of 201 to 250, six units for a blood sugar of 251 to 300, eight units for a blood sugar between 301 and 350, and 10 units for a blood sugar between 351 and 400.

Observation on 09/30/24 at 11:31 A.M. revealed RN #208 preparing to administer insulin to Resident #38. RN #208 verified the order and the dose of insulin, turned the dose selector on the pen to display four. RN #208 pulled up Resident #38's sleeve, opened the alcohol pad, cleansed the lateral left arm, waited a few seconds to allow the alcohol to dry and then placed the injector pen against the skin of the of Resident #38's left arm and pressed the dose button. RN #208 did not prime the insulin pen prior to administration of insulin.

Interview on 09/30/24 at 11:35 A.M. with RN #208 revealed RN #208 was unaware of the need to prime insulin pens prior to use.

Interview on 10/01/24 at 10:00 A.M. with the Director of Nursing (DON) verified insulin pens require priming after the needle is applied and before dialing the prescribed dose into the pen for administration to a resident. The DON verified nurses are provided education upon hire on medication administration including the use of insulin pens.

Review of the manufacturer's instructions for use for the Novolog Flex Pen revealed after the needle is in place, prime the needle before taking the injection. To prime the needle, dial the pen to two units, and holding the pen with the needle pointing upward, press the push button until insulin appears at the tip of the needle. Once the priming is complete, make sure the dose selector is set at zero and then dial the number of units needed to inject.

Review of the Lispro Kwik Pen instructions for use dated July 2023 revealed priming the pen before each injection removes the air from the needle and cartridge that may collect during normal use and ensures the pen is working correctly. Also, if the pen is not primed before each injection the resident may get too much or too little insulin.

Review of the undated facility policy titled, Administration and Documentation of Medications

Based on record review, staff interview, and review of facility policy, the facility failed to ensure the timely physician notification of laboratory results affecting one Resident (#57) of three residents reviewed for physician laboratory services. The facility census was 68.

Findings include:

Review of the medical record for Resident #47 revealed an admission date of 02/17/22, diagnoses included major depressive disorder, lymphedema, chronic kidney disease, congestive heart failure, and morbid obesity.

Review of the quarterly Minimum Data Set (MDS) dated 07/05/24 revealed Resident #47 was cognitively intact, was dependent on staff to meet activities of daily living and was incontinent of bowel and bladder.

Review of the physician order dated 08/09/24 revealed a urinalysis with culture and sensitivity to be completed once due to confusion. An additional physician order was placed for a urinalysis with culture and sensitivity on 08/17/24 and included may straight catheterize if needed.

Review of the Laboratory Results Report dated 08/15/24 revealed Resident #47 had urine collected for a urinalysis on 08/11/24 at 5:00 P.M., the urine was received in the laboratory on 08/12/24 and resulted on 08/15/24. Review of the laboratory results for the urinalysis revealed positive blood (normal is negative), greater than 50 white blood cells and a few bacteria with the urine culture results showing Klebsiella pneumoniae with the medications listed for the organism sensitivity.

Review of the medical record and the nurse progress notes for Resident #46 revealed the urinalysis results were called to the provider on 08/19/24 at 1:54 P.M. (four days later) with an order for Cipro 500 milligrams (mg) once a day for three days obtained.

Interview on 10/01/24 at 10:30 A.M. with Licensed Practical Nurse (LPN) #235 verified LPN #235 had collected the urine on 08/11/24. LPN #235 further stated she was off for a few days and upon returning noted the urinalysis results had not been reviewed and on 08/19/24 LPN #235 called the provider with the results and obtained the antibiotic order.

Review of the undated facility policy titled, Laboratory Services and Reporting

Based on medical record review, staff interview, and review of the facility policies, the facility failed to ensure fall investigations were completed, and failed to ensure post-fall assessments were completed. This affected two (#12 and #14) of three residents reviewed for falls. The facility census was 68.

Findings include:

1. Review of the medical record for Resident #12 revealed an admission date of 08/07/19 with diagnoses of dementia and congestive heart failure.

Review of the quarterly Minimum Data Set (MDS) assessment dated 03/19/24 revealed Resident #12 had impaired cognition, required substantial/maximal assistance for chair to bed transfers and was dependent for toileting hygiene. Further review revealed Resident #12 had no falls since the previous assessment.

Review of the Fall Risk Evaluation dated 02/06/24 revealed Resident #12 was at risk for falls.

Review of the Incident Log revealed Resident #12 had unwitnessed falls on 06/01/24 and 06/16/24.

Review of the facility's incident report for the fall on 06/01/24 at 12:30 A.M. revealed Resident #12 fell from his wheelchair in his room. Resident #12 was assessed for injury and found to have no injuries. However, Resident #12 complained of a pain level of 3 (on a scale of 1-10) and received medication for pain.

Review of the facility's incident report for the fall on 06/16/24 at 9:35 P.M. revealed Resident #12 fell in the smoking area while attempting to transfer himself from a chair to his wheelchair. Resident #12 was found to be without injury.

Interview on 06/24/24 at 3:57 P.M. with the Director of Nursing (DON) confirmed no additional fall investigation including a root cause analysis was completed for Resident #12's falls beyond the information contained in the incident report.

2. Review of the medical record for Resident #14 revealed an admission date of 04/27/22 with diagnoses of alcohol abuse, epilepsy, and spinal stenosis. Further review revealed Resident #14 was admitted to the hospital during the course of this investigation.

Review of the quarterly MDS assessment dated 04/04/24 revealed Resident #14 had intact cognition, used a wheelchair for ambulation and was independent for chair to bed transfers.

Review of the current care plan for Resident #14 revealed he preferred not to wear shoes or socks. Additionally, Resident #14 had an activities of daily life self-care performance deficit and his care plan included an intervention to encourage the use of a call light for assistance.

Review of the Fall Risk Evaluation dated 05/10/24 revealed Resident #14 was at risk for falls.

Review of the Incident Log revealed Resident #14 fell on 05/30/24 at 6:22 A.M., on 06/06/24 at 4:15 P.M., on 06/10/24 at 10:30 P.M., on 06/13/24 at 1:50 P.M., on 06/13/24 at 4:02 P.M., on 06/16/24 at 7:00 P.M., on 06/17/24 at 5:00 P.M., on 06/21/24 at 6:40 P.M., on 06/21/24 at 7:27 P.M., and on 06/22/24 at 3:45 P.M.

Review of the incident report and investigation for the unwitnessed fall on 05/30/24 revealed Resident #14 fell in his room while attempting to transfer himself from his wheelchair to the bed. No additional information regarding lighting in the room, footwear, or accessibility to the call light were available.

Review of the incident report and investigation for the unwitnessed fall on 06/06/24 revealed Resident #14 came back from back and was lying on his back on the floor in his room. Resident #14 stated he fell while trying to get into his wheelchair. No additional information regarding footwear or the accessibility of the call light was available.

Review of the incident report and investigation for the unwitnessed fall on 06/10/24 revealed Resident #14 was found on the floor in his room with an abrasion on his right temple. No additional information was available regarding lighting in the room, call light availability, or the potential cause of the abrasion.

Review of the incident report and investigation for the unwitnessed fall on 06/13/24 at 1:50 P.M. revealed Resident #14 was found on the floor in his room next to the bed. Resident #14 stated he was attempting to get into his wheelchair. No additional information was included regarding footwear, accessibility to call light, or the position of the resident when he was found.

Review of the incident report and investigation for the unwitnessed fall on 06/13/24 at 4:02 P.M. revealed Resident #14 was found on the floor in his room. Resident #14 stated he slipped out of bed while attempting to get into his wheelchair. No additional information, such as footwear or accessibility to the call light were included.

Review of the incident report for the unwitnessed fall on 06/16/24 revealed Resident #14 was found on the ground outside with his wheelchair behind him. Resident #14 had a superficial abrasion to his right knee and a contusion on his forehead.

Review of the incident report for the unwitnessed fall on 06/17/24 revealed Resident #14 was found in his room on the floor with another resident. Resident #14 stated he asked another resident for assistance to get up to use the restroom and they both fell to the floor. Resident #14 had abrasions to his left and right arms.

Review of the incident report for the unwitnessed fall on 06/21/24 at 6:40 P.M. revealed Resident #14 was found lying on the floor in his room. Resident #14 stated he was attempting to transfer from the bed to his wheelchair.

Review of the incident report and medical record for the unwitnessed fall on 06/21/24 at 7:27 P.M. revealed Resident #14 was returned to the facility by firefighters with abrasions to the bridge of his nose, his right upper eyebrow and skin abrasion and contusion to his upper forehead.

Review of the incident report for the unwitnessed fall on 06/22/24 revealed Resident #14 was found on the ground at the front entrance to the facility. Resident #14 was bleeding from the head. Staff took Resident #14 to his room and cleaned him up, then called Emergency Medical Services (EMS) to transport Resident #14 to the hospital.

Interviews on 06/24/24, 07/01/24, and 07/02/24 with the DON confirmed the fall investigations were incomplete for Resident #14's falls on 05/30/24, 06/06/24, 06/10/24 and both falls on 06/13/24. Additionally, the DON confirmed the fall investigations were initiated and ongoing at the time of the investigation for the falls on 06/16/24, 06/17/24, 06/21/24 and 06/22/24. Further, the DON confirmed neurological checks should be performed for any unwitnessed falls and confirmed no neurological checks were performed per protocol for Resident #14's nine unwitnessed falls from 05/30/24 through 06/21/24. Additionally, the DON confirmed a Fall Risk Assessment should be completed after each fall, and none were completed for the nine falls from 05/30/24 through 06/21/24.

The facility was unable to provide a policy regarding fall investigation processes or procedures.

Review of the policy Fall Prevention Program

Based on observation, staff interview, and review of the planned menu, the facility failed to ensure vegetables were provided per the planned menu. This affected seven (#15, #16, #17, #18, #19, #20, and #71) of 66 residents who received the noon meal. The facility identified two (#35 and #69) residents received nothing from the kitchen. The facility census was 68.

Findings include:

Observation during the noon meal service 06/24/24 from approximately 12:00 P.M. until 12:16 P.M. revealed Cook #301 plating meals. Interview with Cook #301 during the observation confirmed a regular meal would consist of a chicken sandwich with fries and a side of cooked vegetables. Continued observation revealed Cook #301 did not have enough vegetables to provide a side of vegetables on the last few meal trays. Interview on 06/24/24 at 12:16 P.M. with Cook #301 verified she did not have enough vegetables for the last few meal trays. Cook #301 did not provide an explanation regarding why there was not enough vegetable or why she did not prepare more.

Observation of meal trays during meal service on 06/24/24 between 12:23 P.M. and approximately 12:35 P.M. revealed seven resident trays (#15, #16, #17, #18, #19, #20, and #71) did not have a serving of vegetables on them. State Tested Nurse Aide #102 confirmed no vegetable serving was on each of the identified resident trays.

Interview on 07/01/24 at 10:45 A.M. with Dietary Manager (DM) #302 revealed Cook #301 should have made a side salad when she ran out of vegetables during the noon meal service on 06/24/24. DM #302 stated Cook #301 was new and probably did not know she should make a salad to provide a vegetable after the cooked vegetables ran out.

Review of the facility menu dated 06/24/24 revealed residents should receive a one-half cup portion of Italian blend mixed vegetables with their noon meal.

This deficiency represents non-compliance investigated under Complaint Number OH00154416. Additionally, this deficiency represents continued non-compliance from the annual survey completed 05/23/24.

Based on medical record review and staff interview, the facility failed to ensure antibiotics were prescribed appropriately to treat Urinary Tract Infections (UTI). This affected one (#12) of two residents reviewed for treatment of UTIs. The facility census was 68.

Findings include:

Review of the medical record for Resident #12 revealed an admission date of 08/07/19 with diagnoses of dementia and congestive heart failure.

Review of the quarterly Minimum Data Set (MDS) assessment dated 03/19/24 revealed Resident #12 had impaired cognition, required substantial/maximal assistance for chair to bed transfers and was dependent for toileting hygiene.

Review of a progress note dated 06/13/24 revealed Resident #12 was seen by hospice who ordered Bactrim ds (antibiotic) 800 mg for 10 days and to collect urine and send for a urinalysis and culture and sensitivity (UA C&S).

Review of a physician order dated 06/14/24 revealed a UA C&S were ordered for Resident #12.

Review of a progress note dated 06/15/24 revealed Resident #12 continued on oral antibiotic for pain and burning during urination.

Review of the lab results dated 06/19/24 revealed Resident #12's urine specimen leaked in the transport container and a new specimen should be obtained. There was no evidence a new specimen was obtained.

Review of the June 2024 MAR revealed Resident #12 received Bactrim ds as ordered.

Interview on 07/01/24 at 12:15 P.M. with Infection Preventionist (IP) #502 confirmed the facility could provide no evidence a UA C&S was completed for Resident #12 to determine what bacteria was present in the resident's urine, and which antibiotic would be appropriate. IP #502 confirmed the facility did not follow the Antibiotic Stewardship Protocol by not obtaining a UA C&S.

This was an incidental finding discovered over the course of the complaint investigation.

Based on medical record review, review of resident fund account documentation, and staff interview, the facility failed to provide notification of a spend down when residents reached $200.00 less than their maximum Supplemental Security Income (SSI) benefit. This affected three (#18, #13, and #28) of five residents reviewed for resident funds in a facility census of 67.

Findings include:

1. According to the medical record, Resident #18 was admitted to the facility on 08/19/21. Review of Resident #18's current fund account balance as of 05/23/24 was $3,590.32 and exceeded the total SSI limit by $1,790.32. Further review revealed no documentation contained in the medical record indicated Resident #18 received a notice when reaching $200.00 less than the benefit limit.

2. According to the medical record, Resident #13 was admitted to the facility on 10/05/19. Review of Resident #13's current fund account balance as of 05/23/24 was $2,399.27 and exceeded the total SSI limit by $599.27. Further review revealed no documentation contained in the medical record indicated Resident #13 received a notice when reaching $200.00 less than the benefit limit.

3. According to the medical record, Resident #28 was admitted to the facility on 03/15/22. Review of Resident #28's current fund account balance as of 05/23/24 was $1,910.00 and exceeded the total SSI limit by $310.00. Further review revealed no documentation contained in the medical record indicated Resident #28 received a notice when reaching $200.00 less than the benefit limit.

On 05/23/24 at 12:22 P.M., interview with the Administrator verified Resident #13, Resident #18, and Resident #28 lacked spend down notification when exceeding the SSI benefit allowable balance.

Based on observation, resident and staff interview, and review of the facility policy, the facility failed to maintain a homelike environment for four (#7, #34, #51, and #54) of four residents reviewed for environmental concerns. The facility census was 67. Findings include: 1. Review of the medical record for Resident #7 revealed an admission date of 11/22/21 with diagnoses of quadriplegia and type two diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment dated 02/29/24 revealed Resident #7 had intact cognition. Observation on 05/20/24 at 8:14 A.M. of Resident #7, who was lying in his bed, revealed a bed rail on the right side of his bed, none on the left, and a crooked headboard. Concurrent interview with Resident #7 revealed he appreciated using the bed rails and wished the right bed rail (against the wall) was replaced. Additionally, he was concerned his headboard was crooked and wished it was fixed. Interview and observation on 05/20/24 at 10:55 A.M. with Licensed Practical Nurse (LPN) #281, in Resident #7's room, confirmed the bed rail on the wall side was hanging down below the bed, out of reach of Resident #7, and confirmed the headboard was crooked. 2. Review of the medical record for Resident #34 revealed an admission date of 04/15/23 with a diagnosis of depression. Review of the comprehensive MDS assessment dated 04/09/24 revealed Resident #34 had intact cognition. Observation and interview on 05/20/24 at 10:03 A.M. with Resident #34, who was lying in his bed, revealed a large brownish-colored stain on his privacy curtain. Resident #34 was in the bed furthest from the door and interview confirmed the resident used the privacy curtain frequently and Resident #34 stated the stain bothered him. Further observation revealed the stain was observed to be approximately 10 inches in diameter. Interview and observation on 05/22/24 at 1:58 P.M. with Housekeeper #226 confirmed the soiled privacy curtain in Resident #34's room. 3. Review of the medical record for Resident #51 revealed an admission date of 05/01/22 with a diagnosis of chronic kidney disease. Review of the comprehensive MDS assessment dated 04/04/24 revealed Resident #51 had intact cognition. Interview and observation on 05/20/24 at approximately 9:10 A.M. with Resident #51, in his room, revealed surface level paint was scraped off the wall alongside his bed. Resident #51 stated the lack of paint and scraped wall bothered him. Interview and observation on 05/22/24 at 3:58 P.M. with Director of Maintenance #219, in Resident #51's room, confirmed the wall alongside Resident #51's bed was scraped and the paint was scraped off down to the drywall. Director of Maintenance #219 stated the disrepair was not brought to his attention. 4. Review of the medical record for Resident #54 revealed an admission date of 03/01/21 with a diagnosis of depression. Review of the quarterly MDS assessment dated 04/02/24 revealed Resident #54 had impaired cognition. Observation on 05/20/24 at approximately 8:10 A.M. revealed Resident #54 sleeping in bed. There were two holes visible in the resident's fitted sheet that were approximately both two inches in diameter. Observation on 05/21/24 at 7:57 A.M. revealed staff entered Resident #54's room to provide his breakfast tray. Resident #54 was lying in bed and stated he was not ready for breakfast at that time. Further observation revealed the two holes remained in the fitted sheet to the resident's bed. Observation and interview on 05/22/24 at 7:35 A.M. with Housekeeper #226 confirmed the two holes in Resident #54's fitted sheet were visible from the hallway. Housekeeper #226 stated she was in the room earlier in the week to deep clean and did not noticed the holes. Review of the policy, Safe and Homelike EnvironmentBased on observation, resident and staff interview, and review of the facility policy, the facility failed to maintain a homelike environment for four (#7, #34, #51, and #54) of four residents reviewed for environmental concerns. The facility census was 67.

Findings include:

1. Review of the medical record for Resident #7 revealed an admission date of 11/22/21 with diagnoses of quadriplegia and type two diabetes mellitus.

Review of the quarterly Minimum Data Set (MDS) assessment dated 02/29/24 revealed Resident #7 had intact cognition.

Observation on 05/20/24 at 8:14 A.M. of Resident #7, who was lying in his bed, revealed a bed rail on the right side of his bed, none on the left, and a crooked headboard. Concurrent interview with Resident #7 revealed he appreciated using the bed rails and wished the right bed rail (against the wall) was replaced. Additionally, he was concerned his headboard was crooked and wished it was fixed.

Interview and observation on 05/20/24 at 10:55 A.M. with Licensed Practical Nurse (LPN) #281, in Resident #7's room, confirmed the bed rail on the wall side was hanging down below the bed, out of reach of Resident #7, and confirmed the headboard was crooked.

2. Review of the medical record for Resident #34 revealed an admission date of 04/15/23 with a diagnosis of depression.

Review of the comprehensive MDS assessment dated 04/09/24 revealed Resident #34 had intact cognition.

Observation and interview on 05/20/24 at 10:03 A.M. with Resident #34, who was lying in his bed, revealed a large brownish-colored stain on his privacy curtain. Resident #34 was in the bed furthest from the door and interview confirmed the resident used the privacy curtain frequently and Resident #34 stated the stain bothered him. Further observation revealed the stain was observed to be approximately 10 inches in diameter.

Interview and observation on 05/22/24 at 1:58 P.M. with Housekeeper #226 confirmed the soiled privacy curtain in Resident #34's room.

3. Review of the medical record for Resident #51 revealed an admission date of 05/01/22 with a diagnosis of chronic kidney disease.

Review of the comprehensive MDS assessment dated 04/04/24 revealed Resident #51 had intact cognition.

Interview and observation on 05/20/24 at approximately 9:10 A.M. with Resident #51, in his room, revealed surface level paint was scraped off the wall alongside his bed. Resident #51 stated the lack of paint and scraped wall bothered him.

Interview and observation on 05/22/24 at 3:58 P.M. with Director of Maintenance #219, in Resident #51's room, confirmed the wall alongside Resident #51's bed was scraped and the paint was scraped off down to the drywall. Director of Maintenance #219 stated the disrepair was not brought to his attention.

4. Review of the medical record for Resident #54 revealed an admission date of 03/01/21 with a diagnosis of depression.

Review of the quarterly MDS assessment dated 04/02/24 revealed Resident #54 had impaired cognition.

Observation on 05/20/24 at approximately 8:10 A.M. revealed Resident #54 sleeping in bed. There were two holes visible in the resident's fitted sheet that were approximately both two inches in diameter.

Observation on 05/21/24 at 7:57 A.M. revealed staff entered Resident #54's room to provide his breakfast tray. Resident #54 was lying in bed and stated he was not ready for breakfast at that time. Further observation revealed the two holes remained in the fitted sheet to the resident's bed.

Observation and interview on 05/22/24 at 7:35 A.M. with Housekeeper #226 confirmed the two holes in Resident #54's fitted sheet were visible from the hallway. Housekeeper #226 stated she was in the room earlier in the week to deep clean and did not noticed the holes.

Review of the policy, Safe and Homelike Environment

Based on medical record review and staff interview, the facility failed to ensure Minimum Data Set (MDS) assessments were completed accurately for two (#7 and #56) of three residents reviewed for urinary catheters. The facility census was 67.

Findings include:

1. Review of the medical record for Resident #7 revealed an admission date of 11/22/21 with a diagnosis of neuromuscular dysfunction of the bladder.

Review of a physician order dated 01/09/24 revealed Resident #7 had an indwelling urinary (Foley) catheter.

Review of the quarterly MDS assessment dated 02/29/24 revealed Resident #7 had intact cognition and did not have an indwelling urinary catheter.

Observation on 05/21/24 at 7:52 A.M. revealed Resident #7 was sleeping in bed with a covered Foley catheter hanging from the bed frame.

Interview on 05/23/24 at approximately 4:30 P.M. with Licensed Practical Nurse (LPN) #372 confirmed Resident #7 had a urinary catheter and confirmed the MDS assessment dated 02/29/24 indicated Resident #7 did not have a urinary catheter.

2. Review of the medical record for Resident #56 revealed an admission date of 09/01/21 with a diagnosis of obstructive and reflux uropathy.

Review of the quarterly MDS assessment dated 03/11/24 revealed Resident #56 had impaired cognition and did not have a urinary catheter.

Observation on 05/21/24 at 1:05 P.M. revealed Resident #56 was ambulating in the hallway with a urinary catheter collection bag affixed to the wheelchair.

Interview on 05/23/24 at 2:07 P.M. with MDS Coordinator #392 confirmed Resident #56 had a urinary catheter and the MDS assessment dated 03/11/24 was completed in error.

The state published no narrative for this citation.

Based on observation, medical record review, and staff interview, the facility failed to provide resident-centered activity opportunities. This affected one (#35) of 24 residents reviewed for the provision of activities in a facility census of 67.

Findings include:

Review of Resident #35's medical record revealed an admission date to the facility on 02/20/24 with the diagnoses including dementia with mood disturbance, generalized anxiety disorder, type two diabetes mellitus, chronic obstructive pulmonary disease, panic disorder, retention of urine, major depressive disorder, peripheral vascular disease, and hypertension.

Review of the most current Minimum Data Set (MDS) assessment dated 02/27/24 assessed Resident #35 with severe cognitive impairment, no behaviors exhibited, required partial to moderate assistance with activities of daily living, was incontinent of bowel and bladder, received a therapeutic diet, had no risk for pressure ulcer development, and received antianxiety, antidepressant, antiplatelet and hypoglycemic medications.

Review of the medical record revealed a plan of care developed on 02/21/24 to address Resident #35's placement on a memory care unit due to impaired cognitive function secondary to a diagnosis of dementia or impaired thought processes. Interventions included for staff to ask yes/no questions in order to determine the resident's needs, communicate with the resident/family/caregivers regarding the resident's capabilities and needs, cue, reorient, and supervise as needed, discuss concerns about confusion, disease process, nursing home placement with resident/family/caregivers, and the resident will receive specialized programing based of her cognitive ability and physical limitation.

Further review of the medical record noted an additional plan of care dated 02/27/24 to address Resident #35 having little or no activity involvement related to anxiety, depression, disinterest, immobility, physical limitations, poor adjustment to the facility/unit, and the resident wishes not to participate. Interventions included the resident will participate in activities of choice two to three times per week by review date, invite and encourage the resident's family members to attend activities with resident in order to support participation, remind the resident that the resident may leave activities at any time and was not required to stay for entire activity, and the resident preferred to socialize with staff and family.

Observation on 05/20/24 at 12:03 P.M. noted Resident #35 residing on a secured memory care unit with six additional residents. Resident #35 was propelling throughout the unit in a wheelchair. The resident was tearful at times and attempted to exit the facility by pulling on exit doors. Interview with Licensed Practical Nurse (LPN) #261 at the time of observation revealed no additional staff was working on the memory care unit. LPN #261 indicated she was unable to provide activities to the residents due to being busy with providing care. LPN #261 was unaware regarding Resident #35 activity interest.

On 05/21/24 at 6:05 A.M. interview with State Tested Nurse Aide (STNA) #368 revealed she assumed care of the residents residing on the memory care unit the previous evening (05/20/24) at approximately 8:00 P.M. STNA #368 stated during the evening Resident #35 attempted to exit the facility through the exit doors. STNA #368 attempted to give verbal prompts to the resident to gain the resident's attention and the resident became aggressive. STNA #368 stated she had no specific training to work on memory care unit including specific resident interest for activities or training to address resident behaviors.

Observations continued on 05/21/24 at 7:30 A.M., 9:02 A.M., 10:25 A.M., and 11:25 A.M. with no resident specific activity engagement offered or provided to Resident #35.

On 05/21/24 at 10:35 A.M. interview with STNA #340 confirmed there were no specific activities or programs to addressed memory care placement for Resident #35.

On 05/21/24 at 10:41 A.M. interview with LPN #261, during review of Resident #35 medical record, confirmed there were no specific or specialized programing to address Resident #35 cognitive ability and physical limitations. Resident# 35 was noted sitting in a wheelchair with no activity engagement at that time.

On 05/21/24 at 11:11 A.M. interview with Licensed Practical Nurse (LPN) #501, during a review of Resident#35 plan of care, revealed the entry related to program plan, and LPN #501 confirmed there was no specific program contained in the medical record.

Observation on 05/21/24 at 12:54 P.M. and on 05/21/24 at 1:02 P.M., revealed Resident #35 was noted to be tearful and attempting to exit facility. LPN #264 was attempting to redirect and the resident became more verbally agitated. On 05/21/24 at 1:05 P.M. interview with LPN #264, during review of medical record, confirmed there were no specific intervention or activities were listed to assist with de-escalating the resident's exit-seeking behavior.

On 05/22/24 at 5:50 A.M. interview with Licensed Social Worker (LSW) #385 requested protocol, policy, criteria, service plan for residents residing on memory care unit. LSW #385 verified Resident #35's plan of care indicated there were resident specific program interventions; however, no resident specific program interventions or activities were contained in the medical record as being completed.

On 05/22/24 06:05 A.M., interview with STNA #365 stated she assumed care of Resident #35 and residents residing on the memory care unit on 05/21/24 at 10:30 P.M. through 05/22/24 at 6:30 A.M. STNA #365 stated no specific interventions were provided to her to address resident behaviors or activity needs. STNA #365 was informed Resident #35 was exit-seeking when assuming care from the previous shift; however, no interventions were provided to address the behavior. STNA #365 verified no specific plan of care or program activity was available as a resource when Resident #35 or other residents needed behavioral or psychosocial support. At approximately 5:00 A.M., STNA #365 observed Resident #35 in her room seated in her chair with no clothing from the waist down and clothing on the floor. STNA #365 asked if she could assist Resident #35 with removing the clothing from the floor and Resident #35 became agitated and began yelling at STNA #365. STNA #365 proceeded to exit the room and did not return. There was no opportunity to assist the resident with toileting or potential incontinence care was not provided during the shift due to potential behaviors and Resident #35 becoming aggressive or agitated with the staff interactions.

Review of facility activity calendar for 05/20/24 noted at 11:00 A.M. exercise and at 2:00 P.M. bowling activities were to occur. On 05/21/24 at 11:00 A.M. coffee and donuts and at 2:00 P.M. memory game activities were to occur.

On 05/22/24 at 1:45 P.M. interview with Activity Director #170, during a review of the facility activity calendar, revealed she attempted to complete the same scheduled activities for the resident residing outside the memory care unit. AD #170 indicated there were no assigned activity staff to provide activities specific to the level of the residents residing on the memory care unit, and many times the nursing staff are responsible for providing activities when not providing resident care.

Based on medical record review, observation, resident interview, and staff interview, the facility failed to ensure ancillary services were provided to residents with hearing impairments. This affected one (#170) of one residents reviewed for hearing. The facility census was 67.

Findings include:

Review of the medical record identified Resident #170 was admitted to the facility on 12/02/20. Diagnoses included heart failure, hypertension, hyperlipidemia, and depression.

Review of the quarterly Minimum Data Set assessment dated 02/27/24 identified Resident #170 was cognitively intact and was dependent on staff assistance for a majority of the activities of daily living. Resident #170 did not use hearing aids.

Review of the social service progress notes dated 12/22/22 identified Resident #170 was seen by audiology who reported a physician consult for wax removal and for a medical consult to obtain medical clearance for hearing aids.

Review of the hearing instrument medical clearance form dated 12/22/22 identified Resident #170 had severe to profound hearing loss in the right ear and moderate to profound hearing loss in the left ear. Hearing aids were recommended for both ears to allow the resident to enjoy attending activities more frequently; to help the resident to hear and understand nursing staff, therapists, family, religious services, or staff better; to help increase the resident's level of social interaction; and to help the resident to become as independent as possible through improved understanding and safety.

Review of Resident #170's medical record, including audiology provider notes, on 05/21/24 identified no evidence the resident was ever referred for or received hearing aids. Resident #170 had a physician order dated 04/03/24 for an audiology consult for hearing aids.

During an observation and interview on 05/20/24 at 9:18 A.M., Resident #170 had difficulty responding to interview questions due to difficulty hearing. Resident #170 reported being at the facility for years and had not had an examination for hearing aids although the resident felt there was a need for them. Resident #170 reported being able to communicate with staff but it was difficult not being able to hear well and that people had to yell for the resident to hear.

During an interview on 05/22/24 at 11:38 A.M., Social Services Director (SSD) #385 confirmed the facility was unaware of Resident #170's medical clearance and recommendation for hearing aids dated 12/22/22 and were also unaware of the physician's order dated 04/03/24 for an audiology consult for hearing aids until identified during the survey. SSD #385 also confirmed Resident #170 had not been referred, seen, or evaluated for hearing aids since the recommendation was made on 12/22/22.

Based on observation, medical record review, resident and staff interview, and review of the facility wound treatment policy, the facility failed to ensure resident pressure ulcer treatments were applied in accordance with physician orders. This affected two (#25 and #65) of two sampled residents reviewed for pressure ulcer treatment in a facility census of 67. Findings include: 1. Review of the medical record revealed Resident #25 admitted to the facility on 12/04/23 with the diagnoses including osteomyelitis of the right ankle and foot, cerebral infarction, chronic embolism and thrombosis of the deep veins in the lower extremity, chronic hepatitis, hypertension, encephalopathy, and osteoarthritis. Review of the most current Minimum Data Set (MDS) assessment dated 05/03/24 Resident #25 was assessed with severe cognitive impairment, was dependent on staff for the completion of activities of daily living, was incontinent of bowel and bladder, received nutrition via tube feeding, and was on a mechanically altered diet. Review of a pressure sore risk assessment dated 03/31/24 revealed Resident #25 at very high risk of pressure sore development. Review of a weekly wound evaluation documented on 03/26/24 revealed Resident #25 had a pressure ulcer to the buttock assessed as present on admission. The wound was described as a stage four wound (full-thickness skin and tissue loss) measuring 1.8 centimeters (cm) long by(x) 1.9 cm wide x 0.3 cm deep. A small amount of blood tinged (serosanguinous) drainage was noted. On 03/26/24 Resident #25 received a physician order for the treatment of the wound to be cleansed with normal saline, pat dry, apply hydrofera blue, cover with foam adhesive dressing, and change every three days and as needed for soiling. Review of wound physician wound evaluation and management summary documentation on 04/23/24 recorded the right buttock wound as a healing stage four pressure ulcer measuring 0.2 cm long x 0.3 cm wide x 0.1 cm deep with moderate serous drainage. According to wound physician orders the dressing was to be continued with no changes. Observation on 05/21/24 at 10:47 A.M., during wound evaluation with Licensed Practical Nurse (LPN) #372, the nurse removed Resident #25's adult brief and discovered no dressing was applied to the buttock wound. Wound Center Physician #1 proceeded to assess and measured the right buttock stage four pressure ulcer at 0.2 cm long x 0.3 cm wide x 0.1 cm deep with moderate serous exudate. LPN #372 was unaware the dressing had been removed and was not in place as ordered by the physician. On 05/21/24 at 11:12 A.M. interview with State Tested Nurse Aide (STNA) #308 revealed Resident #25 was provide morning activities of daily living by a hospice nurse aide. STNA #308 was not informed the resident did not have the dressing applied to the buttock wound. 2. Review of the medical record for Resident #65 revealed an admission date of 02/20/24 with diagnoses of severe protein-calorie malnutrition, anxiety, and depression. Further review revealed Resident #65 was admitted to the facility under the care of hospice. Review of the admission MDS assessment completed 02/27/24 revealed Resident #65 had intact cognition. Resident #65 was not at risk for developing pressure injuries, no pressure injury was present on admission, and a pressure reducing mattress was in place. Review of the quarterly Braden Scale for predicting pressure sore risk assessment dated 04/13/24 revealed Resident #65 was at risk for developing pressure sores. Review of the skin observation tool completed on 04/25/24 revealed Resident #65's skin was intact. Review of a progress note dated 04/29/24 revealed Resident #65 was found with an open area on her coccyx and two areas on the left buttocks, one area measuring 1.0 cm long x 1.0 cm wide and the other area measuring 0.5 cm long x 0.5 cm wide. Depth of the wounds was not included in the progress note. Review of a Wound Care Physician progress note dated 05/01/24 revealed Resident #65 was found with two stage three pressure ulcers (full thickness skin loss) to her left buttock. One pressure ulcer (Site #1) measured 0.4 cm long x 0.3 cm wide x 0.1 cm deep with moderate serous exudate and 40 percent (%) granulation tissue. The other pressure ulcer (Site #2) measured 1.0 cm long x 0.5 cm wide x 0.1 cm deep with moderate serous exudate and 40% granulation tissue. Review of the physician orders for Resident #65 dated 05/04/24 revealed treatment orders for the left buttock to cleanse both wounds with normal saline, pat dry, apply hydrofera blue to the wound bed, cover with foam dressing, and change three times per week and as needed. Review of a nursing treatment progress note dated 05/18/24 revealed Resident #65 was found with no dressing on her left buttock wounds. Review of wound measurements provided by Wound Care LPN #372 revealed both stage three pressure ulcers were measured on 05/01/24, 05/08/24, and 05/15/24, and both wounds decreased in size. Interview on 05/20/24 at 10:46 A.M. with Resident #65 revealed she had no concerns with her care and treatment and further stated her buttock wounds were healed. Interview on 05/21/24 at 3:46 P.M. with Wound Care LPN #372 confirmed she performed wound care and took weekly measurements on Resident #65's wounds. Wound Care LPN #372 stated the wound care physician rounded once monthly to observe the wounds and conduct measurements as Resident #65 was under hospice care. Interview on 05/22/24 at 11:19 A.M. with State Tested Nurse Aide (STNA) #344 revealed Resident #65 wore pull-up briefs and usually used the restroom independently. Observation of Resident #65's wound care on 05/22/24 at 2:05 P.M. with Wound Care LPN #372 revealed Resident #65 had no dressing in place on her left buttock. Concurrent interview with Wound Care LPN #372 confirmed no dressing was in place. Further observation revealed the left buttock wounds were healing and no concerns were identified during wound care. Measurements obtained during the observation for Site #1 revealed 0.5 cm long x 0.3 cm wide x 0.1 cm deep and for Site #2 revealed 0.3 cm long x 0.4 cm wide x 0.1 cm deep. Review of the policy Wound Treatment ManagementBased on observation, medical record review, resident and staff interview, and review of the facility wound treatment policy, the facility failed to ensure resident pressure ulcer treatments were applied in accordance with physician orders. This affected two (#25 and #65) of two sampled residents reviewed for pressure ulcer treatment in a facility census of 67.

Findings include:

1. Review of the medical record revealed Resident #25 admitted to the facility on 12/04/23 with the diagnoses including osteomyelitis of the right ankle and foot, cerebral infarction, chronic embolism and thrombosis of the deep veins in the lower extremity, chronic hepatitis, hypertension, encephalopathy, and osteoarthritis.

Review of the most current Minimum Data Set (MDS) assessment dated 05/03/24 Resident #25 was assessed with severe cognitive impairment, was dependent on staff for the completion of activities of daily living, was incontinent of bowel and bladder, received nutrition via tube feeding, and was on a mechanically altered diet.

Review of a pressure sore risk assessment dated 03/31/24 revealed Resident #25 at very high risk of pressure sore development.

Review of a weekly wound evaluation documented on 03/26/24 revealed Resident #25 had a pressure ulcer to the buttock assessed as present on admission. The wound was described as a stage four wound (full-thickness skin and tissue loss) measuring 1.8 centimeters (cm) long by(x) 1.9 cm wide x 0.3 cm deep. A small amount of blood tinged (serosanguinous) drainage was noted.

On 03/26/24 Resident #25 received a physician order for the treatment of the wound to be cleansed with normal saline, pat dry, apply hydrofera blue, cover with foam adhesive dressing, and change every three days and as needed for soiling.

Review of wound physician wound evaluation and management summary documentation on 04/23/24 recorded the right buttock wound as a healing stage four pressure ulcer measuring 0.2 cm long x 0.3 cm wide x 0.1 cm deep with moderate serous drainage. According to wound physician orders the dressing was to be continued with no changes.

Observation on 05/21/24 at 10:47 A.M., during wound evaluation with Licensed Practical Nurse (LPN) #372, the nurse removed Resident #25's adult brief and discovered no dressing was applied to the buttock wound. Wound Center Physician #1 proceeded to assess and measured the right buttock stage four pressure ulcer at 0.2 cm long x 0.3 cm wide x 0.1 cm deep with moderate serous exudate. LPN #372 was unaware the dressing had been removed and was not in place as ordered by the physician.

On 05/21/24 at 11:12 A.M. interview with State Tested Nurse Aide (STNA) #308 revealed Resident #25 was provide morning activities of daily living by a hospice nurse aide. STNA #308 was not informed the resident did not have the dressing applied to the buttock wound.

2. Review of the medical record for Resident #65 revealed an admission date of 02/20/24 with diagnoses of severe protein-calorie malnutrition, anxiety, and depression. Further review revealed Resident #65 was admitted to the facility under the care of hospice.

Review of the admission MDS assessment completed 02/27/24 revealed Resident #65 had intact cognition. Resident #65 was not at risk for developing pressure injuries, no pressure injury was present on admission, and a pressure reducing mattress was in place.

Review of the quarterly Braden Scale for predicting pressure sore risk assessment dated 04/13/24 revealed Resident #65 was at risk for developing pressure sores.

Review of the skin observation tool completed on 04/25/24 revealed Resident #65's skin was intact.

Review of a progress note dated 04/29/24 revealed Resident #65 was found with an open area on her coccyx and two areas on the left buttocks, one area measuring 1.0 cm long x 1.0 cm wide and the other area measuring 0.5 cm long x 0.5 cm wide. Depth of the wounds was not included in the progress note.

Review of a Wound Care Physician progress note dated 05/01/24 revealed Resident #65 was found with two stage three pressure ulcers (full thickness skin loss) to her left buttock. One pressure ulcer (Site #1) measured 0.4 cm long x 0.3 cm wide x 0.1 cm deep with moderate serous exudate and 40 percent (%) granulation tissue. The other pressure ulcer (Site #2) measured 1.0 cm long x 0.5 cm wide x 0.1 cm deep with moderate serous exudate and 40% granulation tissue.

Review of the physician orders for Resident #65 dated 05/04/24 revealed treatment orders for the left buttock to cleanse both wounds with normal saline, pat dry, apply hydrofera blue to the wound bed, cover with foam dressing, and change three times per week and as needed.

Review of a nursing treatment progress note dated 05/18/24 revealed Resident #65 was found with no dressing on her left buttock wounds.

Review of wound measurements provided by Wound Care LPN #372 revealed both stage three pressure ulcers were measured on 05/01/24, 05/08/24, and 05/15/24, and both wounds decreased in size.

Interview on 05/20/24 at 10:46 A.M. with Resident #65 revealed she had no concerns with her care and treatment and further stated her buttock wounds were healed.

Interview on 05/21/24 at 3:46 P.M. with Wound Care LPN #372 confirmed she performed wound care and took weekly measurements on Resident #65's wounds. Wound Care LPN #372 stated the wound care physician rounded once monthly to observe the wounds and conduct measurements as Resident #65 was under hospice care.

Interview on 05/22/24 at 11:19 A.M. with State Tested Nurse Aide (STNA) #344 revealed Resident #65 wore pull-up briefs and usually used the restroom independently.

Observation of Resident #65's wound care on 05/22/24 at 2:05 P.M. with Wound Care LPN #372 revealed Resident #65 had no dressing in place on her left buttock. Concurrent interview with Wound Care LPN #372 confirmed no dressing was in place. Further observation revealed the left buttock wounds were healing and no concerns were identified during wound care. Measurements obtained during the observation for Site #1 revealed 0.5 cm long x 0.3 cm wide x 0.1 cm deep and for Site #2 revealed 0.3 cm long x 0.4 cm wide x 0.1 cm deep.

Review of the policy Wound Treatment Management

The state published no narrative for this citation.

Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure nutrition assessments were completed upon admission and quarterly. This affected one (#22) of two residents reviewed for nutrition. The facility census was 67. Findings include: Review of the medical record for Resident #22 revealed an admission date of 11/30/23 with diagnoses of chronic kidney disease, type two diabetes mellitus, delusional disorders, hyperlipidemia, and a body mass index indicating the resident was overweight. Review of the quarterly Minimum Data Set (MDS) assessment dated 03/12/24 revealed Resident #22 had intact cognition. Review of the current care plan revealed Resident #22 was at risk for malnutrition related to a diagnoses of chronic kidney disease, diabetes mellitus, and bipolar disorder. Interventions included to update food preferences and provide supplement as ordered. Review of the weight history for Resident #22 revealed non-significant weight gain of five pounds over five months. Review of the medical record revealed no nutritional assessment was completed for Resident #22 since admission. Interview on 05/21/24 at 9:39 A.M. with Regional Registered Dietitian (RRD #388) stated initial nutritional assessments should be completed within 72 hours of admission and quarterly nutritional assessments should be completed quarterly thereafter. Further interview with RRD #388 confirmed no nutritional assessments were completed for Resident #22. RRD #388 stated Resident #22 went to the hospital shortly after admission and the brief discharge to the hospital disrupted the way nutritional assessments were assigned in her chart. RRD #388 confirmed Resident #22 was not at nutrition risk. Review of the undated policy titled, Nutritional ManagementBased on medical record review, staff interview, and review of the facility policy, the facility failed to ensure nutrition assessments were completed upon admission and quarterly. This affected one (#22) of two residents reviewed for nutrition. The facility census was 67.

Findings include:

Review of the medical record for Resident #22 revealed an admission date of 11/30/23 with diagnoses of chronic kidney disease, type two diabetes mellitus, delusional disorders, hyperlipidemia, and a body mass index indicating the resident was overweight.

Review of the quarterly Minimum Data Set (MDS) assessment dated 03/12/24 revealed Resident #22 had intact cognition.

Review of the current care plan revealed Resident #22 was at risk for malnutrition related to a diagnoses of chronic kidney disease, diabetes mellitus, and bipolar disorder. Interventions included to update food preferences and provide supplement as ordered.

Review of the weight history for Resident #22 revealed non-significant weight gain of five pounds over five months.

Review of the medical record revealed no nutritional assessment was completed for Resident #22 since admission.

Interview on 05/21/24 at 9:39 A.M. with Regional Registered Dietitian (RRD #388) stated initial nutritional assessments should be completed within 72 hours of admission and quarterly nutritional assessments should be completed quarterly thereafter. Further interview with RRD #388 confirmed no nutritional assessments were completed for Resident #22. RRD #388 stated Resident #22 went to the hospital shortly after admission and the brief discharge to the hospital disrupted the way nutritional assessments were assigned in her chart. RRD #388 confirmed Resident #22 was not at nutrition risk.

Review of the undated policy titled, Nutritional Management

Based on observation, medical record review, staff interview, personnel file review, and memory care unit criteria documentation review, the facility failed to ensure residents with diagnosis of dementia received appropriate care and services and staff working with those resident were provided sufficient education to ensure those care and services needs were met to ensure the residents maintained their highest practicable physical, mental, and psychosocial well-being. This affected one (#35) of one residents reviewed for dementia related behavioral services in a facility census of 67.

Findings include:

Review of the medical record revealed Resident #35 admitted to the facility on 02/20/24 with the diagnoses including dementia with mood disturbance, generalized anxiety disorder, type two diabetes mellitus, chronic obstructive pulmonary disease, panic disorder, retention of urine, major depressive disorder, peripheral vascular disease, and hypertension.

Review of the most current Minimum Data Set (MDS) assessment dated 02/27/24 assessed Resident #35 with severe cognitive impairment, no behaviors exhibited, required partial to moderate assistance with activities of daily living, was incontinent of bowel and bladder, received a therapeutic diet, was at no risk for pressure ulcer development, and received antianxiety, antidepressant, antiplatelet and hypoglycemic medications.

On 02/21/24 a physician order was obtained to admit Resident #35 to the memory care unit.

Review of the medical record revealed a plan of care developed on 02/21/24 to address Resident #35 placement on a memory care unit due to diagnosis of impaired cognitive function secondary to diagnosis of dementia or impaired thought processes. Interventions included to ask yes/no questions in order to determine the resident's needs, communicate with the resident/family/caregivers regarding residents capabilities and needs, cue, reorient, and supervise as needed, discuss concerns about confusion, disease process, and nursing home placement with resident/family/caregivers, and the resident received specialized programing based of her cognitive ability and physical limitation.

Further review of the medical record noted an additional plan of care dated 02/27/24 to address Resident #35 having little or no activity involvement related to anxiety, depression, disinterest, immobility, physical limitations, poor adjustment to the facility/unit, and the resident wished not to participate. Interventions included the resident will participate in activities of choice two to three times per week by the review date, invite/encourage the resident's family members to attend activities with resident in order to support participation, remind the resident that the resident may leave activities at any time and is not required to stay for entire activity, and the resident preferred to socialize with staff and family.

On 05/11/24 at 8:37 P.M. transfer form documentation noted Resident #35 had been having a behavioral meltdown since the beginning of the shift and tried to attack one of the other residents. The physician was notified and agreed to send Resident #35 to a geriatric psychiatric hospital evaluation. According to the medical record Resident #35 was returned to the facility the same evening with no new orders or interventions.

On 05/13/24 physician progress notes revealed staff to report Resident #35 was having increased anxiety and agitation for the last week. The resident was wandering into other resident's rooms, lashing out verbally, pacing up and down the hallway, and was crying/tearful. A new order to increase the antianxiety medication hydroxyzine to 50 milligrams (mg) twice daily due to increased agitation and anxiety. No non-pharmacological intervention was indicated.

Observation on 05/20/24 at 12:03 P.M. noted Resident #35 residing on a secured memory care unit with six additional residents. Resident #35 was propelling throughout the unit in a wheelchair. The resident was tearful at times and attempted to exit the facility by pulling on exit doors. Interview with Licensed Practical Nurse (LPN) #261 at the time of observation revealed no additional staff were working on the memory care unit. LPN #261 indicated she was unable to provide activities to the residents due to being busy with providing care. LPN #261 was unaware regarding Resident #35 activity interest.

On 05/21/24 at 6:05 A.M. interview with State Tested Nurse Aide (STNA) #368 revealed she assumed care of the residents residing on the memory care unit the previous evening (05/20/24) at approximately 8:00 P.M. STNA #368 stated during the evening Resident #35 attempted to exit the facility through the exit doors. STNA #368 attempted to give verbal prompts to the resident to gain the resident's attention and the resident became aggressive. STNA #368 stated no specific training to work on memory care unit, including specific resident interest for activities was provided to her as well as no specific interventions to address behaviors. STNA #368 indicated she observed the resident during the night; however, no interactions occurred due to fear of causing Resident #35 to become aggressive.

Observations continued on 05/21/24 at 7:30 A.M., 9:02 A.M., 10:25 A.M., and 11:25 A.M. no resident specific engagement was offered or provided to Resident #35.

On 05/21/24 at 10:35 A.M. interview with STNA #340 confirmed no specific programs or interventions to addressed memory care placement for Resident #35.

On 05/21/24 at 10:41 A.M. interview with LPN #261, during review of Resident #35 medical record, confirmed no specific or specialized programing to address Resident #35 cognitive ability and physical limitation. Resident# 35 was noted sitting in wheelchair with no activity engagement.

On 05/21/24 at 11:11 A.M. interview with Licensed Practical Nurse (LPN) #501, during a review of Resident #35 plan of care, revealed the entry related to program plan. LPN #501 confirmed there was no specific program contained in the resident's medical record.

Observation on 05/21/24 at 12:54 P.M. and on 05/21/24 at 1:02 P.M. revealed Resident #35 was noted to be tearful and attempting to exit facility. LPN #264 was attempting to redirect and the resident became more verbally agitated. On 05/21/24 at 1:05 P.M. interview with LPN #264, during review of medical record, confirmed no specific interventions or activities were listed to assist with de-escalating the exit seeking behavior.

On 05/22/24 at 5:50 A.M. interview with Licensed Social Worker (LSW) #385 requested protocol, policy, criteria, and service plan for residents residing on the memory care unit. LSW #385 verified Resident #35's plan of care indicated resident specific program interventions; however, no resident specific program interventions were noted as completed the medical record.

On 05/22/24 6:05 AM interview with STNA #365 stated care of Resident #35 and residents residing on the memory care unit was assumed on 05/21/24 at 10:30 P.M. through 05/22/24 at 6:30 A.M. STNA #365 stated no specific interventions were provided to her to address resident behaviors or activity needs. STNA #365 was informed Resident #35 was exit seeking when assuming care from staff on the previous shift; however, no interventions were provided to address the behavior. STNA #365 verified no specific plan of care or program activity was available as a resource when Resident #35 or other residents needed behavioral or psychosocial support. At approximately 5:00 A.M., STNA #365 observed Resident #35 in her room seated in her chair with no clothing from the waist down and clothing on the floor. STNA #365 asked if she could assist Resident #35 with removing the clothing from the floor and Resident #35 became agitated and began yelling at STNA#365. STNA #365 proceeded to exit the room and did not return as there was no opportunity to assist the resident with toileting or potential incontinence care due to potential behaviors and Resident #35 becoming aggressive or agitated with the interaction from staff.

Review of facility Memory Care Unit (MCU) documentation noted the secure unit was designed to serve those with specific memory impairment related to dementia. The unit differs from other units due to being secure, and most residents are at risk for elopement and wear a wandering device to alert staff if they come to close to an exit or attempt to leave the unit unattended. There is limited access of others to the unit making for a restful and calmer environment. The staffing on the unit differs as the needs of the individuals with dementia require more interaction, diversion, and redirection to maintain not only safety by contentment. Each resident has their own special box which contains items that help to calm, allowing reminiscing, or bring joy. Items of meaning. The box is used when a resident is upset, showing signs of frustration and staff needs to offer one on one time to assist the resident in obtaining a non-distressed demeanor. Medications are usually limited to essential medications only.

Review of STNA #368's personnel file noted a hire date of 04/25/24 as a State Tested Nurse Aide. No information or documentation contained in the medical record revealed specific training or orientation to work on the memory care unit (MCU) or with the residents residing on the MCU.

On 05/23/24 at 10:08 A.M. interview with the Administrator, during a review of STNA #368's personnel file, confirmed no information or documentation contained in the medical record revealed STNA #368 received specific training or orientation to work with residents on the MCU.

The state published no narrative for this citation.

The state published no narrative for this citation.

Based on observation, staff interview, and review of the menu, spreadsheet, and facility recipe, the facility failed to ensure pureed meals were prepared according to the recipe. This affected four (#25, #42, #44, and #62) of four residents ordered a pureed texture diet. The facility census was 67.

Findings include:

Review of the menu for the lunch meal on 05/21/24 revealed residents on a regular textured diet received chicken enchiladas, mexican rice, roasted corn, and pudding. Further review revealed residents on a pureed diet would receive pureed enchiladas, pureed rice, pureed lima beans, and pudding.

Observation and interview on 05/21/24 at 10:00 A.M. revealed Cook #195 preparing pureed food for the lunch meal. Cook #195 placed 10 chicken breasts into the food processor and pureed them until smooth. Cook #195 added an unmeasured amount of chicken broth to thin the chicken. Cook #195 stated four (#25, #42, #44, and #62) residents received pureed diets and some received double portions, so she consistently made extra portions of pureed foods.

Continued observation revealed Cook #195 placed an unmeasured amount of cooked green beans into the food processor and blended until smooth. Further interview with Cook #195 confirmed the residents who received puree foods would receive only chicken and green beans for the lunch meal.

Observation during meal service on 05/21/24, beginning at 11:35 A.M. revealed residents who received the pureed meal received chicken, green beans, and pudding for dessert.

Interview on 05/21/24 at 12:58 P.M. with Dietary Manager #216, during concurrent review of the lunch menu spreadsheet, confirmed Cook #195 should have pureed the prepared chicken enchiladas and the rice and provided all food items to residents on a pureed diet.

Interview on 05/22/24 at 1:44 P.M. with Cook #195 confirmed she was aware there were recipes and directions on how to puree the meals for residents. Cook #195 confirmed she did not follow the recipe for pureed enchiladas on 05/21/24 and pureed only chicken breasts. Cook #195 stated it was a very busy day and could provide no further explanation why she did not follow the recipe.

Review of the recipe/procedure for preparing for pureed chicken enchiladas revealed staff should place prepared chicken enchiladas in the food processor and add fluid and blend until smooth.

Based on observation, resident and staff interview, medical record review, and review of a facility policy, the facility failed to ensure pureed foods were served at an appropriate texture and failed to ensure residents received diets at an appropriate texture to meet their needs. This affected four (#25, #42, #44, and #62) of four residents ordered a a pureed texture diet and one (#11) of two residents reviewed for nutrition. The facility census was 67.

Findings include:

1. Observation and interview on 05/21/24 at 10:00 A.M. revealed Cook #195 was preparing pureed food for the lunch meal. Cook #195 placed 10 chicken breasts into the food processor and pureed them until smooth. Cook #195 added an unmeasured amount of chicken broth to thin the chicken. Cook #195 stated four (#25, #42, #44, and #62) residents received pureed diets and some received double portions, so she consistently made extra portions of pureed foods.

Observation during meal service on 05/21/24, beginning at 11:35 A.M. revealed Cook #195 serving pureed chicken covered in enchilada sauce. The texture of the chicken appeared firm and crumbly.

Interview on 05/21/24 at 12:09 P.M. with Regional Registered Dietitian (RRD) #388 revealed the kitchen staff was recently educated on preparation of pureed foods.

Interview at the end of meal service on 05/21/24 at approximately 12:35 P.M. with Cook #195 revealed she identified no concerns with the pureed chicken texture and further stated she added enchilada sauce to the chicken for additional moisture.

Review of a pureed test tray on 05/21/24 at 12:40 P.M. with RRD #388 confirmed the pureed chicken crumbled and did not have a uniform, cohesive texture, even after mixing with the provided enchilada sauce. RRD #388 confirmed the pureed chicken was not an appropriate texture to provide to residents on a pureed diet.

2. Review of the medical record revealed Resident #11 admitted to the facility on 04/01/24 with the diagnoses including chronic obstructive pulmonary disease, type two diabetes mellitus, coronary artery disease, paranoid schizophrenia, neuromuscular dysfunction of bladder, retention of urine, benign prostatic hyperplasia with lower urinary tract symptoms, suprapubic urinary catheter, history of urinary tract infection, bipolar disorder, anxiety disorder, hypertension, and anemia.

Review of the most current Minimum Data Set (MDS) assessment dated 04/08/24 assessed Resident #11 with intact cognition, was dependent on staff for the completion of activities of daily living, utilized an indwelling catheter related to urination, was continent of bowel, and received no specialized or modified diet.

Review of physician orders revealed on 04/01/24 Resident #11 was ordered a regular diet, regular texture, and thin consistency.

On 04/10/24 a nursing plan of care was implemented to address Resident #11 potential/actual impairment to skin integrity related to fragile skin. Interventions also included nutritional support to encourage good nutrition and hydration in order to promote healthier skin.

Observation and interview on 05/20/24 at 12:38 P.M. noted Resident #11 attempting to eat lunch. Resident #11 was noted without teeth or dentures. The resident was unable to eat the slice of pork tenderloin due to having no teeth. The resident stated since his admission he was leaving his dentures with his son due to not wanting to loose them in the facility.

Observation and interview on 05/21/24 at 7:50 A.M. noted Resident #11 was seated in the unit lounge and eating breakfast independently. The resident ate scrambled eggs and hot cereal; however, Resident #11 stated he was unable to eat a slice of ham during interview.

On 05/21/24 at 7:52 A.M. interview with State Tested Nurse Aide (STNA) #308 during observation noted Resident #11's with a sliced portion of ham remaining on plate and unable to consume due to lack of teeth or dentures. STNA #308 confirmed the resident was not able to eat the piece of ham.

On 05/21/24 at 12:45 P.M. interview with RRD #388 stated she was unaware Resident #11 was not wearing dentures and had requested a diet texture modification. RRD#388 also indicated the speech and language pathologist was not aware of the resident's diet texture status.

Review of the policy titled, Puree Food Preparation

Based on observation, staff interview, and review of a facility policy, the facility failed to use appropriate hand hygiene while preparing and serving food items. This directly affected all residents with the exception of two (#5 and #43) residents who were identified to receive no food from the kitchen. The facility census was 67. Findings include: 1. Observation on 05/21/24 at 11:28 A.M. at the beginning of meal service revealed Cook #195 washed her hands and put on disposable gloves. Cook #195 then removed lids from the steam table and put on oven mitts to remove food from the oven. Cook #195 removed the oven mitts, picked up a food thermometer, and took the temperature of a pan of enchilada sauce. Cook #195 then used a towel to pick the pan of sauce back up, opened the oven door, and placed the pan inside the oven. Continued observation revealed Cook #195, wearing the same pair of disposable gloves, sat out meal tickets and beginning to plate food. Cook #195 touched the spatula for the enchiladas and the scoops for beans, rice, and enchilada sauce. Continued observation on 05/21/24 at 11:36 A.M. revealed Cook #195, wearing the same pair of disposable gloves, and using her fingers to help slide the enchilada off the spatula and onto the plate, then Cook #195 scooped rice, corn, and enchilada sauce onto the plate. Cook #195 then picked up a new plate, used her gloved hand to slide the enchilada onto another plate, and served rice, corn, and enchilada sauce. Interview on 05/21/24 at approximately 11:38 A.M. with Dietary Aide #198 revealed the two residents whose meals Cook #195 just plated were for Resident #29 and Resident #59. Interview on 05/21/24 at 11:38 A.M. with Cook #195 confirmed she had not changed her gloves since the beginning of meal service, touched the steam table lids, touched the serving utensils, and put her gloved hands into the oven mitts before touching the enchiladas during plating. Cook #195 stated the enchilada was about to fall off the plate and therefore she was trying to keep the food in place. 2. Observation on 05/21/24 at approximately 11:55 A.M. revealed Dietary Manager (DM) #216 telling kitchen staff Resident #38 requested a turkey sandwich. Observation on 05/21/24 at 12:03 P.M. revealed Cook #193 was wearing disposable gloves and opened the walk-in refrigerator using a gloved hand on the handle. Cook #193 came out from the walk-in refrigerator carrying a large container of mayonnaise. Cook #193 opened the mayonnaise jar then used a knife to spread mayonnaise on a piece of bread while holding the bread with the other hand. Cook #193 then picked up a slice of cheese, placed it on the sandwich, picked up the bread, put the slice on top of the turkey sandwich, and held the sandwich it place while he cut it in half before placing it on a plate. Cook #193, wearing the same disposable gloves, then walked to a large bag of chips and reached inside for a handful of chips and placed them on the plate with the sandwich. Interview on 05/21/24 at 12:09 P.M. with Cook #193 confirmed he did not change his gloves at any time after entering the walk-in refrigerator, touching the mayonnaise, touching the knife, and before he touched the sandwich and chips for Resident #38. Cook #193 was not aware he should not handle foods with the same gloves used to touch unsanitized kitchen items. 3. Observation on 05/22/24 at 1:43 P.M. revealed Cook #192 was preparing side salads and chef salads. Cook #192 was observed to reach her bare hand into a large container of shredded cheese and sprinkle the cheese onto the salads. Interview at that time with Cook #192 revealed she felt it was safe and appropriate to touch the cheese with her bare hands. Interview on 05/22/24 at 1:45 P.M. with Dietary Manager #216 confirmed staff should not be using bare hands when preparing ready-to-eat food for residents. Review of the policy titled, Dietary Employee Personal HygieneBased on observation, staff interview, and review of a facility policy, the facility failed to use appropriate hand hygiene while preparing and serving food items. This directly affected all residents with the exception of two (#5 and #43) residents who were identified to receive no food from the kitchen. The facility census was 67.

Findings include:

1. Observation on 05/21/24 at 11:28 A.M. at the beginning of meal service revealed Cook #195 washed her hands and put on disposable gloves. Cook #195 then removed lids from the steam table and put on oven mitts to remove food from the oven. Cook #195 removed the oven mitts, picked up a food thermometer, and took the temperature of a pan of enchilada sauce. Cook #195 then used a towel to pick the pan of sauce back up, opened the oven door, and placed the pan inside the oven.

Continued observation revealed Cook #195, wearing the same pair of disposable gloves, sat out meal tickets and beginning to plate food. Cook #195 touched the spatula for the enchiladas and the scoops for beans, rice, and enchilada sauce. Continued observation on 05/21/24 at 11:36 A.M. revealed Cook #195, wearing the same pair of disposable gloves, and using her fingers to help slide the enchilada off the spatula and onto the plate, then Cook #195 scooped rice, corn, and enchilada sauce onto the plate. Cook #195 then picked up a new plate, used her gloved hand to slide the enchilada onto another plate, and served rice, corn, and enchilada sauce.

Interview on 05/21/24 at approximately 11:38 A.M. with Dietary Aide #198 revealed the two residents whose meals Cook #195 just plated were for Resident #29 and Resident #59.

Interview on 05/21/24 at 11:38 A.M. with Cook #195 confirmed she had not changed her gloves since the beginning of meal service, touched the steam table lids, touched the serving utensils, and put her gloved hands into the oven mitts before touching the enchiladas during plating. Cook #195 stated the enchilada was about to fall off the plate and therefore she was trying to keep the food in place.

2. Observation on 05/21/24 at approximately 11:55 A.M. revealed Dietary Manager (DM) #216 telling kitchen staff Resident #38 requested a turkey sandwich.

Observation on 05/21/24 at 12:03 P.M. revealed Cook #193 was wearing disposable gloves and opened the walk-in refrigerator using a gloved hand on the handle. Cook #193 came out from the walk-in refrigerator carrying a large container of mayonnaise. Cook #193 opened the mayonnaise jar then used a knife to spread mayonnaise on a piece of bread while holding the bread with the other hand. Cook #193 then picked up a slice of cheese, placed it on the sandwich, picked up the bread, put the slice on top of the turkey sandwich, and held the sandwich it place while he cut it in half before placing it on a plate. Cook #193, wearing the same disposable gloves, then walked to a large bag of chips and reached inside for a handful of chips and placed them on the plate with the sandwich.

Interview on 05/21/24 at 12:09 P.M. with Cook #193 confirmed he did not change his gloves at any time after entering the walk-in refrigerator, touching the mayonnaise, touching the knife, and before he touched the sandwich and chips for Resident #38. Cook #193 was not aware he should not handle foods with the same gloves used to touch unsanitized kitchen items.

3. Observation on 05/22/24 at 1:43 P.M. revealed Cook #192 was preparing side salads and chef salads. Cook #192 was observed to reach her bare hand into a large container of shredded cheese and sprinkle the cheese onto the salads. Interview at that time with Cook #192 revealed she felt it was safe and appropriate to touch the cheese with her bare hands.

Interview on 05/22/24 at 1:45 P.M. with Dietary Manager #216 confirmed staff should not be using bare hands when preparing ready-to-eat food for residents.

Review of the policy titled, Dietary Employee Personal Hygiene

Based on observation, medical record review, resident and staff interviews, and review of a facility policy, the facility failed to ensure each resident's electronic medical record was complete and accurate. This affected two (#19 and #220) of 19 resident records reviewed. The facility census was 67.

Findings include:

1. Review of the medical record for Resident #19 revealed an admission date of 10/15/20 with diagnoses of type two diabetes mellitus and peripheral vascular disease.

Review of the quarterly Minimum Data Set (MDS) assessment dated 04/06/24 revealed Resident #19 had intact cognition and had no wounds at the time of the assessment.

Review of a wound care service provider note dated 04/30/24 revealed Resident #19 had a skin tear on the left foot, second toe. Review of a provider note dated 05/07/24 revealed the skin tear on the left foot, second toe was scabbed. Further review of the provider notes from 05/14/24 and 05/21/24 revealed the wound on the left foot, second toe continued to be monitored by wound care.

Review of discontinued physician orders dated 05/02/24 to 05/14/24 and 05/16/24 to 05/21/24 revealed Resident #19 received treatment to a wound on the right toe, second digit.

Review of a current physician order dated 05/22/24 revealed Resident #19 received treatment to a wound on the right toe, second digit.

Review of the treatment administration record (TAR) dated May 2024 for Resident #19 revealed staff were signing off treatment was completed to the right toe, second digit.

Interview and observation on 05/22/24 at 7:43 A.M. with Licensed Practical Nurse (LPN) #260 confirmed Resident #19's wound was on her left foot, the second toe. LPN #260 confirmed the order was incorrect as it indicated it was for the right toe. LPN #260 was familiar with the wound and had provided treatment to the second toe on the left foot.

2. Review of the medical record for Resident #220 revealed an admission date of 05/15/24 with diagnoses of paraplegia, chronic obstructive pulmonary disease, congestive heart failure and chronic respiratory failure, and neuromuscular dysfunction of the bladder.

Review of the nursing assessment completed 05/16/24 revealed Resident #220 was alert and oriented to person, place, time, and situation and had intact cognition. Further review revealed Resident #220 had a diagnoses of neurogenic bladder and had an indwelling urinary (Foley) catheter.

Review of Resident #220's progress notes on 05/22/24 at 3:47 P.M. revealed the most recent progress note was dated 05/20/24.

Interview with Resident #220 on 05/20/24 at 10:24 A.M. revealed Resident #220 was satisfied with her care and had no concerns. Concurrent observations also revealed no concerns regarding care.

Interview on 05/22/24 at approximately 9:30 A.M. with LPN #260 revealed Resident #220 went to the hospital the previous evening.

Interview on 05/22/24 at 10:01 A.M. with the Interim Director of Nursing (DON) confirmed Resident #220's record did not include any information regarding Resident #220's transfer to the hospital the previous evening.

Interview on 05/22/24 at 10:26 A.M. with LPN #372 revealed the medical record should include nursing documentation of a change in condition and an e-interact transfer-out form. LPN #372 confirmed the documents were not completed for Resident #372.

Review of the policy titled, Documentation in Medical Record

Based on observation, record review, staff interview, hospice staff interview, and review of the facility policy, the facility failed to ensure communication and coordination of care occurred between the facility and the hospice provider. This affected one (#65) of one residents reviewed for hospice care. The facility census was 67. Findings include: Review of the medical record for Resident #65 revealed an admission date of 02/20/24 with diagnoses of severe protein-calorie malnutrition, anxiety, and depression. Further review revealed Resident #65 was admitted under the care of hospice. Review of the admission Minimum Data Set (MDS) assessment completed 02/27/24 revealed Resident #65 had intact cognition. Resident #65 was not at risk for developing pressure injuries, no pressure injury was present on admission, and a pressure reducing mattress was in place. Review of the quarterly Braden Scale for predicting pressure sore risk assessment dated 04/13/24 revealed Resident #65 was at risk for developing pressure sores. Review of the skin observation tool completed on 04/25/24 revealed Resident #65's skin was intact. Review of a progress note dated 04/29/24 revealed Resident #65 was found with an open area on her coccyx and two areas on the left buttocks, one measuring 1.0 centimeters (cm) long by 1.0 cm wide and the other measuring 0.5 cm long by 0.5 cm wide. Review of a wound care physician progress note dated 05/01/24 revealed Resident #65 was found with two stage three pressure ulcers (full-thickness skin loss) to her left buttock. One of the pressure ulcers measured 0.4 cm long by 0.3 cm wide by 0.1 cm deep with moderate serous exudate and 40 percent (%) granulation tissue The other pressure ulcer measured 1.0 cm long by 0.5 cm wide by 0.1 cm deep with moderate serous exudate and 40% granulation tissue. Recommendations included the addition of a Group-2 mattress (non-powered pressure-reducing mattress), upgrade the offloading chair cushion, offload the wounds, and reposition per facility protocol. Review of a progress note dated 05/02/24 revealed Resident #65's wounds on her left buttock were assessed as stage three pressure ulcers and the area on her left buttock was moisture-associated skin damage (MASD). Further review revealed Resident #65 required a low-air-loss mattress and a cushion to her wheelchair to be supplied by hospice. Review of the physician orders for Resident #65 dated 05/04/24 revealed treatment orders for the left buttock to cleanse both wounds with normal saline, pat dry, apply hydrofera blue to the wound bed, cover with foam dressing, and change three times per week and as needed. Further review of physician orders revealed there were no orders for a specialty mattress or a cushion to Resident #65's wheelchair were entered at the time of review on 05/22/24. Review of the current care plan revealed Resident #65 was at risk for potential/actual skin impairment related to fragile skin. Interventions included monitoring and documenting location, size, and treatment of skin injury. Interview on 05/20/24 at 10:46 A.M. with Resident #65 revealed she had no concerns with her care and treatment and further stated her buttock wounds were healed. Observation of Resident #65's bed and wheelchair with Wound Care Licensed Practical Nurse (LPN) #372 revealed Resident #65 had a standard mattress and in her wheelchair was a folded bed blanket, white washcloths, and a thin pillow. There was no cushion observed in the chair. Interview with LPN #372 confirmed the special pressure-reducing mattress and gel cushion were not in place for Resident #65. Interview on 05/22/24 at 11:23 A.M. with Hospice Triage Nurse (HTN) #393 revealed hospice received communication from the facility on 05/03/24 requesting an alternating cushion for Resident #65's wheelchair. HTN #393 stated hospice was able to provide a wheelchair cushion but not an alternating one. HTN #393 further stated hospice did not provide a mattress for Resident #65, but had an order dated 05/03/24 for a gel cushion to be sent to the facility. Review of the policy titled, Coordination of Hospice ServicesBased on observation, record review, staff interview, hospice staff interview, and review of the facility policy, the facility failed to ensure communication and coordination of care occurred between the facility and the hospice provider. This affected one (#65) of one residents reviewed for hospice care. The facility census was 67.

Findings include:

Review of the medical record for Resident #65 revealed an admission date of 02/20/24 with diagnoses of severe protein-calorie malnutrition, anxiety, and depression. Further review revealed Resident #65 was admitted under the care of hospice.

Review of the admission Minimum Data Set (MDS) assessment completed 02/27/24 revealed Resident #65 had intact cognition. Resident #65 was not at risk for developing pressure injuries, no pressure injury was present on admission, and a pressure reducing mattress was in place.

Review of the quarterly Braden Scale for predicting pressure sore risk assessment dated 04/13/24 revealed Resident #65 was at risk for developing pressure sores.

Review of the skin observation tool completed on 04/25/24 revealed Resident #65's skin was intact.

Review of a progress note dated 04/29/24 revealed Resident #65 was found with an open area on her coccyx and two areas on the left buttocks, one measuring 1.0 centimeters (cm) long by 1.0 cm wide and the other measuring 0.5 cm long by 0.5 cm wide.

Review of a wound care physician progress note dated 05/01/24 revealed Resident #65 was found with two stage three pressure ulcers (full-thickness skin loss) to her left buttock. One of the pressure ulcers measured 0.4 cm long by 0.3 cm wide by 0.1 cm deep with moderate serous exudate and 40 percent (%) granulation tissue The other pressure ulcer measured 1.0 cm long by 0.5 cm wide by 0.1 cm deep with moderate serous exudate and 40% granulation tissue. Recommendations included the addition of a Group-2 mattress (non-powered pressure-reducing mattress), upgrade the offloading chair cushion, offload the wounds, and reposition per facility protocol.

Review of a progress note dated 05/02/24 revealed Resident #65's wounds on her left buttock were assessed as stage three pressure ulcers and the area on her left buttock was moisture-associated skin damage (MASD). Further review revealed Resident #65 required a low-air-loss mattress and a cushion to her wheelchair to be supplied by hospice.

Review of the physician orders for Resident #65 dated 05/04/24 revealed treatment orders for the left buttock to cleanse both wounds with normal saline, pat dry, apply hydrofera blue to the wound bed, cover with foam dressing, and change three times per week and as needed.

Further review of physician orders revealed there were no orders for a specialty mattress or a cushion to Resident #65's wheelchair were entered at the time of review on 05/22/24.

Review of the current care plan revealed Resident #65 was at risk for potential/actual skin impairment related to fragile skin. Interventions included monitoring and documenting location, size, and treatment of skin injury.

Interview on 05/20/24 at 10:46 A.M. with Resident #65 revealed she had no concerns with her care and treatment and further stated her buttock wounds were healed.

Observation of Resident #65's bed and wheelchair with Wound Care Licensed Practical Nurse (LPN) #372 revealed Resident #65 had a standard mattress and in her wheelchair was a folded bed blanket, white washcloths, and a thin pillow. There was no cushion observed in the chair. Interview with LPN #372 confirmed the special pressure-reducing mattress and gel cushion were not in place for Resident #65.

Interview on 05/22/24 at 11:23 A.M. with Hospice Triage Nurse (HTN) #393 revealed hospice received communication from the facility on 05/03/24 requesting an alternating cushion for Resident #65's wheelchair. HTN #393 stated hospice was able to provide a wheelchair cushion but not an alternating one. HTN #393 further stated hospice did not provide a mattress for Resident #65, but had an order dated 05/03/24 for a gel cushion to be sent to the facility.

Review of the policy titled, Coordination of Hospice Services

Based on review of previous survey results, medical record review, and staff interview, the facility failed to established an effective Quality Assessment and Assurance committee to identify quality deficiencies and take action to ensure these deficiencies were properly reviewed and acted upon. This had the potential to affect all 67 residents in the facility. The facility census was 67.

Findings include:

Review of the facility's previous survey results revealed the facility received a deficiency for failing to provide residents with the necessary assistance with activities of daily living (ADLs) during complaint surveys completed on 10/13/22, 02/14/23, 04/14/23, 09/06/23, 02/22/24, and 03/25/24.

Review of the medical records for four (#10, #19, #26, and #43) residents during the annual survey conducted 05/20/24 through 05/23/24 revealed the facility failed to provide timely and adequate assistance with ADLs which was confirmed through observation and interviews.

During an interview on 05/23/24 at 4:21 P.M., the Administrator verified the facility had received deficiencies for not providing necessary assistance with resident ADLs on numerous occasions since the previous annual survey.

Based on review of Quality Assessment and Assurance (QAA) committee sign-in sheets and staff interview, the facility failed to ensure all required members of the QAA committee attended meetings at least quarterly. This had the potential to affect all 67 residents residing in the facility. The facility census was 67.

Findings include:

Review of the QAA committee meeting sign-in sheets for 2023 revealed the Medical Director or designee did not attend any meetings for the second quarter between April and June 2023.

During an interview on 05/23/24 at 2:19 P.M., the Administrator verified there was no evidence the Medical Director or designee attended any QAA committee meetings in the second quarter between April and June 2023.

The state published no narrative for this citation.

Based on observation, resident and staff interview, record review, and review of the facility policy, the facility failed to ensure residents were safely transferred using a mechanical lift. This affected one (#17) of one resident reviewed for transfers. The facility census was 68.

Findings include:

Review of the medical record for Resident #17 revealed an admission date of 03/18/24 with diagnoses of hemiplegia and hemiparesis and history of stroke.

Review of the five-day Minimum Data Set (MDS) assessment dated 03/24/24 revealed Resident #17 had impaired cognition and was dependent on staff for bed-to-chair transfers.

Review of the current physician orders for Resident #17 revealed no orders for using a mechanical lift to transfer Resident #17.

Review of the current care plan revealed Resident #17 was totally dependent on one to two people for transfers. The care plan did not indicate how Resident #17 should be transferred.

Observation on 04/11/24 at 1:31 P.M. revealed Resident #17 sitting in a recliner chair and State Tested Nurse Aide (STNA) #101 entered Resident #17's room pushing a mechanical overhead lift into his room. Continuous observation on 04/11/24 between 1:31 P.M. and 1:37 P.M. revealed no additional staff entered Resident #17's room. At 1:37 P.M., Resident #17 was in bed, and STNA #101 was exiting the room with the mechanical overhead lift. Interview at that time with STNA #101 revealed she transferred Resident #17 from the chair to the bed using the mechanical lift by herself. STNA #101 stated she would need to check Resident #17's care plan to determine whether two staff were required to assist him during transfers. STNA #101 was unable to verify whether an overhead mechanical lift always required two staff during resident transfers.

Interview on 04/11/24 at 5:05 p.m. with Resident #17 stated he felt staff treated him well and he felt safe when staff transferred him with the mechanical lift.

Interview on 04/11/24 at 5:18 P.M. with the Administrator confirmed the facility's policy regarding transfers indicated two staff members must be used when transferring residents with a mechanical lift.

Subsequent interview on 04/11/24 at 6:19 P.M. with the Administrator, after a review with Unit Manager #301, confirmed Resident #17's medical record did not clarify the method by which Resident #17 should be transferred.

Review of the policy titled Safe Resident Handling/Transfers

Based on medical record review, observation, staff interview, resident interview, and review of facility policy, the facility failed to ensure the residents received timely incontinence care. This affected two (#13 and #14) of three residents observed for incontinence care. The facility census was 68.

Findings include:

1. Review of the medical record for Resident #13 revealed an admission date of 07/13/22. Diagnoses included chronic obstruction pulmonary disease, chronic kidney disease, and major depressive disorder.

Review of the Minimum Data Set (MDS) assessment dated 03/26/24 revealed Resident #13 was cognitively impaired and was dependent on staff for toilet hygiene and bathing and was incontinent of bowel and bladder.

Review of the care plan for Resident #13 revealed the resident had an activities of daily living performance deficit related to impaired balance, shortness of breath secondary to chronic obstructive pulmonary disease. Interventions included one staff assistant for bathing and toilet use, with transfers requiring the assistance of one to two staff.

Observation and interview on 04/11/24 at 9:45 A.M. of inconvenience care for Resident #13 performed by State Tested Nursing Assistant (STNA) #501 revealed Resident #13 had a saturated brief and when turning Resident #13 to clean and remove the soiled brief both the lift pad and the fitted sheet covering the mattress under the lift sheet were wet. Interview with STNA #501 at the time of the observation verified this was the first time STNA #501 had provided care to Resident #13 since starting the 6:30 A.M. shift. STNA #501 verified Resident #13 had a saturated brief and needed a total bed change due to the linens being soiled of urine.

Interview on 04/11/24 at 9:50 A.M. with Resident #15 revealed the last time staff had been in the room to assist with care was between 5:00 A.M. and 5:30 A.M.

2. Review of the medical record for Resident #14 revealed an admission date of 09/03/20. Diagnoses included neurocognitive disorder with Lewy bodies, epilepsy, anxiety disorder, major depressive disorder, bipolar disorder, chronic kidney disorder, and dementia.

Review of the quarterly Minimum Data Set (MDS) assessment dated 01/02/24 revealed Resident #14 was cognitively impaired and was dependent on staff for all activities of daily living and was incontinent of bowel and bladder.

Review of the care plan for Resident #14 revealed incontinence of bladder and bowel related to dementia, weakness, and impaired mobility. Interventions included the use of disposable briefs, check, and change frequently and as needed for incontinence with the perineum washed, rinsed, and dried and clothing changed as needed if soiled, moisture barrier to skin.

Observation of incontinence care on 04/11/24 at 9:58 A.M. for Resident #14 performed by State Tested Nursing Aide (STNA) #501 revealed a bulging brief with crystals present on the brief upon removing from the front of Resident #14.

Interview with STNA #501 at the time of the observation verified Resident #14 was heavy wetter and this was the first time STNA #501 had checked and changed Resident #14 since the beginning of the 6:30 A.M. shift.

Review of the undated facility policy titled Incontinence

Based on record review, staff and pharmacist interview, observation, review of the manufacturer instructions, and review of the facility policy, the facility failed to procure an insulin pen needle to properly administer insulin via an insulin pen to the resident according to manufacturer instructions. This affected two (#15 and #16) of two residents reviewed for insulin administration.

Findings include:

1. Review of the medical record for Resident #16 revealed an admission date of 10/14/22. Diagnosis included type II diabetes mellitus. Review of the physician order dated 02/22/24 revealed Resident #16 was to receive 45 units of insulin glargine (100 units per milliliter) subcutaneously once a day.

Observation on 04/11/24 from 9:23 A.M. to 9:37 A.M. of medication administration for Resident #16 revealed Licensed Practical Nurse (LPN) #502 removed an unopened glargine insulin pen from the medication refrigerator. LPN #502 dialed the insulin pen to 45, cleansed the tip of insulin pen with alcohol, picked up the insulin syringe from the top of the medication cart, picked up the insulin pen, stuck the insulin syringe into the tip of the insulin pen and withdrew the 45 units of insulin. At 9:37 A.M., LPN #502 took the insulin syringe and injected the insulin into Resident #16's right lower abdomen. LPN #502 did not utilize the insulin pen to administer insulin into Resident #16's abdomen.

Interview with LPN #502 immediately following the administration insulin to Resident #16 verified LPN #502 pulled the insulin out of the insulin pen with an insulin syringe due to the nurse not having a needle cap for the insulin pen.

2. Review of the medical record for Resident #15 revealed an admission date of 11/13/23. Diagnosis included type II diabetes mellitus. Review of a physician order for Resident #15 dated 02/12/24 revealed Fiasp (insulin) 100 units per milliliter was to be administered subcutaneously per sliding scale.

Observation on 04/11/24 at 11:14 A.M. revealed Licensed Practical Nurse (LPN) #201 was preparing to administer sliding scale coverage to Resident #15 for a blood sugar of 293. LPN #201 removed an insulin Fiasp pen and an insulin syringe from the medication cart for the 100-hall. LPN #201 picked up the insulin syringe and stuck the needle of the syringe into the tip of the insulin pen and withdrew six units of insulin. LPN #201 took the insulin syringe and injected the insulin into Resident #15's left thigh. LPN #201 did not utilize the insulin pen to administer insulin into Resident #15's thigh.

Interview with LPN #201 at the time of the observation revealed the facility did not have insulin needle caps for the insulin pens and insulin has been withdrawn from the insulin syringes for about a week.

Interview on 04/11/24 at 11:36 A.M. with the Consulting Pharmacist #510 revealed no knowledge of the facility using insulin syringes to withdrawal insulin from pens. Consulting Pharmacist #510 stated a needle cap should be attached to the insulin pen to ensure the proper dose of insulin administration.

Review of the undated facility policy titled Timely Administration of Insulin

Based on observations, staff interviews, review of product information, and review of the facility policy, the facility failed to ensure food was cooked to the proper temperature before serving to residents. This affected all residents in the facility except 14 residents identified by the facility who did not consume the fish ( #13, #17, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, and #30). The facility census was 68.

Findings include:

Observation of meal service on 04/15/24 at 11:24 A.M. with Dietary Manager (DM) #300 revealed she prepared baked fish sticks for the noon meal. DM #300 checked the temperature of the fish sticks and determined they were 151 degrees Fahrenheit (F). Interview on 04/15/24 at 11:32 A.M. with DM #300 revealed the fish sticks should be 160 degrees F and confirmed they only reached 151 degrees F. DM #300 progressed with meal service and did not reheat the fish sticks.

Observation during dining on 04/15/24 between 11:30 A.M. and 12:30 P.M. revealed residents in the dining room consumed fish sticks and voiced no concerns.

Interview on 04/15/24 at 3:17 P.M. with Registered Dietitian #515 confirmed the fish sticks should have been cooked to 165 degrees F.

Review of the product information for the fish sticks revealed they should be cooked to an internal temperature of 165 degrees F.

Review of the policy titled Food Safety Requirements

Based on observation, resident interview, staff interview, and review of Resident Council meeting minutes, the facility failed to ensure resident call lights were answered in a timely manner. This affected one (Resident #05) of one resident reviewed for call lights. The facility census was 67.

Findings include:

Review of Resident #05's medical record revealed the resident was admitted to the facility on 10/04/21. Diagnoses included heart failure, asthma, weakness, and hypertension.

Review of Resident #05's quarterly Minimum Data Set 3.0 assessment dated 01/12/24 revealed the resident was assessed as cognitively intact and dependent on staff assistance for showering/bathing and personal hygiene. No behaviors were noted within the assessment.

Observation on 03/25/24 from 10:29 A.M. to 10:58 A.M. revealed Resident #05's call light had been activated for at least 29 minutes. At 10:58 A.M., State Tested Nurse Aide (STNA) #156 entered Resident #05's room and stated they would retrieve supplies to assist Resident #05 in getting washed up for the day. Resident #05 reactivated his call light prior to 11:13 A.M., as STNA #156 had not yet returned to the resident's room. STNA #156 returned to the resident's room at 11:24 A.M. with the necessary supplies.

Interview with Resident #05 at the time of observation revealed Resident #05 had spoken with STNA #156 on 03/25/24 at approximately 6:45 A.M. and STNA #156 was going to assist Resident #05 in getting washed up for the day after breakfast, which took place at 7:30 A.M. After waiting for a couple of hours, Resident #05 activated his call light and had since been waiting for a response. Resident #05 reported STNA #156 took fantastic care of him, but that staffing and call light response time was an issue.

Interview on 03/25/24 at 11:56 A.M. with STNA #156 verified Resident #05's call light had been activated for a prolonged period of time and the resident had been waiting for assistance to get washed up since after breakfast. STNA #156 reported the facility was short-staffed, and the staff member was unable to assist the resident in a timely manner.

Review of Resident Council meeting minutes dated 03/19/24 revealed a concern of call light response time was noted.

This deficiency was an incidental finding discovered during the course of this complaint investigation.

Based on record review, resident interview, staff interview, and review of facility policy, the facility failed to ensure residents received assistance with bathing as scheduled. This affected one (Resident #05) of three residents reviewed for activities of daily living. The facility census was 67.

Findings include:

Review of Resident #05's medical record revealed the resident was admitted to the facility on 10/04/21. Diagnoses included heart failure, asthma, weakness, and hypertension.

Review of Resident #05's quarterly Minimum Data Set 3.0 assessment dated 01/12/24 revealed the resident was assessed as cognitively intact and dependent on staff assistance for showering/bathing and personal hygiene. No behaviors were noted within the assessment.

Review of Resident #05's plan of care revised 08/23/23, revealed the resident had an activities of daily living self-care performance deficit related to activity intolerance, fatigue, limited mobility, shortness of breath, and weakness. Interventions included the resident required extensive assistance of between one and two staff with bathing/showering twice weekly and as necessary.

Review of Resident #05's bathing task documentation revealed the resident was scheduled for bathing on Wednesdays and Saturdays during the day shift. Review of the bathing documentation from 03/09/24 through 03/24/24 revealed the resident did not receive assistance on three of five scheduled days (03/09/24, 03/13/24, and 03/23/24). The medical record contained no evidence the resident was offered or refused assistance with bathing on these dates.

Interview on 03/25/24 at 10:29 A.M. with Resident #05 revealed the resident often did not receive assistance with bathing as scheduled and/or requested. The resident reported receiving assistance bathing as scheduled on 03/20/24 and reported requesting and not receiving assistance bathing on 03/23/24.

An interview on 03/25/24 at 5:19 P.M. with the Administrator and Director of Nursing verified there was no evidence Resident #05 was offered, refused, or received assistance bathing on 03/09/24, 03/13/24, and 03/23/24.

Review of the facility policy titled, Resident Showers

Based on observation, record review, and staff interview, the facility failed to ensure residents received baths and/or showers as scheduled. This affected two (Residents #3 and #19) of five sampled residents reviewed activities of daily living. The census was 65.

Findings include:

1. Record review revealed Resident #3 was admitted to the facility on 11/27/22 with diagnoses including, generalized arthritis, chronic obstructive pulmonary disease, cerebral infarction, hemiplegia affecting right side, morbid obesity, anxiety disorder, major depression, bipolar disorder, and fibromyalgia.

Review of the Minimum Data Set (MDS) assessment, dated 12/05/23, documented Resident #3 was cognitively intact. Resident #3 required supervision or touching assist with activities of daily living and was incontinent of bowel and bladder.

Review of the plan of care dated 04/12/23 revealed Resident #3 had an activity of daily living (ADL) self-care performance deficit related to disease process, and additional ADL assistance related to diagnosis of hemiplegia. Interventions include to provide showers two times a week and as necessary.

Review of bathing task documentation revealed Resident #3 scheduled for bathing/shower on Tuesday and Friday during day shift. Review of the bathing documentation from 01/23/24 and 02/21/24 noted one shower provided on 01/26/24 at 2:29 P.M. No further showers were documented to be provided and no documentation contained in the medical record indicated the resident refused.

On 02/21/24 at 11:32 A.M. interview with the Administrator during a review of the medical record and shower documentation confirmed showers were not given as scheduled and refusals were not followed up with additional opportunities.

2. Resident #19 admitted to the facility on 11/07/23 with the diagnosis including, dislocated cervical vertebrae, spondylolisthesis, transient ischemic attack, coronary artery disease, second degree burn of head, face and neck, pressure ulcer stage 3 sacral region, Parkinson disease, chronic obstructive pulmonary disease, chronic viral hepatitis c, human immunodeficiency virus, dysphagia, hypertension, schizoaffective disorder bipolar type, and major depression.

Review of Resident #19 medical record census noted he was hospitalized between 02/02/24 and 02/06/24.

On 02/06/24 Resident #19 was readmitted to the facility from the hospital and a nursing readmission assessment assessed Resident #19 to require staff assistance with activities of daily living and utilize a wheelchair for mobility. According to brief interview for mental status assessment dated 02/14/24 Resident #19 was assessed with moderately impaired cognition.

On 11/15/23 a nursing plan of care was implemented to address Resident #19 activity of daily living (ADL) self-care performance deficit related to Impaired balance. Interventions included the following, provide resident preferred dressing/grooming routine, check nail length and trim and clean on bath day and as necessary, use short, simple instructions such as hold your washcloth in your hand; Put soap on your washcloth; Wash your face; to promote independence.

Review of bathing task documentation noted Resident #2 scheduled for bathing/shower on Wednesday and Saturday during day shift. Review of the shower task documentation between 01/21/24 to 02/21/24 revealed eight opportunities (not including days of hospitalization) for showers. Three showers were documented as provided on 02/10/24 at 2:29 P.M. and 10:29 P.M., and 02/14/24 at 1:02 P.M. One shower on 02/21/24 at 11:25 A.M. was refused. No further documentation recorded Resident #19 received a shower as scheduled.

During an observation on 02/21/24 at 11:56 A.M., Resident #19 was in his room. His fingernails were extremely long, jagged, and curling under. Resident #19 stated he was not receiving bathing or grooming as scheduled and has not refused. The resident stated he prefers his fingernails to be trimmed.

According to fingernail trimming documentation Resident #19 fingernails were trimmed on 02/10/24 at 10:29 P.M. Resident #19 stated his fingernails had not been trimmed since admission to the facility.

On 02/21/24 at 1:05 P.M. interview with the Director of Nursing (DON) confirmed the lack of documentation indicating shower and bathing completed as scheduled for Resident #2, #3, #19. The DON also verified lack of fingernail grooming for Resident #19.

This deficiency represents non-compliance investigated under Complaint Number OH00151078.

Based on observation, record review and interview, the facility failed to ensure corridor floor tile was maintained free of damage, debris, heavy stains and extensive tracking. This affected 62 residents residing in the north and south nursing units, excluding three residents (#20, #21, #22) residing in the dementia unit. Facility census 65.

Findings include:

On 02/21/24 at 5:45 A.M. observation of facility floor conditions were as follows;

1. The north hall between administrator office and north nurses station discovered heavily worn floor tiles with wax residue removed from surface and wax build-up residue in doorway thresholds. Floor tiles were identified with black stains and scattered paper debris, including two extinguished cigarettes. Interview with State Tested Nurse Aide (STNA) #300 at 5:50 A.M. verified and stated a resident had discarded them after coming inside from smoking.

2. The north halls between the nurses station and exit door near room 110 Flooring and flooring tiles from the cross corridor doors next to the north lounge leading to exit door near room 211 were heavily soiled tiles with wax finish heavily worn and black staining throughout the corridor. Heavy debris and existing wax buildup was observed on floor tiles in resident room entry door thresholds and Multiple articles of paper and random debris materials were scattered on the floors throughout the corridors.

3. Outside administrator office and near room 306, floor tiles were broken exposing concrete sub flooring surrounding metal drain cover.

4. Next to north lounge at the cross corridor door, flooring tile was missing with exposed concrete sub flooring. The concrete sub flooring was also worn away leaving a hole or divot in the floor.

5. Observation in north unit lounge discovered nine floor tiles located under television with a black substance.

6. Located behind north nurses station discovered a missing area of broken floor tile measuring approximately 10 inches by five inches exposing concrete sub flooring.

7. Observation of the south unit corridors noted heavy excess floor wax residue appearing black and brown in color built up along base boards and entry door thresholds.

Review of Facility floor waxing maintenance documentation revealed no evidence indicating when the north nursing unit had been stripped, cleaned or waxed.

On 02/21/24 at 7:20 A.M. interview with the administrator during observation confirmed the compromised condition of the flooring tiles and debris.

On 02/22/24 between 6:10 A.M. and 6:35 A.M. tour of facility with Environmental Director (ED) #1 confirmed flooring conditions. ED #1 stated there was no documentation to provide indicating when the corridor floors on the North unit were last deep cleaned or waxed.

This is an incidental deficiency discovered during the course of this complaint investigation.

Based on medical record review, observation, resident interview and staff interview, and review of facility policy, the facility failed to ensure residents were provided assistance with nail care and shaving. This affected one (#14) of three residents reviewed for activities of daily living. The facility census was 57.

Findings include:

Review of Resident #14's medical record revealed an admission date of 02/13/23. Diagnoses included anemia, moderate protein-calorie malnutrition, alcoholic cirrhosis of liver with ascites, atrial fibrillation, viral hepatitis B, benign prostatic hyperplasia, hypertension, chronic obstructive pulmonary disease (COPD), and osteoarthritis.

Review of the annual Minimum Data Set (MDS) assessment dated 07/29/23 revealed Resident #14 was severely cognitively impaired and required extensive assistance with dressing, toilet use, and personal hygiene. Additionally, Resident #14 had no refusals of care.

Review of a plan of care focus area, revised on 02/21/23, revealed Resident #14 had an activities of daily living (ADLs) self-care performance deficit related to disease process. Interventions included the resident required staff assistance with bathing/showering two times weekly, was dependent for dressing, required extensive staff assistance for toileting, and required staff assist to maximize independence for personal hygiene.

Review of state tested nurse aide (STNA) task documentation from 08/07/23 through 09/05/23 revealed Resident #14 required limited to total dependence for personal hygiene.

Observation on 09/05/23 at 9:30 A.M. of Resident #14 revealed the resident had long fingernails, with debris under the nails, and was unshaven. Concurrent interview with Resident #14 revealed he complained to staff about his fingernails, but had not received assistance with trimming them. In addition, Resident #14 stated he preferred to be clean shaven, but the staff did not do shave him.

Interview on 09/05/23 at 10:27 A.M. with Registered Nurse (RN) #136 verified Resident #14 had long fingernails, with debris under the nails, and was unshaven. RN #136 stated nail care and shaving should be offered on shower days but residents have the right to refuse care. RN #136 was unaware of Resident #14 refusing care.

Interview on 09/05/23 at 1:50 P.M. with STNA #168 revealed Resident #14 did not refuse care and required assistance with nail care and shaving. STNA #168 stated she just returned from vacation and she was unsure why Resident #14 had not received nail care or assistance with shaving.

Review of an undated facility policy titled, Activities of Daily Living

Based on observation, staff interview, and review of a facility policy, the facility failed to ensure residents utilized non-combustible containers to extinguish smoking materials. This had the potential to affect 18 (#1, #4, #6, #7, #11, #15, #16, #20, #26, #29, #30, #35, #36, #38, #42, #48, #55, and #56) residents identified by the facility as residents who smoke. The facility census was 57.

Findings include:

Observation on 09/05/23 at 10:44 A.M., revealed the designated resident smoking area was located on a covered patio in a courtyard area outside the dining room. Further observation of the smoking area revealed two uncovered metal buckets, two plastic flower pots, and a small plastic garbage can containing cigarette butts. Continued observation revealed Resident #7 dropped a lit cigarette butt onto the ground. Additionally, nine cigarette butts were observed laying under the bushes next to the smoking patio.

Observation and interview on 09/05/23 at 2:47 P.M., with the Administrator verified the cigarette butts laying around the bushes on the smoking patio, and verified the plastic garbage can, the two uncovered metal buckets, and two plastic flower pots containing multiple cigarette butts. The Administrator pointed out there were two fire safe receptacles for cigarette butts, but noted the residents were using one as a table for a radio. The Administrator stated appropriate fire safe containers were available but residents continued to use unapproved containers.

Review of a facility policy titled, Smoking Policy/Procedure

Based on observation, staff interview, and review of a kitchen cleaning schedule, the facility failed to maintain the kitchen in a clean and sanitary manner. This had the potential to affect all 57 residents identified by the facility as receiving food from the kitchen. The facility census was 57.

Findings include:

Observation on 09/05/23 at 8:30 A.M. of the kitchen revealed a black substance on the ceiling over the dishwasher, on the walls to the left and right of the dishwasher, and on the wall over the single sink in the dish room.

Observation and interview on 09/05/23 at 8:40 A.M. with Dietary Manager (DM) #110 confirmed the black substance on the walls and the ceiling in the kitchen dish room and stated she believed it to be mildew. DM #110 explained the exhaust system over the dishwasher did not work, resulting in moisture being contained in the areas. While dietary staff turned on the exhaust system in the main kitchen area, DM #110 stated it was not helpful in the dish room. DM #110 stated the facility had someone come out and clean the dish room walls and ceiling a couple of months ago, but the cause of the mildew had not been addressed.

Interview on 09/05/23 at 12:53 P.M. with the Administrator revealed she had the dish room walls professionally cleaned a couple of months ago. The Administrator was unaware the mildew concern was still present, and stated she was unaware the exhaust system over the dishwasher did not work.

Follow-up interview on 09/06/23 at 10:23 A.M. with the Administrator revealed DM #110 added to spray and wipe areas of mold or mildew to the monthly and weekly cleaning schedule as of today.

Review of an undated Monthly/Weekly Kitchen Cleaning Schedule revealed the schedule did not address the cleaning of soiled walls or ceilings.

This deficiency represents non-compliance investigated under Complaint Number OH00144911.

Based on observation, resident and staff interview, review of pest control services reports, and review of a facility policy, the facility failed to maintain an effective pest control program. This had the potential to affect all 57 residents of the facility. The facility census was 57.

Findings include:

Observation on 09/05/23 at 8:30 A.M. of the kitchen revealed several gnats flying around the kitchen.

Observation and interview on 09/05/23 at 8:40 A.M. with Dietary Manager (DM) #110 verified the gnats in the kitchen and stated she did not know why the facility could not get rid of them.

Random observations on 09/05/23 from 8:45 A.M. through 8:50 A.M. revealed gnats in the facility hallways, bathrooms, and resident rooms.

Interview on 09/05/23 at 8:51 A.M. with Unit Manager (UM) #155 verified the gnats in the facility. UM #155 stated they kept coming up with different ways to catch them, but it was not working. UM #155 stated the gnats were all over, not just at the facility, but all over.

Interview and observation on 09/05/23 at 9:14 A.M. with Resident #56 revealed the resident was sitting on the side of her bed. Interview with Resident #56 stated she saw flying bugs in the facility, and stated there was a flying bug flying near her at the time of the interview. Observation at that time revealed what appeared to be a gnat flying around Resident #56's head.

Observation on 09/05/23 at 1:35 P.M. of the television room, located near the dining room, revealed several gnats flying in the room. Interview with Resident #21 during the observation stated there were gnats everywhere in the facility and the facility needed to do something about them.

Interview on 09/06/23 at 8:55 A.M. with Maintenance Director (MD) #130 confirmed the facility had an issue with gnats. MD #130 stated the facility received routine pest control services monthly and gnats was something they had been working on, noting the product provided to him by the pest control company was ineffective. MD #130 stated the facility had a new chemical supplier as of last week, and MD #130 spoke with a sales representative yesterday and ordered a new product to use to treat for gnats. MD #130 stated most of the calls he received were related to gnats.

Review of a pest control service report dated 07/24/23 revealed the facility was provided with a one gallon size chemical for treatment of gnats.

Review of a pest control service report dated 08/11/23 revealed no service provided to address gnats in the facility.

Review of an undated facility policy titled, Pest Control Program

Based on medical record review, resident and staff interview and review of the facility policy, the facility failed to ensure residents had daily weights taken and recorded as physician ordered. This affected one (Resident #21) of three residents reviewed for weights. The facility census was 60.

Findings include:

Review of Resident #21's medical record revealed an admission date of 05/18/23. Diagnoses included congestive heart failure, mild protein calorie malnutrition, and dementia.

Review of the admission Minimum Data Set (MDS) assessment dated 05/25/23 revealed Resident #21 was moderately cognitively impaired. Resident #21 was totally dependent on staff for bed mobility and transfers. Resident #21 displayed no behaviors during the review period. Resident #21 had no significant weight changes during the review period.

Review of Resident #21's physician orders revealed an order dated 05/25/23 for daily weights every day shift related to congestive heart failure.

Review of Resident #21's weights from 05/25/23 to 06/12/23 revealed Resident #21's weight was not documented as being completed on 05/26/23, 05/27/23, 05/29/23, 06/04/23, 06/05/23, 06/07/23, 06/09/23, 06/10/23 or 06/11/23. Resident #21 was not weighed nine times out of 19 opportunities.

Interview on 06/13/23 at 2:33 P.M. with State Tested Nursing Assistant (STNA) #374 revealed Resident #21 was able to make her needs known and was cooperative with care. STNA #374 reported Resident #21 was to have her weight taken every day.

Interview on 06/13/23 at 2:38 P.M. with Resident #21 found her to be alert and aware. Resident #21 reported she was not getting weighed every day.

Interview on 06/13/23 at 2:54 P.M. with the Director of Nursing (DON) verified Resident #21's weights were not documented daily as physician ordered. The DON reported she was unable to find any refusals for the missing days.

Review of the facility policy titled Weight Monitoring

Based on record review and interview, the facility failed to ensure the pharmacy supplied all the resident's medications in a timely manner upon admission. This affected one (Resident #3) of six residents reviewed for medications. The facility census was 67.

Findings include:

Record review revealed Resident #3 was admitted to the facility on 03/11/23, readmitted on 04/06/23 and discharged on 04/13/23. Diagnoses for Resident #3 included acute kidney failure, altered mental status, pain in hip, obesity, asthma, migraines, and chronic pain syndrome.

Review of the comprehensive Minimum Data Set (MDS) assessment, dated 04/05/23, revealed the resident had intact cognition and required the assistance of one person for activities of daily living.

Review of Resident #3's Medication Administration Record (MAR) dated March 2023 revealed the resident was ordered to receive Hydrocodone-Acetaminophen 5/325 milligrams (mg) one tablet every four hours as needed for left hip pain to start on 03/11/23 at 2:30 P.M. The MAR indicated the resident's first dose of pain medication was not administered until two days later on 03/13/23 at 5:21 A.M. Resident #3 had a documented pain level of eight out of 10, 10 being the highest pain.

Review of the resident's MAR for March 2023 revealed the resident was to receive Clonazepam (Klonopin) 0.5 mg two times a day for anxiety for 15 days starting on 03/11/23 at 9:00 P.M. Per the MAR, the first dose was not received until one day later on 03/12/23 at 9:00 P.M.

During interview on 05/18/23 at 9:20 A.M., Resident #3 revealed the resident stated she was to receive her pain medications on a schedule to prevent break through pain every four hours. Resident #3 stated she was told when she arrived at the facility her medications would be filled, and she would be receiving her medications per order. Resident #3 stated she was comfortable the first day she was in the facility but stated her pain was still controlled from the medications she had received at the hospital prior to admission to the facility. Resident #3 denied any issues with completing her ADLs while waiting for her pain medications and her Klonopin. Resident #3 stated on the second day she was at the facility when she asked for her medications she again was told her medications were not filled by the pharmacy and she would have to wait. Resident #3 stated she was uncomfortable by this time and was getting anxious but continued to wait until her medications were available. On day three, she finally demanded her pain and anxiety medications and was told again her medications were not filled by pharmacy but the nurse could get them from either another patient or the emergency box and she received her first dose of Klonopin and Hydrocodone. The resident denied any further missed doses.

During an interview on 05/18/23 at 11:33 A.M., the Director of Nursing (DON) verified the missed doses of medications in the MAR for the Hydrocodone and the Klonopin. The DON verified both of the medications were in the emergency supply and could have been administered per physician order to the resident at the time they were ordered. The DON stated the pharmacy did not supply the correct pain and anti-anxiety medications for Resident #3 in a timely manner.

This deficiency represents non-compliance investigated under Complaint Number OH00142286.

Based on medical record review, resident and staff interview, and policy review, revealed the facility failed to complete residents showers in a timely manner. This affected two (#38 and #75) of three residents reviewed for bathing. The census was 68.

Findings include:

1. Review of Resident #38's medical record revealed an admission date of 03/13/22. Diagnoses included cerebral vascular accident, hemiplegia and hemiparesis, dysphasia, nicotine dependence, mental and behavior disorders, congestive heart failure.

Review of Resident #38's quarterly Minimum Data Set (MDS) dated 01/25/23 revealed the resident was assessed with intact cognition and required an extensive assistance with transfers and personal hygiene.

Review of Resident #38's most recent care plan revealed the resident had an activity of daily living deficiency and self-care performance deficit related to an impaired balance and stroke. Resident #38 required an assistance by one staff with bathing and showering twice weekly and as necessary.

Review of Resident #38's shower schedule revealed he was to be provided a showered every Tuesday and Friday on day shift.

Review of Resident #38's shower documentation for the previous 30 days revealed the resident received a shower or bed bath on 03/14/23, 03/31/23, and 04/11/23. The resident's electronic medical record was documented as not applicable on 03/23/23, 03/26/23, 04/01/23, 04/02/23, 04/06/23, and 04/08/23. Resident #38 refused a shower on 03/17/23, 03/21/23, 03/24/23, 04/04/23, and 04/07/23.

Review of Resident #38's progress notes dated 03/13/23 through 04/12/23 revealed the only mention of bathing refusals were documented on 04/04/23 and 04/06/23.

2. Review of Resident #75's medical record revealed an admission date of 11/12/17 with diagnoses of cerebral infarction, hemiplegia and hemiparesis, chronic obstructive pulmonary disease, chronic kidney disease, dementia, congestive heart failure, and hydrocephalus.

Review of Resident #75's quarterly MDS dated 01/13/23 revealed the resident had an intact cognition. He required extensive assistance for bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing.

Review of Resident #75 most recent care plan revealed he had a self-care deficit and required assistance with activities of daily living and mobility. The resident required a two person assist for all care. He was to be encouraged to shower twice weekly and as needed.

Review of Resident #75's medical record revealed he was to be provided a shower every Monday and Thursday on day shift.

Review of Resident #75's shower documentation for the previous 30 days revealed he was given a bed bath or shower on 03/16/23, 03/20/23, 03/27/23, 03/30/23, 04/06/23, 04/10/23. He refused on 04/01/23. The resident's electronic medical record was documented as not applicable on 03/23/23, 03/26/23, 04/06/23, and 04/08/23. No documentation was provided for bathing on 03/23/23 and 04/03/23.

Review of Resident #75's progress notes dated 03/13/23 through 04/12/23 revealed there was no mention of missing or refusal of showers.

Interview with Resident #75 on 04/12/23 at 2:10 P.M. stated he would like to receive more baths and showers than were offered to him. He stated he used to bath daily at home.

Interview with the Director of Nursing (DON) on 04/12/23 at 2:17 P.M. verified Resident #38 and Resident #75 were not bathed per their care plan and bathing schedule. The DON stated the nursing staff were not to used not applicable when charting showers and there was to be a progress note regarding any missing showers or refusals.

Review of the facility shower instruction sheet revealed showers must be completed as charted. A shower sheet must be completed and staff should inform the nurse of any new skin issues. If a resident refused a shower, staff should notify the nurse and have them attempt to get the resident to agree to the shower. If the resident still refused then the nurse and the state tested nurse aide (STNA) both must document the refusal. Changes to the shower schedule are only to be made by a unit manager, assistant director of nursing, or DON.

Review of the facility policy titled, Resident Showers

Based on observation, resident and staff interview, and medical record review, the facility failed to ensure interventions were implemented to prevent further decline in mobility and related range of motion. This affected one (#2) of three residents reviewed for mobility and range of motion maintenance. The census was 70.

Findings include:

Review of Resident #2's medical record revealed and admission dated of 02/23/21. Diagnoses included muscle wasting and atrophy, morbid obesity, congestive heart failure, acute and chronic respiratory failure with hypoxia, lymphedema, atrial fibrillation, state three chronic kidney disease, major depression, metabolic encephalopathy, hypertension, epilepsy, and urinary retention.

Review of the Minimum Data Set (MDS) assessment dated 01/02/23 revealed Resident #2 was assessed with moderately impaired cognition, was dependent on staff for the completion of activities of daily living, required the extensive physical assistance of two staff for transfer and physical assistance of one staff for bed mobility, and utilized a wheelchair for mobility.

Review of Resident #2's nursing plan of care developed on 03/09/21 to address activities of daily living (ADL) self-care performance deficit revealed interventions to include extensive assistance by two staff members to turn and reposition in bed every two hours and as necessary, extensive assistance by one staff member for dressing, extensive assistance by one staff member with personal hygiene and oral care, and extensive assistance by one or two staff members for toileting. Further review of the interventions revealed Resident #2 required dependent assistance by two staff members to move between surfaces as necessary with a mechanical lift for transfers. Staff were to encourage Resident #2 to participate to the fullest extent possible with each interaction and physical therapy or occupational therapy would evaluate and treat per physician orders.

Review of a physical therapy (PT) discharge summary dated 07/27/22 revealed services provided to Resident #2 between 06/01/22 and 07/27/22. The PT goal included the resident will safely ambulate on level surfaces using parallel bars with stand by assistance with continuous steps and with even step length 95 percent (%) of the time to facilitate increased participation in functional activity. Prior to the onset of therapy, Resident #2 ambulated 25 feet 85% of the time, and on discharge of 07/27/22, Resident #2 ambulated five feet 80% of the time. PT discharge recommendations included continuation of safety deficits and measures in order to restore mobility to prior level of function. There were no interventions or instructions provided to staff or Resident #2 to prevent further decline or promote the resident's mobility or range of motion.

Review of PT evaluation and plan of treatment documentation dated 12/21/22 revealed Resident #2 diagnoses description as muscle wasting and atrophy. Resident #2 was referred to PT services secondary to dizziness. Resident #2's lower extremity bearing status was weight bearing as tolerated. Resident #2 was also referred due to decrease in independence with functional mobility tasks, warranting PT service to increase independence and restore mobility to prior level of function. Resident #2's most recent prior PT services were on 06/01/22. The clinical impression noted the PT evaluation for dizziness was completed, and due to body habitus (physical build), Resident #2 was unable to tolerate it. There was a recommendation for a medication review due to new onset of dizziness with medical change. There was no additional documentation contained in the medical record to include the additional delivery of treatment to address Resident #2's mobility or range of motion.

Review of Resident #2's medical record electronic task tracking documentation between 02/21/23 and 03/21/23 revealed the resident walked in the corridor with one person physical assist eleven times. Further review of the documentation revealed Resident #2 walking in the corridor was documented as not applicable 27 times during the same time frame. According to documentation on how Resident #2 walked in the corridor task tracking revealed Resident #2 walked with total dependence twice, extensive assistance six times, limited assistance twice, and supervision once during the same time frame.

On 03/22/23 at 7:57 A.M., Resident #2 was observed in bed with a wheelchair located at the foot of the bed. State Tested Nurse Aide (STNA) #201 was observed to provide Resident #2 with assistance repositioning in bed and related incontinence care. Resident #2 was alert and actively participating.

Interview on 03/22/23 at 9:15 A.M., with Resident #2 confirmed receiving therapy in late December 2022 and experienced dizziness; however, had not received therapy, range of motion, or strengthening exercises since that time.

Interview on 03/22/23 at 9:17 A.M., with STNA #201 confirmed being assigned to Resident #2's for daily care. STNA #201 verified no instruction or interventions were available or provided to direct staff regarding the delivery of Resident #2's specific exercises, range of motion, or mobility.

Interview on n 03/22/23 at 10:05 A.M. with Rehabilitation Director (RD) #1, during a review of Resident #2's most current physical therapy evaluation dated 12/21/22, confirmed the resident was experiencing dizziness and therapy recommendations were for Resident #2 to have a medication review due to new onset of dizziness with medical change. There was no further therapy provided since 12/21/22. Further interview with RD #1 confirmed no specific maintenance exercises, range of motion, mobility instruction, or interventions to promote Resident #2's strengthening were established or recommended.

Interview on 03/22/23 at 1:15 P.M. with the Director of Nursing (DON) and Regional Registered Nurse #1, during a review of Resident #2's medical record, verified no current interventions were contained in the medical record promoting Resident #2 maintenance of mobility or range of motion. The DON indicated the resident's task documentation regarding walking in the corridor was marked in error and no attempts had been initiated to ambulate Resident #2 since the 12/21/22 PT evaluation.

This deficiency represents non-compliance investigated under Complaint Number OH00140821.

Based on observation, resident and staff interview, and policy review, the facility failed to ensure call lights were accessible to residents. This affected three residents (#35, #46, and #52) out of three residents reviewed for call lights. The facility census was 65.

Findings include:

Observation on 01/31/23 at 9:08 A.M. to 9:15 A.M. revealed Resident #52's call light was hooked to the blanket at the foot of the bed and out of reach of the resident. Resident #46's call light was observed in a pop can box on the nightstand out of reach of the resident.

Interview on 01/31/23 at 9:14 A.M., with Licensed Practical Nurse (LPN) #255 verified Resident #46 and #52's call lights were out of reach.

Observation and interview on 01/31/23 at approximately 9:18 P.M. of Resident #35's call light revealed the call light was hooked to a sheet at the head of the bed out of reach. Resident #35 verified she was unable to reach her call light.

Interview on 01/31/23 at 9:21 A.M., with the State Tested Nursing Assistant (STNA) #212 verified Resident #35's call light was out of reach.

Review of the policy titled Call Lights: Accessibility and Timely Response, revised October 2022 revealed staff will ensure the call light is within reach of the resident and secure as needed.

This deficiency represents non-compliance investigated under Complaint Number OH00139250.

This is an example of continued non-compliance from the survey dated 12/13/22.

Based on medical record review and staff interview, the facility failed to ensure baseline care plans included necessary care for each resident. This affected two residents (#72 and #73) out of four residents reviewed for baseline care plans. The facility census was 65.

Findings include:

1. Review of the medical record for Resident #72 revealed an admission date of 12/24/22 and a discharge date of 01/04/23. Diagnoses included COVID-19, depression, chronic kidney disease, and pressure ulcers of the right buttock and sacral region.

Review of Resident #72's Minimum Data Set (MDS) dated 12/29/22 revealed Resident #72 was severely cognitively impaired. The resident was totally dependent on staff for bed mobility, transfer, and bathing. Resident #72 required extensive assistance with dressing and personal hygiene. Resident #72 had an indwelling catheter and was always incontinent of bowels and displayed no behaviors during the review period.

Review of the baseline care plan for Resident #72 revealed no plan was initiated for wounds.

2. Review of the medical record for the Resident #73 revealed an admission date of 11/23/22 and a discharge date of 12/24/22. Diagnoses included multiple sclerosis, colostomy status and COVID-19.

Review of the baseline care plan dated 11/23/22 revealed no care plan for Resident #73's ileostomy.

Review of Resident #73's MDS dated 11/30/22 revealed Resident #73 was cognitively intact. The resident was totally dependent on staff for transfer, dressing, toilet use, personal hygiene and bathing. Resident #73 required extensive assistance with eating. Resident #73 had an indwelling catheter and ostomy. She was noted to be occasionally incontinent of urine and always incontinent of bowel. Resident #73 displayed no behaviors during the review period.

Interview on 02/01/23 at 2:31 P.M., with the Director of Nursing (DON) verified Resident #72 had no care plan for pressure wounds and Resident #73 had no care plan for her ileostomy. The DON verified both residents had the issues upon admission and should have been included in baseline care plan.

This deficiency represents non-compliance investigated under Complaint Number OH00139087.

Based on medical record review and staff interview, the facility failed to ensure the comprehensive care plan included resident specific care needs. This affected one resident (#73) out of three residents reviewed for comprehensive care plans. The facility census was 65.

Findings include:

Review of the medical record for the Resident #73 revealed an admission date of 11/23/22 and a discharge date of 12/24/22. Diagnoses included multiple sclerosis, colostomy status and COVID-19.

Review of the baseline care plan dated 11/23/22 revealed no care plan for Resident #73's ileostomy.

Review of Resident #73's MDS dated 11/30/22 revealed Resident #73 was cognitively intact. The resident was totally dependent on staff for transfer, dressing, toilet use, personal hygiene and bathing. Resident #73 required extensive assistance with eating. Resident #73 had an indwelling catheter and ostomy. She was noted to be occasionally incontinent of urine and always incontinent of bowel. Resident #73 displayed no behaviors during the review period.

Review of the comprehensive care plan revealed Resident #73 had no plan for her ileostomy.

Interview on 02/01/23 at 2:31 P.M., with the Director of Nursing (DON) verified Resident #73 had no care plan for her ileostomy.

This deficiency represents non-compliance investigated under Complaint Number OH00138975.

Based on medical record review, observation, resident and staff interview, and policy review, the facility failed to ensure residents who required staff assistant were provided timely incontinence care and personal hygiene. This affected one resident (#20) out of three residents reviewed for incontinence care. The facility census was 65.

Findings include:

Review of the medical record revealed Resident #20 was admitted on 11/22/21. Diagnosis included quadriplegia, type two diabetes mellitus without complications, dysphagia, neuromuscular dysfunction of bladder, hyperlipidemia, hypertension, and muscle wasting and atrophy.

Review of the Minimum Data Set (MDS) assessment dated 01/20/23 revealed the resident was moderately cognitively impaired. Resident #20 required extensive two person assistance for bed mobility and transfers and extensive one person assistance for toilet use and dressing. Resident #20 had an indwelling catheter and was always incontinent of bowel.

Review of the care plan dated 12/08/22 revealed Resident #20 had bowel incontinence due to decreased mobility and required extensive assistance by one to two staff with toilet use.

Observation and interview on 01/30/23 at 10:04 A.M. Resident #20 was in bed without clothing with an incontinence pad under the brief. The incontinence pad appeared to be saturated in liquid stool. Resident #20 stated he was waiting for a shower.

Observation and interview on 01/30/23 at 11:23 A.M. revealed State Tested Nursing Assistant (STNA) #275 entered Resident #20's room. The STNA #275 verified Resident #20 had diarrhea earlier that morning and last received incontinence care between 7:00 and 7:30 A.M. that morning. The STNA #275 verified the incontinence pad was soiled in stool and stated she was assisting Resident #20 to the shower at this time.

Review of the facility policy titled Activities of Daily Living, dated 2022 revealed residents who are unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Review of the facility policy titled Incontinence Care, dated 2022 revealed based on the resident's comprehensive assessment, all residents that are incontinent will receive appropriate treatment and services. Residents that are incontinent of bladder or bowel will receive appropriate treatment to prevent infections and to restore continence to the extent possible.

This deficiency represents non-compliance investigated under Complaint Number OH00139660.

Based on medical record review, staff interview, review of the hospital discharge and referral records, and policy review, the facility failed to ensure treatments were completed per physician orders. This affected four residents (#72, #70, #16, and #09) out of four reviewed for wounds. In addition the facility failed to ensure wound assessments were completed upon admission. This affected one resident (#72) out of four residents reviewed for wounds. The facility census was 65. Findings include: 1. Review of the medical record for Resident #72 revealed an admission date of 12/24/22 and a discharge date of 01/04/23. Diagnoses included COVID-19, depression, chronic kidney disease, and pressure ulcers of the right buttock and sacral region. Review of the baseline care plan revealed pressure ulcers were not initiated for Resident #72. Review of Resident #72's Minimum Data Set (MDS) dated 12/29/22 revealed Resident #72 was severely cognitively impaired. Resident #72 was totally dependent on staff for bed mobility, transfer, and bathing. The resident required extensive assistance with dressing and personal hygiene. Resident #72 had an indwelling catheter and was always incontinent of bowels. Review of Resident #72's nurses notes dated 12/24/22 at 4:44 PM revealed the resident was admitted due to atrial fibrillation, kidney disease stage four, diabetes, hypertension, congestive heart failure, amputation right below knee. The resident was alert and oriented to self only. Was a Full Code. Had no known allergies. The resident required two-person extensive assistance with rolling and transfers. Needed assistance with meals. The resident had a wound on the coccyx, scrotum scabs, a left lower leg/thigh skin tear. The resident was living at home with grandchildren but was found uncared for and soiled by Emergency Medical Service (EMS). Review of the nursing admission dated 12/24/22 for Resident #72 revealed a pressure wound to the coccyx with no measurements or description of the wound. The resident had wounds to the right hip, the right lateral thigh, and the sacrum with no measurements or type of wound and no description. Review of the physician orders dated December 2022 revealed treatment orders dated 12/29/22 for Resident #72 to cleanse the coccyx with normal saline, pat dry, apply triad past, cover with bordered foam to change every other day and as needed. The right distal thigh leave open to air. The right hip and the right lateral leg, cleanse with normal saline, pat dry, apply adaptic, cover with border foam every Monday, Wednesday, and Friday (M-W-F) and as needed. The Right posterior thigh cleanse with normal saline, pat dry, apply acetic acid five percent wet to moist gauze, cover with abdominal pad (ABD) and medi fix tape to change daily and as needed. Apply triad hydrophilic wound dress paste to scrotum every shift. Review of the Treatment Administration Record (TAR) dated January 2023 for Resident #72 revealed treatments not completed on 01/01/23 day shift to scrotum, and right posterior thigh. Review of the discharge instructions from hospital revealed Resident #72 had a pressure injury to coccyx first assessed on 12/14/22, a pressure injury to the right lower back assessed on 12/14/22, a pressure injury posterior leg/proximal right upper assessed on 12/14/22, a wound to right upper posterior distal leg assessed on 12/14/22, and a pressure injury to the scrotum assessed on 12/14/22. Wound orders included coccyx border foam to be changed M-W-F, right hip and right lateral leg adaptic, foam M-W-F. Review of the hospital referral note for Resident #72 revealed right posterior thigh ulcer had progressed as expected to necrosis. Necrosis is firmly adherent, non-boggy, no pain demonstration on palpation. No purulence. No odor. Drainage is serosanguineous, scant amount. Surrounding areas are with lightly adherent yellow slough and hyper granular tissue. The coccyx area with what appeared to be a ruptured bullae, non-necrotic without surrounding erythema edema or induration, no purulence. Scrotum very edematous with open area anteriorly with yellow slough and distally with red viable tissue. Does have scattered scabs. Also has skin breakdown extending towards perineum. Review of the weekly wound evaluation for Resident #72 dated 12/29/22 revealed a coccyx deep tissue injury with slough and necrotic tissue visible. The wound measured 14.2 centimeters in length by 12.2 centimeters in width by 0.1 centimeters in depth. Orders for triad cream and foam daily. Review of the weekly wound evaluation for Resident #72 dated 12/30/22 revealed right proximal thigh acquired on 12/24/22 had necrotic tissue present, blue/green drainage, measured nine centimeters in length, 20 centimeters in width, and 0.2 centimeters in depth. Peri-wound tissue red. Wound edges well defined. Interview on 01/31/23 at 1:58 P.M., with the Director of Nursing (DON) verified treatments were not documented on 01/01/23 for Resident #72. The DON verified no measurements or description of Resident #72's wounds were obtained on admission. The DON said nursing staff were to measure and evaluate wounds on admission. The DON stated the nurse who completed the admission assessment was no longer employed at the facility due to progressively not signing off on medications and treatments. 2. Review of the medical record for Resident #09 revealed an admission date of 05/27/21. Diagnoses included hemiplegia and hemiparesis, history of COVID-19, dysphagia, major depressive disorder, mild protein malnutrition, and displaced fracture of the left ulna. Review of Resident #09's MDS dated 01/07/23 revealed Resident #9 was moderately cognitively impaired. The resident required extensive assistance with bed mobility transfer, dressing, toilet use and personal hygiene. Review of the TAR dated January 2023 for Resident #09 revealed a treatment to the left lateral ankle cleanse with normal saline, pat dry, apply skin prep to the peri-wound, apply santyl (debridement agent) to the wound bed and cover with border gauze daily was not completed on day shift on 01/11/23, 01/12/23 and 01/23/23. Review of the wound note dated 01/30/23 revealed the wound to the left lateral ankle is improving. Interview on 01/31/23 at 1:58 P.M., with the DON verified treatments were not documented on 01/11/23, 01/12/23, and 01/23/23 for Resident #09. 3. Review of the medical record for Resident #70 revealed an admission date of 08/23/22 and a discharge date of 01/23/23. Diagnoses included muscle wasting, memory deficit, hemiplegia and hemiparesis, fracture of neck of the left femur, chronic ulcer of left ankle, fracture of thoracic T11-T12 vertebra, vulva cancer, major depressive disorder, anxiety disorder, and epilepsy. Review of Resident #70's MDS dated 01/05/23 revealed #70 was moderately cognitively impaired. The resident required extensive assistance with bed mobility, toilet use and personal hygiene. Resident #70 required limited assistance with eating and was totally dependent on staff for transfer. Review of the TAR for Resident #70 dated December 2022 revealed irrigate left lateral ankle with normal saline, apply mupirocin two percent ointment, cover with abdominal (ABD) padding then wrap with dry gauze roll daily was not completed day shift on 12/27/22 and 12/29/22. Further review of the TAR for Resident #70 dated December 2022 revealed a left femur surgical incision cleanse, pat dry, dry dressing daily was not completed on day shift 12/27/22 and 12/29/22 and mupirocin calcium ointment two percent to the left ankle topically every day shift was not completed on 12/27/22 and 12/29/22. Review of the Physician Progress note dated 01/11/23 revealed the left ankle wound healed with no signs of infection. Interview on 01/31/23 at 1:58 P.M. with the DON verified treatments were not documented on 12/27/22 and 12/29/22 for Resident #70. 4. Review of the medical record for Resident #16 revealed and admission date of 07/13/22. Diagnoses included chronic obstructive pulmonary disease, pressure ulcer of left buttock unstageable, pressure ulcer of the sacral region unstageable, panic disorder, major depressive disorder, schizoaffective disorder bipolar type, and retention of urine. Review of Resident #16's MDS dated 01/23/23 revealed the resident was cognitively intact. Resident #16 required extensive assist of one for bed mobility, dressing, and personal hygiene. Resident #16 required total dependence of two for transfers. The resident required total dependence of one for toilet use and bathing. Resident #16 required supervision of one for locomotion in wheelchair and eating. Resident #16 had two unstageable pressure ulcers due to coverage of the wound bed by slough and/or eschar. Review of the wound care note dated 01/23/23 revealed the wounds to the sacrum and the ischium were stable. Review of the TAR for Resident #16 dated January 2023 revealed a sacral pressure ulcer treatment included cleanse with normal saline, pat dry, apply acetic acid 0.25 percent wet to moist dressing, cover with dry dressing twice daily was not completed on day shift 01/01/23 and 01/03/23 and on night shift on 01/02/23. Further review of the TAR for Resident #16 dated January 2023 revealed a treatment to the left ischium to cleanse with normal saline, pat dry, apply hydrofera blue rope for tunneling, cover with bordered gauze three times daily was not completed at 6:00 A.M. on 01/14/23, 01/15/23, 01/22/23, 2:00 P.M. on 01/15/23, 01/22/23, and 01/26/23, 10:00 P.M. on 01/22/23. Interview on 01/31/23 at 1:58 P.M., with the DON verified treatments were not documented at 6:00 A.M. on 01/14/23, 01/15/23, and 01/22/23 for ischium. The treatments were not documented at 2:00 P.M. on 01/15/23, 01/22/23, and 01/26/23 for ischium. The treatment to the ischium was not documented on 01/22/23 at 10:00 P.M., and the treatment was not documented for the sacral pressure ulcer on day shift on 01/01/23 and 01/03/23 and night shift on 01/02/23. Review of facility policy titled Pressure Injury Prevention and ManagementBased on medical record review, staff interview, review of the hospital discharge and referral records, and policy review, the facility failed to ensure treatments were completed per physician orders. This affected four residents (#72, #70, #16, and #09) out of four reviewed for wounds. In addition the facility failed to ensure wound assessments were completed upon admission. This affected one resident (#72) out of four residents reviewed for wounds. The facility census was 65.

Findings include:

1. Review of the medical record for Resident #72 revealed an admission date of 12/24/22 and a discharge date of 01/04/23. Diagnoses included COVID-19, depression, chronic kidney disease, and pressure ulcers of the right buttock and sacral region.

Review of the baseline care plan revealed pressure ulcers were not initiated for Resident #72.

Review of Resident #72's Minimum Data Set (MDS) dated 12/29/22 revealed Resident #72 was severely cognitively impaired. Resident #72 was totally dependent on staff for bed mobility, transfer, and bathing. The resident required extensive assistance with dressing and personal hygiene. Resident #72 had an indwelling catheter and was always incontinent of bowels.

Review of Resident #72's nurses notes dated 12/24/22 at 4:44 PM revealed the resident was admitted due to atrial fibrillation, kidney disease stage four, diabetes, hypertension, congestive heart failure, amputation right below knee. The resident was alert and oriented to self only. Was a Full Code. Had no known allergies. The resident required two-person extensive assistance with rolling and transfers. Needed assistance with meals. The resident had a wound on the coccyx, scrotum scabs, a left lower leg/thigh skin tear. The resident was living at home with grandchildren but was found uncared for and soiled by Emergency Medical Service (EMS).

Review of the nursing admission dated 12/24/22 for Resident #72 revealed a pressure wound to the coccyx with no measurements or description of the wound. The resident had wounds to the right hip, the right lateral thigh, and the sacrum with no measurements or type of wound and no description.

Review of the physician orders dated December 2022 revealed treatment orders dated 12/29/22 for Resident #72 to cleanse the coccyx with normal saline, pat dry, apply triad past, cover with bordered foam to change every other day and as needed. The right distal thigh leave open to air. The right hip and the right lateral leg, cleanse with normal saline, pat dry, apply adaptic, cover with border foam every Monday, Wednesday, and Friday (M-W-F) and as needed. The Right posterior thigh cleanse with normal saline, pat dry, apply acetic acid five percent wet to moist gauze, cover with abdominal pad (ABD) and medi fix tape to change daily and as needed. Apply triad hydrophilic wound dress paste to scrotum every shift.

Review of the Treatment Administration Record (TAR) dated January 2023 for Resident #72 revealed treatments not completed on 01/01/23 day shift to scrotum, and right posterior thigh.

Review of the discharge instructions from hospital revealed Resident #72 had a pressure injury to coccyx first assessed on 12/14/22, a pressure injury to the right lower back assessed on 12/14/22, a pressure injury posterior leg/proximal right upper assessed on 12/14/22, a wound to right upper posterior distal leg assessed on 12/14/22, and a pressure injury to the scrotum assessed on 12/14/22. Wound orders included coccyx border foam to be changed M-W-F, right hip and right lateral leg adaptic, foam M-W-F.

Review of the hospital referral note for Resident #72 revealed right posterior thigh ulcer had progressed as expected to necrosis. Necrosis is firmly adherent, non-boggy, no pain demonstration on palpation. No purulence. No odor. Drainage is serosanguineous, scant amount. Surrounding areas are with lightly adherent yellow slough and hyper granular tissue. The coccyx area with what appeared to be a ruptured bullae, non-necrotic without surrounding erythema edema or induration, no purulence. Scrotum very edematous with open area anteriorly with yellow slough and distally with red viable tissue. Does have scattered scabs. Also has skin breakdown extending towards perineum.

Review of the weekly wound evaluation for Resident #72 dated 12/29/22 revealed a coccyx deep tissue injury with slough and necrotic tissue visible. The wound measured 14.2 centimeters in length by 12.2 centimeters in width by 0.1 centimeters in depth. Orders for triad cream and foam daily.

Review of the weekly wound evaluation for Resident #72 dated 12/30/22 revealed right proximal thigh acquired on 12/24/22 had necrotic tissue present, blue/green drainage, measured nine centimeters in length, 20 centimeters in width, and 0.2 centimeters in depth. Peri-wound tissue red. Wound edges well defined.

Interview on 01/31/23 at 1:58 P.M., with the Director of Nursing (DON) verified treatments were not documented on 01/01/23 for Resident #72. The DON verified no measurements or description of Resident #72's wounds were obtained on admission. The DON said nursing staff were to measure and evaluate wounds on admission. The DON stated the nurse who completed the admission assessment was no longer employed at the facility due to progressively not signing off on medications and treatments.

2. Review of the medical record for Resident #09 revealed an admission date of 05/27/21. Diagnoses included hemiplegia and hemiparesis, history of COVID-19, dysphagia, major depressive disorder, mild protein malnutrition, and displaced fracture of the left ulna.

Review of Resident #09's MDS dated 01/07/23 revealed Resident #9 was moderately cognitively impaired. The resident required extensive assistance with bed mobility transfer, dressing, toilet use and personal hygiene.

Review of the TAR dated January 2023 for Resident #09 revealed a treatment to the left lateral ankle cleanse with normal saline, pat dry, apply skin prep to the peri-wound, apply santyl (debridement agent) to the wound bed and cover with border gauze daily was not completed on day shift on 01/11/23, 01/12/23 and 01/23/23.

Review of the wound note dated 01/30/23 revealed the wound to the left lateral ankle is improving.

Interview on 01/31/23 at 1:58 P.M., with the DON verified treatments were not documented on 01/11/23, 01/12/23, and 01/23/23 for Resident #09.

3. Review of the medical record for Resident #70 revealed an admission date of 08/23/22 and a discharge date of 01/23/23. Diagnoses included muscle wasting, memory deficit, hemiplegia and hemiparesis, fracture of neck of the left femur, chronic ulcer of left ankle, fracture of thoracic T11-T12 vertebra, vulva cancer, major depressive disorder, anxiety disorder, and epilepsy.

Review of Resident #70's MDS dated 01/05/23 revealed #70 was moderately cognitively impaired. The resident required extensive assistance with bed mobility, toilet use and personal hygiene. Resident #70 required limited assistance with eating and was totally dependent on staff for transfer.

Review of the TAR for Resident #70 dated December 2022 revealed irrigate left lateral ankle with normal saline, apply mupirocin two percent ointment, cover with abdominal (ABD) padding then wrap with dry gauze roll daily was not completed day shift on 12/27/22 and 12/29/22.

Further review of the TAR for Resident #70 dated December 2022 revealed a left femur surgical incision cleanse, pat dry, dry dressing daily was not completed on day shift 12/27/22 and 12/29/22 and mupirocin calcium ointment two percent to the left ankle topically every day shift was not completed on 12/27/22 and 12/29/22.

Review of the Physician Progress note dated 01/11/23 revealed the left ankle wound healed with no signs of infection.

Interview on 01/31/23 at 1:58 P.M. with the DON verified treatments were not documented on 12/27/22 and 12/29/22 for Resident #70.

4. Review of the medical record for Resident #16 revealed and admission date of 07/13/22. Diagnoses included chronic obstructive pulmonary disease, pressure ulcer of left buttock unstageable, pressure ulcer of the sacral region unstageable, panic disorder, major depressive disorder, schizoaffective disorder bipolar type, and retention of urine.

Review of Resident #16's MDS dated 01/23/23 revealed the resident was cognitively intact. Resident #16 required extensive assist of one for bed mobility, dressing, and personal hygiene. Resident #16 required total dependence of two for transfers. The resident required total dependence of one for toilet use and bathing. Resident #16 required supervision of one for locomotion in wheelchair and eating. Resident #16 had two unstageable pressure ulcers due to coverage of the wound bed by slough and/or eschar.

Review of the wound care note dated 01/23/23 revealed the wounds to the sacrum and the ischium were stable.

Review of the TAR for Resident #16 dated January 2023 revealed a sacral pressure ulcer treatment included cleanse with normal saline, pat dry, apply acetic acid 0.25 percent wet to moist dressing, cover with dry dressing twice daily was not completed on day shift 01/01/23 and 01/03/23 and on night shift on 01/02/23.

Further review of the TAR for Resident #16 dated January 2023 revealed a treatment to the left ischium to cleanse with normal saline, pat dry, apply hydrofera blue rope for tunneling, cover with bordered gauze three times daily was not completed at 6:00 A.M. on 01/14/23, 01/15/23, 01/22/23, 2:00 P.M. on 01/15/23, 01/22/23, and 01/26/23, 10:00 P.M. on 01/22/23.

Interview on 01/31/23 at 1:58 P.M., with the DON verified treatments were not documented at 6:00 A.M. on 01/14/23, 01/15/23, and 01/22/23 for ischium. The treatments were not documented at 2:00 P.M. on 01/15/23, 01/22/23, and 01/26/23 for ischium. The treatment to the ischium was not documented on 01/22/23 at 10:00 P.M., and the treatment was not documented for the sacral pressure ulcer on day shift on 01/01/23 and 01/03/23 and night shift on 01/02/23.

Review of facility policy titled Pressure Injury Prevention and Management

Based on medical record review, staff and family interview, review of the hospital documentation, and policy review, the facility failed to ensure care was provided to prevent an avoidable fall with injury and was thoroughly investigated to determine the root cause analysis to identify potential hazards to reduce and/or eliminate falls with major injury. This resulted in Actual Harm when State Tested Nursing Assistant (STNA) #245 rolled Resident #70 away from her during care and the resident held onto the nightstand next to the bed. Subsequently, the night stand moved and Resident #70 shifted, fell onto the floor, and had complaints of hip and back pain. Resident #70 was sent to the hospital four days later after having continued pain with a left femoral neck fracture and a Thoracic (T)12 compression fracture which required surgical intervention. This affected one (#70) out of three residents reviewed for falls. The facility census was 65.

Findings include:

Review of the medical record revealed Resident #70 was admitted to the facility on 08/23/22 and discharged on 01/23/23. Diagnoses included muscle wasting and atrophy, hemiplegia and hemiparesis following cerebrovascular disease, muscle weakness, fracture of part of the neck of the left femur, fracture of the thoracic (T)11 and T12 vertebra, fracture of the lower end of the left femur, cerebral infarction, and wedge compression fracture of the thoracic vertebra.

Review of the minimum data set (MDS) assessment dated 10/05/22, prior to the fall with injury, revealed Resident #70 had moderate impaired cognition, required two-person extensive assistance for bed mobility and transfers. The resident required one-person extensive assistance for personal hygiene, toilet use, and dressing.

Review of the plan of care dated 08/23/22 revealed Resident #70 had a plan in place for falls due to deconditioning and gait/balance problems. Interventions included grab bars to both sides of the bed, updated 11/22/22, educate resident to be careful when assisting with activities of daily living, anticipate and meet the resident needs, follow the facility protocol, evaluate, and treat the resident needs. A plan dated 09/14/22 revealed Resident #70 was totally dependent on one staff for repositioning and turning in bed, set up assistance for personal hygiene, and totally dependent on one staff for dressing.

Review of the physician orders dated from November 2022 through discharge date 01/23/23 revealed Resident #70 had a low air loss mattress and there were no orders documented for assist/grab bars for both sides of the bed.

Review of the fall documentation dated 11/22/22 revealed State Tested Nursing Assistant (STNA) stated Resident #70 was turned onto the right side as she was changing the bed sheets on the other side, the resident stated she was going to fall and the STNA helped the resident to the floor as she started to fall slowly out of the bed. Licensed Practical Nurse (LPN) #219 was at the nurse's station at the time of the incident. A head-to-toe assessment was initiated, and no bruising, bleeding, or abrasions were noted at the time. Only a small superficial tear to the right knee was noted. Resident #70 rated pain a 10 out of 10 with 10 being the worst pain and Tylenol was due again in one hour. Resident #70 had vital signs assessed, the physician and the resident representative were notified and were to monitor the resident. The Interdisciplinary team (IDT) met regarding Resident #70's fall with injury. The root cause analysis was completed showing compliance with care. An intervention of bilateral side rails during patient care was implemented. Intervention in place would prevent the resident from pushing off furniture and allowing resident to participate in positioning with care. Resident #70 was a part of the intervention decision.

Review of the pain evaluation dated 11/22/22 at 1:30 P.M. revealed Resident #70 complained of pain rated at a 10 to the right hip and the right knee.

Review of the hospital documentation dated 11/26/22 revealed Resident #70 presented to the Emergency Room (ER) from the nursing facility with complaint of hip and back pain after a fall in the facility two days ago. Resident #70 reported limited short-term memory and does not recall the initial time of the injury. The nursing facility reported radiological exams obtained at their facility due to complaints of pain with findings of a left femoral neck fracture and a T12 compression fracture. Imaging has been completed at the hospital with confirmation of an impacted left femoral neck fracture on the computerized tomography (CT) scan of the left hip and a T12 wedging and compression fracture as well as a small retro pulsed fragment into the spinal canal superiorly at T12 but without canal stenosis or evidence of cord compression visualized on the thoracic spine CT.

Interview on 01/30/23 at 2:43 P.M. with STNA #245 verified she was familiar with Resident #70 and had regularly provided care for the resident. STNA #245 verified she had provided care for the resident the date she had a fall with injury. STNA #245 reported she was the only aide in the room and was providing incontinence care to Resident #70. STNA #245 stated the resident was rolled to the right side with the left leg hanging over the right leg. The nightstand was against the bed and Resident #70 used her hands on the nightstand to support herself. STNA #245 stated the resident appeared stable and not at risk of falling. The aide left the side of the bed to bag the brief and believes the resident then shifted applying pressure to the nightstand causing it to move and Resident #70 fell out of the bed. STNA #245 stated she was in the room when it occurred but could not reach the resident in time. STNA #245 called for help and an additional aide and nurse came to assist and they used a mechanical lift to transfer Resident #70 from the floor back to the bed.

Telephone interview on 01/31/23 at 9:18 A.M. with Resident #70's family representative revealed she believed the facility dropped the resident in November 2022 although the facility reported to her, Resident #70 had inched out of the bed on her own.

During an interview on 02/14/23 at 10:37 A.M. with the Director of Nursing (DON) she stated STNA #245 was not doing anything improper during care for Resident #70 at the time of her fall. The DON stated no corrective action was taken and education was provided to STNA #245. The DON stated she had STNA #245 show her in the resident's room after the resident went to hospital what happened during the fall.

Follow up interview on 02/14/23 at 11:12 A.M. with the DON, after requesting the root cause analysis, she stated she had not kept her root cause analysis; therefore, it could not be provided.

Follow up interview on 02/14/23 at 11:16 A.M. with STNA #245 revealed Resident #70's bed was mid-way in the air up to her waist and she had an air mattress. She rolled the resident away from her and onto her right side with her left leg over her right. STNA #245 said the nightstand slowed her fall; however, the resident was heavy set, so the resident hit the ground with some force. STNA #245 said Resident #70 had used the nightstand before to hold onto and the resident did not have a side rail on the right side at the time of the incident. STNA #245 said the trash bag was on the end of the bed and she just turned to place the linens in the bag when the fall occurred. After the nurse came in and assessed the resident she had complained of pain in her hip and back.

During a follow up interview on 02/14/23 at 1:55 P.M. the DON said the Quality Assurance and Performance Improvement (QAPI) will discuss falls/falls with injury in the February QAPI. The DON stated she used her incident logs as auditing tools for falls. She verified nursing should turn residents towards them, not away from them while providing care. The DON stated she verbally educated STNA #245 after the fall and was unable to produce any written education for the staff regarding falls. No specific information related to Resident #70's fall after it had been requested was provided.

Review of the policy titled Fall Risk Assessment, undated revealed it is the policy of this facility to provide an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents.

This deficiency represents noncompliance in Complaint Number OH00139660.

Based on medical record review, observation, staff interview, policy review, and review of Center for Disease Control and Prevention (CDC) guidelines, the facility failed to ensure COVID-19 positive residents were isolated for the required timeframe and facility staff wore personal protective equipment properly during a COVID-19 outbreak in the facility. This had the potential to affect 16 residents (#04, #05, #06, #07, #08, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, and #20) who resided on the hall and were not positive for COVID-19. The facility census was 65.

Findings Include:

1. Review of the medical record revealed Resident #09 was admitted on 07/31/21. Diagnoses included hemiplegia and hemiparesis, history of COVID-19, dysphagia, major depressive disorder, mild protein malnutrition, and displaced fracture of left ulna.

Review of Resident #09's Minimum Data Set (MDS) dated 01/07/23 revealed Resident #09 was moderately cognitively impaired.

Review of the physician order dated 01/18/23 revealed an order for Resident #09 to maintain standard and transmission based-precautions (TBP) due to positive for COVID-19 every day and night shift for ten days. The order was dated to end on 01/28/23.

Review of the physician order dated 01/25/23 revealed a discontinued physician order for Resident #09's standard and TBP due to COVID-19 with the reason for discontinuation documented as resident tested for covid, results negative.

Interview on 02/01/23 at approximately 12:00 P.M., with the Director of Nursing (DON) verified Resident #09 tested positive for COVID-19 on 01/18/23 and verified the order to discontinue isolation early. The DON verified Resident #09 should have remained on TBP for a full ten days.

2. Observation and interview on 01/25/23 at 8:50 A.M. of Licensed Practical Nurse (LPN) #547 passing medications on the 100 hallway. The LPN #547 had an N95 mask on her neck under her chin and not covering her mouth or her nose. The LPN #547 verified she was not wearing her N95 properly. She stated she had just returned to work from having COVID and wearing the N95 over her mouth and nose made it hard for her to breath. LPN #547 verified staff were to wear N95 respirators and eye protection in all areas of the facility.

Interview on 01/25/23 at 8:55 A.M., with the Administrator and the DON verified the facility was in outbreak status and all staff were required to wear N95 respirators and eye protection regardless of having recently having had COVID or not.

Review of the facility policy titled Coronavirus (COVID-19) Prevention and Management

Based on record review, interview, self-reported incident review, and policy review the facility failed to timely report allegation of abuse. This affected two (Resident #23 and Resident #74) of four residents reviewed for abuse. The facility census was 71.

Findings include:

Review of Medical Record for Resident #23 revealed admission date 08/23/22 with diagnoses including but not limited to major depressive disorder, schizophrenia, anxiety disorder, and unspecified psychosis not due to a substance or known physiological condition.

Review of Minimum Data Set (MDS) for Resident #23 dated 12/05/22 revealed resident was cognitively intact. Resident required extensive assist of one for bed mobility, transfers, dressing, toileting, personal hygiene, and bathing. Supervision for meals.

Review of Care Plan for Resident #23 revision on 12/12/22 revealed resident is/has potential to be physically aggressive (hit another resident) related to history of harm to others. Interventions included but not limited to administer medications as ordered, analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document, anticipate resident ' s needs: food, thirst, toileting needs, comfort levels, body positioning, assess and address for contributing sensory deficits, give the resident as many choices as possible about care and activities.

Further review of Care Plan dated 12/09/22 for Resident #23 revealed resident has behavior problem (stealing money from staff and residents, continues to ask for money and attempts to go to the store and was educated on unsafe practices but continued to repeat same behavior). Will often refuse to wear his splint to his left hand/wrist. Interventions included but not limited to anticipate and meet resident ' s needs, explain all procedures to the resident before starting and allow resident to adjust to changes if reasonable, discuss resident ' s behavior, explain/reinforce why behavior is inappropriate and/or unacceptable to the resident.

Review of Nurses Note for Resident #23 dated 12/11/22 at 6:59 P.M. revealed dietary came to nurse and said two residents were fighting in the smoking area. Writer went to smoking area to see what was happening. Residents were no longer fighting. Writer assessed resident who was hit. Writer asked what happened. Director of Nursing was notified. Family was notified. Resident is alert and oriented and is not in any pain. Residents are separated and are in separate rooms. Resident in bed comfortable with call light in reach.

Review of Medical Record for Resident #74 revealed admission of 06/17/22 with diagnoses including but not limited to major depressive disorder, bipolar disorder, and schizoaffective disorder.

Review of MDS for Resident #74 dated 10/26/22 revealed resident was cognitively intact. Resident required limited assist of one for bed mobility, transfers, eating, and personal hygiene. Extensive assist of one for toileting and dressing. Supervision for locomotion on and off the unit.

Review of Care Plan for Resident #74 revision on 12/12/22 revealed resident is/has potential to be physically aggressive (punch another resident) related to history of harm to others. Interventions included but not limited to anticipate resident ' s needs: food, thirst, toileting needs, comfort level, body positioning, assess and address contributing deficits, communication, provide physical and verbal cues to alleviate anxiety, give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out staff member when agitated, and give resident as many choices as possible about care and activities.

Review of Self-Reported Incident (SRI) revealed date of discovery as 12/11/22 at 3:15 P.M. and SRI was submitted on 12/12/22.

Interview on 12/20/22 at 3:50 P.M. with Administrator verified SRI was submitted after the two hours as required per facility policy.

Review of policy titled Abuse, Neglect, and Exploitation revised October 2022 revealed reporting of all alleged violations to the administrator, state agency, adult protective services and to all other required agencies within specified timeframe's: immediately, but not more than two hours after the allegation is made, if the events that cause the allegation involve abuse, or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

This deficiency represents non-compliance investigated under Complaint Number OH00138521.

Based on observation, staff and resident interviews, and policy review, the facility failed to ensure call lights were within reach of the residents. This affected six residents (#37, #43, #52, #72, #86, and #96) of six residents reviewed for call lights. The facility census was 73. Findings include: Observation on 12/12/22 from 10:20 A.M. to 11:00 A.M. revealed call lights were lying on the floor in Resident #86, #96, #37, and #43's room and were out of reach of the resident. Resident #52 and #72's call lights were observed draped over the nightstand facing away from the residents. Resident #86, #96, #37, #43, #52, and #72 were all lying in their respective beds and were unable to reach their call light. Interview on 12/12/22 at 10:28 A.M. with State Tested Nursing Assistant (STNA) #525 verified the call lights on the floor for Resident #86, #96, and #37. STNA #525 verified Resident #86, #96, and #37 could not reach their call lights. Interview on 12/12/22 at 10:40 A.M. with Resident #72 stated she could not reach her call light. Interview on 12/12/22 at 10:59 A.M. with the Director of Nursing (DON) verified the call lights were out of reach for Resident #72, #52, and #43. Interview on 12/13/22 at 3:09 P.M. with the Administrator verified the facility did not have any residents who could not utilize a call light. Review of the policy titled Call Lights: Accessibility and Timely ResponseBased on observation, staff and resident interviews, and policy review, the facility failed to ensure call lights were within reach of the residents. This affected six residents (#37, #43, #52, #72, #86, and #96) of six residents reviewed for call lights. The facility census was 73.

Findings include:

Observation on 12/12/22 from 10:20 A.M. to 11:00 A.M. revealed call lights were lying on the floor in Resident #86, #96, #37, and #43's room and were out of reach of the resident. Resident #52 and #72's call lights were observed draped over the nightstand facing away from the residents. Resident #86, #96, #37, #43, #52, and #72 were all lying in their respective beds and were unable to reach their call light.

Interview on 12/12/22 at 10:28 A.M. with State Tested Nursing Assistant (STNA) #525 verified the call lights on the floor for Resident #86, #96, and #37. STNA #525 verified Resident #86, #96, and #37 could not reach their call lights.

Interview on 12/12/22 at 10:40 A.M. with Resident #72 stated she could not reach her call light.

Interview on 12/12/22 at 10:59 A.M. with the Director of Nursing (DON) verified the call lights were out of reach for Resident #72, #52, and #43.

Interview on 12/13/22 at 3:09 P.M. with the Administrator verified the facility did not have any residents who could not utilize a call light.

Review of the policy titled Call Lights: Accessibility and Timely Response

Based on staff interview, record review, and review of the facility's abuse policy, the facility failed to implement their abuse policy for investigating incidents of alleged abuse. This affected two residents (#29 and #53) of six reviewed for abuse. The facility census was 72. Findings include: 1. Review of the medical record for the Resident #29 revealed an admission date of 02/28/22 and medical diagnoses of type 2 diabetes, schizoaffective disorder, and legal blindness. Review of the quarterly minimum data set (MDS) dated 08/04/22 revealed Resident #29 had intact cognition and required extensive assistance of one person for transfers, bed mobility, dressing, toileting, and hygiene, and supervision with setup help only for eating. Review of Resident #29's progress note dated 07/29/22 revealed she informed staff a nurse was very nasty to her and Resident #29 felt unsafe with her as her nurse. Interview on 10/12/22 at 4:28 P.M. with the Administrator revealed she recalled the allegation made by Resident #29, as noted in the progress note dated 07/29/22. Continued interview revealed the Administrator could provide no evidence an investigation was completed. She further confirmed no self reported incident (SRI) was created. 2. Review of the medical record for the Resident #53 revealed an admission date of 06/14/22. Diagnoses included dorsalgia, chronic pain, conversion disorder with seizures or convulsions. Review of the quarterly MDS assessment for Resident #53, dated 07/02/22, revealed Resident #53 had impaired cognition and was totally dependent on two people for bed mobility, totally dependent on one person for toileting, required extensive assistance of two people for transfers, dressing, and required extensive assistance of one person for eating. Review of a progress note dated 08/01/22 for Resident #53 revealed the resident informed staff the morning nurse aide handled her very roughly. Further review revealed the administrative team would be notified. Interview on 10/11/22 at 3:09 P.M. with the Administrator, Licensed Social Worker (LSW) #507, and Unit Manager #500 revealed the LSW #507 remembered the incident with Resident #53 and reported it during the morning meeting. The Administrator and the LSW #507 agreed the LSW #507 was tasked with investigating the incident. The LSW #507 revealed he had not been trained on the formal process for investigating abuse and neglect. The Administrator and the LSW #507 confirmed they could not provide any evidence of any investigation into the allegation and the Administrator confirmed no SRI was created. Review of facility policy titled Abuse, Neglect and ExploitationBased on staff interview, record review, and review of the facility's abuse policy, the facility failed to implement their abuse policy for investigating incidents of alleged abuse. This affected two residents (#29 and #53) of six reviewed for abuse. The facility census was 72.

Findings include:

1. Review of the medical record for the Resident #29 revealed an admission date of 02/28/22 and medical diagnoses of type 2 diabetes, schizoaffective disorder, and legal blindness.

Review of the quarterly minimum data set (MDS) dated 08/04/22 revealed Resident #29 had intact cognition and required extensive assistance of one person for transfers, bed mobility, dressing, toileting, and hygiene, and supervision with setup help only for eating.

Review of Resident #29's progress note dated 07/29/22 revealed she informed staff a nurse was very nasty to her and Resident #29 felt unsafe with her as her nurse.

Interview on 10/12/22 at 4:28 P.M. with the Administrator revealed she recalled the allegation made by Resident #29, as noted in the progress note dated 07/29/22. Continued interview revealed the Administrator could provide no evidence an investigation was completed. She further confirmed no self reported incident (SRI) was created.

2. Review of the medical record for the Resident #53 revealed an admission date of 06/14/22. Diagnoses included dorsalgia, chronic pain, conversion disorder with seizures or convulsions.

Review of the quarterly MDS assessment for Resident #53, dated 07/02/22, revealed Resident #53 had impaired cognition and was totally dependent on two people for bed mobility, totally dependent on one person for toileting, required extensive assistance of two people for transfers, dressing, and required extensive assistance of one person for eating.

Review of a progress note dated 08/01/22 for Resident #53 revealed the resident informed staff the morning nurse aide handled her very roughly. Further review revealed the administrative team would be notified.

Interview on 10/11/22 at 3:09 P.M. with the Administrator, Licensed Social Worker (LSW) #507, and Unit Manager #500 revealed the LSW #507 remembered the incident with Resident #53 and reported it during the morning meeting. The Administrator and the LSW #507 agreed the LSW #507 was tasked with investigating the incident. The LSW #507 revealed he had not been trained on the formal process for investigating abuse and neglect. The Administrator and the LSW #507 confirmed they could not provide any evidence of any investigation into the allegation and the Administrator confirmed no SRI was created.

Review of facility policy titled Abuse, Neglect and Exploitation

Based on staff interview, record review, and review of the facility's abuse policy, the facility failed to implement their abuse policy for reporting incidents of alleged abuse. This affected two residents (#29 and #53) of six reviewed for abuse. The facility census was 72. Findings include: 1. Review of the medical record for the Resident #29 revealed an admission date of 02/28/22 and medical diagnoses of type 2 diabetes, schizoaffective disorder, and legal blindness. Review of the quarterly minimum data set (MDS) dated 08/04/22 revealed Resident #29 had intact cognition and required extensive assistance of one person for transfers, bed mobility, dressing, toileting, and hygiene, and supervision with setup help only for eating. Review of Resident #29's progress note dated 07/29/22 revealed she informed staff a nurse was very nasty to her and Resident #29 felt unsafe with her as her nurse. Interview on 10/12/22 at 4:28 P.M. with the Administrator revealed she recalled the allegation made by Resident #29, as noted in the progress note dated 07/29/22. Continued interview revealed the Administrator could provide no evidence an investigation was completed. She further confirmed no self reported incident (SRI) was created. 2. Review of the medical record for the Resident #53 revealed an admission date of 06/14/22. Diagnoses included dorsalgia, chronic pain, conversion disorder with seizures or convulsions. Review of the quarterly MDS assessment for Resident #53, dated 07/02/22, revealed Resident #53 had impaired cognition and was totally dependent on two people for bed mobility, totally dependent on one person for toileting, required extensive assistance of two people for transfers, dressing, and required extensive assistance of one person for eating. Review of a progress note dated 08/01/22 for Resident #53 revealed the resident informed staff the morning nurse aide handled her very roughly. Further review revealed the administrative team would be notified. Interview on 10/11/22 at 3:09 P.M. with the Administrator, Licensed Social Worker (LSW) #507, and Unit Manager #500 revealed the LSW #507 remembered the incident with Resident #53 and reported it during the morning meeting. The Administrator and the LSW #507 agreed the LSW #507 was tasked with investigating the incident. The LSW #507 revealed he had not been trained on the formal process for investigating abuse and neglect. The Administrator and the LSW #507 confirmed they could not provide any evidence of any investigation into the allegation and the Administrator confirmed no SRI was created. Review of facility policy titled Abuse, Neglect and ExploitationBased on staff interview, record review, and review of the facility's abuse policy, the facility failed to implement their abuse policy for reporting incidents of alleged abuse. This affected two residents (#29 and #53) of six reviewed for abuse. The facility census was 72.

Findings include:

1. Review of the medical record for the Resident #29 revealed an admission date of 02/28/22 and medical diagnoses of type 2 diabetes, schizoaffective disorder, and legal blindness.

Review of the quarterly minimum data set (MDS) dated 08/04/22 revealed Resident #29 had intact cognition and required extensive assistance of one person for transfers, bed mobility, dressing, toileting, and hygiene, and supervision with setup help only for eating.

Review of Resident #29's progress note dated 07/29/22 revealed she informed staff a nurse was very nasty to her and Resident #29 felt unsafe with her as her nurse.

Interview on 10/12/22 at 4:28 P.M. with the Administrator revealed she recalled the allegation made by Resident #29, as noted in the progress note dated 07/29/22. Continued interview revealed the Administrator could provide no evidence an investigation was completed. She further confirmed no self reported incident (SRI) was created.

2. Review of the medical record for the Resident #53 revealed an admission date of 06/14/22. Diagnoses included dorsalgia, chronic pain, conversion disorder with seizures or convulsions.

Review of the quarterly MDS assessment for Resident #53, dated 07/02/22, revealed Resident #53 had impaired cognition and was totally dependent on two people for bed mobility, totally dependent on one person for toileting, required extensive assistance of two people for transfers, dressing, and required extensive assistance of one person for eating.

Review of a progress note dated 08/01/22 for Resident #53 revealed the resident informed staff the morning nurse aide handled her very roughly. Further review revealed the administrative team would be notified.

Interview on 10/11/22 at 3:09 P.M. with the Administrator, Licensed Social Worker (LSW) #507, and Unit Manager #500 revealed the LSW #507 remembered the incident with Resident #53 and reported it during the morning meeting. The Administrator and the LSW #507 agreed the LSW #507 was tasked with investigating the incident. The LSW #507 revealed he had not been trained on the formal process for investigating abuse and neglect. The Administrator and the LSW #507 confirmed they could not provide any evidence of any investigation into the allegation and the Administrator confirmed no SRI was created.

Review of facility policy titled Abuse, Neglect and Exploitation

Based on observation, staff interview, and record review, the facility failed to provide assistance with eating. This affected one resident (#64) of three reviewed for assistance with eating. The facility census was 72.

Findings include:

Review of the medical record for Resident #64 revealed an admission date of 09/21/22 with medical diagnoses of occlusion and stenosis of vertebral artery, fracture of humerus, and weakness.

Review of the 5-day minimum data set (MDS) dated 09/28/22 revealed Resident #64 was rarely/never understood, and he required extensive assistance of one person for eating.

Review of the current care plan for Resident #64 revealed he was at nutrition risk and required set-up for and assistance with all meals.

Interview on 10/11/22 at 10:21 A.M. with State Tested Nurse Aide (STNA) #104 revealed Resident #64 required assistance with eating.

Observation on 10/11/22 at 12:39 P.M. revealed Resident #64 lying in bed. His tray table was within reach next to his bed and a lunch tray was on the tray table. The drink was empty, the plate was uncovered revealing a mechanical soft taco salad. A separate bowl containing fruit was also on the tray. Resident #64's silverware remained wrapped in a napkin. Attempted interview at this time with Resident #64 was unsuccessful.

Observation on 10/11/22 at 12:47 P.M. revealed Hospitality Aide (HA) #300 carrying Resident #64's tray from his room and placing it in the meal cart. Interview at that time with the HA #300 confirmed she removed his tray, confirmed the silverware was still tightly wrapped in a napkin, and confirmed the taco salad appeared to be only slightly eaten, if at all. The HA #300 stated Resident #64 doesn't eat very much and there was food on his bed, and she assumed he had eaten which was why she had removed his tray. Further interview revealed hospitality aides were not allowed to feed residents within their scope of practice.

Interview and observation on 10/11/22 at approximately 12:49 P.M. with the Unit Manager (UM) #500 confirmed Resident #64 required assistance with eating, and confirmed his silverware remained wrapped tightly on the tray inside the meal cart.

Interview on 10/11/22 at 3:27 P.M. with the UM #500 confirmed Resident #64 could not have eaten the noon meal of taco salad without silverware.

Interview on 10/12/22 at 9:55 A.M. with the Registered Nurse (RN) #206 revealed Resident #64 required assistance with eating.

The facility was unable to provide a policy regarding feeding assistance with meals.

This deficiency substantiates Complaint Number OH00136192.

Based on observation and interview, the facility failed to post daily staffing information. This had the potential to affect all residents in the facility. The facility census was 72.

Findings include:

Observation on 10/11/22 at 8:47 A.M. revealed there was no daily staffing information posted.

Interview on 10/11/22 at 8:47 A.M. with the Director of Nursing (DON) revealed the daily staffing information was not posted in the facility.

Interview on 10/12/22 at 2:00 P.M. with the DON confirmed the daily staffing information was not posted as required on 10/11/22. Observation at that time revealed it was posted in an easily accessible area. Interview at that time with the Administrator confirmed the font on the staffing information was too small to read.

This deficiency substantiates Complaint Number OH00136192.

Based on observation, staff and resident interview, and review of the facility work order logs, the facility failed to ensure resident toilet facilities were maintained in proper working order. This affected two residents (#73, and #74) out of four residents reviewed for functional restrooms. The facility census was 74.

Findings include:

On 09/28/22 at 7:26 A.M. observation of the resident restroom for Resident #73 and #74 with the Director of Environmental Services (DES) #01 noted the toilet was covered with a clear trash bag and an out of service sign. Interview with the DES #01 at the time verified the toilet was out of service and indicated they were unaware.

On 09/28/22 at 7:30 A.M. interview with the state tested nurse aide (STNA) #300 and STNA #301 revealed the toilet inside Resident #73 and Resident #74's restroom had been out of service and a maintenance work order had been generated weeks ago.

On 09/28/22 at 2:50 P.M. interview with Resident #73 revealed they had to use the bathroom down the hall or in an empty resident room due to the toilet inside their room being broken. The resident was unable to indicate the length of time the toilet had been out of service.

Review of the work order logs from 07/01/22 to 09/30/22 revealed no documentation indicating the toilet in Resident #73 and Resident #74's restroom had been reported as broken or repaired.

This deficiency substantiates Complaint Number OH00134461.

Based on review of the resident council minutes, review of the call light audits, and staff and resident interview, the facility failed to ensure resident concerns related to delayed call light response times were responded to and resolved timely. This had the potential to affect all residents except four residents (#17, #29, #39, and #03) identified by the facility who would not understand the use of a call light. The facility census was 74.

Findings include:

Review of the resident council minutes dated from 07/21/22 revealed nursing concerns noting aides do no answer call lights in a timely manner. On the 08/18/22 resident council meeting no follow-up to call light response times was indicated. On 09/15/22 the resident council minutes document seven residents in attendance (#34, #35, #73, #36, #33, #53, and #70). Resident council revealed nursing concerns documented aides were not responding to call lights.

Review of the call light audits dated from July, August, and September 2022 noted call lights responded to between two minutes and 25 minutes.

On 09/28/22 between 8:30 A.M. and 9:10 A.M. interview with seven current residents (#01, #59, #58, #68, #49, #30, and #10) revealed call light response times of 45 minutes, one hour, one hour and 45 minutes, and undetermined. Residents reported incontinence episodes as a majority of results for the long wait times.

On 09/28/22 at 10:30 A.M. interview with the Administrator during a review of resident council minutes and call light audits verified resident concerns from July and September 2022 had not been addressed or corrected regarding call light responses.

This deficiency substantiates Master Complaint Number OH00135215.

Based on observation, staff and resident interview, medical record review, facility medication administration reference guide, policy review, and manufacturer recommendations for use instructions, the facility failed to ensure the administration of medications were provided in accordance with approved standards of practice. There were 36 opportunities for error with three medications administered in error. The calculated medication error rate was 8.33 percent (%). This affected two residents (#30, and #69) out of five residents reviewed for medication administration. The facility census was 74.

Findings include:

1. Observation and interview on 09/27/22 at 8:25 A.M. noted Licensed Practical Nurse (LPN) #400 obtained Resident #30's Lantus insulin pen injector from the medication cart. LPN #400 placed a single use needle on the pen and dialed a dose of 13 units of insulin. LPN #400 had not primed the pen with two units of insulin. LPN #400 proceeded to Resident #30's room and administered the insulin to the resident. The resident consumed breakfast and Resident #30 verified the insulin was due for administration at 7:00 A.M. Additional interview with LPN #400 verified the residents insulin was due for administration prior to eating and during the 7:00 A.M. medication administration. LPN #400 also indicated they were unaware the Lantus insulin pen injector required a two unit prime before administering a prescribed dose of insulin to a resident.

Review of the medical record noted a physician order dated 05/11/22 for Resident #30 to receive the administration of Lantus SoloStar Solution Pen-injector Inject 13 units subcutaneously one time a day for Diabetes Mellitus. Scheduling detail listed on the order listed a specific time of 7:00 A.M. Additional record review of the medication administration record (MAR) noted the time of Lantus SoloStar insulin should be administered at 7:00 A.M.

Review of facility policy titled Medication Administration, dated 2022 authorized staff is directed to administer medications within 60 minutes prior to or after scheduled time unless otherwise ordered by physician. Additionally, administer medication as ordered in accordance with manufacturer specifications.

According to the facility medication administration reference guide dated August 2022 instructs insulin pen administration to include placing a new needle as required with each access to insulin pen. Prime (Air Shot) insulin pens prior to each administration with 2 units or manufacturer's recommendations. Hold the pen with the needle up, tap to move any air bubbles to the top.

According to LANTUS SOLOSTAR Single-Patient-Use Prefilled Pen instructions for use revised 01/2021 revealed Always perform the safety test before each injection. Performing the safety test ensures that you get an accurate dose by: ensuring that pen and needle work properly removing air bubbles. Check the label on your SoloStar to make sure you have the correct insulin. The LANTUS SoloStar is grey with a purple injection button. Take off the pen cap. Check the appearance of your insulin. LANTUS is a clear insulin. Do not use this SoloStar if the insulin is cloudy, colored or has particles. Wipe the Rubber Seal with alcohol. Remove the protective seal from a new needle. Line up the needle with the pen, and keep it straight as you attach it(screw or push on, depending on the needle type). Select a dose of 2 units by turning the dosage selector. Take off the outer needle cap and keep it to remove the used needle after injection. Take off the inner needle cap and discard it. You may have to perform the safety test several times before insulin is seen. If no insulin comes out, check for air bubbles and repeat the safety test two more times to remove them. If still no insulin comes out, the needle may be blocked. Change the needle and try again. If no insulin comes out after changing the needle, your SoloStar may be damaged. Do not use this SoloStar.

2. Observation on 09/27/22 at 8:55 A.M. noted Registered Nurse (RN) #500 obtain Resident #69's medications from the medication cart. RN #500 stated the resident was ordered a Budesonide inhaler and the inhaler was not available in the cart. RN #500 stated they would have to order the medication from the pharmacy to be delivered later in the day. RN #500 indicated the inhaler was to be administered twice daily. At 8:57 A.M. RN #500 administered Resident #69 medications excluding the Budesonide inhaler.

Review of the medical record for Resident #69 revealed on 07/26/22 Budesonide Suspension 1 milligram (MG)/2 milliliter (ML) one application inhalation two times daily for chronic obstructive pulmonary disease. According to the order specific times for application/administration were 9:00 A.M. and 9:00 P.M.

Review of facility policy titled Medication Administration, dated 2022 authorized staff is directed to administer medications within 60 minutes prior to or after scheduled time unless otherwise ordered by physician.

This deficiency substantiates Master Complaint Number OH00135215.

Based on observation, staff and resident interview, medical record review, facility medication administration reference guide, policy review, and manufacturer recommendations for use instructions, the facility failed to ensure the administration of insulin included the proper dosage and the prescribed timeframe to prevent significant medication errors. This affected one resident (#30) out of five residents reviewed for medication administration. The facility census was 74.

Findings include:

1. Observation and interview on 09/27/22 at 8:25 A.M. noted Licensed Practical Nurse (LPN) #400 obtained Resident #30 Lantus insulin pen injector from the medication cart. LPN #400 placed a single use needle to the pen and dialed a dose of 13 units of insulin. LPN #400 had not primed the pen with two units of insulin. LPN #400 proceeded to Resident #30's room and administered the insulin to the resident. Resident #30 consumed breakfast and the resident verified the insulin was due for administration at 7:00 A.M. Interview with LPN #400 verified the residents insulin was due for administration prior to eating and during the 7:00 A.M. medication administration. LPN #400 also indicated they were unaware the Lantus insulin pen injector required a two unit prime before administering a prescribed dose of insulin to a resident.

Review of the medical record noted a physician order dated 05/11/22 for Resident #30 to receive the administration of Lantus SoloStar Solution Pen-injector Inject 13 units subcutaneously one time a day for diabetes mellitus. Scheduling detail listed on the order listed a specific time of 7:00 A.M. Additional record review of the medication administration record (MAR) noted the time of Lantus SoloStar insulin should be administered at 7:00 A.M.

Review of policy titled Medication Administration, dated 2022 authorized staff is directed to administer medications within 60 minutes prior to or after scheduled time unless otherwise ordered by physician. Additionally, administer medication as ordered in accordance with manufacturer specifications.

According to the facility medication administration reference guide dated August 2022 instructs insulin pen administration to include placing a new needle as required with each access to insulin pen. Prime (Air Shot) insulin pens prior to each administration with two units or manufacturer's recommendations. Hold the pen with the needle up, tap to move any air bubbles to the top.

According to LANTUS SOLOSTAR Single-Patient-Use Prefilled Pen instructions for use revised 01/2021 revealed Always perform the safety test before each injection. Performing the safety test ensures that you get an accurate dose by: ensuring that pen and needle work properly removing air bubbles. Check the label on your SoloStar to make sure you have the correct insulin. The LANTUS SoloStar is grey with a purple injection button. Take off the pen cap. Check the appearance of your insulin. LANTUS is a clear insulin. Do not use this SoloStar if the insulin is cloudy, colored or has particles. Wipe the Rubber Seal with alcohol. Remove the protective seal from a new needle. Line up the needle with the pen, and keep it straight as you attach it(screw or push on, depending on the needle type). Select a dose of 2 units by turning the dosage selector. Take off the outer needle cap and keep it to remove the used needle after injection. Take off the inner needle cap and discard it. You may have to perform the safety test several times before insulin is seen. If no insulin comes out, check for air bubbles and repeat the safety test two more times to remove them. If still no insulin comes out, the needle may be blocked. Change the needle and try again. If no insulin comes out after changing the needle, your SoloStar may be damaged. Do not use this SoloStar.

This deficiency substantiates Master Complaint Number OH00135215.

Based on observation, resident and staff interview, and facility pest control documentation, the facility failed to ensure sufficient interventions were maintained to control the existence of house flies inside the facility. This affected six residents (#01, #10, #30, #31, #49, #73) out of six observed for environmental pest control. The facility census was 74.

Findings include:

1. Observation on 09/27/22 at 9:45 A.M. noted Resident #01 in bed. A fly strip was observed hanging from the ceiling near the foot of the bed with multiple flies on the surface. Several flies were observed in the room flying near the resident and landing on multiple surfaces inside the room. Interview with the resident at the time revealed the flies have been a concern for an undetermined time.

2. Observation on 09/27/22 at 8:26 A.M. and 09/28/22 at 9:02 A.M. noted multiple flies in Resident #30 and #31's room. The flies were landing on the resident beds, and food tray at the bedsides. Both residents verified flies have been an ongoing concern.

3. On 09/28/22 at 8:55 A.M. Resident #49 was observed in bed with the meal tray on the overbed table. Multiple flies were landing on the meal tray. Resident #49 stated he had finished his breakfast.

4. On 09/28/22 at 9:10 A.M. Resident #10 was observed seated in bed with a meal tray placed in front of them. Multiple flies were observed in the room landing on the food and the surfaces inside the room.

5. On 09/28/22 at 2:50 P.M. observation inside Resident #73 room noted the resident laying in bed. No food debris was identified. Several flies were observed landing on objects and surfaces inside the room.

According to most recent pest control for house flies was documented on 08/19/22. Treatment included the placement of two glueboards to fly lights placed on 08/01/22. Additional house fly treatment included placing the fly light station on 08/01/22. No further treatments or inspections for house flies were applied since 08/19/22.

On 09/28/22 at 10:30 A.M., interview with the Administrator verified an ongoing existence of house flies inside the facility and including the resident rooms.

This deficiency substantiates Complaint Number OH00133772.