What is THE MERRIMAN's CMS rating?

THE MERRIMAN has a two-star overall rating from CMS (Centers for Medicare & Medicaid Services), based on health inspections, staffing levels, and quality measures.

How many inspection deficiencies does THE MERRIMAN have?

THE MERRIMAN has 63 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at THE MERRIMAN?

THE MERRIMAN has a two-star staffing rating from CMS with 0.40 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is THE MERRIMAN located?

THE MERRIMAN is located in AKRON, OH. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does THE MERRIMAN have?

THE MERRIMAN has 55 certified beds.

Who owns THE MERRIMAN?

THE MERRIMAN is a for profit - corporation facility and is part of the LIONSTONE CARE chain.

Is THE MERRIMAN safe?

THE MERRIMAN has a clean safety record with no substantiated abuse findings, no immediate jeopardy citations, and is not on any federal watch list.

Do nurses at THE MERRIMAN stick around?

THE MERRIMAN has high staff turnover at 66%. High turnover can mean less continuity of care as staff change frequently.

Was THE MERRIMAN ever fined?

Yes, THE MERRIMAN has been fined $31,385 by federal regulators. Fines are issued for serious violations of Medicare and Medicaid requirements.

Is THE MERRIMAN on any federal watch list?

No, THE MERRIMAN is not on any federal watch list. It is not designated as a Special Focus Facility or SFF Candidate by CMS.

What have inspectors found at THE MERRIMAN?

Medicare inspectors have found 63 deficiencies at THE MERRIMAN: 3 serious, 60 moderate. Each deficiency represents a violation of federal nursing home requirements.

What questions should families ask when visiting THE MERRIMAN?

Families visiting THE MERRIMAN should ask about staff retention and training programs. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does THE MERRIMAN compare to other nursing homes?

THE MERRIMAN has a 2-star overall rating, which is below average compared to other nursing homes in OH. Families should carefully review inspection findings and consider alternatives.

THE MERRIMAN | 25/100 (Grade F)

Jun 2025 2 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0628 (Tag F0628)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed record reviews and interview, the facility failed to ensure resident medical records contained all required disc...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed record reviews and interview, the facility failed to ensure resident medical records contained all required discharging information and appropriate information was communicated to the receiving facility. This affected two residents (Resident #55, and Resident #65) of three residents reviewed for discharge planning. The census was 49. Findings include: 1. Review of the closed medical record for Resident #65 revealed an admission date of 03/13/25 and a discharge of 03/28/25. Diagnoses included aftercare following major joint replacement, dementia and osteoarthritis. Review of the Discharge Return Not Anticipated Minimum Data Set (MDS) 3.0 dated 03/28/25 revealed Resident #65 was cognitively impaired. He required maximum assistance for showering and moderate assistance with toileting. Review of the progress notes revealed there was no indication Resident #65 was being discharged or to where. Review of the March 2025 orders revealed Resident #65 had a follow-up appointment ordered on 03/17/25 scheduled for 03/28/25 at 10:45 A.M. Review of the Discharge summary dated [DATE] revealed Resident #65 was going to an unnamed nursing home. It stated the other facility was transporting him. It also stated Resident #65's doctor's appointment would be followed up in house by the new facility. Review of the printed copy of the summary revealed Resident #65 signed it. Interview on 06/25/25 at 12:10 P.M. with Administrator and Director of Nursing (DON) revealed the prior social worker's last day was 04/04/25. There was coverage by a sister facility's social worker 05/01/25 through 05/05/25. The current social service designee started 06/10/25. Administrator and DON stated they were all helping cover social service's responsibilities including discharge planning. They verified there was a lack of documentation which did not paint a clear picture of Resident #65's discharge plans. They verified Resident #65's appointment was missed because it was not relayed to the receiving facility. Interview on 06/25/25 at 1:00 P.M. with Resident #65's doctor's office revealed he was a no-show for his scheduled appointment on 03/28/25. His appointment had to be rescheduled for 04/23/25. Review of the facility policy titled Discharge Policy, last revised 08/2024, revealed at the time of discharge, the facility will provide the resident/responsible party with an appropriate summary of information to ensure optimal continuity of care. 2. Review of the closed medical record for Resident #55 revealed an initial admission date of 07/03/20 and a re-admission date of 10/07/22. He was discharged on 04/04/25. Diagnoses included chronic obstructive pulmonary disorder, sleep apnea and diabetes. Review of the Discharge Return Not Anticipated MDS 3.0 dated 04/04/25 revealed cognition was not assessed. He was dependent for his activities of daily living. Review of the progress notes revealed there was no indication Resident #55 was being discharged or to where. Review of the the Discharge summary dated [DATE] revealed Resident #55 was going to an unnamed nursing home. Interview on 06/25/25 at 12:10 P.M. with Administrator and Director of Nursing (DON) revealed the prior social worker's last day was 04/04/25. There was coverage by a sister facility's social worker 05/01/25 through 05/05/25. The current social service designee started 06/10/25. Administrator and DON stated they were all helping cover social service's responsibilities including discharge planning. They verified there was a lack of documentation which did not paint a clear picture of Resident #55's discharge plans. They verified Resident #65's appointment was missed because it was not relayed to the receiving facility. Review of the facility policy titled Discharge Policy, last revised 08/2024, revealed at the time of discharge, the facility will provide the resident/responsible party with an appropriate summary of information to ensure optimal continuity of care. This deficiency represents non-compliance investigated under Complaint Number OH00162554.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

Based on observations and interviews with staff the facility failed to label and date food and failed to ensure dietary staff wore hair restraints. This had the potential to affect all 49 residents wh...

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Based on observations and interviews with staff the facility failed to label and date food and failed to ensure dietary staff wore hair restraints. This had the potential to affect all 49 residents who received food from the kitchen. The census was 49. Findings include: Observation and interview on 06/24/25 at 10:45 A.M. of the kitchen revealed [NAME] #305 and Dietary Aide #227 were not wearing hair restraints in the food preparation area. They verified they did not have hair restraints on at that time. Observation and interview on 06/24/25 at 10:55 A.M. of the cooler revealed a small pan of two hamburgers in broth, a large plastic bucket of meatballs and a large pan of hamloaf were all undated and unmarked. Dietary Supervisor #412 verified the observation at this time. Review of the facility policy titled Labeling and Dating, undated, revealed proper date labeling was essential for food safety, legal compliance and quality contorl in the kitchen. Review of the facility policy titled Food Safety and Sanitation, copyrighted 2023, revealed hair restraints were required and should cover all hair on the head. [NAME] nets were required when facial hair was visible. This deficiency represents non-compliance investigated under Complaint Number OH00162554.

Jan 2025 11 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

Based on observation, interview, record review and review of facility policy, the facility did not ensure Resident #5 had properly sized clothing to maintain his right to dignity. This affected one re...

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Based on observation, interview, record review and review of facility policy, the facility did not ensure Resident #5 had properly sized clothing to maintain his right to dignity. This affected one resident (Resident #5) out of 21 residents reviewed for dignity. The facility census was 53. Findings include: Review of the medical record for Resident #5 revealed an admission date of 03/24/23 with diagnoses including schizophrenia, anemia, pain in left knee, muscle weakness, essential hypertension, history of falling, and other abnormalities of gait and mobility. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/03/25, revealed Resident #5 was cognitively intact, hallucinated and had delusions, had not rejected care, could walk independently with a walker, and required setup or clean up assistance for upper and lower body dressing and for putting on footwear. Observation on 01/21/25 at 11:11 A.M. revealed Resident #5 was in his room in full view of the hallway. The resident's gray sweatpants were so large on him he had to hold them up with his hand and every time he let go of the sweatpants, the pants would fall to his ankles exposing his legs and white disposable brief. Interview with Resident #5 at the time of observation revealed the resident was alert but unable to answer questions, as his focus of the interview was making statements he was a king . Observation on 01/21/25 at 12:11 P.M. revealed as Resident #5 was standing at the end of his bed and was writing on a piece of paper on his overbed table in his room, his gray sweatpants were around his ankles with his legs and white disposable brief exposed and in full view of the hallway outside his room. Observation on 01/22/25 at 8:51 A.M. revealed Resident #5 was observed to be holding up his sweatpants as he walked down the hallway with his walker. Observation on 01/22/25 at 9:00 A.M. revealed Resident #5's sweatpants were down to his ankles with his white disposable brief in full sight of other residents and staff in the outside smoking area as he smoked a cigarette. At the time of observation, Occupational Therapy Assistant #346 confirmed Resident #5's pants were down to his ankles with his legs and brief exposed in the outside smoking area as four residents were going outside to smoke and proceeded to alert staff so he could be brought inside. Interview on 01/22/25 at 9:06 A.M. with Certified Nursing Assistant (CNA) #335 confirmed Resident #5's pants were too large on him and would often fall to his ankles exposing his brief in open view of the hallway. Interview on 01/22/25 at 10:59 A.M. with Assistant Director of Nursing #377 confirmed Resident #5's pants were really large, but he had no guardian or family to provide clothes for him. She stated the facility had tried to find him better fitting clothing but could not give a reason why the facility hadn't found more appropriately fitting pants and went on to state having appropriately sized clothes for residents was above her. Interview on 01/23/25 at 9:27 A.M. with CNA #323 confirmed Resident #5 was wearing pants too big for him and would fall down exposing his lower body. CNA #323 stated she would go to laundry and find pants that would fit him. Review of facility policy Resident Rights, revised December 2016, revealed the resident had the right to a dignified existence.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

Based on record review, and interviews the facility failed to develop person-centered care plans to identify triggers of Post Traumatic Stress Disorder (PTSD) for Resident #10 and Resident #29. This a...

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Based on record review, and interviews the facility failed to develop person-centered care plans to identify triggers of Post Traumatic Stress Disorder (PTSD) for Resident #10 and Resident #29. This affected two residents (#10 and #29) of 21 residents reviewed for care plans. The facility identified three residents (#10, #29, and #37) with PTSD. The facility census was 53. Findings include: 1. Review of the medical record for Resident #29 revealed an admission date of 02/03/23. Pertinent diagnoses included post traumatic stress disorder, anxiety disorder, depression, and bipolar disorder. Review of Trauma Life Events Checklist, dated 07/28/23, revealed Resident #29 had a transportation accident and witnessed a transportation accident, had a serious accident at work, home or during recreational activity, had been physically assaulted and witnessed physical assault, had been assaulted with a weapon and witnessed assault with a weapon, had been sexually assaulted, had experienced other unwanted or uncomfortable sexual experiences, had been held in captivity, had witnessed a sudden accidental death, had witnessed serious injury, harm, or death to someone else, and had witnessed other very stressful events or experiences. Review of Resident #29's care plan, dated 11/21/24, revealed the resident had a history of trauma/PTSD since he was a survivor of crimes. Interventions included: attain the highest practicable physical, mental and psychosocial well-being to assure resident's safety; assist resident and family with access to psychiatry and psychosocial services; identify triggers for trauma; provide care in treating past trauma with coordination of resident's attending physician and/or psychiatric services. There were no specific triggers listed in the care plan. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 12/17/24, revealed Resident #29 was cognitively intact. Interview on 01/21/25 at 12:05 P.M. with Resident #29 revealed large crowds was a trigger for him and if he was in a crowd of people it would cause him anxiety related to PTSD. Resident #29 stated since he had been at the facility he stayed to himself in his room to avoid being triggered. Interview on 01/22/25 at 11:41 A.M. with Certified Nursing Assistant (CNA) #400 revealed she didn't know crowds were a trigger for Resident #29. Interview on 01/22/25 at 11:43 A.M. with Registered Nurse #328 revealed she was aware there were residents with PTSD, but she was unaware if Resident #29 had any triggers. Interview on 01/22/25 at 3:22 P.M. with Activity Aide #383 revealed she was not aware Resident #29 would be triggered by crowds. Interview on 01/22/25 at 3:48 P.M. with Social Services Director (SSD) #351 revealed she didn't think she had the ability to ask for triggers for residents with PTSD, and she was unaware of any triggers for Resident #29. SSD #351 verified there were no triggers identified on Resident #29's care plan for PTSD. 2. Review of the medical record for Resident #10 revealed an admission date of 07/25/23. Pertinent diagnoses included post traumatic stress disorder (PTSD), insomnia, depression, chronic pain syndrome, and abnormalities of gait and mobility. Review of Resident #10's care plan, which was initiated on 07/31/24, revealed no care plan for PTSD and no identified triggers. Review of the quarterly MDS 3.0 assessment, dated 10/30/24, revealed Resident #10 was cognitively intact, and for seven to 11 days during the assessment reference period the resident had little interest or pleasure in doing things, had trouble falling or staying asleep or sleeping too much; had trouble concentrating on things such as reading the newspaper or watching television; moved or spoke slowly that other people had noticed or the opposite being fidgety or restless that you have been moving around more than usual. Review of a 12/23/24 psychiatry note in Resident #10's medical record revealed he had been referred to their services for depression. Resident #10 had a PTSD diagnosis, and he endorsed symptoms of flashbacks and nightmares. The resident reported being hit by a motor vehicle causing him to have multiple surgeries and being in a coma for about nine months. The note indicated there had been no mention of this incident per chart review. Plan was for staff to monitor and report to the psychiatrist for worsening signs/symptoms of PTSD. Interview with Resident #10 on 01/21/25 at 12:05 P.M. confirmed he had a diagnosis of PTSD from getting hit by a car. He stated his triggers were big groups of people and when he was spoken to in an aggressive or disrespectful manner. Interview on 01/22/25 at 11:41 A.M. with Certified Nursing Assistant (CNA) #400 revealed she didn't know the triggers for Resident #10. Interview on 01/22/25 at 11:43 A.M. with Registered Nurse #328 revealed she was aware there were residents with a PTSD, but she did not know the triggers for Resident #10. Interview on 01/22/25 at 3:22 P.M. with Activity Aide #383 revealed she was not aware of triggers for Resident #10. Interview on 01/22/25 at 3:48 P.M. with SSD #351 revealed she didn't think she had the ability to ask for triggers for residents with PTSD and was unaware of any triggers for Resident #10. Review of Resident #10 care plan and interview on 01/22/25 at 4:58 P.M. with SSD #351 confirmed there was no care plan for PTSD and no triggers on the care plan. Review of facility Trauma-informed Care in Nursing Facilities education material, dated 10/25/24 with staff signatures, revealed the facility would realize the widespread impact of trauma and understand potential paths for recovery, recognize the signs and symptoms of trauma in clients, families, staff, and others involved with the system and would actively seek to resist re-traumatization. Review of facility policy Trauma Informed Care, revised March 2019, revealed nursing staff would be trained on screening tools, trauma assessment and how to identify triggers associated with re-traumatization and trauma care would be culturally sensitive and person centered.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0688 (Tag F0688)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interview the facility failed to ensure Resident #21 wore a hand splint according to p...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interview the facility failed to ensure Resident #21 wore a hand splint according to physician order. This affected one resident (Resident #21) of one resident reviewed for splint devices. The facility identified three residents (#6, #12 and #21) with orders for hand splints. The facility census was 53. Findings include: Review of the medical record for Resident #21 revealed an admission date of 08/27/23. Diagnoses included chronic pain, hemiplegia and hemiparesis following cerebral infarction (stroke), and anxiety disorder. Review of Resident #21's occupational therapy evaluation and plan of treatment, dated 07/08/24, revealed the resident had been referred to therapy due to increased assist and worsening left upper extremity tone, especially in his hand, and the resident had a functional limitation present due to a contracture. Review of Resident #21's physician orders revealed an order dated 08/16/24 for left resting hand splint to be on in A.M. and removed in P.M. Check skin prior to and after application. Inform CNP(certified nurse practitioner)/MD (doctor of medicine) of refusals every shift. Review of Resident #21's occupational Discharge summary, dated [DATE], revealed Resident #21 received occupational therapy from 07/08/24 to 09/05/24 and by discharge on [DATE] the resident was wearing the splint for eight hours without signs or discomfort and prognosis was excellent to maintain current level of care with consistent staff support. The discharge recommendation was to continue use of left resting hand splint. Review of the care plan, dated 08/16/24, revealed Resident #21 had an alteration in musculoskeletal status related to impairment to the left side. Interventions included left resident hand splint to be on in A.M. and removed P.M. Check skin prior to and after application, Inform CNP/MD of refusals. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 11/13/24, revealed Resident #21 was moderately impaired cognitively and had impairment on one side of functional limitation in range of motion for upper extremity, and had no rejection of care. Further review of progress notes from 07/24/24 to 01/21/25 in Resident #21's medical record revealed no documentation of the resident refusing to wear his splint. Review of the task section in Resident #21's medical record for the past 30 days revealed no evidence the splint was applied as ordered on 12/30/24, 12/31/24, 01/01/25, 01/02/25, 01/03/25, 01/04/25, 01/05/25, 01/06/25, 01/08/25 and 01/09/25. The task documentation revealed the last time staff marked Resident #21 wore his splint was on 01/12/25. Observation on 01/21/25 at 10:58 A.M. revealed the resident had a contracted left hand and was not wearing a splint. Interview with Resident #21 at time of observation revealed he had a splint but didn't know where it was, and the last time he wore his splint was a couple weeks ago. Observation on 01/22/25 at 8:48 A.M. revealed Resident #21 was not wearing a splint to his contracted left hand. Interview on 01/22/25 at 9:09 A.M. with Certified Nursing Assistant (CNA) #335 stated he (Resident #21) wears a thing for his hand. I don't know why he is not wearing it, and therapy would know why he isn't wearing it. Interview on 01/22/25 at 11:29 A.M. with Director of Therapy #375 and Occupational Therapist #313 both confirmed Resident #21 wasn't wearing his splint and didn't know why. They stated he needed to wear the split for contracture prevention and if he didn't wear it, he had the potential for his contracture to get worse. Interview on 01/22/25 at 11:46 A.M. with CNA #400 revealed she thought he was supposed to wear a splint but was not sure if he had one. Observation of Resident #21's room with CNA #400 at the time of interview revealed Resident #21's splint was sitting on top of his dresser, which was next to the door. Interview on 01/23/25 at 2:20 P.M. with the Director of Nursing (DON) confirmed Resident #21's medical record under the task section indicated the last time it was documented the splint had been applied was on 01/12/25. The DON stated the aides were supposed to document when they applied the splint, and if nothing was marked, the splint had not been applied. Review of facility policy Adaptive Equipment, revised January 2024, revealed the use of adaptive equipment, which included splints, would be carried out or supervised by members of the nursing staff to assist residents with attaining or maintaining their highest level of physical well-being.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and facility policy review, the facility failed to ensure Resident #5 and Resi...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and facility policy review, the facility failed to ensure Resident #5 and Resident #29 were free from potential accident hazards related to smoking. This affected two residents (#5 and #29) of four residents reviewed for accidents/hazards. The facility identified 29 residents (#4, #5, #6, #10, #11, #13, #15, #16, #17, #18, #21, #23, #29, #31, #32, #34, #38, #40, #41, #43, #44, #45, #46, #48, #49, #50, #51, #56, #156) as smokers. The facility census was 53. Findings include: 1. Record review revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including schizophrenia, generalized muscle weakness and need for assistance with personal care. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #5 had intact cognition with hallucinations and delusions but no behavioral symptoms or rejection of care. He was independent with mobility using a walker. Review of the care plan for Resident #5 dated 01/17/25 revealed he was a smoker and was at risk for injury related to smoking. Interventions included educate on risks of smoking and offer cessation assistance, smoking apron to be worn when smoking, smoking assessment quarterly and as needed and supervise smoking. Further review of the medical record for Resident #5 revealed a Smoking and Safety assessment dated [DATE] and completed by Assistant Director of Nursing (ADON) #377. The assessment revealed the resident smoked cigarettes and was deemed to be a safe independent smoker. Review of the incident/accident log dated 10/01/24 to 01/22/25 revealed Resident #5 had not had any documented burns or other accidents related to smoking. Further review of the medical record also revealed the resident had not been treated for any burns or other accidents related to smoking during this time period. Observation on 01/22/25 at 8:51 A.M. and 9:06 A.M. revealed Resident #5 was smoking a cigarette in the outside smoking area. When Resident #5 was done smoking his cigarette his threw his cigarette butt toward the building which landed on the ground. Resident #5 was not wearing a smoking apron and the pants he was wearing had nine burn holes in the pants. At the time of observation, Licensed Practical Nurse (LPN) #336 was present and confirmed the burn holes in Resident #5's pants. LPN #336 stated Resident #5 was supposed to wear a smoking apron and confirmed he hadn't been wearing one at this time. Interview on 01/22/25 at 9:10 A.M. with Certified Nursing Assistant (CNA) #335 revealed almost all Resident #5's clothes had burn holes in them. Observation of Resident #5's clothes in his wardrobe with CNA #335 revealed black sweat pants with 30 burn holes on the front, five t-shirts/shirts with one to 23 burn holes on each item, a gray and black jacket with 16 burn holes on the front and a pair of gray shorts with six burn holes on the front of the pants. The size of the burn holes n the clothing ranged from pencil-eraser sized to quarter coin size. At the time of observation, CNA #335 confirmed the condition of the clothing with the burn holes present. Interview on 01/22/25 at 10:59 A.M. with ADON #377 revealed she had completed Resident #5's smoking assessment on 01/21/25 in response to concerns raised by the State agency Life Safety Code surveyor on 01/21/25 pertaining to safe smoking by another resident in the facility. ADON #377 stated she did not thoroughly inspect Resident #5's clothing to see if there were any burn holes and that should have been done because that was one of the questions on the assessment to determine if he was safe to smoke independently. ADON #337 stated if she had noticed burn holes on his clothing the resident would be encouraged to wear a smoking apron and the interdisciplinary team would discuss if a smoking apron was sufficient or if the resident would need to be a supervised smoker. ADON #337 revealed there were currently no residents she was aware of who wore a smoking apron at this time. She stated throwing a lit cigarette butt to the ground was not an appropriate way to extinguish the cigarette which was another risk factor on the smoking assessment indicating unsafe smoking. She stated the resident should be able to extinguish the cigarette appropriately and throw it in the receptacle for cigarette butts. 2. Review of medical record for Resident #29 revealed an admission date of 02/03/23 with diagnoses including chronic obstructive pulmonary disease, bipolar disorder, chronic pain, chronic combined systolic (congestive) and diastolic heart failure, essential hypertension , tobacco use, anxiety disorder, and other psychoactive substance abuse. Review of the care plan dated 06/01/23 revealed Resident #29 was a smoker but it was noted on 12/17/24 smoking cessation was in place. Interventions included the resident would comply with facility smoking policy and the resident verbalized safe smoking practices. Review of Resident #29's physician's orders revealed an order dated 09/28/23 for oxygen three liters per minute as needed for respiratory support. Review of quarterly Minimum Data Set (MDS) 3.0 assessment, dated 12/17/24, revealed Resident #29 was cognitively intact and was on oxygen during the assessment reference period. Review of progress notes dated 12/25/24 through 01/20/25 revealed no documented incidents of the resident smoking in his room. Observation on 01/21/25 at 9:45 A.M. with Director of Maintenance (DM) #370 revealed an odor of smoke in the hallway near Resident #29's room. Further investigation found the odor to be emanating from Resident #29's room. Upon entering Resident #29's room with DM #370, the resident was observed sitting in a recliner located between the bed and doorway. A blue plastic lighter, a thin metal pipe approximately eight inches long with burnt soot on the end, two toothpick size pieces of wood with soot on the ends, a small metal clip with soot on it fastened to a metal handle and a yellow vape device with Pulse THC were observed sitting on a rolling table beside Resident #29's recliner. Further observation noted a red sign on Resident #29's doorway to indicate no smoking oxygen in use in the room of Resident #29. Resident #29 had an oxygen mask on his face at the time of the observation but was not smoking. DM #370 verified the above findings at the time of the observation. A progress note entry dated 01/21/25 revealed suspected smoking violation. Cup with water and cigarette butts observed in room. Oxygen in room not being used. Resident educated on smoking policy and changed to supervised smoking. Placed on increased supervision. Will reassess in 72 hours. Resident alert and oriented and able to verbalize understanding of smoking policy. Administrator will issue 30 day discharge notice for any subsequent infraction. Interview on 01/21/25 at 9:49 A.M. with Resident #29 revealed he was a smoker. Additionally, when asked about smoking in his room Resident #29 admitted he had previously smoked in his room but stated he was not smoking at the time when the observations were made. A review of the facility's smoking policy revealed the facility allowed residents to smoke in the designated smoking area located in a small courtyard near the east side of the building. Further review of the policy revealed if deemed competent they were responsible for acquiring and maintaining their own smoking materials including lighters, but the policy did not include provisions for residents who were smokers, used oxygen and the elimination sources of ignition in the areas of those residents.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, facility policy review , and review of manufacturer's user guide, the facility...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, facility policy review , and review of manufacturer's user guide, the facility failed to ensure Resident #21's head strap for the BiPAP ( bilevel positive airway pressure) machine was clean and sanitary and failed to ensure Resident #34's oxygen tubing was dated. This affected two residents (#21 and #34) out of two residents reviewed for respiratory care. The facility census was 53. Findings include: 1. Review of medical record for Resident #21 revealed an admission date of 08/27/23. Diagnoses included chronic obstructive pulmonary disease (COPD) and cancer lesion. Review of physician orders for Resident #21 revealed an order dated 08/27/23 to replace BiPAP mask, headgear/straps and tubing every night shift every three months. Review of quarterly Minimum Data Set (MDS) 3.0 assessment, dated 11/13/24, revealed Resident #21 was moderately impaired cognitively, exhibited no behaviors or rejection of care, and was on a noninvasive mechanical ventilator. Review of Resident #21's care plan revealed a care plan for COPD with interventions including use of a BiPAP machine at bedtime with full face mask to be applied at hour of sleep (HS) and as needed. Observation on 01/22/25 at 8:49 A.M. of Resident #21's head straps for his BiPAP machine revealed the head straps connected to the face mask and the straps were dirty and saturated with what appeared to be blood stains. Resident #21 had a growth, red in color and approximately the size of a golf ball around his left temple area. Interview with Resident #21 stated he had a growth on the side of his head which would bleed at times causing blood to get on the straps of his BiPAP machine. Observation on 01/23/25 at 9:19 A.M. revealed the head straps for his BiPAP machine remained dirty and saturated with what appeared to be blood stains. At the time of observation, Resident #21 stated the red color on his mask straps was from blood from the growth on the side of his head which he would sometimes pick, causing the area to bleed. He stated the straps had been replaced a couple weeks ago. Observation on 01/23/25 at 10:43 A.M. of Resident #21 with Registered Nurse #328 confirmed the straps were dirty with what appeared to be blood. At the time of observation, RN #328 stated that's disgusting, and the straps should have been replaced with new straps. Interview on 01/23/25 at 1:24 P.M. with the Director of Nursing (DON) confirmed a bloody head strap should have been replaced or washed. Review of facility policy CPAP/BiPAP Support,revised April 2023, revealed the policy didn't address the cleanliness of the head straps. Review of manufacturer user guide, undated, revealed it is important that you regularly clean the device. 2. Review of the medical record revealed Resident #34 was admitted on [DATE] with a primary diagnosis of COPD. Review of physician orders for Resident #34 dated 11/20/24 revealed an order for oxygen at two to four liters via nasal cannula continuous to maintain oxygen saturation greater than or equal to 92 percent as needed for shortness of breath and change oxygen tubing every week, one time a day every Sunday. Observation on 01/21/25 at 10:52 AM revealed Resident #34 sitting on the edge of his rollator with a portable oxygen canister over the handle of the rollator. The tubing to the portable oxygen canister was not labeled with a date of when it was last changed and the oxygen flow rate was set to four liters. To the left of the resident next to his bed was an oxygen concentrator running at four liters which was connected to nasal cannula tubing (tubing that goes into the nose to administer oxygen) and not connected to the resident at the time of the observation. The oxygen tubing was not labeled with a date of when it was last changed. Resident #34 stated he used the oxygen concentrator when in the room and when he would leave the room he would use his portable oxygen. An interview on 01/21/25 at 11:15 AM with Registered Nurse (RN) #500 revealed she was not sure about the oxygen policy or when to change the oxygen tubing. She stated every facility was different and she could not recall from memory when to change the tubing. RN #500 verified the tubing should be labeled with a date of when it was last changed. Observation on 01/21/25 at 2:00 PM of Resident #34 with the DON verified the oxygen tubing was not labeled on Resident #34. The DON stated it was the policy to label and date oxygen tubing. The DON revealed the procedure was to change the tubing every 72 hours. The DON stated the staff needed a refresher on the oxygen administration policy and procedures so she would conduct an inservice on that policy. Review of facility policy labeled, Oxygen Administration dated 04/01/23 revealed under the policy Explanation and Compliance Guidelines it stated: to change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

Based on observation, interview and record review the facility failed to ensure all insulin medications were accurately labeled to ensure safe administration of medications. This affected three reside...

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Based on observation, interview and record review the facility failed to ensure all insulin medications were accurately labeled to ensure safe administration of medications. This affected three residents (Resident #3, #15 and 36) of nine residents reviewed for medication storage. The census was 53. Findings include: 1. Review of the medical record for Resident #3 revealed admission date 06/27/24. Diagnoses included type two diabetes mellitus and depression. Review of the physician orders for January 2025 revealed Humalog (insulin) Kwik Pen 100 units per milliliter (unit/ml) eight units subcutaneous (SQ), three times a day and per sliding scale. Order for Toujeo Solostar (long-acting insulin) 40 units at bedtime. 2. Review of the medical record for Resident #15 revealed an admission date 06/11/24. Diagnoses included type two diabetes mellitus. Review of the physician orders for January 2025 revealed Fiasp pen 100 unit/ml to give per sliding scale. 3. Review of the medical record for Resident #36 revealed an admission date 01/26/23. Diagnoses included type two diabetes mellitus and depression. Review of the physician orders for January 2025 revealed Fiasp (insulin) SQ per sliding scale. Toujeo Solostar (long-acting insulin) 40 units at bedtime. Observation on 01/22/25 at 9:49 A.M. of medication cart #2 revealed Humalog Kwik Pen 100 unit/ml for Resident #3 opened and not dated when it was opened, Fiasp pen 100 unit/ml opened and not dated when it was opened for Resident #36, Fiasp pen 100 unit/ml for Resident #15 was opened and not dated and two Toujeo 300 unit/ml pens not dated when opened and the labels with resident names were not on the insulin pens. Interview on 01/22/25 at 9:55 A.M. with Register Nurse (RN) #325 verified all insulin's are to be dated when they are opened and all medications are to have the resident name on them. RN #325 verified Resident #3, #15 and #36's insulin's were not dated when they were opened to ensure they were not outdated and that two Toujeo insulin pens did not have a label for which resident medications and how to take it, also they were not dated. Review of the facility policy, Storage of Medications, dated 04/2007 revealed the facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. Review of the pharmacy guideline for insulin storage revealed Humalog, Fiasp and Torjeo are to be refrigerated until they are used. After insulins were opened, they have to be dated with open date and disregarded after 28 days.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0805 (Tag F0805)

Could have caused harm · This affected 1 resident

Based on observation, record review and interview the facility did not ensure Resident #9 received pureed food to meet individual needs. This affected one resident (Resident #9) of five residents revi...

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Based on observation, record review and interview the facility did not ensure Resident #9 received pureed food to meet individual needs. This affected one resident (Resident #9) of five residents reviewed for food/nutrition. The facility identified one resident (#9) as receiving pureed food texture. The facility census was 53. Findings include: Review of the medical record for Resident #9 revealed an admission date of 02/14/22 with diagnoses including severe protein-calorie malnutrition, dementia without behavioral disturbance, and oropharyngeal phase dysphagia (difficulty swallowing between the mouth and esophagus). Review of the physician orders for Resident #9 dated January 2025 revealed active orders for a regular diet, mechanical soft with puree meats texture, regular-thin consistency, large portions, and snacks three times a day after meals with a start date of 05/24/23. Observation on 01/22/25 at 1:27 P.M. of Resident #9's lunch meal revealed Resident #9 was served mechanical soft (ground with gravy) Salisbury steak. There was no pureed meat. The meal ticket on Resident #9's lunch tray revealed he was to be served mechanical soft, large portions with puree meat only. Interview on 01/22/25 at 1:27 P.M. during the above observation with Dietary Manager (DM) #303 verified Resident #9 was served mechanical soft meat but should have received pureed meat. DM #303 stated she was in the process of checking diet orders against the meal tickets to ensure they were updated but had not gotten to Resident #9's yet so she was unclear of Resident #9's diet order.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

Based on observation, interview and review of facility policy the facility did not maintain clean bathing and shower rooms for all residents excluding 20 residents (Resident #2, # 3 #7, #8, #9, #12, #...

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Based on observation, interview and review of facility policy the facility did not maintain clean bathing and shower rooms for all residents excluding 20 residents (Resident #2, # 3 #7, #8, #9, #12, #15, #17, #19, #21, #22, #23, #24, #25, #26, #28, #32, #33, #35 and #46) the facility identified as not using the bathing and shower rooms. The facility census was 53. Findings include: Observation on 01/21/25 at 10:42 A.M. of the facility bathing room used for all residents who preferred and/or needed bathing revealed the toilet in the bathing room had no water in the toilet and had feces in the bowl. There was no signage on the toilet saying it was not to be used. The floor was dirty and there was dirt built up around the edges of the floor. Observation on 01/21/25 at 10:50 A.M. of the facility shower room used for all residents who could shower revealed there were missing tiles on the floor of the shower area, and the shower was leaking with a black substance on the wall of the shower. The grout along the bottom of the shower was black/brown in color. Used gloves were on the floor, a dirty towel was sitting on an old cloth chair and there was a gritty dirt build-up on the floor behind the door. Interview on 01/21/25 at 10:53 A.M. with Housekeeper (HK) #340 verified and observed all concerns of the bathing room and shower room. HK #340 verified both the shower room and bathing room were in use for residents to use for baths and showers. Review of the facility policy, Bathrooms, dated 04/2006 revealed bathrooms shall be maintained in a clean and sanitary manner and shall be cleaned on a daily basis. Review of the facility policy, Floor, dated 12/2009 revealed floors shall be maintained in a clean, safe and sanitary manner.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Menu Adequacy (Tag F0803)

Could have caused harm · This affected multiple residents

Based on observation, interview, and record review the facility failed to ensure the correct serving size of mechanical soft meat was served to Resident #5, #14, #25, #32, #35 and #156. This affected ...

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Based on observation, interview, and record review the facility failed to ensure the correct serving size of mechanical soft meat was served to Resident #5, #14, #25, #32, #35 and #156. This affected six residents (#5, #14, #25, #32, #35, and #156) of seven residents (#5, #9, #14, #25, #32, #35, and #156) the facility identified as receiving a mechanical soft diet excluding Resident #9 who had a physician order for mechanical soft diet with pureed meats only. The facility census was 53. Findings include: Review of the menu revealed for 01/22/25 lunch meal included Salisbury steak, mashed potatoes, and lima beans. Review of the menu/diet spreadsheet revealed for the mechanical soft diet the ground Salisbury steak serving utensil was a #6 scoop (5.33 ounces). Review of the diet type report dated 01/22/25 revealed Residents #5, #14, #25, #32, #35, and #156 had physician orders for the mechanical soft diet. Observation on 01/22/25 between 11:52 A.M. and 1:02 P.M. of lunch tray line service revealed Dietary [NAME] (DC) #361 serving the mechanical soft (ground) Salisbury steak using an ivory colored handle scoop. Interview on 01/22/25 at 1:04 P.M. with Dietary Manager (DM) #303 verified the ivory handled scoop was a #10 scoop providing 3.20 ounces and the #6 scoop providing 5.33 ounces should had been used per the diet spreadsheet for the mechanical soft (ground) Salisbury steak.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0802 (Tag F0802)

Could have caused harm · This affected most or all residents

Based on observation, interviews, and record review the facility failed to ensure there was sufficient dietary staff for timely meal service. This had the potential to affect all residents who receive...

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Based on observation, interviews, and record review the facility failed to ensure there was sufficient dietary staff for timely meal service. This had the potential to affect all residents who received meals from the kitchen. The facility did not identify any residents who did not eat by mouth. The facility census was 53. Findings include: Review of the mealtimes provided by the facility revealed breakfast at 8:00 A.M., lunch at 12:00 P.M., and dinner at 5:00 P.M. Observations during the initial tour of the kitchen on 01/21/25 from 9:45 A.M. to 10:11 A.M. revealed three staff plating breakfast trays for resident meal service. Interview on 01/21/25 between 10:11 A.M. and 10:16 A.M. with Dietary [NAME] (DC) #376, DC #309 and Dietary Aide (DA) #372 revealed the kitchen was short staffed and this affected meals not being served from the kitchen in a timely manner. DC #376 verified today's breakfast was late, as it should have went out at 8:00 A.M., lunch would then be late too, and late meals happened due to not enough staffing in the kitchen. Interviews on 01/21/25 between 10:10 A.M. and 3:59 P.M. with Residents #11, #19, #16, #29, and #56 stated the meals were always late. Interview on 01/21/25 at 10:35 A.M. with Resident #45 stated he still had not received breakfast yet and breakfast was at 8:00 A.M. Observation on 01/21/25 at 12:58 P.M. of the nursing unit and dining areas revealed no meal carts. Interview at this with Certified Nurse Aides (CNA) #323 stated lunch had not been brought down yet. Interview on 01/23/25 at 8:35 A.M. with Dietary Manager (DM) #303 stated she had heard complaints from residents regarding late meals and that it was related to insufficient dietary staffing. DM #303 stated she had recently hired three new staff for the 6:00 A.M. to 2:00 P.M. shift that covers breakfast and lunch. DM #303 stated the new staff were to start orientation on 01/28/25.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

Based on observations, interview, and record review, the facility failed to ensure food was stored, prepared and served under sanitary conditions. This had the potential to affect all 53 residents rec...

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Based on observations, interview, and record review, the facility failed to ensure food was stored, prepared and served under sanitary conditions. This had the potential to affect all 53 residents receiving meals from the kitchen, as the facility identified no residents who did not eat by mouth The facility census was 53. Findings include: Observations during the initial tour of the kitchen on 01/21/25 from 9:45 A.M. to 10:11 A.M. revealed the following sanitation concerns: • The floor of the small storage room where pots, pans and various kitchware for resident meal servce was stored was dirty with dirt stains and debris under the storage racks. • The stove had a heavy build-up of stains and food debris. • The prep table across from the stove had moderate food debris and stains on it. • The robotcoup (blender used to mechanically alter food) had various dried food debris and stains all over it. • The large, black plug in fan next to the robotcoup had a moderate amount of dust on the fan blades and blade cover. • The floor where the steamer and plate warmer were located had a moderate amount of dirt stains, crumbs and debris. • The small silver counter/stand the mixer sat on had various food crumbs and stains. • Walk-in cooler #1 floor had various debris, a cracked egg with dried yolk, an old onion and various debris under the racks. The rack on the left had a medium silver pan of green beans covered with saran wrap not labeled or dated. Next to it was another medium sized pan covered with saran wrap with parchment paper inside and an unknown food item that was also not labeled and dated. • Walk-in freezer #1 and #2 both had various food, crumbs, and debris throughout floor. • Underneath the rack across from walk-in freezer had a slice of bread and debris. • The dry storage area had several boxes greater than 15 boxes including sugar, cans of pop, condiments, and other food items stored directly on the floor. • On top of the ice machine were several dried, sticky red and tan stains. • There was a pile of several dirty towels on the three compartment sink. • Observed next to the steam table was a cart that had on the top shelf plates, and the middle and bottom shelves had several insulated bottoms for the plates. There were various crumbs/food debris, and stains all over the cart. • The bottom shelf of the steam table had various food debris and crumbs. • The floor where the dish machine was had dirt stains and various debris, there was a large brown, plastic container that had standing water under the dish machine. Observed on top of the dish machine was a large whitish dried substance and various debris. Interview on 01/21/25 between 10:11 A.M. and 10:16 A.M. with Dietary [NAME] (DC) #376 verified the identified findings and stated the kitchen was short staffed so cleaning was not getting done as it should. Reviewed policy Food Receiving and Storage, revised October 2017 revealed food in designated dry storage areas shall be kept off the floor (at least 18 inches) and clear of sprinkler heads, sewage/waste, disposable pipes and vents. All foods stored in the refrigerator or freezer will be covered, labeled, and dated. Reviewed policy Sanitation, revised October 2008 revealed the food service area shall be maintained in a clean and sanitary manner.

Jan 2025 6 deficiencies 1 Harm

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Accident Prevention (Tag F0689)

A resident was harmed · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Bas...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on closed record review, interview, and policy review, the facility failed to provide necessary intervention, including a bed of appropriate size for Resident #56 to prevent a fall with injury during personal care. Actual harm occurred on 12/16/24 when Resident #56, who was dependent on staff for incontinence care and personal hygiene sustained a fall out of bed while staff were providing incontinence care, resulting in a distal fracture to the end of her right femur and a closed distal fracture to the end of her left femur. The facility identified the resident needed a king bariatric bed rather than a queen (bed) as the root cause of the fall. This affected one resident (#56) of three residents reviewed for accidents. Findings include: Review of Resident #56's closed medical record revealed the resident was admitted on [DATE] and discharged on 12/19/24 with diagnoses including morbid obesity, major depressive disorder and poly osteoarthritis. Review of Resident #56's physician orders revealed an order dated 04/02/24 to use a mechanical (Hoyer) lift for transfers with two staff members; an order dated 07/03/24 for bilateral assist bars to the bed to enhance bed mobility per the resident's request every shift; and an order dated 08/29/24 for a low air loss mattress to the bed. Review of Resident #56's Occupational Therapy Discharge Summary from services provided 07/09/24 to 08/16/24 revealed the resident's highest practical level was achieved. The discharge recommendations indicated to discharge with staff assistance and the resident continuing with help. A restorative program was not indicated. The resident was independent with eating, setup/cleanup assistance with oral hygiene, dependent with toilet hygiene, required substantial/maximal assistance with dressing the upper body, was dependent with dressing the lower body, dependent with washing, dependent with showering/bathing and dependent with putting on and removing footwear. Review of Resident #56's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition; had no impairment on the upper extremities; impairment on both sides on the lower extremities; used a wheelchair mobility device; and was dependent (on staff) for showering, toileting, dressing and personal hygiene. Review of Resident #56's progress note dated 12/16/24 at 5:38 P.M. authored by Licensed Practical Nurse (LPN) #821 revealed the resident was being provided care and turned and repositioned. The resident slid) off the mattress and the certified nursing assistant (CNA) assisted her to the floor. The resident landed on one knee and complained of pain. She was transferred to the hospital. Review of Resident #56's Witnessed Fall form dated 12/16/24 at 5:00 P.M. revealed the resident was getting care and being turned and repositioned when she slid off the mattress and the CNA assisted her to the floor. Review of Resident #56's fall witness statement form dated 12/16/24 authored by CNA #845 revealed as the staff were changing the resident, she went to roll over and slid off the mattress and was guided down to the floor. Review of Resident #56's fall witness statement dated 12/16/24 authored by CNA #864 revealed when the staff were cleaning up the resident, she turned to the side and slid, and CNA #845 guided her to the floor. Review of an Orthopedic Surgery Consultation Note dated 12/16/24 at 9:27 P.M. revealed Resident #56 was evaluated for bilateral distal femur fractures sustained after a ground level fall. The resident had a past medical history of severe morbid obesity with a weight of 207.7 kilograms (kg) or 456.9 pounds. The resident stated she sustained a fall when her cleaning care was trying to get her out of bed, and she fell on both of her knees. The resident stated she had been bedbound for the past four years in which she used a wheelchair for two of those years. The resident was told she needed surgery; however, she declined the surgery after a thorough conversation about the risks and benefits of proceeding with the surgery versus declining the surgery. Review of Resident #56's progress note dated 12/17/24 at 2:34 A.M. authored by LPN #876 revealed the resident was admitted (to the hospital) for sepsis, distal fracture to the end of the right femur and a closed distal fracture to the end of the left femur. Interview on 01/06/25 at 7:32 A.M. with LPN #821 revealed on 12/16/24, staff were providing incontinence care for Resident #56 when the resident slid off the mattress and onto the floor. LPN #821 revealed more than one staff member was in the room with Resident #56, however CNA #845 was the resident's main caregiver at the time of the fall. LPN #821 confirmed Resident #56 had half side rails and her feet slid from the bed when the staff rolled her. Interview 01/06/25 at 8:11 A.M. with Therapy Supervisor #856 revealed Resident #56 required maximum assistance with activity of daily living (ADL) care and stated there were usually at least two staff required to assist the resident. Telephone interview on 01/06/25 at 3:24 P.M. with CNA #845, a CNA identified to be assisting with Resident #56's care on 12/16/24 when the resident fell out bed revealed there were three staff including herself who were providing care to the resident at the time of the incident. She stated CNA #864 and CNA Agency #983 were in the room with her and they were on one side of the bed while she was on the other. CNA #845 stated CNA #864 and CNA Agency #983 rolled Resident #56 towards her and the resident's foot and leg slipped off the bed and she was unable to hold the resident upright. The resident fell to the floor on one knee and was then lowered to the floor. The CNA denied the resident's half bed rail broke at the time of the incident. During the interview, the CNA revealed she was unsure how many staff members were required to provide care to Resident #56, but stated there were usually three to four staff members who were needed to assist with rolling the resident (in bed). During the interview CNA #845 stated she felt the resident needed a bigger bed. Telephone interview on 01/06/25 at 3:45 P.M. with CNA #864, who was also identified to be assisting with Resident #56's care on 12/16/24 revealed she was in the room with CNA #845 providing care (there were a total of three staff members present) and when the resident was rolled (in bed), her leg slipped out of bed and the resident went down to the floor on one knee. CNA #864 stated CNA #845 attempted to help the resident to the floor by guiding her with her body. She stated after the incident, they had the nurse evaluate the resident. Interview on 01/07/25 at 9:38 A.M. with the Director of Nursing (DON) revealed Resident #56 had a care plan in place for two or more staff for assistance with bed mobility and incontinence care and stated there were always more than two assisting. Review of a facility quality assurance program improvement plan related to Resident #56 and the fall sustained on 12/16/24 revealed the facility identified the resident needed a king bariatric bed rather than a queen (bed) as the root cause of the fall. Review of the Managing Falls and Fall Risk policy revised 08/2024 indicated the staff, with the input of the attending physician or nurse practitioner as needed, would implement a fall prevention plan to reduce the specific factor(s) of falls for each resident at risk or with a history of falls. This deficiency represents non-compliance investigated under Complaint Number OH00160814 and Complaint Number OH00160613. The deficient practice was corrected on 12/18/24 when the facility implemented the following corrective actions: On 12/16/24 the Administrator and Director of Nursing (DON) initiated a Quality Assurance and Performance Improvement (QAPI) plan to address Resident #56's fall. On 12/17/24 Resident #56 was transferred to the emergency room (ER). On 12/17/24 the DON ordered a new larger bed for Resident #56 that was delivered on 12/18/24. On 12/17/24 a whole house audit was completed to ensure appropriate mattress surface for bed mobility for all residents. From 12/17/24 to 12/18/24 staff education was completed related to bed mobility and safety concerns. From 12/18/24 to 01/10/25 staff interviews were completed to address if they felt they had enough room to turn residents in bed, with no issues noted. From 12/20/24 to 01/10/25 continuing audits were to ensure the corrective actions were effective, with no issues noted.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure Residents #9 and #44's mighty shake nutritional...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure Residents #9 and #44's mighty shake nutritional supplements were provided as ordered. This finding affected two (Residents #9 and #44) of four residents reviewed for meals. Findings include: 1. Review of Resident #9's medical record revealed the resident was admitted on [DATE] with diagnoses including cellulitis of the left toe, other muscle spasm and peripheral vascular disease. Review of Resident #9's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #9's physician orders revealed an order dated 12/07/24 for a regular diet, regular texture, regular thin consistency; and an order dated 12/12/24 for a mighty shake two times a day for supplement. Review of Resident #9's Individual Nutrition Recommendations/Response form dated 12/10/24 revealed the resident was ordered four ounces of might shake twice daily with breakfast and lunch, a multivitamin with minerals daily and weekly weights for four weeks. The physician agreed with the recommendations and signed the form on 12/12/24. Review of Resident #9's lunch meal ticket dated 01/07/25 revealed the resident was on a regular diet. Under the preferences section of the ticket, a mighty shake was listed with a plus sign. Observation on 01/07/25 at 1:19 P.M. with the Director of Nursing (DON) revealed Resident #9's meal tray did not include the mighty shake, applesauce cake or bread per the menu and meal ticket. The resident had a chicken pot pie and green beans on his plate. Interview on 01/07/25 at 1:20 P.M. with the DON confirmed Resident #9's meal tray did not include the mighty shake nutritional supplement as ordered. 2. Review of Resident #44's medical record revealed the resident was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including malignant neoplasm of the brain, unspecified severe protein-calorie malnutrition and major depressive disorder. Review of Resident #44's admission MDS 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment. Review of Resident #44's Individual Nutrition Recommendations/Response form dated 05/15/24 revealed the resident had a diagnosis of protein calorie malnutrition as noted in the hospital documentation. The recommendations included a four ounce mighty shake twice daily with breakfast and lunch. Review of Resident #44's physician orders revealed an order dated 11/11/24 revealed the resident was on a regular diet, regular texture with a thin consistency. Review of Resident #44's meal ticket dated 01/06/25 for the breakfast meal indicated the resident was on a regular diet, disliked scrambled eggs and no pork including ham or bacon and the resident's preferences included a mighty shake, oatmeal every morning and hot tea (one cup). Observation on 01/06/25 at 8:40 A.M. revealed Resident #44's meal tray was placed on her overbed table which consisted of two small pieces of French toast sticks, a fork, oatmeal, a tea bag with no hot water, orange juice and no mighty shake nutritional supplement as indicated on the meal ticket. Review of the Food and Nutrition Services policy revised 10/2017 revealed each resident was provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. This deficiency represents non-compliance investigated under Complaint Numbers OH00160613 and OH00160213.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure Resident #27's medication was available and administered as ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure Resident #27's medication was available and administered as ordered. This finding affected one (Resident #27) of four residents reviewed for medication administration. Findings include: Review of Resident #27's medical record revealed the resident was admitted on [DATE] with diagnoses including alcoholic dependence, lumbar degenerative disc disease, anxiety and depression. Review of Resident #27's Discharge Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #27's hospital Discharge Orders form revealed an order to take Acamprosate Calcium (helps people who were dependent on alcohol to abstain from drinking it) 333 milligrams (mg) enteric coated (EC) one tablet by mouth three times daily for 10 days. Do not crush, chew or split. The last dose was administered 11/09/24 at 7:57 A.M. Review of Resident #27's hospital discharge Medication Administration Report (from 11/07/24 to 11/09/24) dated 11/09/24 revealed an order for Acamprosate EC tablet 333 mg give three times day (do not crush, chew or split). The Acamprosate was administered in the hospital on [DATE] at 5:12 P.M. and 9:49 P.M., 11/08/24 at 08:13 A.M., 1:47 P.M. and 8:19 P.M. and on 11/09/24 at 7:57 A.M. Review of Resident #27's physician orders dated 11/10/24 revealed the Acamprosate Calcium oral tablet was ordered to administer 333 mg by mouth three times a day for 10 days for behaviors due at 6:00 A.M., 2:00 P.M. and 10:00 P.M. starting on 11/10/24 and ending on 11/20/24. Review of Resident #27's medication administration records (MARS) indicated the medication was administered on 11/16/24 at 10:00 P.M. and 11/18/24 at 2:00 P.M. All other entries from 11/10/24 to 11/20/24 revealed to hold the medication or see nursing notes. Review of Resident #27's nursing progress notes from 11/10/24 to 11/20/24 did not reveal documentation or validation to hold the resident's Acamprosate Calcium oral tablet for behaviors. Review of Resident #27's encounter visit note dated 12/05/24 at 12:00 A.M. revealed the resident had alcoholic cirrhosis of the liver without ascites and to continue Acamprosate Calcium oral tablet delayed release 333 mg take one capsule three times a day with meals. Interview on 01/07/25 at 9:38 A.M. with the Director of Nursing (DON) confirmed Resident #27's Acamprosate medication was not administered as ordered. The DON confirmed the resident's medical record and progress notes did not have evidence why the medication was not administered or held by the nursing staff. Interview on 01/08/25 at 10:30 A.M. with Medical Director #702 indicated he was not aware Resident #27 did not receive his Acamprosate Calcium medication as ordered. Telephone interview on 01/08/25 at 11:12 A.M. with Pharmacy #701 confirmed Resident #27's Acamprosate Calcium medication was not sent to the facility on [DATE]. Telephone interview on 01/08/25 at 2:30 P.M. with [NAME] President (VP) of Quality Pharmacy #502 revealed the pharmacy received two prescriptions for Resident #27's Acamprosate Calcium and one discontinue order for the Acamprosate calcium. VP of Quality Pharmacy #502 indicated the pharmacist canceled both prescriptions in error and the facility did not receive Resident #27's Acamprosate calcium as ordered. Review of the Administering Medications policy revised 12/2012 revealed medications shall be administered in a safe and timely manner, and as prescribed. Review of the Acamprosate Calcium manufacturer directions dated revealed the treatment with the medications should be initiated as soon as possible after the period of alcohol withdrawal, when the resident had achieved abstinence and should be maintained if the resident relapses. The medications should be used as part of a comprehensive psychosocial treatment program. This deficiency represents non-compliance investigated under Complaint Numbers OH00160613 and OH00160213.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure a mediation error rate of 5% or less. A total o...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure a mediation error rate of 5% or less. A total of 26 medications were administered with two errors for a medication error rate of 7.69%. This finding affected two (Residents #27 and #53) of four residents reviewed for medication administration. Findings include: 1. Review of Resident #27's medical record revealed the resident was admitted on [DATE] with diagnoses including alcoholic cirrhosis, lumbar degenerative disc disease, anxiety and depression. Review of Resident #27's Discharge Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #27's physician orders revealed an order dated 11/10/24 for vitamin D3 (cholecalciferol) 50 mcg (micrograms) or 2000 international units (IU) give by mouth one time a day for vitamin D deficiency. Observation on 01/06/25 at 8:00 A.M. with Licensed Practical Nurse (LPN) #821 of Resident #27's medication administration revealed eight medications were administered including vitamin D3 400 IU (10 mcg). Interview on 01/06/25 at 9:56 A.M. with LPN #821 confirmed Resident #27 was ordered 2000 IU and was administered 400 IU in error. 2. Review of Resident #53's medical record revealed the resident was admitted on [DATE] with diagnoses including atherosclerotic heart disease, gastro-esophageal reflux disease without esophagitis and anemia. Review of Resident #53's MDS 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #53's physician orders revealed an order dated 12/09/23 for omeprazole capsule delayed release 20 mg give one capsule by mouth one time a day related to gastro-esophageal reflux disease without esophagitis. Observation on 01/06/25 at 8:18 A.M. with LPN Assistant Director of Nursing (ADON) #871 of Resident #53's medication administration revealed nine medications were administered. LPN ADON #871 was not observed to administer the resident's omeprazole 20 milligrams (mg) as ordered. Interview on 01/06/25 at 10:15 A.M. with LPN ADON #871 confirmed Resident #53 was not administered the omeprazole as ordered. A total of 26 medications were administered with two errors for a medication error rate of 7.69%. Review of the Administering Medications policy revised 12/2012 revealed medications shall be administered in a safe and timely manner, and as prescribed. This deficiency represents non-compliance investigated under Complaint Numbers OH00160613 and OH00160213.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Menu Adequacy (Tag F0803)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure the menus and spreadsheets were followed as pla...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure the menus and spreadsheets were followed as planned. This finding affected Residents #9, #13, #27 and #44 and had the potential to affect all 55 residents residing in the facility. Findings include: 1. Review of Resident #9's medical record revealed the resident was admitted on [DATE] with diagnoses including cellulitis of the left toe, other muscle spasm and peripheral vascular disease. Review of Resident #9's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #9's physician orders revealed an order dated 12/07/24 for a regular diet, regular texture, regular thin consistency; and an order dated 12/12/24 for a mighty shake two times a day for supplement. Review of the Menus and Spreadsheets for 01/07/25 revealed the lunch meal consisted of chicken pot pie, tossed salad, wheat bread, applesauce cake, choice of dressing, margarine and coffee or tea. Review of Resident #9's lunch meal ticket dated 01/07/25 revealed the resident was ordered a regular diet and under the preferences section of the form, it stated a mighty shake with a plus sign next to it. Observation on 01/07/25 at 1:19 P.M. with the Director of Nursing (DON) confirmed Resident #9's meal tray did not include the mighty shake, applesauce cake or bread per the menu and meal ticket. The resident had a chicken pot pie and green beans on his plate. No other items were on the resident's tray. Interview on 01/07/25 at 1:20 P.M. with the DON confirmed Resident #9's lunch meal did not include the mighty shake, applesauce cake or bread per the menu and meal ticket. 2. Review of Resident #13's medical record revealed the resident was admitted on [DATE] with diagnoses including multiple sclerosis, anxiety disorder and spondylitis. Review of Resident #13's Quarterly MDS 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #13's physician orders revealed an order dated 06/06/24 for a regular diet, regular texture, regular thin consistency with yogurt included for breakfast and cottage with included with lunch and dinner. Review of the Menus and Spreadsheets for 01/06/25 revealed the breakfast meal consisted of choice of cereal, breakfast pizza, margarine, juice of choice, 2% milk, coffee/tea. Review of Resident #13's meal ticket dated 01/06/25 for the breakfast meal revealed the resident was on a regular diet, disliked processed fruit cups or canned fruit and preferred extra sauces and gravies, fresh fruit, yogurt at breakfast, 2% milk, orange juice, regular coffee and water. Interview on 01/06/25 at 6:12 A.M. with Resident #13 indicated they never bring him his preferences that were on his meal ticket and the food was always cold. Observation on 01/06/25 at 8:15 A.M. revealed Resident #13's breakfast tray included two small pieces of French toast sticks, bacon, oatmeal, juice, coffee and water. The resident's meal tray did not include the resident's yogurt or fruit which were identified on the meal ticket. Interview on 01/06/25 at 8:16 A.M. with Certified Nursing Assistant (CNA) #830 confirmed Resident #13's meal tray included two small pieces of French toast sticks and did not include the yogurt or fruit identified on the meal ticket under preferences. Review of the French Toast Sticks Manufacturer Directions (on the back of the package) with Dietary Director #820 indicated the serving size for the French toast sticks was four pieces. Interview on 01/06/25 at 9:32 A.M. with Dietary Director #820 indicated the breakfast pizza was a pizza with sausage gravy on top. She stated the substitute for the breakfast pizza should have been scrambled eggs and toast as the breakfast pizza was not delivered by the food company. Review of the Menus and Spreadsheets for 01/07/25 revealed the lunch meal consisted of chicken pot pie, tossed salad, wheat bread, applesauce cake, choice of dressing, margarine and coffee or tea. Review of Resident #13's lunch meal ticket dated 01/07/25 revealed the resident was on a regular diet, disliked processed fruit, fruit cups and canned fruit and preferred cottage cheese at lunch and dinner. Observation on 01/07/25 at 1:13 P.M. revealed Resident #13's lunch meal tray consisted of a chicken pot pie and green beans. No other food items were on the resident's food tray. Observation on 01/07/25 at 1:18 P.M. with the DON confirmed Resident #13's lunch meal tray did not have the applesauce cake, bread or cottage cheese as indicated in the menus and resident meal ticket. Interview on 01/07/25 at 1:19 P.M. with the DON confirmed Resident #13's lunch tray did not include the applesauce cake, bread or cottage cheese as indicated on the lunch meal ticket. 3. Review of Resident #27's medical record revealed the resident was admitted on [DATE] with diagnoses including alcoholic cirrhosis, lumbar degenerative disc disease, anxiety and depression. Review of Resident #27's Discharge MDS 3.0 assessment dated [DATE] revealed the resident had intact cognition. Review of Resident #27's Individual Nutrition Recommendations/Response form dated 11/04/24 revealed the resident was to receive large portions at lunch and dinner with a mighty shake four ounces twice daily with breakfast and lunch. Review of the Menus and Spreadsheets for 01/06/25 revealed the breakfast meal consisted of choice of cereal, breakfast pizza, margarine, juice of choice, 2% milk, coffee/tea. Review of Resident #27's meal ticket dated 01/06/25 for breakfast under the preferences section included a mighty shake with no beef, no pork, a choice of juice (4 fluid ounces) and water (9 fluid ounces). Observation on 01/06/25 at 8:37 A.M. revealed Resident #27's breakfast meal tray consisted of two small French toast sticks, oatmeal, orange juice, water and a mighty shake. The resident did not have an overbed table in his room to sit the meal tray on. Review of the French Toast Sticks Manufacturer Directions (on the back of the package) with Dietary Director #820 indicated the serving size for the French toast sticks was four pieces. Interview on 01/06/25 at 9:32 A.M. with Dietary Director #820 indicated the breakfast pizza was a pizza with sausage gravy on top. She stated the substitute for the breakfast pizza should have been scrambled eggs and toast as the breakfast pizza was not delivered by the food company. Review of the Menus and Spreadsheets for 01/07/25 revealed the lunch meal consisted of chicken pot pie, tossed salad, wheat bread, applesauce cake, choice of dressing, margarine and coffee or tea. Observation on 01/07/25 at 1:29 P.M. with the DON revealed Resident #27's lunch meal included a chicken pot pie, mighty shake and green beans. The meal did not include the bread or applesauce cake per the menu and meal ticket. Interview on 01/07/25 at 1:30 P.M. with the DON confirmed Resident #27's lunch meal did not include the bread or applesauce cake per the menu and meal ticket. 4. Review of Resident #44's medical record revealed the resident was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including malignant neoplasm of the brain, unspecified severe protein-calorie malnutrition and major depressive disorder. Review of Resident #44's admission MDS 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment. Review of Resident #44's Individual Nutrition Recommendations/Response form dated 05/15/24 revealed the resident had a diagnosis of protein calorie malnutrition as noted in the hospital documentation. The recommendations included a four ounce might shake twice daily with breakfast and lunch. Review of Resident #44's physician orders revealed an order dated 11/11/24 which indicated the resident was on a regular diet, regular texture with a thin consistency. Review of the Menus and Spreadsheets for 01/06/25 revealed the breakfast meal consisted of choice of cereal, breakfast pizza, margarine, juice of choice, 2% milk, coffee/tea. Review of Resident #44's meal ticket dated 01/06/25 for the breakfast meal indicated the resident was on a regular diet, disliked scrambled eggs and no pork including ham or bacon and the resident's preferences included a mighty shake, oatmeal every morning and hot tea (one cup). Observation on 01/06/25 at 8:40 A.M. revealed Resident #44's meal tray was placed on her overbed table which consisted of two small pieces of French toast sticks, a fork, oatmeal, a tea bag with no hot water, orange juice and no mighty shake as indicated on the meal ticket. Interview on 01/06/25 at 8:41 A.M. with CNA #888 confirmed Resident #44's breakfast meal tray did not include the hot water for the tea or the mighty shake. CNA #888 also confirmed the resident's meal tray had two small pieces of French toast sticks and no spoon for the oatmeal. Interview on 01/06/25 at 9:32 A.M. with Dietary Director #820 indicated the breakfast pizza was a pizza with sausage gravy on top. She stated the substitute for the breakfast pizza should have been scrambled eggs and toast as the breakfast pizza was not delivered by the food company. Dietary Director #820 also indicated the hot water for Resident #44's tea should have come down on the food cart and the resident's mighty shake should have been on the tray. Review of the French Toast Sticks Manufacturer Directions (on the back of the package) with Dietary Director #820 indicated the serving size for the French toast sticks was four pieces. Review of the Menus and Spreadsheets for 01/07/25 revealed the lunch meal consisted of chicken pot pie, tossed salad, wheat bread, applesauce cake, choice of dressing, margarine and coffee or tea. Review of Resident #44's lunch meal ticket dated 01/07/25 revealed the resident disliked broccoli, scrambled eggs and no pork including ham bacon and pork. The preferences section including a mighty shake with a plus sign next to it and hot tea (one cup). Observation on 01/07/25 at 1:40 P.M. with the DON revealed Resident #44's meal tray did not include the resident's applesauce cake or bread per the menu and meal ticket. Interview on 01/07/25 at 1:41 P.M. with the DON confirmed Resident #44's lunch meal tray did not include the applesauce cake or bread per the menu and meal ticket. Review of the Food and Nutrition Services policy revised 10/2017 revealed each resident was provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. This deficiency represents non-compliance investigated under Complaint Numbers OH00160613 and OH00160213.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0804 (Tag F0804)

Could have caused harm · This affected most or all residents

Based on observation, record review and interview, the facility failed to ensure palatable food temperatures were consistently served to residents. This finding had the potential to affect all 55 resi...

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Based on observation, record review and interview, the facility failed to ensure palatable food temperatures were consistently served to residents. This finding had the potential to affect all 55 residents who reside in the facility and were provided meals from the kitchen. Findings include: Review of the Food Temperature Log form dated 12/15/24 to 12/21/24 revealed no evidence food temperatures to ensure food safety and palatability were obtained for breakfast, lunch and dinner on 12/15/24, dinner on 12/16/24, dinner on 12/17/24, breakfast, lunch and dinner on 12/18/24, 12/19/24, 12/20/24 and 12/21/24. Review of the Food Temperature Log form dated 12/22/24 to 12/28/24 revealed no evidence food temperatures to ensure food safety and palatability temperatures were obtained for breakfast, lunch and dinner on 12/22/24, 12/23/24, 12/24/24, 12/25/24, dinner on 12/26/24, breakfast, lunch and dinner on 12/27/24 and 12/28/24. Observations on 01/06/25 at 11:49 A.M. revealed [NAME] #870 obtained temperatures of the carrots, rice, breaded fish, mashed potatoes and hamburger patties for appropriate temperatures using a food thermometer. [NAME] #870 documented the food temperatures on the Food Temperature Log form dated 12/29/24 to 01/04/25. Review of the Food Temperature Log form dated 12/29/24 to 01/04/25 revealed no evidence food temperatures to ensure food safety and palatability temperatures were obtained for breakfast, lunch and dinner were not filled out on the form and the form was blank. The facility did not have a Food Temperature Log form from 01/05/25 to 01/11/25 and no evidence food temperatures were obtained on 01/05/25. A test tray was completed with Dietary Director #820 on 01/06/25 at 12:09 P.M. consisting of breaded fish, carrots, rice and milk. The fish carrots and rice did not have concerns with palatability. The milk's temperature was 54.7. Interview on 01/06/25 at 6:11 A.M. with Resident #11 indicated the food was bad but offered alternatives. Interview on 01/06/25 at 6:12 A.M. with Resident #13 indicated the food was institutional grade and was always cold. Interview on 01/06/25 at 8:06 A.M. with Resident #27 stated they always provided beef and pork when he did not want beef or pork. Interview on 01/06/25 at 12:12 P.M. with Dietary Director #820 confirmed the milk did not meet the required temperature under 40 degrees Fahrenheit and staff were not consistently check food temperatures as evidenced by the blank sections under the Food Temperature Logs from 12/15/24 to 01/06/25. Interview on 01/07/25 at 10:31 A.M. with Resident #44 ' s daughter indicated the food was inconsistent and that was why they brought a refrigerator to the resident ' s room. She stated the food was always completely lacking. Review of the Food and Nutrition Services policy revised 10/2017 revealed each resident was provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident.

Jun 2024 1 deficiency

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

Based on staff interview, observation and review of facility documents, the facility failed to maintain a sanitary kitchen. This had the potential to affect all of the residents residing in the facili...

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Based on staff interview, observation and review of facility documents, the facility failed to maintain a sanitary kitchen. This had the potential to affect all of the residents residing in the facility with the exception of Resident #18. The facility census was 45 residents. Findings include: Interview on 06/27/24 at 7:33 A.M. with the Director of Nursing (DON) confirmed the Kitchen Manger (KM) was sent home due to poor work performance. The DON confirmed when the KM was not present in the building, the cook working was in charge of supervision of the staff in the kitchen. Observation on 06/27/24 at 8:15 A.M. of the kitchen revealed the following concerns: - Dried liquid spills on the storage shelving under the juice and coffee dispenser. - The flooring throughout the kitchen was sticky with grease build-up and dried food/liquid under the cooking equipment and food preparation tables. - There were three food carts with three shelves on wheels in the kitchen with dirt, grease, dried liquid and food particles present on the three shelves. - The food preparation area had knives stored in an upright position along the end of the table with a thick build-up of grease and food under the knives. - There was no lid on the large trash receptacle located next to the cooking area. - The alcove where the utensils were stored had a milk crate on the floor with plastic lids used to cover the pans in the steam table and stainless-steel lids for the pots and pans. There was a phone with cord and base covered with dust, dirt and grease hanging from the utensil racks used to store the long-handled cooking utensils. - The stove top had a thick layer of grease and food build-up around all the burners and had a thick coating of grease and dried food in the oven and outside surface of the stove door. - There was black grease/food build-up under the stove, steamer, food preparation tables and three sink dish washing area. - The breakfast meal had been served from a steam table with buildup of food, dirt on all surfaces of the steam table. - The metal chest style food warmer had a thick coating of dried food on the inside surfaces of the food warmer. - The walls in the kitchen had a greasy film with dried food/liquid present on the walls surrounding the food preparation and dishwashing area. - The dishwashing area had water leaking from a pipe under the dishwashing station with a plastic tub placed under the pipe to catch the leaking water. The water in the plastic tub was dark brown/black and had food particles floating in the water. There was an unpleasant odor emanating from the water in the plastic tub. Interview on 06/27/24 at 9:00 A.M with [NAME] #46 confirmed the Surveyor's concerns identified during the kitchen tour. [NAME] #46 further confirmed the facility did not have the proper cleaning products available to properly clean the stove, oven and other cooking equipment. [NAME] #46 stated the floors were not mopped and swept on a daily basis. [NAME] #46 stated the kitchen floors had not been cleaned appropriately for approximately five to six months. [NAME] #46 stated she had notified the KM of the need for proper cleaning supplies and a consistent routine for cleaning the kitchen several times during the past few months. [NAME] #46 stated the kitchen staff during the evening shift from 4:00 P.M. to 8:00 P.M. did not have proper supervision to ensure the daily cleaning duties were performed. Observation on 06/27/24 at 9:06 A.M. of the area outside of the kitchen exit door and entering the dining room area revealed the meal service area cupboards and counters had dried food/liquid spills on the floor, counters and cupboard doors. There were papers and other clutter placed on the counters in the meal service area. Interview on 06/27/24 at 9:08 A.M. with Dietary Aide (DA) #47 confirmed the meal service area was dirty with dried food spills and was cluttered with nonessential items. Interview 06/27/24 at 10:00 A.M. with [NAME] #46 confirmed she was unable to find any completed cleaning duties checklists. [NAME] #46 confirmed staff were supposed to completed the checklist daily and initial on the form and then turn the form into the KM. Review of the facility document titled Cleaning Duties Checklist for the A.M. undated revealed the kitchen staff were supposed to initial and check out with the KM when the duties were completed each day. The duties included to change the sanitization buckets every two hours, throw away old and used products in the food cooler, organize the food cooler and freezer, ensure all food products were labeled and dated appropriately, sanitize and clean debris on the three-sink compartment area, wash pots/pans and clean all sinks, remove the trash, complete the food preparation for the following day, clean/sanitize the steam table and organize the area, sweep and mop the floors in the kitchen from the ice machine to the dry storage area, clean the steamer/stovetop/oven and shut down all appliances, check with the dietary aides to assist them if needed and check out with the dietary manager after completion of the checklist. The checklist had an area for the staff member to place their initials with the date at the bottom of the form. Review of the facility document titled Cleaning Duties Checklist P.M. undated revealed kitchen staff were supposed to change the sanitization buckets every two hours, wipe down/sanitize all work areas, fill out temperature logs, organized the spice shelf and remove clutter from the long shelf against the wall, sweep and mop the service line/front table are/preparation areas, wash pots/pans and clean all sinks, complete preparation needed for the next shift, organize the dry storage area and ensure all food items were off the floor, take snacks down to all the floors, clean the microwave and toaster, remove trash from the kitchen, clean the steam table/service area, assist dietary aides as needed and to check out with the kitchen manager to ensure all duties were completed. The checklist had an area for the staff member to place their initials with the date at the bottom of the form. This deficiency represents noncompliance investigated under Complaint Number OH00155055.

Mar 2024 3 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

Based on observation and staff interview, the facility failed to maintain complete medical records in residents medical charts. This had the potential to affect all 48 residents residing at the facili...

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Based on observation and staff interview, the facility failed to maintain complete medical records in residents medical charts. This had the potential to affect all 48 residents residing at the facility. The facility census was 48. Findings include: Observation on 03/07/24 at 2:31 P.M., with Director of Nursing (DON) revealed a large stack, several inches thick of several resident's information that included: laboratory results, physician progress notes, signed physician orders, and resident monthly summaries. The paper work had various dates from 12/12/24 through 03/05/24. Interview with the DON, at the time of observation, revealed she was unsure why the medical records person had not been filing the resident information in the medical records timely. DON confirmed there were records unfiled from 12/12/24 through 03/05/24 that potentially could affect the care and treatment of all residents. This deficiency represents noncompliance investigated under Complaint Number OH00150880.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0555 (Tag F0555)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of a notification of termination of services letter to a physician, review of a notificat...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of a notification of termination of services letter to a physician, review of a notification letter to residents of the change in the Medical Director and rounding physician, review of notification letter to residents of their transfer of physician, review of doctor election form, review of eLicense.ohio.gov website, staff interview, physician interview, Ombudsman interview, resident interview, and review of facility policies, the facility failed to discuss the need for alternative physician services with residents and honor the resident's right to maintain their physician of their choice. This affected and/or had the potential to affect seven residents (#5, #12, #13, #15, #25, #34, and #41) of seven residents who had been receiving services from Physician #1 but were required by the facility to change to a new physician or Physician #2. The facility census was 48. Findings include: 1. Review of Resident #12's medical record revealed an admission date of 07/03/20 with diagnoses including hemiplegia and hemiparesis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 was moderately cognitively impaired. Review of the Resident Profile revealed Resident #12 was a patient of Physician #2. Interview on 02/29/24 at 2:48 P.M., with Resident #12 revealed he was a patient of Physician #1. Resident #12 revealed that was the physician of his choice/who he wanted. The resident revealed facility staff asked him if he wanted to stay with him or go with the new guy and he told them he wanted to stay with Physician #1. Interview with Resident #12's wife revealed the facility did not discuss with her about Resident #12 changing physicians from Physician #1 to Physician #2. 2. Review of Resident #34's medical record revealed an admission date of 09/29/22 with a diagnosis including chronic obstructive pulmonary disease. Review of the Medicare five-day MDS assessment dated [DATE] revealed Resident #34 was severely cognitively impaired. Review of the Resident Profile revealed Resident #34 was a patient of Physician #2. Interview on 02/29/24 at 2:54 P.M., with Resident #34 revealed she had Physician #1 and wanted to keep him. Resident #34 revealed no one asked her to change physicians. Record review of the facility generated letter, undated and directed to residents, families and Responsible Parties revealed neither Resident #34 nor the resident's responsible party had a signed consent to switch physician's on file. Although, Physician #2 was currently listed on the resident's profile as the resident's physician. 3. Review of Resident #25's medical record, revealed an admission date of 11/15/16 with a diagnosis including atherosclerotic heart disease. Review of the quarterly MDS assessment dated [DATE], for Resident #25 revealed the resident was cognitively intact. Review of the Resident Profile revealed Resident #25 was a patient of Physician #2. Interview on 02/29/24 at 2:56 P.M. with Resident #25 revealed she was asked a few days ago about changing physicians. Resident #25 revealed she never agreed to change physicians. Record review of the facility generated letter, undated and directed to residents, families and Responsible Parties revealed neither Resident #25 nor the resident's responsible party had a signed consent to switch physician's on file. Although, Physician #2 was currently listed on the resident's profile as the resident's physician. 4. Review of Resident #15's medical record revealed an admission date of 08/04/21. The resident had a diagnosis including dementia. Review of the quarterly MDS assessment dated [DATE] revealed Resident #15 was severely cognitively impaired. Review of the Resident Profile revealed Resident #15 was a patient of Physician #2. Interview on 02/29/24 at 2:59 P.M., with Resident #15 revealed she did not know anything about a physician. Record review of the facility generated letter, undated and directed to residents, families and Responsible Parties revealed neither Resident #15 nor the resident's responsible party had a signed consent to switch physician's on file. Although, Physician #2 was currently listed on the resident's profile as the resident's physician. 5. Review of Resident #13's medical record revealed an admission date of 09/29/18 with a diagnosis including cerebral palsy. Review of the quarterly MDS assessment dated [DATE] revealed Resident #13 was cognitively intact. Review of the Resident Profile revealed Resident #13 was a patient of Physician #2. Interview on 03/04/24 at 1:12 P.M., with Resident #13 revealed he was never asked if he wanted to change physicians. Resident #13 revealed they told him last Friday or Saturday (03/01/24 or 03/02/24) he had to change (physicians) and to sign a form because Physician #2 was his doctor now. Resident #13 revealed he wanted to stay with Physician #1, but stated he had no choice. 6. Review of Resident #5's medical record revealed an admission date of 06/30/23 with a diagnosis including type two diabetes mellitus. Review of the quarterly MDS assessment dated [DATE] revealed Resident #5 was cognitively intact. Review of the Resident Profile revealed Resident #5 was a patient of Physician #2. Interview on 03/04/24 at 1:17 P.M., with Resident #5 revealed she was visiting a friend one day in the Assisted Living apartments (date not provided) and she was told Physician #1 was an excellent doctor, so she asked Physician #1 to be her doctor; Physician #1 accepted, and he became her doctor Resident #5 revealed then the facility told her she was changing physicians. Resident #5 revealed she was never told who she would have (as a physician) and was never asked who she wanted to be her physician. 7. Review of Resident #41's medical record revealed an admission date of 12/11/18 with a diagnosis including major depressive disorder. Review of the annual MDS assessment dated [DATE] revealed the resident was cognitively intact. Review of the Resident Profile revealed Resident #41 was a patient of Physician #2. Interview on 03/04/24 at 1:28 P.M., with Resident #41 revealed the facility required him to sign a paper to change doctors. Resident #41 revealed he wanted Physician #1 to be his physician, but Licensed Practical Nurse (LPN) #606, said no, he had to change, and he had to sign the paper. Interview on 02/29/24 at 4:57 P.M., with the Administrator and Director of Nursing (DON) confirmed the facility gave a letter to Physician #1 terminating his services at the facility. The Administrator revealed Physician #1 refused to sign the new facility Credentialing Form (Implemented 02/01/24), so he was no longer allowed to see residents at the facility. The Administrator revealed Physician #1's last day was 02/26/24. The new Medical Director, Physician #2 was the only physician practicing at the facility and all Physician #1's residents were now patients of Physician #2. The Administrator revealed all residents were notified and had signed a form agreeing to change from Physician #1 to Physician #2. The Administrator and DON revealed they were unable to recall the exact date residents were notified of the change. Interview on 03/04/24 at 1:31 P.M., with LPN #606 revealed she gave all residents who were former residents of Physician #1 forms to let them know Physician #1, would no longer be working at the facility. LPN #606 informed the residents Physician #526 would be their new physician and she had the residents sign the form. LPN #606 revealed she delivered the forms to the residents on either Thursday or Friday (02/29/24 or 03/01/24) of the previous week. LPN #606 confirmed the forms were not dated. Throughout the interview, LPN #606 never indicated Physician #2 would be the residents' new doctor. LPN #606 confirmed Physician #526 was another physician that came to the facility and was able to see residents. Interview on 03/04/24 at 2:50 P.M., with the Facility Ombudsman revealed she had spoken with the Administrator and Physician #1 about resident having the right to choose their own physician. The Ombudsman revealed she spoke with one resident at the facility who wanted to stay with Physician #1. The Ombudsman did not identify who the resident was or when she spoke to the resident. The Ombudsman revealed she would advocate for the residents to see any physician they wanted. Interview on 03/04/23 at 3:22 P.M., with Physician #1 revealed he reviewed the facility new credentialing contract and agreed with 98% of it. Physician #1 revealed he refused to sign the contract because of the portion indicating the administrator had the right to terminate his services with no cause. Physician #1 revealed he believed that was what the facility was trying to do and as soon as he signed the contract and the ink dried, he was done (his services would be terminated with no cause). The second reason he stated he refused to sign the contract was related to the facility wanting him to have hospital privileges to refer residents. Physician #1 indicated usually when residents were admitted to the hospital, they admit to a hospitalist. Physician #1 revealed he was in internal medicine, not very many doctors go to the hospital anymore and he did not sign the contract based on those two items. Physician #1 revealed he had been at this facility since October 2015 and was not aware of any issues or concerns expressed to him. Physician #1 revealed after he was given the termination letter, he spoke with each of his patients at the facility and none of them wanted to change physician. Physician #1 confirmed each resident voluntarily signed a form (Doctor Election), he provided for them, confirming their choice to not change physicians and to continue with his services. Review of the form titled Doctor Election revealed on 02/04/24, Resident #5, #12, #13, the Power of Attorney of Resident #15, Resident #25, #34, and #41, signed the form electing they would like to continue services with Physician #1. Interview on 03/06/24 at 11:00 A.M., with Regional Director of Operations #523 revealed concerns Physician #1 would not sign e-scripts and would not follow facility policies. Regional Director of Operations #523 revealed he was not sure what policies were not followed but stated he would ask the Administrator. Regional Director #524 entered and revealed Physician #1 refused to sign e-scripts and that was why the facility no longer wanted him to provide services to residents in the facility. At 11:36 P.M., the DON entered the conversation and revealed additional concerns with Physician #1 that included he was not signing monthly orders timely or writing some prescriptions correctly. The DON revealed Physician #1 told her he could see residents at his office, but she did not believe he had an office, so all residents had their physician services transferred to Physician #2. Review of the eLicense.Ohio.gov website verified Physician #1 was a Doctor of Medicine with the Medical Board and his license was active with no current restrictions on practice. There was no evidence provided Physician #1 was not qualified and properly licensed as a medical physician able to practice medicine in the State of Ohio. There was no evidence provided of any current disciplinary action taken against the physician's license preventing him from providing direct medical care to the residents of the facility. Review of an undated facility generated letter, completed by Administrator, directed to residents, family and friends of the facility revealed the facility was switching Medical Directors on 02/01/24. At the end of February 2024 (Physician #1) would no longer be rounding at the facility, contact the facility with any questions or concerns. Review of an undated facility generated letter, directed to residents, families and responsible parties revealed on 02/26/24 the (facility) implemented a physician credentialing policy/agreement, requiring that any physician seeking admitting and attending privileges at our facility agree to abide by certain policies and procedures in order to obtain such privileges. Your current attending physician, (Physician #1) has elected not to enter into the agreement. Therefore, effective immediately, (Physician #1) will no longer be following residents at (the facility). As a result, your care will be transitioned to (Physician #2), our new Medical Director. Alternatively, you may identify and select a different physician of your choice, who must then be approved via facilities credentialing process and agree to abide by the applicable policies and procedures referenced above in order to obtain attending privileges. We ask that you please sign below to acknowledge your receipt and understanding of this notification. If you have any questions, please feel free to let us know. Under the notation was an area to be signed by Resident or Responsible Party. Review of the undated policy titled, Attending Physician Credentialing, included admitting and attending privileges may be granted, maintained, suspended and or terminated at any time, in the sole discretion of Facilities Administrator, regardless of the status of any corrective action. Should privileges be suspended or terminated, the attending physician agrees to cooperate in transitioning their patients to another physician who has privileges at the facility according to the patients choice, or if the patient does not assert such a choice, then to the care of the physician designated by the Medical Director. The credentialing also included maintaining unencumbered admitting privileges at a hospital that has a current transfer agreement with the facility and inform facility immediately if their privileges are revoked or encumbered in any way. Review of the undated policy tilted Resident Rights, revealed Physician choice: The right upon request, to be assigned, within the capacity of the home to make the assignment, to the staff physician of the residents choice, and the right, in accordance with rules and written policies and procedures of the home, to select as the attending physician a physician who is not on the staff of the home. It is the facilities policy to abide by all resident rights, and to communicate these rights to residents and their designated representative in a language they can understand. The policy included the facility must inform the resident if the facility determines that the physician chosen by the resident is unable or unwilling to meet the requirements specified in this part and the facility seeks alternate physician participation to assure provision of appropriate and adequate care and treatment. The facility must discuss the alternative physician participation with the resident and honor the residents preference if any among options. This deficiency represents noncompliance investigated under Complaint Number OH00150880.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0865 (Tag F0865)

Could have caused harm · This affected multiple residents

Based on record review and interview, the facility failed to ensure their Quality Assurance and Performance Improvement (QAPI) program committee thoroughly evaluated, identified areas in need of impro...

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Based on record review and interview, the facility failed to ensure their Quality Assurance and Performance Improvement (QAPI) program committee thoroughly evaluated, identified areas in need of improvement, and corrected deficient practice. This affected three of three residents reviewed for choice of physician (#15, #42 and #24) and one (#43) of three residents reviewed for accuracy of documentation. The facility census was 49. Findings include: Review of the facility's survey tracking history revealed the facility had a complaint survey completed on 03/14/24 which resulted in concerns residents were not provided with their physician of choice, and inaccuracy of the medical record in relation to the wound care documentation. Interview on 04/16/24 at 3:16 P.M. with Resident #15 revealed he was previously a patient of Physician #1. He further stated they booted out his previous physician and he was referred to some doctor [Physician #2] who I don't know. During this interview, Resident #15 voiced that his opinion didn't matter because the facility would not allow Physician #1 in the facility, and he did not think Physician #1 had anywhere outside the facility to keep seeing him. Throughout the interview, Resident #15 was alert, oriented to person and place, demonstrated an organized thought pattern, and made his wishes clear he preferred to maintain Physician #1 as his attending physician. Interview on 04/16/24 at 3:45 P.M. with Resident #42 revealed he had a different physician (Physician #2), but if he had the option, he would have preferred to continue seeing Physician #1. Resident #42 further revealed he was not given other options from which to choose a new physician, stating no, they gave him to me. He also stated it was his belief, based on conversation with facility staff, there was no office where he could go to see Physician #1. Interview on 04/16/24 at 4:50 P.M. with Resident #24 revealed facility staff informed her Physician #1 could no longer come to the facility and that the facility assigned her to a different doctor that was supposed to be the new medical director, Physician #2. Resident #24 then stated she informed the facility she preferred that if Physician #1 was not allowed to see her anymore she would like to see if Physician #4 because he reminded her of Physician #1. During the interview, Resident #24 confirmed she never received a definitive response regarding the possibility of Physician #4 taking over as her attending, just that Physician #2 was now the physician for the facility. At the time of the interview, Resident #24 expressed she must not have had a choice, other than to use their doctor. Interview on 04/17/24 at 1:30 P.M. with the Administrator revealed he typed and signed an attestation indicating residents were offered their choice of physicians on 03/21/24, but he was not the person who spoke to the listed residents and was unable to confirm how the questions or options were presented. The administrator said the social worker spoke to the residents on 03/21/24. Interview on 04/17/24 at 1:52 P.M. with Social Services Designee (SSD) #366 revealed she asked residents if they wanted to use Physician #2 in the facility, informed them Physician #1 did not have an office to see patients outside the facility, and told them if they were dissatisfied with Physician #2, she could help them make arrangements to find another primary care provider (PCP) in the community, if they had someone in mind. During the interview, SSD #366 confirmed she did not provide residents with names or contact information for any other physicians from which to choose. She further confirmed she was uncertain of the date she had these conversations; and she had no formal documentation of specifics from the conversations. During the interview, SSD #366 presented a small piece of notebook paper she used to take notes. Review of this notebook paper revealed it contained a list of five resident names, including Resident #15, and whether they received a letter. The notebook paper did not specify dates, times, exactly who she spoke with, or full content of the conversations. Upon receipt of a requested copy of this notebook paper at approximately 2:10 P.M. on 04/17/24 there was a hand-written notation with new information indicating - Residents asked if they want [Physician #2] or help w/ new PCP or setting up rides to PCP/ [Physician #1] in comm.? Interviewed on 03/21/24 was also added near the bottom of this notebook paper. Interview on 04/17/24 at 4:19 P.M. with Physician #1 revealed he was a nursing home doctor and worked in facilities. He confirmed he did not have his own office but rented space from Physician #3, which was located approximately five to six miles from the facility. Physician #1 explained he did not typically see patients at this rented space because for most residents residing in nursing homes it was impractical for the residents to make many office visits. However, he said he could make arrangement to see residents at this rented space if needed, but believed the facility staff shared with the residents he did not have an office. Interview on 04/18/24 at 1:08 P.M. with Physician #3 confirmed Physician #1 leased space within his medical practice. During this interview, Physician #3 confirmed Physician #1 saw patients in that office space a couple times a year and could continue to make arrangements for patient appointments in his office as needed. Review of the eLicense.Ohio.gov website verified Physician #1 was a Doctor of Medicine with the Medical Board and his license was active with no current restrictions on practice. There was no evidence provided Physician #1 was not qualified and properly licensed as a medical physician able to practice medicine in the State of Ohio Interview with the Administrator on 04/18/24 at 12:35 P.M. revealed the facility held monthly QAPI meetings and the medical director was expected to attend quarterly. The Administrator confirmed the last meeting was held on 03/29/24 with the interdisciplinary team and the medical director was not in attendance for that meeting. During this interview, the Administrator confirmed the team reviewed the facility's progress with audits related to open surveys exited on 01/30/24 and 03/14/24. Regarding audits, the Administrator stated he uploaded the audits to the Information Dissemination Collection (EIDC) system but her did not review them. The Administrator confirmed no problems with the execution of their approved plan of correction were identified and the committee did not identify potential ongoing non-compliance during the QAPI meeting held on 03/29/24. Review of the QAPI meeting notes from 03/29/24 revealed no indication any concerns were identified regarding the facility's execution of the written plan of correction or ongoing non-compliance. Review of the State Operations Manual (SOM), chapter seven, section §7317 titled Acceptable Plan of Correction effective 11-16-18 revealed the facility must develop a plan to monitor their ongoing performance toward compliance and ensure solutions put into place are sustained. Section §7317 also revealed when a plan of correction is approved, it is the facility who is ultimately accountable for managing their own compliance. 2. Review of Resident #43's Medication Administration Record (MAR) and the Treatment Administration Record (TAR) for February 2024 revealed there was no documentation of the following wound care treatments for the following wounds on the following dates: Right upper buttock- missing documentation for ordered treatments on 02/02/24, 02/15/24, 02/16/24, 02/17/24, 02/22/24, 02/23/24 (morning treatments), and 02/29/24 (both treatments). Right knee- missing documentation for ordered treatment on 02/02/24. Right posterior scalp- missing documentation for ordered treatment on 02/08/24. Left toes and left heel- missing documentation for ordered treatments on 02/02/24, 02/15/24, 02/16/24, 02/17/24, 02/22/24, and 02/23/24. Left first toe- missing documentation for ordered treatment on 02/29/24. Coccyx- missing documentation for ordered treatments scheduled the mornings of 02/15/24, 02/15/24, 02/16/24, 02/22/24, 02/23/24, and 02/29/24, and the scheduled evening treatment on 02/29/24. Review of the progress notes revealed no documentation on 02/02/24, 02/08/24, 02/15/24, 02/16/24, 02/17/24, 02/22/24, 02/23/24, or 02/29/24 regarding Resident #43's wound care. Review of the MAR and the TAR for March 2024 revealed there was no documentation of the following wound care treatments for the following wounds on the following dates: Right upper buttock- missing documentation for ordered treatment on 03/30/24. Right posterior scalp- missing documentation for ordered treatment on 03/01/24, 03/04/24, and 03/05/24. Left great toe- missing documentation for ordered treatment on 03/03/24. Left heel- missing documentation for ordered treatment on 03/11/24. Review of the progress notes revealed no documentation on 03/01/24, 03/03/24, 03/04/24, 03/05/24, 03/11/24, or 03/30/24 regarding Resident #43's wound care. Review of Resident #43's MAR and TAR for March 2024 revealed there was no documentation of the following wound care treatments for the following wounds on the following dates: Right upper buttock- missing documentation for ordered treatments on 04/05/24 and 04/09/24. Right posterior scalp- missing documentation for ordered treatments on 04/01/24, 04/05/24, 04/08/24, 04/09/24, 04/12/24, and 04/13/24. Left great toe- missing documentation for ordered treatments on 04/01/24, 04/05/24, 04/08/24, 04/12/24, and 04/13/24. Left heel- missing documentation for ordered treatment on 04/01/24, 04/04/24, 04/05/24, 04/08/24, 04/09/24, 04/12/24, and 04/13/24. Review of the progress notes revealed no documentation on 04/01/24, 04/04/24, 04/05/24, 04/08/24, 04/09/24, 04/12/24, or 04/13/24 regarding Resident #43's wound care. Interview on 04/17/24 at 9:45 A.M. with Licensed Practical Nurse (LPN) #304 revealed nurses who completed wound care and treatments were to sign-off the care and treatments were completed on the MAR or TAR. Resident refusal of wound care was to be documented on the MAR or TAR and in the progress notes. Interview on 04/17/24 at 1:25 P.M. with the Director of Nursing (DON) confirmed completed wound care should be documented on the MAR or TAR and nurses should document if the resident refused medications or treatments. Interview on 04/18/24 at 12:25 P.M. with the DON revealed wound audits were conducted by LPN #304 so she could not speak to how the audits were conducted. Interview with the Administrator on 04/18/24 at 12:35 P.M. revealed the facility held monthly QAPI meetings and the medical director was expected to attend quarterly. The Administrator confirmed the last meeting was held on 03/29/24 with the interdisciplinary team and the medical director was not in attendance for that meeting. During this interview, the Administrator confirmed the team reviewed the facility's progress with audits related to open surveys exited on 01/30/24 and 03/14/24. Regarding audits, the Administrator stated he uploaded the audits to the Information Dissemination Collection (EIDC) system but he did not review them. The Administrator indicated the QAPI committee did not identify problems with the execution of their approved POC or potential ongoing non-compliance during the QAPI meeting held on 03/29/24. Interview on 04/18/24 at 1:20 P.M. with LPN #304 revealed the wound audits completed for the facility's plan of correction did not capture missing documentation on the MAR or the TAR during week two and week four audits of Resident #43's wound care. Review of the policy last reviewed in August 2023 titled Wound Care revealed treatments were to be documented in the medical record. Refusals and the reason for refusal were also to be documented. Review of the QAPI meeting notes from 03/29/24 revealed no indication any concerns were identified regarding the facility's execution of the written POC or potential ongoing compliance Review of the State Operations Manual (SOM), chapter seven, section §7317 titled Acceptable Plan of Correction effective 11-16-18 revealed the facility must develop a plan to monitor their ongoing performance toward compliance and ensure solutions put into place are sustained. Section §7317 also revealed when a plan of correction is approved, it is the facility who is ultimately accountable for managing their own compliance.

Jan 2024 5 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

Based on observation, interview, medical record review, and review of facility policy, the facility failed to ensure wound care was completed as ordered, treatments provided were rendered according to...

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Based on observation, interview, medical record review, and review of facility policy, the facility failed to ensure wound care was completed as ordered, treatments provided were rendered according to appropriate standards of care to decrease the risk of infection, and the record accurately reflected care that was provided. This affected one resident (#26) out of three residents reviewed for wound care. The facility census was 49. Findings include: Review of the medical record for Resident #26 revealed an admission date of 04/19/23 with diagnoses including chronic obstructive pulmonary disease (COPD), blindness in the right eye, chronic systolic (congestive) heart failure, type two diabetes mellitus, essential hypertension, stage two chronic kidney disease, and acquired absence of the left leg below the knee. Review of the annual Minimum Data Set (MDS) assessment completed on 01/26/24 revealed Resident #26 had intact cognition and had no known wounds at the time the MDS assessment was completed. Review of the physician orders revealed an order for wound care of the left distal leg to be performed once daily from 03/23/24 through 04/16/24 to cleanse with normal saline (NS), apply Medi honey to the wound bed, and cover with a dry border dressing. Further review revealed an order dated 04/17/24 to cleanse the wound to Resident #26's left distal leg with NS, apply Medi honey to the wound bed, and cover with a dry border dressing every shift. Review of the medication administration record (MAR) and the treatment administration record (TAR) for March 2024 revealed no documentation Resident #26's wound care was completed as ordered. Review of the progress notes revealed no indication Resident #26 received ordered wound care or was offered and refused wound care treatments on 03/29/24 or 03/30/24. Review of the MAR and TAR for April 2024 revealed no documentation Resident #26's wound care was completed as ordered on 04/03/24, 04/07/24, 04/08/24, or 04/09/24. The TAR revealed documentation wound care was completed as ordered from 04/10/24 through 04/16/24. The MAR and TAR for 04/17/24 revealed wound care was signed off in two spots, one on the MAR for the day shift treatment signed-off by Licensed Practical Nurse (LPN) #397 and one on the TAR in the discontinued 5:00 A.M. time slot by LPN #392. Review of the progress notes revealed Resident #26 received wound care on 04/03/24 during wound rounds but further review revealed no indication Resident #26 received or was offered and refused wound care treatments as ordered on 04/07/24, 04/08/24, or 04/09/24. Observation on 04/17/24 at 9:45 A.M. of Resident #26's wound care, rendered by LPN #304 revealed LPN #304 did not use a clean field when she placed the wound care supplies, including an extra pair of gloves, onto Resident #26's bed with no bag or container in the vicinity to discard the old dressing or soiled supplies. The old dressing LPN #304 removed from Resident #26's wound was dated 04/15/24 (two days prior to the observation). LPN #304 was observed changing her gloves between removal of the old dressing and performance of wound care, but no hand hygiene was performed between glove changes. Once the dressing change was completed, LPN #304 removed the used supplies from the bed with her right hand, removed her right glove from the inside out to cover the bottom half of the used supplies, then handed the glove with half of the used supplies hanging out to Resident #26 to dispose of. At this time, normal saline solution was noted squirting out of the saline bullet from inside the used glove onto Resident #26's bed as he disposed of soiled dressing supplies into the trash can at the head of his bed, where the soiled dressing and supplies remained. Interview with LPN #304 at the time of the wound care observation (04/17/24 at 9:45 A.M.) confirmed the dressing she removed was dated 04/15/24. A follow-up interview on 04/17/24 at 9:55 A.M. with LPN #304 confirmed she did not set up a clean field for the dressing supplies, did not use a barrier to protect Resident #26's bedding, did not have a bag or trash receptacle nearby for disposal of soiled dressing and supplies, and did not perform hand hygiene between glove changes. LPN #304 said she typically did not use anything to lay underneath the gathered dressing supplies to use as a clean field. During the interview, LPN #304 confirmed nurses who completed the dressing changes should sign-off the dressing change had been completed on the MAR or TAR and that refusals should be documented as well. Interview with Resident #26 on 04/17/24 at 11:45 A.M. revealed he was supposed to get daily dressing changes, but the nurses did not always complete the dressing changes daily. Resident #26 said he was getting his dressing changed every morning at approximately 5:00 A.M., but lately they have been missing it. Resident #26 went two to three days in a row without a dressing change at least once in the past month and other days here and there, also indicating some agency staff on night shift did not attempt to change his dressing and then it just did not get done at any point that day because nobody checked or asked him. Resident #26 confirmed his dressing was not changed one other day this week but could not confirm which day. He further confirmed the dressing change observed at 9:45 A.M. was the only time his dressing was changed on this date (04/17/24). An interview with LPN #304 on 04/17/24 at 10:25 A.M. confirmed Resident #26's wound care was signed-off on 04/16/24 and 04/17/24 on the TAR although the dressing she removed on this date was dated 04/15/24. LPN #304 further confirmed if a resident refused treatment, the nurse was responsible for indicating the refusal on the TAR by using codes 2 for refused or a 9 for other/see nurses notes but the TAR did not contain any such documentation for the dates of 04/03/24, 04/07/24, 04/08/24, or 04/09/24. Interview on 04/17/24 at 1:25 P.M. with the Director of Nursing (DON) confirmed documentation of wound care orders should be charted on the MAR or TAR and nurses should document if the resident refused medications or treatments. Further interview confirmed no documentation was present on the TAR or in the progress notes that wound care was provided to Resident #26 on 03/29/24, 03/30/24, 04/07/24, 04/08/24, and 04/09/24, or that he refused wound care on these dates. Review of an email from LPN #392 confirmed she signed that Resident #25 received wound care on 04/16/24, but she had not performed the ordered dressing change. Review of the policy last reviewed August 2023 titled Wound Care revealed the following: Step one in the wound care procedure required use of a disposable cloth or paper towel to establish a clean field on the resident's overbed table where all dressing supplies should be placed prior to completing the ordered wound care. Step three required staff to place a disposable cloth under the wound or next to the resident to serve as a barrier to protect the bed linen and other body sites. Gloves were to be changed after removal of the old dressing, then hands should be washed and dried thoroughly before donning new gloves to clean the wound and apply the ordered treatment and dressing. Disposable items were to be disposed of in a designated container. Treatments were to be documented in the medical record. Refusals and reason for refusal should be documented.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure Resident #44's pressure ulcer wound care was co...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure Resident #44's pressure ulcer wound care was completed as ordered and failed to ensure the accuracy of Resident #44's medical record. This finding affected one (Resident #44) of one resident reviewed for pressure wounds. Findings include: Review of Resident #44's medical record revealed the resident was admitted on [DATE] with diagnoses including essential hypertension, chronic kidney disease and hypothyroidism. Resident #44 was admitted with a stage four pressure wound (wound which extends below the subcutaneous fat into deep tissues, including muscle, tendons, and ligaments) to the coccyx (gluteal cleft) identified as full thickness and a unstageable (unable to stage pressure wound due to necrosis) pressure wound of the right, upper buttock identified as full thickness. Review of Resident #44's Clinical admission form dated 01/19/24 revealed the resident had a buttocks (generalized) pressure wound which measured 2 centimeters (cm) length by 4 cm width by 0.8 cm depth and a right buttock deep tissue injury (DTI) which measured 8 cm by 5 cm. Review of Resident #44's physician orders revealed an order dated 01/19/24 (discontinued 01/30/24) to cleanse the sacrum wound, pat dry, apply calcium alginate and cover with a foam dressing. Per staff, this order applied to both the right hip and coccyx. Review of Resident #44's medication administration records (MARS) and treatment administration records (TARS) from 01/19/24 to 01/30/24 revealed the wound care was completed as ordered. Review of Resident #44's Initial Wound Evaluation and Management Summary form dated 01/24/24 revealed the resident had a stage four pressure wound to the coccyx (full thickness) measuring 4.6 centimeters (cm) length by 1.5 cm width by 1.0 cm depth with 90% (percent) slough and 10% granulation tissue. The wound was debrided on this date. The form indicated the Dressing Treatment Plan included to apply quarter strength Dakins-moistened gauze to the wound bed and a gauze island with border dressing twice daily for thirty days. Apply zinc ointment to the peri wound twice daily for 30 days. Review of Resident #44's Initial Wound Evaluation and Management Summary form dated 01/24/24 revealed an unstageable pressure wound of the right, upper buttock (full thickness) measuring 7.8 cm length by 5.4 cm width by 0.1 cm depth. The wound was debrided on this date. The form indicated the Dressing Treatment Plan included to apply quarter strength Dakins-moistened gauze to the wound bed and a gauze island dressing with border twice daily for thirty days. Apply zinc ointment to the peri wound twice daily for 30 days. Review of Resident #44's physician orders revealed an order dated 01/24/24 to current was to cleanse the right upper buttock with Dakins, apply Dakins moistened gauze, apply zinc to the peri-wound, cover with a dry border dressing and an order dated 01/24/24 to cleanse the coccyx with Dakins, apply Dakins moistened gauze, apply zinc to the peri-wound, cover with a dry border dressing. Review of Resident #44's progress note dated 01/29/24 at 5:23 A.M. authored by Licensed Practical Nurse (LPN) #805 indicated the wound care was done on the coccyx, cleansed with Dakins, apply moistened gauze, apply zinc to the peri-wound, cover with a border dressing. Observation on 01/29/24 at 6:40 A.M. with LPN #805 and State Tested Nursing Assistant (STNA) #804 of Resident #44's pressure ulcer wound care revealed the staff rolled the resident to the right side and removed the resident's incontinence brief. LPN #805 removed the dressing to the right upper buttock pressure wound (no dressing was observed on the coccyx), removed her gloves and washed her hands. LPN #805 put on new gloves, cleansed the right upper buttock and coccyx with half strength Dakins solution and replaced a foam dressing to the right hip. LPN #805 did not place a dressing on the coccyx and did not change her gloves between cleansing the right upper buttock pressure wound and the coccyx pressure wound. LPN #805 did not apply zinc oxide cream to the peri wound areas of the right hip or the coccyx pressure wounds. The incontinence brief was replaced and the staff left the room. Interview on 01/29/24 at 6:50 A.M. with LPN #805 confirmed Resident #44 did not have a pressure wound dressing to the coccyx upon first examination of the resident's sacral wounds. LPN #805 confirmed she did not apply the dressing to the right upper buttock pressure wound as ordered because the facility did not have quarter strength Dakins solution, did not have the zinc oxide cream for the peri wound and did not have the right foam dressing to cover the resident's right upper buttock pressure wound. LPN #805 also confirmed she did not place a dressing to the coccyx pressure wound because she could not find the correct dressing for the coccyx wound. She also confirmed she did not place zinc oxide cream to the peri wound of the coccyx as ordered. Interview on 01/29/24 at 9:37 A.M. with LPN Wound Nurse #810 indicated the facility had the supplies but the nursing staff do not go to the central supply room in the basement for the supplies. Interview on 01/30/24 at 10:59 A.M. with LPN #806 confirmed she placed new orders for Resident #44's right upper hip/buttock pressure wound and coccyx pressure wound on 01/24/24 and staff were signing off both the order for the calcium alginate order from 01/24/24 to 01/30/24 in error which should have been discontinued. She confirmed Resident #44's current physician orders was for the Dakins solution to the coccyx and right hip/buttock area. Interview on 01/30/24 at 11:48 a.m. with LPN Minimum Data Set (MDS) #820 confirmed Resident #44 had both the coccyx and right upper hip/buttocks wounds upon admission which did not deteriorate and remained at the same staging and size. Review of the Wound Care policy reviewed 08/23 indicated the purpose of the procedure was to provide guidelines for the care of wounds to promote healing and stated to verify the physician's order for the procedure and gather the equipment and supplies as needed.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

Based on interview, medical record review, and policy review the facility failed to ensure a complete and accurate medical record for one resident (#43) of three residents reviewed for wound care. The...

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Based on interview, medical record review, and policy review the facility failed to ensure a complete and accurate medical record for one resident (#43) of three residents reviewed for wound care. The facility census was 49. Findings include: Review of the medical record for Resident #43 revealed an admission date of 01/19/24 with diagnoses including metabolic encephalopathy, moderate protein-calorie malnutrition, stage three chronic kidney disease, type two diabetes mellitus, stage four pressure ulcer of sacral region, unstageable pressure ulcer of right buttock, pressure-induced deep tissue damage of other site, unstageable pressure ulcer of other site, and pressure-induced deep tissue damage of left heel. Review of the Minimum Data Set (MDS) assessment completed on 03/08/24 revealed Resident #43 had intact cognition and the presence of one stage four and two unstageable pressure ulcers, which were present on admission to the facility. Review of physician orders revealed Resident #43 had the following wound care orders to his right upper buttock: From 01/30/24 to 02/05/24 cleanse with ¼ strength Dakins, use clean gauze moistened with Dakins and apply to wound bed, leaving gauze in place (do not remove), apply zinc to peri-wound, cover with dry border dressing twice daily. May use ½ strength Dakins as a substitute. From 02/05/24 to 02/28/24 cleanse with ¼ strength Dakins, use clean gauze moistened with Dakins and apply to wound bed, leaving gauze in place (do not remove), apply zinc to peri-wound, and cover with super absorbent gel dressing twice a day. May use ½ strength Dakins as a substitute. From 02/28/24 to 03/06/24 cleanse with ¼ strength Dakins, pack loosely with one large piece of Alginate calcium with silver, apply zinc to peri-wound, and cover with super absorbent gel dressing twice a day. May use ½ strength Dakins for substitute. From 03/06/24 to 03/14/24 cleanse with ¼ strength Dakins, pack loosely with a collagen sheet, then pack loosely with one large piece of Alginate calcium with silver, apply zinc to peri-wound, and cover with super absorbent gel dressing once a day. May use ½ strength Dakins for substitute. Beginning 03/14/24 cleanse with 1/4 strength Dakins solution, pack loosely with one large piece of alginate calcium with silver, then pack loosely with collagen sheet, apply zinc to peri-wound, and cover with super absorbent gel dressing once daily. May use ½ strength Dakins as a substitute. Review of physician orders revealed from 01/25/24 to 02/05/24 Resident #43 had an order to cleanse the right knee with normal saline (NS), apply Betadine, and cover with a dry border dressing one time a day. Review of physician orders revealed from 01/24/24 to 03/14/24 Resident #43 had an order to apply Skin prep daily, once a day to right posterior scalp. Review of physician orders revealed from 01/25/24 to 03/14/24 Resident #43 had an order to cleanse left toes and left heel with NS, apply Betadine, cover with abdominal (ABD) pad, and wrap with Kerlix once daily. Review of physician orders revealed beginning 03/26/24 Resident #43 had an order to cleanse left firs toe with NS, apply Betadine, and cover with bordered gauze every night shift for wound treatment. Review of physician orders revealed Resident #43 had the following wound care orders to his left heel: From 03/07/24 to 03/25/24 cleanse with NS, apply Betadine, ABD pad, and Kerlix. once a day. From 03/14/24 to 04/10/24 cleanse with NS, apply sodium hypochlorite gel (if not available, use Betadine), cover with ABD, and wrap with Kerlix once a day. Beginning 04/10/24 cleanse with NS, apply Betadine, cover with an ABD pad, and wrap with Kerlix one time a day. Review of physician orders revealed Resident #43 had the following wound care orders to his coccyx: From 01/30/24 to 02/05/24, between gluteal folds use clean gauze moistened with Dakins ½ strength solution and apply to wound bed, leaving the Dakin's-soaked gauze in place (do not remove), apply zinc to peri-wound, and cover with a dry border dressing twice a day. From 02/0/24 to 02/07/24, between gluteal folds use clean gauze moistened with Dakins ½ strength solution and apply to wound bed, leaving the Dakin's-soaked gauze in place (do not remove), apply zinc to peri-wound, and cover with super absorbent gel dressing two times a day. From 02/07/24 to 03/06/24, between gluteal folds cleanse with Dakins ½ strength, apply alginate calcium silver to wound bed, leave in place (do not remove), apply zinc to peri-wound, and cover with super absorbent gel dressing. Review of the Medication Administration Record (MAR) and the Treatment Administration Record (TAR) for February 2024 revealed there was no documentation of the following wound care treatments for the following wounds on the following dates: Right upper buttock- missing documentation for ordered treatments on 02/02/24, 02/15/24, 02/16/24, 02/17/24, 02/22/24, 02/23/24 (morning treatments), and 02/29/24 (both treatments). Right knee- missing documentation for ordered treatment on 02/02/24. Right posterior scalp- missing documentation for ordered treatment on 02/08/24. Left toes and left heel- missing documentation for ordered treatments on 02/02/24, 02/15/24, 02/16/24, 02/17/24, 02/22/24, and 02/23/24. Left first toe- missing documentation for ordered treatment on 02/29/24. Coccyx- missing documentation for ordered treatments scheduled the mornings of 02/15/24, 02/15/24, 02/16/24, 02/22/24, 02/23/24, and 02/29/24, and the scheduled evening treatment on 02/29/24. Review of the progress notes revealed no documentation on 02/02/24, 02/08/24, 02/15/24, 02/16/24, 02/17/24, 02/22/24, 02/23/24, or 02/29/24 regarding Resident #43's wound care. Review of the MAR and the TAR for March 2024 revealed there was no documentation of the following wound care treatments for the following wounds on the following dates: Right upper buttock- missing documentation for ordered treatment on 03/30/24. Right posterior scalp- missing documentation for ordered treatment on 03/01/24, 03/04/24, and 03/05/24. Left great toe- missing documentation for ordered treatment on 03/03/24. Left heel- missing documentation for ordered treatment on 03/11/24. Review of the progress notes revealed no documentation on 03/01/24, 03/03/24, 03/04/24, 03/05/24, 03/11/24, or 03/30/24 regarding Resident #43's wound care. Review of the MAR and TAR for March 2024 revealed there was no documentation of the following wound care treatments for the following wounds on the following dates: Right upper buttock- missing documentation for ordered treatments on 04/05/24 and 04/09/24. Right posterior scalp- missing documentation for ordered treatments on 04/01/24, 04/05/24, 04/08/24, 04/09/24, 04/12/24, and 04/13/24. Left great toe- missing documentation for ordered treatments on 04/01/24, 04/05/24, 04/08/24, 04/12/24, and 04/13/24. Left heel- missing documentation for ordered treatment on 04/01/24, 04/04/24, 04/05/24, 04/08/24, 04/09/24, 04/12/24, and 04/13/24. Review of the progress notes revealed no documentation on 04/01/24, 04/04/24, 04/05/24, 04/08/24, 04/09/24, 04/12/24, or 04/13/24 regarding Resident #43's wound care. Interview on 04/17/24 at 9:45 A.M. with Licensed Practical Nurse #304 revealed nurses who completed wound care and treatments were to sign-off the care and treatments were completed on the MAR or TAR. Resident refusal of wound care was to be documented on the MAR or TAR and in the progress notes. Interview on 04/17/24 at 1:25 P.M. with the Director of Nursing confirmed completed wound care should be documented on the MAR or TAR and nurses should document if the resident refused medications or treatments. Review of the policy last reviewed in August 2023 titled Wound Care revealed treatments were to be documented in the medical record. Refusals and the reason for refusal were also to be documented.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0865 (Tag F0865)

Could have caused harm · This affected multiple residents

Based on observation, record review and staff interview, the facility failed to ensure their Quality Assurance and Performance Improvement (QAPI) program committee thoroughly evaluated, identified are...

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Based on observation, record review and staff interview, the facility failed to ensure their Quality Assurance and Performance Improvement (QAPI) program committee thoroughly evaluated, identified areas in need of improvement, and data related to the issues was being monitored to determine if the plan of correction was being implemented as written and corrections were being sustained, and to determine if revisions were necessary. This had the potential to affect eight residents (Residents #3, #18, #22, #23, #26, #28, #43, and #48) who were receiving wound care treatments. The facility census was 49. Findings include: Review of the facility's survey tracking history revealed the facility had a complaint survey completed on 01/30/24 which resulted in concerns wound care was not being completed as ordered for one resident with a pressure ulcer and inaccuracy of the medical record in relation to the wound care documentation. Review of the facility's written plan of correction (POC) revealed the facility had an approved plan in place, including: Wound care education to facility nurses on 01/29/24 by the Director of Nursing (DON). The wound care doctor that rounded at the facility provided an educational video for facility nurses. The DON or designee was to audit all residents with pressure wounds twice a week for four weeks through observation and chart review to ensure accurate wound care and documentation. Review of the written wound care education and in-service log for wound care training completed by the DON on 01/29/24 revealed a total of six licensed nurses and one maintenance staff member attended the wound care training. Review of the current nursing staff roster revealed a total of 12 licensed practical nurses (LPNs), including the assistant director of nursing (ADON) and the Minimum Data Set (MDS) Coordinator and five registered nurses (RNs) were employed by the facility. Additionally, the Admissions Director and the Staffing Coordinator were also LPNs. Interview on 04/18/24 at 12:25 P.M. with the DON confirmed the in-service log contained all the signatures of nurses who attended the wound care training and that the training consisted of review of the following three policies: Wound Care, last reviewed 08/21; Pressure Injury risk Assessment, last reviewed 08/2021; and Pressure Injury Treatment, undated. There was no mention of a video and no documentation of a wound care educational video in the binder that contained evidence of the facility's implementation of their POC. Review of the audit tracking forms to ensure the facility completed audits of all residents with pressure wounds twice a week for four weeks through observation and chart review revealed the facility failed to complete wound audits more than once a week and failed to review residents with pressure wounds during week three of the audits. Interview on 04/18/24 at 12:25 P.M. with the DON revealed wound audits were conducted by LPN #304 so she could not speak to how the audits were conducted. Interview on 04/18/24 at 1:20 P.M. with LPN #304 revealed she completed an audit on one resident on Wednesdays and one resident on Thursdays, instead of all residents with pressure injuries twice a week. She further confirmed the audits completed in week three were on residents with non-pressure injuries. During the interview, LPN #304 admitted she misunderstood what she was required to do as part of the facility's POC related to wound audits. LPN #304 further confirmed the audits did not capture missing documentation on the medication administration record (MAR) or the treatment administration record (TAR) during week two and week four audits of Resident #43's wound care. Interview with the Administrator on 04/18/24 at 12:35 P.M. revealed the facility held monthly QAPI meetings and the medical director was expected to attend quarterly. The Administrator revealed the last meeting was held on 03/29/24 with the interdisciplinary team and the medical director was not in attendance for that meeting. The Administrator said the team reviewed the facility's progress with audits related to open surveys exited on 01/30/24 and 03/14/24. Regarding wound care audits and wound care training, the Administrator revealed LPN #304 was tasked with completing training and audits. He further stated LPN #304 sent him weekly audits to upload to the Enhanced Information Dissemination Collection (EIDC) system and he trusted that the staff assigned to carry out parts of the POC were doing what they were supposed to be doing and therefore he did not review the information. The Administrator confirmed no problems with the facility's execution of their approved POC were identified during the QAPI meeting held on 03/29/24. Review of the QAPI meeting notes from 03/29/24 revealed no indication any concerns were identified regarding the facility's execution of the written POC. Observations, interviews, medical record reviews, and review of facility policies and procedures on 04/16/24 through 04/18/24 revealed the facility failed to ensure wound care was completed as ordered, treatments provided were rendered according to appropriate standards of care to decrease the risk of infection, and the record accurately reflected care that was provided. Please refer to F684 and F842. Review of the State Operations Manual (SOM), chapter seven, section §7317 titled Acceptable Plan of Correction effective 11-16-18 revealed the facility must develop a plan to monitor their ongoing performance toward compliance and ensure solutions put into place are sustained. Section §7317 also revealed when a plan of correction is approved, it is the facility who is ultimately accountable for managing their own compliance.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0727 (Tag F0727)

Could have caused harm · This affected most or all residents

Based on record review and interviews, the facility failed to ensure registered nurse coverage at least eight hours per day, seven days per week. This finding had the potential to affect all 54 reside...

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Based on record review and interviews, the facility failed to ensure registered nurse coverage at least eight hours per day, seven days per week. This finding had the potential to affect all 54 residents residing in the facility. Findings include: Review of the staffing schedules from 12/24/23 to 12/30/23 with Human Resources (HR) #811 revealed no evidence of registered nurse (RN) coverage on 12/25/23 for at least eight hours as required. Interview on 01/29/24 at 10:07 A.M. with HR #811 confirmed the facility did not have RN coverage of at least eight hours on 12/25/23. This deficiency represents non-compliance investigated under Complaint Number OH00149612.

Oct 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0660 (Tag F0660)

Could have caused harm · This affected 1 resident

Based on record review and interview the facility failed to implement a safe discharge including the provision of medications for Resident #49. This affected one (Resident #49) of three residents revi...

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Based on record review and interview the facility failed to implement a safe discharge including the provision of medications for Resident #49. This affected one (Resident #49) of three residents reviewed for discharge planning and implementation. The census was 46. Findings include: Review of the medical record for Resident #49 revealed an admission date of 08/18/23 and discharge date of 09/11/23. Diagnoses included unspecified severe protein-calorie malnutrition, depression, anxiety disorder, and multiple myeloma not having achieved remission. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 08/24/23, revealed the resident had intact cognition. Review of the nurse progress note dated 09/11/23 revealed Licensed Practical Nurse (LPN) #102 was unable to provide medications upon discharge due to Resident #49 leaving the building without notifying LPN #102. Interview on 10/07/23 at 10:29 A.M. with the Administrator revealed Resident #49's discharge summary and medications were completed upon discharge. The LPN who discharged Resident #49 did not provide medications to the resident or family member. The LPN did not contact the Director of Nursing (DON) indicating the medications were not provided. The Administrator stated the facility was not aware of the medications not being provided until the home healthcare company called asking about the medications which was on 09/13/23. The Administrator stated the DON faxed the medication list to have the prescriptions filled. Review of facility policy titled Discharge Process, dated 2022, revealed staff were to reconcile all pre-discharge medications with post-discharge medications during discharge. This deficiency represents non-compliance investigated under Complaint Number OH00146558.

Sept 2023 2 deficiencies

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected most or all residents

Based on review of a facility Legionella water management plan documentation, staff interview, and review of Centers for Disease Control and Prevention (CDC) guidance, the facility failed to fully imp...

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Based on review of a facility Legionella water management plan documentation, staff interview, and review of Centers for Disease Control and Prevention (CDC) guidance, the facility failed to fully implement a complete water management program to prevent the growth of Legionella bacteria. This had the potential to affect all 47 residents residing in the facility. The census was 47. Findings include: Review of the facility undated document titled, Legionella Water Management Plan, revealed the plan lacked any information about how the facility would intervene when control measures were not met, failed to address ongoing monitoring of the plan's effectiveness, and no documentation of preventative measures or testing of the water system besides temperature monitoring to maintain the water system free of Legionella bacteria. Interview with Maintenance Director (MD) #945 on 09/11/23 at 9:02 A.M. verified the lack of information in the facility's Legionella water management plan. Review of the CDC webpage revealed guidance under the title of, Overview of Water Management Programs, and revealed water management programs identify hazardous conditions and take steps to minimize the growth and transmission of Legionella and other waterborne pathogens in building water systems. Developing and maintaining a water management program is a multi-step process that requires continuous review. Such programs are now an industry standard for many buildings in the United States. Further review of the webpage under the subsection titled, Key Elements, revealed there were seven key elements of a Legionella water management program which included to establish a water management program team, describe the building water systems using text and flow diagrams Burden of Waterborne Disease, identify areas where Legionella could grow and spread, decide where control measures should be applied and how to monitor them, establish ways to intervene when control limits are not met, make sure the program is running as designed (verification) and is effective (validation), and document and communicate all the activities. This deficiency represents non-compliance investigated under Complaint Number OH00146173.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0922 (Tag F0922)

Could have caused harm · This affected most or all residents

Based on observation, staff interview, interview with a water service representative, review of an emergency water supply contract, and review of water company recommendations, the facility failed to ...

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Based on observation, staff interview, interview with a water service representative, review of an emergency water supply contract, and review of water company recommendations, the facility failed to ensure an adequate usable emergency water source was available for use in the event of a service disruption. This had the potential to affect all 47 residents residing in the facility. The facility census was 47. Findings include: Observation of the facility's emergency water supply with Maintenance Director (MD) #945 on 09/11/23 at 9:02 A.M. revealed twenty five-gallon plastic water jugs in the facility's basement. The jugs were coated in dust and dirt. Eleven of the bottles had delivery date stickers of 09/25/17, and nine of the bottles had delivery date stickers of 08/27/13. Interview with MD #945 on 09/11/23 at 9:02 A.M., during observation of the facility's emergency water supply, verified the dates and the condition of the water jugs, and verified there was no other emergency water source available at the facility at the time of the observation. Continued interview with MD #945 stated the water observed in the basement was the sole emergency water supply for the skilled nursing facility and the attached residential care facility (RCF). The RCF was noted to have a capacity of 71 residents and a current census of 39 residents. Review of the facility's emergency water supplier's website revealed the provider recommended using five-gallon water jugs within two years. Review of the current emergency water supply contract revealed the facility signed a contract for emergency water from a new provider on 01/01/23. Interview with Water Service Company Worker (WSCW) #805 on 09/13/23 at 9:45 A.M. verified no water supply deliveries were made to the facility, and stated he was just contacted by the facility on 09/11/23 to schedule delivery. WSCW #805 verified a delivery was scheduled for 09/14/23.

Aug 2023 3 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, review of facility self-reported incidents (SRIs), and facility policy review the facility fa...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, review of facility self-reported incidents (SRIs), and facility policy review the facility failed to ensure Resident #47 was free from staff to resident verbal abuse. This affected one resident (47) of two self-reported incidents reviewed for abuse. Findings include: Record review revealed Resident #47 was admitted to the facility on [DATE] with diagnoses including adjustment disorder with mixed anxiety and depression, anxiety disorder, bipolar, major depression disorder, and insomnia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #47 had intact cognition and required extensive assistance with activities of daily living. Review of facility SRI tracking number 238135 dated 08/15/23 revealed Resident #47 reported a nightshift male State Tested Nursing Assistant (STNA) #111 was using inappropriate language. STNA #111 was as needed (PRN) help. During the investigation, the Director of Nursing (DON) was notified that STNA #112 was also heard using inappropriate language with Resident #47. Review of Resident #47's witness statement dated 8/19/23 revealed she rang her call light for ice. STNA #112 was upset that she had to answer the call light. Resident #47 rang the call light again and asked the STNA for ice again. The STNA proceeded to yell at Resident #47 using the F word. Review of Resident #39's statement, roommate to Resident #47, dated 08/19/23 revealed Resident #47 rang her call light and the STNA came in with an attitude and swearing using the F word. Review of STNA #112's statement dated 08/19/23 revealed she answered Resident #47's call light for ice. STNA #112 went to go find cups stored in the basement and returned upstairs and found Resident #47's call light ringing. STNA #112 stated she was annoyed at Resident #47 and started yelling because she had not given her a chance to come back with the ice. Review of the DON's statement dated 08/19/23 revealed STNA #111 was immediately suspended. Several attempts to contact STNA #111 about the incident were unsuccessful. Interview with the DON on 08/24/23 at 10:22 A.M. revealed during the investigation he interviewed STNA #112, and she admitted that she yelled at Resident #47. Interview with the Administrator on 08/24/23 at 2:57 P.M. revealed in the interview with STNA #112 she admitted to yelling at Resident #47. The Administer stated it was clear that verbal abuse occurred with Resident #47 and substantiated SRI tracking number 238135. Review of the policy titled Freedom from Abuse, Misappropriation, Involuntary seclusion, neglect and exploitation, dated January 2020, revealed residents must not be subjected to abuse by anyone, including, but not limited to; facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family member or legal guardian, friends and/or other individuals. This deficiency represents non-compliance investigated under Master Complaint Number OH00145800.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

Based on resident interview, observation, staff interview, and facility policy review the facility failed to ensure a homelike environment that was free of pests. This affected five Residents (#18, #3...

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Based on resident interview, observation, staff interview, and facility policy review the facility failed to ensure a homelike environment that was free of pests. This affected five Residents (#18, #30, #32, #41 and #47) of 47 residents residing at the facility. Findings include: Review of the pest control service documentation from 05/11/23 through 08/08/23 revealed the facility was previous treated for flies, gnats, ants, and mice. Review of the maintenance log dated 06/01/23 through 08/23/23 - revealed no pest issues. Interview on 08/23/23 at 8:30 A.M. with Resident #47 stated she had gnats flying around her orange juice cup this morning. Observation on 08/23/24 at 12:30 P.M. of Resident #41's room revealed there were five small flies sitting on the countertop next to a used washcloth. At this time the Director of Nursing (DON) verified the finding. Interview on 08/23/23 at 3:30 P.M. with Resident #39, roommate to Resident #47, stated gnats were flying around Resident #47's breakfast this morning. Interview on 08/23/23 at 3:55 P.M. with the Maintenance Director (MD) #114 stated he had no knowledge of any fly or gnat issues. The pest control company comes out monthly and as needed. The MD #114 stated a month ago pest control treated for mice. Observation on 08/23/24 at 4:20 P.M. with the MD #114 of Resident #30's room revealed there were five small flies on the side of her tray table. Observation on 08/23/24 at 4:25 P.M. with the MD #114 of Resident #18's room revealed there was a recliner chair with a cup holder on the side. There was a Styrofoam cup with a straw that was surround with 10 small flies, next to the cup was a plastic spoon with a dried red substance and was covered with three very small flies. Interview on 08/23/23 at 4:30 P.M. with the DON, revealed he was unaware of any pests' issues until today. Interview on 08/24/23 at 8:22 A.M. with Resident #30 stated there were flies in her room. Observation at this time revealed there was a very small black fly on the tray table next to her bed. Interview on 08/24/23 at 9:02 A.M. with Resident #32 stated he had gnats in his room and in his bathroom. Observation at this time revealed there were three gnats on his pillow, five gnats on the wall to the bathroom, and several flying around in the bathroom. At this time the DON verified the finding. Review of the undated policy titled Work Order and Emergency call revealed all staff at the facility must create a work order for any repair or problem on any environment resident rooms. Hallways, bathrooms, and common areas. This deficiency represents non-compliance investigated under Complaint Number OH00145688.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

Based on observation, interview, and facility policy review the facility failed to serve food at a safe/palatable temperature. This had the potential to affect 46 out of 47 residents who ate meals fro...

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Based on observation, interview, and facility policy review the facility failed to serve food at a safe/palatable temperature. This had the potential to affect 46 out of 47 residents who ate meals from the facility's kitchen. One resident (#39) was identified as received nothing by mouth. The facility census was 47. Findings include: Observation of the tray line on 08/24/23 from 11:15 A.M. through 12:09 A.M. revealed food was above 165 degrees Fahrenheit (F) on the tray line, preferences were honored, condiments were available, and every tray had appropriate silverware including adaptive equipment. Observation and interview on 08/24/23 at 12:15 P.M. revealed the meal cart with meals was parked in front of the dining room. Interview with Licensed Practical Nurse (LPN) #101 stated meal trays were not passed due to the facility had four agency Stated Tested Nursing Assistants (STNAs) working the floor. LPN #101 stated they do not know the meal tray delivery routine. Observation of test tray and interview on 08/23/23 at 12:30 P.M. with Dietary Manager (DM) #115 revealed the ham was 102 degrees F, Brussel sprouts were 93 degrees F, and mashed sweet potatoes were 110 degrees F. The ham was lukewarm, the mashed sweet potatoes looked like an orange scoop of pureed food. The sweet potatoes tasted lukewarm and had a pureed consistency with no texture. Interview with DM #115 revealed the ham, and the Brussel sprouts did not meet the facility policy temperature guidelines. DM #115 stated the meal tray pass took too long. DM #115 stated that there was one resident (#39) that did not receive food from the kitchen. Interview on 08/24/23 at 2:30 P.M. with Resident # 30 stated her lunch meal was cold today. Interview on 08/24/23 at 2:35 P.M. with Resident #47 stated her lunch meal was lukewarm. Interview on 08/24/23 at 2:40 P.M. with Resident #24 stated she did not eat her lunch meal because it did not look appetizing. Review of the undated facility policy titled Food Serving Temperatures revealed food should be at an acceptable temperature at preparation and at point of service of the resident. The point of service temperature to residents will be within the range of 120 to 140 degrees F. This deficiency represents non-compliance investigated under Master Complaint Number OH00145688.

Jul 2023 1 deficiency

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

Based on observation and interview, the facility failed to monitor temperatures effectively and maintain safe and comfortable temperatures in all resident areas. This affected 12 (#4, #5, #8, #19, #21...

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Based on observation and interview, the facility failed to monitor temperatures effectively and maintain safe and comfortable temperatures in all resident areas. This affected 12 (#4, #5, #8, #19, #21, #22, #28, #29, #33, #34, #36, and #37) of 44 residents observed for comfortable environment in the facility. Findings include: On 07/10/23 from 5:30 P.M. to 5:55 P.M., observations of the facility revealed residents and staff were sweating and the air temperature felt very warm. On 07/10/23 at 5:33 P.M., interview with Resident #5 stated the air temperature was too hot. On 07/10/23 at 5:33 P.M., interview with Licensed Practical Nurse (LPN) #100 stated the air conditioner was not working and residents had been complaining about the heat all day. On 07/10/23 at 5:35 P.M., interview with Resident #4 stated the air temperature was too hot. On 07/10/23 at 5:39 P.M., interview with Resident #19 stated the air temperature had been too hot for several days. On 07/10/23 at 5:42 P.M., interview with Resident #29 stated the air temperature had been real hot for several days and he had to purchase a fan to try to keep cool. On 07/10/23 at 5:45 P.M., interview with the Director of Nursing (DON) stated the air conditioner had quit working on 07/09/23 around lunch time. On 07/10/23 at 5:46 P.M., interview with the Administrator confirmed the air conditioner quit working on 07/09/23. On 07/11/23 at 8:29 A.M., interview with Licensed Practical Nurse (LPN) #101 stated it was too hot in the facility and residents had been complaining about the heat. On 07/11/23 at 8:38 A.M., interview with LPN #102 stated it had been warmer than usual in the facility over the last few days. On 07/11/23 at 8:42 A.M., interview with Housekeeper #103 stated it was hot in the facility. On 07/11/23 at 8:49 A.M., interview with State Tested Nurse Aide (STNA) #104 stated it had been hot in the facility for several days and residents were complaining about the heat. On 07/11/23 at 8:56 A.M., interview with Housekeeper #105 stated the air temperature had been hot in the facility for several days. On 07/11/23 at 10:39 A.M., interview with Resident #36 stated it was too hot and he had to sit in front of the fan in the hallway to try to stay cool. On 07/11/23 at 10:43 A.M., interview with Maintenance Director #106 stated the air conditioning unit quit working on 07/09/23 and they immediately contacted a repair company. He stated he had been monitoring the temperatures in the facility using a laser thermometer. He explained that a laser thermometer read the temperature of whatever surface it was pointed at and not the actual air temperature. Maintenance Director #106 stated that there was no way to verify the actual air temperature using the laser thermometer. On 07/11/23 at 12:13 P.M., observation of facility temperatures, taken by Maintenance Director #106 using the laser thermometer, revealed the following: The temperature in the resident common area by the nurse's station was 83.0 degrees Fahrenheit (F). The temperature in Resident #8's room was 83.0 degrees F. The temperature in Residents #28 and #29's room was 86.5 degrees F. Maintenance Director #106 verified the temperature readings at the time of observation. On 07/11/23 at 12:20 P.M., interview with Resident #21 stated the air conditioner in his room did not work and it was too hot. On 07/11/23 at 12:27 P.M., interview with STNAs #108 and #109 stated it was too hot in the facility and staff were having difficulty providing resident care in the heat. On 07/11/23 at 12:40 P.M., interview with the Administrator verified the facility did not have the appropriate type of thermometer to ensure air temperature in resident areas was within an appropriate range. On 07/11/23 at 2:56 P.M., interview with Resident #33 stated it had been too in her room hot for a few days. On 07/11/23 at 2:57 P.M., interview with Resident #34 stated the air conditioner in her room did not work properly and her room was too hot. On 07/11/23 at 3:01 P.M., interview with Resident #37 stated she was soaked in sweat when she woke up this morning because of the heat. This deficiency represents non-compliance investigated under Complaint Number OH00144374.

Jun 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and review of the facility's bowel elimination policy and procedure, the facility failed to p...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and review of the facility's bowel elimination policy and procedure, the facility failed to provide interventions when Resident #18 did not have a bowel movement for three days. This affected one (Resident #18) out of three residents reviewed for personal care services. Facility census was 42. Findings include: Review of the medical record revealed Resident #18 was admitted on [DATE] with diagnoses that included but not limited to dementia, psychotic and mood disturbance, and anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 had severe cognitive impairment. Resident #18 required extensive assistance of one for bed mobility, transfers, and toilet use. Resident #18 was occasionally incontinent of bowel and bladder. Review of physician orders revealed orders including Resident #18 was to be scheduled to be toileted every two hours while awake, milk of magnesia orally as needed for constipation if no bowel movent for three days, bisacodyl suppository rectally as needed for constipation if no bowel movement for three days, and a Fleet enema as needed rectally. Review of the treatment administration record (TAR) revealed Resident #18 had a small bowel movement on 06/01/23 during the 7:00 A.M. to 7:00 P.M. shift. The next documented bowel movement was a small bowel movement 06/05/23 during the 7:00 P.M. to 7:00 A.M. shift. Review of the medication administration record (MAR) for June 2023 revealed no evidence Resident #18 was administered milk of magnesia orally as needed for constipation if no bowel movent for three days, bisacodyl suppository rectally as needed for constipation if no bowel movement for three days, or a Fleet enema as needed rectally. Review of the facility's undated Bowel Elimination Policy and Procedure revealed the facility standard of practice for residents noted to have an acute symptomatic period of constipation or lack of bowel elimination would be as follows: if the resident had been without a bowel movement for 48 hours, 120 milliliter of prune juice or bran mixture would be offered. If the resident had been without a noted bowel movement for 72 hours the nurse would consider administering a laxative such as milk of magnesia. If a resident had been without a bowel movement eight hours after milk of magnesia, the nurse would obtain an order, or follow established as needed order for a stimulant laxative such as a suppository and administer. If the resident had been without a bowel movement eight hours after the suppository was given, the nurse would administer an enema as ordered. Communication via email on 06/27/23 at 12:23 P.M. with the Director of Nursing (DON) verified there was no documentation Resident #18 had a bowel movement on 06/02/23, 06/03/23, or 06/04/23. The DON also verified there was no documentation of Resident #18 receiving prune juice, milk of magnesia, a suppository, or an enema. This deficiency represents non-compliance investigated under Complaint Number OH00143725 and OH00143518.

Apr 2023 7 deficiencies 1 Harm

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Deficiency F0697 (Tag F0697)

A resident was harmed · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure Resident #28 received pain medication as ordered by the physi...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure Resident #28 received pain medication as ordered by the physician in a timely manner. This affected one out of seven residents reviewed for medication administration. The facility census was 45. Actual harm occurred when Resident #28, a newly admitted resident with significant injury resulting from a MVA, did not receive ordered narcotic pain medication for approximately 17.5 hours resulting in a lack of effective pain relief, nausea and severe pain for an extended period of time. Findings include: Record review revealed Resident #28 was admitted on [DATE] with diagnoses of thoracic vertebrae fracture, fracture of one left sided rib, fracture of the left fibula shaft resulting from a motor vehicle accident (MVA), intervertebral disc degeneration of the lumbar region, mild cognitive impairment, bone density disorder, urinary incontinence and depression. A review of Resident #28's nursing progress dated 04/17/23 indicated Resident #28 arrived to the facility and transferred to her bed. Resident #28 had bruising and skin tears to both arms, left knee sutures and a right leg splint. The nursing progress note indicated Resident #28 had a lot of bruising on hands, neck, lower abdomen, and left rib. The nursing progress note indicated Resident #28 had moderate pain and the physician was notified. A review of Resident #28's physician orders indicated an order dated 04/17/23 to administer Morphine 15 milligrams (mg) orally two times a day for pain with a start date of 7:00 P.M. and to administer Roxicodone 5 mg every six hours as needed for moderate pain for seven days and to start at 6:30 P.M. on 04/17/23. Review of Resident #28's Medication Administration Record (MAR) dated 04/01/23 to 04/30/23 indicated Resident #28 received a dose of acetaminophen 500 mg orally at 10:00 P.M. on 04/17/23. Resident #28 received the first dose of Roxicodone at 8:32 A.M. on 04/18/23 with a 10 out of 10 pain score (severe pain). The pain medication Morphine 15 mg to administer orally upon rising and at bedtime was not administered at bedtime on 04/17/23 or in the morning on 04/18/23. The MAR indicated the morphine medication was not available in the facility. An interview with Resident #28 on 04/18/23 at 5:10 P.M. indicated the facility was not ready when she arrived to the facility. Resident #28 stated she was in severe pain for over 12 hours without relief and only received acetaminophen (Tylenol) once which did not give her relief. Resident #28 indicated the staff had informed her she would need to wait for the narcotic pain medications (Morphine, Roxicodone) to be delivered the following morning because the medications were not available until pharmacy delivered them to the facility. An interview with Resident #28's caregiver on 04/18/23 at 5:19 P.M. indicated the caregiver walked in the Resident #28's room at approximately 8:30 P.M. to 9:00 P.M. on 04/17/23 and found Resident #28 with the bed completely lowered to the floor, soaking wet with urine, cold, and complaining of pain. Resident #28's caregiver stated the call light was sounding. Resident #28 informed the caregiver she wanted to leave the facility. Resident #28's caregiver stated she agreed to stay the night with Resident #28 to ensure she was cared for properly. The next morning on 04/18/23 the nurse informed her she was unable to administer Resident #28's narcotic pain medication (morphine, Roxicodone) due to the pharmacy had not delivered the medications to the facility yet. Resident #28's caregiver stated Resident #28 was nauseated and in severe pain by the time she finally received her first dose of pain medication in the morning on 04/18/23. An interview with Resident #28's sister on 04/18/23 at 5:36 P.M. indicated Resident #28 had not received her medications and was complaining of pain. The last dose of pain medication Resident #28 received was on 04/17/23 at 3:00 P.M. in the hospital. Resident #28's sister indicated Resident #28 had been in a motor vehicle accident and had numerous injuries and bone fractures and needed her pain medication. An interview with Licensed Practical Nurse (LPN) #62 on 04/19/23 at 10:07 A.M. indicated the pharmacy delivered medications approximately 24 hours after a resident was admitted . LPN #62 stated Resident #28's medications did not arrive until 7:00 A.M. on 04/18/23. LPN #62 indicated licensed nurses who were employed by the facility could remove pain medication and other significant medication from the secured medication storage by using their fingerprint. LPN #62 was employed by a staffing agency and was unable to remove medications from the secured medication storage, only licensed nurses employed by the facility were able to withdraw medications from the secured medication storage system. The agency nurses were required to ask a licensed nurse from the facility to withdraw medications from the secured medication storage system. LPN #62 stated during the night shift from 7:00 P.M. to 7:30 A.M. when there were only licensed nurses employed by the agency working in the facility, there was no one to ask to remove medications from the secured storage system and the resident had to wait until pharmacy delivered the medications to the facility. An interview with Regional Registered Nurse and Director of Nursing (DON) on 04/18/23 at 10:45 A.M. verified Resident #28 did not receive her physician ordered narcotic pain medication in a timely manner. An interview with State Tested Nursing Assistant (STNA) #64 on 04/19/23 at 6:40 A.M. indicated she was working from 7:00 P.M. to 7:00 A.M. on the night Resident #28 was admitted to the facility. STNA #64 stated when the previous shift STNA had given her report she failed to alert her of Resident #28's admission earlier in the evening. STNA #64 was unaware Resident #28 needed assistance. STNA #64 stated Resident #28's caregiver arrived and informed the staff of the lack of pain medications available to administer to relieve Resident #28's pain. STNA #64 stated she provided incontinence care and tried to make Resident #28 as comfortable as possible. An interview with LPN #54 on 04/19/23 at 7:00 P.M. indicated she was assigned to care for Resident #28 during the night shift hours from 7:00 P.M. to 7:30 A.M. on 04/17/23 and stated Resident #28 was upset because her bed was not working and her room was cold. LPN #54 received report from the previous nurse who cared for Resident #28. LPN #54 indicated she was employed by a staffing agency and was unable to remove Resident #28's pain medications from the secured medication storage system and there was no licensed nurses employed by the facility available to request they remove the pain medications from the secured medication system. LPN #54 stated she called the pharmacy at approximately 4:00 A.M. for the Roxicodone pain medication to be delivered as soon as possible and the pain medication arrived at 7:30 A.M. on 04/18/23. LPN #54 stated she administered Resident #28 Tylenol for pain earlier in the evening on 04/17/23 which was somewhat effective and tried to keep her as comfortable as possible. Review of the facility policy and procedure titled Medication Administration dated 06/21/17 indicated medications would be administered by legally-authorized and trained persons in accordance with applicable, State, Local and Federal laws and consistent with acceptable standards of Practice. If a medication was unavailable, contact the pharmacy and document accordingly. This deficiency represents non-compliance investigated under Complaint Number OH00141465.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to ensure Resident #5 was provided dignity during incontinence care. This...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to ensure Resident #5 was provided dignity during incontinence care. This affected one out of three residents reviewed for incontinence care. The facility census was 45. Findings include: Record review revealed Resident #5 was admitted on [DATE] with diagnoses including diabetes mellitus, Alzheimer's disease, adult failure to thrive, cognitive communication deficit, major depression and need for assistance with personal care. Resident #5's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #5 was always incontinent of urine, occasionally incontinent of bowel and needed extensive assistance with toileting and transfers. An interview with Resident #5 on 04/18/23 at 3:32 P.M. indicated the staff did not routinely answer his call light promptly and he was left seated in his wheelchair for long periods of time wet with urine and feces. Resident #5 had pushed his call light at 3:32 P.M. and State Tested Nurse Aide (STNA) #55 answered his call light at 3:42 P.M. STNA #55 turned off his call light and assisted him with incontinence care. An observation on 04/18/23 at 3:42 P.M. of STNA #55 perform incontinence care for Resident #5 revealed a concern with dignity. STNA #55 assisted Resident #5 with standing from his wheelchair and leaning against the bed for support. Resident #5 had urine/feces soaked through his incontinence brief and his under pad was soaked in urine and feces. After cleaning Resident #5's perineal area of feces STNA #55 exited the room leaving Resident #5 standing naked from the waist down to his feet leaning against the bed. STNA #55 re-entered the room to finish cleaning Resident #5's perineal area. Resident #5 indicated he was unable to stand leaning against the bed anymore and needed help back to his wheelchair. STNA #55 assisted him with sitting on the incontinence brief and indicated she needed assistance with repositioning him to apply his incontinence brief correctly. STNA #55 completed the task and removed her gloves and exited the room to find another staff member to assist with repositioning Resident #55 in his wheelchair. An interview with STNA #55 on 04/18/23 at 4:06 P.M. verified the above findings. This deficiency represents non-compliance investigated under Complaint Number OH00141617, OH00141465 and is an example of continued noncompliance from the survey dated 02/15/23.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0660 (Tag F0660)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure a plan for discharge goals and needs was developed in a timel...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure a plan for discharge goals and needs was developed in a timely manner for Resident #15. This affected one out of three residents reviewed for discharge planning. The facility census was 45. Findings include: Record review revealed Resident #15 was admitted on [DATE] with diagnoses including cervical disc disorder with myelopathy (A nervous system disorder that can permanently affect the spinal cord. It causes a loss of sensation, loss of function, and pain or discomfort.), quadriplegia, diabetes mellitus, neurological bowel and bladder, and mild cognitive impairment. Further review of Resident #15's clinical record indicated he was admitted to the facility following a hospital rehabilitation admission for physical and occupational therapy after a fall. Resident #15 had right upper extremity and right lower extremity weakness, left periorbital hematoma and left forehead laceration. Resident #15 was discharged from the rehabilitation hospital to the facility for skilled services to enhance his functional capabilities and return to his private residence. Resident #15's baseline plan of care dated 04/17/23 indicated Resident #15 planned a short term admission to the facility and discharge as planned and have needed services in place. Interventions on the plan of care indicated to review discharge plans quarterly with Resident #15 and arrange needed services in the community prior to discharge. There was no documentation in Resident #15's clinical record of discharge planning. An interview with Resident #15 on 04/18/23 at 11:02 A.M. indicated he was very frustrated with the slowness of his recovery and needed to be discharged as soon as possible to handle personal matters including his living situation. Resident #15 indicated the medical and nursing team seemed to be making all the decisions regarding his discharge plan. Resident #15 stated he was told the social service worker would be talking with him to discuss his discharge needs but had not talked to anyone to solve his current problems with returning to his prior living arrangement. Resident #15 indicated he had a house trailer which was severely damaged by a tornado and had been living with his son. Resident #15's son had assisted him with finding an apartment which had stairs and was too small for him to manage mobility with use of a wheelchair or walker. Resident #15 stated most of his personal belongings were still at the house trailer and he was very anxious about what was going to happen to his house trailer and personal possessions. An interview with the Social Service Designee (SSD) on 04/19/23 at 9:19 A.M. indicated she had not talked to Resident #15 regarding his discharge arrangements. SSD indicated discharge planning was supposed to be conducted with residents within 72 hours after admission to the facility. SSD was unaware of Resident #15's current living living situation and thought he was homeless. SSD verified the above findings and indicated she would meet with Resident #15 to discuss his discharge planning. Review of the facility policy and procedure titled Discharge Process dated 02/02/22 indicated it was the policy of the facility to ensure that a discharge process was completed in accordance to State and Federal requirements. 1. When the facility anticipated discharge, a resident should have a discharge plan that included, but not limited to, the following. a. A post-discharge plan of care that was developed with the participation of the resident and with the resident's consent, the resident representative(s), which would assist the resident to adjust to his or her new living environment. b. The post-discharge plan of care should indicate where the individual planned to reside, any arrangements that had been made for the resident's follow up care and any post-discharge medical and non-medical services. 2. When the facility anticipated discharge, a resident should have a discharge plan that included, but not limited to, the following. a. A final summary of the resident's status to include items in paragraph (b) (1) of *483.20, at the time of the discharge available for release to authorized persons and agencies, with the consent of the resident or resident's representative. b. Reconciliation of all pre-discharge medications with the resident's post-discharge medications, and planned medical follow up and home health services as need per resident care plan. This deficiency represents non-compliance investigated under Complaint Number OH00141465.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure Resident #46 received insulin as ordered. This affected one o...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure Resident #46 received insulin as ordered. This affected one of seven residents reviewed for medication administration. The facility census was 45. Findings include: Resident #46 was admitted on [DATE] with diagnoses including fracture of the left lower leg, head injury, anxiety, depression, diabetes mellitus, pulmonary disease, cocaine abuse, difficulty walking. A review of Resident #46's Medication Administration Record (MAR) dated 03/17/23 indicated to administer Lispro Insulin 100 units per milliliter solution subcutaneously with meals per sliding scale. If the blood sugar measured 150 milligrams per diciliter (mg/dL) to 200 mg/dL administer 2 units of Lispro, 201 mg/dL to 250 mg/dL administer 4 units Lispro, 251 mg/dL to 300 mg/dL administer 6 units Lispro, 301 mg/dL to 350 mg/dL administer 8 units Lispro and 351 mg/dL to 400 mg/dL administer 10 units of Lispro. If the blood sugar measured greater the 400 mg/dL call the physician for further intructions. Further review of the MAR revealed there was no documentation the insulin was administered or a blood sugar was measured with the dinner meal at 5:00 P.M. as scheduled. An interview with Resident #46 on 04/18/23 indicated she did not receive her insulin upon admission to the facility at 11:00 A.M. before her lunch meal. Resident #46 stated when the nurse attempted to administer her insulin she refused because she didn't have anything to eat and didn't want her blood sugar to drop too low. Resident #46 indicated she wore a device on her arm for blood sugar monitoring and the device was broken. Resident #46 indicated the nurse didn't check her blood sugar and was told she would receive a lunch meal. Resident #46 stated she never received her lunch or dinner meal. Resident #46 indicated she attempted to talk to the Administrator and/or Director of Nursing (DON) and had left five messages on their voice mail. Resident #46 indicated the Administrator and the DON never returned her phone call and she never spoke with the administrative staff while in the facility. An interview with Licensed Practical Nurse (LPN) #62 on 04/20/23 at 10:07 A.M. indicated she was assigned to provide care for Resident #46 during the evening hours from 7:00 P.M. until Resident #46's discharge from the facility later in the evening. LPN #62 stated when a resident was admitted to the facility the resident's physician orders needed verified by the physician and then sent to pharmacy. The pharmacy would deliver the medications ordered for the resident the following day. LPN #62 indicated the staff could obtain medications if needed from the facility stored medications in a locked system. LPN #62 indicated she did not know why Resident #46's insulin was not administered at 5:00 P.M. and Resident #46 refused all her medications at bedtime. Resident #46's medications were available to administer at bedtime. An interview with the former Director of Nursing (FDON) on 04/20/23 at 12:17 P.M. revealed she was unaware of Resident #46's wish to speak to her. An interview with Regional Registered Nurse and Director of Nursing (DON) on 04/18/23 at 10:45 A.M. verified the above findings. This deficiency represents non-compliance investigated under Complaint Number OH00141465.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0809 (Tag F0809)

Could have caused harm · This affected 1 resident

Based on record review and interview the facility failed to ensure Resident #46 received a lunch and dinner meal after her admission to the facility. This affected one out of three residents reviewed ...

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Based on record review and interview the facility failed to ensure Resident #46 received a lunch and dinner meal after her admission to the facility. This affected one out of three residents reviewed for meal service upon admission to the facility. Findings include: Resident #46 was admitted to the facility at 11:22 A.M. on 03/17/23 with diagnoses including fracture of the left lower leg with head injury, anxiety, depression, asthma, pulmonary disease, diabetes mellitus, cocaine and other non-psychoactive substance abuse and high blood pressure. Resident #46's physician order dated 03/17/23 indicated a diet order for a regular carbohydrate controlled diet. A review of Resident #46's Medication Administration Record (MAR) dated 03/17/23 indicated to administer Lispro Insulin 100 units per milliliter solution subcutaneously with meals per sliding scale. If the blood sugar measured 150 milligrams per diluent (mg/dL) to 200 mg/dL administer 2 units of Lispro, 201 mg/dL to 250 mg/dL administer 4 units Lispro, 251 mg/dL to 300 mg/dL administer 6 units Lispro, 301 mg/dL to 350 mg/dL administer 8 units Lispro and 351 mg/dL to 400 mg/dL administer 10 units of Lispro. If the blood sugar measured greater the 400 mg/dL call the physician for further instructions. There was no documentation the insulin was administered or a blood sugar was measured with the dinner meal at 5:00 P.M. as scheduled. There was no documentation Resident #46 received a meal tray or amount of meals consumed on 03/17/23. An interview with Licensed Practical Nurse (LPN) #54 on 04/18/23 at 8:30 A.M. indicated the staff were supposed to deliver a snack cart in the evenings routinely and residents admitted in the evening did not receive anything to eat until breakfast the next morning. LPN #53 verified the information in the MAR as described above. An interview with Resident #46 on 04/18/23 at 9:50 A.M. indicated she did not receive her insulin upon admission to the facility at 11:00 A.M. before her lunch/dinner meal. Resident #46 stated when the nurse attempted to administer her insulin she refused because she didn't have anything to eat and didn't want her blood sugar to drop too low. Resident #46 indicated she wore a device on her arm for blood sugar monitoring and the device was broken. Resident #46 indicated the nurse didn't check her blood sugar and was told she would receive a lunch meal. Resident #46 stated she never received her lunch or dinner meal. Resident #46 indicated she attempted to talk to the Administrator and/or Director of Nursing (DON) and had left five messages on their voice mail. Resident #46 indicated the Administrator and the DON never returned her phone call and she never spoke with the administrative staff while in the facility. An interview with Head [NAME] (HC) #66 on 04/19/23 at 7:52 A.M. indicated the evening dietary staff were supposed to provide a snack cart at the end of their shift at approximately 8:00 P.M. The snack cart would be delivered to the nursing station and cold items placed in the refrigerator. HC #66 indicated the snack cart contained five to ten peanut and butter sandwiches, pudding, applesauce, cookies, and other items available to the staff to provide to residents who were admitted after 8:00 P.M. HC #66 indicated there had been problems with staff on the evening shift leaving earlier than the end of their shift and coming and going as they pleased, receiving supplies and may have budget concerns with ordering the proper amount of food items in a timely manner. An interview with Certified Dietary Manager (CDM) #67 on 04/19/23 at 8:38 A.M. revealed the staff working the evening shift were supposed to provide a snack cart to the nursing unit at around 8:00 P.M. before they left for the night. CDM #67 indicated she was unaware the kitchen staff had not routinely delivered the snack cart to the nursing units every evening. CDM #67 indicated the newly hired staff had an attitude and would leave for emergent situations and never return to work. CDM #67 indicated there was a problem with retaining staff once hired and an unwillingness to work their scheduled hours. This deficiency represents non-compliance investigated under Complaint Number OH00141465.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to ensure staff washed their hands to prevent possible cross-contaminatio...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to ensure staff washed their hands to prevent possible cross-contamination of germs during incontinence care for Resident #45 and Resident #5 and failed to ensure proper handling of linens during Resident #5's incontinence care to prevent possible cross-contamination of germs. This affected two out of three resident reviewed for incontinence care. Findings include: 1. Record review revealed Resident #45 was re-admitted on [DATE] with diagnoses including lung disease, intestinal obstruction, morbid obesity, diabetes mellitus, osteoarthritis, anxiety, depression, lymphedema, bipolar disorder, edema, urinary incontinence, and gout. A review of Resident #45's Minimum Data Set (MDS) assessment dated [DATE] indicated she needed extensive assistance with toileting and was always incontinent of bowel and bladder. An observation of State Tested Nursing Assistant (STNA) #56 perform incontinence care for Resident #45 on 04/18/23 at 12:36 P.M. revealed concern with handwashing. STNA #56 entered Resident #56's room washed her hands and donned a pair of disposable gloves. STNA #56 proceeded to assist Resident #45 with removing her incontinence brief and cleaned the urine and feces from Resident #45's perineal area with a wet washcloth. After ensuring Resident #45's perineal area was clean, STNA #56 proceeded to use the same gloved hand to assist Resident #45 with reapplying her oxygen nasal cannula, touched various surfaces in the room including the bedside table, nightstand drawer and cupboards while looking for moisture barrier cream. STNA #56 proceeded to apply moisture barrier cream to Resident #45's perineal area and then removed her gloves. An interview with STNA #56 on 04/18/23 at 12:45 P.M. verified the above observation and confirmation she should have washed her hands and removed her gloves after she cleaned Resident #45's perineal area. 2. Record review revealed Resident #5 was admitted on [DATE] with diagnoses including diabetes mellitus, Alzheimer's disease, adult failure to thrive, cognitive communication deficit, major depression and need for assistance with personal care. Resident #5's most recent quarterly MDS assessment dated [DATE] indicated Resident #5 was always incontinent of urine, occasionally incontinent of bowel and needed extensive assistance with toileting and transfers. An observation on 04/18/23 at 3:42 P.M. of STNA #55 perform incontinence care for Resident #5 revealed concerns with handwashing. STNA #55 assisted Resident #5 with standing from his wheelchair and leaning against the bed for support. Resident #5 had urine/feces soaked through his incontinence brief and his underpad was soaked in urine and feces. STNA #55 donned a pair of gloves and removed the incontinence brief and used a wet washcloth to clean his perineal area. After cleaning Resident #5's perineal area of feces and urine she placed the soiled washcloths directly in Resident #5's sink. STNA #55 then removed the soiled underpad and placed the underpad on the floor. STNA #5 proceeded to remove her gloves and exited the room to obtain additional washcloths to finish cleaning Resident #5's perineal area without washing her hands. STNA #55 exited the room leaving Resident #5 standing naked from the waist down to his feet leaning against the bed. STNA #55 entered the room and donned a second pair of gloves to finish cleaning Resident #5's perineal area. STNA #55 placed the clean incontinence brief in Resident #5's wheelchair and assisted Resident #5 to sit on the brief in his wheelchair. STNA #55 completed the task and removed her gloves and exited the room to find another staff member to assist with repositioning Resident #5 in his wheelchair and apply the incontinence brief correctly without washing her hands after removing her soiled gloves. An interview with STNA #55 on 04/18/23 at 4:06 P.M. verified the above findings. A review of the facility policy and procedure titled Hand Washing (undated) indicated staff should wash their hands with soap and water after touching bare human body parts other than clean hands and wrists, after handling soiled equipment, before and after donning disposable gloves, and engaging in activities that contaminate the hands. This deficiency represents non-compliance investigated under Complaint Number OH00141617 and is an example of continued noncompliance from the survey dated 02/15/23.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to maintain an clean, sanitary, homelike environment. This affected three...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to maintain an clean, sanitary, homelike environment. This affected three of nine residents interviewed (Resident #47, Resident #45 and Resident #46) and had the potential to affect all the residents in the facility. There were 45 residents residing in the facility. Findings include: A tour of the facility on 04/18/23 from 7:30 A.M. to 7:45 A.M. revealed residents in their rooms and in the common areas of the facility. There was dried food on the floor in the dining area and the common hallways had several areas with dried liquid spills, scuffs, ground in gray areas in the floor wax. The common bathroom outside room [ROOM NUMBER] and by the linen closet had dirt build-up around the edges of the bathroom floor and under the sink. The lighting in the bathroom by the linen closet was very dim. Resident #19's/Resident #37's and Resident #23's/Resident #31's semi-private rooms had dried liquid spills on the floor and ground in grey areas in the wax. Observations on 04/18/23 at 6:55 A.M. revealed dried food and liquids on the floor in the activity room. There was dried liquid stains, scuffs and stains in the hallway by Rooms 1 through 10. Built-up dirt and ground-in gray areas on the floor outside room [ROOM NUMBER] and bathroom by the linen closet. The bathroom light was very dim and it was difficult to see in the common bathroom by the linen closet. Observation on 04/18/23 at 8:00 A.M. revealed Housekeeper #53 using a broom to sweep up the food crumbs and emptied the trash receptacle but did not mop the floor in the main dining area. Observation on 04/18/23 at 8:15 A.M. revealed residents were seated in the dining room eating their breakfast. Dried liquid spills and dried food remained stuck to the floor. Observation on 04/18/23 at 10:00 A.M. revealed three meal trays from the previous dinner meal on the two tables by the nursing station. Observation on 04/18/23 at 11:18 A.M. revealed Resident #45's room had dried food and liquid spills on the floor and the floor was sticky and had ground in dirt in the wax. Observation on 04/18/23 at 10:30 A.M. revealed the hallway by Rooms 20 to room [ROOM NUMBER] had a large area of brown, rust colored staining on the floor with scuffs/dirt marks on the walls. Observation on 04/19/23 at 6:10 A.M. revealed a meal tray on the floor outside of room [ROOM NUMBER], the meal tray did not have a meal ticket to identify to whom the tray belonged. The observation was verified by Licensed Practical Nurse (LPN) #63 at the time of the observation. An interview with Resident #46 on 04/18/23 at 9:50 A.M. indicated she had a broken bed, her room was dirty, the clothing rod in the closet was broken and her bed was not working properly. An interview with Resident #47 on 04/18/23 at 10:35 A.M. revealed her bed was not working correctly, the bed was lowered all the way to the floor. Resident #47 stated her room was dirty and the housekeeping staff did not clean under the beds or clean the dried liquid stains on the walls. Resident #47 stated she asked to be discharged as soon as possible due to the poor condition of the facility and lack of cleanliness. An interview on 04/18/23 at 10:45 with Regional Environmental Services Director indicated the housekeeping staff were supposed to sweep and mop all common areas of the facility and resident rooms daily. All surfaces in resident rooms were supposed to be sanitized and cleaned daily. All trash in the common areas and resident rooms was to be removed daily. All window sills should be wiped, dusted daily. All common and resident bathrooms should be mopped, toilets/sinks sanitized. Deep cleaning of resident rooms should be performed upon discharge from the facility. For residents who resided in their room long term, their room should be deep cleaned every three to five days. Deep cleaning included removing all furniture, privacy curtain removed and cleaned, window treatment cleaned, mop and buff the floor and all surfaces sanitized and dusted. The floor technician should clean, mop and buff all common floors in the common areas daily. The floor technician would assist the housekeeping staff when needed to mop and buff the floors of resident rooms. An interview with Resident #45 on 04/18/23 at 11:18 A.M. revealed her room was cleaned occasionally but her roommate often spilled her beverage and food on the floor. Resident #45 stated the housekeeping staff did not clean up the area often enough to keep her room clean. On 04/19/23 at 6:15 A.M. there were three resident meal trays from the dinner meal on 04/18/23. One meal had been consumed by Resident #39 and the other two meal trays did not have the residents' meal ticket. The trays had left-over food items and beverages on the trays and had been left on the tables during the overnight hours. At the time of the observation LPN #63 indicated the meal trays should have been placed on the dirty meal cart and returned to the kitchen after the dinner meal to be washed and uneaten foods discarded. LPN #63 verified their were areas of ground in dirt/grime and walls in the hallway from Rooms 20 to 25 had dried liquid spills, scuffs, dark black scuffs/dirt and the large brown/rust colored stain was still present on the floor in the hallway. On 04/19/23 at 6:45 A.M. an interview with Maintenance/Housekeeping Director (MHD) indicated Resident #47's room was cold due to the previous resident had opened the window for fresh air and the staff didn't realize the window was open. MHD stated a crank was used to open and close the window which was operating correctly and he closed the window in the morning on 04/18/23. MHD stated he had worked in the facility for just over one year and the building had been neglected for many years. MHD stated he started with ensuring the electrical, plumbing and heating and cooling systems were working properly according to the current regulatory codes. All the common areas and resident room floors had been stripped five times due to severe wax build-up and re-waxed. Plans were in place to replace all the resident room flooring with low maintenance vinyl flooring. All woodwork in the hallways had been painted but when the floors were waxed there was splashing of wax, cleaning solution, black marks and the woodwork needed painted again. During the interview MHD verified the facility still needed routine proper cleaning and was still in the process of ensuring all housekeeping staff were aware of their cleaning responsibilities and set-up a system to ensure all areas of the facility were cleaned/deep cleaned properly. All the wall paper in the building needed removed and new wallpaper installed. On 04/19/23 at 7:30 A.M. MHD verified the above findings. This deficiency represents non-compliance investigated under Complaint Number OH00141465, OH00141402.

Mar 2023 2 deficiencies

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0921)

Could have caused harm · This affected most or all residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain a clean and sanitary environment and failed to ensure suppli...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain a clean and sanitary environment and failed to ensure supplies were available for resident care. This effected three residents (#2, #3, and #12) out of three residents who had concerns about the cleanliness of the floors and of the resident rooms. This had the potential to affect all 42 residents residing in the facility. Findings include: 1. Observations during the initial tour of the facility on 03/13/23 from 7:30 A.M. to 8:15 A.M. revealed the following concerns regarding cleanliness: • An elevator was used to go down to the long-term care unit, the grates of the elevator were filled with grayish black dirt, small pieces of paper and dust. The elevator floor was noted to have dirt and debris on it with a cobweb noted in the back right hand corner of the floor. • Resident #2 was noted to have dirt and dark gray areas near the baseboard of the room and had dirt spots observed intermittently on the floor. • On the long-term care unit by room [ROOM NUMBER] there was grout that was missing between two pieces of the linoleum floor. That space had noted dust, small pieces of paper and dirt in it. Further down the hall, the handrail on the opposite side of room [ROOM NUMBER] was wobbly and appeared loose. Intermittently down the same walls with the handrail there were a number of areas with wallpaper peeling off of the wall. The clock that hung in the hall did not have any hands on it and it was not functioning. • Resident #28's wall, which was cited during the annual survey completed on 02/15/23, was patched with a thin piece of white paneling that was nailed to the wall. At the top of the paneling, there were two nails sticking out of the wood that appeared to not have been nailed all the way in which were sharp and hazardous to a resident if he/she ran their hand against the wall. • Resident #3's privacy curtain had what looked like a blood stain, there was dirt and dust noted in the corner of the door frame, and the hall outside of the room was noted to have dirt along the baseboards. A walk through with Administrative Assistant #241 on 03/14/23 from 9:15 A.M. to 11:00 A.M., verified all the above findings. During this walk through, it was also noted on the hallway by room [ROOM NUMBER] there was an orange circular pill on the floor. Administrative Assistant #241 verified the finding and took it to the nurse who stated the pill was a vitamin. Interview with Maintenance/Housekeeping Director #296 on 03/14/23 at 12:30 P.M. revealed he was aware of the continual need for updates because the building was old. He stated he was aware of the wallpaper peeling in various areas, the stained, dirty floors, and the gouges in the walls. He stated he did have plans to remove all of the old wallpaper and stated they did not have floor scrubber, but he was able to fix the old one in the basement and planned on scrubbing and waxing all of the floors on the long-term care unit. 2. Interview and observation on 03/13/23 from 8:05 A.M. through 8:12 A.M. with State Tested Nursing Assistant (STNA) #279 revealed there was not enough linen to provide resident care in the morning. Inventory of the linen cart near room [ROOM NUMBER] revealed no washcloths or towels available; inventory in the linen closet revealed no washcloths or towels; inventory on the linen cart near room [ROOM NUMBER] revealed no washcloths and four towels; and inventory on the linen cart near room [ROOM NUMBER] revealed no washcloths or towels available. STNA #279 verified the findings at the time of the observation. Observation of the laundry room on 03/13/23 at 8:15 A.M. with Laundry Aide #307 revealed there were no folded washcloths or towels available in the laundry room. Laundry Aide #307 was taking clean laundry out of the dryer and over to the folding table. The clean, dried laundry had towels and washcloths available. Laundry Aide #307 stated her shift started at 7:00 A.M. and she usually took fresh linens to the floor around 8:00 A.M. Interview on 03/13/23 at 11:00 A.M. with Environmental Director #296 revealed first laundry shift is 6:00 A.M. to 3:00 P.M. and second shift is 3:00 P.M. to 10:00 P.M. Laundry was usually delivered twice a shift. The last load of laundry for the second shift was in the dryer, so first shift could start folding laundry for that day. If the aides do not have laundry on the floor, they can come and get it from the dryer. This deficiency represents non-compliance investigated under Master Complaint Number OH00140734 and Complaint Numbers OH00140589 and OH00140496 and is an example of continued non-compliance from the survey dated 02/15/23.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0924 (Tag F0924)

Could have caused harm · This affected most or all residents

Based on observation and interview, the facility failed to ensure handrails in the corridors were firmly secured. This had the potential to affect all 42 residents residing in the facility. Findings ...

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Based on observation and interview, the facility failed to ensure handrails in the corridors were firmly secured. This had the potential to affect all 42 residents residing in the facility. Findings include: Observation during the tour of the facility with Administrative Assistant #241 on 03/14/23 at 9:00 A.M. revealed the handrails on the right side of the corridors of rooms 1 through 10 were not firmly secured. All residents used the corridor with the loose handrails to access the dining room and the gathering area by the nurse's station. Administrative Assistant #241 verified the handrails were not firmly secured. Interview with Maintenance Director #296 on 03/14/23 at 11:30 A.M. revealed he was aware of the unsecured handrails but had not fixed them yet. This deficiency represents non-compliance investigated under Complaint Numbers OH00140589 and OH00140496.

Feb 2023 8 deficiencies 1 Harm

SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Pressure Ulcer Prevention (Tag F0686)

A resident was harmed · This affected 1 resident

Based on observation, interview, record review, and review of facility policy on wound care, the facility failed to obtain diagnostic testing as ordered to identify and treat a possible infection of R...

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Based on observation, interview, record review, and review of facility policy on wound care, the facility failed to obtain diagnostic testing as ordered to identify and treat a possible infection of Resident #31's Stage IV (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) pressure ulcer of the sacrum. Actual harm occurred on 02/06/23 when Resident #31 was sent to the emergency room and admitted to the hospital for an infection of the sacral wound. This affected one (Resident #31) of two residents reviewed for pressure ulcers. The census was 41. Findings include: Review of the medical record for Resident #31 revealed an admission date of 11/22/22 with diagnoses including stage four pressure ulcer of the sacral region, history of osteomyelitis of the vertebra in the sacral and sacrococcygeal region, altered mental status, and anxiety disorder. Review of the Braden Scale Assessment, dated 11/22/22, revealed Resident #31 scored an 11 and was at high-risk for pressure ulcers. Review of the weekly skin assessment, dated 11/23/22, revealed Resident #31 had a sacral wound on admission. Review of the comprehensive Minimum Data Set (MDS) Assessment, dated 11/28/22, revealed Resident #31 was severely cognitively impaired and required extensive assistance or total dependence for activities of daily living (ADL). The assessment also indicated Resident #31 was at-risk for developing pressure ulcers and had one stage four pressure ulcer. Review of the wound care center notes, dated 12/05/22, revealed Resident #31's sacral wound was a Stage IV pressure ulcer, had exposed muscle, the wound bed was pink, there was a medium amount of serosanguinous (thin and watery fluid) drainage, and the wound measured 8 centimeters (cm) in length, 3 cm in width, and 1.5 cm in depth. Review of the care plan revised 01/17/23 revealed Resident #31 had pressure ulcers due to decreased hemoglobin and hematocrit, impaired nutrition, immobility, and non-compliance, she was admitted with a stage four pressure ulcer to the sacrum, and she received pro-stat twice daily. Interventions included administer medications as ordered, administer treatments as ordered, monitor wound healing and measure when possible, assess and document status of wound healing progress, report improvements and declines to the physician, educate resident on causes of skin breakdown, follow facility policies for the treatment of skin breakdown, inform resident and family of new skin breakdown, provide supplements as ordered to promote wound healing, monitor dressing to ensure it adheres, report loose dressing to the nurse, provide diet as ordered, report signs of infection to physician, obtain and monitor diagnostic work as ordered, report diagnostic results to physician and follow up as indicated, and treat pain per orders. Review of the wound care center notes, dated 01/23/23, indicated Resident #31's sacral wound was deteriorating, the wound bed consisted of pink tissue and slough, there was exposed muscle and bone, and there was a medium amount of serosanguinous drainage. A wound culture and x-ray were ordered to rule out osteomyelitis. Review of the physician's orders identified orders dated 01/23/23 for a sacral wound culture to be obtained at the bedtime dressing change and a sacral x-ray to rule out osteomyelitis. Review of the x-ray results, dated 01/23/23, for Resident #31 indicated there was no intrinsic bony abnormality and the soft tissues were unremarkable. There was no evidence the physician was notified of the results. Review of the medical record for Resident #31 revealed no wound culture results for 01/23/23 were identified. Review of the wound evaluation flow sheet, dated 01/25/23, indicated Resident #31's sacral wound was pink in color with no signs of infection and measured at 7 cm in length, 6 cm in width, and 3.5 cm in depth. Review of the wound care center notes, dated 01/30/23, indicated Resident #31's sacral wound was deteriorating, there was a medium amount of serosanguinous drainage, and there was a foul odor noted. The wound bed was 25% pink, 25% slough, and 50% necrotic tissue with exposed bone and muscle. A wound culture and x-ray were ordered to rule out osteomyelitis. Review of the wound evaluation flow sheet, dated 01/30/23, indicated Resident #31's sacral wound was pink in color, necrotic, and measured at 8 cm in length, 8 cm in width, and 4 cm in depth. Review of the physician's orders dated 01/30/23 identified orders for a lumbar sacral x-ray for osteomyelitis. Review of the x-ray results, dated 01/30/23, indicated there was degenerative changes at the L2 and L3 vertebrae and the paravertebral tissues (non-bony tissues around the vertebrae) were unremarkable. There was no evidence the physician was notified of the results. Review of the physician's orders dated 01/31/23 identified orders for a wound culture of sacrum. Review of the medical record for Resident #31 revealed no wound culture results for 01/31/23 were identified. On 02/06/23 at 11:35 A.M., observation of Resident #31 revealed she was screaming loudly while the wound care team was providing care including Resident #31's dressing change. On 02/06/23 at 12:05 P.M., observation of Resident #31's room revealed emergency medical services (EMS) was transporting her to the emergency room. Interview at the time of observation with Licensed Practical Nurse (LPN) # 501 revealed Resident #31 was being sent to the emergency room for wound care and possible osteomyelitis. Review of the wound care center notes, dated 02/06/23, indicated Resident #31's sacral wound was deteriorating, there was a medium amount of serosanguinous drainage, and there was a foul odor noted. The wound bed was 25% pink, 25% slough, and 50% necrotic tissue with exposed bone and muscle. The wound care center ordered to send Resident #31 to the hospital for osteomyelitis with bone palpable, malodorous, necrotic tissues, and to check for sepsis. Review of the wound evaluation flow sheet, dated 02/06/23, indicated Resident #31's sacral wound was pink in color with no infection, there was a foul odor, and the tissue was necrotic with bone prominent. The wound measured at 11 cm in length, 18 cm in width, and 3.5 cm in depth. Review of the progress note dated 02/06/23 at 2:06 P.M. revealed Resident #31 was sent to the emergency room for deterioration of the sacral wound with malodorous and necrotic tissue, osteomyelitis, and bone palpable. Review of the progress note dated 02/06/23 at 11:04 P.M. revealed Resident #31 was admitted to the hospital due to a wound infection. On 02/08/23 at 4:35 P.M., interview with Assistant Director of Nursing (ADON) #600 verified Resident #31 was sent to the emergency room for further evaluation of her wound. She also verified the wound evaluation flow sheet completed on 02/06/23 at 2:09 P.M. indicated Resident #31's sacral wound was pink in color with no infection. ADON #600 stated that assessment was incorrect because Resident #31 did have signs of infection, the wound was gray in color and malodorous. On 02/13/23 at 12:40 P.M., interview with Wound Nurse Practitioner (NP) #507 confirmed Resident #31's sacral wound had signs of infection and she had ordered wound cultures on 01/23/23 and 01/31/23 that the facility never completed. She also stated the facility never reported x-ray results to her after she ordered x-rays to rule out osteomyelitis. Wound NP #507 stated when she observed Resident #31's sacral wound on 02/06/23, it was getting worse and she ultimately sent Resident #31 to the emergency room for wound evaluation because the facility did not complete the diagnostic tests as ordered. On 02/13/23 at 2:56 P.M., interview with the Director of Nursing (DON) verified no wound cultures were completed for Resident #31's sacral wound. On 02/14/23 at 11:06 A.M., interview with Resident #31's sister stated her sacral wound was improving prior to admission to the facility and she does not feel the facility was providing appropriate care and treatment to treat the wound. She stated Resident #31's wound continued getting worse while a resident of the facility and that she ended up in the hospital because the wound got infected. Review of facility policy titled Wound Care Policy and Procedure, dated 08/2022, indicated wound treatments would be completed per physician orders. Review of facility policy titled Wound Treatment Management, dated 03/2021, indicated treatments would be provided in accordance with physician orders, treatments would be based on the type of wound and characteristics of the wound (including the presence of infection or need to address bacteria), the facility would follow specific physician's orders for providing wound care, and the changes of wound characteristics would be monitored to determine if modifications in treatments were needed.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to treat residents with respect and dignity at all time...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to treat residents with respect and dignity at all times. This affected three residents (#19, #26, #27) out of six residents reviewed for dignity. The facility census was 41. Findings include: 1. Record review for Resident #27 revealed an admission date of 09/16/21 and a readmission date of 12/23/21. Diagnoses included but not limited to adult failure to thrive, anxiety disorder, depression, and diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/31/22, revealed the resident had severely impaired cognition. The resident required supervision with one staff for activities of daily living. Review of the physician's orders for January 2023 revealed Resident #27 was ordered a no concentrated sweet with mechanical soft texture diet and regular consistency liquids. Observation on 02/06/23 at 12:00 P.M. revealed Resident #27 was at a table with three other residents (Resident #19, #21 and #29). Resident #27 was upset that the other residents had their food, and she didn't have hers. Resident #29 stated that they should serve all residents at the table the same time. Resident #21 offered Resident # 27 some coffee and Resident #19 was upset because Resident # 27 was asking her for food. Licensed Practical Nurse (LPN) #360 verified Resident #27 didn't have her food yet and told Resident #27 that she would get her tray to her as soon as possible. LPN #360 turned around and Resident # 27 went for the exit door in her wheelchair. LPN #360 redirected Resident #27 back to the table. Resident #27's tray was given to her at 12:10 P.M. by LPN #360. Review of in-service given to staff on 11/09/22 titled, Customer Service revealed people at the same table should be fed at the same time. 2. Record review for Resident #19 revealed an admission date of 11/10/22. Diagnoses included but not limited to dementia, depression, and hyperlipidemia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/31/22, revealed the resident had severely impaired cognition. The resident was independent for activities of daily living except toileting and personal hygiene required supervision with one staff member. Interview on 02/07/23 at 3:00 P.M. with Residents #21 and #29 revealed the night before they were sent to their rooms from the dining room. Resident #29 stated Resident #13 wouldn't put down the television remote and Resident #13 raised his hand to hit Resident #29. Licensed Practical Nurse (LPN) #333 told the residents go to their rooms and eat dinner in their rooms. Residents #21 and #29 felt it was wrong because Resident #13 was the one who started things. The residents did not reveal Resident #19 was involved in the situation. Interview on 02/07/23 at 04:11 P.M. with LPN #501 revealed on 02/06/23 all residents were cleared out of the dining room due to an altercation between two residents. All residents that were in the dining room were sent back to their rooms for a 20-minute cool down and had to stay in their rooms for the 20 minute cool down period. She was not the nurse who initiated the cool down period, she was just on the floor when it happened. Interview on 02/07/23 at 3:58 P.M. with Director of Nursing (DON) revealed that she was in her office and heard residents were temporarily separated from each other. The residents dispersed to their rooms. Interview on 02/07/23 at 4:00 P.M. with Administrator revealed that she didn't know of the incident but would start an investigation. Interview on 02/09/23 at 11:52 A.M. with Administrator revealed Resident #13 wanted the television on while Resident #21 and #29 wanted it off. LPN #333 dispersed all residents from the dining room but didn't tell the residents that couldn't come back to the dining room. Administrator did not reveal Resident #19 was involved in the situation. Interview on 02/09/23 at 1:00 P.M. with Administrator, DON, Assistant Director of Nursing (ADON), and Corporate Nurse revealed Licensed Practical Nurse (LPN) #333 was in the DON's office when they heard residents voice being raised. Neither the DON nor LPN #333 could tell what the residents were saying. LPN #333 went to the dining room. Assistant Director of Nursing (ADON) stated that she was in her office and heard loud voices and went to the dining room. At the dining room, ADON heard LPN #333 state to the residents (#13, #19, #21 and #29) that they needed to disperse for a few minutes. Although Resident #19 was directed to disperse from the area, there was no evidence she was involved in the situation to show the need to leave the area and discontinue watching television. Interview on 02/09/23 at 2:00 P.M. with LPN #333 revealed she was in the DON's office and heard loud voices, so she went to investigate and in the dining room, she witnessed residents were having a disagreement over the television. LPN #333 revealed she stated, Come on guys, please stop and when the residents wouldn't stop, she asked them to leave the room and come back later. Review of in-service given to staff on 11/09/22 titled, Customer Service revealed treat each resident like an adult no matter what their cognitive function level is. 3. Resident #26 was admitted to the facility on [DATE] with diagnoses including necrotizing fasciitis, COVID-19, diabetes, congestive heart failure, a stroke, osteomyelitis, and a pressure ulcer to the sacral region. The resident was admitted to the facility with the pressure ulcer to the sacrum. Review of the comprehensive quarterly Minimum Data Set (MDS) assessment, dated 01/03/23, revealed the resident was cognitively intact. Catheter care and a dressing change were observed for Resident #26 on 02/07/23 from 1:30 P.M. to 2:30 P.M. and was completed by Assistant Director of Nursing (ADON) #600. Upon entrance to the resident's room this surveyor observed the drainage bag for the resident's foley catheter (a device inserted into a patient's body to drain urine from the bladder) was on the left side of the resident's bed in full view of the hallway and did not have a privacy cover over the drainage bag. The drainage bag contained dark gold urine with sediment. ADON #600 confirmed the bag should have a privacy cover and said she would get one. ADON #600 closed the door to the resident's room but did not pull the privacy curtain. Resident #26 did not have a roommate. At 1:45 P.M. during catheter care the door to the room opened without anyone knocking. ADON #600 immediately called out resident care and the staff member immediately left the room. ADON #600 identified the person as being someone from therapy but she did not know who as she was new to the facility and confirmed the staff member should have knocked prior to entering. ADON #600 completed catheter care and proceeded to the dressing change. While the dressing change was being completed the door started to open again without anyone knocking and ADON #600 again called out resident care. The door was secured and the dressing change continued. ADON #600 again confirmed people should be knocking prior to entering any resident's room. This deficiency represents non-compliance investigated under Complaint Number OH00139256.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provided adequate feeding assistance to Resident #16....

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provided adequate feeding assistance to Resident #16. This affected one (#16) of three residents reviewed for activities of daily living. The census was 41. Findings include: Review of the medical record for Resident #16 revealed an admission date of 07/25/16. Diagnoses included paranoid schizophrenia, dementia without behavioral disturbance, anxiety disorder, and major depressive disorder. Review of the physician's orders for February 2023 identified orders for a regular diet with mechanical soft texture. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 required extensive assistance of one staff for eating. Review of the nutrition care plan revised 12/16/22 revealed Resident #16 was at-risk for alteration in nutrition and hydration due to hospice, history of medications that could cause weight changes, paranoid schizophrenia, hallucinations, dementia, hypothyroid, depression, COVID-19, and pocketing food. Interventions included provide assistance with meals/snacks as necessary. On 02/08/23 at 8:07 A.M., observation of the breakfast meal revealed Resident #16's tray was delivered at this time. The tray was placed on the table over her bed and the cover was removed from the plate. At 8:10 A.M., Resident #16 was asleep in her bed with her breakfast tray uncovered on the table over her bed. No staff were present in the room at the time. At 8:22 A.M., State Tested Nurse Aide (STNA) #505 entered Resident #16's room, called her name one time, and then left the room without attempting to provide feeding assistance. Interview at the time of observation with STNA #505 verified the observation and she stated Resident #16 did not want breakfast. At 8:44 A.M., STNA #326 entered Resident #16's room, obtained one spoonful of food and held it up to her mouth. Resident #16 did not open her eyes. STNA #326 put the spoonful of food back on the plate, wiped Resident #16's mouth, and walked out of the room. Interview at the time of observation with STNA #326 verified the observation and he stated Resident #16 did not feel like eating this morning. Over the course of 43 minutes, these were the only two observations of staff interacting with Resident #16. At 8:50 A.M., STNA #506 removed Resident #16's breakfast tray from her room. Review of facility policy titled Activities of Daily Living (ADLs), Supporting, dated 08/2021, revealed staff would provide appropriate support and assistance with dining at meals and snacks. Extensive assistance was defined as the resident performing part of the activity and staff providing weight bearing support.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to ensure oxygen tubing was dated when changed and that a physician's order was in place for oxygen use for Resident #12. This a...

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Based on observation, interview, and record review, the facility failed to ensure oxygen tubing was dated when changed and that a physician's order was in place for oxygen use for Resident #12. This affected one (Resident #12) of one reviewed for oxygen use. The census was 41. Findings include: Review of the medical record for Resident #12 revealed an admission date of 04/30/15 and re-admission date of 09/27/22. Diagnoses included acute respiratory failure with hypoxia, obstructive sleep apnea, chronic obstructive pulmonary disease, anxiety disorder, and major depressive disorder. Review of the physician's orders for February 2023 identified orders for a Triology sleep machine to be applied at bedtime and removed upon waking. No orders were identified for oxygen use during the daytime hours. On 02/06/23 at 11:00 A.M., observation of Resident #12 revealed oxygen was in use at 3 liters (L) and the oxygen tubing was not dated. On 02/06/23 at 11:04 A.M., interview with Licensed Practical Nurse (LPN) #501 verified Resident #12 was receiving oxygen at 3 L, the oxygen tubing was not dated, and she could not identify physician's orders for oxygen use during daytime hours. Review of facility policy on oxygen therapy, not dated, revealed a physician must order oxygen therapy.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0806 (Tag F0806)

Could have caused harm · This affected 1 resident

Based on observations, interview and record review, the facility failed to honor resident preferences regarding menu choices. This affected three residents (#3, #4, and #6) of three residents reviewed...

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Based on observations, interview and record review, the facility failed to honor resident preferences regarding menu choices. This affected three residents (#3, #4, and #6) of three residents reviewed for choices. The facility census was 41. Findings include: 1. Record review for Resident #3 revealed an admission date of 09/04/20. Diagnoses included but not limited to hemiplegia and hemiparesis following cerebral infarction, major depressive disorder and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/31/22, revealed the resident had intact cognition. The resident required supervision with one staff for activities of daily living except eating which was independent. Review of the physician's orders for January 2023 revealed Resident #3 was ordered a regular diet with no restrictions. Review of the care plan dated 09/10/20 with a revision date of 01/10/23 revealed Resident #3 had a potential for alteration in nutrition due to diagnoses. Interventions included but not limited to provide diet as ordered and honor preferences. Observation of lunch tray line on 02/08/23 from 11:45 A.M. through 12:11 P.M. revealed Residents #3 had ice cream written on their diet ticket but did not receive it. This was verified by Dietary Manager #388 at 11:53 A.M. 2. Record review for Resident #4 revealed an admission date of 09/29/18 and a readmission date of 11/12/20. Diagnoses included but not limited to cerebral palsy, diabetes mellitus, major depressive disorder, and paranoid schizophrenia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/01/23, revealed the resident had intact cognition. The resident required extensive assistance with one staff for activities of daily living except eating which was independent. Review of the physician's orders for January 2023 revealed Resident #4 was ordered a low concentrated sweet, no added salt diet with regular texture and regular liquid consistency. Review of the care plan dated 10/01/18 with a revision date of 01/07/20 revealed Resident #3 had a potential for alteration in nutrition due to diagnoses. Interventions included but not limited to provide diet as ordered and honor preferences. Observation of lunch tray line on 02/08/23 from 11:45 A.M. through 12:11 P.M. revealed Residents #4 had ice cream written on their diet ticket but did not receive it. This was verified by Dietary Manager #388 at 11:53 A.M. 3. Record review for Resident #6 revealed an admission date of 12/05/11 and a readmission date of 03/07/19. Diagnoses included but not limited to atrial fibrillation, and paranoid schizophrenia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/25/23, revealed the resident had intact cognition. The resident was independent for eating and required supervision with one staff for mobility and transfer. Review of the physician's orders for January 2023 revealed Resident #4 was ordered a reduced concentrated sweet, diet with regular texture and regular liquid consistency. Review of the care plan dated 12/10/18 with a revision date of 01/24/23 revealed Resident #3 had a potential for alteration in nutrition due to diagnoses. Interventions included but not limited to provide diet as ordered and honor preferences such as salads. Observation on 02/06/23 12:07 P.M. revealed Resident #6 did not receive the salad she ordered for lunch. This was verified at time of observation by Licensed Practical Nurse (LPN) # 360. Interview on 02/07/23 at 1:45 P.M. with Dietary Manager #388 revealed that she was trying to make the tray line more efficient and now she had enough staff to do it.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility policy, the facility failed to ensure staff followed prop...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility policy, the facility failed to ensure staff followed proper infection control procedures when entering and exiting COVID-19 isolation rooms and failed to ensure proper infection control procedures were used during wound care for Resident #26. This affected nine residents (#9, #14, #23, #26, #29, #137, #139, #237, and #287). The census was 41. Findings include: 1. Review of the medical record for Resident #139 revealed an admission date of 02/07/23 with a diagnosis of COVID-19. Review of the physician's orders for February 2023 identified orders for isolation due to COVID-19 through 02/09/23. Review of the care plan dated 02/07/23 revealed Resident #139 had an actual infection related to COVID-19. Interventions included isolation precautions as ordered, all services to be provided in room while on isolation, and personal protective equipment (PPE) would be worn. On 02/08/23 at 1:05 P.M., observation of Resident #139's room revealed a cart of PPE located outside the door and a sign posted next to the door indicating droplet isolation precautions with steps for donning and doffing a N95 mask, gown, gloves, and face shield. Observation at this time of State Tested Nurse Aide (STNA) #505 revealed she entered Resident #139's room wearing only a surgical mask and face shield. She moved Resident #139's bedside table, put the lid on top of the plate, and carried the meal tray out of the room to place on the tray cart in the hallway. At no time did STNA #505 perform hand hygiene, doff the surgical mask, or sanitize the face shield she wore into Resident #139's room. Interview at the time of observation with STNA #505 verified the observation and she stated I didn't read the sign, I just went in to get the tray. STNA #505 then immediately walked into the room of Residents #14 and #237, without performing hand hygiene or changing her PPE, and she touched the bedside tables and retrieved one meal tray from the room. Without performing hand hygiene or changing her PPE, STNA #505 then walked down the hall to the nurse's station, touched the desk, touched papers on the desk, removed papers from the bulletin board, replaced papers on the bulletin board, and wrote something down on a piece of paper. On 02/08/23 at 1:15 P.M., she entered the room of Resident #287 and touched the wheelchair, touched the side of the bed, and spoke to Resident #287 for one minute before exiting the room. She did not change her PPE or perform hand hygiene before entering the room or when exiting the room. On 02/08/23 at 1:19 P.M., without performing hand hygiene or changing her PPE, she opened the door and stepped inside the room of Residents #9 and #29. She immediately went down the hall, opened the door and entered the room of Residents #23 and #137. At no point since exiting Resident #139's room was STNA #505 observed changing her PPE or performing hand hygiene. On 02/08/23 at 1:19 P.M., interview with STNA #505 verified the observations and stated she only completed hand hygiene as needed throughout the day. She then continued down the hall without changing her PPE or performing hand hygiene. On 02/08/23 at 3:54 P.M., interview with the Director of Nursing (DON) verified Resident #139 was on isolation for COVID-19. She stated the PPE for a COVID-19 isolation room included a gown, gloves, N95 mask, and eye protection. The DON indicated all PPE would be donned prior to entering and doffed when exiting the room. She also stated hand hygiene should be performed before entering the room and when exiting the room. Review of facility policy titled Infection Prevention and Control Program, dated 11/2020, revealed all staff would perform hand hygiene between resident contacts, after handling contaminated objects, after PPE removal, and before and after performing resident care procedures. The policy also indicated staff would wear appropriate PPE. Review of the document by the Centers for Disease Control and Prevention (CDC) titled Use Personal Protective Equipment (PPE) When Caring for Residents with Confirmed or Suspected COVID-19, not dated, which the facility included in their infection control education to staff, revealed healthcare personnel must be trained on proper PPE use and PPE for COVID-19 isolation rooms included a gown, N95 respirator or face mask, face shield or goggles, and gloves. It also indicated PPE would be donned prior to entering the room, doffed when exiting the room, and hand hygiene would be performed prior to donning PPE, when exiting the room, and prior to donning a new face mask. 2. Resident #26 was admitted to the facility on [DATE] with diagnoses including necrotizing fasciitis, COVID-19, diabetes, congestive heart failure, a stroke, osteomyelitis, and a pressure ulcer to the sacral region. The resident was admitted to the facility with the pressure ulcer to the sacrum. Review of the comprehensive quarterly Minimum Data Set (MDS) assessment, dated 01/03/23, revealed the resident was cognitively intact. Catheter care and a dressing change were observed for Resident #26 on 02/07/23 from 1:30 P.M. to 2:30 P.M. and was completed by Assistant Director of Nursing (ADON) #600. ADON #600 first completed foley catheter (a device inserted into a patient's body to drain urine from the bladder) first. After completing catheter care ADON #600 tossed the soiled washcloths onto the floor. They were not placed into a plastic bag. ADON #600 then began to change the dressings to the resident's bilateral knees, right foot, bilateral hips, and sacrum. ADON #600 removed each soiled dressing, changed her gloves, cleansed the wounds, changed her gloves, dressed the wounds, and dated each one. At no time did ADON #600 wash her hands after removing her gloves. Standard infection control protocols were not implemented during catheter care or the dressing changes. Interview with ADON #600 on 02/07/23 at 2:30 P.M. revealed she did not think about it when she tossed the soiled washcloths on the ground and thought she had washed her hands while changing Resident #26's dressing.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0921)

Could have caused harm · This affected multiple residents

Based on observation and staff interview, the facility failed to ensure a clean and well-maintained environment. This affected five residents (#13, #27, #28, #138, and #238) rooms of 41 resident occup...

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Based on observation and staff interview, the facility failed to ensure a clean and well-maintained environment. This affected five residents (#13, #27, #28, #138, and #238) rooms of 41 resident occupied rooms and two common areas. This had the potential to affect all 41 residents that resided in the facility. Findings include: 1. Observation on 02/06/23 at 11:12 A.M. revealed there was feces on the toilet and toilet seat of Resident #238. The Director of Nursing verified at time of observation. 2. An environmental tour was conducted with the Maintenance Director on 02/09/23 from 9:32 A.M. through 10:15 A.M. revealed the following: - Wallpaper was peeling in common area near the nurses station. - Resident #13's wall had peeling paint located next to the bed. - Resident #27's wallpaper was peeling and had a hole in the wall. - Resident #28's blinds were broken. - The central shower room had paint peeling from the ceiling. - Resident #138's door frame was cracked and frayed. This deficiency represents non-compliance investigated under Complaint Number OH00139256.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

Based on observations, interview and record review, the facility failed to ensure that the kitchen was clean and sanitary and dish washing protocols were followed to ensure dishes were sanitized. This...

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Based on observations, interview and record review, the facility failed to ensure that the kitchen was clean and sanitary and dish washing protocols were followed to ensure dishes were sanitized. This had the potential to affect 39 of 41 residents receiving food from the kitchen. Resident #31 received no food by mouth (NPO). The facility census was 41. Findings include: Tour of the kitchen on 02/06/23 from 8:30 A.M. to 8:50 A.M. with [NAME] #371 revealed in the reach in freezer, chicken was not wrapped properly, labeled, or dated and frozen veggies were not labeled or dated when opened. In the walk-in refrigerator, turkey was not labeled or dated, and old desserts located on the baker's rack were not covered, labeled or dated. [NAME] #371 verified findings at time of observation. Observation of dish machine on 02/06/23 at 8:50 A.M. revealed the dish machine did not reach proper final rinse temperature (180 degrees Fahrenheit) after several empty racks went through the high temperature dish machine. The final rinse temperature was 150 degrees Fahrenheit (F). Dietary Aide #402 stated the dish machine had to be manually filled for the past two weeks but had no issues without the dish machine reaching proper temperatures and that they couldn't get it fixed sooner because the company stated that the account balance must be paid prior to service. Dietary Aides started washing dishes in the three-compartment. Dietary Aide #300 could not test the sanitizer in the three-compartment sink because the only test strips that were available were a high range bleach test and the sanitizer for the three-compartment sink was a quat based sanitizer. On 02/06/23 at 9:20 A.M. Dietary Manager #388 tested the three-compartment sink at it was between 200 and 400 parts per million (ppm). Interview on 02/06/23 at 9:38 A.M. with Maintenance Director #302 revealed the dish machine was not working properly because it wouldn't fill up because of a bad solenoid. The staff had to fill the dish machine manually, but the final rinse did work and was at proper temperature. Maintenance Director #302 was checking the dish machine to see why final rinse temperature was not reaching proper temperature. Maintenance Director #302 noticed the booster heater was not on. Interview on 02/06/23 at 10:24 A.M. with Dish machine and Chemical Technician #500 revealed that last Thursday (02/02/23) he came out because the dish machine was not filling up. The staff manually filled the machine up and the final rinse was working at that time since the final rinse water is fresh water coming into the machine. DCT #500 stated the high range bleach test strips were used for testing bleach solutions used for c-diff or norovirus not the three-compartment sink quat sanitizer. Review of a list of resident diets revealed Resident #31 received no food by mouth (NPO). Review of the facility policy dated 2013 titled, Food Storage revealed leftover food should be stored in cover containers or wrapped carefully and securely. Each item should be clearly labeled and dated before being refrigerated. Review of the facility policy dated 2021 titled, Food Safety- Director of Food and Nutrition Services Responsibilities revealed Director of Food and Nutrition will be responsible for following dishwashing guidelines and techniques will be understood by staff and carried out in compliance with state and local health codes.

Jan 2023 7 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to timely report an allegation of misappropriation for Resident #...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to timely report an allegation of misappropriation for Resident #1. This affected one resident (Resident #1) of three residents reviewed for abuse and neglect. The facility census was 38. Findings Include: Review of the medical record for Resident #1 revealed an admission date of 10/25/21. Diagnoses included acute kidney failure, major depressive disorder, adjustment disorder with depressed mood, and hoarding disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 12/01/22, revealed Resident #1 had intact cognition. Review of progress notes from 09/01/22 through 12/22/22 revealed no concerns with Resident #1 having any behaviors. Review of the plan of care dated 04/06/22 revealed the resident had behaviors related to hoarding. Review of the plan of care with a date revised of 12/15/22 revealed the facility added a problem of Resident #1 making false accusations against staff Resident #1 did not like. Record review of an untitled, single page document provided by the Administrator In Training (AIT) and dated 12/08/22 revealed on 12/08/22 an unnamed State Tested Nursing Assistant (STNA) reported another unnamed STNA was asking an unnamed Resident for bus fare. A unnamed Resident was interviewed and denied giving a staff member money. The unnamed STNA was interviewed and stated he did not ride the bus and denied asking residents for money. The document was silent from any evidence of any other residents or staff being interviewed about the allegation or that the allegation was reported to the state agency. The document was signed by the AIT and dated 12/08/22. Interview on 12/14/22 at 2:15 P.M. with the AIT revealed a staff member reported to the Director of Nursing (DON) an allegation State Tested Nursing Assistant (STNA) #413 received money from a resident identified as Resident #1. The AIT stated she called STNA #413 and asked him if he had ever taken money from a resident to get a ride home on the bus, and STNA #413 stated nothing had happened and he did not take the bus. The AIT then stated she spoke with Resident #1 who voiced no concerns, so the AIT decided there was no reason to file a self-reported incident (SRI) to the state agency for the alleged misappropriation. Interview on 12/27/22 at 9:30 A.M. with Resident #1 revealed a man did ask her for money but she could not remember exactly who it was or the date she was asked for the money. She stated she did not give him any money and reported it to the staff. Interview with STNA #413 on 12/27/22 at 1:30 P.M. revealed he was questioned by the Administrator and the DON about asking a resident for money. STNA #413 denied ever asking any resident for money or taking any money from any resident. Interview on 12/28/22 at 2:55 P.M. with the AIT revealed it was STNA #505 who reported to the AIT that STNA #413 was asking residents for money for bus [NAME]. The AIT stated she had no additional evidence of an investigation into the allegation of misappropriation, as she had interviewed other staff and residents but did not document any of the interviews. The AIT explained because the bus [NAME] was not a significant amount of money, she did not need to file an SRI. The AIT was not able to verify exactly how much money was alleged to be misappropriated. Review of the undated facility policy titled, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, revealed it is the facility's policy to investigate all alleged violations involving abuse, neglect, misappropriation of resident property, exploitation or mistreatment, including injuries of unknown source, and for allegations of misappropriation, it should be reported to the Ohio Department of Health no later than 24 hours from the time of the allegation was made known to a staff member. This deficiency represents non-compliance investigated under Complaint Number OH00136561.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to thoroughly investigate an allegation of misappropriation for R...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to thoroughly investigate an allegation of misappropriation for Resident #1. This affected one resident (Resident #1) of three residents reviewed for abuse and neglect. The facility census was 38. Findings Include: Review of the medical record for Resident #1 revealed an admission date of 10/25/21. Diagnoses included acute kidney failure, major depressive disorder, adjustment disorder with depressed mood, and hoarding disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 12/01/22, revealed Resident #1 had intact cognition. Review of progress notes from 09/01/22 through 12/22/22 revealed no concerns with Resident #1 having any behaviors. Review of the plan of care dated 04/06/22 revealed the resident had behaviors related to hoarding. Review of the plan of care with a date revised of 12/15/22 revealed the facility added a problem of Resident #1 making false accusations against staff Resident #1 did not like. Record review of an untitled, single page document provided by the Administrator In Training (AIT) and dated 12/08/22 revealed on 12/08/22 an unnamed State Tested Nursing Assistant (STNA) reported another unnamed STNA was asking an unnamed Resident for bus fare. A unnamed Resident was interviewed and denied giving a staff member money. The unnamed STNA was interviewed and stated he did not ride the bus and denied asking residents for money. The document was silent from any evidence of any other residents or staff being interviewed about the allegation or that the allegation was reported to the state agency. The document was signed by the AIT and dated 12/08/22. Interview on 12/14/22 at 2:15 P.M. with the AIT revealed a staff member reported to the Director of Nursing (DON) an allegation State Tested Nursing Assistant (STNA) #413 received money from a resident identified as Resident #1. The AIT stated she called STNA #413 and asked him if he had ever taken money from a resident to get a ride home on the bus, and STNA #413 stated nothing had happened and he did not take the bus. The AIT then stated she spoke with Resident #1 who voiced no concerns, so the AIT decided there was no reason to file a self-reported incident (SRI) to the state agency for the alleged misappropriation. Interview on 12/27/22 at 9:30 A.M. with Resident #1 revealed a man did ask her for money but she could not remember exactly who it was or the date she was asked for the money. She stated she did not give him any money and reported it to the staff. Interview with STNA #413 on 12/27/22 at 1:30 P.M. revealed he was questioned by the Administrator and the DON about asking a resident for money. STNA #413 denied ever asking any resident for money or taking any money from any resident. Interview on 12/28/22 at 2:55 P.M. with the AIT revealed it was STNA #505 who reported to the AIT that STNA #413 was asking residents for money for bus [NAME]. The AIT stated she had no additional evidence of an investigation into the allegation of misappropriation, as she had interviewed other staff and residents but did not document any of the interviews. The AIT explained because the bus [NAME] was not a significant amount of money, she did not need to file an SRI. The AIT was not able to verify exactly how much money was alleged to be misappropriated. Review of the undated facility policy titled, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, revealed it is the facility's policy to investigate all alleged violations involving abuse, neglect, misappropriation of resident property, exploitation or mistreatment, including injuries of unknown source, and for allegations of misappropriation, it should be reported to the Ohio Department of Health no later than 24 hours from the time of the allegation was made known to a staff member. This deficiency represents non-compliance investigated under Complaint Number OH00136561.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and observation, the facility failed to ensure residents with wounds had an ordered dressing i...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and observation, the facility failed to ensure residents with wounds had an ordered dressing in place for Resident #27 and failed to ensure the dressing covering the wound for Resident #20 was dated and timed. The facility also failed to ensure wound care was provided in a clean and sanitary manner consistent with proper infection control procedures for Resident #20 and Resident #27. This affected two residents (Resident # 20 Resident #27) out of three residents reviewed for wound care. The facility census was 38. Findings Include: 1. Resident #20 was admitted to the facility on [DATE]. Her admitting diagnoses included necrotizing fasciitis, type two diabetes, heart failure, loss of vision of the left eye, encephalopathy, pressure ulcer of sacral region, and osteomyelitis of vertebra and sacral region. Review of the Minimum Data Set (MDS) 3.0 assessment for Resident #20, dated 09/19/22, revealed this resident had moderate cognitive impairment and needed extensive assistance of one person for bed mobility, dressing, toilet use and personal hygiene. Resident #20 was totally dependent on two staff members for transfers and was totally dependent on one staff member for eating. Review of Resident #20's bowel/bladder assessment from this MDS revealed Resident #20 had an indwelling urinary catheter. Review of Resident #20's physician orders revealed on 12/27/22 she was ordered to have her sacral wound ulcer cleaned with normal saline, dampen sterile gauze with Daykin's solution (a solution used to clean wounds) and let the gauze sit in the Daykin's solution for two minutes. Lightly pack the wound bed with gauze and Medihoney gel and cover with a thick padded dressing and tape all sides to ensure stool does not get into the wound. On 12/27/22 at 11:00 A.M. an observed dressing change was conducted of Licensed Practical Nurse (LPN) #504 and State Tested Nursing Assistant (STNA) #502 preparing Resident #20 for the wound dressing change by rolling Resident #20 onto her left side. After the resident was repositioned, further observation revealed this resident did have an intact dressing on her coccyx wound but the dressing was not dated or timed. After LPN #504 gathered all the supplies for the wound dressing change LPN #504 proceeded to apply two pairs of gloves on each hand, remove Resident #20's old dressing and the packing from the wound. Without washing her hands or changing the gloves, LPN #504 cleaned the wound with normal saline, applied the Medihoney, applied the Daykin's-soaked gauze to the wound and covered the wound with a thick dressing and taped it in place. An interview on 12/27/22 at 11:10 A. M. with LPN #504 at the time of the observation verified the dressing was not dated or timed. Interview with LPN #504 on 12/27/22 at 1:50 P.M. verified she did not perform hand hygiene nor change into clean gloves after removing the old dressing and then applying the new dressing to Resident #20's sacral wound. 2. Resident #27 was admitted to the facility on [DATE]. Her admitting diagnoses included encephalopathy, osteomyelitis of the vertebra, sacral and sacrococcygeal region, pressure ulcer stage four, Barrettes esophagus, diabetes mellitus, peripheral vascular disease and depression. Review of this resident's Minimum Data Set (MDS) 3.0 assessment, dated 11/28/22, revealed this resident had severe cognitive impairment. Functionally, this resident needed extensive assistance of two people for bed mobility, and dressing. She was totally dependent on one to two staff for transfers, toilet use, eating, and personal hygiene. Review of this resident's physician orders dated 12/27/22 revealed this resident was ordered to have her sacral wound cleaned with normal saline, pat dry, pack with gauze and Medihoney and cover with an abdominal wound dressing daily. For the left heel ulcer the physician ordered on 12/13/22 to cleanse the left heel with normal saline, pat dry and apply Medihoney paste and cover with a dry sterile dressing and wrap with Kerlix (gauze). An observation was conducted on 12/27/22 at 1:00 P.M. of LPN #504 performing wound dressing changes for Resident #27. LPN #504 gathered the supplies, cleaned her scissors then set the scissors down directly on the counter by the resident's sink without establishing a clean barrier for the scissors. LPN #504 proceeded to open the sterile dressing and cut the dressing into strips with the scissors that were laying on the unclean counter. She placed these strips in a clean cup and poured normal saline on them. Observation of Resident #27's stage four coccyx wound revealed, after she was rolled to her left side, the resident did not have a dressing on her wound to remove before the new dressing was applied. Interview with LPN #504 at the time of the observation verified there was no dressing on the wound. LPN #504 proceeded to place two pairs of gloves on her hands then cleaned the wound and applied the Medihoney to the bed of the wound. LPN #504 then picked up the dressing strips she had cut with the unclean scissors and covered the sacral wound with the strips. LPN #504 did not apply a clean dressing over the wound instead repositioned Resident #27's disposable brief over the wound and with the help of an aide rolled the resident onto her back. LPN #504 proceeded to change the left heel dressing by using the unclean scissors to open the sterile dressing from the packet and cut the dressing with the same scissors and placed the dressing strips into a cup of saline. LPN #504 did not wash her hands or change her gloves in between changing the sacral dressing and the left heel wound dressing. She then picked up the dressing strips with the same gloved hands and began cleaning the wound area in an up and down motion instead of cleaning from the cleanest area to the dirty area per standards of practice for wound cleaning. LPN #504 verified at the time of the observation she had not cleaned the scissors between the dressing changes from the sacral wound to the heel wound nor did she wash her hands or change her gloves. Review of the facility policy titled Wound Care Policy and Procedure, dated August 2022, stated wound dressing orders are to be verified, completed as ordered and marked with the nurses initials, date and time the dressing was applied. A disposable cloth should be used to establish a clean field, all items to be used including scissors should be placed on the clean field, hands should be washed and dried thoroughly and after removing a dressing the hands should be washed and dried thoroughly and new gloves applied to the hands. This deficiency represents non-compliance under Complaint Number OH00138358.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0744 (Tag F0744)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview the facility failed to ensure Resident #27's dementia related behaviors during...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview the facility failed to ensure Resident #27's dementia related behaviors during a dressing change were properly recognized by staff and addressed for Resident #27's highest practicable well being. This affected one resident (Resident #27) out of three residents reviewed for behaviors . The facility census was 38. Findings included: Review of the medical record revealed Resident #27 was admitted to the facility on [DATE]. Her diagnoses included encephalopathy, schizophrenia, osteomyelitis of the vertebra, sacral and sacrococcygeal stage four pressure ulcer and depression. Review of Resident #27's Minimum Data Set (MDS) 3.0 assessment, dated 11/28/22, revealed Resident #27 had severe cognitive impairment, needed extensive assistance of two people for bed mobility and dressing and was totally dependent on one to two staff for transfers, toilet use, eating, and personal hygiene. Review of Resident #27's plan of care, updated 12/26/22, revealed Resident #27 was resistive to care and refused medications/treatments at times related to altered mental status, encephalopathy and schizophrenia. Interventions for this plan of care included: Allow resident to make decisions about treatment regime to provide a sense of control; Educate resident/family/caregivers of the possible outcome of not complying with care; Encourage as much participation/interaction by the resident as possible; Give clear explanation of all care activities prior to and as they occur during each contact and if resident resists with care, reassure the resident, leave and return five to 10 minutes later and try again. Observation on 12/27/22 at 12:00 P.M. of Resident #27 getting her wound dressing changed by Licensed Practical Nurse (LPN) #504 and State Tested Nursing Assistant (STNA) #413 revealed the resident crying and screaming out during the entire time the wound was being cleaned and dressed by the nurse. The resident continuously cried and screamed and not the nurse nor the aide assisting with the dressing change offered to comfort Resident #27 or stopped in the process of performing this dressing change to offer reassurance, ask Resident #27 what was wrong, assess for pain or offer any break to the resident. The nurse also did not prepare Resident #27 on what she could expect during the dressing change instead starting in on the dressing change with no explaination. At one point during the dressing change, Resident #27's roommate yelled out Is she ok? An interview conducted on 12/27/22 at 12:00 P.M. with LPN #504 during the observation revealed LPN #504 said she was not sure what to do because the resident had dementia and could resist care. When by the surveyor about the resident's plan of care and what interventions were care planned for refusal of care for Resident #27, LPN #504 had no response except she hated to see residents like this and not knowing what to do for Resident #27. When asked about the screaming and crying by Resident #27, LPN #504 said she did not know if the resident was in pain or was it due to dementia related behavior. LPN #504 verified she did not follow the care planned interventions of allowing the resident to make decisions about treatment, giving a clear explanation of all care prior to doing the care, reassuring the resident during care and reapproaching in five to 10 minutes if refusing care. This deficiency resulted from an incidental finding during the investigation of Complaint Number OH00138358.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0805 (Tag F0805)

Could have caused harm · This affected 1 resident

Based on observation and interview, the facility did not ensure pureed food was prepared at the appropriate consistency for Resident #31. This affected one Resident (#31) of one Resident reviewed for ...

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Based on observation and interview, the facility did not ensure pureed food was prepared at the appropriate consistency for Resident #31. This affected one Resident (#31) of one Resident reviewed for mechanically altered diet. The facility census was 38. Findings included: An observation was conducted on 12/27/22 at 10:00 A.M. with Dietary Manager (DM) #436 of [NAME] #425 preparing pureed pork and pureed macaroni. After [NAME] #436 pureed the pork, DM #436 tasted it and told [NAME] #425 it needed to be pureed longer due to lumpy texture. [NAME] #425 then pureed macaroni and DM #436 said it still had lumps in it. Interview with DM #436 during the observation on 12/27/22 at 10:00 A.M. revealed the facility had been serving pureed food molds but were now pureeing foods in house and currently had only one resident (Resident #31) who was ordered a mechanical soft diet with pureed meats. A policy on pureed food was unavailable. This deficiency represents non-compliance investigated under Complaint Number OH00136561.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0810 (Tag F0810)

Could have caused harm · This affected 1 resident

Based on observation, medical record review, and staff interviews, the facility failed to ensure Resident #6 was provided with adaptive equipment at meals to maintain the highest practicable level of ...

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Based on observation, medical record review, and staff interviews, the facility failed to ensure Resident #6 was provided with adaptive equipment at meals to maintain the highest practicable level of independence while eating. This affected one Resident (#6) of three residents reviewed for adaptive equipment at meals. The facility census was 38. Findings included: Review of the medical record for Resident #6 revealed an admission date of 12/23/21 with diagnoses including but not limited to encephalopathy, depression, diabetes mellitus, and anxiety. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 02/02/22, revealed Resident #26 had impaired cognition and required extensive assistance with activities of daily living. Review of the physician's orders for December 2022 revealed a diet order for no concentrated sweets (NCS) with mechanical soft texture and regular-thin consistency liquids and an order for the Resident to use built-up utensils, small cups, and individual bowls for all meals. Review of the care plan dated 09/20/21 with a revision date of 04/28/22 revealed Resident #6 was at risk for altered nutritional status related to diagnoses. Interventions included but not limited to resident to use built-up utensils, small cups, and individual bowls for all meals. Observation on 12/27/22 at 12:12 P.M. revealed that Resident #6 did not have her food portions in individual bowls and her utensils were not built up. [NAME] #425 verified the findings at time of observation. Review of facility policy dated 06/2019 titled, Assistive Device/Splints/Adaptive Equipment revealed assistive devices will be given to avoid any functional decline. This deficiency resulted from incidental findings during the investigation of Complaint Number OH00136561 and OH00136936.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

Based on observations, interview and record review, the facility failed to ensure food was stored, prepared and served under sanitary conditions. This had the potential to affect 37 of 38 residents re...

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Based on observations, interview and record review, the facility failed to ensure food was stored, prepared and served under sanitary conditions. This had the potential to affect 37 of 38 residents receiving food from the kitchen. One Resident (Resident #27) received no food by mouth (NPO). The facility census was 38. Findings include: Observation of the facility kitchen during the initial tour on 12/27/22 from 6:10 A.M. to 6:25 A.M. with [NAME] #425 revealed hamburger patties were in the reach-in refrigerator with no label or date to reflect when the patties were put into the refrigerator. In the walk-in cooler was a half-case of moldy celery and blood from thawing ground beef was leaking on the floor. Several prepared desserts were not covered, labeled, or dated. Also, the microwave oven used to heat up resident foods had food splatter on the inside indicating it was not being kept clean. Interview with [NAME] #425 at the time of the observations verified the findings at time of observation. Review of the facility policy titled Food Safety- Director of Food and Nutrition Services Responsibilities, dated 2021, revealed Director of Food and Nutrition will be responsible for providing safe foods to all individuals. This deficiency represents noncompliance investigated under Complaint Number OH00137872.

Feb 2020 3 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure Resident #12 and Resident #35 were provided a di...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure Resident #12 and Resident #35 were provided a dignified dining experience. This affected two residents (#35 and #12) of 22 residents eating lunch in the dining room. Findings include: 1. The lunch meal was observed on 02/18/20 from 12:25 P.M. through 1:10 P.M. During the observation, Resident #35 was observed sitting at table number 6 which was the table where residents needing staff assistance to eat their meals were seated. State Tested Nursing Assistant (STNA) #710 and #732 were seated. The two STNAs spoke with each other throughout the meal regarding various subjects including their personal life. Resident #35 was not addressed by either STNA throughout the course of the meal. Interview with the Administrator and Registered Nurse (RN) #701 confirmed in an interview on 02/18/20 at 2:30 P.M. STNA #710 and #732 should not have been discussing personal business during the course of Resident #35's meal. 2. Resident #12 was admitted to the facility on [DATE] with diagnoses that included cerebral palsy, type one diabetes and schizophrenia. The comprehensive assessment dated [DATE] indicated the resident was cognitively intact and could feed himself with meal setup. Observation on 02/18/2020 of the noon meal beginning at 12:08 P.M. in the main dining room revealed three STNAs, STNA #450, #451 #452 were serving the lunch meal to 22 residents in the area. The STNAs finished serving the residents and began assisting residents with eating. Resident #12 did not have a lunch tray at this time. Ten minutes after the service of the last tray at 12:45 P.M., Resident #12 asked the kitchen staff (Dietary #706) if he was going to receive a meal. The staff was surprised he did not get a tray. The resident was hidden from her view by a square pole. She immediately began preparing a tray for the resident. An interview at 12:48 P.M. with Dietary #706 regarding Resident#12 having to wait for his meal revealed the resident's meal ticket wasn't sent down as she had no slip for him. However, based on the observation of the meal, the three STNAs, who were in the dining room did not ensure all residents, including Resident #12 received a meal timely.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0676 (Tag F0676)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure Resident #9 was provided adequate assistance wit...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure Resident #9 was provided adequate assistance with mobility to ensure the resident was properly positioned in her wheelchair. This affected one resident (#9) of one resident reviewed for positioning. Findings include: Resident #9 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, spinal stenosis, transient cerebral ischemic attack and dementia. Review of activity of daily living (ADL) progress notes, dated 12/19/2019 revealed bed mobility items documented were provided during wound care treatment/evaluation. Lifted resident's legs into bed (extensive (ext) assist). Assisted resident to turn in bed/chair (ext assist). Placed pillow to assist resident with positioning (ext assist). Assisted resident to a sitting position (ext assist). Review of the annual comprehensive assessment dated [DATE] revealed the resident was cognitively impaired and required extensive assistance from staff for bed mobility and transfers. The Physical Function Observation evaluation dated 01/02/2020 revealed the resident had abnormal head and/or body positioning and poor hand grasp. Observation on 02/18/2020 at 10:17 A.M., 02/19/2020 at 10:45 AM. and 02/20/2020 at 11:00 A.M. revealed Resident #9 was observed to be leaning to the right, over the arm of the tilt in space wheelchair. Interview on 02/20/20 at 10:54 A.M. with Registered Nurse (RN) #454 revealed Resident #9 could not reposition herself without staff assistance. She also verified the resident wasn't currently on any restorative programs or therapies. The surveyor asked if she noticed the resident leans to the right in her wheelchair. RN #454 revealed she did not notice, but she could place a pillow on the resident's right side to help prop her up correctly, until she could get in touch with the physician. She verified the resident was leaning to right, with no assistive device in place at the time of the interview.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

2. Observation of the lunch meal on 02/18/20 from 12:25 P.M. through 1:10 P.M. revealed Resident #13 was sitting in a wheelchair with his urinary (Foley) catheter drainage bag laying directly on the f...

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2. Observation of the lunch meal on 02/18/20 from 12:25 P.M. through 1:10 P.M. revealed Resident #13 was sitting in a wheelchair with his urinary (Foley) catheter drainage bag laying directly on the floor and dragging on the ground. The above observation was confirmed by Registered Nurse (RN) #730. Based on observation, record review and interview the facility failed to ensure adequate infection control practices were maintained during a dressing change for Resident #4 to prevent the spread of infection and failed to ensure Resident #13's indwelling urinary catheter was maintained in a manner to prevent the spread of infection. This affected one resident (#4) of two residents reviewed for pressure ulcers and one resident (#13) of two residents reviewed for catheters. Findings include: 1. Review of the medical record revealed Resident #4 was admitted to the facility with diagnoses including heart failure, chronic kidney disease with dialysis and contusions of the bilateral lower extremities. Review of the most recent wound notes revealed the resident had vascular wounds to her left anterior shin and right lower leg. She also had pressure areas on the right and left heels. Observation of the dressing change for Resident #4 with Licensed Practical Nurse (LPN) #400 on 02/20/20 at 8:10 A.M. revealed she had cleaned off the table in the resident's room with bleach wipes and assembled all supplies on the table, including large bandage scissors and the two treatments for the dressings. The treatments consisted of Mesalt, a flat gauze-like material that absorbs wound moisture, which was ordered for the resident's two heel wounds on 02/17/20, and Collagen, a flat gauze-like material that promotes healing, which was ordered for the two impaired skin areas on the resident's bilateral calf/shin areas ordered on 02/10/20. The treatment orders indicated the wounds were all to be cleansed with normal saline, the Mesalt or Collagen treatment applied and covered with a gauze pad and then wrapped with gauze. LPN #400 used the scissors to cut through the packages containing the Mesalt and Collagen, cutting them into smaller sections to apply to the wounds. She laid the cut sections of the treatments, still in packages, on the table covering. LPN #400, assisted by State Tested Nursing Assistant, (STNA) #505, then began the dressing changes. She first removed the dressing to the left shin area. The old dressing was adhered to the resident's skin and wound area, so LPN #400 squirted normal saline onto the old dressing to saturate it and gently removed the old dressing, applying normal saline several times to allow the dressing to be removed without pulling. After the dressing was completely removed, LPN #400 wiped the area with a gauze pad. She did not clean the area with additional normal saline once the old dressing was removed, instead just wiped the saline that was still on the wound from removing the old dressing across the wound area. After washing her hands, LPN #400 gloved and picked up the package of the Collagen that had been cut earlier. She held the outside of the wrapper to remove the new dressing, then ripped pieces from it to fit into the wound bed, patting it into the wound. She then covered the wound with a gauze pad and wrapped it with a gauze wrap. LPN #400 then began the dressing change for the wound on the resident's left heel. That dressing was also adhered to the resident's skin and LPN #400 again used saline to loosen the dressing from the skin, and wiped the excess moisture from the area with a gauze pad. She did not specifically clean the heel wound. She also touched the outside wrapper of the Mesalt treatment with gloved hands prior to manipulating the treatment onto the wound bed. After completing the dressing change for the left heel, LPN #400 began the dressing change for the impaired skin area to the resident's right shin. She again used normal saline to loosen the adhered dressing and wiped the area, without specifically cleaning it. She again touched the outside wrapper of the Collagen treatment prior to ripping and manipulating the treatment onto the wound bed. She completed the dressing change for the right heel but as the old dressing change was not adhered to the skin area, she did cleanse the wound with normal saline as ordered. She did touch the outside of the wrapper of the Mesalt treatment with gloved hands prior to manipulating the treatment onto the wound bed. Review of the facility policy on Dressing Changes, dated 09/29/17, revealed a clean field should be prepared with the necessary equipment and the would should be cleansed after the soiled dressing was removed. An interview with LPN #400 on 02/20/20 at 9:38 A.M. confirmed that although the scissors were clean, she cut through the package of the treatment, touching the treatment itself as she cut through it. She also verified she had touched the outside wrapper of the treatments with gloved hands, then manipulated the treatments with the same gloves prior to applying them directly to the wound bed. She verified she could not ensure the cleanliness of the outside of the treatment wrappers. She also verified she had not specifically cleansed three of the wounds, instead, wiping them dry after using normal saline to remove the old adhered dressings. The findings of the observations were also verified with LPN #405 on 02/20/20 at 10:54 A.M.

THE MERRIMAN

The Good

The Bad

The Ugly 63 deficiencies on record

Questions to Ask on Your Visit

Our Honest Assessment

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THE MERRIMAN

Strengths

Concerns