Ashford of Grove City

Based on medical record review, staff interview, and review of facility policy, the facility failed to administer medications as ordered. This affected one (Resident #10) of three reviewed for medication administration. The census was 58. Findings include: Review of the medical record for Resident #10 revealed an admission date of 04/17/24. Diagnoses included generalized anxiety disorder, type 2 diabetes and depression. Review of the active physician order for Resident #10 revealed tresiba flextouch 100 units(U)/milliliter (ML) give 25 units subcutaneous one time a day at bedtime. Review of the Medication Administration Record (MAR) for Resident #10 revealed the tresiba flextouch 100 U/ML was not administered on the following dates: 09/10/24, 09/11/24, 09/12/24 and 09/13/24. Review of the progress notes for Resident #10 dated 09/14/24 at 1:31 P.M. revealed the pharmacy stated Resident #10's insulin (tresiba flextouch 100 U/ML) was in tonight's tote to go out, the resident was aware and a voicemail (VM) was left for her daughter. Interview with the Administrator on 09/22/24 at 12:27 P.M. revealed the previous Director of Care (DOC) walked out and she was the responsible party to make sure residents have their medications ordered and Resident #10 did not have her tresiba flextouch 100 U/ML administered for the dates of: 09/10/24, 09/11/24, 09/12/24 and 09/13/24 as the facility did not send out for the refill when it became empty. Review of the facility policy titled, MedicationsBased on medical record review, staff interview, and review of facility policy, the facility failed to administer medications as ordered. This affected one (Resident #10) of three reviewed for medication administration. The census was 58.

Findings include:

Review of the medical record for Resident #10 revealed an admission date of 04/17/24. Diagnoses included generalized anxiety disorder, type 2 diabetes and depression.

Review of the active physician order for Resident #10 revealed tresiba flextouch 100 units(U)/milliliter (ML) give 25 units subcutaneous one time a day at bedtime.

Review of the Medication Administration Record (MAR) for Resident #10 revealed the tresiba flextouch 100 U/ML was not administered on the following dates: 09/10/24, 09/11/24, 09/12/24 and 09/13/24.

Review of the progress notes for Resident #10 dated 09/14/24 at 1:31 P.M. revealed the pharmacy stated Resident #10's insulin (tresiba flextouch 100 U/ML) was in tonight's tote to go out, the resident was aware and a voicemail (VM) was left for her daughter.

Interview with the Administrator on 09/22/24 at 12:27 P.M. revealed the previous Director of Care (DOC) walked out and she was the responsible party to make sure residents have their medications ordered and Resident #10 did not have her tresiba flextouch 100 U/ML administered for the dates of: 09/10/24, 09/11/24, 09/12/24 and 09/13/24 as the facility did not send out for the refill when it became empty.

Review of the facility policy titled, Medications

Based on medical record review, resident interview, staff interview, review of facility documents, and review of the facility policy, the facility failed to administer medications as ordered by the physician. This affected one (Resident #155) of six residents reviewed for medication administration. The facility census was 112 residents.

Findings include:

Review of the medical record for Resident #155 revealed an admission date of 04/01/24 with diagnoses including generalized anxiety disorder and depression.

Review of the Medication Administration Record (MAR) for Resident #155 dated June 2024 revealed the resident's bedtime doses of Simvastatin, Tresiba, and Metformin for 06/03/24 were marked LOA (Leave of Absence) on the MAR which indicated the medications were not given as ordered by the physician.

Interview on 07/01/24 at 8:05 A.M. with Resident #155 confirmed she signed out of the facility on an approved LOA on 06/03/24 and returned at 9:30 P.M. the same day. Resident #155 further confirmed she did not receive her evening medications on 06/03/24 because there was no licensed nurse in the facility to administer them.

Interview on 07/02/24 at 1:30 P.M. with the Assistant Director of Care (ADOC) #10 confirmed that on 06/03/24 Licensed Practical Nurses (LPNs) #12 and #22 clocked out before Resident #155 returned from an approved LOA. ADOC #10 further confirmed Resident #155 did not receive her bedtime medications, Simvastatin, Tresiba, and Metformin, because there was no licensed nurse present in the facility to administer them.

Review of the facility document titled Medication Administration Times undated revealed medications ordered for bedtime could be administered between 7:00 P.M. and 11:59 P.M.

Review of the facility document titled Employee Time Entry Report dated 06/03/24 revealed LPN #22 clocked out at 8:40 P.M. and LPN #12 clocked out at 9:02 P.M.

Review of the facility document titled Resident Sign Out/In dated 06/03/24 revealed Resident #115 signed back into the facility from LOA at 9:30 P.M.

Review of the facility policy titled Medication Administration Policy dated 03/31/20 revealed the staff would administer all resident medications as ordered by their physician.

This violation represents noncompliance investigated under Complaint Number OH00155176 and Complaint Number OH00154861 and Complaint Number OH00154542 and Complaint Number OH00154294 and is an example of continued noncompliance from the survey dated 03/15/23.

Based on medical record review, staff interview, and review of the facility policy, the facility failed to record and follow up on resident fall events. This affected one (Resident #210) of three residents reviewed for falls. The facility census was 112 residents.

Findings include:

Review of the medical record for Resident #210 revealed an admission date of 01/12/24 with diagnoses including spinal stenosis, Alzheimer's Disease, and repeated falls and a discharge date of 04/29/24.

Review of the cognitive assessment for Resident #210 dated 01/12/24 revealed the resident had mild cognitive impairment.

Review of the functional assessment for Resident #210 dated 01/12/24 revealed the resident was dependent on staff for activities of daily living (ADLs.)

Review of the service plan for Resident #210 dated 01/12/24 revealed the resident had a potential for falls.

Review of the fall risk assessment for Resident #210 dated 01/12/24 revealed the resident was at moderate risk for falls.

Review of progress notes for Resident #210 revealed had falls on 03/05/24, 03/11/24, and 04/16/24.

Review of the facility incident log dated March and April 2024 revealed the Resident #210's falls on 03/05/24, 03/11/24, and 04/16/24 were not included in the log.

Interview on 07/02/24 at 2:18 P.M. with Assistant Director of Care (ADOC) #10 confirmed Resident #10 had fallen on 03/05/24, 03/11/24, and 04/16/24, but these falls were not included in the facility incident log and the facility had not completed post-fall investigations for the incidents.

Review of the facility policy titled Falls Risk Assessment and Care Plan dated May 2015 revealed the Executive Director or designee should ensure data about falls and interventions were gathered, maintained, and utilized.

Review of the facility policy titled Incident Reporting dated August 2023 revealed the community would provide an accurate account and appropriate follow-up of incidents which occurred in the community or on community property. All associates must complete an incident report form within 24 hours following any incident/unusual occurrence involving any resident.

This violation represents noncompliance investigated under Complaint Number OH00154923 and Complaint Number OH00154294.

Based on observation, staff interview, and review of the facility policy, the facility failed to ensure nurses followed proper infection control protocols during the provision of wound care. This affected one (Resident #99) of three residents sampled for wound care. The facility census was 112 residents.

Findings include:

Observation of a dressing change to wounds on the anterior left shin for Resident #99 on 07/01/24 at 11:58 A.M per Licensed Practical Nurse (LPN) #22 revealed the nurse did not use proper hand hygiene during the dressing change. LPN #22 donned gloves and removed the soiled dressing from Resident #99's shin and then removed the soiled glove from her right hand and donned a clean glove to her right hand without performing hand hygiene. LPN #22 then applied a clean dressing to Resident #99's shin.

Interview on 07/01/24 at 12:08 P.M. with LPN #22 confirmed she did not perform hand hygiene after removing the soiled glove from her right hand or before donning a clean glove to her right hand and applying the clean dressing to Resident #99's shin. LPN #22 confirmed she should have performed hand hygiene after she removed her soiled glove from her right hand and before donning a clean glove to complete the dressing change.

Review of the facility policy titled Infection Control-Universal Precautions dated March 2020 revealed staff should wash their hands immediately after providing personal care to residents, after touching something that could be contaminated, and after removing gloves.

This violation represents noncompliance investigated under Complaint OH00154294.

Based on closed medical record review, review of email between staff, and staff interview, the facility failed to ensure a resident was assessed for assisted living (AL) appropriateness prior to admission. This affected one (#113) of three sampled residents. The facility census was 102.

Findings include:

Review of the closed medical record for Resident #113 revealed an initial admission date of 03/22/24 with the diagnosis including arthritis. The resident was discharged to an acute care hospital on 04/10/24.

Review of an email dated 02/21/24 from the Former Director of Nursing (FDON) #297 to Marketing Director #260 revealed a pre-admission assessment was completed for Resident #113 to determine if Resident #113 was appropriate for assisted living (AL) and he was a level two assisted living and appropriate.

Review of the closed medical record revealed no documentation from the transferring facility detailing the resident's recapitulation of stay to continue the resident's continuity of care.

Review of Resident #113's Assessment Tool Results dated 03/23/24 revealed the resident required total assistance with dressing, mobility, bathing and extensive assistance with toileting and dressing. The assessment indicated the resident had no confusion or forgetfulness. The total score of the assessment was 50 points indicating the resident was at the highest level of five indicating the resident was not appropriate for assisted living.

Review of the medical record revealed no documented evidence the resident was assessed for AL appropriateness.

Interview on 05/15/24 at 4:18 P.M., with the Executive Director (ED) verified the facility had no documented evidence a pre-admission assessment was completed to determine if Resident #113 was appropriate for AL.

This violation represents non-compliance investigated under Complaint Number OH00153606.

Based on closed medical record review, review of communication binder, review of staff statements, and staff interview, the facility failed to assess a resident's health when displaying a change in condition and functional abilities. This affected one (#113) of three sampled residents for assessments. The facility census was 102.

Findings include:

Review of the closed medical record for Resident #113 revealed an initial admission date of 03/22/24 with the diagnosis including arthritis. The resident was discharged to an acute care hospital on 04/10/24.

Review of the resident's progress note dated 03/22/24 at 11:00 A.M. revealed Resident #113 arrived at the facility via car with his son. Resident #113 always used a wheelchair and was incontinent of both bowel and bladder. Resident #113 was noted to have no open areas on arms, legs, or torso; however, the resident refused to allow the nurse to examine his buttocks but stated he had no open areas. Resident #113 had no call pendent, and the Personal Care Assistants (PCA) were to complete every two-hour checks.

Review of the resident's Mini-Mental State Examination Results dated 03/23/24 revealed a score of 26 indicating Resident #113 had no cognitive deficit.

Review of Resident #113's Assessment Tool Results dated 03/23/24 revealed the resident required total assistance with dressing, mobility, bathing and extensive assistance with toileting and dressing. The assessment indicated the resident had no confusion or forgetfulness. The total score of the assessment was 50 points indicating the resident was at the highest level of five indicating the resident was not appropriate for assisted living.

Review of the progress note dated 04/06/24 at 6:06 P.M. revealed Resident #113 had a bowel movement in his chair and attempted to clean himself. The nurse assisted the PCA with incontinence care. The entry documented Resident #113 was unable to assist with standing.

Review of the skin monitoring comprehensive PCA shower sheet dated 04/06/24 revealed Resident #113 received a sponge bath by PCAs #202, #236 and #275 and the resident had no skin issues documented despite the wound to the coccyx being reported to Licensed Practical Nurses (LPN) #238 and #278 on 04/06/24.

Review of the progress note dated 04/08/24 at 7:52 A.M. revealed Resident #113 was provided incontinence care and repositioned in the chair via four staff members. The entry failed to address the sore on the resident's buttocks reported on 04/06/24 to LPN #238 and #278.

Review of the staff statement dated 04/08/24 from LPN #238 revealed she was notified by PCA Resident #113 had redness under his abdominal folds. The statement indicated LPN #238 had seen the resident's buttocks was red and looked like it was from sitting. The LPN documented the resident's skin was intact and had no drainage. The LPN placed a brief note in the CNP's binder as the CNP would be in the facility the next day.

Review of the staff statement dated 04/11/24 from LPN #278 revealed she worked with Resident #113 from 04/04/24 to 04/07/24 from 7:00 A.M. to 7:00 P.M. The statement indicated the LPN assisted three other staff members with incontinence care for Resident #113. The statement indicated the resident was at his baseline; however, the resident required four staff members for incontinence care.

Review of the staff statement dated 04/11/24 from PCA #220 revealed the PCA worked with Resident #113 on 04/06/24 and upon entry to his room he had torn his Depends off and had feces all over his fingers and private area. The statement indicated the resident had what looked like a yeast infection under his abdominal folds and groin. The PCA also documented the resident had a sore on the top of his butt

Based on record review and staff interview, the facility failed to ensure a resident dependent on staff for bathing received scheduled showers. This affected one (#113) of three residents reviewed for bathing. The facility census was 102.

Findings include:

Review of the resident's Mini-Mental State Examination Result dated 03/23/24 revealed a score of 26 indicating Resident #113 had no cognitive deficit.

Review of Resident #113's Assessment Tool Results dated 03/23/24 revealed the resident required total assistance with dressing, mobility, bathing and extensive assistance with toileting and dressing.

Review of the closed medical record for Resident #113 revealed an initial admission date of 03/22/24 with the diagnosis including arthritis. The resident was discharged to an acute care hospital on 04/10/24.

Review of an email dated 02/21/24 from the Former Director of Nursing (FDON) #297 to Marketing Director #260 revealed a pre-admission assessment was completed for Resident #113 to determine if Resident #113 was appropriate for assisted living (AL) and he was a level two assisted living and appropriate.

Review of the resident's progress note dated 03/22/24 at 11:00 A.M. revealed Resident #113 arrived at the facility via car with his son. Resident #113 always used a wheelchair and was incontinent of both bowel and bladder. Resident #113 was noted to have no open areas on arms, legs, or torso; however, the resident refused to allow the nurse to examine his buttocks but stated he had no open areas. Resident #113 had no call pendent, and the Personal Care Assistants (PCA) were to complete every two-hour checks.

Review of the resident's Mini-Mental State Examination Results dated 03/23/24 revealed a score of 26 indicating Resident #113 had no cognitive deficit.

Review of Resident #113's Assessment Tool Results dated 03/23/24 revealed the resident required total assistance with dressing, mobility, bathing and extensive assistance with toileting and dressing. The assessment indicated the resident had no confusion or forgetfulness. The total score of the assessment was 50 points indicating the resident was at the highest level of five indicating the resident was not appropriate for assisted living.

Review of the medical record revealed Resident #113's scheduled showers were every Wednesday and Saturday on the evening shift.

Review of Resident #113's shower documentation revealed the resident received a shower on 03/27/24, a sponge bath on 04/03/24 and 04/06/24. Further review of the resident's medical record revealed no documented evidence the resident was provided a scheduled shower or sponge bath on 03/23/24 and 03/30/24.

Review of the progress note dated 04/06/24 at 6:06 P.M. revealed Resident #113 had a bowel movement in his chair and attempted to clean himself. The nurse assisted the PCA with incontinence care. The entry documented Resident #113 was unable to assist with standing.

Review of the skin monitoring comprehensive PCA shower sheet dated 04/06/24 revealed Resident #113 received a sponge bath by PCAs #202, #236 and #275 and the resident had no skin issues documented despite the wound to the coccyx being reported to Licensed Practical Nurses (LPN) #238 and #278 on 04/06/24.

Interview on 03/15/24 at 1:56 P.M., with Regional Director of Nursing (RDON) #301, verified Resident #113 had not received his scheduled shower or a bed bath on 03/23/34 and 03/30/24.

Based on observation, medical record review, and staff interview, the facility failed to ensure residents with pressure ulcers were comprehensively assessed every seven days and administer the physician ordered treatment as ordered. This affected two (#14 and #43) of three residents reviewed for pressure ulcers. The facility census was 102.

Findings include:

1. Review of the open medical record for Resident #14 revealed an initial admission date of 02/21/23, with the diagnoses including but not limited to Parkinson's disease, anxiety disorder, hyperlipidemia, hypertension and hypothyroidism.

Review of Resident #14's mini-mental state examination results dated 12/28/23 revealed a score of 24 indicating the resident had no cognitive deficit.

Review of Resident #14's Braden scale dated 12/28/23 revealed a score of 15 indicating the resident was at high risk for skin breakdown.

Review of Resident #14's assessment tool results dated 10/10/23 revealed the resident required physical assistance with dressing, supervision/contact guard for mobility, the resident required stand by assistance with bathing and reminders for toileting.

Review of Resident #14's progress note dated 03/08/24 at 6:35 P.M., revealed the resident had a pressure ulcer to her buttocks. The Certified Nurse Practitioner (CNP) #293 examined the wound and ordered to cleanse the wound with soap and water, apply alginate and cover with non adhesive dressing twice daily. The progress note had no staging, measurements, description of the wound or any exudate.

Review of the Medication Administration Record (MAR) for March 2024 revealed an order dated 03/08/24, with a start date of 03/09/24, to cleanse right buttocks with soap and water, apply calcium alginate and cover with adhesive dressing daily. Further review revealed the treatment was not delivered and the order was discontinued on 03/10/24 by the ordering CNP #295.

Review of Resident #14's progress note dated 03/11/24 at 2:17 P.M., revealed the home health company assessed the resident's pressure ulcer to right buttocks and ordered Chamosyn ointment to right buttocks nickel thick three times daily. Further review of the progress note revealed CPN #295 was notified and approved the new order for Chamosyn ointment as written.

Review of Resident #14's progress note dated 03/12/24 at 2:28 P.M., revealed the facility was awaiting Chamosyn ointment to be delivered.

Review of the MAR for March 2024 revealed no documented evidence the Chamosyn ointment was started until 03/14/24.

Review of Resident #14's progress note dated 03/16/24 at 1:30 A.M., revealed the Chamosyn ointment was received and applied to Resident #14's pressure ulcer to the right buttocks.

Review of Resident #14's progress note dated 04/28/24 at 4:53 P.M.,. revealed the resident had a pressure ulcer to both buttocks. The left pressure ulcer measured 1.6 centimeters (cm) by 0.5 cm. The pressure ulcer to the right buttocks measured 0.7 cm by 1.0 cm.

Review of Resident #14's progress note dated 05/05/24 at 8:04 P.M., revealed the pressure ulcer to the left buttocks measured 1.5 cm by 1.5 cm and the pressure ulcer to the right buttocks measures 1.0 cm by 1.0 cm.

Review of Resident #14's progress note dated 05/11/24 at 10:55 P.M., revealed the pressure ulcer to the left buttocks measured 1.0 cm by 0.5 cm and the pressure ulcer to the right buttocks measures 0.5 cm by 0.5 cm.

Further review of Resident #14's progress notes revealed no documented evidence when the pressure ulcer to the left buttocks began, when the physician and family were notified of the development of the pressure ulcer to the left buttocks and an order for the treatment. Additionally, the wound to the resident's right and left buttocks had no comprehensive assessments every seven days completed.

Review of Resident #14's May 2024 physician orders identified an order dated 03/13/24 Chamosyn with Manuka honey ointment with the special instructions to apply a nickel thick amount topically to the resident's buttocks three times a day and as needed.

Observations on 05/15/24 at 2:50 P.M., of PCA #220 provided the physician ordered treatment to Resident #14's pressure ulcer to the left and right buttocks, PCA #220 was observed to enter the apartment, donned a pair of gloves, shut the resident's blind and assisted the resident to stand up. PCA #220 then pulled the resident's pants and incontinence brief down and applied the Chamosyn with Manuka honey ointment to the resident's left and right buttocks.

Interview on 05/20/24 at 11:26 A.M., with the Director of Nursing (DON) verified the resident's medical record contained no documented evidence of a comprehensive assessment of the pressure ulcers to the left and right buttocks or no progress note of when the wound was identified on the left buttocks.

2. Review of the medical record for Resident #43 revealed an initial admission date of 11/30/23, with the diagnoses including Alzheimer's disease, anxiety, constipation, hyperlipidemia and unsteadiness on feet.

Review of Resident #43's Mini-Mental State Examination Result dated 04/10/24 revealed a score of one indicating a severe cognitive deficit.

Review of Resident #43's Assessment Tool Results dated 04/10/24 revealed the resident was dependent on staff for bed mobility, transfers, toileting, bathing, personal hygiene, dressing and eating. The assessment indicated the resident was incontinent of both bowel and bladder. The total score of the assessment was 59 points indicating the resident was at the highest level of five indicating the resident was not appropriate for assisted living.

Review of Resident #43's Braden scale dated 04/10/24 revealed a score of 10 indicating the resident was at a very high risk for skin breakdown.

Review of Resident #43's progress note dated 04/10/24 at 10:19 A.M., revealed the pressure ulcer to the resident's coccyx measured 1.0 cm by 1.5 cm. The entry lacked any documented staging, description of the wound or any exudate.

Review of Resident #43's progress note dated 05/05/24 at 8:23 P.M., revealed the pressure ulcer to the resident's coccyx measured 1.0 cm by 1.0 cm by 0.1 cm. The entry lacked any documented staging, description of the wound or any exudate.

Review of Resident #43's progress note dated 05/19/24 at 10:40 A.M., revealed the resident had a coccyx wound measuring 1.6 centimeters (cm) by 0.5 cm by 0.5 cm. The entry lacked any documented staging or description of the wound or any exudate.

Review of Resident #43's physician orders for May 2024 identified orders dated 03/29/24, to cleanse left heel with normal saline (NS), pat dry and apply border foam dressing every three days and as needed; 03/30/24, cleanse left heel with wound cleanser, pat dry and apply foam dressing every Monday, Friday and as needed; 04/15/24, cleanse right foot and coccyx with wound cleanser apply thera honey and optifoam daily every Monday, Wednesday and Friday; and 05/21/24, cleanse coccyx wound with wound cleanser, pat dry, pack with NS soaked gauze and cover with clean dressing daily.

Review of Resident #43's May 2024 Medication Administration Record (MAR) revealed the orders dated 04/15/24, to cleanse right foot and coccyx with wound cleanser apply thera homey and optifoam daily every Monday, Wednesday and Friday were documented as being completed twice daily instead of daily. Further review revealed the orders dated 03/30/24, to cleanse left heel with wound cleanser, pat dry and apply foam dressing every Monday, Friday and as needed and cleanse left heel with NS, pat dry, apply a border foam dressing daily every three days and both treatments were documented as being completed despite no physician's order for the treatment to be completed every three days. Further review the treatment ordered daily every Monday and Friday to the left heel was being completed twice daily.

Observation on 05/22/2024 at 11:15 A.M., of Resident #43's physician ordered dressing change to the pressure ulcer to coccyx revealed LPN #237 assisted an unknown PCA, turn the resident onto her left side. Resident #43's right leg was observed to have a severe contracture of her right knee and hip to the resident's chest. Resident #43's left hip and knee was contracted inward with the left leg bent backwards with the left foot resting under the right knee. Resident #43 was incontinent of feces. LPN #237 cleansed the resident with disposable wipes. LPN #237 then changed her gloves without sanitizing or washing her hands. She then removed the foam dressing to the resident's coccyx. Resident #43's wound bed was covered with yellow slough. The wound edges were white and macerated. LPN #43, then cleansed the wound with wound cleanser and 2 X 2 gauze pad. LPN #237 then obtained a disposable wipe and cleansed the resident's rectal area, disposed of the wipe, obtained a dollop of Medi-honey on her pinky finger, using the same gloves used to cleanse the resident's rectal area and placed the Medi-honey into the wound. LPN #237 then covered the wound with a foam dressing.

Interview on 05/22/24 at 11:35 A.M., with LPN #237 verified the resident's pressure ulcer was not comprehensively assessed every seven days, and she administered the wrong treatment to the pressure ulcer to the resident's coccyx. Additionally, LPN #237 verified the frequency of the treatments were administered incorrectly as well as treatment orders not being discontinued when a new treatment order was received. LPN #237 verified the pressure ulcer to the resident's coccyx was no longer a stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough or bruising. May also present as an intact or open/ ruptured blister.) and has gotten worse. LPN #237 verified she did not assess the wound.

This violation represents non-compliance investigated under Complaint Number OH00153606. This violation is also an example of continued non-compliance from the complaint survey completed 04/25/24.

Based on observation, record review, staff interview, and facility policy review, the facility failed to notify the physician and/or Certified Nurse Practitioner (CNP) and the resident's sponsor of a significant change. This affected two residents (#14 and #113) of three sampled residents reviewed for change in conation. The facility census was 102.

Findings include:

1. Review of the closed medical record for Resident #113 revealed an initial admission date of 03/22/24 with the diagnosis including arthritis. The resident was discharged to an acute care hospital on 04/10/24.

Review of the resident's Mini-Mental State Examination Result dated 03/23/24 revealed a score of 26 indicating Resident #113 had no cognitive deficit.

Review of Resident #113's Assessment Tool Results dated 03/23/24 revealed the resident required total assistance with dressing, mobility, bathing and extensive assistance with toileting and dressing. The assessment indicated the resident had no confusion or forgetfulness. The total score of the assessment was 50 points indicating the resident was at the highest level of five indicating the resident was not appropriate for assisted living.

Review of the progress note dated 04/06/24 at 6:06 P.M. revealed Resident #113 had a bowel movement in his chair and attempted to clean himself. The nurse assisted the PCA with incontinence care. The entry documented Resident #113 was unable to assist with standing.

Review of the progress note dated 04/08/24 at 7:52 A.M. revealed Resident #113 was provided incontinence care and repositioned in the chair via four staff members. The entry failed to address the sore on the resident's buttocks reported on 04/06/24 to LPN #238 and #278.

Review of the medical record revealed no documented evidence the resident's sponsor or physician and/or CNP was notified of the change in the resident's condition.

Review of the staff statement dated 04/08/24 from LPN #238 revealed she was notified by PCA Resident #113 had redness under his abdominal folds. The statement indicated the LPN seen the resident's buttocks was red and looked like it was from sitting. The LPN documented the resident's skin was intact and had no drainage. The LPN placed a brief note in the CNP's binder as the CNP would be in the facility the next day.

Review of the staff statement dated 04/11/24 from LPN #278 revealed she worked with Resident #113 from 04/04/24 to 04/07/24 from 7:00 A.M. to 7:00 P.M. The statement indicated the LPN assisted three other staff members with incontinence care for Resident #113. The statement indicated the resident was at his baseline, however the resident required four staff members for incontinence care.

Review of the staff statement dated 04/11/24 from PCA #220 revealed the PCA worked with Resident #113 on 04/06/24 and upon entry to his room he had torn his depend off and had feces all over his fingers and private area. The statement indicated the resident had what looked like a yeast infection under his abdominal folds and groin. The PCA also documented the resident had a sore on the top of his butt

Based on record review, observation and interview, the facility failed to ensure a resident was provided a resident activated call system to summon staff for needs. This affected one (#113) of three sampled residents. The facility census was 102.

Findings Include:

Review of the closed medical record for Resident #113 revealed an initial admission date of 03/22/24 with the diagnosis including arthritis. The resident was discharged to an acute care hospital on 04/10/24.

Review of the resident's progress note dated 03/22/24 at 11:00 A.M. revealed Resident #113 arrived at the facility via car with his son. Resident #113 used a wheelchair at all times and was incontinent of both bowel and bladder. The resident had no call pendent, and the Personal Care Assistants (PCA) were to complete every two hour checks.

Review of the resident's Mini-Mental State Examination Result dated 03/23/24 revealed a score of 26 indicating Resident #113 had no cognitive deficit.

Review of Resident #113's Assessment Tool Results dated 03/23/24 revealed the resident required total assistance with dressing, mobility, bathing and extensive assistance with toileting and dressing.

Review of the resident's progress note dated 03/25/24 at 6:40 A.M. revealed Resident #113 was still waiting to receive a call pendent (facility's resident activated call system).

Review of the resident's progress note dated 03/28/24 at 4:25 A.M. revealed the first documented evidence since the resident was admitted to the facility had a resident activated call system in place.

On 05/15/24 at 10:00 A.M., observation of Resident #113's apartment revealed the brown recliner was not positioned to reach the resident activated call system on the wall.

On 03/15/23 at 4:18 P.M., interview with the Executive Director (ED) revealed he was unaware of way the resident had no resident activated call system pendent and thought the only reason would be the resident activated call pendent was on order.

On 05/21/24 at 4:20 P.M., interview with the Director of Nursing (DON) revealed she was unsure why the resident had no resident activated call pendent but the facility could not force the family to pay $100 monthly for the system. She revealed the resident would have to use the call light attached to the wall. She revealed she was unsure how the resident was able to utilize the call light with the placement of his recliner.

Based on closed medical record review, review of hospital documentation, staff interviews, Certified Nurse Practitioner (CNP) interview, level of care bracket points review, and facility policy review, the facility failed to meet the total care needs of Resident #113 following his admission to the facility resulting in resident neglect. The facility failed to adequately monitor the resident for changes in mental status, activities of daily living (ADL) decline, changes in skin integrity, failed to timely identify areas of skin impairment and provide wound care to the resident's buttocks to prevent a decline in the resident's health status. This resulted in Real and Present Danger and actual harm on 03/22/24 when the facility failed to implement a comprehensive and individualized service plan to address the total care needs of Resident #113, who was identified on admission as having no cognitive deficit, required extensive assistance with ADL and had no skin issues. On 04/06/24, the resident was found to have an open area to the coccyx, a change in mental status, a decline in ADL, and dehydration. The resident was not transferred to the hospital until 04/10/24 at which time he required a 20-day hospitalization for care of an unstageable [the wound bed cannot be visualized, and hence the pressure ulcer/injury cannot be staged] pressure injury to the left and right buttocks and a deep tissue injury (DTI) [Purple or maroon area of discolored intact skin due to damage of underlying soft tissue. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.] to the scrotum, dehydration, acute kidney injury, pleural effusion and acute urinary retention. The resident was released to a skilled nursing facility (SNF) on 04/30/24 under hospice care and expired on 05/16/24. This affected one resident (#113) of three residents reviewed for wounds. The facility census was 102.

On 05/20/24 at 3:57 P.M., the Executive Director (ED) and the Director of Nursing (DON) were notified Real and Present Danger began on 03/22/24 when the facility failed to provide comprehensive and individualized nursing care and wound care to meet Resident #113's care needs resulting in a hospitalization on 04/10/24 where the resident was treated for acute renal failure, pleural effusion, acute urinary retention, weakness, unstageable decubitus ulcer to sacral region and a DTI to his scrotum. The resident was hospitalized until 04/30/24 at which time he was released to a skilled nursing facility (SNF) under hospice care and expired on 05/16/24.

The Real and Present Danger was abated on 05/21/24 when the facility implemented the following corrective actions:

On 04/11/24, Physical Therapy Assistant (PTA) #303 from the facility's contracted therapy company completed Mechanical and Manual Lift Training, Positioning and Transfer Training, with 30 Personal Care Assistants (PCAs) and seven Licensed Practical Nurses (LPN) to educate on proper technique.

On 04/26/24 starting at 6:00 P.M., the following trainings were completed by the DON by or before 04/30/24.

a. Fourteen LPN's and one Medication Technician (MT) were educated on wound care and what to look for when giving a shower and dressing a resident. Any abnormal findings are to be reported to the nurse.

b. Thirty PCAs were educated on how to correctly complete a shower sheet, incontinence care training and wound notification.

On 04/26/24, the ED provided education to all staff on how to report abuse and neglect and reviewed the abuse and neglect policy.

On 04/26/24, Regional Director of Nursing (RDN) #301 educated Program Director of Memory Care, Licensed Practical Nurse (LPN) #237 not to complete pre-move in assessment, unless in the presence of the DON, RDON #301 or Regional Vice President of Senior Living Operations (RVPSLO) #307.

On the following dates, LPN #258 completed skin assessments on all residents residing in the facility on 04/26/24, 04/27/24, 04/28/24, 05/03/24, 05/05/24, 05/10/24, 05/11/24, 05/18/24 and 05/19/24 to determine the status of each resident's skin.

On 04/29/24, the facility implemented weekly Resident Review meetings with the DON, Assistant Director of Nursing (ADON) #305, LPN #237, ED, RDON #301, and/or RVPSLO #307.

On 04/30/24, the DON/designee provided training to 14 LPN's, one MT and 30 PCA's regarding the notification of change of condition to notify family/Power of Attorney (POA), physician/certified nurse practitioner (CNP), and the nurse on duty.

On 05/16/24, the DON provided associate corrective action to LPN #238 and #278 for failing to follow through with intervention for report of redness to a resident's skin and failure to notify the physician of a resident change in condition. Consequences should incident/violation occur again: Progression of disciplinary process up to and including termination. LPN #238 and #278 have signed the statement, I have read and understand this Associate Corrective Action.

On 05/17/24, the DON/designee completed training with 14 LPN's regarding the requirement that two LPN's must complete the admission skin assessments together and document in the progress notes.

On 05/20/24 at 5:00 P.M., the following trainings were completed by the DON, ADON #305, LPN #237 and/or ED:

a. Signs and Symptoms of Dehydration

b. Assisted Living & Memory Care audit for residents without beds. Families and POA notified of potential risk of skin break down for not having a bed for resident.

c. Audit of all admissions starting on 03/22/24 for being properly assessed upon move in.

d. Executive Director educated Marketing Director #260, prior to an assessment, that medical records for no less than the prior 90-days be obtained for review by the DON, ADON #305, or RDON #301.

e. Skin assessment requirement prior to sending a resident out to the Emergency Department, when medically appropriate.

Newly hired nursing staff on or before day 3 of training will receive training from the DON/designee regarding, identification of skin issues, wound notification, incontinence care training, what to look for while giving a shower and dressing a resident and how and what to report to the nurse on duty, DON, ADON and/or ED.

All PCA's will receive quarterly training by facility contracted provider on mechanical and manual lift training, repositioning and transfer training.

All current and newly hired PCA's and nursing staff will receive training from the ED on how to report abuse and neglect for the next six months.

The DON/designee will complete weekly resident skin assessments until 06/30/24, thereafter, every two weeks through 08/31/24. Any identified skin issues will be addressed immediately by notifying the physician and family/POA and putting an intervention in place, along with documentation in resident chart.

Marketing Director #260 or designee will obtain medical records for no less than the prior 90-days from the current residential care facility, skilled nursing facility, primary care provider, hospital or other known healthcare facility and provide them to the DON/designee.

Weekly meetings with the DON, ADON #305, LPN #237, ED, RDON #301, and/or Regional RVPSLO #307 to review residents will be ongoing until the Quality Assurance and Performance Improvement (QAPI) committee determines standards are being met at least quarterly.

The DON/designee will reference the Perry and Potter: Manual and Clinical Nursing Skills & Techniques to ensure we are providing care in accordance with acceptable standards of practice.

Prospective residents who have an initial assessment that is greater than 14 days will need to be reassessed prior to move in. Initial assessments are to be completed by the DON, ADON #305, RDON #301 or RVPSLO #307. RDON #301 provided education to the DON, Executive Chief (EC) #246 and Marketing Director #260 on 05/20/24.

The DON or designee will audit five random staff members weekly for 30 days, bi-weekly for an additional 30 days, and then random thereafter reviewing the following:

a. Abuse and neglect.

b. Dehydration signs and symptoms.

c. Notification on change of condition.

d. What to report to a nurse.

On 05/21/24, RDON #301, the DON and LPN #237 completed re-education of all 27 PCAs on the following:

a. How to complete a shower sheet.

b. Incontinence care training and wound notification.

c. What to look for when giving a shower and dressing a resident. Report to nurse immediately.

On 05/21/24, RDON #301, the DON and LPN #237 completed re-education of all 14 LPNs on the following:

a. How to complete a shower sheet.

b. Incontinence training and wound notification.

c. What to look for when giving a shower and dressing a resident. Report to nurse immediately.

d. Wound Care Training.

The DON, ADON #305 and LPN #237 will review residents with known skin issues weekly with RDON #301 on-going.

Human Resource Coordinator or designee, shall audit all new hire files for training within one week of start date:

a. LPN in wound care training.

b. PCA in how to complete a shower sheet.

c. PCA in incontinence training and wound notification.

d. LPN and PCA what to look for when giving a shower and dressing a resident. Report to nurse immediately.

e. Report non-compliance to DON immediately for follow-up.

The ED or designee will address any trends identified with the QAPI Committee. An action plan will be developed and implemented to ensure compliance.

Although the Real and Present danger was abated on 05/21/24, the violation continues as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance.

Findings include:

Review of the closed medical record for Resident #113 revealed an initial admission date of 03/22/24 with the diagnosis including arthritis. The resident was discharged to an acute care hospital on 04/10/24.

Review of an email dated 02/21/24 from the Former Director of Nursing (FDON) #297 to Marketing Director #260 revealed a pre-admission assessment was completed for Resident #113 to determine if Resident #113 was appropriate for assisted living (AL) and he was a level two assisted living and appropriate.

Review of the history and physical (H&P) dated 02/27/24 revealed Resident #113's skin was normal. The assessment indicated Resident #113 had occasional confusion and had evidence of dementia or cognitive decline. The H&P documented the only diagnosis was arthritis and was treated with Ibuprofen 200 milligrams (mg) with the special instructions to take two capsules every four hours as needed for pain and/or fever.

Review of the closed medical record revealed no documentation from the transferring facility detailing the resident's recapitulation of stay to continue the resident's continuity of care.

Review of the resident's progress note dated 03/22/24 at 11:00 A.M. revealed Resident #113 arrived at the facility via car with his son. Resident #113 always used a wheelchair and was incontinent of both bowel and bladder. Resident #113 was noted to have no open areas on arms, legs, or torso; however, the resident refused to allow the nurse to examine his buttocks but stated he had no open areas. Resident #113 had no call pendent, and the Personal Care Assistants (PCA) were to complete every two-hour checks.

Review of Resident #113's Braden scale dated 03/23/24 revealed a score of 14 indicating Resident #113 was at high risk for skin breakdown.

Review of the resident's Mini-Mental State Examination Results dated 03/23/24 revealed a score of 26 indicating Resident #113 had no cognitive deficit.

Review of Resident #113's Assessment Tool Results dated 03/23/24 revealed the resident required total assistance with dressing, mobility, bathing and extensive assistance with toileting and dressing. The assessment indicated the resident had no confusion or forgetfulness. The total score of the assessment was 50 points indicating the resident was at the highest level of five indicating the resident was not appropriate for assisted living.

Review of Resident #113's progress note dated 03/25/24 at 6:40 A.M. revealed Resident #113 was still waiting to receive a call pendent.

Review of CNP #295's progress note dated 04/04/24 revealed Resident #113 was seen to take over care. The resident was alert and oriented, jovial and appropriate for the situation. The resident's lungs were clear to auscultation with no rhonchi or wheezing. The resident had no edema or abdominal distention. The resident has generalized weakness and utilized a recliner and wheelchair.

Review of the progress note dated 04/06/24 at 6:06 P.M. revealed Resident #113 had a bowel movement in his chair and attempted to clean himself. The nurse assisted the PCA with incontinence care. The entry documented Resident #113 was unable to assist with standing.

Review of the skin monitoring comprehensive PCA shower sheet dated 04/06/24 revealed Resident #113 received a sponge bath by PCAs #202, #236 and #275 and the resident had no skin issues documented despite the wound to the coccyx being reported to Licensed Practical Nurses (LPN) #238 and #278 on 04/06/24.

Review of the progress note dated 04/08/24 at 7:52 A.M. revealed Resident #113 was provided incontinence care and repositioned in the chair via four staff members. The entry failed to address the sore on the resident's buttocks reported on 04/06/24 to LPN #238 and #278.

Review of the staff statement dated 04/08/24 from LPN #238 revealed she was notified by PCA Resident #113 had redness under his abdominal folds. The statement indicated LPN #238 had seen the resident's buttocks was red and looked like it was from sitting. The LPN documented the resident's skin was intact and had no drainage. The LPN placed a brief note in the CNP's binder as the CNP would be in the facility the next day.

Review of CNP #293's progress note dated 04/10/24 revealed Resident #113 was seen for an acute visit per nursing request due to coccyx wound. Resident #113 was seen in his recliner in an adult diaper and had slid down and his torso was resting on the seat of the recliner with his neck upright. Resident #113 was unable to answer any questions and yelled out whenever staff attempted to reposition or move his legs. Resident #113 was unable to provide information on how long he had been in his chair. The resident had asked for water. The CNP was unable to obtain blood pressure (BP), his pulse was irregular, and his oxygen saturation was 95%. The residents ' peripheral pulses were weak. Resident #113 had a toxic appearance (A toxic appearing patient is a clinical term used to describe a patient who looks very ill and may have serious symptoms such as lethargy, poor perfusion, marked hypo/hyperventilation, cyanosis, tachypnea, and tachycardia with poor capillary refill.), dry oral mucous membranes, scattered expiratory wheezing, and irregular heart rate with two plus pitting edema to bilateral lower extremities. The resident's bilateral lower extremities were also noted to have erythematous with abrasions scattered all over the anterior area of his upper legs. The resident's abdomen was distended. Resident #113 was weak/deconditioned and unable to assist with repositioning. Resident #113 was assessed as being lethargic and had poor skin turgor. The CNP documented the altered mental status and dehydration was life threatening and ordered the resident be transferred via 911 to the local acute care hospital. The CNP contacted the admitting provider and updated the physician on the resident's emergency condition.

Review of the progress note dated 04/10/24 10:52 A.M. revealed Resident #113 was sent to the local acute care hospital by the CNP. The entry documented no assessment of the resident or reason for the transfer to the local acute care hospital.

Review of the resident's progress note from 03/22/24 to 04/10/24 revealed no documentation reflecting the resident had a pressure ulcer, change in mental status, or symptoms of dehydration.

Review of the resident's discharge physician orders identified orders dated 03/22/24 for Ibuprofen 200 milligrams (mg) with the special instructions to administer two capsules every four hours as needed for pain or fever and 04/10/24 noting 911 to emergency department for encephalopathy and dehydration. Further review revealed no documented evidence the resident had any treatment or wound inventions in place for the unstageable wound.

Review of the resident's acute care hospital documentation dated 04/10/24 revealed the resident was transferred to the local emergency department due to possible dehydration via emergency medical services (EMS). The resident was found to have an acute kidney injury (AKI) related to a blood urea nitrogen (BUN) level of 94 (normal 7 to 20 milligrams per deciliter (mg/dL) and a creatinine level of 4.63 (normal 0.7 to 1.2 mg/dL). The resident was also found to have an elevated white blood cell count (WBC) of 14.6 (normal 4.0 to 11.0 microliters). The resident was found to have an unstageable necrotic decubitus ulcer to the coccyx with macerated skin around the buttocks. The resident was also found to be retaining 1800 milliliters (ml) of fluid in his bladder with a normal bladder being able to hold 500 ml of urine. An indwelling urinary catheter was placed. Resident #113 was admitted to the acute care hospital with pleural effusion, AKI, acute urinary retention, weakness, and an unstageable decubitus ulcer of sacral region with possible infection.

Review of the initial wound consult progress note dated 04/10/24 while in the emergency department revealed Resident #113 arrived at the facility with an unstageable pressure injury to bilateral buttocks and coccyx. The resident was evaluated while resting in the emergency department. The resident was turned to his left side revealing a diffuse unstageable pressure injury to both buttocks and coccyx. There was dark necrotic tissue over the left buttocks with ruddy purpura extending laterally towards the right. There was partial thickness skin loss over the right buttocks with liquefaction of the superior edges of the necrotic base. There is a strong, foul odor present possibly due to the necrotic tissue. The resident groans in pain with any palpation or treatment of the wounds. The resident also had a pressure injury to the anterior scrotum and appears to be due to skin to skin pressure possibly from the resident sitting on his scrotum. It was also recommended for general surgery to evaluate for sharp debridement creating a larger wound cavity instead of slow autolytic debridement. The wound plan consisted of turning every two hours, elevate extremities, antifungal ointment to bilateral feet, legs, and buttocks twice daily, low air loss mattress and dietician consult.

Review of the nephrology consult dated 04/10/24 revealed Resident #113 had AKI and suspected post renal etiology given at least 1800 ml urinary retention in bladder and could have some degree of renal hypoperfusion injury (a condition characterized by acute tubular cell injury and dysfunction. It is caused by a sudden drop in blood flow to the kidneys which can be caused by dehydration and infection) in setting of dehydration.

Review of the staff statement dated 04/11/24 from LPN #278 revealed she worked with Resident #113 from 04/04/24 to 04/07/24 from 7:00 A.M. to 7:00 P.M. The statement indicated the LPN assisted three other staff members with incontinence care for Resident #113. The statement indicated the resident was at his baseline; however, the resident required four staff members for incontinence care.

Review of the staff statement dated 04/11/24 from PCA #220 revealed the PCA worked with Resident #113 on 04/06/24 and upon entry to his room he had torn his Depends off and had feces all over his fingers and private area. The statement indicated the resident had what looked like a yeast infection under his abdominal folds and groin. The PCA also documented the resident had a sore on the top of his butt

Based on record review and staff interview, the facility failed to maintain a complete and accurate medical record. This affected one (#113) of three residents sampled medical record. The facility census was 102.

Findings included:

Review of the closed medical record for Resident #113 revealed an initial admission date of 03/22/24 with the diagnosis including arthritis. The resident was discharged to an acute care hospital on 04/10/24.

Review of an email dated 02/21/24, from the Former Director of Nursing (FDON) #297 to Marketing Director #260, revealed a pre-admission assessment was completed for Resident #113 to determine if Resident #113 was appropriate for assisted living (AL) and he was a level two assisted living and appropriate.

Review of the closed medical record revealed no documentation from the transferring facility detailing the resident's recapitulation of stay to continue the resident's continuity of care.

Review of a psychiatric progress note dated 03/26/24 revealed the assessment contained the information of another resident at the facility.

On 05/15/24 at 1:56 P.M., interview with Regional Director of Nursing (RDON) #301 verified Resident #113's medical record was not complete and accurate.

On 05/15/24 at 3:35 P.M., interview with the ED verified the psychiatric consult was inaccurate and not for Resident #113.

Based on record review, observation, staff interview and review of an electronic mail (e-mail) communication, the facility failed to provide wound care as ordered. This affected one (#10) of three residents reviewed for wounds care. Facility census was 115.

Findings include:

Review of Resident #10's medical record revealed the resident was admitted to the facility on 11/30/23. Diagnoses include Alzheimer's disease, anxiety, unsteadiness on feet, hyperlipidemia, and constipation.

Review of Resident #10's orders revealed the following treatment orders: Cleanse right foot and coccyx with wound cleanser, apply Thera honey and Optifoam three times weekly on Monday, Wednesday, and Friday dated 04/15/24; and Left heel cleanse with wound cleanser pat dry, apply a border foam dressing, change twice weekly and as needed, change on Monday and Friday mornings keep heels floated off mattress when in bed dated 03/30/24.

Review of the treatment administration record (TAR) for April 2024 revealed Resident #10's right foot and coccyx wound care were not documented as completed on 04/15/24, 04/17/24, 04/19/24, and 04/22/24. Resident #10's left heel wound care was not documented as completed on 04/05/24, 04/15/24, and 04/22/24.

Observation of Resident #10 on on 04/25/24 at 8:02 A.M. with Personal Care Assistant (PCA) #290 it was observed the wound dressing to the resident's right foot was dated 04/22/24. During the observation PCA #290 verified the dressing was dated 04/22/24 and the current date was 04/25/24.

Observation of Resident #10 on 04/25/24 at 11:15 A.M. with Licensed Practical Nurse (LPN) #210 revealed the resident was observed lying on her right side with a foam boot to her left foot. Resident #10's boot was removed by LPN #210 and it was noted there was no dressing on the open area to the resident's left heel. Resident #10's incontinent brief was opened and it was observed there was no dressing in place to the resident's coccyx wound and there was no dressing that was in the brief that would have suggested it had been in place and come off. Resident #10's left heel wound was observed to be opened with the wound bed having pink tissue present with no drainage, slough, or necrotic tissue present. Resident #10's coccyx wound was observed to be open and the wound bed was covered in slough.

An interview with LPN #210 on 04/25/24 at 11:20 A.M. verified Resident #10's the left heel wound and the resident coccyx wound did not have the ordered dressings in place. LPN #220 also confirmed she had changed the right foot dressing previously during this current shift as it was to be changed on 04/24/24 and the dressing that was in place was dated 04/22/24.

Review of an e-mail communication dated 04/29/24 at 5:18 P.M. from the Administrator revealed the facility does not have a policy for wound care but would follow the physician orders to treat the wounds.

This violation represents non-compliance investigated under Complaint Number OH00152822.

Based on record reviews, staff interview, and review of facility policy, the facility failed to ensure medication was administered as ordered by the physician. This affected one (Resident #82) of the six residents reviewed for medication administration. The facility census was 108. Findings include: Record review for Resident #82 revealed the resident was admitted to the facility on 12/08/22 and had diagnoses including unspecified dementia with behavioral disturbances, hypertension, and adjustment disorder with anxiety. Review of the active physician order dated 02/03/23, revealed Resident #82 was to be administered 0.5 milligrams (mg) of Lorazepam (anti-anxiety medication) every eight hours at 6:00 A.M., 2:00 P.M., and 10:00 P.M. Review of the facility Controlled Drug Receipt/Record/Disposition Forms for Resident #82's Lorazepam revealed on 03/07/23, a tablet of 0.5 mg Lorazepam was documented to have been removed for administration at 11:00 A.M. and 5:00 P.M. by Licensed Practical Nurse (LPN) #460. On 03/09/23, a tablet of 0.5 mg Lorazepam was documented to have removed for administration at 10:00 A.M. and 5:00 P.M. by LPN #460. No additional tablets were documented to have been removed on 03/07/23 or 03/09/23 for administration. Review of the Medication Administration Record (MAR) for Resident #82 revealed on 03/07/23 the 6:00 A.M. dose of Lorazepam was documented as being administered as ordered, the 2:00 P.M. dose was documented as, 'Drug Not Given' with a note explaining the dose would be administered in the evening due to being ordered for every eight hours, and the 10:00 P.M. dose was documented as being given as ordered. On 03/09/23 the 6:00 A.M. dose of Lorazepam was documented as being administered as ordered, the 2:00 P.M. dose of Lorazepam was documented as being administered as ordered, and the 10:00 P.M. dose was documented as being refused as the resident would not wake up. Interview on 03/14/23 at 11:15 A.M. with Licensed Practical Nurse (LPN) #460 verified when she went to administer medications to Resident #82 the morning of 03/07/23 and 03/09/23, she noticed Resident #82's 6:00 A.M. dose of Lorazepam was not administered. LPN #460 verified she removed a Lorazepam tablet from the narcotic card for Resident #82 on 03/07/23 at 11:00 A.M., on 03/07/23 at 5:00 P.M., on 03/09/23 at 10:00 A.M., and on 03/09/23 at 5:00 P.M. and had administered them to the resident immediately after removing them from the card. LPN #460 verified the resident's Lorazepam was ordered to be administered every eight hours at 6:00 A.M., 2:00 P.M., and 10:00 P.M. LPN #460 was unable to report why Resident #82's 6:00 A.M. Lorazepam was not administered on 03/07/23 and 03/09/23. Review of the facility policy titled, MedicationsBased on record reviews, staff interview, and review of facility policy, the facility failed to ensure medication was administered as ordered by the physician. This affected one (Resident #82) of the six residents reviewed for medication administration. The facility census was 108.

Findings include:

Record review for Resident #82 revealed the resident was admitted to the facility on 12/08/22 and had diagnoses including unspecified dementia with behavioral disturbances, hypertension, and adjustment disorder with anxiety.

Review of the active physician order dated 02/03/23, revealed Resident #82 was to be administered 0.5 milligrams (mg) of Lorazepam (anti-anxiety medication) every eight hours at 6:00 A.M., 2:00 P.M., and 10:00 P.M.

Review of the facility Controlled Drug Receipt/Record/Disposition Forms for Resident #82's Lorazepam revealed on 03/07/23, a tablet of 0.5 mg Lorazepam was documented to have been removed for administration at 11:00 A.M. and 5:00 P.M. by Licensed Practical Nurse (LPN) #460. On 03/09/23, a tablet of 0.5 mg Lorazepam was documented to have removed for administration at 10:00 A.M. and 5:00 P.M. by LPN #460. No additional tablets were documented to have been removed on 03/07/23 or 03/09/23 for administration.

Review of the Medication Administration Record (MAR) for Resident #82 revealed on 03/07/23 the 6:00 A.M. dose of Lorazepam was documented as being administered as ordered, the 2:00 P.M. dose was documented as, 'Drug Not Given' with a note explaining the dose would be administered in the evening due to being ordered for every eight hours, and the 10:00 P.M. dose was documented as being given as ordered. On 03/09/23 the 6:00 A.M. dose of Lorazepam was documented as being administered as ordered, the 2:00 P.M. dose of Lorazepam was documented as being administered as ordered, and the 10:00 P.M. dose was documented as being refused as the resident would not wake up.

Interview on 03/14/23 at 11:15 A.M. with Licensed Practical Nurse (LPN) #460 verified when she went to administer medications to Resident #82 the morning of 03/07/23 and 03/09/23, she noticed Resident #82's 6:00 A.M. dose of Lorazepam was not administered. LPN #460 verified she removed a Lorazepam tablet from the narcotic card for Resident #82 on 03/07/23 at 11:00 A.M., on 03/07/23 at 5:00 P.M., on 03/09/23 at 10:00 A.M., and on 03/09/23 at 5:00 P.M. and had administered them to the resident immediately after removing them from the card. LPN #460 verified the resident's Lorazepam was ordered to be administered every eight hours at 6:00 A.M., 2:00 P.M., and 10:00 P.M. LPN #460 was unable to report why Resident #82's 6:00 A.M. Lorazepam was not administered on 03/07/23 and 03/09/23.

Review of the facility policy titled, Medications

Based on observations, interviews, and record reviews, the facility failed to ensure food portions served to residents were the correct portion size indicated on the spreadsheet for the meal. This affected the 31 residents (#1, #2, #3, #4, #5, #6, #8, #10, #11, #12, #60, #61, #62, #63, #64, #66, #67, #68, #69, #70, #72, #73, #74, #75, #76, #77, #78, #79, #80, #81, #82, and #83) who resided on the memory care unit and received their meals from the facility. The facility census was 108.

Findings include:

Observation on 03/13/23 at 11:35 A.M. revealed Personal Care Assistant (PCA) #570 was observed to be using a four ounce ladle to pour tomato bisque into residents' bowls. PCA #570 verified the ladle was a four ounce ladle and residents were receiving one ladle full of the soup in their bowls

Observation on 03/14/23 at 11:50 A.M. revealed PCA #840 was observed using a two ounce ladle to pour chili into bowls which was being served to the residents on the memory care unit. PCA #840 verified the ladle was a two ounce ladle and residents were receiving one ladle full of chili in their bowls. PCA #840 stated she did not want to put too much into the bowls for fear they would spill and also stated she served residents food portions based on what looked appropriate. PCA #840 denied knowledge of having a spreadsheet which provided the amount of food staff should be serving to residents.

Observation and interview on 03/14/23 at 12:05 P.M. with Cook #580 verified the spreadsheet for the lunch meal called for a six ounce portion of chili to be served to residents, and the ladle PCA #840 was using, was only a two ounce size.

Review of the facility spreadsheet for the lunch meal for 03/13/23 revealed six ounces of tomato bisque was to be served to residents.

Review of the facility spreadsheet for the lunch meal for 03/14/23 revealed six ounces of chili was to be served to residents.

Based on medical record review and staff interview, the facility failed to timely complete an annual functional assessment for a resident. This affected one (#5) of six reviewed. The census was 90.

Findings Include:

Review of Resident #5's medical record revealed the resident was admitted on 07/02/21 with diagnosis that include but are not limited to Alzheimer's disease and heart failure.

Review of Resident #5's assessments revealed the resident did not have a updated functional assessment completed since admission on 07/02/21.

Interview with the Executive Director on 02/15/23 at approximately 4:15 P.M. confirmed Resident #5's functional assessment was not completed as required.

Based on observation and staff interview, the facility failed to store food items in a safe and sanitary manner. This had the potential to affect all 90 residents whom the facility identified as receiving food from the kitchen. The census was 90.

Findings include:

Observation of the kitchen on 02/15/23 at 9:30 A.M. with Dietary Manager (DM) #400 revealed a walk in refrigerator with a gallon container of honey mustard salad dressing was opened and undated, a gallon container of Caesar salad dressing was opened and undated, a gallon container of ranch salad dressing was opened and undated, and baking sheet of cooked chicken breast was covered in plastic wrap and was unlabeled and undated. Observation of the dry food storage area revealed a large rolling flour bin had a scooped stored inside the bin in the flour, a large bag of white cake mix was opened and undated, and a zippered bag of almond flour was opened and undated. Observation of the salad refrigerator revealed a container of prepared chicken salad was opened and undated and had a manufacture's use by date of 01/20/23, a large plastic bin labeled applesauce with a use by date of 01/23/23, a container of mayonnaise was opened and undated with no manufacture's use by date observed, a large bag of shredded cheddar cheese was opened and undated, and three blocks of white American cheese were wrapped in unlabeled plastic wrap and were undated.

Interview with DM #400 during the kitchen observation on 02/15/23 verified the items were not stored correctly during the observation of each separate area in the main kitchen.

Observation of the secured memory care servery with DM #400 on 02/15/23 at 9:55 A.M. revealed a 32 ounce bottle of prune juice and a 64 ounce jar of sliced pickles were opened and undated in the reach-in refrigerator. There was also frosted flakes dry cereal in a bin which contained a serving scoop and had a used by date of 12/09/22 and frosted mini wheat dry cereal in a bin which contained a serving scoop and had a used by date of 12/21/22. Both dry cereal bins were sitting on the servery countertop.

Interview on 02/15/23 with DM #400 verified the items were not stored correctly during the observation of the memory care servery.

Based on observation and staff interview, the facility failed to ensure the dishwasher in the memory care unit sanitized the dish ware. This had the potential to affect all 32 (#5, #10, #100, #101, #103, #104, #105, #106, #107, #108, #109, #110, #111, #112, #113, #114, #115, #116, #117, #118, #119, #120, #121, #122, #123, #124, #125, #126, #127, #128, #129, and #130) residents who reside in the memory care unit. The census was 90.

Findings include:

Observation of the memory care unit servery with Dietary Manager (DM) #400 on 02/15/23 at 9:55 A.M. revealed the servery had its own dishwasher to sanitize the dishware for the memory care residents.

Interview with DM #400 on 02/15/23 at 9:56 A.M. revealed the dishwasher sanitized the dishware through the use of chemicals used to cleanse the dishes. DM #400 stated the chemicals were automatically dispensed to the dishwasher and that was how the dishware was sanitized. DM #400 stated the facility did not have a mechanism to test the chemical sanitation levels of the dishwasher to ensure the dishware was properly sanitized.

Interview with Regional Clinical Nurse #500 on 02/15/23 at 4:30 P.M. confirmed the facility residents had no signs or symptoms of any food borne illness.

The facility identified 32 (#5, #10, #100, #101, #103, #104, #105, #106, #107, #108, #109, #110, #111, #112, #113, #114, #115, #116, #117, #118, #119, #120, #121, #122, #123, #124, #125, #126, #127, #128, #129, and #130) residents who resided in the memory care unit.

Based on review of fire drill reports and staff interview, the facility failed to complete fire drills at least every three months on all shifts and failed to evacuate residents are required. This had the potential to affect all 90 residents living in the facility. The census was 90.

Findings include:

Review of fire drill reports dated between 02/28/22 and 01/31/23 revealed fire drills were conducted on 02/28/22, 03/24/22, 04/29/22, 06/30/22, 07/30/22, 08/31/22, 09/30/22, 10/31/22, 11/30/22, 12/14/22, and 01/31/23. Further review of the fire drill reports during that time frame revealed residents were only evacuated once on 02/28/22 on the day shift. Further review of the fire drill reports revealed the facility did not conduct a fire drill for at least four months on the night shift (last conducted 09/30/22) and at least five months on the day shift (last conducted 08/31/22) as all fire drills conducted on 10/31/22, 11/30/22, 12/14/22, and 01/31/23 were completed on the evening shift. Additionally, the facility did not conduct fire drills at varied times with five of the fire drills (06/30/22, 08/51/22, 09/30/22, 10/31/22, and 11/30/22) being conducted on the last day of the month.

Interview with the Executive Director on 02/15/23 at 1:43 P.M. confirmed the fire drills were not conducted and completed as required.

Based on observation and staff interview, the facility failed to have a carbon monoxide detector in the kitchen. This had the potential to affect all 90 residents in the facility. The census was 90.

Findings include:

Observation of the kitchen on with the Dietary Manager (DM) #400 on 02/15/23 between 9:30 A.M. and 9:50 A.M. revealed the kitchen utilized a gas burning stove. Further observation of the kitchen revealed there was no carbon monoxide detector present in the kitchen area.

Interview with DM #400 on 02/15/23 at 9:50 A.M. confirmed there was no carbon monoxide detector in the kitchen and the facility utilized a gas burning stove to cook the food.

Based on observation, staff interview, and incident report review, the facility failed to maintain hot water temperatures within acceptable ranges. This had the potential to affect four (#5, #101, #106, and #129) of four resident's bedrooms who reside on the secured memory care unit. The census was 90.

Findings include:

Observation of bathroom water temperatures on the secured memory care unit on 02/15/23 between 8:35 A.M. and 8:47 A.M. revealed Resident #101's hot water temperature was 130 degrees Fahrenheit, Resident #106's hot water temperature was 132 degrees Fahrenheit, Resident #129's hot water temperature was 124 degrees Fahrenheit, and Resident #5's hot water temperature was 124 degrees Fahrenheit.

Interview and observation of the water temperatures with the Executive Director on 02/15/23 at 8:47 A.M. confirmed the water temperatures were accurate and over the range of the safe temperature standard. Executive Director confirmed there were no burns reported in the facility.

Review of the incident accident log over the last 12 months confirmed the there were no hot water burns reported.

Based on observation and resident and staff interview, the facility failed to store supplemental oxygen tanks in a safe manner. This affected one (#35) of one residents reviewed for supplemental oxygen. The census was 90.

Findings include:

Review of Resident #35's medical record reevaled an admission date of 01/22/21 with diagnoses that included but are not limited to epilepsy, hypothyroidism, malignant melanoma of the skin, malignant neoplasm of the brain, and cardiac arrhythmia.

Observation of Resident #35's room on 02/15/23 at 10:50 A.M. revealed there was a supplemental oxygen tank standing on end in the room not in a holder. The tank was standing close to the resident's kitchenette approximately four feet from Resident #35's recliner chair she was sitting in.

Interview with Resident #35 on 02/15/23 at 10:55 A.M. stated staff needed to remove the tank. Resident #35 stated the supplemental oxygen tank was usually stored in her room and sat on the floor with no holder to prevent the tank from falling over.

Interview with Licensed Practical Nurse (LPN) #475 on 02/15/23 at 10:57 A.M. confirmed the supplemental oxygen tank in Resident #35's room was standing on end near the kitchenette and was not in a holder.

Based on medical record review and staff interview, the facility failed to provide routine bathing services residents. This affected one (#10) of three residents reviewed for bathing services. The census was 90.

Findings include:

Review of Resident #10's medical record revealed an admission date of 11/10/21 with diagnoses that included but are not limited to urinary tract infection, heart failure, falls, and memory loss.

Review of Resident #10's bathing documentation revealed Resident #10 received showers during the past month on 01/19/23, 01/23/23, 01/29/23 and 02/13/23. Further review of the bathing sheets revealed Resident #10 refused her shower on 02/06/23. There was no documentation provided to support Resident #10 received any showers on the week of 01/29/23 through 02/04/23. There was only one shower sheet the following week of 02/05/23 through 02/11/23, and the shower sheet documented Resident #10 refused the shower offered on 02/06/23.

Interview with Regional Clinical Nurse (RCN) #500 on 02/15/23 at 4:45 P.M. confirmed showers should be provided twice weekly or per the resident's preference. RCN #500 confirmed Resident #10 did not receive routine showers as per schedule.

This violation represents non-compliance investigated under Master Complaint Number OH00139710, Complaint Number OH00138867, and Complaint Number OH00135597.

Based on observation, staff and resident interviews, and record review, the facility failed to take effective measures to prevent the presence of ants and black insects in a resident's room. This affected one (Resident #79) of the three residents reviewed for physical environment. The facility census was 96.

Findings included:

Medical record review for Resident #79 revealed an admission date of 11/10/21. Diagnoses included dementia and hypothyroidism.

Review of the functional assessment dated 02/22/22 revealed Resident #79 was alert and oriented to person, place, time, and situation and required one person assistance with transfers, wheelchair mobility, and toileting.

Observation and interview on 08/05/22 at 9:12 A.M. of Resident #79's room revealed a dozen small black ants crawling on the floor, two dead black insects in the resident's toilet, two dead black insects on the floor near the resident's bathroom, and one dead black insect on Resident #79's windowsill. Resident #79 confirmed the ants crawling on her floor near her bed and the dead black insect on her windowsill. Resident #79 stated she had made housekeeping aware of the insects.

Interview on 08/05/22 at 9:18 A.M. with Memory Care Coordinator #370 confirmed a dozen small ants crawling on Resident #79's floor near her bed, two dead black insects in the resident's toilet, and two dead black insects on her floor.

Interview on 08/05/22 at 12:06 P.M. with Maintenance Director (MD) #325 revealed the pest control company only applied treatment for insects, ants, mosquitos to the common areas on the first and second floor. MD #325 stated he did not have the pest control company apply insect treatment to any resident rooms in the past six months for ants, insects, or mosquitos. MD #325 stated when he received a complaint about insects in a resident's room, he would apply insect spray in the resident's room. MD #325 stated he was not able to provide any documentation to support treatment was completed to Resident #79's room.

Review of the facility's Pest Control Service History report revealed the pest control company provided treatment for insects in the dining room and common areas on the first floor on 03/21/22, 04/22/22, 05/19/22, and 07/21/22. The documentation did not support treatment for insects to any resident rooms on those dates.

This violation substantiates Complaint Number OH00134045.