What is MCKINLEY NURSING's CMS rating?

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

How many inspection deficiencies does MCKINLEY NURSING have?

MCKINLEY NURSING has 40 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at MCKINLEY NURSING?

MCKINLEY NURSING has a two-star staffing rating from CMS with 0.44 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 MCKINLEY NURSING located?

MCKINLEY NURSING is located in CANTON, OH. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does MCKINLEY NURSING have?

MCKINLEY NURSING has 176 certified beds.

Who owns MCKINLEY NURSING?

MCKINLEY NURSING is a for profit - corporation facility and operates independently (not part of a chain).

Is MCKINLEY NURSING safe?

MCKINLEY NURSING 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 MCKINLEY NURSING stick around?

MCKINLEY NURSING has average staff turnover at 38%, which is typical for the nursing home industry.

Was MCKINLEY NURSING ever fined?

No, MCKINLEY NURSING has no federal fines on record, indicating a clean compliance history with Medicare and Medicaid requirements.

Is MCKINLEY NURSING on any federal watch list?

No, MCKINLEY NURSING 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 MCKINLEY NURSING?

Medicare inspectors have found 40 deficiencies at MCKINLEY NURSING: 1 serious, 37 moderate, 2 minor. Each deficiency represents a violation of federal nursing home requirements.

What questions should families ask when visiting MCKINLEY NURSING?

Families visiting MCKINLEY NURSING should ask about daily routines, communication with families, how they handle medical emergencies. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does MCKINLEY NURSING compare to other nursing homes?

MCKINLEY NURSING has a 3-star overall rating, which is average compared to other nursing homes in OH. Consider visiting multiple facilities before making a decision.

MCKINLEY NURSING | 55/100 (Grade C)

Jan 2025 4 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

Safe Environment (Tag F0584)

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 ensure a clean, sanitary, and homelike environment for...

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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 ensure a clean, sanitary, and homelike environment for residents. This affected one resident (Resident #72) out of three residents reviewed for quality of care and treatment. The facility census was 154. Findings include: Review of the medical record for Resident #72 revealed an admission date of 11/26/24. Diagnoses included diabetes mellitus type one, acquired absence of the left leg below the knee, major depressive disorder, and noninfectious gastroenteritis. Review of Resident #72's care plan dated 01/07/25 revealed the resident displayed behavioral symptoms not directed toward others as evidenced by defecating on the floor and in the trash can instead of utilizing the bedside commode that was provided for him. Review of Resident #72's Minimum Data Set assessment dated [DATE] revealed the resident required supervision and touch assistance for toileting hygiene and showering and bathing. The assessment indicated the resident utilized a motorized wheelchair. Observation on 01/13/25 at 11:25 A.M. of Resident #72 and his room revealed upon entering the room a strong sour smell of vomit and feces was present. On the floor was a full urinal filled with urine, a basin full to the top of vomit, applesauce cups open and scattered on the floor, old food laying on the floor, dishes in his sink with old food still present, a large bin filled to the top with bags of trash, disposable bed pads covered in feces placed into a pile next to the residents bed, and a dead cockroach stuck to a glue trap behind the residents refrigerator. The resident who was a partial amputee was noted to be in the fetal position on his bed. He was calm and pleasant but reported he had been ill since the night before. Licensed Practical Nurse (LPN) #201 entered the resident's room during the observation and confirmed the findings. Interview with LPN #201 on 01/13/25 at 11:30 A.M. revealed Resident #72's room was commonly a mess. She reported if he did not smoke, he got sick and he threw up frequently. She stated he was ill a lot and would not clean up after himself. She reported the resident was compliant with care, and she was going to give him medication to assist with his nausea. LPN #201 did not attempt clean up before leaving the room. A follow up interview and observation of Resident #72's room on 01/13/25 at 12:45 P.M. revealed the residents room was in the same condition it was at 11:25 A.M. the basin of vomit remained full and sitting on the floor, the residents urinal was not emptied, the food and trash remained on the floor, and the disposable incontinence briefs were not placed in the trash or removed from the room. Interview with the resident during the observation revealed he had a chronic gastrointestinal (GI) issue that caused stomach upset, nausea, vomiting, and diarrhea. He reported he was too ill and needed assistance with keeping his room clean. He stated no one had came in to clean his room on this day, but he would like for it to be cleaned. Interview on 01/13/25 at 12:51 P.M. with Certified Nurse Assistant (CNA) #205 reported she was one of the CNA's on Resident #72's hall. She stated that the resident was sick often and his room was usually a mess. She stated housekeeping was usually the one who went in and cleaned his room. She stated she had not been in his room on this day. Interview on 01/13/25 at 1:00 P.M., Housekeeper #207 reported she was told by her manager that they would go into Resident #72's room after lunch to clean it up. She reported it was usually a mess and took more than one person to clean it up. She reported, at times, the resident did refuse to let them clean up, but she had not attempted to clean the room on this day. Interview on 01/14/25 at 1:35 P.M., Housekeeping Supervisor #208 reported that she attempted to clean Resident #72's room on 01/13/24 in the morning, but he refused. She stated she went back in around 1:00 P.M. and was able to clean it. She stated she reported his refusal to Licensed Social Worker (LSW) #304. Interview on 01/14/25 at 2:35 P.M. with LSW #304 revealed Housekeeping Supervisor #208 did not report to her on 01/13/25 that Resident #72 refused to allow staff to clean his room. She continued that yesterday (01/13/25) she reported to housekeeping that they needed to go in and clean Resident #72's after observing what it looked like at 9:00 A.M. that morning. Interview on 01/14/25 at 10:22 A.M. the Director of Nursing verified it would be her expectation that if facility staff observed issues related to infection control/sanitation issues they should be addressed timely by facility staff if the resident was being complaint with treatment. She confirmed this was not done. This deficiency represents non-compliance investigated under Complaint Number OH00161141.

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 F0925 (Tag F0925)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, and review of pest control customer service reports, the facility fai...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, and review of pest control customer service reports, the facility failed to eradicate cockroaches from Resident #72's room. This affected one resident (#72) out of three residents reviewed for pest control. The facility census was 154. Findings include: Review of the medical record for Resident #72 revealed an admission date of 11/26/24. Diagnoses included diabetes mellitus type one, acquired absence of the left leg below the knee, major depressive disorder, and noninfectious gastroenteritis. Review of Resident #72's care plan dated 01/07/25 revealed the resident displayed behavioral symptoms not directed toward others as evidenced by defecating on the floor and in the trash can instead of utilizing the bedside commode that was provided for him. Review of Resident #72's Minimum Data Set assessment dated [DATE] revealed the resident was cognitively intact required supervision and touch assistance for tilting hygiene and showering and bathing. The assessment indicated the resident utilized a motorized wheelchair. Interview and observation on 01/13/25 at 11:25 A.M. of Resident #72 and his room revealed upon entering the room a strong sour smell of vomit and feces was present. On the floor was a full urinal filled with urine, a basin full to the top of vomit, applesauce cups open and scattered on the floor, old food laying on the floor, dishes in his sink with old food still present, a large bin filled to the top with bags of trash, disposable bed pads covered in feces placed into a pile next to the residents bed, and a dead cockroach stuck to a glue trap behind the residents refrigerator. Licensed Practical Nurse (LPN) #201 entered the resident's room during the observation and confirmed the findings. Interview on 01/13/25 at 12:45 P.M. with Resident #72 revealed the resident was aware of cockroaches being in his room. He stated the facility had put traps in his room to catch them and on two occasion he left his room while the exterminator came in. Review of the pest control company customer service report dated 11/30/24 revealed Resident #72's room was inspected and treated for cockroaches on this date. Review of the service report dated 12/18/24 revealed the resident's room was treated again. Review of the 12/27/24 service report revealed the resident's room was difficult to do a thorough service because so much personal items and clothing were thrown throughout the room. The action section stated for the facility to please address the sanitation issue. Continued review of the service reports revealed the pest control company had not reassessed the room. Interview on 01/14/25 at 2:50 PM with the Administrator revealed Resident #72 was admitted on [DATE]. A couple days after admission, staff reported seeing cockroaches in the resident's room. He reported they contacted their pest control company who came in and treated the room on 11/30/24, 12/18/24, and 12/27/24. He stated the company came in monthly and checked the preventative traps. He confirmed the resident's sanitation issues were a reason why the cockroaches had not completely been eradicated from Resident #72's room. This deficiency represents non-compliance investigated under Complaint Number OH00161141.

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

Menu Adequacy (Tag F0803)

Could have caused harm · This affected most or all residents

Based on review of the facility menu, review of resident council meeting minutes, observation, staff interview and resident interview, the facility failed to ensure menus were prepared in advance and ...

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Based on review of the facility menu, review of resident council meeting minutes, observation, staff interview and resident interview, the facility failed to ensure menus were prepared in advance and updated periodically and failed to ensure residents received the correct portion sizes based on the menus. This had the potential to affect all 154 residents who resided in the facility. Findings include: Review of the Resident Council Meeting Minutes dated 12/31/24 revealed the food committee meeting was not held on this day due to the absence of the Dietary Manager. The council voted to reschedule the food committee meeting as soon as possible. Review of the facility menu (in January 2025) revealed the facility was utilizing the menu for spring and summer 2024. The date on the top of the menu for 01/13/25, revealed the menu was to be used for 07/22/24. It was also noted that residents were supposed to receive eight ounces of spaghetti and meat sauce. Observation on 01/13/25 at 12:00 P.M. revealed Dietary Aide (DA) #202 had utilized a regular-non measurable serving spoon to place one spoonful of spaghetti onto each resident's plate. Interview on 01/13/25 at 12:25 P.M. Assistant Dietary Manager #200 stated the facility was supposed to switch over to the fall/winter menu, but that had not happened yet. She reported due to ordering errors or issues with the trucks coming in timely the menu had changed several times over the last month. She confirmed at this time that the facility did not keep a substitution log or have a way to track what meal had been served. Assistant Dietary Manager #200 also confirmed DA #202 utilized a non-measurable serving spoon to plate the residents spaghetti. Interview on 01/14/25 at 10:17 A.M. with the Administrator revealed dietary concerns were discussed in the monthly food committee meeting held by the Dietary Manager, who had recently been off work. He revealed he was unable to find the minutes from recent food committee meetings. He stated no one had made him aware of the dietary concerns so he had not done any investigation into resident concerns. Interview on 01/14/25 at 10:22 A.M. the Director of Nursing stated she had heard from residents that the portion sizes were small, but she was not sure if the facility had looked into the concerns. Interview on 01/14/25 at 10:25 A.M. with Resident #73 revealed he was often served food that was not on the menu and portion sizes were too small. He reported the concern had been brought up in resident council, but nothing had been done. Interview on 01/14/25 at 10:35 A.M. with Resident #74, who identified himself as the resident council president, reported residents had repeatedly brought up in resident council and at the food committee meeting that residents were not being served the correct meals and portions were too small. He reported he did not believe the Dietary Manager was taking their concerns seriously. Interview on 01/14/25 at 10:49 A.M., Activity Director (AD) #300 revealed he was usually present for the food committee meetings and the resident council meetings. He continued that dietary issues were usually discussed in the food committee and the Dietary Manager was responsible for addressing those concerns. He went on to say he had witnessed residents having concerns related to the menu and portion sizes in the facility. AD #300 confirmed the facility had not yet rescheduled a time for the food committee meeting that was canceled in December 2024. Interview on 01/14/25 at 2:25 P.M. Resident #67 reported she was often served meals that were not what she had chosen and often times the portion sizes were too small. This deficiency represents non-compliance investigated under Complaint Number OH00161141 and OH00161383.

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 and staff interviews, the facility failed maintain a sanitary kitchen and food storage areas and failed to ensure infection control was maintained while serving the lunch meal. Th...

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Based on observation and staff interviews, the facility failed maintain a sanitary kitchen and food storage areas and failed to ensure infection control was maintained while serving the lunch meal. This affected all residents who resided in the facility, as the facility identified all residents as receiving kitchen services. The facility census was 154. Findings Include: 1. Observation of the facility kitchen on 01/13/25 from 9:20 A.M. through 9:40 A.M. revealed the facility kitchen floors were scattered with torn sugar packets, pieces of old discarded food, crumbs, and dark sticky substances were covering parts of the floor. Several walls were noted to have dried up liquids that were previously splashed from food or drinks. Observation of the facility's chemical dishwasher revealed the top to be covered with dust, an abundance of what appeared to be crumbs from food, two dirty wash cloths, and a dried-up dirty sponge. The kitchen also had a large light with the name echo lab used to kill gnats and directly under the echo lab light, the facility was noted to have soup bowls on a drying cart. Interview on 01/13/25 at 9:40 A.M. Assistant Dietary Manager (ADM) #200 confirmed the sanitation findings and reported that due to recent staff changes, the facility's kitchen staff had fallen behind on some of the cleaning. She continued that the facility had a cleaning schedule and that the kitchen should have been cleaned at least two times a day. She reported the kitchen staff had not been signing off that the cleaning had been completed and she was unable to find the cleaning schedule. 2. Observation on 01/13/25 at 12:00 P.M. revealed Dietary Aide (DA) #202 washed her hands and begin plating food for the entire facility. She was observed grabbing plates from the cart and placing food on the plates. DA #202 was observed with ungloved hands, adjusting her hair net, and then she grabbed a bread stick with her ungloved hand and placed it on a resident's plate. She continued to use her ungloved hands to open the refrigerator and obtain a storage container of cheese, grab the cheese with her ungloved hand and place it on a hamburger. She then continued to plate resident food using her ungloved hand to grab breadsticks and place them on various resident's plates. During the observation, DA #202 was observed dropping spaghetti onto the tray line and using her ungloved hand to pick it up and place it on residents' plate and then wiping her hand off on her clothing. Interview on 01/13/25 at 12:25 P.M. with Assistant Dietary Manager (ADM) #200 confirmed the kitchen sanitation issues observed with DA #202. This deficiency represents non-compliance investigated under Complaint Number OH00161141 and OH00161383.

Apr 2024 4 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 F0660 (Tag F0660)

Could have caused harm · This affected 1 resident

Based on record review, interview, and policy review, the facility failed to ensure a timely discharge/transfer and failed to provide the resident or resident representative with required documentatio...

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Based on record review, interview, and policy review, the facility failed to ensure a timely discharge/transfer and failed to provide the resident or resident representative with required documentation upon discharge. This affected one (Resident #1) of three residents reviewed for discharge/transfer. The facility census was 150. Findings include: Review of Resident #1's closed medical record revealed an admission date of 02/04/20 with diagnoses that included schizoaffective disorder, anxiety, heart failure, atrial fibrillation, asthma, and the use of anticoagulant therapy. The resident was discharged to another nursing facility on 03/06/24. Review of the Minimum Data Set (MDS) quarterly assessment, dated 01/01/24, revealed the resident had intact cognition with delusions, physical and verbal behaviors, and rejection of care noted. a. Review of the medical record revealed the resident's Discharge Planning form, dated 03/06/24 and completed by Social Services Designee #301, revealed there was no resident or resident representative signature. During interview on 03/26/24 at 11:56 A.M., Resident #1's power of attorney (POA) stated that at the time of her mother's discharge from the facility, there were no discharge instructions or paperwork provided and there was no assistance with transporting the resident's belongings from the resident's room. The POA stated this was very unprofessional. The POA further stated the receiving facility continued to ask for the MDS assessment, however, the facility continued to delay sending the information and her mother had to wait until the next week to be admitted to the new facility. During interview on 03/27/24 at 10:39 A.M., the Director of Nursing (DON) confirmed Resident #1's Discharge Planning form was not signed by the resident or resident representative. b. Review of email communication, dated 02/22/24 at 2:24 P.M., from Social Services Designee (SSD) #300 to Admissions Coordinator #400 (employee at the facility the resident was being transferred to) revealed the receiving facility had an open spot for Resident #1 the following week. Review of email communication, dated 02/28/24 at 2:47 P.M., from Admissions Coordinator #400 to Social Services Designee (SSD) #300 revealed a request for Level II Pre-admission Screening and Resident Review (PASARR) (a screening to ensure residents are not inapropriately placed in a nursing home) results and sections C and GG from the current MDS. Review of email communication, dated 02/29/24 at 9:59 A.M., from Admissions Coordinator #400 to Social Services Designee (SSD) #300 revealed an additional request for section C and GG from the MDS. Review of email communication, dated 02/29/24 at 12:30 P.M., from Social Services Designee (SSD) #300 to Admissions Coordinator #400 revealed, I have been told that we do not send that information out. Review of email communication, dated 02/29/24 at 1:59 P.M., Admissions Coordinator #400 to Social Services Designee (SSD) #300 revealed, these are needed by the insurance provider to do the transfer desktop level of care. I am not sure why this is an issue as it's part of what's needed for the level of care which needs done before she can transfer. I am confused by this, let me forward you the email from the insurance provider requesting it. Interview on 03/27/24 at 10:23 A.M., Social Services Designee (SSD) #300 confirmed he was asked for MDS assessment on 2/28/24, however he was told by Business Office Manager (BOM) #302 that he was not required to send the MDS data because Resident #1's insurance did not require this for admission. SSD #300 confirmed the MDS data was not sent to the receiving facility until 03/04/24. Interview on 03/28/24 at 10:45 A.M., Admissions Coordinator #400 confirmed that the facility did have an open spot for the resident during the week of 02/25/24; however, there was a delay in the transfer because of continued requests for the MDS assessment and the resident could not be admitted until the following week. Admissions Coordinator #400 stated this information was required before the facility could admit the resident. Interview on 03/28/24 at 12:05 P.M., the Administrator confirmed the MDS assessment data is part of Resident #1's medical record. Review of the facility's policy, Discharging the Resident, dated August 2008, revealed the purpose of this procedure is to provide guidelines for the discharge process. Collect the resident's personal effects. Put them in a cart for transporting to the pickup area. Assist the family in loading the resident's personal effects. Say goodbye to the resident and family. This deficiency represents non-compliance investigated under Complaint Number OH00151767.

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 F0661 (Tag F0661)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to ensure a discharge summary which included a recapit...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to ensure a discharge summary which included a recapitulation (concise summary) of the resident's stay at the facility, was completed. This affected one (Resident #1) of three residents reviewed for discharge. The facility census was 150. Findings include: Review of Resident #1's closed medical record revealed an admission date of 02/04/20 with diagnoses that included schizoaffective disorder, anxiety, heart failure, atrial fibrillation, asthma, and the use of anticoagulant therapy. The resident was discharged to another nursing facility on 03/06/24. Review of the Minimum Data Set (MDS) quarterly assessment, dated 01/01/24, revealed the resident had intact cognition with delusions, physical and verbal behaviors, and rejection of care noted. Review of the medical record revealed no evidence that the discharge summary was completed at the time of Resident #1's discharge on [DATE]. During interview on 03/27/24 at 10:39 A.M., the DON confirmed she could not find evidence that a discharge summary was completed for Resident #1 at the time of discharge. Review of facility policy titled, Discharge Summary and Plan, dated August 2006, revealed when a resident's discharge is anticipated, a discharge summary and post discharge plan will be developed to assist the resident to adjust to his/her new living environment. The discharge summary will include a recapitulation of the resident's stay at this facility and a final summary of the resident's status at the time of the discharge in accordance with established regulations governing release of resident information and as permitted by the resident. This deficiency represents non-compliance investigated under Complaint Number OH00151767.

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

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, and policy review, the facility failed to maintain appropriate infection control precautions wh...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and policy review, the facility failed to maintain appropriate infection control precautions when Licensed Practical Nurse (LPN) #320 did not properly dispose of a used insulin syringe with needle. This had the potential to affect 31 residents (#3, #7, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40) of 31 residents residing on [NAME] Hall. The facility census was 150. Findings include: Observation on 03/27/24 at 12:40 P.M. revealed a used insulin syringe, with the sheath pulled over the needle, lying on the floor approximately five feet from the nursing station. This surveyor continued observation. At 12:45 P.M., the Director of Nursing (DON) confirmed the needle was lying on the floor and then retrieved it, without donning gloves, and walked approximately 20 feet to the location of the medication cart and placed the syringe into the sharps disposal container (rigid, puncture-resistant plastic or metal with leak-resistant sides and bottom, and a tight-fitting, puncture-resistant lid with an opening to accommodate depositing a sharp but not large enough for a hand to enter). Interview on 03/28/24 at 12:46 P.M. with LPN #320 revealed she was certain the insulin syringe was used to administer insulin to Resident #3. LPN #320 stated that she must have missed the sharps disposal container and apologized. The DON and LPN #302 confirmed Resident #3 did not have any communicable diseases. Interview on 03/28/24 at 12:50 P.M., the DON confirmed all needles and sharps should be properly disposed of after use. Review of the facility's policy titled, Insulin Administration, dated April 2007, revealed the purpose of the policy to provide guidelines for the safe administration of insulin to residents with diabetes. Steps in the procedure include to dispose of the needle in the designated container. This deficiency is an incidental finding discovered during the complaint investigation.

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 and staff and resident interviews, the facility failed to ensure cinnamon rolls were properly prepared to ensure palatability and an appetizing appearance. This had the potential ...

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Based on observation and staff and resident interviews, the facility failed to ensure cinnamon rolls were properly prepared to ensure palatability and an appetizing appearance. This had the potential to affect all residents residing in the facility. The facility census was 150. Findings include: Observation on 03/27/24 at 12:28 P.M. with State Tested Nursing Assistant (STNA) #303 revealed Resident #6 had eaten approximately 10% of his lunch tray. Observation of the uneaten cinnamon roll revealed the roll, still covered with clear plastic, was approximately the size of a 50-cent piece in diameter and the texture was hard and crunchy. During interview on 03/27/24 at 12:29 P.M., STNA #303 revealed residents had complained that they were unable to eat the cinnamon rolls because they were too hard and appeared overcooked. STNA #303 verified Resident #6's cinnamon roll appeared overcooked and was hard throughout. During interview on 03/27/24 at 12:31 P.M. Resident #6 stated he didn't eat his cinnamon roll because it was hard. During interview on 03/27/24 at 12:34 P.M., Registered Nurse (RN) #304 stated residents had complained to her that the cinnamon rolls were too hard to eat. During interview and observation on 03/27/24 at 12:38 P.M., Resident #7 was sitting at a table in the dining room, and stated his cinnamon roll was very hard and gross. Observation revealed the cinnamon roll was approximately the size of a 50-cent piece in diameter and the texture appeared to be hard and overcooked. Interview on 03/28/24 at 11:17 A.M. with Dietary Manager (DM) #304 revealed she was made aware of the concern regarding the cinnamon rolls served on 03/27/24. DM #304 confirmed all the cinnamon rolls served for lunch were not properly prepared. DM #304 stated a dietary cook did not place the tray of cinnamon rolls over a steam table to allow the dough to rise before baking, which resulted in the very small size and texture. DM #304 confirmed the cinnamon rolls were not palatable nor appetizing in their appearance and should not have been served to the residents. DM #304 stated the dietary cook who prepared the cinnamon rolls, had been educated on the proper preparation of the cinnamon rolls. This deficiency represents non-compliance investigated under Complaint Number OH00151976 and Complaint Number OH00151767.

Mar 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

Deficiency F0727 (Tag F0727)

Could have caused harm · This affected most or all residents

Based on record review and staff interview, the facility failed to ensure the services of a registered nurse were used for at least eight consecutive hours a day, seven days a week as required. This h...

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Based on record review and staff interview, the facility failed to ensure the services of a registered nurse were used for at least eight consecutive hours a day, seven days a week as required. This had the potential to affect all 150 residents residing in the facility. Findings Include: Review of facility staffing schedules revealed on 01/01/24 there was no evidence the services of a registered nurse (RN) were used for at least eight consecutive hours on this date. The schedule reflected there was no RN scheduled for, or present in the building during this entire day. Interview with the Administrator on 03/02/24 at 3:10 P.M. confirmed the facility did not have a registered nurse scheduled or working on 01/01/24. The facility was unable to provide any evidence to support a registered nurse worked in the facility on this date. This deficiency represents non-compliance investigated under Complaint Number OH00150409.

Dec 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

Menu Adequacy (Tag F0803)

Could have caused harm · This affected most or all residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, review of the facility menu spread sheets, review of the printed tray cards, and medical ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, review of the facility menu spread sheets, review of the printed tray cards, and medical record review, the facility failed to ensure proper food portions were served to meet the individual needs of Resident #143 who was ordered double portions, and failed to ensure proper food portions were served to all residents receiving meals from the kitchen. This had the potential to affect all residents receiving meals from the kitchen except Resident #37 who the facility identified as receiving nothing by mouth. The facility census was 147. Findings include: 1. Observation of the lunch meal trayline on 12/12/23 from 11:18 A.M. to 12:55 P.M. with Dietary Cook/Supervisor (DC/S) #413 revealed [NAME] #419 used one number-eight, gray handled ( four ounce) scoop to dish out the regular and mechanical soft turkey [NAME] and one number-12, green handled (two and two-third ounce) scoop to dish the puree turkey [NAME] and the puree mashed sweet potatoes. Review of facility Fall and Winter 2023 to 2024 spread sheet for Tuesday, week three revealed the correct portion size for the regular and mechanical soft turkey [NAME] was one eight-ounce spoodle (portion controlled serving spoon) and the puree turkey [NAME] was one number-six, white handled (five and one-third ounce) scoop. The puree mashed sweet potato was one number-eight (four ounce) gray handled scoop. Review of the of facility Fall and Winter 2023 to 2024 spread sheet for Tuesday, week three and interview on 12/12/23 at 2:50 P.M. with DC/S #413 revealed she was unaware of what the color of the handle of the scoop represented. She confirmed the residents who received the regular, mechanical soft and puree turkey [NAME] and the puree mashed sweet potatoes did not receive the full portion sizes since the residents who received regular and mechanical soft turkey [NAME] received four ounces instead of eight ounces, the residents who received the puree turkey [NAME] received two and two-third ounces instead of five and one third ounces, and the residents who received puree mashed sweet potatoes received two and two-third ounces instead of four ounces. DC/S #413 stated she had never seen a spread sheet. She indicated the facility had been printing out production sheets which listed the portion sizes, but since the employee who printed them out had been on leave of absence, there had not been any production sheets printed for about a month. 2. Review of medical record for Resident #143 revealed an admission date of 05/25/23. Diagnoses included fatty liver, hypo-osmolality (low levels of electrolytes in blood) and hyponatremia (low sodium levels in the blood), atherosclerotic heart disease, and essential hypertension (high blood pressure). Review of physician orders for Resident #143 revealed an order dated 05/26/23 for mechanical soft, double portions diet. Observation of Resident #143's breakfast tray and review of the resident's breakfast tray card on 12/13/23 at 9:21 A.M. with State Tested Nursing Assistance (STNA) #347 revealed Resident #143 received a single portion of eggs, one piece of toast, one bowl of hot cereal, and one bowl of sliced bananas. Resident #143's tray card placed on his breakfast tray did not indicate he was to receive double portions. At the time of observation, STNA #347 confirmed Resident #143 received a single portion for breakfast and his tray card had not indicated he should be receiving double portions. Interview on 12/13/23 at 9:34 A.M. with Dietary Manager (DM) #505 confirmed Resident #143's breakfast tray card should have specified the resident was on double portions. DM #505 stated he did audits to compare tray card and physician orders, and he had no idea how that got missed. This deficiency represents non-compliance investigated under Complaint Number OH00148558.

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, staff interview, and review of facility policy, the facility failed to ensure food was served in a sanitary manner when a dietary staff member with artificial nails was observed ...

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Based on observation, staff interview, and review of facility policy, the facility failed to ensure food was served in a sanitary manner when a dietary staff member with artificial nails was observed not wearing gloves during tray line. This had the potential to affect 146 residents who received food from the kitchen. The facility identified one resident (#37) as not receiving anything by mouth. The facility census was 147. Findings include: Observation of the tray line on 12/12/23 from 11:18 A.M. to 12:55 P.M. with Dietary Cook/Supervisor (DC/S) #413 revealed Dietary Aide (DA) #432 had long, artificial nails with a three dimensional nail charm attached to the right fourth finger. DA #432 was not wearing gloves to cover the artificial nails and was setting up the trays on trayline for the lunch meal service. Interview with the Administrator on 12/12/23 at 3:38 P.M. revealed gloves should be worn by any dietary employee who has artificial nails, and DA #432 should have been wearing gloves to cover the artificial nails while on tray line. Review of undated facility policy Personal Hygiene revealed the food handler must wear gloves if artificial nails are worn to work in order to reduce the risk of food borne illness and food handler hazards. This deficiency represents non-compliance as an incidental finding during the investigation of Complaint Number OH00148558.

Nov 2023 4 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** Based on closed record review, hospital record review, facility policy review and interview the facility failed to implement com...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed record review, hospital record review, facility policy review and interview the facility failed to implement comprehensive and individualized fall/safety interventions to prevent falls including a fall with injury for Resident #200. Actual Harm occurred on 09/27/23 when Resident #200, who had moderate cognitive impairment and required extensive two-person assistance for bed mobility and transfers was transferred to the emergency room per family request due to changes in condition. Record review revealed the resident sustained three falls between 09/25/23 and 09/27/23 without evidence of adequate interventions being in place at the time of the falls. Following a second fall on 09/27/23, the resident was picked up off the floor by Central Supply #808, an employee who was not qualified/trained to provide direct resident care. The resident was subsequently diagnosed with non-displaced left rib fractures and re-injury of a previous pelvic fracture. This affected one resident (#200) of three residents reviewed for falls. Findings include: Review of Resident #200's closed medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including a fracture of the superior rim of the left pubis, weakness and major depressive disorder. Hospital documentation dated 09/15/23 (prior to admission) revealed the resident had presented to the hospital with pain following a fall at home on [DATE]. The resident was diagnosed with a left superior pubic ramus fracture and possible left inferior pubic ramus fracture. Review of Resident #200's hospital admission orders dated 09/18/23 indicated she had a primary diagnosis of left pelvic fracture with a secondary diagnosis of falls. A fall risk assessment, dated 09/18/23 revealed the resident was at high risk for falls. A plan of care, created 09/19/23 revealed Resident #200 was at risk for falls due to her history of falls prior to admission, her mental status and her general weakness. The goal developed was for the resident to remain free from significant injury due to her risk of falls. Interventions included the resident needed assistance with transfers, does reposition in wheelchair and does try to ambulate without assistance; staff to report any falls to family/physician and fall interventions, which may include vital signs, neurological exams, medication reviews, lab work, x-rays and any intervention that may be ordered by the physician. Review of Resident #200's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment and required extensive two person assist for bed mobility, dressing, toilet use, personal hygiene and bathing as well as limited two person assist for transfers. Review of Resident #200's progress note dated 09/25/23 at 6:00 P.M. indicated the STNA reported the resident was sitting in front of the bathroom. The note indicated no injuries were noted. The resident had no change in range of motion (ROM) to extremities, neurological checks were initiated and the supervisor was notified. In addition, record review revealed no evidence comprehensive or individualized fall/safety interventions were initiated following this incident. Following the fall, the resident was encouraged to call for (staff) assistance. Review of Resident #200's progress note dated 09/26/23 at 9:15 A.M. indicated the resident was extremely confused, stated she had $25.00 under her breakfast tray for her groceries. The son indicated the resident did not have money. Review of Resident #200's progress note dated 09/26/23 at 2:26 P.M. indicated the resident was confused and forgetful and propelled herself in the wheelchair without difficulty. Review of Resident #200's progress note dated 09/26/23 at 4:15 P.M. indicated the police officer came to the facility due to the resident calling them and she had reported that her children were stealing her clothing and her belongings. The staff were unable to redirect the resident and the supervisor was aware. Review of Resident #200's progress note dated 09/26/23 at 5:02 P.M. indicated the resident called the police and stated her children were taking her belongings and selling them. The resident was confused to the month but was aware of the year and that she was at the nursing facility. Record review revealed no evidence of new fall/safety interventions being initiated following the changes in behavior/increased confusion exhibited by the resident on 09/26/23. Review of Resident #200's progress note dated 09/27/23 at 7:29 A.M. indicated at 4:00 A.M. the resident came out of her room and thought it was morning. The resident was re-educated, and she had returned to her room. At 5:00 A.M. the resident came out of the room and stated the STNA kicked her a**. When questioned, the resident stated it happened right at the time of the interview. The resident then lowered herself to the floor and started to crawl across the floor. Staff tried to encourage the resident to return to the wheelchair. She refused and started to roll down the hall. The Registered Nurse (RN) Supervisor was notified and able to get the resident back to her room. The resident refused the 6:45 A.M. neurological check and refused lab work. Record review revealed no evidence this incident was investigated or evidence interventions were initiated to prevent additional falls/promote resident safety. Review of Resident #200's progress note dated 09/27/23 at 11:52 A.M. revealed the resident was sent to the hospital via the emergency technicians (EMT) per the family's request for evaluation and treatment (due to the resident not acting herself). The resident did not return to the facility after being transferred to the emergency room. Review of Resident #200's hospital documentation dated 09/27/23 indicated the resident arrived to the emergency room on [DATE] at 12:30 P.M. and was evaluated in the trauma bay by the physician. The resident was able to move all of her extremities but had decreased range of motion in the bilateral lower extremities secondary to pain. X-ray of the chest did show possibility of rib fractures as well as a re-injury of her known pelvic fracture. Dedicated rib x-rays were obtained which showed evidence of non-displaced left rib fractures. Review of the hospital radiology report (one view chest x-ray), dated 09/27/23 at 12:38 P.M. indicated a slight cortical step-off of the left lateral 6th through 8th ribs. The impression included findings were suspicious for a nondisplaced left lateral 6th through 8th ribs and consider a rib series for further evaluation. Review of the hospital radiology report (two view rib x-ray), dated 09/27/23 at 2:15 P.M. indicated the resident had a slight cortical step-off of the left lateral second rib. Subtle cortical irregularity of the left lateral 4th and 5th ribs may be overlap of adjacent ribs on the x-ray. Previously described left lateral 6th through 8th rib step-off was not appreciated on this exam. The impression was a nondisplaced left lateral second rib fracture and questionable left 4th and 5th rib fractures versus artifacts. Interview on 11/03/23 at 6:26 A.M. with Licensed Practical Nurse (LPN) #803 indicated she took care of Resident #200 on (09/27/23) the day that she was sent out. She confirmed around 4:00 A.M., the resident came out of the room and was observed putting herself on the ground from the wheelchair. LPN #803 indicated both herself, STNA #804 and STNA #805 picked the resident back up and put her in a wheelchair. LPN #803 indicated she had assessed her following this incident and indicated the resident had no concerns with pain or injuries. LPN #803 indicated around five minutes later, the resident placed herself on the floor again and was screaming (this incident was not documented in the medical record progress note). LPN #803 stated the resident would not allow the STNAs and the nurse to pick her up to place her back in the wheelchair following the second fall. LPN #803 indicated she called the nursing supervisor to come see the resident, but Central Supply #808 came to the floor first and picked the resident up and placed her back in the wheelchair. Interview on 11/03/23 at 6:30 A.M. with STNA #804 indicated Resident #200 had come out of her room (on 09/27/23) in her wheelchair and stated STNA #805 had beat her up. She indicated the resident then placed herself on the floor and was yelling. STNA #804 confirmed Central Supply #808 put Resident #200 back in the chair the second time the resident was on the floor (on this date). Interview on 11/03/23 at 6:36 A.M. with STNA #805 indicated on 09/27/23 Resident #200 threw herself on the floor and LPN #803, STNA #804 and STNA #805 picked the resident up and placed her in the wheelchair. STNA #805 indicated five minutes later the resident was on the floor again and would not let the nursing staff pick her up so Central Supply #808 came and picked her up and put her back in the wheelchair. Interview on 11/03/23 at 7:09 A.M. with Central Supply #808 indicated he went upstairs to deliver linens and observed Resident #200 on the floor screaming. He stated at that point, he observed the nursing staff standing near the resident and the resident on the floor. He stated he went over and picked the resident up and placed her in the wheelchair. When questioned, he stated he picked up Resident #200 from the floor under both arms and placed her in her wheelchair. Interview on 11/03/23 at 7:17 A.M. with LPN Unit Manager (UM) #810 indicated she was called to the second floor because Resident #200 was crawling around on the floor. She indicated when she got to the unit, Resident #200 was already in her wheelchair, and she took the resident back to her room and completed neurological checks on the resident. She stated she did not observe any injuries. LPN UM #810 indicated later in the day, Resident #200's daughter wanted to take the resident home and requested the resident go to the emergency room for treatment. LPN UM #810 confirmed the resident did not return to the facility after being transferred to the hospital. Interview on 11/03/23 at 7:45 A.M. with the Administrator indicated Resident #200's son came to the facility and wanted to know about the fall as well as the rib fracture that was sustained following the fall on 09/27/23 per the hospital documentation. The Administrator indicated the resident had a history of falls and he felt it was an old rib fracture. Interview on 11/03/23 at 9:25 A.M. with the Administrator confirmed the facility did not identify the gradual change in Resident #200's mental status (following admission) and the facility did not have a fall investigation for resident falls that occurred after her admission on [DATE]. The Administrator verified the lack of evidence of new fall/safety interventions being initiated for the resident and also indicated he was not aware Central Supply #808 had picked the resident up off the floor when she sustained the second fall on 09/27/23. Review of the Fall Clinical Protocol policy revised 08/2008 indicated the staff and physician would continue to collect and evaluate information until either the cause of the fall was identified, or it was determined that the cause could not be found or that finding a cause would not change the outcome or the management of falling and fall risk. This deficiency represents non-compliance investigated under Complaint Number OH00147385.

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

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed record review, facility policy review, and interview the facility failed to notify Resident #200's family and ph...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed record review, facility policy review, and interview the facility failed to notify Resident #200's family and physician of changes in the resident's condition. This affected one resident (#200) of three residents reviewed for change in condition. Findings include: Review of Resident #200's hospital documentation dated 09/15/23 indicated the [AGE] year-old female presented with ongoing pain following a fall. The resident fell at home 09/14/23 and was evaluated in the emergency department (ER). She was diagnosed with a left superior pubic ramus fracture and possible left inferior pubic ramus fracture. The resident was neurovascularly intact, alert and oriented, and able to bear some weight but with pain. Review of Resident #200's closed medical record revealed the resident was admitted to the facility on [DATE] with diagnosis including a fracture of the superior rim of the left pubis, weakness and major depressive disorder. A plan of care, created 09/19/23 revealed Resident #200 was at risk for falls due to her history of falls prior to admission, her mental status and her general weakness. Interventions included but were not limited to, staff to report any falls to family/physician. Review of Resident #200's progress note dated 09/18/23 at 4:15 P.M., 09/19/23 at 6:24 A.M., 09/20/23 at 3:08 P.M., 09/21/23 at 3:37 A.M., 09/22/23 at 11:38 P.M., 09/23/23 at 12:50 P.M. and 09/24/23 at 6:42 A.M. noted the resident was alert and oriented (times two to three). Review of Resident #200's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment and required extensive two person assist for bed mobility, dressing, toilet use, personal hygiene and bathing as well as limited two person assist for transfers. Review of Resident #200's progress note dated 09/24/23 at 2:48 P.M. revealed the resident was alert with periods of confusion. The note did not indicate if this was a change for the resident or the resident's baseline orientation. Review of Resident #200's progress note dated 09/25/23 at 6:16 A.M. revealed the resident was agitated and confused during the shift, yelling at the State Tested Nursing Assistant (STNA) to get out of her apartment and calling the police that someone put something in her drink. Record review revealed no evidence the resident's physician or family were notified of this change in behavior. Review of Resident #200's progress note dated 09/25/23 at 6:00 P.M. indicated the STNA reported the resident was sitting in front of the bathroom. No injuries were noted. No change in range of motion (ROM) to all extremities or neurological checks were identified and the supervisor was notified. Review of the progress note revealed no evidence the resident's physician or family were notified of incident. A fall evaluation form completed by the facility on 09/25/23 revealed the resident had ROM of four quadrants without pain or limitation and the daughter was notified of the fall. Review of Resident #200's progress note dated 09/27/23 at 7:29 A.M. indicated at 4:00 A.M. the resident came out of her room and thought it was morning. The resident was re-educated, and she had returned to her room. At 5:00 A.M. the resident came out of the room and stated the STNA kicked her a**. When questioned, the resident stated it happened right at the time of the interview. The resident then lowered herself to the floor and started to crawl across the floor. Staff tried to encourage the resident to return to the wheelchair. She refused and started to roll down the hall. The Registered Nurse (RN) Supervisor was notified and able to get the resident back to her room. The resident refused the 6:45 A.M. neurological check and refused lab work. Record review revealed no evidence the resident's physician or family were notified of this change in behavior. Review of Resident #200's progress note dated 09/27/23 at 11:52 A.M. revealed the resident was sent to the hospital via the emergency technicians (EMT) per the family's request for evaluation and treatment. Review of Resident #200's progress note dated 09/27/23 at 5:00 P.M. revealed the daughter stated they were taking the resident home from the hospital and she would not return to the facility. Interview on 11/03/23 at 6:26 A.M. with Licensed Practical Nurse (LPN) #803 indicated she took care of Resident #200 on (09/27/23) the day that she was sent out. She confirmed around 4:00 A.M., the resident came out of the room and was observed putting herself on the ground from the wheelchair. LPN #803 indicated both herself, STNA #804 and STNA #805 picked the resident back up and put her in a wheelchair. LPN #803 indicated she had assessed her following this incident and the resident had no concerns with pain or injuries. LPN #803 indicated around five minutes later, the resident placed herself on the floor again and was screaming. LPN #803 stated the resident would not let the STNAs and the nurse pick her up to place her back in the wheelchair. LPN #803 indicated she called the nursing supervisor to come see the resident, but Central Supply #808 came to the floor first and picked the resident up and placed her back in the wheelchair. Interview on 11/03/23 at 6:36 A.M. with STNA #805 indicated (on 09/27/23) Resident #200 threw herself on the floor and herself as well as LPN #803 and STNA #804 picked the resident up and placed her in the wheelchair. STNA #805 indicated five minutes later the resident was on the floor again and would not let the staff pick her up so Central Supply #808 came on the floor and picked her up and put her back in the wheelchair. Interview on 11/03/23 at 7:45 A.M. with the Administrator confirmed Resident #200 had a change in mental status/falls and the physician or family were not notified timely of these changes/incidents. Review of the Change in a Resident's Condition or Status policy revised 08/2008 indicated the facility shall promptly notify the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status, changes in the level of care, billing/payments, resident rights etc. This deficiency represents non-compliance investigated under Complaint Number OH00147385.

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 F0659 (Tag F0659)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed record review, job qualification review, and interview the facility failed to ensure Resident #200 was transferr...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed record review, job qualification review, and interview the facility failed to ensure Resident #200 was transferred by an employee who was qualified to do so following a fall. This affected one resident (#200) of three residents reviewed for falls. Findings include: Review of Resident #200's closed medical record revealed the resident was admitted on [DATE] and discharged to the hospital on [DATE]. Resident #200 had diagnoses including a fracture of the superior rim of the left pubis, weakness and major depressive disorder. Review of Resident #200's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment and required extensive two person assist for bed mobility, dressing, toilet use, personal hygiene and bathing as well as limited two person assist for transfers. Review of Resident #200's progress note dated 09/27/23 at 7:29 A.M. indicated at 4:00 A.M. the resident came out of her room and thought it was morning. The resident was re-educated, and she had returned to her room. At 5:00 A.M. the resident came out of the room and stated the State Tested Nursing Assistant (STNA) kicked her a**. When questioned, the resident stated it happened right at the time of the interview. The resident then lowered herself to the floor and started to crawl across the floor. Staff tried to encourage the resident to return to the wheelchair. She refused and started to roll down the hall. The Registered Nurse (RN) Supervisor was notified and able to get the resident back to her room. The resident refused the 6:45 A.M. neurological check and refused lab work. Review of Resident #200's progress note dated 09/27/23 at 11:52 A.M. revealed the resident was sent to the hospital via the emergency technicians (EMT) per the family's request for evaluation and treatment. Interview on 11/03/23 at 6:26 A.M. with Licensed Practical Nurse (LPN) #803 indicated she took care of Resident #200 on (09/27/23) the day that she was sent out. She confirmed around 4:00 A.M., the resident came out of the room and was observed putting herself on the ground from the wheelchair. LPN #803 indicated both herself, STNA #804 and STNA #805 picked the resident back up and put her in a wheelchair. LPN #803 indicated she had assessed her following this incident and the resident had no concerns with pain or injuries. LPN #803 indicated around five minutes later, the resident placed herself on the floor again and was screaming. LPN #803 stated the resident would not let the STNAs and the nurse pick her up to place her back in the wheelchair. LPN #803 indicated she called the nursing supervisor to come see the resident, but Central Supply #808 came to the floor first and picked the resident up and placed her back in the wheelchair. Interview on 11/03/23 at 6:30 A.M. with STNA #804 indicated on 09/27/23 Resident #200 had come out of her room in her wheelchair and stated that STNA #805 had beat her up. She indicated the resident then placed herself on the floor and was yelling. STNA #804 confirmed Central Supply #808 put Resident #200 back in the chair the second time the resident was on the floor and the nursing supervisor came up and assessed the resident. Interview on 11/03/23 at 6:36 A.M. with STNA #805 indicated on 09/27/23 Resident #200 threw herself on the floor and herself as well as LPN #803 and STNA #804 picked the resident up and placed her in the wheelchair. STNA #805 indicated five minutes later the resident was on the floor again and would not let the staff pick her up so Central Supply #808 came on the floor and picked her up and put her back in the wheelchair. Interview on 11/03/23 at 7:09 A.M. with Central Supply #808 indicated he went upstairs to deliver linens and observed Resident #200 on the floor screaming. He stated at that point, he observed the nursing staff standing near the resident and the resident on the floor. He stated he went over and picked the resident up and placed her in the wheelchair. Interview on 11/03/23 at 7:45 A.M. with the Administrator indicated confirmed Central Supply #808 was not trained to transfer residents from the floor to the wheelchair. Review of the Central Supply Minimum Qualifications form dated 12/22/94 indicated the position included locations and work areas in which an incumbent in this position was expected to work in the inventory service area and throughout the facility. Essential functions of the job include maintaining the inventory levels by stocking shelves, organizing supplies, purchasing and maintaining vendor relationship, recommend and follow budget, maintain records of purchase, passing out medical, personal, general and incontinent supplies, unloading supplies deliveries and maintaining security on the locked cabinet. This deficiency represents non-compliance investigated under Complaint Number OH00147385.

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 F0740 (Tag F0740)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed record review, hospital record review, and interview the facility failed to identify and provide the necessary b...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed record review, hospital record review, and interview the facility failed to identify and provide the necessary behavioral health care and services to Resident #200 related to a substance abuse disorder to assist the resident to attain or maintain her highest practicable physical, mental and psychosocial well-being following admission for rehabilitation/treatment of a fall with fracture. This affected one resident (#200) of three residents reviewed for safety/falls. Findings include: Review of Resident #200's hospital documentation dated 09/15/23 indicated the [AGE] year-old female presented with ongoing pain following a fall. The resident fell at home 09/14/23 and was evaluated in the emergency department (ER). She was diagnosed with a left superior pubic ramus fracture and possible left inferior pubic ramus fracture. She had a dog at home, and she did not want to leave the dog alone, so she had insisted on going home with pain medication and a walker. She returned with pain that she was unable to manage. She had now arranged for somebody to take care of her dog and would like placement in a facility to recover from her injury. The pain was in her left groin and was rated an 8 out of 10 (on a scale of one to 10). She was neurovascularly intact, alert and oriented, and able to bear some weight but with pain. The resident's social history included beer daily with an average of one drink per day and marijuana daily. Review of Resident #200's hospital documentation dated 09/18/23 revealed the resident had pubic rami fractures and had a plan for (nursing home) placement. Today she indicated she was a heavy drinker and given a dose of the anti-anxiety medication, Ativan (anti-anxiety) prior to the assessment. No signs of withdrawal were noted and the note indicated would continue to monitor. Review of Resident #200's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including a fracture of the superior rim of the left pubis, weakness and major depressive disorder. Review of Resident #200's medical record did not reveal orders for alcohol withdrawal monitoring or treatment. There was no reference to the resident receiving Ativan at the hospital in relation to the resident indicating she was a heavy drinker. Review of the resident's baseline/acute plan of care revealed no care plan had been developed for the resident's substance abuse disorder or major depressive disorder. Review of Resident #200's progress note dated 09/18/23 at 4:15 P.M. indicated the resident arrived at the facility alert and oriented times two. Review of Resident #200's progress note dated 09/19/23 at 6:24 A.M. indicated the resident was alert and oriented times two. Review of Resident #200's progress note dated 09/20/23 at 3:08 P.M. indicated the resident was alert and oriented times two. Review of Resident #200's progress note dated 09/21/23 at 3:37 A.M. revealed the resident was alert and oriented. Review of Resident #200's progress note dated 09/22/23 at 11:38 P.M. revealed the resident was alert and oriented. Review of Resident #200's progress note dated 09/23/23 at 12:50 P.M. revealed the resident was alert and oriented times three. Review of Resident #200's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment and required extensive two person assist for bed mobility, dressing, toilet use, personal hygiene and bathing as well as limited two person assist for transfers. Review of Resident #200's progress note dated 09/24/23 at 6:42 A.M. revealed the resident was alert and oriented. Review of Resident #200's progress note dated 09/24/23 at 2:48 P.M. revealed the resident was alert with periods of confusion. Review of Resident #200's progress note dated 09/25/23 at 6:16 A.M. revealed the resident was agitated and confused during the shift, yelling at the State Tested Nursing Assistant (STNA) to get out of her apartment and calling the police that someone put something in her drink. Review of Resident #200's progress note dated 09/25/23 at 6:00 P.M. indicated the STNA reported the resident was sitting in front of the bathroom. Review of Resident #200's progress note dated 09/26/23 at 9:15 A.M. indicated the resident was extremely confused, stated she had $25.00 under her breakfast tray for her groceries. The son indicated the resident did not have money. Review of Resident #200's progress note dated 09/26/23 at 2:26 P.M. indicated the resident was confused and forgetful and propelled herself in the wheelchair without difficulty. Review of Resident #200's progress note dated 09/26/23 at 4:15 P.M. indicated the police officer came to the facility due to the resident calling them and she had reported that her children were stealing her clothing and her belongings. The staff were unable to redirect the resident and the supervisor was aware. Review of Resident #200's progress note dated 09/26/23 at 5:02 P.M. indicated the resident called the police and stated her children were taking her belongings and selling them. The resident was confused to the month but was aware of the year and that she was at the nursing facility. Review of Resident #200's progress note dated 09/27/23 at 7:29 A.M. indicated at 4:00 A.M. the resident came out of her room and thought it was morning. The resident was re-educated, and she had returned to her room. At 5:00 A.M. the resident came out of the room and stated the STNA kicked her a**. When questioned, the resident stated it happened right at the time of the interview. The resident then lowered herself to the floor and started to crawl across the floor. Staff tried to encourage the resident to return to the wheelchair. She refused and started to roll down the hall. The Registered Nurse (RN) Supervisor was notified and able to get the resident back to her room. The resident refused the 6:45 A.M. neurological check and refused lab work. Review of Resident #200's progress note dated 09/27/23 at 11:52 A.M. revealed the resident was sent to the hospital via the emergency technicians (EMT) per the family's request for evaluation and treatment (due to the resident not acting herself). Interview on 11/03/23 at 6:26 A.M. with Licensed Practical Nurse (LPN) #803 indicated she took care of Resident #200 on (09/27/23) the day that she was sent out. She confirmed around 4:00 A.M., the resident came out of the room and was observed putting herself on the ground from the wheelchair. LPN #803 indicated around five minutes later, the resident placed herself on the floor again and was screaming. LPN #803 stated the resident would not allow the STNAs and the nurse to pick her up to place her back in the wheelchair following the second fall. LPN #803 indicated she called the nursing supervisor to come see the resident, but Central Supply #808 came to the floor first and picked the resident up and placed her back in the wheelchair. Interview on 11/03/23 at 6:30 A.M. with STNA #804 indicated Resident #200 had come out of her room (on 09/27/23) in her wheelchair and stated that STNA #805 had beat her up. She indicated the resident then placed herself on the floor and was yelling. Interview on 11/03/23 at 6:36 A.M. with STNA #805 indicated on 09/27/23 Resident #200 threw herself on the floor the first time and LPN #803, STNA #804 and STNA #805 picked the resident up and placed her in the wheelchair. STNA #805 indicated five minutes later the resident was on the floor again and would not let the nursing staff pick her up so Central Supply #808 came on the floor and picked her up and put her back in the wheelchair. Interview on 11/03/23 at 7:17 A.M. with LPN Unit Manager (UM) #810 indicated she was called to the second floor because Resident #200 was crawling around on the floor. She indicated when she got to the unit, Resident #200 was already in her wheelchair. Interview on 11/03/23 at 9:25 A.M. with the Administrator confirmed the facility did not identify the gradual change in Resident #200's mental status (following admission). There was no evidence the facility identified and implemented a comprehensive and individualized plan to address the resident's substance abuse disorder prior to admission to ensure the resident attained/maintained her highest physical, mental and psychosocial well-being. This deficiency is an incidental finding to Complaint Number OH00147385.

Aug 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

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · 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 facility self-reported incident review, record review, policy review, resident interview and staff interview the facility failed to ensure Resident #1 was free from staff to resident verbal abuse. This affected one resident (#1) of three residents reviewed for abuse. The facility census was 150. Findings include: Review of facility self-reported incident (SRI) #237331 revealed on 07/21/23 a verbal altercation occurred between Resident #1 and Licensed Practical Nurse (LPN) #205. The incident was immediately reported to the shift supervisor who notified the facility Administrator and Director of Nursing (DON). The incident was reported to Ohio Department of Health on 07/21/23. Further review of the facility SRI and facility investigation revealed a statement from Resident #1 was obtained on 07/24/23 which indicated LPN #205 entered her room with medications, inhaler, and cup of water. Resident #1 indicated LPN #205 brought very little water, and Resident #1 told LPN #205 with an attitude she needed additional water. LPN #205 gave the resident attitude back. Resident #1 yelled at LPN #205 to leave her room, but LPN #205 would not leave. Resident #1 stated she got up out of bed and she pushed LPN #205. Resident #1 indicated staff members entered the room to check on the incident. LPN #205 refused to provide any additional details in her statement at this time. Review of State Tested Nurse Aide (STNA) #211's witness statement obtained on 07/21/23 indicated she was at the unit nurse's station when she heard Resident #1 screaming at the top of her lungs. STNA #211 indicated when she arrived at the room, LPN #205 and Resident #1 were arguing back and forth about water. She further indicated they called each other [expletive], fat [expletive], and kept going. She indicated LPN #205 did not walk away, she stayed and argued with Resident #1. She further indicated that LPN #205 told Resident #1 she belonged on the Taft unit (secured behavior unit). Review of STNA #219's witness statement obtained on 07/21/23 indicated she was at the unit nurse's station when she heard Resident #1 screaming. STNA #219 indicated Resident #1 and LPN #205 were going back and forth, Resident #1 called LPN #205 a fat [expletive]. STNA #219 and STNA #211 got in between Resident #1 and LPN #205. Resident #1 got out of her bed and attacked LPN #205. LPN #205 stood there and told Resident #1 your [expletive] hits don't hurt and that [expletive] needs to be on Taft (secured behavior unit). Review of LPN #205's undated witness statement indicated she entered Resident #1's rooms with her medications and inhaler. Resident #1 said something she couldn't hear and asked her what she said. Resident #1 then screamed at her she needed more water. LPN #205 indicated she told Resident #1 she didn't need to scream at her. Resident #1 then threw the water on LPN #205 and called her a fat [expletive]. LPN #205 asked Resident #1 if she was going to take her medications and Resident #1 threw her medications on the floor, jumped out of her bed, and started to attack LPN #205. LPN #205 indicated Resident #1 was punching and grabbing her. Resident #1 grabbed her arm and twisted it behind her telling her I'm going to break this mother [expletive]. Resident #1 called LPN #205 a fat [expletive] and continued to hit her. STNAs #211 and #219 entered the room at some point, but she was unsure of when. LPN #205 indicated she did not call Resident #1 any names until she started hitting her. Review of Resident #1's medical record revealed an admission date of 02/13/14 with diagnoses including schizoaffective disorder, anxiety disorder, and major depression. Further review of Resident #1's medical record including the Minimum Data Set (MDS) 3.0 annual assessment dated [DATE] revealed an independent cognition level. Interview with Resident #1 on 08/11/23 at 11:08 A.M. revealed a few weeks ago she had a verbal altercation with a nurse during evening medication pass. She didn't bring in enough water and she yelled at the nurse, the nurse wouldn't leave, so she jumped out of bed and pushed her. They called each other names back and forth until the STNAs broke it up. Interview with the facility Administrator on 08/11/23 at 10:45 A.M. verified a verbal abuse incident between Resident #1 and LPN #205. Review of the facility policy titled Abuse Prevention Program, dated 02/2017, revealed the facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of the residents. The deficient practice was corrected on 08/02/23 when the facility implemented the following corrective actions: • LPN #205 was suspended on 07/21/23 and terminated on 07/25/23. • Staff witness statements were obtained on 07/21/23. • An SRI was created on 07/21/23. • An SRI investigation was completed on 07/28/23. • Resident #1 was provided with counseling services. • Resident #1's psychologist and psychiatrist were made aware of the incident. • All staff abuse prevention education was completed by 07/26/23. • All current residents in the facility were interviewed for abuse/mistreatment by 08/02/23. • On-going audits and monitoring were completed for abuse/mistreatment. This deficiency represents non-compliance investigated under Complaint Number OH00145146.

May 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

Deficiency F0558 (Tag F0558)

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 call lights were within resident reach. This affected one resid...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to ensure call lights were within resident reach. This affected one resident (Resident #76) of 32 residents observed for call light accessibility. The facility census was 148. Findings include: Record review revealed Resident #76 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder, hypertension, type two diabetes mellitus, major depressive disorder, and chronic obstructive pulmonary disease. Observation on 04/24/23 at 10:37 A.M. revealed Resident #76's call light was coiled up and zip tied together, hanging against the wall and out of the resident's reach. Interview at the time of the observation with Resident #76 revealed she did not know how long the call light had been hanging that way. Interview on 04/24/23 at 10:40 A.M. with Licensed Practical Nurse (LPN) #556 confirmed Resident #76's call light was coiled up and zip tied hanging against the wall, out of Resident #76's reach. LPN #556 verified Resident #76 would not have access to the call light in an emergency and did not know how long it was coiled up and zip tied. This deficiency represents non-compliance investigated under Complaint Number OH00135062.

CONCERN (D)

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

Deficiency F0602 (Tag F0602)

Could have caused harm · This affected 1 resident

Based on self-reported incident review, medical record review, policy review and staff interview, the facility failed to ensure narcotic medications were not misappropriated by staff members. This aff...

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Based on self-reported incident review, medical record review, policy review and staff interview, the facility failed to ensure narcotic medications were not misappropriated by staff members. This affected three residents (Residents #68, #99 and #111) of five residents reviewed for misappropriation. The facility census was 148. Findings include: Review of the facility Self-Reported Incident (SRI) #230289 with a created date of 12/19/22 revealed Licensed Practical Nurse (LPN) #701 alleged Registered Nurse (RN) #658 was possibly misappropriating resident narcotic medications. Further review of SRI #230289 and the facility investigation found that RN #658 misappropriated narcotic medications from Residents #68, #99 and #111. Further review of SRI #230289 revealed RN #658 was also identified in an SRI for another facility in 2017 with the allegation of misappropriation of resident narcotics. The SRI was substantiated and RN #658 was terminated from the other facility 1. Facility investigation determined RN #658 misappropriated three narcotic medications on 12/17/22 from Resident #68. Review of Resident #68's medical record including controlled drug receipt/record disposition form revealed misappropriation of narcotic medications on: a. RN #658 forged the signature of LPN #701, who was not working the resident unit at the time of administration, on Resident #68's controlled drug receipt/record/disposition form. Oxycodone (narcotic opioid analgesic medication) five milligrams (mg) was administered on 12/17/22 at 10:45 (no indication A.M. or P.M.). b. RN #658 forged the signature of LPN #604, who was not working the day of administration, on Resident #68's controlled drug receipt/record/disposition form Oxycodone five mg was administered on 12/17/22 at 4:45 (no indication of A.M. or P.M.). c. RN #658 documented on Resident #68's controlled drug receipt/record/disposition form Oxycodone five mg was administered on 12/17/22 at 10:45 (no indication of A.M. or P.M.). Medication was previously documented as administered, see example 1 a. 2. Facility investigation determined RN #658 misappropriated narcotic medication on 12/16/22 for Resident #99. Review of the Resident #99's controlled drug receipt/record/disposition form revealed a fictitious/unknown staff member signed out Oxycodone five mg for Resident #99 on 12/16/22 at 8:00 P.M. RN #658 was working Resident's #99's unit at the time of documented administration. 3. Facility investigation determined that on 12/17/22 at 3:00 P.M. and 10:00 P.M. LPN #604 administered hydrocodone/acetaminophen (narcotic opioid analgesic medication) to Resident #111. The facility determined that LPN #604 was not working at the time of documented administration and also that Resident #111 was on a leave of absence from the facility during the time of administration. RN #658 forged the signature of a different staff member, LPN #604, when administering. On 04/27/23 at 10:20 A.M. interview with the Administrator and Director of Nursing verified RN #658 was misappropriating resident narcotic medications by signing out resident narcotic medications using other staff names when the staff were not in the building, working the unit of the resident for administration, using a fictitious/unknown staff member name and documenting administration of narcotic pain medications to residents while on leave from the facility. Continued interview revealed RN #658 resigned before the facility could get her statement for the investigation. Review of the facility policy Abuse Prevention Program with a revision date of 02/07/17 indicated this facility desires to prevent abuse, neglect, exploitation, mistreatment and misappropriation of resident property by establishing a resident sensitive and resident secure environment.

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

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

Based on observation, record review and interview the facility failed to ensure residents received the assistance needed for activities of daily living (ADLs). This affected two residents (Resident #8...

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Based on observation, record review and interview the facility failed to ensure residents received the assistance needed for activities of daily living (ADLs). This affected two residents (Resident #89 and #143) of three residents reviewed for ADLs. The census was 148. Findings Include: 1. Review of the medical record for Resident #89 revealed an admission date of 09/14/22. Diagnoses included the need for assistance with personal care, vitreous hemorrhage (blood in the space between the eye's lens and retina), bilateral cataracts, bipolar disorder, anxiety disorder, major depressive disorder, and diabetes with neuropathy. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/31/23, revealed the resident had moderately intact cognition, severely impaired vision, and minimally impaired hearing. Behaviors included delusions and verbal behavioral symptoms directed at others. The resident required the extensive assistance of two staff for transfers. The resident was totally dependent for locomotion, dressing, and personal hygiene. The extensive assistance of one staff was needed for eating and toilet use. Bathing did not occur. Interview on 04/24/23 at 12:07 P.M. with Resident #89 revealed he was blind, very hard of hearing, couldn't walk, and had such bad neuropathy in his hands he couldn't feel anything. The resident stated he hadn't had a shower, or had his hair washed in seven weeks. Review of the point of Care History from 03/01/23 through 04/30/23 revealed no record of the resident receiving a shower or bath. Review of the Bath/Shower sheets for March and April 2023 for Resident #89 revealed in March there were two days where the state tested nursing assistant (STNA) and nurse had signed. In April the was one refusal and two days with only a nurse signature and treatment in place was noted. It was not clear if Resident #89 was bathed or showered those days. Interview on 05/01/23 at 1:22 P.M. with Registered Nurse (RN) #518 verified showers had not occurred as scheduled for Resident #89 after reviewing the Bath/Shower sheets and the point of care history. 2. Review of the medical record for Resident #143 revealed an admission date of 10/04/22. Diagnoses included cerebral infarction, polyarthritis, and the need for assistance with personal care. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/06/23, revealed the resident had moderately impaired cognition. Interview and observation on 04/24/23 at 11:38 A.M. with Resident #143 revealed the resident's fingernails were long on both hands. The fingernails on the left hand were thick, long and dark colored. The resident stated he had tried to cut them with his toenail cutter but could not get through them. Interview on 04/26/23 at 10:03 A.M. with LPN #615 verified Resident #143's fingernails on his left hand were thick and long and the fingernails on his right hand needed to be soaked and cut. Review of the Care of Fingernails/Toenails policy and procedure dated 04/07 revealed nail care included daily cleaning and regular trimming. Stop and report to the nurse supervisor if there is evidence of ingrown nails, infections, pain, or if nails are too hard or too thick to cut with ease. This deficiency represents non-compliance investigated under Complaint Number OH00135062.

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

Based on medical record review, staff interview and policy review, the facility failed to monitor resident weights as ordered by the physician. This affected one (Resident #138) of three residents rev...

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Based on medical record review, staff interview and policy review, the facility failed to monitor resident weights as ordered by the physician. This affected one (Resident #138) of three residents reviewed for weight loss. The facility census was 148. Findings include: Review of Resident #138's medical record revealed an admission date of 11/12/22 with diagnoses that included Alzheimer's disease with dementia, hypothyroidism and hypertension. Review of the physician's orders dated 11/12/22 revealed to obtain weekly weights for four weeks then monthly. Review of Resident #138's weight records revealed weights were obtained on 11/12/22 and then on 12/02/22. There was no evidence of any additional weights obtained between 11/12/22 and 12/02/22. On 04/27/23 at 11:35 A.M. interview with the Director of Nursing verified weights were not obtained per physician's orders following admission. Review of the facility policy Weight Assessment and Intervention with a revision date of 08/2008 indicated nursing staff will measure resident weight on admission and weekly for three weeks thereafter. If no weight concerns are noted at this point, weight will be measured monthly thereafter. This deficiency represents non-compliance investigated under Complaint Number OH00135062.

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 F0728 (Tag F0728)

Could have caused harm · This affected most or all residents

Based on review of personnel files, review of schedules and interview, the facility failed to ensure employees who completed a Nurse Aide Training and Competency Evaluation program successfully comple...

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Based on review of personnel files, review of schedules and interview, the facility failed to ensure employees who completed a Nurse Aide Training and Competency Evaluation program successfully completed state testing within the appropriate time frames. This had the potential to affect all 148 residents residing in the facility. Findings include: On 04/25/23 at 10:25 A.M., review of personnel files with Human Resources (HR) Director #520 verified Helping Hand #528 completed a nurse aide training course on 10/26/22. HR #520 stated Helping Hand #528 had taken part of the state test but had not successfully completed both portions of the two part test. HR Director #520 indicated Helping Hand #528 remained on the schedule as a nursing assistant. On 04/25/23 at 2:13 P.M., HR Director #520 provided the name of a second aide, Helping Hand #541 who completed her nurse aide training classes on 11/22/22 but broke her wrist and was off work from January 2023 to 03/22/23 and was still working as an aide. Review of schedules from 03/25/23 to 04/25/23 revealed the following: Helping Hand #528 worked as a nursing assistant on 03/26/23, 03/28/23, 03/29/23, 03/31/23, 04/03/23, 04/04/23, 04/05/23, 04/06/23, 04/07/23, 04/08/23, 04/11/23, 04/12/23, 04/14/23, 04/17/23, 04/20/23, 04/21/23, 04/22/23, 04/23/23 and 04/24/23. , Helping Hand #541 worked as a nursing assistant on 03/27/23, 03/28/23, 03/30/23, 04/01/23, 04/02/23, 04/06/23, 04/07/23, 04/10/23, 04/11/23, 04/13/23, 04/15/23, 04/17/23, 04/19/23, 04/21/23, and 04/24/23. On 05/01/23 at 12:55 P.M., Registered Nurse (RN) #508 stated when aides had worked four months after their certificate for nurse aide training programs were completed, she relied on HR Director #520 or Scheduler #509 to inform her the employee could no longer work as a nurse aide pending successful completion of the state testing. RN #508 indicated Helping Hands #528 and #541 would have worked as nursing assistants if their names were listed beside a section on the schedule. This deficiency represents non-compliance investigated under Complaint Number OH00135062.

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 observation and staff interview the facility failed to ensure the kitchen was maintained in a clean and sanitary condition. This had the potential to affect the 147 residents receiving food f...

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Based on observation and staff interview the facility failed to ensure the kitchen was maintained in a clean and sanitary condition. This had the potential to affect the 147 residents receiving food from the facility. The facility identified Resident #55 as receiving no food by mouth. The facility census was 148. Findings include: Observation of the kitchen during the initial tour on 04/24 23 starting at 9:41 A.M. with Dietary Manager (DM) #519 revealed the following concerns: • The tiled floors were discolored with ground in dirt and wax, giving a darkened appearance. The grout between the tiles was also darkened and needing cleaned. • The microwave was dirty with food spills inside • The dish-machine needed to be wiped down. There were crumbs and dust on top with detergent spills down the sides. • The spice table had dried spills down the side. • The stove top was dusty/dirty, and the knobs of the stove were sticky to touch. • The ice machine had a pink gritty substance on the inside of the lid. • There was a large container of cereal not labeled or dated in dry storage and a bag of frozen omelets not labeled and dated in the freezer. • There were three sour cream containers and crates of individual chocolate milk cartons that were outdated. DM #519 verified the above findings at the time of observation.

CONCERN (F)

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

Garbage Disposal (Tag F0814)

Could have caused harm · This affected most or all residents

Based on observation and staff interview the facility failed to ensure the dumpster area was maintained in a clean and sanitary condition. This had the potential to affect all residents. The facility ...

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Based on observation and staff interview the facility failed to ensure the dumpster area was maintained in a clean and sanitary condition. This had the potential to affect all residents. The facility census was 148. Findings include: Observation of the facility's dumpster area on 04/24 23 at 9:41 A.M. with Dietary Manager (DM) #519 revealed the following concerns: a. Three of six dumpster lids were not closed. b. There was a large bag of trash outside the dumpsters with miscellaneous gloves, papers, and other trash on the ground. DM #519 verified the above findings at the time of observation.

Jan 2020 9 deficiencies

CONCERN (D)

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 observation, record review and interview the facility failed to assess, monitor and treat Resident #20's left lower leg...

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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 assess, monitor and treat Resident #20's left lower leg scar and wounds. This affected one out of three residents reviewed for skin issues. Findings include: Resident #20 was admitted on [DATE] with diagnoses including heart disease, traumatic brain injury following a motor vehicle accident, schizophrenia, dementia, morbid obesity and cognitive communication deficit. An interview with Resident #20 on 01/12/20 at 10:41 A.M. indicated he had sustained an injury to his lower left leg and had developed a clot from a car accident in the past. An observation at the time of the interview revealed Resident #20's left lower leg had a large discolored scarred area (approximately 4 centimeters wide by 6 centimeters long) with two scabbed areas on each end of the scar. The scarred skin had skin that was peeling off in powdery flakes. Review of Resident #20's nursing assessments and physician assessments dated 09/01/2019 to 01/13/20 revealed no documentation or his left lower leg wounds or scar. Resident #20's clinical record had no plan of care or interventions to care for the left lower leg scar or scabbed areas/wounds. An interview with Licensed Practical Nurse (LPN) #709 on 01/13/20 at 2:20 P.M. verified there was no treatment ordered by the physician to care for Resident #20's left lower leg scar and wounds. An observation and interview with Resident #20 with LPN #709 present, at the time of the interview, verified his left lower leg scar was flaking and had two scabbed areas on each end of the scar. Resident #20 indicated the scar bothered him sometimes and he said he rubbed and scratched the area due to pain and itching. LPN #709 indicated Resident #20 had not complained to her about the scarred area and said she hadn't noticed the scar with two scabbed areas and flaking. LPN #709 agreed some kind of skin treatment needed ordered to care for these areas. An interview with the Director of Nursing on 01/13/20 at 3:30 P.M. verified the above findings.

CONCERN (D)

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** 2. Review of Resident #78's medical record revealed an admission to the facility on [DATE] with diagnoses including aspiration p...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #78's medical record revealed an admission to the facility on [DATE] with diagnoses including aspiration pneumonia, weakness and anemia. Review of Resident #78's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident had a memory impairment. Review of Resident #78's physician orders revealed an order dated 01/02/20 for nursing staff to cleanse the coccyx pressure ulcer with wound cleanser, apply a nickel-thick amount of Santyl ointment (a debriding agent) and cover with Calcium Alginate (absorbent agent) and a foam dressing daily and as needed. Observation on 01/13/20 at 3:07 P.M. with Licensed Practical Nurse (LPN) #803 revealed the resident was turned to complete the pressure ulcer care. There was no dressing to Resident #78's coccyx pressure ulcer. Resident #78 was observed lying on a sheet saturated with urine. There was no dressing observed in the bed or on the floor. Interview on 01/13/20 at 3:15 P.M. with LPN #803 confirmed Resident #78's wound care dressing was not in place at the time of the observation and he was unable to determine how long the resident had been lying on the urine soaked sheets without a dressing to cover the coccyx pressure ulcer. LPN #803 confirmed there was no dressing in the bed or on the floor at the time of the observation. Interview on 01/14/20 at 10:30 A.M. with Registered Nurse (RN)/Assistant Director of Nursing (ADON) #804 confirmed she was not informed by care staff that Resident #78's wound care dressing had been removed or come off. RN/ADON #804 indicated she was unaware of how long Resident #78 lay in the urine soiled bedding with no dressing on his coccyx ulcer. Based on observation, record review and interview the facility failed to ensure Resident #47's and Resident #78's pressure ulcer treatments were provided as ordered by the physician. This affected two out of three residents reviewed for pressure ulcers. Findings include: 1. Resident #47 was admitted on [DATE] with diagnoses including hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following a cerebral vascular accident (stroke)affecting the non-dominant side, respiratory disease, heart disease, Alzheimer's disease, schizophrenia, anxiety and depression. Review of Resident #47's wound assessment dated [DATE] indicated a stage III pressure ulcer (a full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to underlying fascia and presents as a deep crater with or without tunneling or undermining of adjacent tissue) on the left heel measuring 0.5 centimeters (cm) long by 2.0 cm wide and 0.2 cm deep. The wound assessment dated [DATE] indicated a stage III pressure ulcer was present on his/her coccyx area and measured 0.4 centimeters (cm) long by 0.1 cm wide and 0.2 cm deep. A review of Resident #47's physician orders dated 01/01/20 to 01/31/20 revealed an order dated 01/08/20 for a wound treatment to the left heel and coccyx pressure ulcers. The physician orders directed nursing staff to cleanse the left heel ulcer with wound cleanser and apply skin prep spray and cover with Tegaderm foam adhesive dressing daily and as needed. The other treatment was to cleanse the coccyx ulcer with wound cleanser and apply Medi-honey and cover with foam Tegaderm adhesive dressing once a day. An observation on 01/15/20 at 10:58 A.M. of Resident #47's incontinence care, performed by State Tested Nursing Assistant (STNA) #401 and STNA #609, revealed no dressing covering the coccyx ulcer and the left heel dressing was dated 01/13/20. STNA #401 and STNA #609 verified these observations. Review of Resident #47's treatment administration record (TAR) from 01/01/20 to 01/31/20, with the Assistant Director of Nursing (ADON), revealed Resident #47's left heel and coccyx pressure ulcer treatments were not signed as completed by nursing staff on 01/14/20.

CONCERN (D)

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

Deficiency F0761 (Tag F0761)

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 insulin vials were dated when opened. This aff...

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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 insulin vials were dated when opened. This affected one Resident (#110) out of five residents reviewed for insulin storage on the [NAME] unit. The facility census was 167. Findings include: Review of the medical record revealed Resident #110 was admitted on [DATE] with diagnoses including diabetes mellitus. Review of physician orders for January 2020 revealed Resident #110 was ordered Levemir (insulin) 26 units, injected subcutaneously (SQ), at bedtime, Novolog (insulin) 25 units SQ in the morning, 13 units SQ in the afternoon, and 16 units SQ in the evening. Observation on 01/15/20 at 11:06 A.M. of the medication cart on the [NAME] unit revealed open vials of Levemir and Novolog insulin for Resident #110. There were no dates on these insulin vials to indicate the date they were opened. Interview on 01/15/20 at 11:06 A.M. with Registered Nurse #600 verified Resident #110's Levemir and Novolog insulin vials were open and undated. This concern was verified with the nurse. Review of the pharmacy list of expiration dates for insulin revealed Levemir insulin expires 42 days after the vial was opened and Novolog insulin expires 28 days after the vial was opened.

CONCERN (D)

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

Medical Records (Tag F0842)

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 #110's medical record included documen...

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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 #110's medical record included documentation the resident was provided wine per the physician order. This finding affected one (Resident #110) of thirty-five resident records reviewed for documentation. Findings include: Review of Resident #110's medical record revealed the resident was admitted on [DATE] with diagnoses including schizoaffective disorder, diabetes and anxiety. Review of Resident #110's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident exhibited moderate cognitive impairment. Review of Resident #110's physician order dated 05/13/19 indicated the resident may have a glass of wine with dinner once a day as needed and the family was to provide the wine. Review of Resident #110's medication administration record (MAR) from 01/01/20 to 01/15/20 did not reveal evidence the resident received the wine. Interview on 01/12/20 at 12:39 P.M. with Resident #110 indicated she should have wine every night after dinner and sometimes she did not receive the wine. Observation of the medication storage room on 01/15/20 at 10:18 A.M. with Registered Nurse (RN) #801 revealed 13 bottles of Sutter Home Sweet Riesling California Wine, single serve size bottles, 187 milliliters each, which is just over six ounces each. Interview on 01/15/20 at 10:28 A.M. with Resident #110's guardian confirmed she delivered 16 bottles of wine to the facility on [DATE]. Although 16 bottles of wine were delivered on 01/10/20, there were only 13 bottles of wine remaining and there was no documentation to indicate wine was provided to Resident #110 in January 2020. Interview on 01/15/20 at 10:40 A.M. with the Director of Nursing (DON) confirmed the facility staff should be charting on the MAR when Resident #110 received the wine. She said nursing staff had been providing the resident the wine upon request and confirmed the resident's medical record did not reflect the resident's actual wine consumption.

CONCERN (E)

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

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected multiple residents

Based on observation, interview, and record review, the facility failed to provide the residents on the Taft unit with appropriate water containers. This affected Resident #68 and Resident #316 and af...

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Based on observation, interview, and record review, the facility failed to provide the residents on the Taft unit with appropriate water containers. This affected Resident #68 and Resident #316 and affected 25 of 26 other residents on the Taft unit, Residents #10, #29, #30, #33, #42, #43, #52, #61, #83, #85, #86, #88, #89, #95, #96, #104, #105, #117, #126, #135, #136, #146, #160, #162, and #420. Resident #9 received thickened liquids and was not permitted a water pitcher/cup. The facility census was 167. Finding include: Observation on 01/12/20 from 9:58 A.M. through 11:51 A.M. revealed residents on the Taft unit did not have water pitchers or dedicated cups for water in their rooms. No individual water pitchers or large cups were noted in the common areas. A water pitcher with small clear plastic cups was at the nurse's station for residents to get water. Interview on 01/12/20 at 10:32 A.M. with Resident #68 revealed she saved used pop bottles to put water in for her room. An observation at that time revealed Resident #68 had a pop bottle with water on her over bed table. No water pitcher or water cups were noted in her room. Interview on 01/13/20 at 11:58 A.M. with Resident #316 revealed his family brought him food and a beverage from an outside restaurant. Resident #316 stated he was keeping his cup so he could put water in it to keep in his room. No water pitcher or water cups were noted in his room. Interview on 01/13/20 at 1:25 P.M. with Resident #4, during the resident council meeting, revealed all residents were not provided individual cups or water pitchers. Resident #4 stated some residents had to go to the nurse's station to ask for water. Interview on 01/14/20 at 8:38 A.M. with State Tested Nursing Assistant (STNA) #411 revealed residents had water pitchers but often left them sitting around where other residents could take them. STNA #411 stated there was a resident on the Taft unit that received thickened liquids so it was not safe for residents to leave their water pitchers or cups sitting in the common areas. STNA #411 verified Resident #9 was the only resident on the Taft unit that received thickened liquids and would not have a water pitcher or cup provided at the bedside. Interview on 01/14/20 at 8:43 A.M. with Licensed Social Worker (LSW) #200 confirmed there were not individual water pitchers for residents on the Taft unit because there were residents with orders for thickened liquids. Interview on 01/14/20 at 11:59 A.M. with the Director of Nursing (DON) revealed she was not sure why there were no individual water pitchers or cups provided for residents on the Taft unit. The DON stated it could be because of residents with fluid restrictions, thickened liquids, or behaviors. Review of the policy and procedure for Serving Drinking Water, dated August 2008, revealed the purpose was to provide residents with a fresh supply of drinking water and to provide adequate fluids for the residents. The necessary equipment and supplies included a water pitcher and cup.

CONCERN (E)

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

Deficiency F0730 (Tag F0730)

Could have caused harm · This affected multiple residents

Based on record review and interview the facility failed to ensure all state tested nurse aides (STNAs) completed twelve hours of in-service education annually. This affected one of three STNA's revie...

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Based on record review and interview the facility failed to ensure all state tested nurse aides (STNAs) completed twelve hours of in-service education annually. This affected one of three STNA's reviewed who had been employed greater than one year. This had the potential to affect all 28 residents residing on the Taft unit, Residents #9, #10, #29, #30, #33, #42, #43, #52, #61, #68, #83, #85, #86, #88, #89, #95, #96, #104, #105, #117, #126, #135, #136, #146, #160, #162, #316 and #420. The facility census was 167. Findings include: Review of the personnel record for STNA #407 revealed a hire date of 04/08/16. There was no documentation found to indicate STNA #407 had received at least 12 hours of continuing education for the last annual period of 04/08/18 through 04/08/19 as required. On 01/15/20 at 1:35 P.M., interview with the Human Resource (HR) Director confirmed STNA #407 did not have any paper documenting of continuing education in the personnel file for the review period. The HR Director said staff also uses the computer based education program called Relias to complete continuing education. Review of the completed education on the Relias program for STNA #407 revealed no education was completed for the review period. This was verified at that time with the HR director. STNA #407 was assigned to work on the Taft unit which had 28 residents, Residents #9, #10, #29, #30, #33, #42, #43, #52, #61, #68, #83, #85, #86, #88, #89, #95, #96, #104, #105, #117, #126, #135, #136, #146, #160, #162, #316 and #420.

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 observation and interview the facility failed to maintain the kitchen in a sanitary manner. This affected 166 of 167 residents residing in the facility. Resident #78 was identified as ordered...

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Based on observation and interview the facility failed to maintain the kitchen in a sanitary manner. This affected 166 of 167 residents residing in the facility. Resident #78 was identified as ordered nothing by mouth to eat or drink. Findings include: Observation of the kitchen was conducted during the initial tour on 01/12/20 from 8:30 A.M. to 9:00 A.M. with Dietary Manager #102. The following concerns were observed and verified with Dietary Manager #102 at that time: 1. There was a soiled cleaning cloth hanging on the side of a plastic storage container. Inside the storage container were clean scoops and a zip-lock bag of saltine crackers. The Dietary Manager #102 indicated the container was for resident snacks and verified the soiled cloth should not be there. 2. There was a steel pan with slices of bread covered with plastic wrap which was not dated. Dietary Manger #102 indicated they were drying the bread for bread crumbs but verified the bread should have been dated. 3. There was a drain in front of the ovens with a steel cover which was visibly dirty underneath with food debris and leaves. 4. There were no lids on either of the two trash cans. 5. There was a plastic tub with the clean steel steam table lids in it. The tub was littered with food debris and small pieces of paper. There was a trash can without a lid right beside this shelf. Dietary Manger #102 indicated he did not know why the trash can was placed right beside the clean steam table pans and lids. 6. There was a four tier black cart, two gray three tier carts (one had the cartons of milk on it being served to the residents) and a small three tier steel cart. All of the carts were soiled with dried liquid spills and food debris. 7. There were two gray meal tray transportation carts and one steel meal tray transportation cart. They had visible dirt with dried food and dried liquid spills on the inside and outside. 8. In the salad refrigerator, there was one plastic container of sliced black olives and one plastic container of sliced onions covered with plastic wrap. They were not dated when opened/cut. 9. There was a five pound container of cottage cheese with the expiration date 01/05/20 in the walk-in refrigerator. 10. There was a pack of hot dog buns on the bread rack with green mold observed on the buns. 11. There was an old used tea bag laying on the the dish rack where the clean dishes are stored after they come out of the dish washer.

MINOR (C)

Minor Issue - procedural, no safety impact

Transfer Notice (Tag F0623)

Minor procedural issue · This affected most or all residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure Residents #78 and #167 were notified in writing the reason f...

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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 Residents #78 and #167 were notified in writing the reason for the discharge in an easily understood language. This affected two (Residents #78 and #167) of four resident records reviewed for hospitalization and had the potential to affect all 168 residents residing in the facility. Findings include: 1. Review of Resident #78's medical record revealed the resident was admitted to the facility on [DATE], discharged to the hospital on [DATE] and returned to the facility on [DATE] with diagnoses including aspiration pneumonia, weakness and anemia. Review of Resident #78's Minimum Data Set (MDS) 3.0 assessment dated [DATE] confirmed the resident had a memory problem. Review of Resident #78's progress note dated 12/10/19 at 9:45 A.M. indicated the emergency technicians transported the resident to the hospital and a report was given to the resident's significant other. Resident #78's medical record did not contain evidence the resident or family was notified in writing the reason for the discharge in an easily understood language. Interview on 01/13/20 at 4:49 P.M. with Admissions Coordinator #802 confirmed the resident or family were not notified in writing the reason for the discharge to the hospital in an easily understood language. 2. Review of Resident #167's closed medical record revealed the resident was admitted to the facility on [DATE] and discharged to the hospital on [DATE] with diagnoses including anemia and depression. Review of Resident #167's progress note dated 11/18/19 at 9:19 A.M. indicated on 11/15/19 the resident was admitted to the hospital for respiratory failure. Resident #167's medical record did not contain evidence the resident or the resident's representative were notified in writing the reason for the discharge to the hospital in an easily understood language. Interview on 01/13/20 at 4:53 P.M. with Admissions Director #802 confirmed Resident #167's family were not notified in writing the reason for the discharge in an easily understood language.

MINOR (C)

Minor Issue - procedural, no safety impact

Deficiency F0625 (Tag F0625)

Minor procedural issue · This affected most or all residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure Residents #78 and #167 were provided written notification of...

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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 Residents #78 and #167 were provided written notification of the bed-hold policy upon discharge to the hospital. This affected two of four resident records reviewed for hospitalization and had the potential to affect any of the 168 residents residing in the facility. Findings include: 1. Review of Resident #78's medical record revealed the resident was admitted to the facility on [DATE], discharged to the hospital on [DATE] and returned to the facility on [DATE] with diagnoses including aspiration pneumonia, weakness and anemia. Review of Resident #78's Minimum Data Set (MDS) 3.0 assessment dated [DATE] confirmed the resident had a memory problem. Review of Resident #78's progress note dated 12/10/19 at 9:45 A.M. indicated the emergency technicians transported the resident to the hospital and a report was given to the resident's significant other. Resident #78's medical record did not contain evidence the resident or family were notified in writing of the bed-hold policy at the time of transfer to the hospital or within twenty-four hours as required. Interview on 01/13/20 at 4:49 P.M. with Admissions Coordinator #802 confirmed Resident #78's family was not provided the written bed-hold policy during the transfer to the hospital or within twenty-four hours as required. 2. Review of Resident #167's closed medical record revealed the resident was admitted to the facility on [DATE] and discharged to the hospital on [DATE] with diagnoses including anemia and depression. Review of Resident #167's progress note dated 11/18/19 at 9:19 A.M. indicated on 11/15/19 the resident was admitted to the hospital for respiratory failure. Resident #167's medical record did not contain evidence the resident or family were notified in writing of the bed-hold policy at the time of transfer to the hospital or within twenty-four hours as required. Interview on 01/13/20 at 4:53 P.M. with Admissions Director #802 confirmed Resident #167's or the resident's family were not notified of the bed-hold policy upon discharge to the hospital or within twenty-four hours as required.

Dec 2018 8 deficiencies

CONCERN (D)

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

Safe Environment (Tag F0584)

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 ensure rooms for Resident #143 and Resident #132 were...

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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 ensure rooms for Resident #143 and Resident #132 were maintained in a clean manner. This affected two of five residents reviewed for environmental concerns. Findings include: 1. Resident #143 was admitted to the facility on [DATE] with diagnoses including heart failure, obesity, asthma, schizophrenia, depression, anxiety, and hypertension. Resident #143's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed his cognition was intact, did not reject care, was independent with activities of daily living, and required set up help with toilet use and personal hygiene. Review of Resident #143's progress notes and behavior tracking for November 2018 and December 2018 revealed no evidence he declined his room being cleaned or was resistant to staff helping clean his room. Observation on 12/03/18 at 11:30 A.M. of Resident #143 revealed he was in bed with no sheet on the mattress, his bedside table and breathing machine had an unknown substance all over the surface. There was a plastic cup on end of his bed, and a pile of laundry was on the floor. On his bedside table were five empty clear vials. Observation on 12/04/18 at 2:56 P.M. with Licensed Practical Nurse (LPN) #32 of Resident #143 revealed he was lying in bed with no sheet on the mattress, and he still had an unknown substance on the surface of his bedside table and breathing machine. There were milk cartons and a plastic cup on the end of his bed. On his bedside table were two empty clear vials. Interview at this time with LPN #32 revealed Resident #143 received Albuterol breathing treatments as needed for shortness of breath, and the clear plastic vials held the Albuterol solution for his breathing treatment. LPN #32 confirmed the above observation at this time, and explained he was non-complaint with bathing and cleaning. When LPN #32 picked up the vials off the table, the vials were stuck to the table. Interview on 12/06/18 at 11:13 A.M. with Environmental Services Director #145 revealed resident rooms were cleaned everyday and no one had reported problems with cleaning Resident #143's room. 2. Resident #132 was admitted on [DATE] with diagnoses including human immunodeficiency virus (HIV) acute cerebral vascular disease, and hemiplegia (paralysis) of dominant side. Resident #132's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed her cognition was intact and no episodes of rejection of care. Review of Resident #132's progress notes and behavior tracking for November 2018 revealed no evidence she declined housekeeping services or did not allow the facility to help clean her room. Interview on 12/06/18 at 9:49 A.M. with LPN #69 revealed Resident #132's room was cluttered and she would not allow staff to help or move things off of her bed. Interview on 12/06/18 at 10:42 A.M. with the Director of Nursing (DON) confirmed there was no evidence Resident #132 was non-complaint with any assistance in November 2018. Interview on 12/06/18 at 1:37 P.M. with the Administrator revealed Resident #132's family had expressed concerns about the cleanliness of her room on 11/24/18. Interview on 12/06/18 at 2:13 P.M. with Laundry #146 revealed on 11/24/18 she helped clean Resident #132's room because the family was very upset. Laundry #146 revealed the resident had papers, unopened packs of snacks, and clothes all over the room. Resident #132's bed sheets were dirty, there were empty milk cartons, and items from meal trays all over the room. This deficiency substantiates Complaint Number OH00101368.

CONCERN (D)

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

Deficiency F0679 (Tag F0679)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and interview the facility failed to provide activities of preference or offer assis...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and interview the facility failed to provide activities of preference or offer assistance to attend activities for Resident #27. This affected one (Resident #27) of three reviewed for activities. Findings include: A medical record review revealed Resident #27 was admitted to the facility on [DATE] with the diagnoses of epilepsy, traumatic brain injury, mood disorder, major depressive disorder, altered mental status, anxiety disorder, schizophrenia, muscle weakness, and dementia without behavioral disturbance. Review of the quarterly Minimum Data Set 3.0 (MDS) dated [DATE] revealed Resident #27 had severely impaired cognition and was totally dependent on staff for all his care. Review of the plan of care updated 11/29/18 revealed Resident #27 would attend one group activity on the unit per quarter such as reading bee or music and would be provided with 1-2 social visits by activity staff weekly, Observations on 12/03/18 at 11:26 A.M. and 2:28 P.M., on 12/04/18 at 9:58 A.M., 1:38 P.M., 2:01 P.M., and 4:59 P.M., and on 12/05/18 at 11:33 A.M., 1:30 P.M., and 5:13 P.M. revealed Resident #27 was in bed sleeping. Review of the October 2018 activity attendance record revealed Resident #27 had attended seven individual activities. Review of the November 2018 activity attendance record revealed Resident #27 had attended seven individual activities. Review of the December 2018 activity attendance record revealed Resident #27 had not attended any activities. Review of the Preferences for Everyday Living Inventory (PELI) revealed Resident #27 indicated pet visits, religion and cultural activities were very important to him. An interview on 12/05/18 at 6:04 P.M. with Activity Director (AD) #168 revealed Resident #27 slept most of the time and the staff did not wake him to attend activities. She indicated he enjoyed church services and reading bee. She verified Resident #27 had not been taken to group activities such as reading bee or to church services per his PELI choices during October, November or December 2018.

CONCERN (D)

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 onrecord review, observation, interview, and review of facility policy, the facility failed to identify and monitor a brui...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based onrecord review, observation, interview, and review of facility policy, the facility failed to identify and monitor a bruise on Resident #120's left hand. This affected one (Resident #120) of two residents reviewed for skin conditions. Findings include: Resident #120 was admitted on [DATE] with diagnoses including paroxysmal atrial fibrillation (intermittent and sudden onset of rapid heart rate). Resident #120's 60 day Minimum Data Set (MDS) assessment dated [DATE] revealed his cognition was moderately impaired, he was totally dependent on one staff for toileting, was totally dependent on two staff for transfers, and required the extensive assistance of two persons for bed mobility. Resident #120's physician orders revealed he was ordered xarelto (a blood thinner) on 10/16/18. Resident #120's comprehensive care plan for alteration in clotting time and being at risk of hemorrhage, dated 09/12/18, revealed there an intervention to monitor the resident's skin for bruising once a day, and as needed. Observation on 12/03/18 at 2:43 P.M. and on 12/04/18 at 9:14 A.M. revealed the resident had a dark purple bruise on his left hand. Resident #120's MDS, dated [DATE] at 1:42 A.M., revealed the bruise was not documented under skin assessments for other skin problems present. Review of Resident #120's medical record contained no evidence the bruise on his left hand was identified or monitored. Interview on 12/04/18 at 2:43 P.M. with Licensed Practical Nurse (LPN) #32 revealed the nurses typically measured and documented bruises upon discovery. LPN #32 verified Resident #120 had a bruise on his left hand and no evidence of the bruise being identified or monitored could be found in his medical record. Interview on 12/04/18 at 2:46 P.M. with State Tested Nursing Assistant #180 revealed the bruise on Resident #120's hand was there on Sunday, 12/02/18, and she figured the bruise was already documented. Review of the facility policy, Measurement, Assessment, of Pressure Ulcers, Wounds and Other Skin Problems, undated, revealed skin conditions other than ulcers, such as bruises, will be described upon initial observation and documented.

CONCERN (D)

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

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #166 was admitted to the facility on [DATE] with diagnoses of schizoaffective disorder and asthma. She was alert and...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #166 was admitted to the facility on [DATE] with diagnoses of schizoaffective disorder and asthma. She was alert and oriented to person, time and place. She came to the facility with an order for a regular diet with thin liquids . She passed away on 11/03/18 at a local hospital. Review of Resident #166's dining cards revealed she had been on a regular diet with low concentrated sweets since coming to the facility. Review of the speech therapy plan of care dated 02/03/18 revealed Resident #166 was on a regular diet. Review of progress notes dated 05/08/18, 07/31/18 and 10/23/18 revealed Registered Dietician #164 stated Resident #166 continued on a puree, low concentrated sweets diet. All notes indicated the same information to include diet remains appropriate, will follow and update as needed and diet compliance was encouraged. Review of diet orders for Resident #164 revealed on 08/04/18 an order was written for a pureed, low concentrated sweets diet and on 10/23/18 an order was written for a regular, low concentrated sweets diet. Review of the care plan dated 08/04/18 and 10/23/18 revealed nothing related to a specialized diet or concerns with dysphagia (difficulty swallowing). An interview on 12/05/18 at 3:30 P.M. with the Director of Nursing (DON) revealed former Resident #166 was always on a regular diet with thin liquids while in the facility. An incorrect order was written for a pureed diet for this resident on 08/04/18, however, all therapy evaluations and kitchen information verified she was to receive a regular diet. An interview on 12/05/18 at 3:52 P.M. with Speech Therapist #124 revealed since 2017 Resident #166 was never treated for dysphagia (difficulty swallowing). The resident received speech therapy starting on 10/23/18 for strategies with swallowing due to some coughing and needing some cueing. Resident #166 was impulsive with her intake and would often take large bites of food at one time. Her diet was never changed from a regular diet as they never had a reason to change it. An interview on 12/06/18 with Registered Dietician (RD) #164 at 9:10 A.M. revealed her progress notes indicated Resident #166 was on a pureed diet, however, they were in error. She said she followed the doctor's orders, however, a nurse had put the wrong diet order in the system. RD #164 had been called in to talk to the Administrator and the Director of Nursing about inaccurate documentation. Based on interview and record review the facility failed to ensure accurate and complete documentation for Resident #132 related to refusing assistance with care and for Resident #166 related to ordered diet. This affected two (Resident #132 and Resident #166) of 37 residents whose medical records were reviewed for accuracy. Findings include: 1. Resident #132 was admitted on [DATE] with diagnoses including human immunodeficiency virus (HIV) acute cerebral vascular disease with hemiplegia (a stroke with partial paralysis/weakness) anxiety, and depressive disorder. Resident #132's quarterly Minimum Data Set assessment dated [DATE] revealed her cognition was intact, she required limited assistance with dressing, and was independent with set up help for personal hygiene and bathing. Resident #132's physician orders revealed her shower days were Wednesday and Saturday when skin observations were completed. Review of Resident #132's Point of Care History for September 2018 revealed she had a shower on 09/08/18, a partial bed bath on 09/22/18, and a completed bed bath on 09/27/18. Resident #132's Point of Care history for October 2018 revealed she had a partial bed bath on 10/06/18 and 10/20/18. Resident #132's Point of Care history for November 2018 revealed she had a partial bed bath on 11/03/18 and 11/09/18. Resident #132's medical record contained no additional evidence of completed showers. Review of Resident #132's Point of Care History from 11/01/18 through 11/23/18 related to personal hygiene, revealed the facility only documented how the resident maintained personal hygiene on 11/06/18, 11/07/18, 11/09/18, 11/14/18, 11/15/18, 11/19/18, and 11/21/18. All other days were unanswered. Review of Resident #132's progress notes and behavior/intervention monthly flow record from 11/01/18 through 11/23/18 revealed no evidence she refused assistance with care. Resident #132's activities of daily living comprehensive care plan, dated 11/06/14, revealed she had a self care deficit due to right arm weakness. The care plan identified that she needed assistance at times with dressing, bathing, and personal hygiene, and preferred to be independent but will ask for assistance. Interview on 12/06/18 at 9:23 A.M. with State Tested Nurse Aide (STNA) #36 revealed Resident #132 had a history of refusing showers and oral care. STNA #36 revealed they reported refusals to the charge nurse and they could document the task not occurring in the electronic charting system. STNA #36 revealed since she started working at the facility in August 2017, Resident #132 did not let anyone touch or comb her hair, and this was reported to the nurse. Interview on 12/06/18 at 9:49 A.M. with LPN #69 revealed Resident #132 refused skin care, showers and hair care. LPN #69 said Resident #132 had a behavior tracker and if refusals became a pattern it should be documented on the behavior tracker and verified Resident #132's refusals were a pattern. Interview on 12/06/18 at 10:45 A.M. with STNA #112 revealed the staff rarely saw Resident #132's hair because she always had a bonnet on. STNA #112 revealed when a resident refused care they reported it to a nurse and documented the refusal of care in the electronic charting system. STNA #112 revealed they charted daily on all resident activities of daily living. On 12/06/18 at 10:42 A.M. the Director of Nursing verified the lack of consistent and accurate documentation of Resident #132's refusals to allow staff to assist with care.

CONCERN (E)

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

ADL Care (Tag F0677)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interviews, staff interviews and medical record review the facility failed to ensure personal hygiene was comp...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interviews, staff interviews and medical record review the facility failed to ensure personal hygiene was completed for all residents. This affected three (Residents #58, #64, and #81) of three residents reviewed for activities of daily living. Finding Include: 1. Review of the Medical Record for Resident #58 revealed an admission date 10/05/17. Diagnoses included peripheral vascular disease, obesity and swelling of lower limbs. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #58 was cognitively intact and required extensive assist for personal hygiene. Review of the Activity of Daily Living (ADL) care plan dated 01/15/18 revealed Resident #58 needed extensive assist with her ADL's due to weakness of both lower extremities and obesity. The staff was to set-up and assist the resident with personal hygiene. Review of physician orders dated 05/01/18 revealed the resident may receive ancillary services including seeing a Podiatrist. Observation on 12/04/18 at 8:26 A.M. revealed Resident #58's toenails were very long and curling under her toes. Interview on 12/04/18 at 8:27 A.M. with Resident #58 revealed she had not seen the podiatrist since she's been at facility and the staff do not cut her toenails. Resident #58 stated she would like her toenails trimmed because they were too long. Interview on 12/04/18 at 3:27 P.M. with Social Worker (SW) #16 revealed Resident #58 was on the list to be seen by the podiatrist. SW #16 verified that Resident #58 had not been seen by the podiatrist in the last year. SW #16 confirmed Resident #58 had not refused to see the podiatrist and was not a diabetic, and the nurses could cut her toenails. Interview on 12/04/18 at 3:52 P.M. with Licensed Practical Nurse (LPN) #30 verified Resident #58's toenails were very long, curling under her toes and needed trimmed. 2. Review of Medical Record for Resident #64 revealed an admission date 04/03/18. Diagnoses included obesity, type 2 diabetes and heart failure. Review of the quarterly MDS dated [DATE] revealed intact cognition and the resident required extensive assist for personal hygiene. Review of the care plan dated 10/04/18 for potential complications related to diabetes revealed interventions including inspect feet for bunions, calluses, and cracking, encourage proper foot care and refer to the podiatrist for foot care and trimming of nails. Review of the physician orders dated 09/15/18 revealed for ancillary services including seeing the podiatrist. Review of her 360-care form dated 04/06/18 revealed Resident #64's spouse signed the consent form for Resident #64 to see the podiatrist. Observation on 12/03/18 at 10:28 A.M. revealed Resident #64's feet were covered with dry flaky skin and her toenails were very long and curling under toes. Interview on 12/03/18 at 10:30 A.M. with Resident #64 revealed she had never seen the podiatrist for foot care and her toenails have not been cut since coming to the facility. Resident #64 stated it had been a long time since anyone has applied lotion to her feet or legs, and she would like her toenails trimmed and lotion applied to her feet. Interview on 12/04/18 at 3:35 P.M. with SW #16 revealed Resident #64's husband had signed the authorization for Resident #64 to see the podiatrist. SW #16 stated Resident #58 had not refused to see the podiatrist and was a diabetic, so her toenails needed to be trimmed by the podiatrist. SW #16 verified that Resident #64 had not seen the podiatrist since she was admitted to the facility. Interview on 12/04/18 3:58 P.M. with LPN #104 verified Resident 64's toenails were very long, curling under her toes and needed trimmed. LPN #104 stated the staff should apply lotion to Resident #64 when her skin was dry and scaly. LPN #104 verified Resident #64's feet were very dry and scaly, and she had never applied lotion to Resident #64's feet. Interview on 12/04/18 at 2:45 P.M. with State Tested Nurse's Assistant (STNA) #40 revealed she had not trimmed Resident #64's toenails or applied lotion to her feet. STNA #40 stated Resident #40's toenails were to be trimmed by the podiatrist or nurse. 3. Resident #81 was admitted on [DATE] with diagnoses including Parkinson's disease, muscle weakness, pain in shoulder joint, and depressive disorder. Review of Resident #81's activities of daily living functional care plan, started 08/12/13 revealed he had a self care deficit due to muscle weakness and Parkinson and required the assistance of two persons for activities of daily living (ADLs). Review of Resident #81's last podiatry visit report dated 08/11/16 revealed he was seen for painful long nails, and a manual abridgement of one to five nails was completed. It was indicated to follow up with podiatry in two to three months for continued at risk foot care. Resident #81's medical record contained no evidence he was seen by podiatry after this date. Resident #81's MDS assessment dated [DATE] revealed his cognition was intact, and he was totally dependent on one person for personal hygiene and bathing. Resident #81's medical record contained no evidence that he preferred not to be shaven. Resident #81's Treatment Flowsheets from 10/01/18 through 10/31/18 revealed his skin should be observed twice a week on shower days, Wednesday and Saturday. The flow sheet was not signed off as completed on 10/03/18, 10/06/18, 10/10/18, 10/20/18, 10/24/18, 10/31/18. The Treatment Flow sheets from 11/01/18 through 11/30/18 revealed it was not signed off as completed on 11/07/18. Resident #81's Point of Care History from 10/01/18 through 11/30/18 revealed he received a bed bath on 10/01/18, a shower on 10/06/18, a bed bath on 10/09/18, and a bed bath on 10/10/18, a partial bed bath on 11/27/18, a bed bath on 11/28/18, and a partial bed bath on 11/29/18. Interview on 12/03/18 at 2:43 P.M. with Resident #81 revealed he missed a couple showers in November, and missed another shower recently on a Saturday because the facility was short on staff. Resident #81 revealed he could not shave himself. He said he tried to get the aides to shave him but they say they cannot do it or they do not know how. Resident #81 revealed he'd been on the list for four or five months to see the podiatrist but had not been seen yet. Resident #81 revealed his toenails were very long. Observation at this time revealed he had excessive facial hair. Interview on 12/04/18 at 5:09 P.M. with State Tested Nursing Assistant (STNA) #85 revealed the restorative STNA's shaved resident #81 because he had a skin problem. Interview on 12/04/18 at 5:26 P.M. with Resident #81 with the DON present revealed the needed to be shaved by staff and the STNAs stated they did not know how to do it. The DON at this time confirmed he had long facial hair. Interview on 12/05/18 at 7:46 A.M. with Restorative Licensed Practical Nurse (LPN) #37 revealed restorative staff were not solely responsible for shaving Resident #81. Interview on 12/05/18 at 10:17 A.M. with DON confirmed there was no evidence of additional showers for Resident #81 and typically residents were shaved on shower days. Interview on 12/05/18 at 11:15 A.M. with DON revealed residents were seen by the podiatrist on admission, and the podiatrist was there quarterly for any resident who needed to see the podiatrist. Observation on 12/05/18 at 2:21 P.M. revealed Resident #81's toenails were long especially the right great toe. During the observation, Resident #81 stated he was last seen by the podiatrist in March, but has not been seen since. The DON was present at the time and verified the observation. This deficiency substantiates Complaint Number OH00101368.

CONCERN (E)

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

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #142 was admitted on [DATE] with diagnoses including schizoaffective disorder, hypercholesterolemia and hypertension...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #142 was admitted on [DATE] with diagnoses including schizoaffective disorder, hypercholesterolemia and hypertension. Resident #142's annual MDS assessment dated [DATE] revealed her cognition was intact, she was independent in eating, was on a mechanically altered therapeutic diet, and had experienced a five percent weight loss in the last 30 days or a 10 percent weight loss in the last six months. Resident #142's progress note dated 10/23/18 revealed her weight was 107 pounds which triggered as a significant weight loss over 30 days. The resident was refusing her high calorie med pass nutritional supplement, and was started on a magic cup nutritional supplement. Resident #142's progress note dated 10/30/18 revealed the resident was refusing her magic cup nutritional supplements, as well as other supplements. Resident #142's physician orders revealed on 10/31/18 she was ordered to be weighed every Monday. Review of Resident #142's Treatment Flowsheet for November 2018 revealed no weights were recorded for 11/05/18, 11/12/18, or 11/19/18. Interview on 12/06/18 at 12:11 P.M. with the Director of Nursing (DON) confirmed Resident #142's weights were not completed as ordered. Based on medical record review, observation, interview and review of facility policy for Weight Assessment and Intervention, the facility failed to Resident #54 was served thickened liquids as ordered, accurate weights were obtained for Residents #216 and weights were obtained as ordered for Resident #142. This affected three (Resident #142, #216 and #54) of seven residents reviewed for nutrition. The facility census was 171. Findings included: 1. Resident #54 was admitted to the facility on [DATE] with the diagnoses including Alzheimer's disease, dementia, and dysphagia (difficulty swallowing). Review of the plan of care dated 03/18/14 revealed Resident #54 was to have a regular diet with nectar thick liquids. Review of the physician's order dated 12/06/17 revealed Resident #54 was to have a regular diet with nectar thick liquids and nectar thick milk in cereal. On 12/03/18 at 12:47 P.M. during observation of the lunch meal, Resident #54 was served a regular meal with regular gravy. Review of the resident's diet ticket served with her meal revealed she was to have thickened gravy. At the time of the observation Licensed Practical Nurse (LPN) #23 verified Resident #54 was to have thickened liquids and was served thin gravy. 2. Resident #216 was admitted to the facility on [DATE] with diagnoses of dementia with behavioral disturbance, traumatic brain injury, schizoaffective disorder, dysphagia (difficulty swallowing) anxiety disorder, delusional disorder, paranoia, diabetes mellitus, alcohol abuse, hypertension, major depressive disorder, and chronic pain. Review of the annual Minimum Data Set (MDS) 3.0 revealed Resident #216 had moderately impaired cognition, required extensive to total assist with his activities of daily living, and received a therapeutic diet. Review of a physician's order revealed Resident #216 had an order for Ensure Clear (a nutritional supplement) to be given once daily dated 02/27/17, and an order for a pureed diet dated 11/23/18 Review of the medical record revealed Resident #216's weights were; on 12/06/18 was 137 lbs. on 12/04/18 was 194 lbs. on 11/23/18 was 165 lbs. on 10/18/18 was 158 lbs. on 09/09/18 was 164 lbs. on 08/30/18 was 170 lbs. on 07/24/18 was 166 lbs. on 06/20/18 was 157 lbs. on 05/21/18 was 169 lbs. on 04/25/18 was 158 lbs. on 03/20/18 was 158 lbs. on 02/27/18 was 165 lbs. on 01/25/18 was 162 lbs. Review of the dietitian's progress notes revealed the following. The notes dated 04/24/18 at 12:08 P.M. revealed Resident #216 continued a mechanical soft, low concentrated sweets (LCS) diet. He received a box of ensure clear daily due to past weight loss. His current body weight (CBW) was 158 lbs. and had not changed significantly. The resident's weight had varied from 145-165 lbs. over the past 180 days. Dietician notes dated 05/22/18 at 2:29 P.M. revealed the resident's CBW was 169 lbs. and he triggered for a significant weight gain. Dietician notes on 06/26/18 at 11:37 A.M. revealed Resident #216's weight was 157 lbs., and he triggered as a 30-day weight loss. The resident weighed 158 lbs. in April, so suspected the resident did not gain weight in May as that weight suggested. Dietician notes on 07/17/18 at 10:56 A.M. revealed the resident continued a mechanical soft, LCS diet. His intake was usually 76-100 percent of meals. He received ensure clear daily due to past weight loss. His most recent weight was 157 lbs. with July's weight pending. Suspected the May weight of 169 lbs. was inaccurate. Dietician notes on 07/31/18 at 2:29 P.M. revealed the resident's monthly weight was 166 lbs. and he triggered for a significant weight gain but was stable. Suspected the June weight of 157 lbs. was inaccurate. Dietician notes on 10/16/18 at 10:29 A.M. revealed the resident's CBW was 164 lbs. and he remained stable over 30 days, 90 days and 180 days. An interview on 12/06/18 at 9:13 A.M. with Registered Dietitian (RD) #164 indicated she reviewed the weights and they had nutrition risk meetings on Tuesdays to discuss all the weight losses. She indicated she visited the facility one to two days a week depending on the census and work load. She said she would have to look at Resident #216's record to determined why she documented the weights were inaccurate in May and June. She indicated the resident should have been reweighed after the 12/04/18 weight of 194 lbs. An interview on 12/06/18 at 9:30 A.M. with Licensed Practical Nurse (LPN) #37 indicated she monitored resident weights and all residents were weighed upon admission and weekly for the first month. Residents should be reweighed if there was an unusual weight gain or loss from the previous month. She indicated there was no reweigh for the resident's weight of 194 lbs on 12/04/18 because she had written on her tracking sheet he had a prior weight of 192 lbs. She verified the 192 lbs. weight was not documented in the computer. She indicated the 194 lbs. weight was probably done with the Hoyer (mechanical) lift but there was no documentation verifying the Hoyer lift was used. She verified the resident had a 29 lb. weight gain from 11/23/18 to 12/04/18. She indicated when she entered the weights into the computer, the computer would list all the resident vital signs, so she may not see the last weight on her screen unless she scrolled all the way down the screen, which she did not do. On 12/06/18 at 10:19 A.M. interview with LPN #37 revealed the 194 lbs. weight was documented on the wrong resident. She indicated the resident was reweighed and he weighed 137 lbs. She indicated the dietitian was notified. An interview on 12/06/18 at 2:08 P.M. with RD #163 indicated Resident #216 was always weighed with the Hoyer lift until today when he was weighed with the weight chair. She indicated there had been some issues with the Hoyer lift not weighing properly. She verified there was no documentation of the weights being inaccurate due to Hoyer malfunctioning. She indicated the resident was relatively stable in his weights until October. She also indicated there were no new interventions in place due to his weight being stable around 165 lbs. She indicated she did not believe the 06/20/18 weight of 157 was correct. She stated his admission weight was 137 lbs. and he had gained weight since admission. She indicated the resident was ordered Ensure Clear prior to her employment, and she had not spoken to the family about alternative nutrition due to his weight being stable. She verified the lack of appropriate follow up due to inaccurate weights per the facility policy and it was unclear how much weight Resident #216 had gained or lost due to the inaccuracy of the documentation. On 12/06/18 at 3:10 P.M. interview with LPN #37 indicated she was given a list from the nutritional risk meetings of residents who needed reweights and those reweights were the ones she did. She was never given a notice for a reweigh on Resident #216. She verified there were no reweighs or new interventions in place for Resident #216's weight loss of 12 lbs. from 05/21/18 to 06/20/18, the six-pound weight loss from 08/30/18 to 09/09/18, and the six-pound weight loss from 09/09/18 to 10/18/18. Review of the facility policy, Weight Assessment and Intervention, dated 08/08 revealed any weight change of greater than or less than five pounds within 30 days would be retaken for confirmation. If the weight was verified, nursing would immediately notify the dietitian in writing. The dietitian would respond within 24 hours of receipt of written notifications.

CONCERN (E)

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

Deficiency F0804 (Tag F0804)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and review of the Pureed diet policy the facility failed to ensure recipes were followed for pu...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and review of the Pureed diet policy the facility failed to ensure recipes were followed for pureed meals which affected sixteen (Resident #'s 83, 110, 150, 216, 18, 109, 31, 37, 152, 117, 11, 318, 82, 129, 53 and 24) of sixteen residents currently ordered a pureed diet and failed to ensure foods reached palatable temperatures for Resident #38 and Resident #35. This affected all 16 of 16 residents on a pureed diet, and two (Resident #38 and Resident #35) of four residents reviewed for food concerns. Findings include: 1. An observation on 12/04/18 at 11:09 A.M. in the kitchen of [NAME] #120 preparing puree foods for sixteen residents revealed she did not have a recipe in front of her. She did not measure the amounts of food going into the processor and used water to thin down the food to her desired texture. This was verified by Dietary Manager #24 who stated he would now go and get the recipe book and keep it for them to follow. An interview on 12/04/18 at 11:10 A.M. with [NAME] #120 revealed she was never told or taught to follow a recipe when pureeing food. She stated she had to guess on what to use and she usually just filled the food processor about halfway full for all items. She did not weigh or measure amounts and was not sure how many people received puree food in the facility. A taste test of the ready to serve pureed Salisbury steak on 12/04/18 at 11:13 A.M. revealed the food was somewhat bland and had small chewy bits of meat. This was verified by [NAME] #120 who stated she did not always taste the food before serving it. An interview and observation on 12/04/18 at 11:20 A.M. with Prep [NAME] #121 revealed she would puree the dessert items with milk as she believed it worked the best. She did not follow a recipe for specific instructions for the cake she was pureeing. She had never been trained on how to puree. This was verified by Dietary Manager #24. An interview on 12/05/18 at 11:06 A.M. with Dietary Manager #24 revealed he had just completed training on pureeing foods correctly with recipes. He said he had never done that before but understood he should have done this earlier. Review of the Pureed Diet policy, 2017 edition revealed the puree process consisted of weighing or measuring the number of drained portions required for the standardized recipe. If the recipe does not yield the correct texture, add a measured amount of fluid or thickening agent. Guidelines should be followed per the Principles and Guidelines for Menu Planning which revealed all pureed meats should be weighed prior to measuring to equal one ounce of protein. Desserts (pureed cakes) should be well soaked in milk or well slurried. 2. Resident #38 was admitted on [DATE] with diagnoses including bipolar disorder, orthopedic aftercare and schizoaffective disorder. Resident #38's quarterly Minimum Data Set (MDS) assessment, dated 10/05/18 revealed her cognition was intact. Interview on 12/03/18 at 12:39 P.M. with Dietary Aide #140 revealed the facility took food temperatures in the kitchen but did no get a temperature reading of the foods once they were on the steam table before service on the unit. Observation at this time revealed Dietary Aide #140 was serving the [NAME] unit from the steam table in the [NAME] dining room. Interview on 12/03/18 at 12:43 P.M. with Resident #38 revealed the food on the hall trays were being covered on this day, but the facility typically did not cover the plates delivered in the halls. Resident #38 revealed the facility used to plate hall trays in the kitchen, but since plating the hall trays from the steam table on the unit, the food had been cold. Observation on 12/03/18 at 1:04 P.M. with Dietary Aide #132 of Resident #38's lunch tray that was served to her room revealed the pork was 115 degrees Fahrenheit. Dietary Aide #132 confirmed this observation at this time. 3. An interview on 12/03/18 at 2:43 P.M. with Resident #35 revealed her food was barely hot when it got to her room. She indicated they served the food from the steam table to the residents in the dining room and then when they were done in the dining room the plated up the food from the steam table for the hall trays and it was always cold. She indicated she had her family purchase a microwave, so she could heat up her own food. An observation on 12/04/18 at 6:06 P.M. revealed Resident #35 received her meal tray, a sausage sandwich on a hot dog bun and baked beans. At 6:13 P.M. Dietary Manager (DM) #24 tested the temperature of Resident #35's food. The sausage was 93 degrees Fahrenheit (F) and the baked beans were 83 degrees F. DM #24 indicated the food temperature should be at 135 degrees F and he was not sure why the food was not up to temperature. He verified at this time Resident #35's food was not at the proper temperature.

CONCERN (E)

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and review of the kitchen cleaning schedule and the policy for cleaning steam tables the facilit...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and review of the kitchen cleaning schedule and the policy for cleaning steam tables the facility failed to maintain the kitchen including steam tables in a clean and sanitary manner. This had the potential to affect 32 Residents that resided on the [NAME] unit (Resident #8, Resident #6, Resident #132, Resident #67, Resident #50, Resident #266, Resident #120, Resident #7, Resident #122, Resident #89, Resident #23, Resident #143, Resident #77, Resident #37, Resident #30, Resident #49, Resident #152, Resident #131, Resident #33, Resident #81, Resident #32, Resident #38, Resident #93, Resident #34, Resident #5, Resident #76, Resident #51, Resident #130, Resident #78, Resident #94, Resident #36 and Resident #71) and 28 residents who resided on the Presidential unit (Resident #82, Resident #125, Resident #57, Resident #42, Resident #24, Resident #134, Resident #63, Resident #316, Resident #150, Resident #58, Resident #46, Resident #64, Resident #20, Resident #317, Resident #156, Resident #165, Resident #48, Resident #128, Resident #62, Resident #318, Resident #115, Resident #163, Resident #56, Resident #47, Resident #319, Resident #128, Resident #98 and Resident #104). The facility census was 171. Findings include: 1. An observation on 12/03/18 at 8:31 A.M. of the kitchen revealed the dishwasher had food particles on the top of it and dried foods and dirty hand prints on the front. There was one freezer handle with food on it and other debris and two cooler handles with hand smudges and caked on food. This was verified by Dietary Manager (DM) #24. An interview on 12/03/18 with DM #24 at 8:39 A.M. revealed he could see the dirt and foods on things but it was better than it used to be when he first arrived at the facility. An observation on 12/04/18 at 8:40 A.M. and at 2:36 P.M. revealed appliances remained unclean with hand and fingerprints, obvious food residue and food crumbs on shelves above the food preparation area. The dishwasher still had crumbs on the top of it. This was verified by DM #24 and Dishwasher #122 at the time of the observation. Review of the daily cleaning schedule for the kitchen dated 06/06/16 revealed tasks for each day to include to wipe and clean racks, to wipe and clean the dishroom, to clean the preparation areas, to clean and sanitize all coolers inside and out and to clean shelves. 2. Interview on 12/05/18 at 2:30 P.M. with Resident #257 revealed the steam table in the [NAME] dining room was filthy and did not look appealing. Resident #257 stated she did not like that her food was being served out of a steam table that had not been cleaned thoroughly. Observation on 12/05/18 at 2:33 P.M. of the steam table revealed dried foods on the front and sides visible to the residents. On 12/05/18 at 3:30 P.M. the Administrator verified the steam tables in the [NAME] and Presidential Dining Rooms were not clean and had dried foods on them. Interview on 12/05/18 at 4:41 P.M. with DM #24 revealed all steam tables should be cleaned on the weekends by dietary staff. DM #24 stated he had no documentation of when the steam tables on the [NAME] and Presidential units were last cleaned. DM #24 stated he noticed on 12/05/18 the steam tables were not clean and verified the steam tables in [NAME] and Presidential Dining Rooms were used to serve all resident meals, on those units. Review of facility policy titled Weekend Cleaning for Steam Tables, dated 10/13/17, revealed steam tables are to be cleaned on the weekend.

MCKINLEY NURSING

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