How many inspection deficiencies does THE LAURELS OF WALDEN PARK have?

THE LAURELS OF WALDEN PARK has 73 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at THE LAURELS OF WALDEN PARK?

THE LAURELS OF WALDEN PARK has a three-star staffing rating from CMS with 0.79 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is THE LAURELS OF WALDEN PARK located?

THE LAURELS OF WALDEN PARK is located in COLUMBUS, OH. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does THE LAURELS OF WALDEN PARK have?

THE LAURELS OF WALDEN PARK has 225 certified beds.

Who owns THE LAURELS OF WALDEN PARK?

THE LAURELS OF WALDEN PARK is a for profit - individual facility and is part of the CIENA HEALTHCARE/LAUREL HEALTH CARE chain.

What questions should families ask when visiting THE LAURELS OF WALDEN PARK?

Families visiting THE LAURELS OF WALDEN PARK 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 THE LAURELS OF WALDEN PARK compare to other nursing homes?

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

THE LAURELS OF WALDEN PARK

Name: THE LAURELS OF WALDEN PARK
Address: 5700 KARL ROAD, COLUMBUS, OH, 43229, US
Telephone: (614) 846-5420
Rating: 2.0

5700 KARL ROAD, COLUMBUS, OH 43229 · (614) 846-5420

For profit - Individual 225 Beds CIENA HEALTHCARE/LAUREL HEALTH CARE Data: November 2025

Trust Grade

23/100

#798 of 913 in OH

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Last Inspection: April 2023

Over 2 years since last inspection. Current conditions may differ from available data.

Overview

The Laurels of Walden Park has received a Trust Grade of F, indicating significant concerns about the facility's quality and care. Ranking #798 out of 913 nursing homes in Ohio places it in the bottom half of the state, while its county rank of #43 out of 56 means that only a few local options are worse. The facility is worsening, with issues increasing from 5 in 2024 to 19 in 2025. Staffing is somewhat stable, with a 3/5 star rating and a turnover rate of 32%, which is better than the state average of 49%. However, the facility has faced serious incidents, including a failure to manage pressure ulcers leading to severe skin damage, neglect in addressing a resident's dangerously low potassium levels, and inadequate wound care that resulted in a maggot infestation in a previous resident's wound. While the nursing home has some staffing stability, these serious violations raise significant concerns about the quality of care provided.

Trust Score: F
In Ohio: #798/913
Safety Record: High Risk
Inspections: Getting Worse
Staff Stability: 32% turnover. Near Ohio's 48% average. Typical for the industry.
Penalties: $10,980 in fines. Lower than most Ohio facilities. Relatively clean record.
Skilled Nurses: Each resident gets 47 minutes of Registered Nurse (RN) attention daily — more than average for Ohio. RNs are trained to catch health problems early.
Violations: 73 deficiencies on record. Higher than average. Multiple issues found across inspections.

★★☆☆☆

2.0

Overall Rating

★★★☆☆

3.0

Staff Levels

★★★★★

5.0

Care Quality

★☆☆☆☆

1.0

Inspection Score

↔

Stable

2024: 5 issues

2025: 19 issues

The Good

5-Star Quality Measures · Strong clinical quality outcomes
Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record
Staff turnover below average (32%)
16 points below Ohio average of 48%

Facility shows strength in quality measures, fire safety.

The Bad

2-Star Overall Rating

Below Ohio average (3.2)

Below average - review inspection findings carefully

Staff Turnover: 32%

14pts below Ohio avg (46%)

Typical for the industry

Federal Fines: $10,980

Below median ($33,413)

Minor penalties assessed

Chain: CIENA HEALTHCARE/LAUREL HEALTH CARE

Part of a multi-facility chain

Ask about local staffing decisions and management

The Ugly 73 deficiencies on record

5 actual harm

Aug 2025 13 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

Pressure Ulcer Prevention (Tag F0686)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, interviews with staff at orthopedic medical office, review of National Pressure Injury Advisory Panel (NPIAP) guidance, and facility policy review, the facility failed to implement interventions to prevent the development of pressure ulcers when wearing a splint device and failed to timely identify the resident's pressure ulcers until it reached an advanced stage. Actual harm occurred on 07/30/25 when Resident #37 developed two avoidable unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) pressure ulcers to the underside of the index finger and to the left side of the palm hand when the facility did not remove Resident #37's splint device by the orthopedic clinic's instructions. This affected one (Resident #37) of two residents reviewed for pressure ulcers. The facility census was 209. Findings include: Review of the medical record for Resident #37 revealed an admission date of 08/26/25 with diagnoses including rhabdomyolysis, Alzheimer's disease, generalized muscle weakness, restlessness and agitation, anxiety disorder, and primary generalized osteoarthritis. Review of the care plan dated 08/26/24 revealed there was a skin prevention plan for Resident #37. Interventions included conducting weekly head-to-toe skin assessments; document and report abnormal findings to the physician; and follow facility policies/protocols for the prevention/treatment of impaired skin integrity; The care plan was not updated to reflect Resident #37 was wearing a splint device beginning 05/15/25 and no interventions were added to the care plan to reduce the risk of pressure ulcers with the use of splint device. Review of the after-visit summary (AVS) from Medical Center Orthopedic Clinic #500 revealed Resident #37 was seen on 05/15/25 for left wrist pain. The clinic was unable to obtain a meaningful history from the resident largely due to him being nonverbal and unable to recall any details of his condition. Similarly, his aide accompanying him was also unable to provide a history as to how long the condition had been present. During Resident #37's physical exam, his left wrist had persistent flexion, was unable to passively extend past neutral, sat in full flexion, was very tight and spastic in fingers, his wrist was held in full pronation, his elbow was largely unaffected, and he moved this and his shoulder spontaneously. Overall, he was unable to cooperate with the exam. The results of an x-ray for his left wrist showed some concerns for scapholunate (SL) diastasis, which is a widening (or separation) of the space between the scaphoid and lunate bones in the wrist. The physician's assessment and plan for Resident #37's left spastic hemiplegia stated he did not suspect the deformity was caused by an injury or SL ligament tear. The resident had spastic hemiplegia on the left with unclear etiology. The orthopedic physician stated this was likely due to either a stroke or advancing Alzheimer's disease. The orthopedic physician stated he would fit the resident with a wrist splint to keep him closer to neutral for both comfort and hygiene with no plans for surgical intervention. There were no physician orders on the After Visit Summary. Review of the physician orders dated 05/15/25 revealed an order to remove splint to left wrist and assess skin for any irritation, skin breakdown, swelling, or abnormalities, and report to the medical doctor (MD)/certified nurse practitioner (CNP) if any abnormalities were noted, every shift for prevention. Review of the Braden Scale for Predicting Pressure Sores dated 06/11/25, revealed Resident #37 was at low risk for developing pressure sores with a score of 16. Review of the significant change Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #37 was cognitively impaired. Resident #37 was at risk for developing pressure ulcers with a pressure-reducing device for bed and had the application of nonsurgical dressings and ointments. Review of a nursing progress note on 07/30/25 at 6:38 A.M. revealed Resident #37 was given a bed bath this shift, left hand skin under splint was assessed, mild edema was noted on the thumb, index, and middle finger, no new skin issues were noted, and the plan of care continued. A nursing progress note dated 07/30/25 at 3:45 P.M. revealed upon assessment of removal of the resident's splint to left hand, nurse noticed guest had dark skin/scab-like tissue to lateral left thumb and lateral pinky finger. No swelling to wrist or hands, slight amount of swelling to middle finger noted. Betadine was applied to site and wrapped with Kerlix with immediate intervention to discontinue splint order. Wound nurse in building assessed site. Review of the skin and wound evaluation dated 07/30/25 revealed Resident #37 developed an unstageable pressure ulcer to the left plantar - second digit (index finger) proximal, in-house acquired on 07/30/25. The initial measurements were 8.4 centimeters (cm) area, 6.0 cm in length, 1.9 cm width, not applicable (N/A) for depth, and 100% of the wound filled with eschar (blood and serous fluid) exudate. Additionally, a second skin and wound assessment dated [DATE] revealed Resident #37 had a second unstageable pressure ulcer to the left dorsum hand, distal, in-house acquired on 07/30/25 measuring 4.7 cm area, 3.8 cm length, 1.6 cm width, N/A depth, and 100% of the wound filled with eschar. Review of the physician order for Resident #37 dated 07/30/25 revealed an order to cleanse left medial hand with normal saline, pat dry, apply Betadine-moistened gauze, cover with ABD pad, wrap with Kerlix, and secure with tape every day shift and as needed (PRN) if soiled or dislodged and cleanse left lateral hand with the same treatment and frequency. Interview on 08/05/25 at 3:53 P.M. with Wound Nurse #870 stated it was not possible for the wound on Resident #37's finger to progress to an unstageable wound from 6:38 A.M. to 3:45 P.M. when she assessed the resident's finger. Interview on 08/07/25 at 8:56 A.M. with Licensed Practical Nurse (LPN) #140 revealed the initial reason for applying the splint was swelling, so an X-ray was ordered to rule out a fracture. When Resident #37 was sent to the orthopedic doctor, staff attempted to obtain an after-visit summary but never received it despite requesting it. She reported there were no instructions on how long the splint should be worn, but therapy worked with Resident #37. She explained the splint was intended to stabilize the wrist, extending approximately two inches above it. She stated she had not seen similar splints on other residents. She also stated the pressure ulcer aligned with where the splint was placed, indicating the splint caused the ulcer. There was no documented evidence that the facility attempted to obtain the after-visit summary. Interview on 08/07/25 at 9:18 A.M. with Clinical Director #600 at the Medical Center Orthopedic Clinic #500 revealed when someone came to the clinic, a staff member should have accompanied them and obtained the after-visit summary. She stated the first line of the visit note indicated an aide had accompanied Resident #37 but could not provide any medical history. Resident #37 was first seen on 05/15/25. On 05/22/25, someone from the nursing home called stating they had not received the after-visit summary. On 05/23/25, the office had documentation that the after-visit summary was sent at 10:18 A.M. and confirmed it was faxed to the facility. The note stated the resident would be fitted with a splint to keep the wrist stable, with no follow-up needed. There was no wearing schedule documented in the note, but Clinical Director #600 stated the splint was for comfort and could be removed whenever needed, including during bathing. She stated it should be removed while sitting at rest, and the only time it should be worn was during activity. It should not be worn 24 hours a day. Interview on 08/07/25 at 9:38 A.M. with the Athletic Trainer #700 at the Medical Center Orthopedic Clinic #500 office revealed Resident #37's splint should be worn for comfort only and removed for hygiene. If the splint was too tight, residents/staff were shown how to loosen the Velcro straps. The splint should also be removed for eating, and it was typically recommended that it be removed at night, worn only during the day for comfort and support. She stated that if a splint was worn continuously without removal, it would cause dry skin and irritation. Athletic Trainer #700 confirmed the splint had been given to Resident #37 in May. Athletic Trainer #700 stated if the splint had been removed twice a day and the skin assessed, no issues should have occurred. If the splint was too tight, it would cause pressure injuries. Interview on 08/07/25 at 2:08 P.M. with LPN #140 confirmed Resident #37's splint was not removed except during the twice-daily skin checks. LPN #140 also confirmed the fax number provided above was correct. She confirmed an aide had accompanied Resident #37 to his appointment but could not recall the aide's name. Observation on 08/07/25 at 2:08 P.M. with Wound Nurse #870 revealed the wound on Resident #37's finger was moist with Betadine, with a scab covering the area and pink tissue visible at the center. After removing the gauze, staff noted the dorsal side of the finger showed scabbed tissue with surrounding pink skin. The wound nurse described the area as having superficial skin involvement. The left dorsal wound appeared to have some depth with a central scab, and the wound nurse noted the depth could not be assessed until the scab detached. Review of the facility policy titled Skin Management dated 05/01/10 with a revision date of 09/19/24, revealed the policy aims to identify and implement interventions to prevent clinically unavoidable pressure injuries. It outlines an overview where residents with wounds, pressure injuries, or at risk for skin compromise are evaluated and treated to promote prevention and healing, with ongoing monitoring. Practice guidelines include a baseline total body skin evaluation upon admission, weekly Braden Scale assessments for four weeks, and appropriate preventive measures and interventions for at-risk residents. Residents with skin impairments receive physician-ordered treatment, with documentation of impairment details. The policy also addresses interdisciplinary team evaluations, weekly skin assessments, and the management of pressure injuries, vascular ulcers, skin tears, and bruises, including notification protocols and documentation requirements. Management tools and cross-references to other guidelines are provided to support compliance. Review of the NPIAP guidance titled 2019 Prevention and Treatment of Pressure Ulcers/Injuries: Quick Reference Guide 2019 revealed to reduce the risk of medical device related pressure injuries, review and select medical devices with considerations to minimize issue damage, utilize the correct sizing/shape of the device for the individual and correctly secure the device. Assess the skin under and around medical devices for signs of pressure related injury as part of routine skin assessment. Remove medical device as soon as medically feasible. Use prophylactic dressing beneath a medical device to reduce the risk of medical device related pressure injuries. This deficiency represents non-compliance investigated under Complaint Number OH00167149 (1260022).

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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, resident, guardian and staff interviews, and review of facility policy, the facility failed to maintain a safe, clean and homelike environment in resident rooms. This affected two (Resident #18 and #70) of seven residents reviewed for homelike environment. The facility census was 209 residents.Findings include: Record review revealed Resident #18 was admitted to the facility on [DATE]. Resident #18 had been appointed a guardian on 01/13/25. Interview with the guardian for Resident #18 on 08/04/25 at 1:54 P.M. stated the sink in Resident #18's room had been leaking and the faucet that been loose since March 2025. She stated she had notified the facility of this concern and it has never been fixed. Observations on 08/04/25 at 2:48 P.M., 08/07/25 at 8:54 A.M. and 3:46 P.M., and on 08/11/25 at 8:26 A.M. revealed Resident #18's sink faucet was loose and dripping. The baseboard, approximately three feet in length, behind the toilet was separated from the wall, revealing a dark brown and black surface underneath. An interview with the roommate of Resident #18, Resident #70, on 08/07/25 at 8:54 A.M. stated he used the sink when he was up in his wheelchair. He stated the had told the facility about the loose, leaky sink faucet and it has never been fixed. An interview with Registered Nurse (RN) #330 on 08/11/25 at 8:23 A.M. stated he was aware of the loose leaking sink in Resident #18's room but not aware about the baseboard that was separated from the wall. An interview with Maintenance Workers #801 and #821on 08/11/25 at 8:26 A.M. confirmed Resident #18's sink faucet was loose, leaking and that the baseboard was separated from the wall revealing a dark surface area. They stated that they would fix the baseboard and sink. An interview with Housekeeper #591 on 08/11/25 at 10:49 A.M. revealed she was aware of the separated baseboard and the loose and leaking sink faucet in Resident #18's room and she had reported it to her supervisor. Review of the undated facility policy titled Daily Cleaning of Guest Rooms revealed housekeeping is to report any items that need repaired to the maintenance department. Review of the facility policy titled Federal and State- Resident Rights and Facility Responsibilities dated 05/14/24 revealed the resident has the right to a safe, clean, comfortable and homelike environment. Housekeeping and maintenance services will maintain a sanitary, orderly and comfortable interior.

CONCERN (D) 📢 Someone Reported This

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

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, policy review, and review of the facilities Self-Reported Incidents (SRI), the facility failed to timely report allegations of physical and verbal abuse and injuries of unknown origin to the State Survey Agency. This affected three (#6, #72, and #183) of eight residents reviewed for abuse. The facility census was 209. Findings include: 1. Review of the medical record for Resident #6 revealed the resident was admitted on [DATE]. Diagnoses included alcoholic cirrhosis of the liver without ascites, permanent atrial fibrillation, chronic obstructive pulmonary disease (COPD), and schizoaffective disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 had severe cognitive impairment. Review of the nursing notes dated 12/23/24 documented an interdisciplinary team (IDT) meeting regarding an incident of physical aggression received on 12/21/24. The resident was observed with a bleeding nose and stated, He punched me. All involved parties were made aware, an assessment was completed by the floor nurse, and the immediate intervention was to move the resident to another room. The IDT agreed with the room change. The nursing notes dated 12/31/24 at 8:30 A.M. documented the resident was found with bruising and skin tears to the face, blood on the face and bathroom floor, feces smeared on the body, and one gripper sock on foot with urine on the floor. The resident stated, I probably hit my head. Vital signs were stable. The nursing notes dated 01/02/25 documented an IDT meeting was held to address the bruising and skin tears. The injury was consistent with contact with the bathroom door, and a night light was ordered for the resident’s room. Review of the facilities SRIs from 12/21/24 through 01/02/25 revealed there were no SRIs reported for the allegation of physical abuse for Resident #6 for the incident on 12/21/24 and there was no SRI filed for the injuries of unknown origin on 12/31/24. Interview on 08/07/25 at 11:15 A.M. with the Administrator confirmed the facility did not submit an SRI involving Resident #6 for the physical abuse incident on 12/21/24 and injury of unknown origin on 12/31/24. At 2:07 P.M., the Administrator confirmed an SRI was submitted approximately eight months late following discussion during the survey. 2. Record review for Resident #72 revealed the resident was admitted to the facility on [DATE]. Diagnoses included bipolar disorder, intellectual disabilities, and chronic pain. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #72 had moderately impaired cognition. Review of the nursing progress note dated 06/27/25 revealed Resident #183 was cursing out Resident #72 calling her a 'fat expletive'. This nurse went to investigate the noise and Resident #183 called the nurse an expletive as well. Resident #183 cursing kept going on even when this nurse intervened. Resident #183 made Resident #72 cry. Review of the facility SRI control number 262200, dated 06/30/25, revealed Resident #183 was witnessed by staff screaming profanity words at Resident #72. This SRI was filed three days after the verbal abuse allegation occurred. The nursing progress note dated 07/30/25 revealed Resident #183 was verbally abusive towards residents in the dining area. Resident #183 used words like 'expletive you' and 'expletive' prompting immediate intervention from this nurse and the day shift nurse. Despite being asked to refrain from using such inappropriate language, Resident #183 got more angry and escalated his behavior using even more explicit language. Resident #183 eventually stopped and was escorted to his room to rest. There was no SRI filed with the Stage Survey Agency (SA) by the facility for the allegation of verbal abuse by Resident #183 on 07/30/25. Interview with the Administrator on 08/11/25 at 10:45 A.M. confirmed an SRI for the allegation of verbal abuse which occurred on 06/27/25 between Resident #183 and Resident #72 was not completed until 06/30/25, three days after the incident occurred. The Administrator additionally confirmed no SRI had been completed for the allegation of verbal abuse by Resident #183 on 07/30/25. Review of the facility policy titled Abuse Prohibition, effective 10/14/22, revealed the Administrator or designee will notify any State or Federal agencies of allegations per state guidelines two hours if abuse allegation or serious injury; all other not later than 24 hours.

CONCERN (D) 📢 Someone Reported This

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

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

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, staff interviews, and review of a facility policy, the facility failed to ensure allegations of verbal and physical abuse and injuries of unknown origin were thoroughly investigated. This affected three (#6, #72 and #183) of eight residents reviewed for abuse. The facility census was 209. Findings include: 1. Record review for Resident #72 revealed the resident was admitted to the facility on [DATE]. Diagnoses included bipolar disorder, intellectual disabilities, and chronic pain. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #72 had moderately impaired cognition. Review of the nursing progress note dated 06/27/25 revealed Resident #183 was cursing out Resident #72 calling her a 'fat expletive'. This nurse went to investigate the noise and Resident #183 called the nurse an expletive as well. Resident #183 cursing kept going on even when this nurse intervened. Resident #183 made Resident #72 cry. Review of the facilities investigation revealed it was not initiated until three days later on 06/30/25. The nursing progress note dated 07/30/25 revealed Resident #183 was verbally abusive towards residents in the dining area. Resident #183 used words like 'expletive you' and 'expletive' prompting immediate intervention from this nurse and the day shift nurse. Despite being asked to refrain from using such inappropriate language, Resident #183 got more angry and escalated his behavior using even more explicit language. Resident #183 eventually stopped and was escorted to his room to rest. The facility was unable to provide any investigation into the allegation of verbal abuse by Resident #183 on 07/30/25. Interview with the Administrator on 08/11/25 at 10:45 A.M. confirmed the investigation of the allegation of verbal abuse involving Residents #183 and #72 which occurred on 06/27/25 was not initiated until 06/30/25, three days after the incident occurred. The Administrator additionally confirmed no investigation had been completed for the allegation of verbal abuse by Resident #183 on 07/30/25. 2. Review of the medical record for Resident #6 revealed the resident was admitted on [DATE]. Diagnoses included alcoholic cirrhosis of the liver without ascites, permanent atrial fibrillation, chronic obstructive pulmonary disease (COPD), and schizoaffective disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 had severe cognitive impairment. Review of the nursing notes dated 12/23/24 documented an interdisciplinary team (IDT) meeting regarding an incident of physical aggression received on 12/21/24. The resident was observed with a bleeding nose and stated, He punched me. All involved parties were made aware, an assessment was completed by the floor nurse, and the immediate intervention was to move the resident to another room. The IDT agreed with the room change. The nursing progress notes dated 12/31/24 at 8:30 A.M. documented Resident #6 was found with bruising and skin tears to the face, blood on the face and bathroom floor, feces smeared on the body, and one gripper sock on foot with urine on the floor. The resident stated, I probably hit my head. Vital signs were stable. The nursing notes dated 01/02/25 documented an IDT meeting was held to address the bruising and skin tears. The injury was consistent with contact with the bathroom door, and a night light was ordered for the resident’s room. The facility was unable to provide any investigations into the physical aggression incident on 12/21/24 and any investigation into the injuries of unknown origin Resident #6 sustained. An interview conducted on 08/07/25 at 11:15 A.M. with the Administrator confirmed although injuries and an incident were documented, no formal investigation was initiated to determine the cause or to identify responsible parties. There was no evidence of staff interviews, injury assessments of other residents, or follow-up actions consistent with a proper abuse investigation. The Administrator acknowledged the facility failed to conduct a thorough investigation into the alleged abuse incidents involving Resident #6. Review of the facility policy titled Abuse Prohibition effective 10/14/22 revealed allegations by anyone who becomes aware of verbal, physical, mental, sexual or emotional abuse and mistreatment, neglect, exploitation, involuntary seclusion or misappropriation of property must be immediately reported to his/her Administrator. A preliminary, on-site investigation will be initiated within twenty-four (24) hours of any report.

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 F0688 (Tag F0688)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, staff interviews and review of facility policy, the facility failed to provide residents who had contractures their splint devices as physician ordered. This affected two (Residents #144 and 209) of four residents reviewed for range of motion. The facility identified 19 residents with contractures. The facility census was 209. Findings include: 1. Review of the medical record for Resident #144 revealed an admission date of 03/27/17 . Diagnoses included paralytic syndrome, polyneuropathy, and contracture right hand and wrist 10/01/18. Review of the physician orders dated 11/12/22 revealed Resident #144 was to have a right palm protector applied between 7:00 A.M. and 7:00 P.M. for up to eight hours daily. Review of Resident #144’s care plan dated 10/20/23 and last updated 08/07/25 revealed Resident #144 had a functional ability deficit and required assistance with self-care related to his contracture of his right hand and wrist. A goal was to improve of maintain current level of function in activities of daily living. A listed intervention was to apply right palm protector between 7:00 A.M. and 7:00 P.M. as tolerated for up to eight hours a day. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #144 had moderately impaired cognition and required substantial maximum assistance with upper body dressing and personal hygiene. Review of Resident #144’s comprehensive nursing quarterly assessment dated [DATE] revealed Resident #144 had a decreased range of motion. Observations on 08/04/25 at 12:09 P.M. and 5:15 P.M., 08/05/25 at 7:23 A.M, 10:33 A.M, and 2:29 P.M., and on 08/06/25 at 9:06 A.M. revealed Resident #144 was not wearing his palm protector. An interview with Licensed Practical Nurse (LPN) #630 on 08/06/25 at 9:55 A.M. confirmed Resident #144 was not wearing his palm protector as ordered. LPN #630 stated the restorative aide, Certified Nursing Aide (CNA) #825 was responsible for applying the palm protector for Resident #144. An interview with CNA #825 on 08/06/25 at 10:25 A.M. revealed she did not ever apply the palm protector to Resident #144’s hand. CNA #825 indicated that perhaps the other restorative aide, CNA #885, applied the palm protector to Resident #144. An interview with CNA #885 on 08/06/25 at 10:57 A.M. revealed she did not apply the palm protector to Resident #144 and that the direct daily care CNAs on Resident #144’s hall were responsible for applying the palm protector. 2. Record review for Resident #209 revealed the resident was admitted to the facility on [DATE]. Diagnoses included contracture of the left hand and left elbow, and hemiplegia and hemiparalysis affecting the left non-dominant side. Review of the active physician's order, dated 08/22/23, revealed to apply left c-roll splint for six hours between 7:00 A.M. and 3:30 P.M. Check skin upon removal. Review of the care plan, revised 04/16/25, revealed Resident #209 had a functional ability deficit and required assistance with self care/mobility. Apply left c-roll splint for six hours between 7:00 A.M. and 3:30 P.M. as tolerated. Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/25/25, revealed Resident #209 had moderately impaired cognition and a functional limitation in range of motion to one upper extremity. Observations on 08/04/25 at 10:40 A.M. and 2:05 P.M. revealed Resident #209 was lying in bed and the resident's left hand and elbow were contracted with no splints or other devices in place. Subsequent observations on 08/05/25 at 8:10 A.M., 10:15 A.M., and 1:40 P.M. revealed Resident #209 was lying in bed and the resident's left hand and elbow were contracted with no splints or other devices in place. Observation and interview on 08/05/25 at 4:00 P.M. with Certified Nursing Assistant (CNA) #125 confirmed Resident #209 had a contracture of the left hand and used to have a splint but did not anymore and had not had one in place on the day of the observation. Observation on 08/06/25 at 10:02 A.M. revealed Resident #209 was lying in bed and the resident's left hand and elbow were contracted with no splints or other devices in place. Review of the facility policy titled Brace and Splint Program effective 05/01/24 revealed properly used, splints and braces can enhance mobility, correct alignment, and protect a specific extremity while maintaining skin integrity and circulation.

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interviews, and facility policy review, the facility failed to complete a thorough fall investigations, failed to ensure residents had adequate footwear to prevent accidents, and failed to appropriately secure the resident's smoking materials. This affected three (Residents #70, #84, and #110) of 12 residents reviewed for accidents. The facility census was 209. Findings include: 1. Review of the medical record for Resident #84 revealed a re-admission date of 12/20/24. Diagnoses included Alzheimer’s disease with late onset, dementia, and osteopenia. Review of the fall risk assessment dated [DATE] revealed Resident #84 was at risk for falls. Review of the plan of care dated 05/17/24 revealed Resident #84 was at risk for falls due to impaired cognition and mobility limitations. Interventions included providing adequate lighting, keeping call light and commonly used items within reach, placing the call light within reach and encouraging the resident to use it for assistance, anticipating and meeting needs as needed, observing for fatigue and unsteadiness and encouraging rest periods as needed, and orienting the resident to surroundings as needed. Review of physician orders for December 2024 identified orders related to fall prevention and management of injuries sustained from the fall. Orders included pain management with acetaminophen as needed for pain relief following the right hip fracture diagnosed post-fall. Mobility orders continued to support the use of a walker and wheelchair for locomotion after the resident returned from the hospital on [DATE]. Review of the nursing notes dated 12/13/24 at 7:30 P.M. revealed Resident #84 was found on the floor in her room with the lights off, complaining of right hip pain and rated it a seven on a pain scale of zero (no pain) to ten (most severe pain). The care plan was immediately adjusted to ensure room lighting remained on. A telehealth note dated 12/14/24 reported an acute right hip fracture diagnosed by X-ray after the fall, with the resident transferred to the hospital for further management. Notes dated 12/16/24 and 12/23/24 documented interdisciplinary team (IDT) meetings addressing the fall and the resident’s return from the hospital, agreeing to continue walker and wheelchair use. Review of the fall investigation dated 12/13/24 revealed the resident had turned off the lights in her room, contributing to the fall. The immediate intervention was to ensure adequate lighting. However, the investigation did not include interviews of staff to determine the root cause of the fall or any additional contributing factors. The care plan was not updated to reflect the use of walker and wheelchair as fall prevention interventions following the resident’s return. The facility failed to comprehensively investigate the fall or modify interventions appropriately. Review of the hospitalization after visit summary (AVS) for Resident #84 revealed an admission date from 12/14/24 to 12/20/24. Resident #84 sustained a fall and was found to have an acute right hip fracture. The x-ray presented a displaced subtrochanteric fracture of the right proximal femur. Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/08/25, revealed Resident #84 had severely impaired cognition and required maximum assistance for toileting, bathing, chair-to-chair transfers, and toilet transfers; moderate assistance for upper extremity dressing, personal hygiene, rolling left to right, sitting to lying, sit to stand, and walking 10 feet; was dependent on staff for putting on and removing footwear; and used a walker and wheelchair for locomotion. Interview on 08/07/25 at 3:29 P.M. with the Director of Nursing stated she was unsure if the resident was asked what she was attempting to do at the time of the fall. She confirmed the interdisciplinary team met post-return and decided to continue walker and wheelchair use but did not add these to the care plan. She also confirmed the intervention to maintain adequate lighting was not new, having been in place since May 2024, and the lights being off contributed to the fall. Interview on 08/07/25 at 3:46 P.M. with the Unit Manager #140 confirmed the resident used a wheelchair for ambulation requiring staff assistance and the resident slept with the lights off in her room at night. 2. Review of the medical record for Resident #110 revealed an admission date prior to 04/15/25. Diagnoses included dementia, unsteadiness on feet, muscle wasting and atrophy, and agitation managed with olanzapine. Review of the plan of care dated 03/29/25 revealed Resident #110 was at risk for falls due to unsteadiness, muscle weakness, and cognitive impairment. Interventions included encouraging the resident to wear appropriate footwear as needed and maintaining a safe environment with even floors free from spills and clutter. On 04/28/25, a new intervention was implemented to include the resident’s non-skid socks were replaced with a new pair. Review of the nursing notes dated 04/26/25 at 9:30 P.M. revealed Resident #110 was found kneeling in front of the bed with a small skin tear above the right eyebrow and bruising to the right cheekbone and nose bridge after an unwitnessed fall. The resident reported slipping while coming from the bathroom, slipping on the floor with non-slip socks whose grips appeared worn and inadequate. Neurological checks were initiated, pain medication administered, and the socks were replaced with new ones. Review of the fall investigation dated 04/28/25 revealed the cause of the fall was attributed to worn non-slip socks that lacked sufficient grip. Immediate intervention included replacing the socks. The care plan continued to reflect fall prevention strategies but did not specifically address routine inspection or replacement of footwear provided by the facility. Interview on 08/07/25 at 1:42 P.M. with the Director of Nursing stated the root cause of the fall was the resident’s worn non-skid socks. She confirmed the facility provided the socks, which were shared and cleaned between residents, but staff did not routinely check the condition of the socks prior to applying them. She confirmed the only new intervention after the fall was replacing the socks with a new pair. Review of the facility policy titled Fall Management last revised on 07/08/2025 revealed the policy aimed to identify hazards and resident risk factors and implement interventions to minimize falls and risk of injury related to falls. It outlined an overview where residents were assisted in attaining and maintaining their highest practical level of function by providing adequate supervision, assistive devices, and/or functional programs, with appropriate interventions to minimize fall risk. Residents were evaluated by the interdisciplinary team for their fall risk, and a plan of care was developed and implemented with ongoing review. If a fall occurred, the interdisciplinary team conducted an evaluation to ensure appropriate measures were in place, coordinated by the Director of Nursing or designee. Practice guidelines included evaluating residents for fall risk upon admission, re-admission, quarterly, annually, and with significant condition changes, developing an initial plan of care, evaluating for injury post-fall, completing incident reports, and conducting post-fall evaluations within 24 to 72 hours. The interdisciplinary team reviewed all falls, modified care plans, and conducted monthly reviews, while the Director of Nursing or designee documented changes and reported data to the Quality Assurance and Performance Improvement (QAPI) committee for trending and recommendations. 3. Review of medical record for Resident #70 revealed an admission date of 11/08/24. Diagnoses included peripheral vascular disease, right and left above knee amputations, and muscle wasting. Review of the care plan dated 10/27/24 revealed Resident #70 wished to use smoking products and was assessed as being unsafe to smoke and needed supervision. The goal was listed to be safe while using smoking products and complying with the smoking policy. An intervention listed was that staff members were to maintain all smoking paraphernalia for all safe and unsafe smokers, including lighters. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #70 was cognitively intact, had rejection of care for one to three days during the assessment period, and utilized tobacco. Resident #70 required substantial to maximum assistance from staff for personal hygiene and partial to moderate assistance with oral hygiene. Review of Resident #70’s smoking assessment dated [DATE] revealed Resident #70 required supervision during smoke break related to his hands having contractures and weakness. Resident #70 was not safe to light smoking materials and did not utilize not oxygen. Resident #70 was not a safe smoker. Review of Resident #70’s physician orders dated 06/24/25 revealed Resident #70 had an order for oxygen at six liters to maintain an oxygen level above 88 percent (%) every shift for shortness of breath as needed. Observations of Resident #70 on 08/04/25 at 10:13 A.M., 12:26 P.M., and 2:50 P.M. revealed Resident #70 had two lighters with liquid visible in them at his bedside within reach on his bedside table. Interview with Nursing Administration #130 on 08/04/25 at 2:53 P.M. confirmed the presence of two lighters within reach of Resident #70 at his bedside. Interview with Activity Aide #211 on 08/05/25 at 4:25 P.M. and with Activity Aide #191 on 08/11/25 at 8:24 A.M. revealed even safe smokers were unable to keep lighters or other smoking paraphernalia on their person. All smoking materials were to be locked up in a smoking lock box. Review of the facility policy titled “Smoking Policy” dated 06/17/25 revealed staff members will maintain all smoking paraphernalia for all safe and safe smokers, including lighters and lighter fluid. This deficiency represents non-compliance investigated under Complaint Number OH00167527 (1260015).

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

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, staff interviews, policy review, and review of hospital records, the facility failed to provide adequate respiratory care for Resident #47 who had localized fly larvae infestation to her tracheostomy and stoma and required hospitalization. This affected one (#47) of five residents reviewed for respiratory care. The facility identified 36 residents residing on the tracheostomy unit. The facility census was 209. Findings included: Review of Resident #47's medical record revealed an admission date of 10/23/24. Diagnoses included acute and chronic respiratory failure, hemiplegia and hemiparesis, tracheostomy and ventilator dependent. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 had severely impaired cognition. Resident #47 was also totally dependent on staff for all care including tracheostomy care. Review of the active physician orders revealed Resident #47 was to receive tracheostomy care every 12 hours which included changing of the disposable inner cannula and to check the skin under the tracheostomy ties on each shift as well. Review of the Treatment Administration Record (TAR) from 04/01/25 to 07/31/25 revealed all tracheostomy care had been completed and signed off by various Respiratory Therapists. Review of the nursing note from 06/30/25 at 5:13 A.M. from Licensed Practical Nurse (LPN) #680 revealed multiple fly larvae (maggots) in and on the tracheostomy site of Resident #47. An order was received to send the resident to the emergency room for further evaluation. Review of the hospital notes dated 06/30/25 revealed three larvae were identified upon arrival to the emergency room. The infestation was removed locally in the emergency room with all larvae being successfully removed. Infectious Diseases was consulted with no recommendations except local removal. Ventilator dependent pneumonia was also summarily ruled out. Wound care was consulted with no recommendations except local removal. Notes state a debridement of the tracheostomy stoma was not necessary. Resident #47 returned to the facility on [DATE]. Observation on 08/05/25 at 10:10 A.M. revealed multiple house flies and fruit flies were flying around the tracheostomy unit. The flies were also landing on multiple surfaces during this observation. Observation of Resident #47 on 08/06/25 at 9:45 A.M. revealed the resident's room was located next to an exit door that opens up to the outside. No observations were made of staff or residents utilizing this door to the outside as it had a sign posted to be used for emergency purposes only. Subsequent observations on 08/06/25 at 12:25 P.M., 08/07/25 at 2:10 P.M., and 08/11/25 at 9:55 A.M. revealed multiple house flies and fruit flies were flying around the tracheostomy unit. The flies were also landing on multiple surfaces during these observations. Interview with Respiratory Therapist #945 on 08/06/25 at 2:45 P.M. verified the tracheostomy and stoma of Resident #47 had been infested with fly larvae and the resident had been sent to the hospital due to the findings on 06/30/25. He stated tracheostomy care was scheduled once per shift, and the eggs may hatch into their larval form in approximately 12 hours. He also verified that due to the findings on that day, the facility had installed florescent fly traps at the ends of each hall and prohibited entry or exiting from the outside doors located at the end of each hall. Prior to 06/30/25, staff frequently used the exit doors on the tracheostomy for various reasons. Attempts to interview Licensed Practical Nurse #680 and Respiratory Therapist #955, who worked on 06/30/25, during the survey were unsuccessful. Review of the facility's undated policy titled Tracheostomy Suctioning revealed there was no relevant information on the care required for fly larvae infestation. This deficiency represents non-compliance investigated under Complaint Number OH00167441 (1260024) and Complaint Number OH00167149 (1260022).

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 F0697 (Tag F0697)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and facility policy review, the facility failed to consistently evaluate the effectiveness of regularly scheduled opioid pain medication in accordance with the resident's comprehensive care plan. This affected one (#159) of five residents reviewed for unnecessary medications. The facility census was 209. Findings include:Review of Resident #159's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included fibromyalgia (long-term condition that involves widespread body pain) and polyarthritis (a form of arthritis affecting five or more joints simultaneously, causing pain, swelling, warmth, and stiffness). Review of the physician order summary dated 03/04/25 revealed Resident #159 had an order for Tramadol (an opioid and treats moderate to severe pain) 50 milligrams (mg) give one tablet by mouth two times a day for polyarthritis. Review of the care plan dated 06/29/25 revealed Resident #159 was at risk for chronic pain and the interventions included evaluate the effectiveness of pain medication as given and review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition as needed. Review of the medication administration record (MAR) from 07/01/25 to 08/11/25 for Resident #159 revealed an order for Tramadol HCL oral tablet 50 mg, give one tablet by mouth two times a day for polyarthritis, scheduled at 8:00 A.M. and 8:00 P.M. There was no pain scale and effectiveness of the medication in association with the administration of Tramadol in the MAR, treatment administration record (TAR), and progress notes. Review of Resident #159's Pain Level Summary from 05/11/25 to 08/11/25 revealed there were no records of a pain level during this time. An interview with Registered Nurse (RN) #660 on 08/11/25 at 9:19 A.M. verified there was no pain scale in Resident #159's MAR or medical record. RN #660 stated that most of the residents have a pain scale and verified there was no documentation the staff were monitoring the effectiveness of Tramadol for Resident #159. An interview with Certified Nurse Practitioner (CNP) #51on 08/11/25 at 9:27 A.M. confirmed any resident receiving scheduled Tramadol should be assessed for pain every time it was given and then evaluated for effectiveness of the Tramadol. Review of the facilities Pain Management policy last revised 3/05/25 revealed each resident identified with pain will have a pain management care plan. The care plan will have: a consistent pain scale to measure the pain and frequency of re-evaluation, a desired level of pain reduction or acceptable level of pain, resident-centered functional outcomes (e.g., ability to participate in favorite activity, visiting with family, ambulating to the dining room, sleeping through the night), pain monitoring and who will monitor for the pain, nursing comfort measures to alleviate pain, and potential adverse effects of treatment.

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 F0699 (Tag F0699)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident and staff interviews, and review of facility policy, the facility failed to identify post traumatic stress disorder (PTSD) triggers on the care plan for Resident #48 and failed to assess Resident #8 for PTSD upon admission. This affected two (Residents #8 and #48) of five residents reviewed for mood and behavior. The facility census was 209.Findings include: 1. Review of the medical record for Resident #48 revealed an admission date of 06/17/25. Diagnoses included PTSD, anxiety disorder, and depression. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #48 was cognitively intact and did not have behaviors. Review of the social services evaluation dated 06/27/25 revealed Resident #48 had experienced a loss of a significant other and a traumatic event of a motor vehicle accident with mass casualties. Symptoms due to her PTSD included flashbacks, hypervigilance, fear, severe anxiety, loneliness and unwanted thoughts. Triggers included people, thoughts and feelings. Review of the care plan dated 07/04/25 revealed Resident #48 had potential for fluctuations in mood due to PTSD. A goal listed was to have stable or improved mood and no signs of symptoms of anxiety. Interventions included administering medications as ordered, approaching in a calm, quiet manner, assisting in developing an activity program, assisting resident to identify coping skills, encouraging resident to verbalize feelings, and observing and reporting to social worker and/or physician when resident has acute change in mood or behavior or when resident is at risk for harm to self. The care plan did not identify any triggers that may help caregivers to not be re-traumatized. Interview with Social Worker #771 on 08/06/25 at 9:23 A.M. confirmed Resident #48’s care plan did not include identified triggers that may re-traumatize Resident #48. 2. Review of the medical record for Resident #8 revealed an admission date of 06/02/25. Diagnoses included surgical amputation, chronic obstructive pulmonary disease , alcoholic cirrhosis of liver, and end stage renal disease. Review of Resident #8's medical record from 06/02/25 to 08/11/25 revealed no indication Resident #8 was accessed for PTSD. An interview on 08/04/25 at 2:28 P.M. with Resident #8 stated he was sad and very depressed. Resident #8 stated he lost his only child (son) to suicide on Easter, April 2025 and recently had his right leg amputated, becoming a bilateral amputee of both legs losing his independence. He denied being suicidal and asked if he could talk to someone. Interview on 08/12/25 at 9:30 A.M. with Social Service Designee #771 confirmed there was no PTSD assessment completed for Resident #8. She was unaware of him losing a son in April of 2025. Review of the facility policy titled “Social Service Documentation” dated 08/01/24 revealed the facility is committed to providing culturally competent, trauma informed care in accordance with professional standards of practice and accounting for residents’ experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. If trauma is identified, care plans to address the trauma, including triggers and interventions to mitigate or lessen re-traumatization will be authored.

CONCERN (D) 📢 Someone Reported This

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

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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Based on observation, staff interview, record review, review of Centers for Disease Control and Prevention (CDC) guidance and review of facility policy, the facility failed to ensure staff followed Enhanced Barrier Precautions (EBP) in designated resident rooms. This affected one (Resident #10) of four residents reviewed for EBP. The facility census was 209. Findings included:Review of the medical record for Resident #10 revealed an admission date of 07/15/21. Diagnoses included chronic obstructive pulmonary disease. Review of Resident #10's physician orders for 08/01/25 to 08/11/25 revealed an active order for Resident #10 to be on EBP related to chronic wound. Observation on 08/05/25 at 2:40 P.M. revealed Certified Nursing Assistant (CNA) #115 assisting Resident #10 at the bedside with gloves on. He went into the resident's bathroom and exited out of the room with gloved hands. CNA #115 was not wearing a gown during provision of care. Interview on 08/05/25 at 2:42 P.M. with CNA #115 confirmed he performed incontinence care for Resident #10 with gloves only. CNA #115 confirmed he did not wear a gown as indicated by the EBP sign outside Resident #10's room. Observation on 08/05/25 at 3:52 P.M. of Resident #10 who resided in bed B revealed outside of her room to the right of her door were two signs for EBP for bed A and Resident #10 bed B. The sign indicated providers and staff must clean their hands, including before entering and when leaving the room, wear gloves and a gown for the following activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting. Device care or use central line, urinary catheter, feeding tube, tracheostomy and wound care (any opening requiring a dressing). Review of the facility policy titled “Enhanced Barrier Precautions (EBP)” dated 03/05/25 revealed the facility is to use EBP in addition to standard precautions for preventing transmission of CDC targeted multidrug-resistant organisms (MDROs). EBP are indicated for residents with chronic wounds. Health care personnel caring for residents on EBP should wear gloves and gowns during high-contact resident care such as dressing, bathing showering, transferring providing hygiene(focused on A.M. and P.M. care) changing linens, changing briefs or assisting with toileting, device care or use, central line, urinary catheter, feeding tube, tracheostomy/ventilator and wound care: chronic wounds. Review of CDC guidance titled Implementation of PPE Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) found at https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html and dated 04/02/24 revealed MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. EBP are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP may be indicated for residents with any of the following: wounds or indwelling medical devices, regardless of MDRO colonization status.

CONCERN (E) 📢 Someone Reported This

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

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

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews, and review of facility policy, the facility failed to ensure residents advance directives were readily available to facility staff and Emergency Medical Service (EMS) personnel. This affected four residents (#17, #129, #198, and #236) of the 51 residents reviewed for advance directives. The facility census was 209. Findings included: 1. Closed record review for Resident #236 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included dementia with severe psychotic disturbance, atrial fibrillation, and repeated falls. Review of the admission Minimum Data Set (MDS) assessment, dated [DATE], revealed Resident #236 was severely impaired cognition. Review of the physician's order, dated [DATE], revealed Resident #235's code status was Do Not Resuscitate Comfort Care Arrest (DNRCC-A) and Do Not Intubate (DNI). Review of the facility's advance directive form, signed by Resident #236's son on [DATE], revealed the resident was to not have Cardiopulmonary Resuscitation (CPR) initiated in the event the resident's heart or breathing stopped. The resident was not to be transported to the hospital for emergency intervention. The form was not signed by the physician. No other advance directive forms were present in the resident's electronic health record. Review of the progress note dated [DATE] at 8:10 P.M. revealed Resident #236's oxygen saturation level was 66 percent. Emergency 9-1-1 was called and resident's son notified. The progress note dated [DATE] at 8:29 P.M. revealed emergency medical services (EMS) personnel in facility currently performing CPR. Nurse Practitioner notified for verbal order for no resuscitation and medics unable to take verbal order over the phone due to needing order signed by the attending. Medics continue working on resident at this time. The progress note dated [DATE] at 9:28 P.M. revealed the resident's condition had changed upon their arrival. CPR was performed by paramedics on site and a pulse was successfully restored. Resident transported to hospital. Review of the EMS run report, dated [DATE], revealed EMS dispatched to facility for difficulty breathing. EMS entered the room and found Resident #236 pulseless and without respirations. Due to staff inability to provide a valid DNR, life saving efforts were initiated. Resident was moved to the floor and compressions were initiated. Initial heart rhythm showed Pulseless Electrical Activity (meaning the heart had electrical activity but no detectable pulse). Advanced Life Support continued. Upon next rhythm check possible Ventricular Fibrillation observed. Emergent transport initiated, resident maintained pulses and was monitored closely throughout transport. Arrived at hospital and transferred care to hospital staff. Review of the hospital visit note, dated [DATE], revealed Resident #236 presented to the hospital in cardiac arrest from skilled nursing facility. Per EMS, resident had a DNRCC but facility unable to find the paperwork and there was no family. Life saving measures continued at the hospital and the resident was revived. Family arrived and confirmed the resident was DNRCC. Care was de-escalated and the resident died quietly with multiple family at bedside. Telephone interview with Registered Nurse (RN) #280 on [DATE] at 2:12 P.M. confirmed Resident #236 had a change in condition around the change of shift on [DATE]. RN #280 confirmed Resident #236 went unresponsive and EMS were called. RN #280 confirmed the resident had an order for DNRCC-A code status but the DNR paperwork signed by the physician could not be located. RN #280 confirmed EMS personnel arrived and began CPR, obtained a heartbeat for the resident, then took him to the hospital. 2. Record review for Resident #17 revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), acute respiratory failure with hypoxia, and atrial fibrillation. Review of the significant change MDS assessment dated [DATE] revealed Resident #17 was mildly impaired cognition. Review of the active care plan, dated [DATE], revealed Resident #17 was full code status. Interventions included code status to be reviewed upon readmission, quarterly, with significant changes, and at the desire of the resident or responsible party. Review of the physician's order, dated [DATE], revealed Resident #17 was to be DNRCC-A. Additional record review for the resident revealed no signed DNR paperwork was available for review in the resident's electronic health record. Observation and interview with Unit Manager #110 on [DATE] at 8:10 A.M. confirmed there was a code status book located at each nurse's station. RN Unit Manager #110 confirmed there was to be DNR paperwork signed by the physician for each resident who wished to be DNR code status. Unit Manager #110 confirmed there was not signed DNR paperwork in the code status book for Resident #17. Record review and interview with Unit Manager #110 on [DATE] at 8:30 A.M. confirmed there was not signed DNR paperwork located in the electronic health record of Resident #17. 3. Review of the medical record for Resident #129 revealed an admission date of [DATE]. Diagnoses included cerebral atherosclerosis and type II diabetes mellitus with hyperglycemia. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #129 was cognitively impaired. Review of Resident #129’s medical chart revealed signed DNR paperwork in electronic medical record (EMR). Review of Resident #129’s physician orders revealed he has active no CPR/DNR order. Observation of the code status book on Resident #129’s nursing unit revealed there was not a signed DNR copy in the code status binder for Resident #129. Interview with Unit Manager #130 on [DATE] at 8:12 A.M. confirmed there was a code status book located at each nurse's station. Unit Manager #130 confirmed there was not a copy of signed DNR paperwork in the code status binder for Resident #129. 4. Review of the medical record for Resident #198 revealed an admission date of [DATE]. Diagnoses included disorder of congestive heart failure and dementia. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #198 was cognitively intact. Review of Resident #198’s physician orders revealed she had an advanced directive code status of DNRCC-A, which indicated Resident #198 did not wish for resuscitative measures to be initiated if they experienced cardiac or respiratory arrest; however, until such an arrest occurs, they would receive full medical treatment. Observation of the code status book on Resident #198’s nursing unit revealed there was not a DNRCC-A signed form in the code status binder for Resident #198. Interview with Registered Nurse (RN) #130 on [DATE] at 9:01 A.M. confirmed there was no advanced directives sheet in the code status binder for Resident #198. RN #130 confirmed if a resident was to code, they would need to be able to pull up the advanced directives in the binder to confirm the resident’s code status. Review of the facility policy titled Ohio Advance Directive effective [DATE] revealed the facility will determine whether the resident's physician issued a DNR Order in another setting and whether the resident would like a DNR Order issued while in the facility. Copies of all advance directives will be obtained from the resident and/or family and placed in the medical record. If applicable, a DNR Order will be obtained from the residents physician and placed in the medical record. This deficiency represents non-compliance investigated under Complaint Number OH00167220 (1260023).

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

ADL Care (Tag F0677)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, medical record review, and policy and procedure review, the facility failed to provide residents who were dependent on staff for activities of daily living (ADLs) adequate care and services for personal hygiene. This affected four (#8, #15, #134, and #209) of eight residents reviewed for ADLs. The facility census was 209. Findings included: 1. Review of the medical record for the Resident #8 revealed an admission date of 06/02/25. Diagnoses included surgical amputation, chronic obstructive pulmonary disease, alcoholic cirrhosis of liver, peripheral vascular disease, and end stage renal disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 had intact cognition and was dependent on staff for showering/bathing, upper body dressing, and personal hygiene. Review of Resident #8's progress notes, shower/bathing sheets, and task information charting sheet for grooming from 07/01/25 to 08/05/25 revealed it did not indicate if staff offered to trim or shave Resident #8's facial hair and/or refused to be shaven. Observation and interview on 08/04/25 at 2:25 P.M. revealed Resident #8 was unshaved, his mustache was long covering his top and bottom lips, and his beard was growing down his neck. The hairs appeared to be at least one inch long. His hair was uncombed. He denied anyone asking if he would like his mustache and beard trimmed or completely shaved off. Resident #8 confirmed he would like his beard and mustache shaved. When asked, if he would like his mustache and beard trimmed or shaved, he replied, “yes.” The nurse on duty was notified by State Survey Agency. Interview on 08/04/25 at 3:00 P.M. with the Unit Manager (UM) #120 confirmed the certified nursing aides (CNAs) should be asking the residents if they would like their facial hair shaved when ADL care was performed. UM #120 confirmed Resident #8's beard and mustache needed to be groomed. Observations on 08/06/25 at 1:00 P.M. and 08/07/25 at 9:00 A.M. revealed Resident #8 had not been shaved. 2. Review of the medical record for Resident #134 revealed an admission date of 11/23/22. Diagnoses included multiple sclerosis, contracture right hand, and gastrostomy status. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #134 had intact cognition was dependent on staff for showering/bathing, upper body dressing, and personal hygiene. Review of Resident #134’s care plan dated 02/12/25 revealed Resident #134 had a functional ability deficit and required assistance with self-care and mobility related to multiple sclerosis. A goal listed was to improve or maintain current level of function in personal hygiene. An intervention listed was to keep her fingernails trimmed and clean. Observations of Resident #134’s nails on 08/04/25 at 11:12 A.M. and 08/07/25 at 3:48 P.M. revealed her right hand was contracted. Her long fingernails were resting against the palm of her contracted right hand. Interview with Resident #134 on 08/04/25 at 11:12 A.M. revealed she had asked nursing to cut her fingernails frequently. She stated after she would ask to have her nails trimmed, nursing would state they would be back to perform the task, but then would not perform nail care. Interview with Certified Nurse Aide (CNA) #735 on 08/07/25 at 3:57 P.M. revealed Resident #134 did not refuse grooming or care. Interview with CNA #145 on 08/07/25 at 3:58 P.M. revealed Resident #134 did not refuse grooming or care. Interview with CNA #825 on 08/07/25 at 4:00 P.M. confirmed Resident #134’s nails were long and untrimmed. Review of the facility policy titled “Routine Resident Care” dated 03/12/25 revealed daily personal hygiene minimally includes assisting residents with their nail care. 3. Medical record review revealed Resident #15 was admitted to the facility on [DATE]. Diagnoses included dementia, psychotic disturbance, mood disturbance, and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 had impaired cognitive function or impaired thought processes. Resident #15 was dependent on staff for personal hygiene. Review of Resident #15's plan of care, dated 06/02/25, revealed Resident #15 had an ADL functional deficit, and required substantial to maximal assistance with all self-care. Interventions included assistance with upper body dressing, and personal hygiene. Review of Resident #15's nursing notes and behavior monitoring sheets from 07/29/25 to 08/11/25 revealed no documentation Resident #15 was resistive to care. Observations on 08/04/25 at 10:20 A.M. and 12:10 A.M. revealed Resident #15 was in bed propped on his right side and appeared unshaven with a long beard. An interview with Registered Nurse (RN) #130 on 08/04/25 at 2:46 P.M. revealed the men get shaved as needed, if the resident allows staff to shave them. When the certified nursing aides get the resident up and dressed, they should be offering to shave the resident and then the resident can refuse or accept. An interview with RN #130 on 08/04/25 at 2:50 P.M. confirmed Resident #15 had several days growth beard. RN#130 asked Resident #15 if he wanted shaved and Resident #15’s sister said he needs to be shaved. RN #130 asked the sister of Resident #15 if he needed shaved daily and Resident #15’s sister said yes. 4. Record review for Resident #209 revealed the resident was admitted to the facility on [DATE]. Diagnoses included diabetes mellitus, contracture of the left hand and left elbow, and hemiplegia and hemiparalysis affecting the left non-dominant side. Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/25/25, revealed Resident #209 had moderately impaired cognition and a functional limitation in range of motion to one upper extremity. Resident #209 was dependent on staff for assistance with personal hygiene. Review of the care plan, revised 04/16/25, revealed Resident #209 had a functional ability deficit and required assistance with self care/mobility. Interventions included keep fingernails clean and trimmed. Observations on 08/04/25 at 10:40 A.M. and 2:05 P.M. and 08/0525 at 8:10 A.M., 10:15 A.M., and 1:40 P.M. revealed Resident #209 was lying in bed and the resident's left hand was contracted and the fingernails on the left hand were long and dirty. Observation and interview on 08/05/25 at 4:00 P.M. with Certified Nursing Assistant (CNA) #125 confirmed Resident #209 had a contracture of the left hand and the fingernails on the resident's left hand were long and dirty and in need of being cleaned and trimmed. CNA #125 obtained a damp washcloth and gently cleansed inside the resident's left hand. Upon removing the white washcloth from the resident's hand, brown debris was present. CNA #125 confirmed the residents hand had a yeast-like odor to it which should not be present. Observation on 08/06/25 at 10:02 A.M. revealed Resident #209 was lying in bed. The resident's left hand was contracted and the fingernails to the left hand continued to be long and dirty. Review of the facility policy titled Routine Resident Care effective 03/12/25 revealed daily personal hygiene minimally included assisting or encouraging residents with washing their face and hands, shaving, nail care, and brushing their teeth and/or providing denture care. This represents noncompliance investigated under Complaint Number OH00167220 (1260023).

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 F0925 (Tag F0925)

Could have caused harm · This affected most or all residents

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Based on observations, resident interviews, staff interviews, and review of facility policy, the facility failed to maintain an effective pest control program. This affected eight residents (#47, #57, #70, #90, #116, #134, #179, and #225) and had the potential to affect all residents living in the facility. The facility census was 209. Findings include: 1. Interview with Resident #90 on 08/04/25 at 9:53 A.M. revealed gnats and roaches were present in the facility on a daily basis. Interview and observation with Resident #57 on 08/04/25 at 9:51 A.M. revealed gnats were present in his room on a daily basis. Several gnats were observed flying around the room and landing on the privacy curtain. Interview and observation with Resident #70 on 08/04/25 at 10:13 A.M. revealed gnats were present in his room on a daily basis. He stated he told management about the gnats in his room. Several gnats were observed to be flying around the room and landing on Resident #70’s tray table. Interview with Resident #116 on 08/04/25 at 10:32 A.M. revealed roaches were in her room on a daily basis and she could feel them crawling on her while she was in bed at times. Interview with Resident #134 on 08/04/25 at 11:12 A.M. revealed roaches and gnats were in her room on a daily basis. Interview and observation with Resident #179 on 08/04/25 at 11:23 A.M. revealed roaches were in the room on a daily basis. A roach was observed crawling across his side table. Resident #179 stated he was concerned they would enter into his continuous positive airway pressure machine or tubing. Interview with Resident #225 on 08/04/25 at 11:35 A.M. revealed he killed multiple roaches crawling across his wall on a daily basis. Observation of a roach crawling on the Unit One hallway was confirmed by Registered Nurse #320 on 08/05/25 at 9:12 A.M. Observation and interview on 08/11/25 at 11:08 A.M. with Maintenance Worker #811 confirmed there were ten gnats that had landed on Resident #57’s privacy curtain. Upon shaking the privacy curtain, the gnats were observed to be alive and flying around the room. Interview with Certified Nursing Assistant (CNA) #205 on 08/06/25 at 11:06 A.M. confirmed there were active roaches in the facility. Interview with Housekeeper #591 on 08/11/25 at 10:49 A.M. confirmed she saw live roaches and gnats in resident rooms on a daily basis. Interview with the Administrator on 08/11/25 at 2:58 P.M. confirmed the pest infestation was ongoing. Although the facility had an active plan to eradicate the pests and pest control education was provided to staff, the facility had not yet assessed the skin of vulnerable residents as part of their correction plan. The Administrator revealed licensed staff would perform skin assessments of vulnerable residents as a part of this correction plan starting immediately. 2. Observation on 08/05/25 at 10:10 A.M. revealed multiple house flies and fruit flies were flying around the tracheostomy unit. The flies were also landing on multiple surfaces during this observation. Observation of Resident #47 on 08/06/25 at 9:45 A.M. revealed the resident's room was located next to an exit door that opens up to the outside. Subsequent observations on 08/06/25 at 12:25 P.M., 08/07/25 at 2:10 P.M., and 08/11/25 at 9:55 A.M. revealed multiple house flies and fruit flies were flying around the tracheostomy unit. The flies were also landing on multiple surfaces during these observations. Interview with Respiratory Therapist #945 on 08/06/25 at 2:45 P.M. verified the tracheostomy and stoma of Resident #47 had been infested with fly larvae and the resident had been sent to the hospital due to the findings on 06/30/25. Review of an undated facility policy titled “Pest Control Policy” revealed the facility would provide an environment free of pests. This deficiency represents non-compliance investigated under Complaint Number OH00167149 (1260022).

Apr 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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, and staff interviews, the facility failed to monitor bruising and bleeding risk for a resident on an anticoagulant. This affected one resident (Resident #45) out of three residents reviewed for anticoagulant medications, and had the potential to affect 48 residents that the facility identified as being on anticoagulant medication. The facility census was 205 residents. Findings include: Review of the medical record revealed Resident #45 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease, dependence on renal dialysis, mood disorder, anemia, anxiety disorder and heart failure. Review of Resident #45's Minimum Data Set (MDS) assessment dated [DATE] revealed that her Brief Interview for Mental Status (BIMS) was 15, indicative of intact cognition. Review of her MDS also revealed that she was receiving anticoagulant medication. Review of Resident #45's physician orders revealed that effective 01/18/25, she had physician orders for Apixaban (an anticoagulant medication) 5 milligrams (mg) one tablet by mouth twice daily. Review of Resident #45's care plan dated 01/27/25 revealed that she was at risk for alteration in hematological status related to anemia and anticoagulant side effects. Interventions, effective 01/27/25, were to administer medications as ordered and observe for side effects of the medication, and to observe for signs of increased bleeding such as bruising. Observation on 04/10/25 at 8:40 A.M. of Resident #45's skin revealed that she had maroon, gray-brown and yellow bruising on her bilateral forearms and gray-brown and yellow bruising on her lower right extremity. Interview on 04/10/25 at 11:04 A.M. with Registered Nurse (RN) #264, who was Resident #45's assigned nurse for the day, revealed that he was unaware of bruising to Resident #45's bilateral forearms and lower right ankle. Further interview confirmed the presence of bruising on Resident #45's lower right ankle and bilateral forearms, and that the resident was receiving anticoagulant medication as ordered. He stated that bruising should be monitored for residents on anticoagulant medication. Interview with the Director of Nursing (DON) on 04/10/25 at 11:06 A.M. confirmed there was no documented evidence of an order to monitor Resident #45's bruising in the medical record, nor did the wound nurse, consulted by the DON, have any evidence of monitoring Resident #45 for bruising. This deficiency represents non-compliance investigated under Complaint Number OH00164173.

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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of facility policy, the facility failed to investigate or assess a resident after a significant weight gain. This affected one resident (Resident #208) out of four residents reviewed for weight changes. The facility census was 205 residents. Findings include: Review of the medical record revealed Resident #208 was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure with hypoxia, encounter for tracheostomy, intracerebral hemorrhage, end stage renal disease, dependence on renal dialysis, dysphagia, and hemiparesis. Review of Resident #208's nutrition care plan dated 11/05/24 revealed he was at risk for nutritional decline. An intervention was to observe and evaluate weight and weight changes. Review of Resident #208's Minimum Data Set (MDS) assessment on 02/20/25 revealed that he was cognitively impaired. Review of Resident #208's weight record revealed that he weighed 169.1 pounds (lbs) on 03/06/25 and he weighed 181.9 lbs on 04/03/25, indicating a significant weight gain of 7.6 percent (%) in less than 30 days. Review of Resident #208's progress notes from 04/03/25 to 04/09/25 revealed that they were silent for any charting related to the weight gain, including acknowledgement/identification of the weight gain or an assessment of the weight gain. Review of Resident #208's progress notes further revealed that he was sent to the hospital on [DATE] related to a change in condition. Interview with Dietitian #440 on 04/09/25 at 5:13 P.M. revealed that on 04/03/25 she input the weight for Resident #208 into the computer, but did not notice the weight change at the time. Further interview confirmed that residents with significant weight changes should be re-weighed within two days. Dietitian #440 confirmed that the weight gain for Resident #208 had not been assessed or documented. Interview with the Director of Nursing (DON) on 04/10/25 at 3:06 P.M. revealed that the dietitian was responsible for monitoring the weekly weights, not the nursing staff. Review of a facility policy titled Weight Management dated 09/22/23 revealed that residents will be monitored for significant weight change on a regular basis. The registered dietitian and DON are responsible for coordination of an interdisciplinary approach to managing the process for prediction, prevention, treatment, monitoring and calculation of significant weight loss and or gain. Reweighs will be initiated for a five-pound variance if the resident is over 100 lbs. Reweighs will be done within 48 to 72 hours. This deficiency represents non-compliance investigated under Complaint Number OH00164173.

CONCERN (D) 📢 Someone Reported This

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

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, resident interview, staff interviews, review of admission checklists and review of facility policy, the facility failed to reconcile admission orders with a resident's previous medication orders to provide required eye drops per resident's expectations and physician orders. This affected one resident (Resident #156) out of three residents reviewed for medication administration. The facility census was 205 residents. Findings Include: Review of the medical record revealed Resident #156 was admitted on [DATE] readmitted on [DATE] with diagnoses that included end stage renal disease, status post cadaver - donor kidney transplant, dependence on renal dialysis, congestive heart failure, presence of cardiac pacemaker, immunodeficiency due to drugs, type two diabetes mellitus with diabetic neuropathy, depression, chronic pain, and sarcoidosis. Review of the physician orders dated 03/23/25, prior to the hospitalization, revealed Resident #156 was to receive Brimonidine Tartrate Ophthalmic Solution 0.2 percent (%) with instructions to administer one drop to each eye twice per day. Review of the hospital after visit summary (AVS) dated 03/31/25 revealed Resident #156 was to receive Brimonidine Tartrate Ophthalmic Solution 0.2 % (Brimonidine Tartrate) with instructions for one drop in each eye twice per day per the skilled nursing facility (SNF). Additional instructions stated that the medication was to be administered once per day, though the administration time chart had a check mark indicating to administer one drop in each eye in the morning and evening. Review of the readmission medication orders, dated 03/31/25, for Resident #156 revealed orders for Brimonidine Tartrate Ophthalmic Solution 0.2 % one drop to each eye daily. Review of the Medication Administration Record (MAR) for April 2025 revealed Resident #156 received Brimonidine Tartrate Ophthalmic Solution 0.2 % one drop to each eye daily for glaucoma from 04/01/25 to 04/09/25. Interview on 04/08/25 at 11:45 A.M. with Resident #156 revealed he was supposed to get eye drops and it was supposed to be from the purple bottle twice a day, but now he was getting it once a day. He revealed it was not a hospital order, it was a veteran's administration (VA) order and he would have to go to the VA and tell them that the facility didn't give it him properly. Interview on 04/10/25 at 8:31 A.M. with Licensed Practical Nurse (LPN) #294 confirmed that when a resident went to the hospital and was gone for more than 24 hours, the orders were discontinued. She stated when the resident returned, the medication orders on the AVS were verified with the physician or nurse practitioner and new orders were entered into the computer. Interview on 04/10/25 at 11:40 A.M. with LPN #294 confirmed Resident #156's hospital AVS, under the heading should continue taking these medications read that Resident #156 should continue to take Brimonidine 0.2% solution with instructions to place one drop in both eyes twice daily per the SNF medication list. The next line read to instill one drop of the medication in both eyes one time per day. The AVS sections indicating the dose and time of day for the medication to be given had a check mark indicating one drop of the medication was administered in the morning in the evening. LPN #294 reviewed the order and stated Resident #156 had been receiving eye drops twice daily prior to the hospitalization, and she also stated that the resident knew his medications. LPN #294 verified that the morning and evening checkmarks indicated that the medication was still to be twice a day, so if she had been the nurse to readmit the resident, she would have verified it with the nurse practitioner when verifying admission orders. LPN #294 also stated the VA physician had just called with the order for Brimonidine 0.2% solution with instructions to administer one drop in both eyes twice daily. Review of the Licensed Nurse admission Checklist dated January 2014 revealed step five on the checklist was to notify the physician and verify orders. Step six was that admission orders were reconciled and communicated to the pharmacy. Review of the policy Medication Administration revised 10/17/23 revealed medications are administered in accordance with the written orders of the attending physician. If a dose is inconsistent with the resident's age and condition or a medication order is inconsistent with the residents current diagnosis or condition, staff are to contact the physician for clarification prior to administration of the medication. The interaction with the physician would be documented in the progress notes and elsewhere in the medical record, as appropriate. This deficiency represents non-compliance investigated under Complaint Number OH00164244, Complaint Number OH00164173, and Complaint Number OH00164031.

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 F0757 (Tag F0757)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interviews, and review of facility policy, the facility failed to monitor side effects of a resident on antipsychotic medications. This affected one resident (Resident #106) out of three residents reviewed for antipsychotic medications, and had the potential to affect 47 residents that the facility identified as being on antipsychotic medication. The facility census was 205 residents. Findings include: Review of the medical record revealed Resident #106 was admitted to the facility on [DATE] with diagnoses that included cerebrovascular disease, schizophrenia, hypothyroidism, dementia, and drug induced dyskinesia. Review of Resident #106's care plan dated 05/08/19 revealed that she was at risk for adverse reaction and side effects related to receiving psychotropic medication due to the resident taking an antipsychotic for schizophrenia. Interventions included observing for side effects related to taking antipsychotic medications such as sedation, headaches, dizziness, diarrhea, anxiety, dystonia, Parkinsonism, restlessness, blurred vision, constipation, dry mouth, tardive dyskinesia and to report abnormal findings to the physician. Review of Resident #106's medication orders revealed effective on 07/29/19, she had physician orders for Paliperidone (an antipsychotic medication) Extended Release 6 milligrams (mg) twice daily. Review of Resident #106's Minimum Data Set (MDS) assessment dated [DATE] revealed that her Brief Interview for Mental Status (BIMS) was 09, indicative of moderately impaired cognition. Review of Resident #106's January 2025 through April 2025 orders, Medication Administration Record (MAR), Treatment Administration Record (TAR), progress notes, and tasks revealed no documented evidence that the resident was being monitored for antipsychotic medication side effects on a daily basis. Interview with the Director of Nursing (DON) on 04/09/25 at 12:39 P.M. revealed that for antipsychotic medications, her expectation would be that even if it was an older order, she would expect to see monitoring for side effects of the medication on a daily basis in the medical record. Interview with the Assistant Director of Nursing (ADON) #250 on 04/09/25 at 12:40 P.M. confirmed that the monitoring for the side effects of antipsychotic medications should be documented in the resident's medical record on a daily basis. She stated that the side effect documentation would be located in the MAR or TAR. Further interview with ADON #250 confirmed that Resident #106 was missing daily documentation of monitoring for side effects of her antipsychotic medication. Review of the facility policy titled Behavior Management updated 04/20/23 revealed that describing behaviors such as agitation, restlessness and fidgeting can aide in identifying medication side effects. This deficiency represents non-compliance investigated under Complaint Number OH00164173.

Feb 2025 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

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Based on medical record review, resident and staff interview, review of a facility self reported incident, review of facility investigation, review of hospital records, and facility policy review, the facility failed to ensure one resident (Resident #145) was free from physical abuse in the facility. The deficient practice affected one (Resident #145) of three reviewed for abuse. The facility census was 204. Findings Include: Review of the medical record for Resident #145 revealed an admission date of 02/01/21. Diagnoses included fracture of nasal bones (01/14/25), hemiplegia affecting unspecified side, personal history of traumatic brain injury, difficulty in walking, other seizures, and unspecified mental disorder due to a known physiological condition. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/26/24, revealed Resident #145 had intact cognition. The resident required minimal assistance which varied from independent to supervision from staff to complete Activities of Daily Living (ADLs). The resident exhibited physical and other behaviors toward others one to three days and verbal behaviors towards others four to six days of the review period. Review of the nurse progress notes dated from 01/13/25 to 01/21/25 revealed on 01/13/25 at 9:55 A.M., Resident #145 was struck twice on his right upper eye. The resident sustained an injury to the right upper eye. The site was cleaned with normal saline and covered with Kalex dressing. The Certified Nurse Practitioner (CNP) was notified and advised to monitor the resident for any changes in condition. An additional note on 01/13/25 at 9:55 A.M. revealed Resident #145 was outside in the smoking area and reported asking (another resident's) family member for a lighter. According to the resident, an argument occurred between them, however, the family member began cursing at him and struck him twice on his right upper eye which led to Resident #145 sustaining an injury to the right upper eye. On 01/13/25 at 2:18 P.M., Resident #145 was seen by the wound nurse for a laceration to the right eyelid. Steri-strips were applied. On 01/13/25 at 4:56 P.M., an addendum note was added stating the resident declined to go to the hospital. On 01/14/25 at an unknown time, a CNP note revealed Resident #145 was seen for follow up to an Emergency Department (ED) visit. The resident reported being assaulted while smoking outside of the facility. According to the resident and the police at bedside Resident #145 was assaulted by a visitor that was at the nursing home. The resident had a chronic fracture of left ulnar styloid but no acute findings. The Computed Tomography (CT) scan of maxillofacial showed an age-indeterminate left nasal bone fracture which was suspected to be old due to Resident #145 not having any pain along the bridge of nose. The resident complained of periorbital pain and bruising but no orbital fracture was noted. Review of the Self Reported Incident (SRI) dated 01/13/25 and untimed revealed an allegation of physical abuse with description as: Resident #145 was hit on the right upper eyebrow by family member. Interviews from both residents and family member stating they got into an argument over a lighter. The family member was escorted out of the building and police were called. Resident #145 refused to make police report but facility continued on with report. The resident complained of nose pain on 01/13/25 and went to the hospital where it was shown the resident had a broken nose. Facility made staff aware not to allow the other resident's family member in the building. Both residents were provided with emotional support. The facility unsubstantiated the allegation due to the facility could not have predicted the event would happen. Review of the facility investigation dated 01/13/25 and untimed revealed interviews and written statements were completed by Resident #145, the Administrator, the Director of Nursing (DON), Registered Nurse (RN) #410, Smoking Aide (SA) #401, and the Alleged Perpetrator (AP) #500. There was no interview or written statement included from Resident #69 who was also on the smoking patio when the incident occurred. Review of the neurological checks completed on Resident #145 revealed the neurological checks were not completed at the proper time intervals. Review of the local hospital record dated 01/14/25 revealed Resident #145 was seen in the ED following being assaulted at his nursing home. The CT scan of the resident's maxillofacial showed an age-indeterminate nasal fracture with suspicion the fracture was an old fracture due to the resident not complaining of any nasal pain. There were no other acute findings noted. Resident #145's right eye was swollen shut with steri-strips already in place upon admission to the ED. The resident was discharged from the ED back to the nursing facility with Ibuprofen (non steroidal anti inflammatory) and Tylenol (analgesic) as needed for pain. Interviews on 02/11/25 at 10:20 A.M. and 1:04 P.M. with the Administrator revealed Resident #145, Resident #48, and Alleged Perpetrator (AP) #500 were outside on the smoking patio. Resident #145 and Resident #48 were both independent smokers. Resident #145 and AP #500 got into an altercation over a lighter or cigarettes and AP #500 hit Resident #145. AP #500 was escorted out of the building. The police were called and a report was filed on Resident #145's behalf. Resident #145 started complaining of pain and was sent to the hospital to be evaluated further. Resident #145 was found to have a fractured nose. AP #500 had not returned to the building since the incident. The Administrator stated the facility had attempted to reach AP #500 to discuss supervised visits at the facility but had not been able to reach the alleged perpetrator. Interview on 02/11/25 at 11:25 A.M. with Resident #145 revealed he was outside on the smoking patio when he asked a man for a cigarette. The man said no and a verbal altercation started, then the man knocked me out. The resident stated his right eye was swollen shut. The resident could not recall the man's name and did not know who the resident was that the man was with. Resident #145 stated he did go to the emergency room but did not recall any other injuries other than his eye being swollen shut. The resident stated he had not seen the man since the incident. Interview on 02/11/25 at 1:28 P.M. with Smoking Aide (SA) #401 revealed Resident #145, Resident #48, AP #500, and Resident #69 were present on the outside smoking patio when the incident occurred. SA #401 stated she was at her desk located inside the dining room area which looks out onto the smoking patio. States she saw them all doing fine, she looked away for a few seconds it seemed like and then Resident #145 and AP #500 were fighting. SA #401 confirmed AP #500 was the aggressor in the incident. Resident #145 fell out of his wheelchair and was laying on his right side with the right side of his face on the cement and AP #500 was still punching him. SA #401 yelled for assistance and immediately responded to the smoking patio to try to break the fight up. Additional staff responded quickly and were able to break up the fight. AP #500 was escorted out of the building. SA #401 stated Resident #145 was bleeding really bad from his eyebrow and handed him a tissue to compress the cut on his eyebrow. The resident also complained of pain to his arm. Resident #145's hand was very swollen. The resident did not complain of pain anywhere else that she recalled. AP #500 had not returned to the facility again since the incident. Interview on 02/11/25 at 4:15 P.M. with the Administrator confirmed the neurological checks for Resident #145 were not completed at the correct time intervals for the resident. Review of facility policy titled Abuse Prohibition Policy, dated 10/14/22, revealed the policy stated, each resident shall be free from abuse. It is the responsibility of all staff to provide a safe environment for the residents. This deficiency represents non-compliance investigated under Complaint Number OH00161880.

CONCERN (D) 📢 Someone Reported This

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

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

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

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Based on medical record review, resident and staff interviews, review of a facility self reported incident, review of the facility investigation, and facility policy review, the facility failed to complete a thorough investigation of an allegation of physical abuse of one resident (Resident #145). The deficient practice affected one resident (Resident #145) of three reviewed for abuse. The facility census was 204. Findings Include: Review of the medical record for Resident #145 revealed an admission date of 02/01/21. Diagnoses included fracture of nasal bones (01/14/25), hemiplegia affecting unspecified side, personal history of traumatic brain injury, difficulty in walking, other seizures, and unspecified mental disorder due to a known physiological condition. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/26/24, revealed Resident #145 had intact cognition. The resident required minimal assistance which varied from independent to supervision from staff to complete Activities of Daily Living (ADLs). The resident exhibited physical and other behaviors toward others one to three days and verbal behaviors towards others four to six days of the review period. Review of the nurse progress notes dated from 01/13/25 to 01/21/25 revealed on 01/13/25 at 9:55 A.M., Resident #145 was struck twice on his right upper eye. The resident sustained an injury to the right upper eye. The site was cleaned with normal saline and covered with Kalex dressing. The Certified Nurse Practitioner (CNP) was notified and advised to monitor the resident for any changes in condition. An additional note on 01/13/25 at 9:55 A.M. revealed Resident #145 was outside in the smoking area and reported asking (another resident's) family member for a lighter. According to the resident, an argument occurred between them, however, the family member began cursing at him and struck him twice on his right upper eye which led to Resident #145 sustaining an injury to the right upper eye. On 01/13/25 at 2:18 P.M., Resident #145 was seen by the wound nurse for a laceration to the right eyelid. Steri-strips were applied. On 01/13/25 at 4:56 P.M., an addendum note was added stating the resident declined to go to the hospital. On 01/14/25 at an unknown time, a CNP note revealed Resident #145 was seen for follow up to an Emergency Department (ED) visit. The resident reported being assaulted while smoking outside of the facility. According to the resident and the police at bedside Resident #145 was assaulted by a visitor that was at the nursing home. The resident had a chronic fracture of left ulnar styloid but no acute findings. The Computed Tomography (CT) scan of maxillofacial showed an age-indeterminate left nasal bone fracture which was suspected to be old due to Resident #145 not having any pain along the bridge of nose. The resident complained of periorbital pain and bruising but no orbital fracture was noted. Review of the Self Reported Incident (SRI) dated 01/13/25 and untimed revealed an allegation of physical abuse with description as: Resident #145 was hit on the right upper eyebrow by family member. Interviews from both residents and family member stating they got into an argument over a lighter. The family member was escorted out of the building and police were called. Resident #145 refused to make police report but facility continued on with report. The resident complained of nose pain on 01/13/25 and went to the hospital where it was shown the resident had a broken nose. Facility made staff aware not to allow the other resident's family member in the building. Both residents were provided with emotional support. The facility unsubstantiated the allegation due to the facility could not have predicted the event would happen. Review of the facility investigation dated 01/13/25 and untimed revealed interviews and written statements were completed by Resident #145, the Administrator, the Director of Nursing (DON), Registered Nurse (RN) #410, Smoking Aide (SA) #401, and the Alleged Perpetrator (AP) #500. There was no interview or written statement included from Resident #69 who was also on the smoking patio when the incident occurred, but not involved in the incident . Interviews on 02/11/25 at 10:20 A.M. and 1:04 P.M. with the Administrator revealed Resident #145, Resident #48, and Alleged Perpetrator (AP) #500 were outside on the smoking patio. Resident #145 and Resident #48 were both independent smokers. Resident #145 and AP #500 got into an altercation over a lighter or cigarettes and AP #500 hit Resident #145. AP #500 was escorted out of the building. The police were called and a report was filed on Resident #145's behalf. Resident #145 started complaining of pain and was sent to the hospital to be evaluated further. Resident #145 was found to have a fractured nose. AP #500 had not returned to the building since the incident. The Administrator stated the facility had attempted to reach AP #500 to discuss supervised visits at the facility but had not been able to reach the alleged perpetrator. Interview on 02/11/25 at 11:25 A.M. with Resident #145 revealed he was outside on the smoking patio when he asked a man for a cigarette. The man said no and a verbal altercation started, then the man knocked me out. The resident stated his right eye was swollen shut. The resident could not recall the man's name and did not know who the resident was that the man was with. Resident #145 stated he did go to the emergency room but did not recall any other injuries other than his eye being swollen shut. The resident stated he had not seen the man since the incident. Interview on 02/11/25 at 1:28 P.M. with Smoking Aide (SA) #401 revealed Resident #145, Resident #48, AP #500, and Resident #69 were present on the outside smoking patio when the incident occurred. SA #401 stated she was at her desk located inside the dining room area which looks out onto the smoking patio. States she saw them all doing fine, she looked away for a few seconds it seemed like and then Resident #145 and AP #500 were fighting. SA #401 confirmed AP #500 was the aggressor in the incident. Resident #145 fell out of his wheelchair and was laying on his right side with the right side of his face on the cement and AP #500 was still punching him. SA #401 yelled for assistance and immediately responded to the smoking patio to try to break the fight up. Additional staff responded quickly and was able to break up the fight. AP #500 was escorted out of the building. SA #401 stated Resident #145 was bleeding really bad from his eyebrow and handed him a tissue to compress the cut on his eyebrow. The resident also complained of pain to his arm. Resident #145's hand was very swollen. The resident did not complain of pain anywhere else that she recalled. AP #500 had not returned to the facility again since the incident. Interview on 02/11/25 at 4:15 P.M. with the Administrator confirmed he had not obtained a written statement or interviewed Resident #69 who was also outside at the time of the incident and witnessed the incident. Review of facility policy titled Abuse Prohibition Policy, dated 10/14/22, revealed the policy stated, each resident shall be free from abuse. The investigation may consist of: interviews with any witnesses to the incident. This deficiency presents non-compliance investigated under Complaint Number OH00161880.

Nov 2024 2 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

Quality of Care (Tag F0684)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed medical record review, hospital record review, review of facility policy and interview, the facility failed to ensure Resident #215 received adequate, timely and necessary care and services to prevent an acute change in condition related to hypokalemia (decreased potassium) level. Actual Harm occurred beginning on 10/25/24 at 3:33 P.M. when Resident #215's laboratory results reflected a low potassium level of 3.0 mmol/L (normal range 3.5 -5.0) (indicative of hypokalemia) which went unreviewed and unaddressed by facility staff. On 10/28/24 Resident #215 began to experience shortness of breath and required supplemental oxygen. On 10/30/24 Resident #215's heart rate was noted to be between 41 and 46 beats per minute (low/bradycardic) and the resident informed staff his automated implanted cardioverter defibrillator (AICD) had alarmed. On 10/31/24 at 7:30 A.M. Resident #215 was noted to have a change in condition including a new irregular pulse with a listed heart rate of 46 (bradycardic), generalized weakness, and signs of delirium. Resident #215 was sent to a local emergency department where he was assessed to have chest pain with an abnormal heart rhythm of Ventricular Tachycardia (VT) and required multiple defibrillations to return to a normal heart rate and rhythm. The hospital records indicated Resident #215's VT was likely precipitated by his significant hypokalemia (low blood potassium) which was listed as 2.6 mmol/ml upon arrival to the emergency department. Resident #215 was subsequently admitted to the hospital and did not return to the facility. This affected one resident (#215) of three residents reviewed for quality of care/emergency care. The facility census was 215. Findings include: Review of the closed medical record for Resident #215 revealed an admission date of 10/22/24. Medical diagnoses included chronic systolic and diastolic heart failure, chronic obstructive pulmonary disease, type two diabetes, chronic respiratory failure, chronic kidney disease, paroxysmal atrial fibrillation, and encounter for adjustment and management of automatic implantable cardiac defibrillator. Resident #215 was transferred to a local hospital on [DATE] and did not return to the facility. Review of Resident #215's hospital discharge notes dated 10/22/24 revealed the resident had a scheduled visit with the cardiologist on 11/06/24. The hospital indicated he had recommended outpatient testing which included obtaining a Basic Metabolic Panel (BMP) and magnesium level in three to five days. Review of Resident #215's physician orders dated 10/24/24 revealed an order to draw a BMP on 10/25/24 and fax the results to the resident's cardiologist. A fax number for the provider was included in the order. Review of Resident #215's BMP result dated 10/25/24 revealed the laboratory specimen was collected that day at 10:20 A.M. The results were reported on 10/25/24 at 3:33 P.M. and revealed his potassium level was low at 3.0 mmol/L. Review of Resident #215's progress notes dated 10/25/24 to 10/31/24 revealed no evidence the physician was notified of the lab results. Review of Certified Nurse Practitioner (CNP) #304's progress note dated 10/29/24 revealed no evidence she was aware of Resident #215's 10/25/24 laboratory result. CNP #304's note referenced labs from the hospital on [DATE]. The note included Resident #215 had an episode of his defibrillator firing; she suggested an appointment with cardiology and the resident agreed. Review of Resident #215's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition. Review of Resident #215's progress notes dated 10/30/24 revealed the residents heart rate that morning had been ranging from 41 to 46 beats per minute (BPM), cardiology was contacted, and a message was left. The resident reported to the nurse that his defibrillator had alarmed and needed to be inspected. The nurse placed another call to the resident's cardiologist and an appointment was scheduled for the following day (10/31/24). The physician and resident were informed, and Resident #215 stated he had been feeling better. Review of a change of condition progress note dated 10/31/24 revealed the resident had a new irregular pulse with a listed heart rate of 46, generalized weakness, and signs of delirium. The progress note indicated the provider had been contacted and ordered Resident #215 to be transferred to a local emergency department. Review of Resident #215's hospital record dated 10/31/24 revealed upon arrival to the emergency department, the resident was found to have chest pain with VT and required multiple defibrillations to return to a normal heart rate and rhythm. The hospital records indicated they were able to interrogate the resident's AICD which reflected the resident was defibrillated six times the night prior (10/30/24) for VT. Resident #215's VT was likely precipitated by his significant hypokalemia which was listed as 2.6 mmol/ml upon arrival to the emergency department. Resident #215 was administered potassium supplements and was subsequently admitted to the hospital for laboratory monitoring and cardiology consultation. Resident #215 did not return to the facility. Interview on 11/26/24 at 9:38 A.M. with Registered Nurse (RN) #300 revealed abnormal laboratory results should be reported to the physician. The laboratory only notified the nurses of critical labs, otherwise, nursing needed to check for results. Interview on 11/26/24 at 10:22 A.M. and 11:41 A.M. with Unit Manager #305 revealed the CNP or physician should be notified of all lab results. She reported she spoke to the nurse who put the order for the BMP and the nurse could not recall where the order came from and did not think it was the facility physician. The nurse was also unsure why the results needed to be faxed to the cardiologist. Unit Manager #305 stated she thought the order came from the hospital when he admitted , so the in-house provider did not know to look for results. Unit Manager #305 verified there was no indication anybody reviewed the results or faxed them to the cardiologist. Interview on 11/26/24 at 11:49 A.M., 12:25 P.M., and 2:05 P.M. with the Director of Nursing (DON) revealed she believed Resident #215's BMP was to be completed in preparation for his cardiology appointment on 11/07/24. She verified there was no evidence his BMP was reviewed in the facility and was aware his 10/31/24 hospitalization involved a low potassium level (hypokalemia). The DON verified as far as nursing staff were aware, as of 10/29/24, the resident's defibrillator only went off once so an appointment with cardiology was made. However, the night of 10/30/24 into the morning of 10/31/24 it went off multiple times, so the night nurse called the on-call physician who agreed to send the resident to the hospital. Review of the facility policy 'Notification of change' dated 02/14/24 revealed the facility must inform the resident, consult with the resident's practitioner, and notify the representative when there is a change in status. A change in status included a need to alter treatment significantly or a significant change in the resident's physical, mental, or psychosocial status. This deficiency represents non-compliance investigated under Complaint Number OH00159685.

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 F0773 (Tag F0773)

Could have caused harm · This affected 1 resident

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Based on record review, staff interview, and policy review, the facility failed to ensure timely notification to the physician or Certified Nurse Practitioner (CNP) of abnormal laboratory values for Resident #37. This affected one (Resident #37) of three residents reviewed for quality of care. The facility census was 215. Findings include: Review of the closed medical record for Resident #215 revealed an admission date of 10/22/24. Medical diagnoses included chronic systolic and diastolic heart failure, chronic obstructive pulmonary disease, type two diabetes, chronic respiratory failure, chronic kidney disease, paroxysmal atrial fibrillation, and encounter for adjustment and management of automatic implantable cardiac defibrillator. Review of Resident #215's hospital discharge notes dated 10/22/24 revealed the resident had a scheduled visit with the cardiologist on 11/06/24. The hospital indicated he had recommended outpatient testing which included obtaining a Basic Metabolic Panel (BMP) and magnesium level in three to five days. Review of Resident #215's physician orders dated 10/24/24 revealed an order to draw a BMP on 10/25/24 and fax the results to the resident's cardiologist. A fax number for the provider was included in the order. Review of Resident #215's BMP result dated 10/25/24 revealed the laboratory specimen was collected that day at 10:20 A.M. The results were reported on 10/25/24 at 3:33 P.M. and revealed his potassium level was low at 3.0 mmol/L. Review of Resident #215's progress notes dated 10/25/24 to 10/31/24 revealed no evidence the physician was notified of the lab results. Interview on 11/26/24 at 9:38 A.M. with Registered Nurse (RN) #300 revealed abnormal laboratory results should be reported to the physician. The laboratory only notified the nurses of critical labs, otherwise, nursing needed to check for results. Interview on 11/26/24 at 10:22 A.M. and 11:41 A.M. with Unit Manager #305 revealed the CNP or physician should be notified of all lab results. She reported she spoke to the nurse who put the order for the BMP and the nurse could not recall where the order came from and did not think it was the facility physician. Unit Manager #305 stated she thought the order came from the hospital when he admitted , so the in-house provider did not know to look for results. Unit Manager #305 verified there was no indication anybody reviewed the results or faxed them to the cardiologist. Interview on 11/26/24 at 11:49 A.M., 12:25 P.M., and 2:05 P.M. with the Director of Nursing (DON) revealed she believed Resident #215's BMP was to be completed in preparation for an upcoming cardiology appointment. She verified there was no evidence his laboratory report was reviewed in the facility. Review of the facility policy 'Notification of change' dated 02/14/24 revealed the facility must inform the resident, consult with the resident's practitioner, and notify the representative when there is a change in status. A change in status included a need to alter treatment significantly or a significant change in the resident's physical, mental, or psychosocial status. This deficiency represents an incidental finding identified while investigating Complaint Number OH00159685.

Oct 2024 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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to appropriately investigate a resident incident. This affected one (Resident #301) of three resident incidents reviewed. The census was 219. Findings Include: Resident #301 was admitted to the facility on [DATE]. His diagnoses were chronic obstructive pulmonary disease, chronic kidney disease, asthma, acute respiratory failure, hypotension, atrial fibrillation, anemia, vascular dementia, congestive heart failure, epilepsy, dorsalgia, alcohol abuse, diverticulitis, suicidal ideation, hydronephrosis, restlessness and agitation, nicotine dependence, sleep apnea, polyneuropathy, and depression. Review of his minimum data set (MDS) assessment, dated 08/28/24, revealed he had a severe cognitive impairment. Review of Resident #301 progress notes and fall investigation, dated 10/05/24, revealed he had an unwitnessed fall while in the facility. Because he had an unwitnessed fall, the facility started neurological checks. Review of the neurological checks, dated 10/05/24 to 10/06/24, revealed they were completed as required, but on 10/06/24 at the 7:30 P.M. check, the documentation stated he was out of the facility. Review of Resident #301 progress notes, dated 10/06/24, revealed he was found by local law enforcement by a liquor store, smelled of alcohol and was acting as if he were intoxicated, so he was taken to the local hospital for interventions. He was sent back to the facility later that evening, where he ate a snack and went to bed. There was no documentation to support the facility knew he went out of the facility and to the liquor store. Review of Resident #301 medical records found no evidence of an investigation and/or incident review of Resident #301 being out of the facility, and then being treated for intoxication by the local hospital. Interview with Licensed Practical Nurse (LPN) #500 on 10/29/24 at 8:43 A.M. revealed she arrived to the facility around 7:00 P.M. on 10/06/24. She stated she went to see Resident #301 for his neuro-check around 7:30 P.M., but she did not see him. She conformed she wrote out of the facility on his neurological check at that time, but she did not know if he was really out of the facility. Then, between 8:15 P.M. and 8:30 P.M., she went to find him again to give his medication; he still wasn't found. She asked some of his friends if the knew where he was; they didn't. Around that same time, the facility received a call from the hospital that Resident #301 was at their building, being treated for intoxication. She confirmed she did not know he was out of the facility until the hospital called. Interview with Director of Nursing on 10/29/24 at 9:30 A.M. confirmed they did not complete an investigation for Resident #301 being out of the facility. She confirmed she did not know when he left, how long he had been out of the facility, did not interview any of the staff that worked during the times that he allegedly left, and did not interview Resident #301 to gather information about the incident. This was an incidental finding related to complaint number OH00158728.

Aug 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one resident (#11) attended a scheduled medical appointment out of the facility out of three residents reviewed. The facility census was 210. Findings include: Review of the medical record for Resident #11 revealed an admission date of 03/12/22. Diagnoses included but were not limited to demyelinating disease of central nervous system, chronic respiratory failure with hypoxia, tracheostomy status, and quadriplegia. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15 out of 15 indicating no cognitive impairment. The resident was assessed to require total dependence on all aspects of care. Review of Resident #11's After Visit Summary from Ohio Health dated 08/06/24 at 9:30 A.M. revealed an appointment for 08/21/24 at 10:00 A.M. with Ohio Health Neuroscience. Further review of Resident #11's medical record revealed no record of the 08/21/24 10:00 A.M. appointment being entered and that the facility set up transport. Review of Resident #11's progress note dated 08/22/24 at 10:58 A.M. revealed the residents wife was in the facility and made the facility aware she rescheduled his appointment that he was supposed to attend yesterday. Order was placed and Unit Manager made aware. Interview on 08/28/24 at 12:32 P.M. the Director of Nursing verified Resident #11's appointment with Ohio Health Neuroscience for 08/21/24 at 10:00 A.M. was never placed into his medical record and the resident did miss the appointment. This deficiency represents non-compliance investigated under Complaint Number OH00157057.

Jan 2024 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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of the facility policy the facility failed to provide care and supervision to prevent residents from eloping from the facility. This affected one (Resident #10) of ten facility-identified residents at risk for elopement. The facility census was 202. Findings Include: Review of the medical record for Resident #10 revealed an admission date of 12/20/23 with diagnoses including metabolic encephalopathy, type two diabetes, hypertension, and chronic kidney disease. Resident #10 was discharged to the hospital on [DATE] following an elopement from the facility. Review of the Minimum Data Set (MDS) assessment for Resident #10 dated 12/20/23 revealed resident was cognitively impaired. Review of the preadmission hospital records for Resident #10 dated 11/27/23 revealed resident was diagnosed with acute encephalopathy, possible multi-infarct dementia and metabolic encephalopathy from hypoglycemia. Further review of the hospital records revealed Resident #10's family reported to the hospital staff that he had exhibited wandering behavior prior to the hospital admission. Review of the admission nurses' note for Resident #10 dated 12/20/23 revealed the resident was admitted to the facility for physical therapy and occupational therapy and was alert to his name only. Review of the elopement risk assessment for Resident #10 completed on 12/20/23 revealed the resident was assessed for elopement risk and received a score of nine which indicated he was not at risk for elopement. Review of the care plan for Resident #10 dated 12/24/23 revealed it did not include interventions for wandering or elopement prevention. Review of the elopement risk assessment for Resident #10 completed on 12/26/23 revealed a score of 13 which indicated Resident #10 was at high risk for elopement. Review of physician orders for Resident #10 revealed an order dated 12/26/23 to place a Wanderguard bracelet (a device to alert the staff if the resident elopes from the facility) on the resident. Review of the nurses' note for Resident #10 dated 12/26/23 revealed the resident expressed a desire to leave the facility. Licensed Practical Nurse (LPN) #100 told Resident #10 to stay close to her and she would call his sister. Resident #10 walked away from LPN #100 towards an emergency exit door and tried to leave. LPN #100 was able to persuade Resident #10 to walk back to his room. LPN #100 assigned a State Tested Nursing Assistant (STNA) to provide one-to-one supervision for Resident #10 until he calmed down. On 12/26/23 at 5:00 P.M. the one-to one supervision was discontinued. Review of the elopement investigation dated 12/27/23 revealed Resident #10 had refused medications on 12/26/23 and 12/27/23 and was last seen in the facility in his bed on 12/27/23 at 2:00 A.M. by LPN #130. At approximately 3:00 A.M. on 12/27/23 LPN #130 was making rounds and noticed the Resident #10 was not in his bed or his bathroom. LPN #130 notified other staff that Resident #10 was missing, and the staff began to search for him. LPN #130 noted the window to the room across from Resident #10's room (Resident #12's room) faced the parking lot and was wide open. The facility notified local police on 12/27/23 at 3:50 A.M. that Resident #10 was missing. Local police found the resident at a bus stop near the facility on 12/27/23 and took the resident to the hospital for an evaluation. Review of the preliminary police investigation report dated 12/27/23 revealed the facility called the police on 12/27/23 at 3:58 A.M. and notified them Resident #10 was missing from the facility and they suspected he exited the building via a bedroom window. Review of the written statements from Registered Nurse (RN) #135, LPN #130 and STNA #140 who worked from 7:00 P. M. on 12/26/23 to 7:00 A. M. on 12/27/23 revealed they began to search for Resident #10 on 12/27/23 at 3:00 A.M. once they were advised he was missing. Each staff member participated in the search and all residents were accounted for except for Resident #10 Review of the hospital emergency report for Resident #10 dated 12/27/23 timed at 9:59 A. M. revealed the resident was found outside the facility wandering and unable to answer questions and had been transported to the emergency room by ambulance. Police confirmed Resident #10 was a missing person who had escaped from the facility. Resident #10 was alert and oriented to person only and was examined by the hospital physician with no injuries. Resident #10's vital signs were stable, and all lab tests and x-rays were within normal limits. Interview on 01/02/24 at 1:00 P. M. with LPN #100 confirmed she worked from 7:00 A.M. to 7:00 P.M. on 12/26/23. LPN #100 confirmed Resident #10 told her early in the shift that he wanted to leave, and she requested he stay with her while she finished passing the medications and then she would call his sister. Resident #10 then walked away towards an emergency exit door and tried to go out the door. LPN #100 followed him towards the door and was able to redirect him back to his room. LPN #100 confirmed she notified the nurse practitioner (NP) of Resident #10's exit seeking behavior and the NP gave an order for a Wanderguard bracelet. LPN #100 confirmed she attempted to place the Wanderguard bracelet on Resident #10 without success. She then assigned STNA #150 to provide one-to-one supervision to the resident until he calmed down. LPN #100 confirmed the one-to-one supervision was discontinued on 12/26/23 at 5:00 P.M. because the resident was no longer displaying agitation and restlessness. LPN #100 confirmed Resident #10 was in his room on 12/26/23 at 7:00 P.M. when she ended her shift. Interview on 1/02/24 at 1:15 P. M. with STNA #150 confirmed she sat with Resident #10 on 12/26/23 from 9:00 A. M. until 5:00 P. M. until he was calm. Interview on 01/04/24 at 9:10 A. M. with Occupational Therapist (OT) #114 and OT #116 confirmed they worked with Resident #10 when he was admitted to the facility from 12/20/23 to 12/25/23. They described Resident #10 as very confused and unable to comprehend simple requests. Interview on 01/02/23 at 2:59 P. M. with the Director of Nursing (DON) confirmed the facility had a secured unit, but Resident #10 was not placed in the unit because he did not have a diagnosis of dementia. The DON further confirmed Resident #10 had an exit-seeking attempt on 12/26/23 and the facility completed a new elopement risk assessment which indicated he was at risk for elopement. The DON confirmed the order for the Wanderguard bracelet for Resident #10 was not implemented because the resident refused. The DON confirmed the facility did not develop an elopement risk care plan for Resident #10, and the resident eloped from the facility on 12/27/23. Review of facility policy titled Elopement Policy dated 04/26/22 revealed the facility would attempt to prevent resident elopements to the extent possible. Elopement occurred when a guest/resident who needed supervision left a safe area without authorization and/or any necessary supervision to do so. This deficiency represents non-compliance investigated under Complaint Number OH00149516.

Nov 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

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

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Based on observation, resident interview, and staff interview, the facility failed to ensure a resident room was maintained in a homelike manner. This affected two (Resident #3 and Resident #4) of five resident rooms reviewed for a homelike environment. The facility census was 206. Findings include: Observation on 11/15/23 at 1:30 P.M. of Resident #3 and Resident #4's room revealed the wood paneling floor next to Resident #4's bed was chipped and the surface underneath the wood paneling floor was exposed. Observation on 11/15/23 at 1:30 P.M. of Resident #3 and Resident #4's bathroom revealed the floor in the bathroom had an approximately two-foot crack in it. Additionally, the flooring had bubbled up around the edges of the bathroom and had turned gray in spots which was not the natural color of the floor. Interview on 11/15/23 at 1:30 P.M. with Resident #3 revealed the bathroom floor appeared as though it needed to be replaced. Interview on 11/15/23 at 1:41 P.M. with Director of Maintenance #321 verified the wood paneling floor next to Resident #4's bed was chipped and the surface underneath the wood paneling floor was exposed. Additionally, Director of Maintenance #321 verified the bathroom floor had an approximately two-foot crack in it and the flooring had bubbled up around the edges and turned gray in spots. He reported he had been unaware of any concerns with the flooring. This deficiency represents non-compliance investigated under Complaint Number OH00147713.

Oct 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, self reported incident (SRI) review, and policy review, the facility failed to properly store controlled substances. This affected one resident (Resident #20) out of the one resident reviewed for controlled substance storage. The facility census was 201. Findings include: Review of the medical record for Resident #20, revealed an admission date of 03/07/22. Diagnoses included: metabolic encephalopathy, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, centrilobular emphysema and restlessness and agitation. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 10 out of 15. The resident was assessed to require extensive assistance with two person physical assist with bed mobility, transfers, and extensive assistance with one-person physical assistance with toilet use and dressing. Review of physician orders revealed Resident #20 was ordered lorazapam (Ativan) one milliliter (ml) injection one time only intramuscular for restlessness and agitation on 09/25/23 at 08:34 A.M. Review of the Medication Administration Record revealed Resident #20 was administered lorazapam one ml injection one time only on 09/25/23 at 3:21 P.M. Review of the Omnicare of Central Ohio Controlled Substance Record revealed two vials of lorazepam two milligram (mg)/ml should be in the medication fridge as of 09/25/23 at 4:00 P.M. Review of the facilities SRI,#239586, dated 09/25/23, revealed that on 09/25/23 around 7:30 P.M. it was reported to the Director of Nursing (DON) that there were two vials of two mg/ml of Ativan unaccounted for Resident #20 from the 400 Hall medication refrigerator. Upon further investigation, the lab contracted phlebotomist did have access to the medication room due to collecting lab samples. Resident #20 was assessed by licensed nurse and did not suffer adverse effects. The medication that was ordered for resident was as needed for behaviors and not given regularly. Interview on 10/18/23 at 11:20 A.M. with the DON revealed Resident #20 had two vials of Lorazepam (Ativan) two mg/ml vials stolen from the facilities 400 medication storage room fridge by a laboratory technician from an outside lab company named on 09/25/23 in the evening and was discovered at shift change around 7:00 P.M. by Licensed Practical Nurse (LPN) #76 and LPN #78 and stated I will tell you what I found during my investigation, there was a [NAME] for blood in this room that the nurse with the key would allow in the lab workers to spin the blood, well, the fridge must of not been locked because the lock to the fridge was not tampered with and I still have the box that was in the fridge and it still locks, so the lab person took it. I have a statement from LPN # 76 stating she allowed the lab tech to enter the room and be unattended. I have been in contact with the lab, and they have fired the lab tech from that evening and now can't find her. I have also moved the lab [NAME] to a new location in its own room so no one but nurses have access to the medication rooms. The DON verified they did not follow their medication storage policy. Review of the facility policy titled Control Substances dated 10/14/22 stated the medication room door will be locked at all times when not monitored by a nurse. This deficiency represents non compliance investigated under Complaint Number OH00147057.

Aug 2023 1 deficiency 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

Quality of Care (Tag F0684)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, wound notes review, staff interview, hospital paperwork review, and facility policy review, the facility failed to ensure wound care orders were in place, as well as ensure comprehensive wound measurements were completed for Former Resident #300 upon readmission to the facility. Actual Harm occurred when Former Resident #300 was found to have maggots in a pre-existing wound to the left calf/foot area and was admitted to the hospital with a gangrenous left foot with maggot infestation and severe pain. This affected one (Former Resident #300) of three residents reviewed for wound care. The facility census was 201. Findings include: Review of the closed medical record for Former Resident #300 revealed an original admission date of 05/11/23 with a readmission date of 07/25/23. Former Resident #300 was discharged to the hospital on [DATE] and had a final discharge date of 08/04/23. Diagnoses included end stage renal disease, acute osteomyelitis of the left ankle and left foot, chronic pain, and peripheral vascular disease. Review of Former Resident #300's 5-day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10 out of 15 indicating moderately impaired cognition for daily decision-making abilities. Former Resident #300 required extensive assistance from two staff members for bed mobility, toilet use, and personal hygiene, and required total dependence on two staff members for transfers. Former Resident #300 was noted to experience impairment to one of their lower extremities and required the use of a wheelchair for mobility. Former Resident #300 was noted to have one venous and one arterial ulcer as well as surgical wounds upon admission to the facility. Review of the plan of care dated 05/12/23 and revised 06/16/23 revealed the Former Resident #300 has actual impairment to their skin integrity related to a surgical wound with dehiscence to the left groin requiring a wound vac, surgical wound to the upper right arm, surgical wound to groin, and arterial ulcer to the left heel, and abrasion to the right hand between the 4th and 5th digit. Interventions included administering medication as ordered, apply pressure reducing mattress to protect skin while in bed, conduct weekly head to toe assessments, encourage good nutrition, follow facility protocols for treatment of injury, observe for signs and symptoms of infection of area, observe location, size and treatment of skin injury, report abnormalities, failure to heal signs and symptoms of infection maceration, treatment to skin impairment as ordered, and to turn and reposition every care round and as needed. Review of the treatment orders for Former Resident #300's left calf/foot revealed a wound treatment order dated from 07/20/23 to 07/25/23 to cleanse the arterial wound to the left leg/foot with normal saline, pat dry and apply Betadine. Apply an abdominal (ABD) pad and wrap with Kerlix daily. Further review of the treatment orders revealed a wound treatment order dated from 07/29/23 through 08/01/23 to cleanse the arterial wound to the left lateral leg/heel with normal saline, pat dry and apply Betadine. Then apply an ABD pad and wrap with Kerlix daily. Review of Former Resident #300's treatment orders put in place upon return to the facility from hospital stay from 07/23/23 through 07/25/23 revealed the following orders: -Cleanse the left anterior upper surgical wound with normal saline, apply a non-adherent gauze and secure with border gauze every day. The order had a start date of 07/26/23 and discontinue date of 07/28/23. -Cleanse left upper leg surgical wound with normal saline, pat dry and apply Silver Alginate. Cover with foam dressing daily. The order had a start date of 07/26/23 and discontinue date of 07/28/23. -Clean right groin with normal saline, apply a non-adherent gauze, apply bandage every day and as needed. The order had a start date of 07/26/23 and discontinue date of 07/28/23. -Cleanse arterial wound to the right heel with normal saline, pat dry and apply Betadine then apply an ABD pad and wrap with Kerlix daily. The order had a start date of 07/26/23 and discontinue date of 08/01/23. Review of the progress note, created by Unit Manager #10, dated 07/21/23 at 1:50 P.M. revealed resident (Former Resident #300) was seen this date by the wound care nurse for wounds to left thigh, left heel, left foot, right heel and bilateral heels. The left heel and left foot wounds had merged creating one large wound. The left dorsum foot wound was resolved out in the electronic chart, and the evaluation and measurements were combined with the left heel. The note indicated to continue current treatment orders. The treatments were completed by the wound care nurse. There was no increased pain or discomfort noted. Review of progress note dated 07/23/23 at 6:30 P.M. created by Registered Nurse (RN) #30 revealed, resident (Former Resident #300) had a change in the level of condition and was confused and disorientated, unable to answer questions appropriately, and was experiencing failure to thrive. Resident (Former Resident #300) was not eating meals or drinking fluids. Vital signs were within normal limits. Resident's (Former Resident #300) left eye and left arm were swollen, and the left side of the face was drooping showing characteristics of a stroke. Resident (Former Resident #300) was sent out to the hospital for further evaluation per orders. Review of the progress note dated 07/25/23 at 3:00 P.M. created by Licensed Practical Nurse (LPN) #20 revealed that resident (Former Resident #300) arrived via EMS (Emergency Medical Services) from the hospital, was alert and oriented, a head-to-toe assessment was done, and Former Resident #300 had a wound on the bilateral heel, wound to the left groin, wound to the anterior upper right thigh, open area to the left elbow, and the sacrum was open to air. Review of Former Resident #300's re-entry Nursing Comprehensive Evaluation dated 07/25/23 revealed the resident currently had skin conditions including the groin area, left thigh (front), left elbow, coccyx, left gluteal fold, right heel, and left heel. Description of each wound had not been completed including wound type, size, or tissue type. Review of the progress note dated 07/28/23 at 1:28 P.M. created by Unit Manager #40 revealed, the resident (Former Resident #300) was seen by the wound care nurses for a surgical wound to left and right groin, medial left thigh, right dorsum foot, right heel, and left heel which had extended to the left lateral calf. While assessing the left lateral calf/heel, this RN (Registered Nurse) wound care nurse noticed the presence of maggots, and the resident (Former Resident #300) was recently readmitted from the hospital and was started on Cipro (an antibiotic) 500 milligrams (mg), and Metronidazole (antibiotic) 500 mg for wound infection. Unable to get measurements of the left lateral leg/heel due to pain and the presence of maggots. New orders were received to send the resident (Former Resident #300) out to the hospital for surgical debridement. All treatments were provided with complaints of pain noted to be at a nine out of 10 on the numeric pain scale in the left lateral leg/heel. Review of the hospital Emergency Department note dated 07/28/23 revealed the resident (Former Resident #300) presented for evaluation of a worsening foot wound/necrosis with increased pain and presence of maggots noted within the wound. Clinically, the resident (Former Resident #300) had significant necrosis of the bilateral feet which was worse on the left with maggots, increased pain, and worsening wound. The resident (Former Resident #300) required admission to hospital for treatment with intravenous (IV) antibiotics and possible amputation. Interview on 08/15/23 at 11:32 A.M. with Unit Manager #40 confirmed Former Resident #300 had an arterial wound to the left foot and left calf area that had joined together to form one large wound. Former Resident #300 was seeing a wound clinic outside the facility, but wound measurements and assessment were still being completed every Friday. Unit Manager #40 claimed Former Resident #300's left foot had very poor circulation and her toes were fused together, and the foot was very hard to touch. This resident liked to wear socks or footies and was not known to remove her own dressing or have issues with the dressing falling off. Prior to coming to this facility, doctors had spoken to the resident and recommended an amputation of the extremity which she refused on multiple occasions. Unit Manager #40 claimed she even tried to speak to the resident about it, but the resident told her she did not want to discuss it because she was not having her foot cut off. Former Resident #300 had a diagnosis of chronic pain but never complained of pain in the left foot. The nursing staff was mainly responsible for completing wound care and dressing treatments. Unit Manager #40 verified Former Resident #300 was out of the facility from 07/23/23 through 07/25/23. When the resident returned to the facility, the floor nurse would have been the one who completed the comprehensive nursing assessment along with the skin/wound assessment. Unit Manager #40 claimed she did not physically see Former Resident #300 until that following Friday (07/28/23) which was this resident's regular scheduled wound assessment day. When she completed her assessment on 07/28/23, she reviewed the orders that were put in place and made the appropriate changes that were needed. Maggots were identified in the wound on Former Resident #300's calf/left foot during her wound assessment on 07/28/23. Unit Manager #40 claimed when she removed the old bandage from this resident's left calf/leg, and it was dated 07/26/23. Unit Manager #40 claimed that most likely the nurse who was working when Former Resident #300 was readmitted to the facility from the hospital put her wound treatment orders in, and she likely went from orders this resident had in place prior to going out to the hospital. Unit Manager #40 confirmed no measurements or assessments were completed for Former Resident #300's multiple wounds until she observed the wound three days after being readmitted from the hospital. Interview on 08/15/23 at 12:44 P.M. with RN #30 revealed she was the nurse who was working on 07/26/23 and was the one who completed the dressing change on Former Resident #300's left calf/leg. RN #30 confirmed this resident's treatment orders did not include a treatment order for her left calf or foot, but she completed this treatment anyway because she was aware of this resident's wound history. RN #30 also claimed that when she was reviewing Former Resident #300's treatment orders, she did see there were orders for treatments to the resident's upper thigh, and one was for a non-adherent dressing and the other was for silver alginate so she just figured one of them was for the left calf/foot but did not report this conflicting order to anyone or have the order clarified. Interview on 08/15/23 at 12:55 P.M. with the Director of Nursing (DON) confirmed when Former Resident #300 returned from the hospital, her After Visit Summary did not have any treatment orders listed in the discharge orders for staff to go from or follow. The admitting nurse would go off the resident's previous treatment orders and then once the wound nurse saw the resident, which was normally within 24 hours of admission or readmission, any needed changes would be made. Review of facility's policy titled Skin Management, revised 07/14/21, revealed Guest/residents with wounds and/or pressure injury and those at risk for skin compromise are identified, evaluated and provided appropriate treatment to promote prevention and healing. Ongoing monitoring and evaluation are provided to ensure optimal guest/resident outcomes. Upon admission-re-admission all guest/residents are evaluated for skin integrity by completing a baseline total body skin evaluation documented in the electronic medical record. Appropriate preventative measures will be implemented on guest/residents identified at risk and the interventions are documented on the care plan. This deficiency represents noncompliance investigated under Complaint Numbers OH00145300, OH00145302 and OH00145148.

Apr 2023 11 deficiencies

CONCERN (D)

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

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of facility policy, the facility failed to ensure Resident #12's dignity was maintained by ensuring she had clothes available to her. This affected one (Resident #12) of one resident reviewed for dignity. The facility census was 207. Findings include: Review of the medical record revealed Resident #12 admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy, cognitive communication deficit, dysphagia, acute respiratory failure with hypoxia, end stage renal disease with dependence on renal dialysis, multiple sclerosis, peripheral vascular disease, and rheumatoid arthritis. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #12 had intact cognition and required the extensive assistance of two persons for dressing. Observation on 04/24/23 at 12:30 P.M. and 3:30 P.M. revealed Resident #12 in her bedroom, she was in a hospital gown. Observation on 04/25/23 at 8:30 A.M. revealed Resident #12 in the unit dining room, she was wearing a hospital gown. Observation on 04/26/23 at 8:30 A.M. and 10:00 A.M. revealed Resident #12 in the unit dining room, she was wearing a hospital gown. Interview on 04/26/23 at 10:07 A.M. with Resident #12 verified she was wearing a hospital gown and did not like it. She reported she did not have clothes in the facility but would wear them if she had them. Interview on 04/26/23 at 12:40 P.M. and 3:54 P.M. with Licensed Practical Nurse (LPN) Administrator #400 verified Resident #12 was wearing a hospital gown and reported the resident only had one pair of pants in the facility. LPN Administrator #400 reported she usually arranged for residents to have clothing in house and would call the resident's power of attorney to bring in clothing for the resident. Review of the policy titled, Guest/resident Dignity and Personal Privacy, revised 04/19/22 revealed caring for residents in a manner that maintained dignity and respect included dressing them in appropriate and desired clothing.

CONCERN (D)

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

MDS Data Transmission (Tag F0640)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and manual review the facility failed to complete a discharge Minimum Data Set (MDS) resident assessment. This affected one (Resident #100) out of three residents reviewed for resident assessments. Facility census was 207. Findings include: Record review revealed Resident #100 was admitted to the facility on [DATE] for short term therapy and skilled nursing services. Resident #100 was discharged from the facility on 12/01/22. Review of Minimum Data Set (MDS) assessments for Resident #100 revealed an entry MDS was completed on 11/18/22 and an admission MDS was completed on 11/25/22. There was no discharge MDS completed. Interview on 04/26/23 at 11:36 A.M. with Licensed Practical Nurse (LPN) #419 confirmed Resident #100 did not have a discharge MDS completed. Review of Resident Assessment Instrument (RAI) manual revised October 2019 Chapter two, Assessments for the Resident Assessment Instrument (RAI), revealed, Discharge Assessment refers to an assessment required on resident discharge from the facility, or when a resident's Medicare Part A stay ends, but the resident remains in the facility (unless it is an instance of an interrupted stay, as defined below).

CONCERN (D)

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

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Review of Resident #81's medical record revealed the resident was admitted to the facility on [DATE], with diagnoses including acute respiratory failure, congested heart failure, dependence on respirator, dysphagia. Review of Resident #81's physician order dated [DATE] revealed an order for Do Not Resuscitate Comfort Care Arrest (DNRCC-A). Review of Resident #81's face sheet revealed Resident #81's code status as DNRCC-A. Review of Resident #81's advanced directive care plan dated [DATE] revealed Resident #81 as a full code requiring Cardio-Pulmonary Resuscitation (CPR). Interview on [DATE] at 2:21 P.M. with Registered Nurse (RN) #404 confirmed Resident #81 had physician orders for a DNRCC-A. RN #404 confirmed Resident #81's advance directive care plan reflected a full code status requiring CPR. Based on medical record review, resident and staff interviews, and review of facility policy, the facility failed to complete quarterly care conferences. This affected one (Resident #44) of three residents reviewed for care conferences. Additionally, the facility failed to ensure a resident's care plan was updated to reflect current advanced directives. This affected one (Resident #81) of one reviewed for care planning advanced directives. The facility's census was 207. Findings include: 1. Review of Resident #44's medical record revealed the resident was admitted to the facility [DATE] with the diagnoses of Parkinson's, unspecified atrial fibrillation, dementia, hypertension, fibromyalgia, and osteoporosis. Review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #44 was cognitively intact and had no behaviors. Resident #44 required extensive assistance with dressing and personal hygiene and supervision for all other activities of daily living. Further review of the medical record revealed Resident #44's only documented care conference took place on [DATE]. There were no additional care conferences documented. Interview on [DATE] at 2:14 P.M. with Resident #44 revealed she had not been to any care conferences at the facility. Interview on [DATE] at 2:52 P.M. with Social Service Staff #630 confirmed the only care conference that was completed for Resident #44 was on [DATE]. Review of the policy titled, Care Planning Conference, revised [DATE] revealed on admission, quarterly annually with a significant change and as needed the interdisciplinary team will hold a care planning conference with the resident, family or representative in participation. The Care Conference will be used to identify the resident's potential or actual problems, needs, goals and discharge plans.

CONCERN (D)

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

Deficiency F0679 (Tag F0679)

Could have caused harm · This affected 1 resident

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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 Resident #159's preferred activities were available to him. This affected one (Resident #159) of two residents reviewed for activities. The facility's census was 207. Findings include: Review of the medical record revealed Resident #159 admitted to the facility on [DATE] with diagnoses including anoxic brain damage, dysphagia, cognitive communication deficit, pressure ulcer of sacral region stage four, systolic heart failure, alcohol abuse, colostomy, and retention of urine. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #159 had severely impaired cognition. The resident was dependent on staff for bed mobility and transfers Review of the plan of care dated 06/03/22 revealed Resident #159 had a potential for impaired social interaction or social isolation related to impaired cognition and physical limitations. He enjoyed watching activities, movies inside his own room, and happy hour every week. Interventions included assuring the activities the resident was attending were compatible with capabilities, encouraging family involvement, providing one on one bedside or in room visits if unable to attend activities out of room, and the resident needed assistance to activity functions. Review of the activity evaluation dated 04/17/23 revealed Resident #159 was unable to communicate effectively so the staff needed interviewed. The assessment revealed it was very important for him to listen to music he liked and that he liked all types, somewhat important that he kept up with the news via TV, and very important for him to do favorite activities. Resident #159 preferred activities in his own room, including watching TV, listening to radio, and watching movies. Observations on 04/24/23 at 10:17 A.M., 11:58 A.M., 1:54 P.M., and 4:01 P.M. revealed Resident #159 in his room, in the farthest bed from the door. Resident #159 was awake, but the lights were off, and there was no TV or music on any point during the observations. Observation on 04/25/23 at 11:55 A.M. revealed Resident #159 in his room, awake in bed, with the lights off, and no TV or music on. Observation on 04/26/23 at 10:05 A.M. revealed Resident #159 in his room, awake in bed, with the lights off, and no TV or music on. Interview on 04/26/23 at 10:05 A.M. with Certified Nursing Assistant (CNA) #489 verified Resident #159 was awake in bed with no TV or music on. She reported Resident #159's roommate did not like the TV on while he was asleep, so they only turned the TV on while the roommate was awake. The only TV in the room was across the room from Resident #159 in front of his roommate's bed. CNA #489 verified Resident #159 was awake and in a dark room with no entertainment. Interview on 04/27/23 at 9:19 A.M. with Licensed Practical Nurse (LPN) Administrator #400 verified Resident #159 did not have a TV facing him and reported she had just spoken to the power of attorney about getting him one. Interview on 04/27/23 at 10:15 A.M. with Activities Assistant #508 revealed she visited Resident #159 for one on ones. She reported she used to turn the TV on for him because he enjoyed the television. Activities Assistant #508 reported she no longer turned his TV on because he did not have one in front of his bed and his roommate did not want it on.

CONCERN (D)

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and facility policy and procedure, the facility failed to ensure residents secured their smoking contraband. This affected one (Resident #25) out of five residents reviewed for accidents. The facility census was 207. Findings include: Review of the medical record for Resident #25 revealed an admission date of 11/15/22 and the diagnoses of schizophrenia, disorganized schizophrenia, and nicotine dependence. Review of the care plan dated 11/16/22 revealed Resident #25 wished to use smoking products and has been assessed as being safe to smoke with supervision and the resident had episodes of choosing not to follow the facility smoking policy and being resistive to turning over smoking materials. Interventions included to assess her ability to smoke safely per facility policy, educate the resident on the smoking policy, the resident is independent with managing smoking materials and accessing the lock box, and staff will maintain all smoking paraphernalia for all unsafe and safe smokers; e.g., cigarettes, cigars, pipes, lighters, lighter fluid, tobacco spit container, e-cigarettes, vaping devices or any other matter or substance that contains a tobacco product. Review of the smoking assessment dated [DATE], revealed Resident #25 was assessed to be an independent smoker who follows smoking guidelines per the facility policy (including returning smoking paraphernalia to designated person or location). Review of the smoking assessment dated [DATE] revealed Resident #25 was alert and consistent but she didn't follow smoking guidelines per the facility policy (including returning smoking paraphernalia to designated person or location). It stated the resident had a lighter and cigarette and the resident refused education and the return of the smoking materials to the floor nurse. It also stated the resident was an unsafe smoker, she is to be supervised while smoking, and after educated, the resident was able to return her smoking materials to her lock box. Review of Resident #25's nurses notes dated 04/26/23 at 11:15 A.M., the aide and the surveyor requested assistance for Resident #25. The surveyor pointed out a cigarette and a lighter. The nurse attempted to retrieve the items and educate the resident. The resident became upset and stated, What do you mean I am on the phone. The resident walked out of her room and the unit. The note dated 04/26/23 at 11:26 A.M. revealed the floor nurse reported the resident had a lighter and a cigarette. The resident was spoken to, and stated she just had the cigarette and lighter this morning, she was going to put her laundry away first, then put her cigarettes and lighter into the smoking lock box. The resident took her smoking items to the lock box. Education and smoking policies were reinforced, the resident verbalized understanding, and the physician and guardian were made aware. Observation on 04/24/23 at 11:24 A.M. revealed Resident #25 with cigarettes and a lighter on nightstand. This observation was not confirmed. Interview and observation on 04/26/23 at 10:36 A.M. with Resident #25 revealed she smokes independently, she has a lock box where she keeps her smoking material, though she does keep her cigarettes and lighter in her room sometimes. It was observed the resident had two lighters and one pack of cigarettes on and in her night stand. She stated one lighter she found outside last night in the smoking area. She stated staff, specifically the people who handle the lockers, have told her before, not to keep contraband in her room, sometimes they ask for the smoking items, but the residents are capable of doing it themselves. Interview and observation on 04/26/23 at 10:40 A.M. with Licensed Practical Nurse (LPN) #439 confirmed Resident #25 had the contraband items in her room, the nurse requested the items and the resident would not give them up, she stated she was getting ready to go outside. Interview on 04/27/23 at 8:45 A.M. with Smoke Aide #563 revealed residents have a locker with keys and thats how they return their contraband after smoking. She stated there are two smoke aides, if one of the aides is inside the building, they will check to make sure residents are putting the smoking items in their lock box, but for some unknown reason, this week, both aides were instructed to be working outside. She stated residents were not suppose to take contraband back to their rooms, they normally put it in their locker, but some might get away with it. She stated Resident #25 had a key yesterday (04/26/23) and today, but she normally puts her items back in her box. She stated the resident is independent for smoking but there are always smoking aides, so everyone is supervised during the day. Review of the undated, laminated sign by the lock boxes revealed it stated, Please return your cigarettes and lighter to your mailbox when finished smoking. If you have lost your key please see staff for a new one. Review of the facility policy and procedure titled, Smoking Policy, dated 10/14/22, revealed staff members maintain all smoking paraphernalia for all unsafe and safe smokers; e.g., cigarettes, cigars, pipes, lighters, lighter fluid, or any other matter or substance that contains a tobacco product. Staff members distribute smoking materials to guests/residents that are unsafe to smoke at the designated smoking times, and to guests/residents that are deemed safe to smoke and may smoke independently, at their request.

CONCERN (D)

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

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, review of the facility policy, and medical record review, the facility failed to ensure Resident #406's nephrostomy bag was in the proper position at all times to prevent backflow of urine into the bladder. This affected one (Resident #406) of two residents reviewed for catheters. The facility census was 207. Findings include: Review of Resident #406's medical record revealed Resident #406 was admitted on [DATE]. Diagnoses included end stage renal disease with dependence on dialysis, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and obstructive and reflux uropathy. Review of the physician order dated 04/11/23 revealed Resident #406 had a nephrostomy tube to her right flank. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #406 had mildly impaired cognition and had an indwelling catheter. Review of the plan of care dated 04/17/23 revealed Resident #406 was at risk for urinary tract infection and catheter related trauma related to having a nephrostomy tube. Interventions included changing catheter and tubing per facility policy, ensuring catheter tubing was secured, ensuring the drainage bag was secured properly with dignity cover in place, observing for and documenting discomfort with urination or due to catheter, documenting intake and output according to policy, providing catheter care according to policy, and reporting any signs of infection to the physician. Observations on 04/24/23 at 2:00 P.M. and 4:20 P.M. revealed Resident #406 was in bed and her nephrostomy bag was clipped to her bed at chest level. Interview on 04/24/23 at 4:20 P.M. with Licensed Practical Nurse (LPN) #451 verified Resident #406's nephrostomy bag was not in the proper location and should be below bladder level. Observation on 04/26/23 at 2:20 P.M. revealed Resident #406 was lying supine in bed with her nephrostomy bag, almost completely under her right thigh. Interview on 04/26/23 at 2:25 P.M. with Registered Nurse (RN) #431 verified the nephrostomy bag was lying under Resident #406's right thigh. RN #431 confirmed the nephrostomy bag should be hanging from the bed; however, she was unable to find a clip to hang the nephrostomy bag at that time. Review of the policy titled Indwelling Urinary Catheter Care and Management revealed the catheter and drainage tubing should be free from kinks and free from dependent loops to allow the free flow of urine. The drainage bag was to be kept below the level of the patient's bladder to prevent backflow of urine into the bladder.

CONCERN (D)

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

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of the Federal Drug Administration Approving Labeling Text, the facility failed to ensure a resident did not receive an antipsychotic medication without an appropriate diagnosis. This affected one (Resident #83) of five residents reviewed unnecessary medication. The facility census was 207. Findings include: Record review for Resident #83 revealed Resident #83 was admitted to the facility on [DATE]. Diagnoses included anxiety, major depression disorder, and chronic pain. The resident's diagnosis list did not include bipolar disorder. Review of Resident #83's physician orders revealed an order dated 04/03/23 for Depakote 125 milligrams (mg) administered three times per day for agitation. Review of the psychiatric progress note dated 01/17/23 revealed Resident #83 was on Depakote 125 milligrams (mg) for bipolar disorder. Interview with Registered Nurse (RN) #400 confirmed the physician order for Resident #83 of Depakote 125 milligrams (mg) for agitation. Review of the Federal Drug Administration Approved Labeling Text dated 10/07/11 revealed Depakote is an anti-epileptic drug indicated for treatment of manic episodes associated with bipolar disorder.

CONCERN (D)

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

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected 1 resident

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Based on observation, medical record review, staff interview, and review of facility policy, the facility failed to ensure a medication error rate below five percent (%). There were five medication errors out of 28 opportunities resulting in a 17.86% medication error rate. This affected two (Resident #34 and #131) of four residents observed during medication pass. The facility census was 207. Findings include: 1. Review of the medical record for Resident #131 revealed an admission date of 07/09/19. Diagnoses included gait abnormalities, muscle weakness, and need for assistance with personal care. Review of the physician orders revealed on 12/14/20, Resident #131 was ordered Senna Plus Docusate Sodium 8.6-50 milligrams (mg) with instructions to give one tablet daily for constipation. Review of the care plan dated 07/18/19 revealed Resident #131 was at risk for constipation related to decreased mobility with interventions to administer medications as ordered and observe for ineffectiveness/side effects. Observation and interview on 04/25/23 at 9:51 A.M. with Licensed Practical Nurse (LPN) #462 revealed he was preparing medications for Resident #131. He placed a Senna 8.6 mg tablet into the pill container and prepared to go into the resident's room to administer the medications. The surveyor stopped him and we reviewed the physician orders together and verified the order was for Senna Plus 8.6 mg - 50 mg. The error was confirmed on 04/25/23 at 9:55 A.M. with LPN #462 and Registered Nurse (RN)/Unit Manager #402. 2. Review of the medical record for Resident #34 revealed an admission date of 02/03/23. Diagnoses included high blood pressure, atrial fibrillation, and diabetes mellitus type two. Review of the physician orders revealed Resident #34 was ordered Eliquis five mg twice daily for deep vein thrombosis prevention (due at 9:00 A.M. and 9:00 P.M.), Hydralazine 50 mg twice daily for high blood pressure (due at 9:00 A.M. and 9:00 P.M.), Oxybutynin five mg twice daily for bladder spasms (due at 9:00 A.M. and 9:00 P.M.), and Gabapentin 300 mg three times daily for low back pain (due at 9:00 A.M., 5:00 P.M. and 9:00 P.M.). Observation on 04/25/23 at 10:20 A.M. with Licensed Practical Nurse (LPN) #462 revealed he attempted to prepare all medications due for the morning administration including Oxybutynin five mg, Hydralazine 50 mg, Eliquis five mg, and Gabapentin 300 mg. Oxybutynin, Hydralazine, Eliquis, and Gabapentin medications were administered to Resident #34 on 04/25/23 at 10:29 A.M. Interview on 04/25/23 at 1:18 P.M. with LPN #462 confirmed the medications for Resident #34 were administered late. Review of the facility policy and procedure titled Medication Administration, dated 10/14/22, revealed staff should verify the medication label against the medication 'administration record for guest/resident name, time, drug, dose, and route. The policy also stated to administer medications within 60 minutes of the scheduled time, unless otherwise specified by the physician.

CONCERN (D)

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

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to ensure Resident #159's activity participation was recorded accurately and by the staff who initiated it. This affected one (Residents #159) of 39 resident records reviewed. The facility census was 207. Findings include: Review of the medical record revealed Resident #159 admitted on [DATE] with diagnoses including anoxic brain damage, systolic heart failure and retention of urine. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #159 had severely impaired cognition. Review of the April 2023 activity documentation report downloaded on 04/25/23 at 3:50 P.M. revealed Resident #159 was listed as conversing with others on 04/04/23, 04/18/23, 04/24/23, and 04/25/23. Resident #159 was listed as watching television or movies on 04/04/23, 04/18/23, 04/24/23, and 04/25/23. No other activities were documented. On 04/27/23 at 4:27 P.M. Activities Director #571 provided an April 2023 activity documentation report time stamped as 04/26/23 at 4:25 P.M. In addition to the activities listed on the 04/25/23 activity report this document indicated Resident #159 participated in the following additional activities: a. One-on-one visits on 04/01/23, 04/02/23, 04/03/23, 04/04/25, 04/05/23, 04/06/23, 04/08/23, 04/09/23, 04/13/23, 04/14/23, 04/17/23, 04/18/23, 04/23/23, 04/24/23, 04/25/23, and 04/26/23. All were time stamped for 4:59 P.M. by Activities Assistant #559. b. Conversing with others on 04/10/23, 04/11/23, 04/12/23, 04/13/23, 04/14/23, 04/15/23, 04/16/23, 04/17/23, again on 04/18/23, 04/20/23, 04/21/23, 04/22/23, 04/25/23, and 04/26/23. All were time stamped for 4:59 P.M. by Activities Assistant #559. c. Sensory stimulation on 04/01/23, 04/02/23, 04/03/23, 04/04/23, 04/05/23, 04/06/23, 04/08/23, 04/09/23, 04/10/23, 04/11/23, 04/12/23, 04/15/23, 04/20/23, 04/21/23, 04/22/23, 04/23/23, 04/24/23, and 04/25/23. All were time stamped for 4:59 P.M. by Activities Assistant #559. d. TV or movies was documented on 04/01/23, 04/02/23, 04/03/23, again on 04/04/23, 04/05/23, 04/06/23, 04/08/23, 04/09/23, 04/10/23, 04/11/23, 04/12/23, 04/13/23, 04/14/23, 04/15/23, 04/16/23, 04/17/23, again on 04/18/23, 04/20/23, 04/21/23, 04/22/23, 04/23/23, 04/25/23, and 04/26/23. All were time stamped for 4:59 P.M. by Activities Assistant #559. Interview on 04/27/23 at 8:03 A.M., 8:55 A.M., and 11:19 A.M. with Activities Director #571 confirmed the additional activities time stamped for 4:59 P.M. were documented by Activities Assistant #559 on 04/26/23. She reported the staff did not do paper documentation for activities and not all of the activities assistants had access to document in the electronic medical record until the previous day. She reported on 04/26/23, Activities Assistant #559 and Activities Assistant #508 went through and documented all the days they believed someone visited Resident #159. Activities Director #571 was unable to provide a reason the activities assistants did not document the activities on paper when they did not have access to the electronic medical record.

CONCERN (D)

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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Based on observation, staff interview, and medical record review, the facility failed to ensure personal protective equipment (PPE) was disposed of properly after providing care for Resident #179, who had Methicillin-Resistant Staphylococcus Aureus (MRSA) in her wound. This affected one (Resident #179) of one resident under transmission-based precautions. The facility census was 207. Findings include: Review of the medical record for Resident #179 revealed an admission date of 09/13/22 with diagnoses including cellulitis of left lower limb, peripheral vascular disease, and open wound to the left lower leg. Review of the physician order dated 04/06/23 revealed Resident #179 had an order for contact isolation for MRSA in the wound. Interview on 04/24/23 at 10:25 A.M. with Licensed Practical Nurse (LPN) #451 revealed Resident #179 was under contact isolation for a wound to her feet and those providing care to the resident required personal protective equipment (PPE) including a gown. Observation on 04/24/23 at 10:30 A.M. revealed Resident #179 had no biohazard containers in her room. Observation on 04/24/23 at 4:00 P.M. of Resident #179 revealed a disposable gown was in a resident trashcan, it was not pushed down and was overflowing from the top of the can. Interview on 04/24/23 at 4:22 P.M. with LPN #451 verified the observation. She was unsure who put the gown in the trash can but confirmed it should not be there. She verified there was no biohazard container in the room and that she usually brought her own trash bag and carried it to the biohazard room.

CONCERN (E)

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

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to ensure Section C for assessing a resident's cognition and mood were assessed in the Minimum Data Set (MDS) 3.0 assessment. This affected six (Residents #77, #151, #57, #406, #15, and #25) of six residents reviewed for accuracy of assessments. The facility census was 207. Findings include: 1. Review of the medical record for Resident #77 revealed an admission date of 01/31/22 with diagnoses including major depressive disorder, paraplegia, neurogenic bowel, neuromuscular dysfunction of the bladder, panic disorder, major depression, and polyneuropathy. Review of Resident #77's quarterly MDS 3.0 assessment dated [DATE] revealed all areas in Section C (Cognition) and Section D (Mood) were marked as 'not assessed.' 2. Review of the medical record for Resident #151 revealed an admission date of 06/10/22 with diagnoses including end stage renal disease with dependence on dialysis, unspecified protein calorie malnutrition, cognitive communication deficit, metabolic encephalopathy, and depression. Review of Resident #151's comprehensive MDS 3.0 assessment dated [DATE] revealed all areas in Section C (Cognition) and Section D (Mood) were marked as 'not assessed.' 3. Review of the medical record for Resident #57 revealed an admission date of 01/19/23 with diagnoses including end stage renal disease with dependence on renal dialysis, dysphagia, type two diabetes mellitus, chronic heart failure, and Alzheimer's disease Review of Resident #57's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed all areas in Section C (Cognition) and Section D (Mood) were marked as 'not assessed.' 4. Review of the medical record revealed Resident #406 was admitted on [DATE] with diagnoses including end stage renal disease with dependence on dialysis, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and obstructive and reflux uropathy. Review of Resident #406's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed all areas in Section D (Mood) were marked as 'not assessed.' 5. Review of the medical record for Resident #15 revealed an admission date of 05/15/19 and the diagnoses of paranoid schizophrenia, depression, and alcohol abuse. Review of Resident #15's annual MDS assessment dated [DATE] revealed the resident did not have a Section C, Brief Interview of Mental Status (BIMS) completed. 6. Review of the medical record for Resident #25 revealed an admission date of 11/15/22 and the diagnoses of schizophrenia, disorganized schizophrenia, and nicotine dependence. Review of Resident #25's quarterly MDS assessment dated [DATE] revealed the resident did not have a Section C, BIMS completed. Interview on 04/26/23 at 4:13 P.M. and on 04/27/23 at 8:03 A.M. with MDS Nurse #418 verified the incomplete MDS sections for Residents #57, #77, #151, #15, #25, and #406. She reported Section C and D were completed by the social worker and verified that if the resident was unavailable a staff interview should have been completed. Review of the policy, Accuracy of MDS, dated 02/22/23, revealed each individual that completed a section of the MDS must verify the accuracy by reviewing the record, observing the resident, communicating with the resident, staff, family, or other licensed professional, or any other route by which information may be obtained. Prior to signing or completing a section of the MDS, the interdisciplinary team should review it to ensure that all information accurately represents the resident's status as of the Assessment Reference Date (ARD).

Nov 2022 8 deficiencies

CONCERN (D)

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

Deficiency F0552 (Tag F0552)

Could have caused harm · This affected 1 resident

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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 #146 was provided the opportunity to participate in decisions regarding the continued use of an indwelling urinary catheter. This affected one resident (#146) of the three residents who were reviewed for urinary catheters or urinary tract infections. Findings include: Record review revealed Resident #146 was admitted to the facility on [DATE] with diagnoses including muscle wasting and atrophy, end stage renal disease, benign prostatic hyperplasia with lower urinary tract symptoms, dependence on renal dialysis and legal blindness. Review of the facility Nursing Comprehensive Evaluation, dated 09/20/22 revealed the resident was assessed to have an indwelling urinary (Foley) catheter. Review of the a certified nurse practitioner (CNP) progress note, dated 09/22/22 revealed the resident had little urine and self catheterized. Nursing to provide catheterization supplies and resident to self catheterize every eight hours as needed. Review of the nursing progress note, dated 09/22/22 revealed the resident was educated with return demonstration, using clean technique (related to the self catherization process). Review of the physician's orders revealed an order dated 09/22/22 (and discontinued on 10/03/22) for the resident to be straight catheterized every eight hours. The resident did not have an order for an indwelling urinary (Foley) catheter during this time period. However, on 09/30/22 an order was written to discontinue Foley catheter. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 09/27/22 revealed the resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 15 (out of 15). The rsident was assessed to require extensive assistance from two staff members for transfers, extensive asssistance from one staff member for toileting, and limited assistance from one staff member for eating. The resident was assessed to have an indwelling Foley catheter. Review of the nursing progress note, dated 09/30/22 revealed the nurse spoke with the CNP to clarify self-catheterization order. The note indicated to remove Foley catheter and continue with self-catheterization every eight hours as previously ordered. Resident out to dialysis at this time. Will remove Foley upon return from treatment on this day. Review of the CNP encounter note, dated 10/01/22 revealed resident with order to discontinue Foley catheter and continue with self catheterization every eight hours. Resident, however, requests Foley be replaced. Advised of increased infection risk and cannot authorize a replacement, but offered to pass on to rounding to discuss further. However, resident refused removal times three attempts. Wants to discuss with rounding first. Rounding notified. Review of the nurse's progress note, dated 10/01/22 revealed guest had an order to remove Foley catheter. This nurse removed Foley catheter. Guest complained about the removal of the Foley catheter after it was removed. CNP made aware. Review of the nurse's progress note, dated 10/01/22 revealed Resident #146 called 911 to take him to the hospital. The emergency squad came and took him to the hospital. Resident was concerned his Foley catheter was removed. CNP notified. Review of the hospital After Visit Summary, dated 10/01/22 revealed the resident was seen for flank pain and diagnosed with urinary retention and acute urinary tract infection (UTI). Review of the CNP progress note, dated 10/03/22, revealed resident being seen for urinary tract infection. The note refleted the resident had sent himself out to the hospital for urinary retention and was found to have a urinary tract infection. Resident had a Foley inserted and 1.5 liters of urine was drained out. Resident to continue with Foley and will follow up with urology. Review of the physician's orders revealed an order, dated 10/03/22 for a 16 French indwelling Foley catheter. Interview with Resident #146 on 11/01/22 at 8:15 A.M. revealed the resident had a indwelling urinary catheter upon admission to the facility which had been in place for more than two years due to the resident not being able to urinate. The resident stated there was trauma to the end of his penis which had been present prior to coming to the facility and his penis was split at the end, which would make it hard to self catheterize. The resident stated he was also blind and had very limited vision. The resident stated the facility removed the catheter without telling him why. The resident stated he did not urinate after removal of the catheter for several hours and had to call 911 to go to the hospital to have a catheter put back in, due to having pain and feeling as though his bladder was full. The resident stated the catheter tubing was not attached to a bag and was capped off, and he or staff opened it up to allow urine to drain when needed. On 11/01/22 at 8:15 A.M. Resident #146 was observed to be rummaging through the refrigerator in his room attempting to find creamer to put in his coffee and was having difficulty due to not having adequate vision. A State Tested Nursing Assistant entered the room with the resident's breakfast tray and oriented the resident to the food placement on his tray by placing the residents hand on each bowl and telling him what was in the bowl. The STNA stated the resident could hardly see and needed assistance with all activities of daily living (ADL's). On 11/03/22 at 2:15 P.M. interview with the Director of Nursing (DON) revealed the facility had received an order to remove Resident #146's Foley catheter (on 09/30/22) due to the resident not having an appropriate diagnosis. There was no evidence the resident was in agreement with this change in care or that the facilty followed up with urology prior to removing the catheter. On 11/03/22 at 3:10 P.M. interview with Registered Nurse (RN) #252 revealed Resident #146 had an indwelling Foley catheter upon admission to the facility and reported having the Foley catheter for more than two years prior to being admitted to the facility. RN #252 stated she removed the resident's catheter as ordered due to the resident not having an appropriate diagnosis and the resident later called 911 due to wanting the catheter replaced.

CONCERN (D)

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

Deficiency F0604 (Tag F0604)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure Resident #164 was not physically restrained for staff convenience. This affected one resident (#164) of the two residents reviewed for physical restraints. Findings include: Record review revealed Resident #164 was admitted to the facility on [DATE] with diagnoses including Huntington's disease, major depressive disorder, unspecified fall, muscle wasting, mild cognitive impairment and schizoaffective disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/05/22 revealed the resident exhibited moderately impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 10 (out of 15). This resident was assessed to require extensive assistance from two staff members for bed mobility and transfers and extensive assistance from one staff member for toileting and walking. This assessment did not note the use of any type of restraints. On 10/31/22 at 10:15 A.M. Resident #164 was observed lying in bed watching television. The right side of the resident's bed was observed to be against the wall and a pillow was observed to be wedged under the fitted sheet on the left side of the bed adjacent to the resident's left arm and torso. On 11/01/22 at 7:10 A.M. Resident #164 was observed lying in bed. The right side of the resident's bed was observed to be against the wall and a pillow was observed to be wedged under the fitted sheet on the left side of the bed adjacent to the resident's left arm and torso. On 11/03/22 at 11:37 A.M. Resident #164 was observed lying in bed. The right side of the resident's bed was observed to be against the wall and a pillow was wedged under the fitted sheet on the left side of the bed adjacent to the resident's left arm and torso. On 11/03/22 at 11:45 A.M. interview with State Tested Nursing Assistant (STNA) #374 and STNA #599 verified staff had wedged the pillow under the fitted sheet on Resident #164's bed. The staff indicated the pillow was placed there to prevent the resident from being able to get up by herself as they were afraid the resident might fall. STNA #599 revealed the resident was able to ambulate with the extensive assistance from one staff member. Record review revealed no physician order/assessment, facility assessment, care plan or justified rationale for the use of the pillow which prevented the resident from independently getting out of bed. Review of the facility policy titled Restraint Management, revised 09/09/22 revealed restraints were not used unless the resident had medical symptoms which warranted the use of the restraint. Physical Restraints were not used for the purpose of discipline or convenience, but only as required to treat the resident's medical symptom. Physical restraints were defined as any manual method, physical or mechanical device, material or equipment attached or adjacent to the resident's body the resident could not remove easily.

CONCERN (D)

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

PASARR Coordination (Tag F0644)

Could have caused harm · This affected 1 resident

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Based on record review, and staff interview the facility failed to ensure Resident #116 was referred for a Pre-admission Screening and Resident Review (PASARR) assessment following a significant change in status and new mental health diagnoses. This affected one resident (#116) of five residents reviewed for PASARR. Findings include: Review of the medical record for Resident #116 revealed an initial admission date 12/08/20 and a re-entry date of 01/21/22. Resident #116 had current diagnoses including major depressive disorder, anxiety, suicidal ideation's, schizoaffective disorder, and psychosis. Review of Resident #116's PASARR, dated 12/03/20 revealed under Section D: Indications of Serious Mental Illness, Mood Disorder was the only diagnosis noted in this section. The PASARR Determination letter revealed, Not Applicable. Review of Resident #116's care plan, dated 12/08/20 and revised 08/03/22 revealed Resident #116 had potential for fluctuations in mood related to diagnoses of major depressive anxiety, insomnia, schizophrenia, psychosis, impulsive at times. Interventions include to administer medications as ordered, redirect and reproach as needed. Review of Resident #116's annual Minimum Data Set (MDS) 3.0 assessment, dated 10/11/22 revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating the resident had intact cognition for daily decision making abilities. The assessment revealed the resident received antipsychotic and antidepressants seven of seven days during the review period. Review of Resident #116's physician orders for November 2022 revealed the resident had orders for the anti-psychotic medication, Seroquel 50 milligrams (mg) tablet, one tablet at night for schizoaffective disorder, Seroquel 25 mg tablets two times a day for schizoaffective disorder, the anti-depressant medication Zoloft 50 mg tablet one tablet daily for depression, the anticonvulsant medication, Depakene Solution 250 mg/ 5 milliliter (ml), give 10 ml by mouth every 8 hours for schizoaffective disorder and the benzodiazepine medication, Klonopin 0.5 mg tablet one tablet daily for anxiety. On 11/03/22 at 2:00 P.M. interview with Social Service Designee (SSD) #209, and #372 confirmed Resident #116's most recent PASARR was dated 12/03/20 and since then, Resident #116 had had newly added mental illness diagnoses which would indicate a new PASARR needed to be completed. SSD #209, and #372 also confirmed a updated PASARR has not been completed for Resident #116. A facility policy was requested at the time of the survey but none was provided.

CONCERN (D)

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

Deficiency F0645 (Tag F0645)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to timely complete a Preadmission Screen and Resident Review (PASARR) for Resident #147 at the time of admission. This affected one resident (#147) of five residents reviewed for PASARR. Findings include: Record review revealed Resident #147 was admitted to the facility on [DATE] and had diagnoses including hallucinations, schizophrenia, major depressive disorder, generalized anxiety disorder, suicide attempt, and personal history of traumatic brain injury. Review of the Preadmission Screening and Resident Review (PASARR) Identification Screen revealed the screen had not been completed until 05/13/22, almost six months after the resident was admitted to the facility. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 09/08/22 revealed the resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 14 out of 15. The assessment revealed the resident required limited assistance from one staff member for bed mobility, limited assistance from two staff members for transfers, limited assistance from one staff member for toileting and supervision with setup help only for eating. On 11/02/22 at 11:45 A.M. interview with Social Service Designee #209 verified the PASARR screen had not been completed until 05/13/22, almost six months after the resident was admitted to the facility.

CONCERN (D) 📢 Someone Reported This

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

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy review and interview the facility failed to ensure timely follow up appointments were scheduled to promote an optimal continuum of care for Resident #23 and Resident #174. The facility also failed to ensure preventative skin interventions were provided as ordered for Resident #33. This affected three residents (#23, #33 and #174) of 37 sampled residents reviewed for quality of care. Findings include: 1. Record review revealed Resident #23 was admitted to the facility on [DATE] with diagnoses including muscle weakness, repeated falls, schizoaffective disorder, muscle wasting and atrophy, altered mental status, bipolar disorder and chronic pain syndrome. Review of the nursing progress note, dated 09/29/22 revealed staff alerted the nurse Resident #23 was on the floor. The resident was observed to be laying on his right side with a cane near the resident. The resident stated he became lightheaded sometimes and while ambulating in the hall lowered himself to the floor. The resident verbalized complaints of pain rated at a 10 out of 10 in both ankles. Certified Nurse Practitioner (CNP) #555 was notified and gave orders for STAT (urgent) x-rays to be performed of both ankles. Review of the x-ray results, performed on 09/29/22 at 11:50 P.M., revealed radiographic views of the right ankle demonstrated a likely subacute fracture of the medial malleolus of the tibia which were nearly completely healed with no acute fractures. Radiographic views of the left ankle demonstrated subacute partially healed mildly displaced likely spiral fracture of the distal left tibial metadiaphysis with no acute fracture. Review of the nursing progress note, dated 09/30/22 revealed CNP #555 was notified of the results of the x-rays completed for Resident #23 and requested the resident be sent to the emergency room (ER) for evaluation. The resident refused stating he would get his pain medication in the morning and requested to have his orthopedic surgeon notified. (The resident had a routine order for the opioid medication, Oxycodone in place prior to the incident due to his diagnosis of chronic pain). Review of CNP #555's encounter note, dated 09/30/22 revealed CNP #555 was notified by nursing staff Resident #23 was noted to have fractures of the left and right ankle from the x-ray taken on 09/29/22. The note revealed the CNP reviewed the report which showed a nearly completely healed fracture of the right ankle, chronic which the resident had seen orthopedics for recently. The CNP note also reflected the resident had a subacute, incompletely healed fracture of the left ankle. The note indicated the resident complained of pain and orders were provided to send him to the hospital, however the resident decided he wanted to stay (in the facility), refused to go to the emergency room (ER) and wanted to follow up outpatient with his orthopedic physician. The resident's primary care physician was notified. Review of the physician's orders revealed an order, dated 09/30/22 for an orthopedic consult related to bilateral ankle fractures. Review of a therapy screen note, dated 09/30/22 revealed Resident #23 had a fall in which x-rays were taken of the bilateral ankles revealing the following: left ankle x-ray (subacute incompletely healed distal tibia spiral fracture). Discussion with CNP about plan of care and instructed to reassess resident after three days to see if inflammation goes down to see if new recommendations needed made. Nursing planning to have follow up with orthopedics as well. Resident was provided a wheelchair as well as an elevating leg rest and educated to use wheelchair for primary mobility at this time in order to decrease weight bearing through bilateral lower extremities. Review of a Therapy Evaluation Note, dated 10/03/22 revealed Resident #23 was reassessed today per request of the CNP. CNP indicated it was up to the therapist discretion regarding the resident's weight bearing status at the time. The note indicated the resident had been given an orthopedic appointment and was awaiting transport to settle the date. Resident was evaluated and was able to perform transfer at supervision from edge of bed to wheelchair and wheelchair to edge of bed. Resident provided with manual ACE wraps for more support and instructed to decrease ACE wraps as resident reported feeling better. The evaluation note contained recommendations to use wheelchair for primary mobility to be conservative and protect left ankle until follow-up with orthopedic physician. The note reflected the resident was experiencing some increased pain as well as edema in bilateral lower extremities which nursing was aware. During the onsite survey, the facility was asked to provide evidence of the orthopedic physician appointment being made for the resident following the order being written on 09/30/22. The following information was provided: A Send Result Report, dated 10/05/22 and timed 10:37 A.M., revealed the urgent Physician Referral Form had not successfully been transmitted by fax. A Send Result Report, dated 10/05/22 and timed 11:52 A.M., revealed the urgent Physician Referral Form had not successfully been transmitted by fax. A Send Result Report, dated 10/06/22 and timed 9:20 A.M., revealed the urgent Physician Referral Form had not successfully been transmitted by fax. A Send Result Report, dated 10/07/22 and timed 4:26 P.M., revealed the urgent Physician Referral Form had not successfully been transmitted by fax. A CNP progress note, dated 10/07/22 revealed the resident was being seen for subacute spiral fracture. The note indicated the resident was educated to remain non-weight bearing until seen by orthopedic physician. Record review revealed between 09/30/22 and 10/07/22 there was no evidence the resident had complaints of increased pain to the ankle areas or requested to go to the hospital. However, there was no evidence the resident was seen by the orthopedic physician or that the orthopedic physician appointment had been made. Review of the nursing progress note, dated 10/08/22 revealed Resident #23 reported pain at a level of 10 out of 10 to the left lower extremity. Resident #23 denied any falls since fall incident on 09/30/22 and requested an x-ray. A new order for an x-ray of left lower extremity was obtained to rule out any new injuries. Review of the physician's orders revealed an order, dated 10/08/22 for a STAT x-ray of the left leg due to swelling and pain. Review of the x-ray results, for the x-ray performed on 10/09/22 at 5:06 P.M. revealed single view of the left knee demonstrated minimal degenerative change. The x-ray also showed a comminuted proximal fibular neck fracture, acute to subacute. Review of the nursing progress note, dated 10/10/22 reflected the x-ray result being received indicating a subacute fracture to left knee suggest healing. The CNP was made aware. The note revealed awaiting orthopedic consultation date and time. Review of the CNP progress note, dated 10/10/22 revealed Resident #23 was seen for a left knee comminuted fracture. The note revealed the resident would be sent to the emergency room for further care at this time. Review of the nursing progress note, dated 10/10/22 revealed 911 was called at 9:10 A.M. Resident #23 was transferred to the hospital on [DATE] at 9:18 A.M. Review of the hospital visit notes revealed the resident was hospitalized from [DATE] through 10/16/22. Hospital visit notes reflected an x-ray of the left ankle which showed acute traumatic fractures of the proximal left fibular metadiaphysis, distal left tibial metadiaphysis as well as of the medial malleolus. An x-ray of the right ankle revealed acute traumatic displaced obliquely oriented fracture involving medial malleolus. On 10/11/22 the resident underwent surgical intervention including an intramedullary nailing of the left tibia and open reduction internal fixation of both ankles. Resident #23 was re-admitted to the facility following the hospitalization on 10/16/22. On 11/02/22 at 10:15 A.M. interview with Resident #23 (who was alert and oriented) revealed the resident had a history of fractures to his ankles and had received orthopedic care in the past. The resident verified he had sustained a fall while independently ambulatory on 09/30/22 and had x-rays performed which he stated showed old fractures according to staff. The resident indicated at the time of the incident he preferred to just follow up with his orthopedic physician and did not want to go to the hospital. However, the resident indicated facility staff did not schedule an appointment for him to be seen by the orthopedic physician. The resident was unaware why the appointment was not made for him. The resident indicated his pain to the areas got worse around 10/10/22 and at that time he did go to the hospital for treatment. During the interview, Resident #23 stated staff provided him a wheelchair to use during that time period (to keep weight off his feet). On 11/02/22 at 2:38 P.M. interview with Physical Therapist (PT) #900 revealed Resident #23 had been evaluated on 10/03/22 due to a fall on 09/30/22 with fractures found upon x-rays performed. PT #900 verified Resident #23 was instructed to use a wheelchair for all mobility except for transfers until seen by the orthopedic doctor, whose appointment was to be scheduled by nursing staff. On 11/02/22 at 4:35 P.M. telephone interview with Receptionist #999 from the orthopedic physician's office revealed the facility contacted their office (by phone) on 10/11/22 to make an appointment for Resident #23 to be seen. The appointment was scheduled for 10/19/22. On 11/03/22 at 9:01 A.M. and 10:10 A.M. interview with Transport Aide #315 revealed the employee scheduled appointments for residents and kept the fax transmission results to prove attempts made. Transport Aide #315 verified attempts to fax the referral for Resident #23 had been done on 10/05/22, 10/06/22, and 10/07/22 and verified the Send Report Result forms showed errors (unsuccessful attempts) had been filed in a folder. Transport Aide #315 revealed on 10/11/22 she phoned the orthopedic office to see if they had received the faxed referral and was told they had not, so she scheduled the appointment (on 10/11/22) for the resident to be seen on 10/19/22 while she was on the phone with them. Transport Aide #315 revealed she was aware Resident #23 was in the hospital on [DATE], but stated she always followed through with the scheduling of appointments. On 11/04/22 at 3:00 P.M. telephone interview with CNP #555 revealed the CNP had been notified of the initial x-ray results indicating Resident #23 had fractures to both ankles and gave an order for the resident to be sent to the ER for evaluation. CNP #555 verified the results of the x-ray were urgent enough to require transport to the hospital at the time the results were received. However, CNP #555 stated the resident had refused to go to the ER and requested to be seen by his orthopedic physician instead. 3. Review of the medical record for Resident #33 revealed an admission date of 08/25/22 with diagnoses including severe protein-calorie malnutrition, dementia with behavioral disturbance, muscle wasting and atrophy and a history of falling. Review of Resident #33's MDS 3.0 assessment, dated 09/01/22 revealed a Brief Interview of Mental Status (BIMS) score of 01 indicating severely impaired cognition for daily decision making abilities. Resident #33 was noted to display inattention, disorganized thinking, and delusions. The assessment revealed Resident #33 required extensive assistance from two staff members for transfers, dressing, toilet use and personal hygiene. The resident had no noted impairments to bilateral upper or lower extremities and required the use of a wheelchair for mobility. Resident #33 was noted to be free of any skin issues or pressure wounds during the assessment review. Review of the care plan, dated 10/19/22 revealed Resident #33 had an actual impaired skin integrity related to pressure injury. The resident's care plan also reflected a history of skin tears with an intervention for bilateral geriatric (geri) sleeves. Review of Resident #33's physician orders for November 2022 revealed an order for geri sleeves to be worn bilaterally (upper extremities) every shift. Review of the treatment administration record (TAR) for November 2022 revealed the order for the bilateral geri-sleeves was included for staff to document implementation on the administration record. On 10/31/22 at 12:03 P.M. Resident #33 was observed sitting in a geri chair in the common area wearing personal clothing which included a short sleeve shirt. The resident was not observed with bilateral geri sleeves in place at that time. On 11/02/22 at 2:50 P.M. Resident #33 was observed sitting in a geri chair in the common area wearing personal clothing which included a short sleeve shirt. The resident was not observed with bilateral geri sleeves in place at that time. On 11/02/22 at 2:52 P.M. interview with Unit Manager #316 confirmed Resident #33 did not have the ordered bilateral geri sleeves in place at this time. Review of facility policy titled Skin Management, revised 07/14/21 revealed guest/residents with wounds and/or pressure injury and those at risk for skin compromise were identified, evaluated and provided appropriate treatment to promote prevention and healing. Ongoing monitoring and evaluation were provided to ensure optimal guest/resident outcome. This deficiency represents non-compliance investigated under Complaint Number OH00136945 and Complaint Number OH00136707. 2. Review of the medical record for Resident #174 revealed an initial admission date of 06/15/22 with the latest readmission of 07/03/22 with the admitting diagnoses of multiple sclerosis (MS), muscle wasting and atrophy, dysphagia, mild protein calorie malnutrition, fistula of vagina to large intestine, calculus of kidney, gastrostomy, vitamin D deficiency, gastroesophageal reflux disease, colostomy, tachycardia, muscle spasm, chronic pain. Review of the hospital Discharge summary, dated [DATE] revealed the resident was to follow up with a local MS clinic with magnetic resonance imaging (MRI) of the cervical and thoracic spine out-patient in one week. Review of the plan of care, dated 07/14/22 revealed the resident was at risk for complications of MS. Interventions included administer medications as ordered, observe/document/report to physician as needed signs/symptoms of damage to cerebellar or brainstem damage, cerebral cortex, motor or sensory control, motor nerve tracts and sacral cord lesions, obtain labs/diagnostic work as ordered, pain management as needed, therapy evaluate and treat as needed and resident/family/caregiver education related to MS treatments. Review of the resident's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/05/22 revealed the resident had clear speech, understood others, made herself understood and cognition was not assessed. The resident's behaviors and depression were not assessed. Review of the medical record revealed no evidence the facility arranged the MRI of the thoracic spine or follow up appointment in one week upon discharge from the acute care hospital on [DATE]. On 11/02/22 at 4:29 P.M. interview with Unit Manager (UM) #256 verified the outpatient MRI of the thoracic spine and the follow up appointment at the local MS clinic were not arranged as ordered upon discharge from the acute care hospital on [DATE].

CONCERN (D)

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

Deficiency F0688 (Tag F0688)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the medical record for Resident #158 revealed an admission date of 03/09/22 with diagnoses including schizoaffective disorder, anxiety disorder, personal history of traumatic brain injury (TBI), major depressive disorder and persistent vegetative state. Review of the care plan, dated 03/09/22 and revised 09/28/22 revealed Resident #158 had an activity of daily living (ADL) self care performance deficit and required assistance with ADL's and mobility. Interventions included apply braces and splints as ordered. The care plan did not contain any information related to family (Grandmother #510) removing the resident's devices. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 09/28/22 revealed Resident #158 was in a persistent vegetative state with no discernible consciousness. The assessment revealed Resident #158 was totally dependent on two or more staff to complete activities of daily living (ADL) care. The resident required oxygen, suctioning and had a tracheostomy in place. Review of the physician's orders revealed an order, dated 10/14/22 for a right Neuroflex elbow splint and right resting hand splint for up to six hours as tolerated with skin check every shift. On 11/01/22 an order was noted for Multipodus boots up to six hours daily as tolerated. Check skin integrity. Multipodus boots are medical braces to address foot and ankle alignment and off load the heel. The boots are an effective, systematic treatment of foot drop, hip rotation and pressure sores due to illness, trauma or immobility. On 11/01/22 at 10:30 A.M. Resident #158 was observed without the right elbow splint in place. On 11/01/22 at 4:15 P.M. Resident #158 was observed without the elbow splint or Multipodus boots in place. On 11/01/22 at 4:15 P.M. interview with the resident's grandmother, Grandmother (GM) #510 revealed she visited the resident daily and spent a lot of time with him in the facility. GM #510 voiced concerns Resident #158's splints and boots were never in place on the resident when she visited and felt he needed them. GM #510 stated she planned to follow up with the therapy department regarding her concerns. During the interview, the resident's grandmother denied she was removing any devices from the resident. On 11/02/22 at 2:14 P.M. Resident #158 was observed without the elbow splint or Multipodus boots in place. On 11/02/22 at 5:21 P.M. Resident #158 was observed without the elbow splint or Multipodus boots in place. The boots were observed sitting on the shelf inside the resident's closet. On 11/02/22 at 5:26 P.M. interview with Rehab Services Director (RSD) #241 revealed Resident #158 had physician's orders to wear Multipodus boots but was not sure when Resident #158 was wearing them. RSD #241 revealed Resident #158 was discharged from physical therapy on Friday, 10/28/22 and all recommendations were discussed with nursing upon discharge from therapy services. To her knowledge Resident #158 tolerated the boots without difficulty. On 11/02/22 at 5:30 P.M. observation and interview with Unit Manager (UM) #256 and Licensed Practical Nurse (LPN) #200 confirmed Resident #158 did not have the elbow splint or Multipodus boots in place at that time. UM #256 revealed restorative therapy aides were to apply the elbow splint and the Multipodus boots on the resident in the morning for two hours and then remove them. UM #256 revealed all physician orders were written for devices to be utilized as tolerated and there were not specific times indicated when the resident should have the devices on and off. UM #256 checked the resident's orders again and confirmed the order was for Resident #158 to have soft cut out boots on when Multipodus boots were off. (During none of the above observations that included an observation of the resident's feet, did the resident have soft boots on either). UM #256 revealed the order was just written on 11/01/22. UM #256 then stated Resident #158's grandmother removed the resident's boots when she visited. UM #256 confirmed if the boots were removed the staff were capable of reapplying the soft cut out boots to Resident #158 but did not do so. On 11/03/22 at 7:32 A.M. Resident #158 was observed without the elbow splint or Multipodus boots in place. On 11/03/22 at 8:12 A.M. interview with Physical Therapist (PT) #513 confirmed she was familiar with Resident #158 and stated she had worked with the resident in therapy on and off since his admission in March 2022. PT #513 revealed Resident #158 had been tolerating six hours with the Multipodus boots on with no adverse effects when he was discharged from therapy services and did not know why nursing or the restorative aide staff would only be leaving the boots on for two hours before removing them. PT #513 revealed Resident #158 did not show any signs or symptoms of discomfort or display any behaviors when the boots were placed. PT #513 confirmed it was her recommendation Resident #158 have soft cut out boots placed anytime the Multipodus boots were not on. PT #513 revealed Resident #158's grandmother did remove the boots at times but confirmed staff should reapply the boots to the resident when the grandmother left the facility to prevent further issues. PT #513 indicated she trained Restorative Aide (RA) #515 on applying the Multipodus boots when Resident #158 was discharged from physical therapy services. PT #513 stated Resident #158 had drop foot upon admission and the Multipodus boots were recommended to prevent that from worsening. On 11/03/22 at 8:40 A.M. Resident #158 was observed without the elbow splint in place. On 11/03/22 at 9:04 A.M. interview with Occupational Therapist (OT) #393 confirmed he was familiar with Resident #158 and had worked with the resident on and off since admission. Resident #158 was discharged from occupational therapy services on 10/10/22 with the recommendations to apply a hinged right elbow splint for up to six hours daily and a resting right hand splint. OT #393 confirmed Resident #158 tolerated the elbow splint for six hours when he was discharged from therapy services. OT #393 indicated he trained Unit Manager (UM) #215 and UM #256 on applying the elbow splint. Review of a progress note, dated 11/03/22 at 10:13 A.M. revealed Unit Manager (UM) #215 received a new order for a restorative nursing program, after this surveyor started investigating the concern. On 11/03/22 at 10:40 A.M. interview with the Director of Nursing (DON) confirmed Resident #158's orders were not clear as to when the resident should have the elbow splint or Multipodus boots applied and taken off. The DON confirmed there was no documented evidence to support staff were applying the elbow splint or the Multipodus boots for Resident #158 as ordered/recommended by therapy. Review of the facility policy titled Contracture Prevention and Management Program, revised 12/01/18 revealed discuss with therapy when to begin restorative program. Review any recommendations from therapy on providing range of motion or splint/brace assistance. Provide specific directions and training as needed. Update care plan and [NAME]. Document resident daily participation, including actual number of minutes participating in point click care. Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure interventions related to contracture management were in place for Resident #39, Resident #77 and Resident #158 as ordered. This affected three residents (#39, #77 and #158) of four residents reviewed for limited range of motion. Findings include: 1. Review of the medical record for Resident #39 revealed an initial admission date of 08/15/22 with the latest readmission date of 09/30/22 and diagnoses including acute and chronic respiratory failure, pneumonia, aphonia, dysphagia, muscle wasting and atrophy, sepsis, heart failure, cerebral palsy, severe protein-calorie malnutrition, metabolic encephalopathy, gastro-esophageal reflux disease, gastrostomy, tracheostomy, hyperlipidemia, neuromuscular dysfunction of bladder, anemia and dependence on ventilator. Review of the nursing comprehensive evaluation dated 08/15/22 revealed the resident was admitted to the facility with contractures and had a diagnoses of quadriplegia. Review of the monthly physician's orders for November 2022 revealed an order (initiated 10/28/22) for a resting left hand splint for up to six hours daily as tolerated with the special instructions to check skin integrity one time a day for restorative (as tolerated). Review of the medical record revealed no documented evidence the resident was not tolerating the left hand resting splint up to six hours daily. On 10/31/22 at 3:37 P.M., observation of Resident #39 revealed bilateral contractures of the wrist and hands with no contracture prevention devices in place as ordered. On 11/01/22 at 4:20 P.M., observation of Resident #39 revealed bilateral contractures of wrist and hands with no contracture prevention devices in place as ordered. On 11/02/22 at 10:20 A.M., observation of Resident #39 revealed bilateral contractures of wrist and hands with no contracture prevention devices in place as ordered. On 11/02/22 at 11:20 A.M., observation of Resident #39 revealed bilateral contractures of wrist and hands with no contracture prevention devices in place as ordered. On 11/02/22 at 2:35 P.M., observation of Resident #39 revealed bilateral contractures of wrist and hands with no contracture prevention devices in place as ordered. On 11/03/22 at 9:15 A.M., observation of Resident #39 revealed bilateral contractures of wrist and hands with no contracture prevention devices in place as ordered. On 11/02/22 at 9:12 A.M., interview with Unit Manager (UM) #256 revealed it was the responsibility of restorative nursing staff to apply the resident's contracture prevention devices/splints. On 11/03/22 at 10:40 A.M., interview with the Director of Nursing (DON) verified the splinting devices were not in place for Resident #39. The DON indicated staff had no knowledge of a splint schedule or who was responsible for the application of the splint(s). 2. Review of the medical record for Resident #77 revealed an initial admission date of 05/12/20 with the latest readmission of 08/19/22 and admitting diagnoses including acute respiratory failure, history of COVID-19, persistent vegetative state, obstructive sleep apnea, pulmonary hypertension, encephalopathy, diabetes mellitus, dysphagia, benign prostatic hyperplasia, chronic kidney disease, cerebral edema, anemia, dependence on ventilator, aphasia, asthma, schizoaffective disorder, major depressive disorder, anxiety disorder, insomnia, chronic respiratory failure, neuromuscular dysfunction of bladder, cerebral infarction, tracheostomy status, hypothyroidism and hyperlipidemia. Review of the nursing comprehensive evaluation, dated 08/19/22 revealed the resident had no restraints in use and range of motion (ROM) was decreased. Review of the monthly physician's orders for November 2022 revealed an order (initiated 08/19/22) to apply bilateral palm protectors for six to eight hours daily as tolerated, check skin integrity every shift. Review of the plan of care (initiated 08/19/22) and last revised 11/02/22 revealed the resident had a self care performance deficit and required assistance with activities of daily living (ADL) related to contractures to hands, cerebral infarction, persistent vegetative state and total care for activities of daily living (ADL) care. Interventions included bilateral palm protectors. On 11/01/22 at 4:15 P.M., observation of Resident #77 revealed the physician ordered palm protectors were not in place. On 11/02/22 at 10:00 A.M., observation of Resident #77 revealed the physician ordered palm protectors were not in place. On 11/02/22 at 12:40 P.M., observation of Resident #77 revealed the physician ordered palm protectors were not in place. On 11/02/22 at 2:40 P.M., observation of Resident #77 revealed the physician ordered palm protectors were not in place. On 11/02/22 at 5:35 P.M., observation of Resident #77 revealed the physician ordered palm protectors were not in place. On 11/3/22 at 7:30 A.M., observation of Resident #77 revealed the physician ordered palm protectors were not in place. On 11/03/22 at 8:30 A.M., observation of Resident #77 revealed the physician ordered palm protectors were not in place. On 11/03/22 at 9:11 A.M., observation of Resident #77 revealed the physician ordered palm protectors were not in place. On 11/02/22 at 5:38 P.M., interview with Licensed Practical Nurse (LPN) #200 revealed restorative aides were responsible to implement and apply the palm protectors to the resident's hands. On 11/03/22 at 8:48 A.M., interview with Restorative Nurse #550 revealed palm protector application was not a restorative program and the State Tested Nursing Assistant (STNA) assigned to the resident's care was responsible for implementing the devices daily. On 11/03/22 at 9:00 A.M., interview with Occupational Therapy (OT) #551 revealed the resident was discharged from OT on 10/21/22 with the recommendation for bilateral palm protectors for six to eight hours as tolerated. OT #551 revealed at the time of discharge the resident tolerated the palm protectors for a minimum of six hours daily and had no reports the resident was not tolerating the palm protectors since discharge from OT. On 11/03/22 at 10:40 A.M., interview with the Director of Nursing (DON) verified the palm protectors were not in place as ordered. The DON revealed staff had no knowledge of when and who was responsible for the application of the devices.

CONCERN (D)

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

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected 1 resident

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Based on observation, record review, review of dialysis communication forms, facility policy and procedure review and interview the facility failed to ensure accurate dialysis communication was communicated between the facility and dialysis center for Resident #126. This affected one resident (#126) of two residents reviewed for hemodialysis. Findings include: Review of the medical record for Resident #126 revealed an admission date on 10/20/21 with medical diagnoses including end stage renal disease, dependence on renal dialysis, chronic viral hepatitis C, and acquired absences of left leg above the knee and right toe(s). Review of the care plan, dated 10/20/21 (and revised 11/04/22) revealed Resident #126 was at risk for complications related to dialysis. Interventions included the facility would utilize the Dialysis Communication form to communicate with the dialysis center. Send the dialysis communication book to the dialysis center with each appointment. Upon return from the dialysis center review the communication book including any progress notes. Provide an update to the physician and any staff member/disciplines as needed. Upon return from the dialysis center observe the resident's access site and obtain vital signs, document findings in the medical record. Report abnormal findings to the physician. Review of nurse's notes dated from 04/01/22 to 10/31/22 revealed no entries related to dialysis communication between the facility and the dialysis center. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/04/22 revealed Resident #126 had mildly impaired cognition with a Brief Interview for Mental Status (BIMS) score of 12 (out of 15). The assessment revealed Resident #126 required supervision with physical help from one staff for toileting and bed mobility and extensive assistance from one staff to complete transfers, dressing, and personal hygiene. The assessment reflected the resident received dialysis. Review of the resident's physician's orders revealed the following: From 09/13/22 to 09/20/22 an order for hemodialysis every Monday, Wednesday and Fridays on-site with a chair time at 5:00 A.M. From 09/20/22 to 10/16/22 an order for hemodialysis every Tuesday, Thursday, and Saturday off-site at a local dialysis center with a pick-up time between 12:15 P.M. to 12:45 P.M. From 10/16/22 to 10/19/22 hemodialysis every Tuesday, Thursday, and Saturday on-site with a chair time between 12:00 P.M. and 12:30 P.M. And an order, dated 10/19/22 for hemodialysis (HD) every Monday, Wednesday, and Friday at the on-site dialysis center with a chair time of 10:15 A.M. to 2:15 P.M. On 11/02/22 at 10:56 A.M. Resident #126 was observed dressed and sitting in his wheelchair sleeping in his room. Interview with the resident at the time of the observation revealed he needed to go to dialysis on-site at the facility. Resident #126 mobilized himself in his wheelchair, left his room, and went to the on-site dialysis center. The resident was not in possession of any dialysis communication forms or dialysis binder. On 11/02/22 at 11:00 A.M. interview with Licensed Practical Nurse (LPN) #217 revealed dialysis communication forms were normally kept in a binder at the nurse's station, but the Director of Nursing had removed the binder off the unit this morning. On 11/02/22 at 11:15 A.M. interview with the Administrator confirmed dialysis communication forms were kept in a binder and agreed to provide the binder for Resident #126's communication forms to be reviewed. The dialysis binder was not provided. Copies of dialysis communication forms for Resident #126 were provided on 11/02/22 at 1:12 P.M. for review. Review of a the Hemodialysis Communication Forms provided from the facility (from 08/2022 through 11/02/22) revealed multiple days that were double documented with non-matching information including vital signs, weights, and additional notes related to the condition of the access site. Examples included but were not limited to the following: On 08/04/22, two dialysis communication forms were completed. One of the forms noted vital signs (v/s) completed before departure showed a blood pressure (BP) 137/79, temperature (T) 97.6, pulse (P) 80, and respirations (R) 16 and no v/s documented upon return. The other form noted v/s prior to departure were BP 123/68, T 97.4, P 80, R 17 and also documented v/s upon return as BP 127/73, T 97.3, P 70, and R 17. No pre-dialysis weight was noted on either form. On 08/09/22, two dialysis communication forms were completed. One documented v/s completed by the facility were BP 157/70, T 97.9, P 78, and R 16. The other form noted v/s completed by the facility were BP 119/68, T 97.6, P 86, and R 18. No pre-dialysis weight was noted on either form. On 08/11/22, two dialysis communication forms were completed. One documented a post-dialysis weight of 48.1 kilograms (kg) and no pre-dialysis weight; the other did not include any weights. One documented v/s completed by the facility upon return as BP 128/70, T 97.6, P 91, and R 18 and noted the access site to be clean; the other noted v/s completed by the facility upon return as BP 128/75, T 97.5, P 80, and R 18 and did not include any notes related to the access site. On 08/25/22, two dialysis communication forms were completed. One documented v/s completed by the facility before departure as BP 143/67, T 97.1, P 70, and R 16 and v/s completed by the facility upon return as BP 133/84, T 97.6, P 74, and R 18. No comments related to the access site and no pre-dialysis weight was noted. On the other form, v/s completed by the facility before departure were BP 153/69, T 97.3, P 82, and R 17. V/S completed by the facility upon return were BP 160/70, T 97.5, P 82, and R 17. The access site was noted as okay. There was not a pre-dialysis weight noted. On 09/01/22, two dialysis communication forms were completed. One documented v/s completed by the facility before departure as BP 149/94, T 97.9, P 80, and R 18. V/s completed by the facility upon return as BP 149/96, T 97.9, P 85, and R 18. The access site was noted as intact. The other form noted v/s completed by the facility before departure as BP 136/70, T 97.6, P 86, and R 17. V/s completed by the facility upon return as BP BP 128/74, T 97.5, P 84, and R 18. There were no comments related to the access site. On 09/03/22, two dialysis communication forms were completed. One documented v/s completed by the facility before departure were BP 121/74, T 97.7, P 77, and R 18. V/s completed by the facility upon return were BP 139/80, T 97.8, P 79, and R 18. The access site was noted as patent. There was no pre-dialysis weight noted. The other form noted v/s completed by the facility before departure as BP 128/80, T 97.8, P 78, R 18. V/s completed by the facility upon return noted no BP documented, T 97.8, no pulse noted, and R 18. Pre-dialysis weight was noted as 50.9 kg. On 09/16/22, two dialysis communication forms were completed. One documented v/s completed by the facility before departure were BP 124/78, T 97.6, P 70, R 18. No v/s upon return were documented. No comments related to the access site were noted. The other form noted v/s completed by the facility before departure were BP 122/70, T 97.9, P 75, and R 18. V/s completed upon return were BP 114/70, T 97.6, P 81, R 18. The access site was noted as clean. On 11/02/22 at 1:15 P.M. interview with the Director of Nursing (DON) confirmed the Dialysis Communication Forms for Resident #126 were double documented with mismatched information on the forms as noted above. The DON could not verify which forms were accurate and which were not. The DON confirmed there should only be one communication form for each date Resident #126 attended dialysis and the form should be completed entirely. Review of the facility policy titled Hemodialysis, revised 10/01/19 revealed the facility completes the appropriate section of the hemodialysis communication form prior to resident receiving each dialysis session and again when the resident returns from hemodialysis. Weights would be completed at dialysis unless otherwise requested by the attending physician.

CONCERN (E)

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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Based on observation, facility policy and procedure review and interview the facility failed to ensure the proper personal protective equipment (PPE) was worn when providing care for residents who tested positive for COVID-19 to prevent the potential spread of COVID-19. This had the potential to affect 33 residents (#37, #93, #125, #10, #178, #156, #153, #98, #56, #136, #161, #127, #3, #59, #101, #84, #14, #11, #114, #139, #15, #38, #103, #55, #130, #137, #108, #163, #33, #42, #120, #106 and #121) who resided on the 300 unit (non-COVID unit) who received care from Registered Nurse (RN) #213. The facility census was 185. Finding include: The facility identified seven residents, Resident #7, #159, #83, #138, #4, #71, and #85 who resided on the facility dedicated COVID-19 unit and who were in isolation for COVID-19 at the time of the survey. On 11/02/22 at 12:02 P.M. observation of the 300 unit revealed a portion of the unit had been converted into a dedicated COVID-19 unit. A section of the unit contained a set of double doors which were closed with signs posed. The signage included what proper PPE was to be worn before going onto the unit, through these closed double doors. The PPE required included an isolation gown, N95 mask, and eye goggles or face shield. At the time of the observation (on 11/02/22 at 12:02 P.M.) observation of the COVID-19 unit revealed residents, who were COVID positive were sitting in the common area eating lunch. Registered Nurse (RN) #213 was observed in the common area with the residents. Observation revealed RN #213 was wearing only a surgical mask and not the required N95 mask while in contact and providing care to the resident's in the dining area. The RN did have eye protection in place. On 11/02/22 at 12:10 P.M. interview with Unit Manager #316 revealed most of the residents on the COVID-19 isolation unit stayed in their rooms, so the proper PPE only needed to be worn when actually entering the residents' rooms. At the time of the interview, Unit Manager #316 verified there were residents observed out of their room in the common area and confirmed that due to residents not being isolated to their rooms, staff should be wearing the proper PPE at all times while on the COVID-19 unit. The unit manager verified RN #213 was only wearing a surgical mask and not an N95 mask at that time. In addition, Unit Manager #316 revealed RN #213 provided care for the residents on the COVID-19 unit as well as residents on the non-COVID portion of the 300 unit, including Resident #37, #93, #125, #10, #178, #156, #153, #98, #56, #136, #161, #127, #3, #59, #101, #84, #14, #11, #114, #139, #15, #38, #103, #55, #130, #137, #108, #163, #33, #42, #120, #106 and #121, who were not in isolation and not positive for COVID-19. Review of the facility Coronavirus (COVID 19) policy, effective 10/05/22 revealed health care personnel (HCP) caring for guests/residents with suspected or confirmed SARS-CoV-2 infection should use full PPE (gown, gloves, eye protection, and a NIOSH-approved N95 or equivalent or higher-level respirator).

Mar 2020 27 deficiencies 2 Harm

SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Pressure Ulcer Prevention (Tag F0686)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview and review of the facility policy on skin management the facility failed to prevent the development of a pressure ulcer to Resident #70's left lateral ankle and failed to ensure interventions were in place to promote pressure ulcer healing. Actual harm occurred on 10/21/19 when Resident #70, who had a diagnosis of dementia, required extensive assistance from staff for bed mobility/positioning and was at high risk for pressure ulcer development, developed an unstageable/Stage IV pressure ulcer to the left lateral ankle as a result of a lack of preventative skin interventions (i.e. turning/repositioning program and pressure relieving heel devices). This affected one resident (#70) of five residents reviewed for pressure ulcers. Findings include: Review of the medical record for Resident #70 revealed an admission date of 07/10/18 with diagnoses including diabetes, Stage 3 kidney disease, cerebral infarction, and dementia. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 07/24/19 revealed the resident had severely impaired cognition and required extensive assistance from two staff for bed mobility and transfers. Review of a plan of care initiated 08/14/19 revealed Resident #70 was at risk for impaired skin integrity/pressure injury related to impaired bed mobility and incontinence of bowel and bladder. Review of interventions to minimize the risk of pressure injury indicated to cue the resident to reposition self as needed. There was no evidence of a turning/repositioning program in place for staff to turn/reposition the resident, even though the resident was identified as requiring assistance from two staff with bed mobility. The plan of care also included interventions of air mattress as ordered and soft heel cut out boots as tolerated. Review of a pressure ulcer risk assessment dated [DATE] revealed Resident #70 was identified as high risk for the development of pressure ulcers. Review of a skin and wound assessment completed 10/15/19 revealed no evidence of any skin breakdown. Review of a nursing progress note, dated 10/21/19 at 2:00 P.M. revealed a new area to the left lateral ankle was noted. The physician was notified and a new treatment order was obtained. The treatment to cleanse left lateral ankle with normal saline, apply calcium alginate with silver, and cover with dry dressing was started on 10/22/19. Review of a skin and wound evaluation form completed 10/23/19 revealed Resident #70 developed an unstageable pressure ulcer containing slough and/or eschar on the left lateral malleolus (ankle) on 10/21/19. (Slough is non-viable yellow, tan, gray, green, or brown tissue; usually moist, can be soft, stringy, and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed; An unstageable ulcer is defined as obscured full thickness skin and tissue loss in which the extent of the tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar. If slough or eschar is removed, a stage three or four pressure ulcer will be revealed). The area measured 2.5 centimeters (cm) long by 2.5 cm wide with depth documented as not applicable. It stated the wound had 60 percent slough with moderate serous exudate. (Exudate is defined as fluid that has been forced out of the tissue or its capillaries because of inflammation or injury). It was identified as a new wound. Review of a wound evaluation report by the wound physician, dated 10/23/19 revealed the resident had a Stage IV pressure wound of the left lateral ankle for at least one day duration. (A Stage IV pressure ulcer is defined as full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer). There was moderate serous exudate. The area measured 3.1 cm by 3.8 cm by 0.5 cm. and had 20 percent slough, 60 percent granulation tissue, and 20 percent bone. The area was debrided (damaged tissue removed from the wound) on 10/23/19. After the development of the pressure ulcer on the left lateral ankle on 10/21/19, the plan of care was revised to include actual skin impairment of Stage IV pressure. However, the plan still indicated to cue the resident to reposition self as needed. An MDS 3.0 assessment, dated 10/21/19 revealed the resident had severely impaired cognition and required extensive assistance from two staff for bed mobility and transfers. There was no evidence of a turning/repositioning program in place for staff to turn/reposition the resident. An MDS 3.0 assessment, dated 01/08/20 revealed the resident had severely impaired cognition and required extensive assistance from two staff for bed mobility and transfers. Record review revealed Resident #70 had physician's orders, dated 01/14/19 for an air mattress to the bed and 03/18/19 for soft cut out boots to both feet as tolerated every shift. Observations on 03/02/20 at 12:11 P.M., 12:45 P.M., 1:22 P.M., 4:08 P.M. and 5:25 P.M. revealed Resident #70 was in bed on his left side. Observations on 03/03/20 at 7:17 A.M. revealed Resident #70 was in bed on his left side. The air mattress had a low pressure light on and the mattress alarm was sounding by beeping loudly. The door to the resident's room was closed with no staff in the room. On 03/03/20 at 7:43 A.M. the air mattress alarm was still beeping and the resident was still on his left side. On 03/03/20 at 7:49 A.M. the resident was still on his left side but the air mattress alarm was no longer beeping and State Tested Nursing Assistant (STNA) #118 was in the room delivering the resident's breakfast tray. On 03/03/20 at 7:58 A.M. the resident was on his left side in bed and the air mattress was flat with the resident sunken down in the middle of the mattress. On 03/03/20 at 9:20 A.M. the resident was in bed on his left side and the air mattress was still flat. On 03/03/20 at 10:07 A.M. the resident was on his left side in bed but the air mattress was inflated and the low air pressure light was off. On 03/03/20 at 12:56 P.M. and 3:20 P.M. the resident was in bed on his left side. Interview on 03/04/20 at 7:30 A.M. with the Licensed Practical Nurse (LPN) #291 who cared for Resident #70 on 03/03/20 revealed she was not aware of any issues with the air mattress on 03/03/20. She stated the air mattress beeps if it is flat. Interview on 03/04/20 at 7:45 A.M. with the STNA #118, who cared for Resident #70 on 03/03/20, revealed she was not aware of any issues with the air mattress on 03/03/20. Interview on 03/04/20 at 7:50 A.M. with Unit Manager #324 revealed she was not aware of any issues with the air mattress on 03/03/20. She stated the hospice aide and nurse were in on 03/03/20 and maybe they reset the air mattress. Interview with Hospice Aide #402 on 03/04/20 at 10:00 A.M. revealed she arrived on 03/03/20 at around 8:30 A.M., provided care for Resident #70, and left around 9:00 A.M. She stated she did not notice anything wrong with the air mattress. Interview with Hospice Nurse #400 on 03/04/20 at 11:45 A.M. revealed he arrived on 03/03/20 at 10:00 A.M. He stated he was with Resident #70 for approximately 15 minutes. (However, no staff were observed in the room on 03/03/20 at 10:07 A.M.) He stated he did not notice anything wrong with the air mattress. He also stated the resident was on his left side when he arrived and when he left. He stated he would have to check with the facility to see if the resident was supposed to be turned/repositioned by staff. He stated the hospice care plan said to assist with repositioning but did not include a frequency. Review of a wound evaluation summary by the wound physician on 03/03/20 revealed Resident #70 had a Stage IV pressure wound of the left lateral ankle for at least 126 days duration. There was moderate serous exudate. The area measured 0.6 cm long by 0.4 cm wide by 0.2 cm deep. The wound was described as 90 percent granulation tissue with 10 percent slough. Observation on 03/04/20 at 7:20 A.M. revealed Resident #70 had a 0.6 cm wide by 0.4 cm long by 0.1 cm deep superficial open area. The center of the wound was primarily pink tissue with a small area of white tissue. At that time, the resident was not observed to have a pressure relieving boot to his right foot. Interview with STNA #118 on 03/04/20 at 10:35 A.M. confirmed Resident #70 was unable to turn himself and was dependent upon staff for turning/repositioning. She stated she turned the resident every two hours and he was usually cooperative with turning. She stated on 03/03/20 she had placed the resident on his left side at 8:00 A.M. (However, the resident was observed on his left side at 7:17 A.M., 7:43 A.M., 7:49 A.M., and 7:58 A.M.). She also stated she placed the resident on his right side at 3:00 P.M. (However, the resident was observed on his left side at 3:20 P.M.). She further stated she was not aware of any boots for the resident to wear on his feet and did not ever put them on. Interview with LPN #291 on 03/04/20 at 10:40 A.M. confirmed Resident #70 was unable to turn himself and required assistance from two staff for turning/repositioning. She stated staff were to turn him every two hours and he was cooperative with turning. She stated he should be repositioned from left side to right side to back every two hours. She stated Resident #70 was unable to stay on his back much in bed but was able to be on his back when he was up in a chair. She stated residents usually get up every day unless they refuse. She stated they did not ask Resident #70 to get up on 03/02/20 or 03/03/20. She stated she was not aware Resident #70 was not repositioned every two hours on 03/02/20 or 03/03/20. She stated the nursing assistants were responsible to apply the pressure relieving boots to the resident's feet. Interview with LPN #293 on 03/04/20 at 11:00 A.M. confirmed she was Resident #70's nurse. She confirmed he was to have pressure relieving boots on both feet. She was not aware the resident did not have one on the right foot on 03/04/20 at 7:20 A.M. Interview with Wound Physician #401 on 03/04/20 at 12:00 P.M. revealed Resident #70 was at high risk for the development of pressure ulcers. He stated the resident should be turned/repositioned every two hours and should wear the pressure relieving boots on both feet. He stated the pressure ulcer on the left ankle was currently healing as long as the pressure was kept off of the area. Review of the facility policy titled Skin Management dated 10/2019 revealed the facility should identify and implement interventions to prevent development of clinically unavoidable pressure injuries. Residents with pressure ulcers and those at risk for skin compromise were identified, evaluated and provided appropriate treatment to promote prevention and healing. It further stated appropriate preventative measures would be implemented on residents identified at risk and the interventions documented on the care plan. Interview with the Director of Nursing on 03/04/20 at 2:20 P.M. revealed appropriate treatment meant what ever fit the resident. She stated a turning/repositioning program would be appropriate for Resident #70. Interview with the Director of Nursing and Corporate Nurse #147 on 03/05/20 at 8:25 A.M. confirmed Resident #70 did not have a preventative turning/repositioning program in place prior to or after developing the Stage IV pressure ulcer on the ankle. The lack of a turning and repositioning program likely contributed to the area on the left lateral ankle being first identified by staff as an unstageable/Stage IV pressure ulcer.

SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Deficiency F0692 (Tag F0692)

A resident was harmed · This affected 1 resident

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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 implement effective and timely nutritional interventions to prevent one resident (Resident #83) from sustaining a significant weight loss and failed to ensure ordered interventions, including whole milk and double protein portions were provided. Actual Harm occurred on 02/26/20 when Resident #83, who had a diagnosis of dementia and required staff supervision for eating was assessed with an unplanned, significant 10.4 pound (9.5%) weight loss in one month. This affected one resident (#83) of six residents reviewed for nutrition. Findings include: Review of Resident #83's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included ataxia, altered mental status, mild cognitive impairment, age related osteoporosis, dementia with behavior disturbance and constipation. Review of Resident # 83's annual Minimum Data Set (MDS) 3.0 assessment, dated 11/27/19 revealed the resident's long and short term memory were impaired and she exhibited moderately impaired cognition. Resident # 83 had no behaviors, no indicators of psychosis and rejected care daily. Resident # 83 required supervision of two staff for bed mobility, supervision of one staff to transfer, supervision from staff with set up help to eat. Resident # 83 had no swallowing problems was 66 inches tall, weighed 110 pounds, was on a therapeutic diet and had no significant weight changes during the assessment reference period. Review of the 11/29/19 nutrition assessment revealed the resident's usual body weight was 120 pounds. Resident #83's weight on 11/26/19 was 109.8 pounds, and her body mass index (BMI) was 17.7, indicating she was underweight. Resident #83 refused any medications to stimulate her appetite or nutritional supplements. Resident #83's diet was a regular diet, regular texture, thin consistency liquids with eight ounces of whole milk at each meal. The nutrition goal was to maintain current weight. No new nutritional recommendations were made at that time. Review of Resident #83's progress note, dated 12/18/2019 at 1:20 P.M. revealed the resident appeared to be choking with mucus coming out of her mouth. The resident was sent to the emergency department (ED) of a local hospital. Resident #83 returned the same day from the ED Review of the progress note, dated 12/19/19 revealed Resident #83's was at risk for choking and her diet was downgraded to a puree diet with eight ounces whole milk each meal. Review of Resident #83's quarterly MDS 3.0 assessment dated [DATE] reflected the resident continued to exhibit cognitive impairment and received a mechanically altered diet. Review of Resident #83's dietary note, dated 02/24/20 revealed on 02/20/20 her weight was 101.8 pounds which reflected a weight loss of 6.8 pounds (6.2%) in two months. The recommendation was to ensure Resident #83 eats well at meals and eats enough to maintain her weight. No new nutritional recommendations were made at that time. Review of the dietary note, dated 03/02/20 revealed on 02/26/20 Resident #83 weighed 98.2 pounds which was assessed/documented to be a severe weight loss of 9.5 % in one month. A new recommendation for double protein portions at all meals was made at that time. Observation of Resident #83 on 03/02/20 at 1:44 P.M. revealed she received a chicken salad sandwich, pasta salad, scalloped apples, juice and water. Resident #83 did not receive whole milk and her food was not pureed. Interview with Licensed Practical Nurse (LPN) #267 confirmed the food was not pureed and the resident did not receive milk. Observation of Resident #83 on 03/03/20 at 8:43 A.M. revealed she received thickened juice and water, pureed cereal, pureed omelet, pureed muffin and pureed fruit. She did not receive whole milk and she did not receive double protein portions. Interview with LPN #294 confirmed her portions looked like everyone else's and she received thickened juice and water. Observation of Resident #83 on 03/05/20 at 9:25 A.M. revealed she did not receive milk with the breakfast meal. Interview with LPN #294 at that time confirmed Resident #83 did not receive milk. Interview with Registered Dietitian (RD) #212 on 03/05/20 at 10:53 A.M. revealed Resident #83 should have received whole milk and she would make sure more was sent out with the meals. RD #212 revealed Resident #83 would only accept certain items if too many food items were sent then she would have a behavior. RD #212 was asked why no recommendations were made on 02/24/20 and she replied she would have to investigate it and get back with the surveyor. Interview with RD #212 on 03/06/20 at 11:33 A.M. revealed she forgot to document on 02/24/20 the recommendation for family to bring in a treat the resident liked when they visited. When asked how often the family visited, she stated about one time a week. Interview with State Tested Nursing Assistant (STNA) #150 on 03/06/20 at 11:58 A.M. revealed she had not seen Resident #83's family visit. Interview with LPN #294 on 03/06/20 at 12:01 P.M. revealed she had not seen Resident #83's family visit. Interview with Registered Nurse (RN) #326 on 03/06/20 at 12:04 P.M. revealed she had not seen Resident #83's family visit.

CONCERN (D)

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

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

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Based on observation, record review and interview the facility failed to ensure Resident #122 was informed of the arrival of her meal tray to accommodate the resident's ability to consume meals in a timely manner. This affected one resident (#122) of one resident reviewed for accommodation of needs. Findings include: Review of Resident #122's medical record revealed an initial admission date of 06/01/07 and a re-entry date of 10/29/19. Diagnoses included quadriplegia, acute respiratory failure with hypoxia and contractures. Review of Resident #122's plan of care, dated 01/21/19 revealed the resident was at nutritional and/or dehydration risk related to consuming less than 75% of most meals. Interventions included providing assistance with meals as needed. The care plan did not provide any additional guidance as to the resident's meal preferences for delivery and/or set up. Review of Resident #122's annual Minimum Data Set (MDS) 3.0 assessment, dated 01/08/20 revealed the resident required supervision with set up help for eating. Record review revealed a physician's order, dated 01/22/20 for a regular diet with regular texture and thin liquid consistency. On 03/02/20 at 1:03 P.M. a meal tray was observed sitting on Resident #122's night stand. The meal tray was not set up for the resident, the foods were not cut/prepped and the tray was not available for her to eat (as it appeared out of her reach). An interview with the resident at the time of the observation revealed she was unaware staff had brought her lunch tray in and she thought the tray had been left over from breakfast. On 03/06/20 at 12:40 P.M. during a follow up interview with Resident #122, the resident voiced concerns that when staff brought her meal tray to her room, they would leave it on the night stand without telling her it was there. The resident revealed the way the privacy curtain was placed, she was not able to see the tray sitting there. The resident stated because of this there were times she did not eat the meal because it got cold or it had a dairy product and she was worried it has spoiled. The resident denied being offered a new meal tray from staff when this occurred. On 03/06/20 at 12:50 P.M. interview with Licensed Practical Nurse (LPN) #322 revealed it was Resident #122's request to have her meal trays placed on her night stand. LPN #322 revealed she had to provide verbal education to multiple staff members over the last few days to ensure the staff were telling Resident #122 when her meal tray arrived because it had been identified the resident was unaware staff were bringing the tray and just leaving it in the room without telling her it was there. This deficiency substantiates Complaint Number OH00110564.

CONCERN (D)

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

Deficiency F0561 (Tag F0561)

Could have caused harm · This affected 1 resident

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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 honor Resident #109's choice/request to share a bed with his wife, Resident #143 with whom he shared a room and failed to ensure Resident #146's choice to not use a clothing protector was honored. This affected two residents (#109 and #146) of three residents reviewed for choices. Findings include: 1. Review of Resident #109's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including chronic pulmonary embolism, heart failure, hyperlipidemia, dementia, post traumatic stress disorder (PTSD), and Type 2 diabetes mellitus. Review of Resident #109's Minimum Data Set (MDS) 3.0 assessment, dated 01/13/20 revealed Resident #109 was moderately cognitively impaired with a Brief Interview of Mental Status (BIMS) score of eight. The MDS further revealed Resident #109 required supervision and/or staff assistance for all activities of daily living Review of the resident council meeting minutes from the meeting dated 02/11/20 revealed Resident #109 expressed a desire to have his and his wife's bed placed together so they could sleep next to each other. Review of the response and facility plan of correction dated 02/11/20 revealed no evidence this request was addressed. The administrator reviewed and dated the response on 02/12/20. Review of a progress note, dated 03/04/20 at 9:15 A.M., revealed Resident #109 requested to have his bed near his wife's bed. The note indicated the resident's power of attorney (POA) was made aware. Interview on 03/03/20 at 12:05 P.M. with Resident #109 revealed a concern that staff would not let him and his wife (Resident #143) share a bed. The resident reported they had been married for almost 60 years and he wanted to sleep next to his wife. The resident stated the staff had told him it was inappropriate. Interview on 03/04/20 at 8:39 A.M. with Staff #333 revealed she was unaware of any reason why Resident #109's request to share a bed with his wife could not be accommodated. Interview on 03/05/20 at 12:40 P.M. with Staff #134 verified Resident #109 had made a request to sleep next to his wife. The staff member revealed she had placed this request on the maintenance log, but never followed up to ensure the beds were moved next to each other. Observation on 03/03/20 at 10:30 A.M. revealed Resident #109's bed was on the right side of the room next to the wall and Resident #143's bed was located next to the window. There were two dressers between the resident's beds. 2. Review of Resident #146's medical record revealed the resident had a plan of care, dated 05/10/19 related to activities of daily living. The care plan revealed the resident preferred no clothing protector. On 03/04/20 at 9:05 A.M. during an observation of the breakfast meal, State Tested Nursing Assistant (STNA) #146 was observed to place a clothing protector on Resident #146. At 9:06 A.M. STNA #146 began feeding the resident . At 9:07 A.M., STNA #146 got up from the table leaving Resident #146. At 9:09 A.M. Resident #146 was observed to pull the clothing protector off. On 03/05/20 at 10:25 A.M. interview with Licensed Practical Nurse (LPN) #294 confirmed Resident #146 did not like to wear a clothing protector.

CONCERN (D)

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

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

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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 comprehensive and thorough investigation was completed following an allegation of sexual abuse involving Resident #20. This affected one resident (#20) of one resident reviewed for abuse. Findings include: Record review revealed Resident #20 was admitted to the facility on [DATE] with diagnoses including pancytopenia, hypokalemia, macular degeneration, blindness, type II diabetes, anxiety disorder, major depressive disorder, insomnia, sensorineural hearing loss, hypertension, adult failure to thrive, corneal ulcer and nicotine dependence. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 02/26/20 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12, which indicated she was moderately cognitively impaired. Review of the facility Self Reported incident (SRI), tracking number 189266, dated 02/27/20 revealed Resident #20 made a sexual abuse allegation against State Tested Nursing Assistant (STNA) #174. The resident reported the STNA molested her by touching her breasts (over her shirt) while she was sitting in her wheelchair. The facility immediately suspended STNA #174 and started an investigation. In review of the investigation documentation, the facility interviewed multiple residents and other staff, but failed to obtain a statement from STNA #174 (the alleged perpetrator) or the activity assistant, who was the staff member identified to be first told about the alleged incident. Interview with Resident #20 on 03/20/20 at 4:00 P.M. confirmed she made an allegation of sexual abuse against STNA #174. Interview with the Administrator on 03/06/20 at 9:45 A.M. confirmed he did not obtain written statements regarding the incident from the activity staff person who was first notified of the incident or from STNA #174 the alleged perpetrator. The administrator revealed he had verbal information from both employees and included that in a summary of the incident that was completed.

CONCERN (D)

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

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

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Based on record review and staff interview the facility failed to ensure Minimum Data Set (MDS) 3.0 assessments were accurate for Resident #207 related to discharge and for Resident #70 related to pressure ulcers. This affected two residents (#207 and #70) of 40 residents whose MDS assessments were reviewed. Findings include: 1. Review of Resident #207's closed electronic medical record revealed an admission date of 11/25/19 and a discharge date of 12/14/19. The resident had diagnoses including chronic kidney disease, history of falling, muscle weakness, cerebral infarction, secondary hyperparathyroidism (an overactive parathyroid) of renal (kidney) origin, muscle wasting and atrophy, benign neoplasm of meninges (the coverings of the brain and spinal cord), pain in left hip, cognitive communication deficit, type II diabetes mellitus with diabetic retinopathy without macular edema, hemoglobinuria (abnormally high concentrations of hemoglobin in the urine) due to hemoysis from other external causes, hypertension, autoimmune hepatitis and unspecified cirrhosis of liver. Review of the Discharge MDS 3.0 assessment, dated 12/14/19 revealed the resident's discharge was planned to an acute hospital. However, review of the progress notes, dated 12/13/19 and 12/14/19 revealed the resident discharged home with her son on 12/14/19 and was not hospitalized . Interview with the Director of Nursing (DON) on 03/05/20 at 12:16 P.M. confirmed Resident #207 discharged home from the facility and was not hospitalized . The DON confirmed the resident's MDS 3.0 assessment, dated 12/14/19 was inaccurate. 2. Review of the medical record for Resident #70 revealed an admission date of 07/10/18 with diagnoses including diabetes, stage three kidney disease, cerebral infarction and dementia. Review of a skin and wound assessment completed 10/15/19 revealed no evidence of any skin breakdown. Review of a nursing progress note, dated 10/21/19 at 2:00 P.M. revealed a new area to the left lateral ankle was noted. The physician was notified and a new treatment order was obtained. The treatment of cleanse left lateral ankle with normal saline, apply calcium alginate with silver, and cover with dry dressing was started on 10/22/19. Review of a skin and wound evaluation form completed 10/23/19 revealed Resident #70 developed an unstageable pressure ulcer containing slough and/or eschar on the left lateral malleolus (ankle) on 10/21/19. (Slough is non-viable yellow, tan, gray, green, or brown tissue; usually moist, can be soft, stringy, and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed. An unstageable ulcer is defined as obscured full thickness skin and tissue loss in which the extent of the tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar. If slough or eschar is removed, a stage three or four pressure ulcer will be revealed). The area measured 2.5 centimeters (cm) long by 2.5 cm wide with depth documented as not applicable. It stated the wound had 60 percent slough with moderate serous exudate. (Exudate is defined as fluid that has been forced out of the tissue or its capillaries because of inflammation or injury). It was identified as a new wound. Review of a wound evaluation report by the wound physician on 10/23/19 revealed the resident had a Stage IV pressure wound of the left lateral ankle for at least one day duration. (A Stage IV pressure ulcer is defined as full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer). There was moderate serous exudate. The area measured 3.1 cm by 3.8 cm by 0.5 cm. and had 20 percent slough, 60 percent granulation tissue, and 20 percent bone. The area was debrided (damaged tissue removed from the wound) on 10/23/19. The wound continued and was measured weekly. The most recent MDS 3.0 assessment, dated 01/08/20 revealed the resident had no pressure ulcers. Review of a wound evaluation summary by the wound physician on 03/03/20 revealed Resident #70 had a Stage IV pressure wound of the left lateral ankle for at least 126 days duration. There was moderate serous exudate. The area measured 0.6 cm long by 0.4 cm wide by 0.2 cm deep. The wound was described as 90 percent granulation tissue with 10 percent slough. Observation on 03/04/20 at 7:20 A.M. revealed Resident #70 to have a 0.6 cm wide by 0.4 cm long by 0.1 cm deep superficial open area. The center of the wound was primarily pink tissue with a small area of white tissue. Interview with Licensed Practical Nurse #304 on 03/04/20 at 11:02 A.M. confirmed the MDS completed on 01/08/20 was inaccurate as Resident #70 developed an unstageable/Stage IV pressure ulcer in October 2019 which the resident still had.

CONCERN (D)

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to develop a comprehensive plan of care for Resident #183 related to a pacemaker. This affected one resident (#183) of 40 residents whose Minimum Data Set (MDS) 3.0 assessments and care plans were reviewed. Findings include: Review of Resident #183's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including unspecified combined systolic and diastolic heart failure, paroxysmal atrial fibrillation, hyperlipidemia, type 2 diabetes mellitus, and hypertension. Review of hospital discharge paperwork, dated 06/08/19 revealed under the section titled history and physical it noted pacemaker with some unidentifiable numbers behind it in parentheses. Review of Resident #183's MDS 3.0 assessment, dated 02/19/20 revealed the resident had mild cognitive impairment with a Brief Interview of Mental Status (BIMS) score of ten. Interview with Resident #183 on 03/02/20 at 11:00 A.M. revealed he had a pacemaker and it had been five years since it was checked. He reported he had notified nursing staff about his pacemaker needing checked but they had not done anything with it. Review of Resident #183's current plan of care (initiated 01/27/20) revealed no plan of care had been developed related to the resident's pacemaker. Interview with MDS #334 and the director of nursing (DON) on 03/05/20 at 8:35 A.M.verified the facility failed to develop a comprehensive and individualized plan of care for Resident #183 related to his pacemaker.

CONCERN (D)

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

Deficiency F0676 (Tag F0676)

Could have caused harm · This affected 1 resident

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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 implement timely and necessary interventions, including the use of adaptive equipment for Resident #83 and Resident #146 who exhibited limitations to self-feeding. This affected two residents (#83 and #146) of six residents reviewed for nutrition. Findings include: 1. Review of Resident #83's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included ataxia, altered mental status, mild cognitive impairment, age related osteoporosis, dementia with behavior disturbance and constipation. Review of Resident # 83's annual Minimum Data Set (MDS) 3.0 assessment, dated 11/27/19 revealed the resident's speech was unclear, she usually understands, usually was understood, her short and long term memory were impaired, the resident recalled her room location and that she was in a nursing home and her cognition was moderately impaired. Resident # 83 had no behaviors, no indicators of psychosis and rejected care daily. Resident #83 required supervision of two staff for bed mobility, supervision of one staff to transfer, supervision with set up help to eat. Resident #83 had no swallowing problems was 66 inches, weighed 110 pounds, had no significant weight changes and was on a therapeutic diet. Review of Resident #83's quarterly MDS 3.0 assessment, dated 01/03/20 revealed the resident understands, was understood and her cognition was moderately impaired. Resident #83 required supervision of one staff for bed mobility and to transfer. Resident #83 received a mechanically altered diet. Review of Resident #83's therapy notes dated 03/03/20 identified self-feeding needs, but no recommendations were made at that time. Observation of Resident #83 on 03/03/20 at 8:43 A.M. revealed the resident received thickened juice and water, pureed cereal, pureed omelet, pureed muffin and pureed fruit on a regular plate and had a plastic spoon. Resident #83 was feeding herself but she had difficulty getting the utensils and beverage containers to her mouth due to involuntary movements the resident was having. Resident #83 had spillage of her food and drink during the meal. Interview with Rehabilitation Director #321 on 03/05/20 on 2:31 P.M. revealed Resident #83 was evaluated by therapy and she had a self-feeding deficit, but her self-feeding deficit was not addressed. Rehabilitation Director #321 revealed the therapist identified Resident #83's ataxia was more pronounced and Rehabilitation Director #321 indicted the resident would need to be evaluated related to self-feeding needs. 2. Review of Resident #146's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included Huntington's disease, personality and behavioral disorder, hallucinations, dysphagia, obsessive compulsive personality disorder, post-traumatic stress disorder, psychosis, major depressive disorder, anxiety, hypertension, constipation and mild cognitive impairment. Review of Resident # 146's MDS 3.0 assessment, dated 01/21/20 revealed the resident's speech was unclear, sometimes she understood, sometimes she understands, her short and long term memory were impaired, she recalled the location of her room, recalled staff names and faces and had moderately impaired decision making skills. Resident #146 had no indicators of psychosis, had physical behaviors, verbal behaviors and other behaviors one to three days and did not reject care. Resident #146 required extensive assistance of two staff for bed mobility, to transfer and required extensive assistance of one staff to eat. Resident #146 received no therapy and no restorative programs. Record review revealed Resident #146 did not have any recommendations for adaptive self-feeding equipment. Review of Resident #146's March 2020 physician's orders revealed an order for plastic utensils with breakfast, lunch and dinner for safety. Observation of Resident #146 on 03/02/20 at 1:44 P.M. revealed the resident received a pureed meal. The food was served on a regular plate and she had regular flatware. Resident #146 had involuntary movements making it difficult to scoop food from the plate and she had spillage from her spoon into her lap. Observation of Resident #146 on 03/04/20 at 8:56 A.M. during the breakfast meal revealed the resident received a plastic spoon, a regular plate and a bowl. Resident #146 received pureed eggs, pureed cereal, pureed sausage, pureed toast, apple sauce and pudding. Resident #146 was attempting to feed herself. She drank the pureed cereal from the bowl. Resident #146 had involuntary movements that made self-feeding difficult. Resident #146 had food spillage from her spoon during the observation. Interview with Licensed Practical Nurse (LPN) #294 on 03/05/20 at 10:25 A.M. revealed when food was put bowls the resident did better with eating. Interview with Rehabilitation Director #321 on 03/05/20 at 11:47 A.M. revealed Resident #146 had nothing triggered for self-feeding. Rehabilitation Director #321 stated Resident #146 would be screened for therapy needs related to self feeding today. This deficiency substantiates Complaint Number OH00110564.

CONCERN (D)

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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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 #109's assistive devices were properly maintained to prevent accidents and failed to ensure fall safety interventions were implemented for Resident #83 to prevent falls/accidents. This affected two residents (#109 and #83) of eight residents reviewed for accidents. Findings include: 1. Review of Resident #109's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including chronic pulmonary embolism, heart failure, hyperlipidemia, dementia, post traumatic stress disorder (PTSD) and Type 2 diabetes mellitus. Review of Resident #109's Minimum Data Set (MDS) 3.0 assessment, dated 01/13/20 revealed Resident #109 was moderately cognitively impaired with a Brief Interview of Mental Status (BIMS) score of eight. The MDS further revealed Resident #109 required total assistance with one person for bathing, extensive assist with one person for transfers, supervision assist from one person for bed mobility and toileting and limited assistance from one person for dressing and personal hygiene. Review of Resident #109's physician's orders revealed a current order, initiated 01/20/20 to check enabler bar check every shift for bed mobility. Review of Resident #109's care plan dated 01/27/20 revealed the resident required assistance with activities of daily living (ADL's) and mobility with interventions including the use of an enabler bar (to the bed). Review of the Maintenance log, dated 02/17/20 through 03/03/20 revealed on 03/02/20 and 03/03/20 a request was made for Resident #109's bed to be fixed. On 03/03/20 the log indicated the bed was fixed. Review of Resident #109's Treatment Administration Record (TAR) from 03/01/20 through 03/05/20 revealed staff were documenting every shift the enabler bar was in place. Interview on 03/02/20 at 1:35 P.M. with Licensed Practical Nurse (LPN) #291 revealed Resident #109's enabler bar was broken and was laying on the floor. She reported it had been there for a while. She furthermore verified the resident's wheelchair brake on the left side was not holding. The LPN revealed she would contact maintenance. On 03/03/20 at 10:15 A.M. Resident #109 was heard telling maintenance staff his wheelchair was not working. Observation on 03/03/20 at 10:31 A.M. revealed Resident #109 had a broken bed rail, which was on the floor and the resident's wheelchair left brake was not holding. On 03/03/20 at 1:35 P.M. Resident #109 was heard telling Registered Nurse (RN) #324 his garb bar and wheelchair were broken. Registered Nurse (RN) #324 informed Resident #109 maintenance was notified and they would come and fix them. Interview on 03/05/20 at 4:30 P.M. with RN #324 revealed Resident #109 used the enabler bar to assist with getting in and out of bed. She stated he used the wheelchair for long distance only. She further verified the TAR dated 03/01/20 through 03/05/20 contained documentation the enabler bar was in place every shift as staff were signing the record indicating the enabler bar was in place, when in fact the bar was not and had been on the floor of Resident #109's room (from at least 03/02/20 through 03/05/20 based on the surveyors observations). 2. Review of Resident #83's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included ataxia, altered mental status, mild cognitive impairment, age related osteoporosis, dementia with behavior disturbance and constipation. Review of Resident # 83's annual Minimum Data Set (MDS) 3.0 assessment, dated 11/27/19 revealed her speech was unclear, she usually understands, usually was understood, her short and long term memory was impaired, she recalled her room location, that she was in a nursing home, and her cognition was moderately impaired. Resident #83 had no behaviors, no indicators of psychosis and rejected care daily. Resident # 83 required supervision of two staff for bed mobility, supervision of one staff to transfer, supervision with set up help to walk and for locomotion. The assessment also revealed the resident had functional limitations in range of motion and used no mobility devices. Resident # 83 had no falls. Resident # 83 used no bed rails, no alarms and no restraints. Review of Resident #83's quarterly MDS assessment, dated 01/03/20 revealed the resident understands, was understood, and her cognition was moderately impaired. Resident # 83 required supervision of one staff for bed mobility and to transfer, she required supervision with set up help to walk, limited assistance of one staff for locomotion on the unit and supervision with set up help for locomotion off the unit. Review of Resident #83's progress notes revealed on 02/27/20 the resident had spontaneous bruising and hipsters were ordered. Resident #83 reported she banged into things in her room. Review of Resident #83's incident report revealed she had a 9 centimeter (cm) by 7 cm bruise on her left buttock, a 15 cm by 9 cm bruise on her right buttock, a 6 cm by 6 cm bruise on her left thigh, a 4cm by 3 cm bruise on her right calf, and multiple smaller bruises on her left calf. Review of Resident #83's March 2020 physician's orders revealed orders for a half rail on one side of her bed for bed mobility and bed against the wall. Further review of Resident #83's progress notes revealed on 03/02/20 at 10:20 A.M. the resident was laying on her left side on the floor of the Unit 3 dining room. Resident #83 was asked what happened and she was unable to explain. A new intervention was implemented to sit in a chair against the wall at meals. Observation of Resident #83 on 03/03/20 at 7:15 A.M. revealed she was laying in bed with the right side of the bed up to the wall and her left side rail down. Observation at 7:45 A.M. revealed Resident #83 was on the floor on her back trying to pull herself up using the foot board of the bed. This was reported to the nurse. Observation at 1:50 P.M. revealed the resident was moved to a room closer to the nurse's station. Resident #83's was in bed, the bed was by the window, not against the wall and the side rail was down. Review of Resident #83's progress note, dated 03/03/20 at 7:55 A.M. revealed the resident was laying on the floor on her back. Resident #83 stated she was going to the bathroom. A new intervention was to move Resident #83 closer to the nurse's station. Observation of Resident #83 on 03/04/20 at 7:20 A.M. revealed the resident was in bed with the bed not against the wall and her side rail not up. Resident #83's wheelchair and overbed table were across the room and not within her reach. At 10:17 A.M. Resident #83 was in bed, the bed was closer to the door and it was not against the wall. At 12:49 P.M. and 1:59 P.M. the resident was observed in bed, the bed was not against the wall and the side rail was down. Interview with Licensed Practical Nurse (LPN) #280 on 03/04/20 at 4:15 P.M. revealed Resident #83 had two falls; one on Monday and one on Tuesday, so she was moved closer to nurse's station. LPN #280 revealed the resident used a wheelchair, her bed was supposed to be near the wall and she used one side rail. Interview with Resident # 83 on 03/05/20 at 7:34 A.M. revealed she liked her bed moved so she could see out the window and she used her side rail to turn and to get out of bed. Resident #83 stated the bruises on her bottom and legs were from were from bumping into the dressers and other items in room. Interview with Registered Nurse (RN) #326 on 03/05/20 at 7:37 A.M. confirmed the resident's bed rail was not up at this time and it was supposed to be. RN #326 also confirmed the bed was supposed to be against the wall and on 03/04/20 it was not. Interview with the Director of Nursing (DON) on 03/05/20 at 9:42 A.M. revealed she put the hipsters in place to pad the resident's hips when bumping into things. The DON stated she did not identify what could have caused the bruises to Resident #83's buttocks and legs and she did not put anything in place to help prevent or minimize the bruising.

CONCERN (D)

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

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

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Based on observation, record review and interview the facility failed to maintain Resident #125's indwelling urinary (Foley) catheter in a manner to prevent the risk of contamination and urinary tract infection. This affected one resident (#125) of nine residents reviewed for infection control. Findings include: Review of Resident #125's medical record revealed an initial admission date of 08/25/17 and a readmission date of 07/08/18 with diagnoses including acute and chronic respiratory failure and benign prostatic hyperpiesia with lower urinary tract symptoms. Review of Resident #125's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/17/20 revealed the resident had severely impaired cognition and required total dependence from two staff members for bed mobility, transfers and assistance from one staff member for toilet use. Resident #125 was noted to have impairments to his bilateral upper and lower extremities and required the use of an indwelling catheter for bladder elimination. Review of Resident #125's plan of care, dated 01/17/20 revealed the resident was at risk for urinary tract infections related to the use of an indwelling catheter and obstructive uropathy. Interventions included to ensure to position the catheter bag and tubing below the level of bladder and to provide catheter care per policy. Review of a current physician's order for Resident #125 revealed an order for the resident to have a 16 french Foley (indwelling urinary) catheter and for it to be changed as needed for blockage or contamination. Observation on 03/02/20 at 10:40 A.M. of Resident #125 revealed the resident's Foley catheter bag was laying directly on the floor beside the resident's bed. Interview on 03/02/20 at 10:43 A.M. with Licensed Practical Nurse (LPN) #348 confirmed Resident #125's Foley bag was laying on the floor and not attached to a non-movable part of the bed. Review of the facility undated policy titled Indwelling Urinary Catheter revealed the Foley bag was to be kept off the floor to reduce the risk of contamination. This deficiency substantiates Complaint Number OH00110377.

CONCERN (D)

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

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

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Based on observation, record review, interview and policy review the facility failed to date and label oxygen administration tubing and failed to place signage on doors indicating oxygen in use in resident rooms. This affected three residents (#123, #81 and #457) of five residents reviewed for respiratory care. Findings include: 1. Review of Resident #123's medical record revealed an admission date of 06/14/18 with diagnoses including type two diabetes mellitus, acute respiratory failure with hypoxia (low oxygen level) and acute chronic diastolic heart failure Review of Resident #123's physician's orders revealed an order dated 11/08/19 for oxygen administration via nasal cannula at two liters per minute as needed for oxygen saturation less than 90% and as needed for shortness of breath (SOB). Review of Resident #123's care plan, dated 01/24/20 revealed the resident was at risk for respiratory complications and to administer medications and treatments per physician orders. Review of Resident #123's Minimum Data Set (MDS) 3.0 assessment, dated 01/08/20 revealed the resident was severely cognitively impaired with a Brief Interview of Mental Status score of five. The MDS further revealed Resident #123 required total assistance of two persons for bed mobility, to transfer, dressing, eating, toileting and hygiene needs. Observation of Resident #123 on 03/02/20 at 1:37 P.M. revealed the resident had a nasal cannula and oxygen concentrator in her room. The oxygen tubing did not contain a label or date. (Dating oxygen tubing is a standard practice to prevent contamination and spreading of bacteria). Interview with Maintenance Supervisor #314 on 03/03/20 at 3:00 P.M. verified Resident #123's oxygen tubing and nasal cannula were unlabeled and undated, and there was no signage on the door indicating oxygen was in use. 2. Review of Resident #81's medical record revealed an admission date of 12/27/19 with diagnoses including dysarthria following cerebral infarction, type 2 diabetes mellitus, chronic obstructive pulmonary disease (COPD) and chronic heart failure. Review of Resident #81's MDS assessment, dated 01/03/20 revealed Resident #81 had a Brief Interview of Mental Status (BIMS) score of eight and moderate cognitive impairment. The MDS further revealed Resident #81 required extensive assistance from one to two persons for bed mobility, transfers, hygiene, bathing, dressing and toileting and required staff supervision with eating. Review of Resident #81's physician's orders revealed an order dated 02/28/20 for oxygen administration 2 liters as needed (PRN) for shortness of breath; maintain saturation levels at 90% or greater every shift. Observation of Resident #81 on 03/02/20 at 11:25 A.M. revealed Resident #81 did not have an oxygen in use sign on her door. Interview with Maintenance supervisor #314 on 03/03/20 at 3:05 P.M. verified Resident #81 did not have any signage on the door indicating oxygen was in use. 3. Review of Resident #457's medical record revealed an admission date of 02/12/20 with diagnoses including heart failure, type 2 diabetes mellitus, obstructive sleep apnea, asthma and hypertension. Review of Resident #457's physician's orders revealed an order, dated 02/12/20 for continuous positive airway pressure (CPAP) with a pressure of 15 at bedtime every shift for sleep apnea. The order indicated to clean tubing with soap and water, rinse with water and let air dry once every seven days. The resident also had an order for oxygen, two liters via nasal cannula as needed for shortness of breath (SOB). Review of Resident #457's care plan revealed the resident was at risk for respiratory complications and to administer medications and treatments per physician orders. Review of Resident #457's MDS 3.0 assessment, dated 02/19/20 revealed Resident #457 was cognitively intact with a Brief Interview of Mental Status (BIMS) score of 15. The MDS further revealed Resident #457 required the extensive assistance of one person for bed mobility, transfers, dressing, personal hygiene and toileting needs and required supervision assistance of setup help only for eating. Observation of Resident #457 on 03/02/20 at 11:30 A.M. revealed the resident had a CPAP machine beside her bed on the nightstand and an oxygen concentrator on the floor next to her bed. The CPAP machine tubing and the oxygen concentrator nasal cannula tubing were unlabeled and undated. Furthermore, there was no signage on the outside of the door identifying oxygen was in use. Interview with Maintenance Supervisor #314 on 03/03/20 at 3:25 P.M. verified Resident #457's oxygen tubing on the CPAP machine and oxygen concentrator were not labeled or dated and there was no signage on the door indicating oxygen was in use. Review of the facility policy titled Use of Oxygen, dated 09/2019 revealed for safe oxygen administration the oxygen cannula or mask should be changed weekly and dated.

CONCERN (D)

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

Deficiency F0757 (Tag F0757)

Could have caused harm · This affected 1 resident

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Based on record review and interview the facility failed to ensure Resident #55 was only administered as needed narcotic pain medication for severe pain as ordered to ensure the medication was necessary for the resident. This affected one resident (#55) of of six residents reviewed for unnecessary medication use. Findings include: Review of Resident #55's medical record revealed an initial admission date of 03/23/16 with a current readmission date of 01/13/19 with diagnoses including acute embolism (blood clot) and thrombosis of lower extremity, peripheral vascular disease, anxiety disorder, chronic obstructive pulmonary disease (COPD), osteoarthritis, acquired absence of right leg above knee, major depressive disorder, pain in joints of right hand and wrist, chronic pain syndrome, low back pain, Type I diabetes mellitus with diabetic neuropathy and osteomyelitis of vertebra. Review of Resident #55's annual Minimum Data Set (MDS) 3.0 assessment, dated 12/26/19 revealed the resident had intact cognition, required supervision only for activities of daily living and was on a scheduled pain medication regimen. The assessment revealed the resident also either received as needed pain medications or was offered as needed pain medication and it was declined. The resident noted frequent pain that limited day to day activities at an intensity level of a six out of ten (on a zero to 10) pain scale. Review of Resident #55's physician's orders revealed an order for Hydromorphone HCL 2 milligrams (mg) with instructions of administering two tablets every six hours as needed for severe pain. The order was written on 01/30/20. Review of the Medication Administration Records (MARs) for Resident #55 revealed Hydromorphone HCL was administered to Resident #55 ten times in January 2020 and 26 times in February 2020 for pain levels rated from 0 to 3 on a pain scale from 0 to 10, where 10 was the highest level of pain. Interview with Resident #55 on 03/03/20 at 8:09 A.M. revealed the resident was taking Hydromorphone and Morphine for pain. The resident confirmed Hydromorphone was an as needed (PRN) pain medication that he received every six hours for pain. Interview with Licensed Practical Nurse #240 on 03/04/20 at 11:16 A.M. revealed a PRN pain medication for severe pain would be administered to a resident if the resident indicated he/she experienced a pain level of five or higher on a pain scale from 0 to 10, where 10 was the highest level of pain. Interview with the Director of Nursing (DON) on 03/04/20 at 12:59 P.M. confirmed the pain level documented on the top of the MAR should reflect the resident's pain level before administering any medication and then there should be documentation after the medication was administered whether the medication was effective (E) or ineffective (IE). The DON confirmed Resident #55 received PRN pain medication when his pain level did not indicate the resident was having pain or the resident was having a low level of pain. The DON confirmed the physician order for Hydromorphone was for the medication to be administered to Resident #55 for severe pain.

CONCERN (D)

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

Deficiency F0805 (Tag F0805)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #109 revealed an admission date of 06/28/19 with diagnoses including diabetes and schizophrenia. Review of physician's orders revealed an order dated 07/05/19 for a low concentrated sweets, mechanical soft texture diet. A dietary note, dated 12/04/19 stated the writer would consult speech therapy to see if Resident #109's diet texture could be upgraded to regular per his request. A Minimum Data Set (MDS) 3.0 assessment, dated 01/13/20 revealed the resident required supervision only for eating. The plan of care stated the resident could tolerate a mechanical soft diet. Observations of the lunch meal on 03/02/20 at 12:40 P.M. revealed Resident #109 had a diet card on his meal tray that stated mechanical soft, low concentrated sweets diet. However, during the meal observation, the resident received a regular chicken salad croissant and pureed pasta salad. Interview with Resident #109 on 03/02/20 at 12:40 P.M. revealed he was upset and stated he could not eat the pureed pasta salad because it looked so bad. Observations on 03/02/20 at 1:45 P.M. revealed State Tested Nursing Assistant #117 picked up Resident #109's lunch tray. She confirmed he did not eat any of his lunch. Interview with Speech Therapist #333 on 03/03/20 at 11:15 A.M. revealed she had spoken to Resident #109 after 12/04/19 and he wanted to stay on a mechanical soft diet. She stated that a mechanical soft diet meant the meat was ground but everything else was regular texture. She stated a mechanical soft diet would include regular texture pasta salad. Review of the facility policy titled Mechanically Altered Diets, dated 04/2010 revealed mechanically altered diets shall be prepared and served as prescribed by the physician. Guests shall be provided with the least restrictive diet to optimize nutritional status and to promote overall satisfaction with meals. All guests with physician's orders for mechanical soft diets shall receive foods of nearly regular textures with the exception of very hard, sticky, or crunchy foods. All guests with a physician's order for a pureed diet shall receive pureed, homogenous, and cohesive foods. Foods shall be pudding like. Interview with Dietary Manager #500 on 03/04/20 at 11:41 A.M. revealed the chicken salad should have been ground for a mechanical soft diet. She further stated the pasta salad should have been regular texture and not pureed for a mechanical soft diet. 3. Review of the medical record for Resident #62 revealed an admission date of 11/25/18 with diagnoses including diabetes mellitus, kidney failure and chronic obstructive pulmonary disease. Resident #62 had a physician's order, dated 08/28/19 for a mechanical soft, low concentrated sweets diet. A dietary note on 11/08/19 stated the resident was on a mechanical soft, low concentrated sweets diet. May have regular texture sausage but limit to three days per week. Meal intakes mostly 76-100%. A Minimum Data Set (MDS) 3.0 assessment, dated 01/01/20 revealed the resident required supervision only with eating. Observations on 03/02/20 at 12:55 P.M. revealed Resident #62 had her lunch meal. The diet card on the meal tray indicated mechanical soft, low concentrated sweets diet. The resident received a pureed sandwich, pureed pasta salad, a regular texture side salad, and regular texture fruit cocktail. The resident ate less than 25% of her meal. Review of the facility policy titled Mechanically Altered Diets, dated 04/2010 revealed mechanically altered diets shall be prepared and served as prescribed by the physician. Guests shall be provided with the least restrictive diet to optimize nutritional status and to promote overall satisfaction with meals. All guests with physician's orders for mechanical soft diets shall receive foods of nearly regular textures with the exception of very hard, sticky, or crunchy foods. All guests with a physician's order for a pureed diet shall receive pureed, homogenous, and cohesive foods. Foods shall be pudding like. Interview with Dietary Manager #500 on 03/04/20 at 11:41 A.M. revealed the chicken salad only should have been ground for a mechanical soft diet. She further stated the pasta salad should have been regular texture and not pureed for a mechanical soft diet. Based on observation, record review, interview and policy review the facility failed to ensure residents received therapeutic diets as ordered. This affected one resident (#83) of six residents reviewed for nutrition and two residents (#62 and #109) of 31 residents reviewed for dining. Findings include: 1. Review of Resident #83's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included ataxia, altered mental status, mild cognitive impairment, age related osteoporosis, dementia with behavior disturbance and constipation. Review of Resident #83's annual Minimum Data Set (MDS) 3.0 assessment, dated 11/27/19 revealed the resident's speech was unclear, she usually understands, usually was understood, her short and long term memory was impaired, recalled her room location and that she was in a nursing home and her cognition was moderately impaired. Resident #83 had no behaviors, no indicators of psychosis and rejected care daily. Resident #83 required supervision of two staff for bed mobility, supervision of one staff to transfer and supervision from staff with set up help to eat. Resident #83 had no swallowing problems, was 66 inches and weighed 110 pounds. The assessment revealed the resident had no significant weight changes and was on a therapeutic diet. Review of Resident #83's quarterly MDS 3.0 assessment, dated 01/03/20 revealed Resident #83 understands, was understood and her cognition was moderately impaired. Resident #83 required supervision from one staff for bed mobility and to transfer. Resident #83 received a mechanically altered diet. Review of Resident #83's progress notes, dated 12/18/2019 at 1:20 P.M. revealed the resident appeared to be choking with mucus coming out of her mouth. The resident was sent to the emergency department (ED) of a local hospital. Resident #83 returned the same day from the ED Review of the progress note, dated 12/19/19 revealed Resident #83's was at risk for choking and her diet was downgraded to a puree diet with eight ounces whole milk each meal. Review of Resident #83's March 2020 physician's orders revealed her diet was a regular pureed texture diet. Observation of Resident #83 on 03/02/20 at 1:44 P.M. revealed she received a chicken salad sandwich, pasta salad, scalloped apples, juice and water. None of the food items were observed to be pureed. Interview with Licensed Practical Nurse (LPN) #267 confirmed the resident's food items were not pureed as ordered.

CONCERN (D)

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

Deficiency F0840 (Tag F0840)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure Resident #183 had timely follow up and care related to a pacemaker. This affected one resident (#183) of one resident reviewed for specialized medical appointments. Findings include: Review of Resident #183's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including unspecified combined systolic and diastolic heart failure, paroxysmal atrial fibrillation, hyperlipidemia, type 2 diabetes mellitus and hypertension. Review of Resident #183's hospital discharge record, dated 06/08/19 revealed under surgical/procedure history, it identified pacemaker with some unidentifiable numbers in parentheses. Review of Resident #183's Minimum Data Set (MDS) 3.0 assessment, dated 02/19/20 revealed Resident #183 had mild cognitive impairment with a Brief Interview of Mental Status (BIMS) score of ten. The MDS further revealed Resident #183 required extensive assist from one to two persons for bed mobility, transfers, hygiene, bathing, dressing and toileting needs and required supervision with setup assistance from staff for eating. Review of Resident #183's progress note, dated 01/13/20 revealed Resident #183 informed the nurse he wanted his pacemaker checked. The nurse contacted the local hospital for information regarding resident's pacemaker. The hospital advised the nurse to contact the resident's cardiologist since the hospital did not have any records of the resident having a pacemaker. The nurse attempted to contact the resident's daughter regarding information on cardiologist. Review of the facility grievance log from 01/2020 revealed on 01/14/20 Resident #183 reported he had a pacemaker issue. The grievance log indicated the resolution was Certified Nurse Practitioner (CNP) and hospital follow-up. Review of a progress note, dated 01/15/20 revealed the nurse spoke with the resident's daughter and she reported that her father did not have a pacemaker or defibrillator. The nurse then contacted a different hospital for records as the resident thought the procedure had been completed at this hospital. The nurse contacted the hospital medical records and they advised the nurse to fax over a request for medical records. Review of Resident #183's physician's progress note, dated 01/15/20 revealed pacemaker was documented under surgical history. Review of Resident #183's physician note, dated 01/19/20 revealed the resident reported to nursing staff his pacemaker needed checked as it had been some time since it was (last checked). He reported he was not having any chest pain or other concerns, just worried it had been some time since it was checked. The physician note revealed the physician completed a record review of the resident's hospital record from 06/2018 which reflected a pacer/ICD wire on imaging. Interview with Resident #183 on 03/02/20 at 11:00 A.M. revealed he had a pacemaker and it had been five years since it was checked. The resident revealed he had informed the nurse (some time ago) that it needed checked but stated nothing had been done about it. Interview with Staff #333 on 03/04/20 at 5:08 P.M. revealed the facility had not located the cardiologist who completed the pacemaker surgery. She further verified the hospital discharge paperwork, dated 06/08/19 revealed the resident had a pacemaker with an unidentifiable number in parentheses. Interview with Registered Nurse (RN) #324 on 03/04/20 at 5:26 P.M. revealed she had been trying since 01/2020 to find out who the cardiologist was that completed the pacemaker surgery. She reported she called one hospital and they reported they had no information on the resident for a pacemaker. She reported she called the same hospital again today and asked for the cardiology department. She reported they were able to verify the resident was a patient there three to four years ago and had not been seen since then. She reported the cardiology department would call her back if they could set an appointment for the resident. Interview with Registered Nurse (RN) #324 on 03/05/20 at 11:30 A.M. revealed Resident #183 now had an appointment with a Heart and Vascular specialist on 03/09/20 at 10:30 A.M. This deficiency substantiates Complaint Number OH00110564.

CONCERN (D)

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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Based on observation, record review and interview the facility failed to maintain adequate infection control practices for Resident #42 related to contact isolation for a Clostridium Difficle (C Diff) infection, for Resident #122 related to droplet isolation precautions for possible influenza and for Resident #70 related to a pressure ulcer dressing change to prevent the spread of infection. This affected three residents (#122, #70 and #42) of nine residents reviewed for infection control. Findings include: 1. Review of Resident #42's medical record revealed an initial admission date of 11/20/19 and a readmission date of 02/26/20 with diagnoses including acute respiratory failure with hypoxia, anoxic brain damage and enterocolitis due to C Diff. Review of a physician's order for Resident #42 revealed an order, dated 02/27/20 for the resident to be placed in contact isolation until 03/09/20 related to the C Diff infection. Also noted was an order, dated 02/27/20 for Vancomycin (an antibiotic) suspension, give 125 milligrams (mg) four times a day for C Diff for 11 days. Review of Resident #42's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 02/27/20 revealed the resident required total dependence from two staff members for bed mobility, transfers and dependence on one staff member for eating via gastrostomy tube/eternal feeding. Review of Resident #42's plan of care, dated 02/28/20 revealed the resident was on contact isolation precautions related to the diagnoses of C Diff. Interventions included contact isolation, administration of ordered medication and to obtain labs and report and abnormal findings to the physician. Observation on 03/02/20 at 12:24 P.M. of the Resident #42's room revealed there was no isolation equipment outside of the room nor was there a sign to inform visitors to see the nurse before entering the room. Interview on 03/03/20 at 9:11 A.M. with Registered Nurse #323 revealed Resident #42 was not presently in contact isolation. However, the resident had an order and care plan in place for isolation which began on 02/27/20 due to positive C Diff results. Review of the facility policy titled Contact Precautions, revised September 2019 revealed it was the intent of the facility to use contact precautions in addition to Standard Precautions for guest/residents known or suspected to have serious illnesses easily transmitted by direct guest/resident contact or by contact with items in the guest's/resident's environment. 2. Review of Resident #122's medical record revealed the resident was placed on droplet isolation precautions on 03/02/20 at 1:21 P.M. due to the possibility of her having influenza. On 03/02/20 at 1:29 P.M. Licensed Practical Nurse (LPN) #270 and Laundry Staff #234 were observed to walk into Resident #122 room without any personal protective equipment (PPE). Resident #122 had a sign on her door for visitors to see the nurse prior to entering the resident's room, and a plastic tote of PPE outside of her door. Interview with LPN #270 and Laundry Staff #234 on 03/02/20 at 1:35 P.M. revealed they knew Resident #122 was on droplet isolation precautions and each time they go into her room they were supposed to put a gown, gloves, and a mask on prior to entering. Both staff verified they had gone in the resident's room jut prior to this interview and had not used any PPE and should have. On 03/03/20 at 8:25 A.M. LPN #247 was observed to enter Resident #122's room and did not apply any PPE equipment prior to entering the room. On 03/03/20 at 8:30 A.M. interview with LPN #247 verified she entered Resident #122's room without utilizing any PPE and the resident was in isolation for a possible influenza infection. Review of facility Droplet Precaution policy, dated September 2019 revealed healthcare personnel were to wear surgical masks for close contact in addition to standard precautions. 3. Review of the medical record for Resident #70 revealed an admission date of 07/10/18 with diagnoses including diabetes, stage three kidney disease, cerebral infarction and dementia. Review of a wound evaluation summary by the wound physician on 03/03/20 revealed Resident #70 had a Stage IV pressure wound of the left lateral ankle for at least 126 days duration. There was moderate serous exudate. The area measured 0.6 centimeters (cm) long by 0.4 cm wide by 0.2 cm deep. The wound was described as 90 percent granulation tissue with 10 percent slough. The resident had a physician's order for a treatment of cleanse left lateral ankle with normal saline, apply calcium alginate with silver, and cover with dry dressing daily. Observation of the treatment on 03/04/20 at 7:20 A.M. revealed Licensed Practical Nurse (LPN) #304 washed her hands and applied clean gloves. She then used her gloved hand to move a mat out of the way that was on the floor and then move the trash can closer to the resident's bed. She then removed the soiled gloves and, without washing her hands, applied clean gloves. She then removed the soiled dressing from Resident #70's left ankle. She then cleansed the wound with normal saline. The resident was observed to have an open area on the left ankle measuring 0.6 centimeters wide by 0.4 centimeters long by 0.1 centimeters deep. LPN #304 then removed her gloves, washed her hands, and applied clean gloved prior to applying the clean dressing. Review of the facility policy titled Hand Hygiene, dated 9/2019 revealed staff were to either wash their hands or use alcohol based hand sanitizer after glove removal. Interview with LPN #304 on 03/04/20 at 11:02 A.M. confirmed staff were to wash their hands each time after removing gloves. This deficiency substantiates Complaint Number OH00110377. This deficiency is also a recite to the complaint survey completed on 01/28/20.

CONCERN (D)

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

Antibiotic Stewardship (Tag F0881)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to implement an effective antibiotic stewardship program to ensure the appropriate use of antibiotics for Resident #25. This affected one resident (#25) of six residents reviewed for unnecessary medication use. Findings include: Record review revealed Resident #25 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, dysphagia, major depressive disorder, acute kidney failure, type II diabetes, atherosclerotic heart disease, heart failure, acute and chronic respiratory failure, hydronephrosis, anemia, hypertension, dementia, hyperlipidemia, osteoporosis, anxiety disorder, and osteoarthritis. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 02/25/20 revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. Review of Resident #25's medical record revealed she was prescribed Doxycycline Hyclate 100 milligrams (mg) twice daily for 14 days (starting 02/29/20) related to infection. There was no documentation to support the justification of an infection or what the specific infection was. Also, there was no documentation to support Resident #25 had signs or symptoms of an infection or the need for an anti-biotic prior to being it prescribed. Finally, the facility did not have documentation (after the antibiotic was prescribed) to support whether the medication was effective. There were no signs or symptoms documented after the medication was prescribed as to what the antibiotic was combating. Interview with Regional Clinical Consultant (RCC) #147 on 03/05/20 at 2:06 P.M. confirmed there was no justification for the use Doxycycline until 03/05/20 because the medical professional who assessed Resident #25 was out of town. She revealed the medical director came in to the facility on [DATE] and documented the antibiotic was for acute bronchitis. Interview with Director of Nursing (DON) on 03/05/20 at 2:24 P.M. confirmed there was no documentation to support signs and symptoms were observed prior to the antibiotic being prescribed. She also confirmed there was no on-going monitoring for signs and symptoms related to whether antibiotic was effective. Review of the facility Antibiotic Stewardship policy, dated May 2016 and Antibiotic Use policy, dated June 2017 revealed facility staff will document in the medical record signs and symptoms of an infection. The policy revealed the facility would follow the McGeer's criteria to determine if an antibiotic was necessary/needed. Then, after three days of antibiotic use, the facility would review and speak with the doctor about the effectiveness and needed for continued use. This deficiency substantiates Complaint Number OH00110377.

CONCERN (E)

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

Resident Rights (Tag F0550)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure residents (#174, #17 and #15) were provided with a dignified dining experience during the lunch meal on 03/02/20 and failed to ensure Resident #50, who had a diagnosis of dementia and was dependent on staff for care was dressed in a manner to promote the resident's dignity. This affected four residents (#174, #17, #15 and #50) of six residents reviewed for dignity. Findings include: 1. Review of Resident #174's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses of schizoaffective disorder, bipolar type, Alzheimer's disease, multiple sclerosis, type 2 diabetes and Vitamin D deficiency. Review of Resident #174's Minimum Data Set (MDS) 3.0 assessment, dated 02/04/20 revealed Resident #174 was severely cognitively impaired with a Brief Interview of Mental Status (BIMS) score of three. The MDS further revealed Resident #174 required extensive assist with one to two persons assist for bed mobility, transfers, hygiene, bathing, dressing and toileting needs and required supervision with set up assistance with eating. Review of Resident #174's diet order, dated 02/07/20 revealed a no added salt diet, regular texture, thin consistency, small portions for weight loss. Review of Resident #17's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including acute respiratory failure with hypoxia, cardiac arrest, anoxic brain damage, moderate protein-calorie malnutrition and hypertension. Review of Resident #17's MDS 3.0 assessment, dated 02/21/20 revealed Resident #17 was severely cognitively impaired with a BIMS score of zero. The MDS further revealed Resident #17 required total assistance with two persons assist for bed mobility, transfers, hygiene, bathing, and toileting needs and required total assistance with one person assist for dressing and eating. Review of Resident #15's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including altered mental status, Vitamin D deficiency, generalized anxiety disorder, unspecified dementia without behaviors and hyperlipidemia. Review of Resident #15's MDS 3.0 assessment, dated 02/17/20 revealed Resident #57 was severely cognitively impaired with a BIMS score of zero. The MDS further revealed Resident #15 required extensive assist with two persons assist for bed mobility, transfer, toileting needs, extensive assist with one person assist for dressing, eating and personal hygiene and total assist with one person assist for bathing. Review of Resident #15's dietary orders dated 09/30/19 revealed an order for a pureed diet, pureed texture, thin consistency. Review of Resident #15's diet order dated 11/15/19 revealed an order for a regular diet, pureed texture, honey consistency, double meal portions all meals, for weight gain for nutrition. The resident also had an order dated 01/15/20 for enteral feed four times a day with Jevity 1.5 bolus with 237 ml (eight-ounce carton) four times a day via enteral tube. Observation on 03/02/20 at 12:23 P.M. of the lunch meal revealed Licensed Practical Nurse (LPN) #291 and Registered Nurse (RN) #359 began to serve lunch trays at this time. At the time the meal started, Resident #174, Resident #17 and Resident #15 were observed seated at the same table. Resident #174 was observed sitting in a wheelchair at the right table in the dining room on the far side, facing away from the window. Resident #17 was sitting in a specialized (Broda) chair across from Resident #174. And to the right of Resident #174 was Resident #15. On 03/02/20 at 12:25 P.M. Resident #15 was observed to be served the lunch meal. The tray was placed to the resident's left. Neither Resident #17 or Resident #174 received their meal tray immediately following Resident #15. On 03/02/20 at 12:37 P.M. a second food tray cart was observed to arrive to the area. As of 03/02/20 at 12:52 P.M. Resident #15 had made no attempts to eat and no staff had attempted to assist the resident. The meal tray remained to the resident's left. On 03/02/20 at 12:55 P.M. a speech therapist was observed assisting Resident #17 to eat. Resident #17 had completed the lunch meal before any staff assisted Resident #15 and before Resident #174 was even served a lunch tray. On 03/02/20 at 1:00 P.M. Resident #174 was served the lunch meal and encouraged by LPN #291 to take small bites. On 03/02/20 at 1:15 P.M. (50 minutes after the resident received the meal tray) a nursing assistant was observed to assist the resident to eat. On 03/02/20 at 1:30 P.M. interview with LPN #291 revealed Resident #15, Resident #17 and Resident #174 should have been served at the same time as they were seated at the same table to promote a more dignified dining experience. The LPN also verified the residents should have been provided more timely assistance with the meal. 2. Review of Resident #50's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included syncope. dysphagia, hyperlipemia, gastro-esophageal reflux disease, depressive disorder, dementia with behavioral disturbance, atherosclerotic heart disease, obsessive compulsive disorder, anxiety disorder, sexual dysfunction, bipolar disorder and schizoaffective disorder. Review of Resident # 50's significant change MDS 3.0 assessment dated [DATE] revealed Resident #50's speech was unclear, he sometimes understood, sometimes understands and his cognition was severely impaired. Resident # 50 had no indicators or psychosis, had physical behaviors one to three days that did not significantly impact the resident or other residents and he did not reject care. Resident # 50 required extensive assistance from two staff for bed mobility and to transfer. Observation of Resident #50 on 03/05/20 at 8:05 A.M. revealed he was in the common area, wearing a hospital gown. At the time of the observation, the resident's left hip and incontinent brief product were exposed and visible to other residents, staff and visitors. Resident #50 was observed at 9:00 A.M. with the same gown on and his hip exposed. Observation of Resident #50 at 2:50 P.M. revealed the resident was wearing the same gown and a sweatshirt. Interview with Licensed Practical Nurse (LPN) #294 on 03/05/20 at 2:51 P.M. revealed Resident #50 was wearing a gown because the resident's clothes were not back from laundry. LPN #294 confirmed the resident's hip and incontinent brief should not be exposed. Observation of Resident #50's closet with LPN #294 at the time of the interview revealed the resident did have a pair of basketball type shorts in the closet. This deficiency substantiates Complaint Number OH00110812 and Complaint Number OH00110564.

CONCERN (E)

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

Deficiency F0569 (Tag F0569)

Could have caused harm · This affected multiple residents

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Based on record review and staff interview the facility failed to provide spend down notifications to residents and/or resident representatives in a timely manner. This affected 12 residents (#15, #50, #62, #64, #66, #80, #82, #130, #140, #148, #159, and #192) of 12 residents reviewed for resident personal fund accounts. Findings include: Review of the resident personal fund account information revealed the following concerns: 1. Review of Resident #15's financial records revealed from 08/02/19 to 12/31/19, the balance was between $2010.19 and $2260.30 (fluctuations when cost of care payment came in and was debited from the account). There was no evidence spend down letters/notifications were sent from August 2019 to December 2019, indicating Resident #15's fund account was within $200 of the maximum allotted amount to have in the account. 2. Review of Resident #50's financial records revealed from 07/29/19 to 12/31/19, the balance was between $2523.00 and $2773.12 (fluctuations when cost of care payment came in and was debited from the account). There was no evidence spend down letters/notifications were sent from August 2019 to December 2019, indicating Resident #50's fund account was within $200 of the maximum allotted amount to have in the account. The facility also documented they did not have guardian contact information for Resident #50 (volunteer guardian) until late November 2019. 3. Review of Resident #62's financial records revealed from 08/02/19 to 12/13/19, the balance was between $2010.19 and $2260.30 (fluctuations when cost of care payment came in and was debited from the account). There was no evidence spend down letters/notifications were sent from August 2019 to December 2019, indicating Resident #15's fund account was within $200 of the maximum allotted amount to have in their account. In addition, review of Resident #62's financial records revealed from 12/13/19 to 12/31/19, the balance was between $6923.21 and $7067.21. There was no evidence a spend down letter/notification was sent for December 2019, indicating Resident #62's fund account was within $200 of the maximum allotted amount to have in their account. 4. Review of Resident #64's financial records revealed from 08/02/19 to 12/31/19, the balance was between $1807.09 and $2007.20 (fluctuations when cost of care payment came in and was debited from the account). There was no evidence spend down letters/notifications were sent from August 2019 to December 2019, indicating Resident #64's fund account was within $200 of the maximum allotted amount to have in their account. 5. Review of Resident #66's financial records revealed from 08/06/19 to 12/31/19, the balance was between $2249.46 and $2431.58 (fluctuations when cost of care payment came in and was debited from the account). There was no evidence spend down letters/notifications were sent from August 2019 to December 2019, indicating Resident #66's fund account was within $200 of the maximum allotted amount to have in their account. 6. Review of Resident #80's financial records revealed from 08/06/19 to 12/31/19, the balance was between $1898.28 and $2005.17 (fluctuations when cost of care payment came in and was debited from the account). There was no evidence spend down letters/notifications were sent from August 2019 to December 2019, indicating Resident #80's fund account was within $200 of the maximum allotted amount to have in their account. 7. Review of Resident #82's financial records revealed from 05/07/19 to 12/31/19, the balance was between $1800.70 and $4701.05 (fluctuations when cost of care payment came in and was debited from the account). There was no evidence spend down letters/notifications were sent in August, October, and November 2019, indicating Resident #82's fund account was within $200 of the maximum allotted amount to have in their account. 8. Review of Resident #130's financial records revealed from 05/07/19 to 12/31/19, the balance was between $1837.04 and $2187.24 (fluctuations when cost of care payment came in and was debited from the account). There was no evidence spend down letters/notifications were sent for September 2019 to December 2019, indicating Resident #130's fund account was within $200 of the maximum allotted amount to have in their account. 9. Review of Resident #140's financial records revealed from 05/07/19 to 12/31/19, the balance was between $1846.06 and $2196.25 (fluctuations when cost of care payment came in and was debited from the account). There was no evidence spend down letters/notifications were sent from September 2019 to December 2019, indicating Resident #140's fund account was within $200 of the maximum allotted amount to have in their account. 10. Review of Resident #148's financial records revealed from 04/02/19 to 12/31/19, the balance was between $2291.02 and $4268.46 (fluctuations when cost of care payment came in and was debited from the account). There was no evidence spend down letters/notifications were sent for May 2019 or from August 2019 to December 2019, indicating Resident #148's fund account was within $200 of the maximum allotted amount to have in their account. 11. Review of Resident #159's financial records revealed from 05/07/19 to 12/31/19, the balance was between $1805.32 and $2205.52 (fluctuations when cost of care payment came in and was debited from the account). There was no evidence spend down letters/notifications were sent from August 2019 to December 2019, indicating Resident #159's fund account was within $200 of the maximum allotted amount to have in their account. 12. Review of Resident #192's financial records revealed from 11/30/19 to 12/31/19, the balance was between $2531.66 to $2526.68 (fluctuations when cost of care payment came in and was debited from the account). There was no evidence spend down letters/notifications were sent from November 2019 to December 2019, indicating Resident #192's fund account was within $200 of the maximum allotted amount to have in their account. Interview with Business Office Manager (BOM) #216 on 03/05/20 at 2:21 P.M. confirmed there was no evidence to support the spend down letters/notifications being sent to the residents and/or representatives identified above.

CONCERN (E)

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

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

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Based on observation and interview the facility failed to implement effective housekeeping and/or maintenance services to ensure the environment on the 100 unit was maintained in a clean and comfortable manner. This affected four residents (#162, #54, #102 and #135) and had the potential to affect all 49 residents who resided on the 100 unit. Findings include: Intermittent observations from 03/02/20 at 10:00 A.M. until 03/04/20 at 9:00 A.M. revealed all three hallway floors of the 100 unit were sticky. While walking on the floor, there was a cracking and suction cup noise from the shoes of those walking down each hallway. It also made the same sounds when residents would be going down the hallway in their wheelchairs; the wheels made the same sticky noises. During the same time period, a persistent/chronic bowel movement/urine/body odor was identified throughout all the hallways of the 100 unit. On 03/03/20 at 9:23 A.M. interview with Resident #162 and on 03/03/20 at 9:46 A.M. interview with Resident #54 revealed environmental concerns. Both resident indicated they did not feel the facility did a great job of cleaning. Both residents confirmed when they were maneuvering down the hallways, the floor was sticky and unclean. The residents shared they had not seen facility staff actually clean the hallway floors in a very long time and had both told the nursing staff about this but nothing had changed. The residents also confirmed the odors in the facility hallways were persistent and indicated it makes them sick. They wished the facility staff could do something about this. On 03/03/20 interview with State Tested Nursing Aide (STNA) #109 at 12:12 P.M. and Licensed Practical Nurse (LPN) #350 at 3:45 P.M. confirmed the presence of odors in the 100 unit hallway. Both staff stated they see the housekeeping staff cleaning the hallways and rooms, but there was a constant odor in the 100 unit. Also, they both confirmed the floor was very sticky and indicated it had not been cleaned/mopped in a while. Intermittent observations between 03/02/20 and 03/03/20 of Resident #102 and Resident #135's bathroom revealed there were blood spots on the floor, near the toilet. There was a fifty cent piece size blood stain on the bathroom floor of the room on 03/02/20 that was present from 10:30 A.M. to 2:45 P.M. When observing the bathroom again on 03/02/20 at 3:30 P.M., the bathroom floor had been cleaned. However, on 03/03/20 from 9:30 A.M. to 12:00 P.M., the bathroom had two dime sized drops of blood on the floor near the toilet. At approximately 1:00 P.M., their bathroom had been cleaned and the blood stains were gone. Interview with Resident #102 and Resident #135 on 03/02/20 at 12:15 P.M. and again on 03/03/20 at 9:45 A.M. revealed concerns that the facility staff do not clean their bathroom on a routine basis. Resident #102 revealed the fifty cent sized blood stain had been on the floor for a couple days. He stated he had told the facility staff about both blood stains, but no one seemed to care to get it cleaned up immediately. This deficiency substantiates Complaint Number OH00110812 and Complaint Number OH00110377.

CONCERN (E)

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

Deficiency F0679 (Tag F0679)

Could have caused harm · This affected multiple residents

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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 develop and implement a comprehensive and individualized activities program to meet the total care needs of all residents. This affected four residents (#48, #50, #83 and #43) of seven residents reviewed for activities. Findings include: 1. Review of Resident #43's medical record revealed an admission date of 12/13/17 with the admitting diagnoses of anoxic brain damage, diabetes mellitus and acute respiratory failure with tracheostomy. Review of the resident's plan of care, dated 08/20/19 revealed the resident had the potential for impaired social interaction related to impaired communication. She preferred to watch television and was on one on one programming. The care plan revealed the resident preferred music therapy, hand massages and painted nails. Interventions included to provide an activity calendar, one to one bedside/in room visits and activities if unable to attend out of room events and assist/escort to activity functions. Review of the resident's comprehensive MDS 3.0 assessment, dated 12/13/19 revealed the resident had no speech, rarely/never understands, rarely/never made herself understood and had a severe cognitive deficit. The assessment indicated a staff interview was conducted for the activity preferences. The staff reported listening to music, keeping up with the news, doing things with group activities and participating in her favorite activities were her activity preferences. Review of the resident's monthly physician's orders for March 2020 revealed an order (initiated 06/25/19) for recreational activities as tolerated. Review of the resident's activity reevaluation dated 02/10/20 revealed the activity staff had added the resident to the one on one activity program. The assessment did not identify the resident's activity preferences. Review of the resident's monthly activity attendance log for December 2019 revealed the resident was provided an activity five days out of 31 days. Review of the resident's monthly activity attendance log for January 2020 revealed the resident was provided an activity four days out of 31 days. Review of the resident's monthly activity attendance log for February 2020 revealed the resident was provided an activity 21 days out of 29 days. Review of the resident's monthly activity attendance log for March 2020 revealed the resident was provided an activity two days out of five days. On 03/05/20 10:43 AM observation of the resident revealed she was in bed with her eyes closed. The television located on the wall between the beds was playing. The resident was positioned towards the door away from the television. On 03/05/20 11:59 AM interview with Registered Nurse (RN) #147 verified the resident did not have an individual activity program to meet her needs. 2. Review of Resident #48's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including cerebral infarction, hypertension, chronic obstructive pulmonary disease, schizophrenia, dysphagia, malignant neoplasm of prostrate, dementia with behaviors, altered mental state, anxiety disorder, alcohol abuse, major depressive disorder and type two diabetes. Review of Resident #48's activity reevaluation, dated 05/09/19, revealed the resident preferred snacks and music events. There was no assessment of Resident #48's music preferences and the assessment did not identify his past or current activity interests. Review of Resident #48's plan of care, dated 05/17/19 revealed the resident attended activities, loved Motown music, attended happy hour, karaoke, sing-a- longs, and Cleveland Browns football. Review of Resident #48's significant change Minimum Data Set (MDS) 3.0 assessment, dated 12/17/19 revealed the resident's speech was unclear, he usually understood, he usually understands, and his cognition was severely impaired. Resident #48 had behaviors not directed toward others that did not significantly affect him or other residents and he did not reject care. Review of Resident # 48's activity preferences revealed it was not very important for him to have reading material, it was very important to listen to music, it was somewhat important for him to be around animals and to keep up on the news, and very important to be in group activities, to do favorite activities and to participate in religious practices. Resident # 48 required extensive assistance of two staff for bed mobility and to transfer. Review of Resident #48's activity progress note, dated 12/17/19 revealed the resident resided on a secure unit for dementia. Resident #48 preferred to sit in common areas and listen to Motown music, attends happy hour, sings karaoke, socializes with other guest and staff and attends sing-a-longs. The note revealed the resident declined the need for activity supplies such as crossword puzzles and coloring sheets. The activity staff would continue to encourage him to engage in activities as tolerated. Review of Resident #48's activity participation logs revealed for December 2019 he participated in exercise once, happy hour twice, independent activities six times and television/movies twice. In January 2020 Resident #48 participated in conversation once, independent activities eight times, sing-along twice and social one time. In February 2020 Resident #48 listened to music twice, pamper me once, party/special event twice, sing-along/karaoke four times, television/movies eight times, conversing with others seven times, cooking club twice, exercise once, games four times, and happy hour once. From 03/01/20 to 03/04/20 Resident #48 participated in games twice, music once, puzzles/word games once, sing-along/karaoke once, special interests once and television music once. Observation of Resident #48 on 03/02/20 at 10:30 A.M. revealed he was asleep in his wheelchair. The television was on but no other activity was occurring even though review of the activity calendar revealed a church service was scheduled at that time. On 03/02/20 at 3:55 P.M. Resident #48 was in his wheelchair in the common area asleep. The television was on, music was playing and Activity Aide (AA) #133 was talking to residents. Review of the activity calendar revealed the scheduled activity at that time was supposed to be karaoke. Observation of Resident #48 on 03/03/20 at 10:23 A.M. revealed Resident #48 was asleep in the common area. The television was on, music was playing, and four other residents were playing corn hole. On 03/03/20 at 2:57 P.M. Resident #48 was in the common area. The television was on The Talk but Resident #48 was not watching it. The activity calendar revealed horse racing was scheduled for that time. Observation on 03/03/20 from 4:15 P.M. until 4:26 P.M. revealed the window coverings were closed, the lights were out and Activity Director (AD) #131, in a loud voice, was repeatedly telling the residents it was time to relax and unwind time. Resident #59 asked for the lights to be turned on. The environment was not calm and relaxing. On 03/04/20 from 10:13 A.M. until 10:44 A.M. Resident #48 was observed seated in the common area with no activity occurring and no resident or staff interaction. Four other residents were bowling. Observation on 03/04/20 from 2:07 P.M. until 2:48 P.M. revealed Resident #48 was sitting in the common area with no activity while five other residents played charades with AA #133. Interview with AD #131 on 03/05/20 at 2:27 P.M. revealed Resident #48 did not actively participate in activities but rather sits in the common area. AD #131 confirmed the resident slept a lot in the common area. The AD verified the resident was not actively engaged in activities of interest or that he preferred during the observations made above. Interview with AD #131 on 03/05/20 at 2:27 P.M. revealed the daily listed activities consisted of: brush-up which was morning grooming, morning news which was the television on a news station (and sometimes later activity staff talked about the news), tea time which was activity staff taking residents to the common area after a meal for the nursing assistants, daily living which was getting ready for a meal, relax and unwind which was shutting the window covers; turning out the lights and putting on soft music, music and meal prep which was taking residents to the dining room for meal, snack and chat pass which was the evening snacks and talking to residents as snacks were passed. The AD was unable to explain why the activities listed on the calendar did not occur as planned based on the observations made. Interview with Licensed Practical Nurse (LPN) #294 on 03/06/20 at 2:18 P.M. revealed Resident #48 had a short attention span and he did not converse with others, mostly he just repeated a word or two. 3. Review of Resident #50's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included syncope. dysphagia, hyperlipemia, gastro-esophageal reflux disease, depressive disorder, dementia with behavioral disturbance, atherosclerotic heart disease, obsessive compulsive disorder, anxiety disorder, sexual dysfunction, bipolar disorder and schizoaffective disorder. Review of Resident #50's plan of care, dated 07/08/19 revealed he preferred games like bingo, whammy and to watch television in his room independently. Review of Resident #50's significant change MDS 3.0 assessment, dated 12/20/19 revealed Resident #50's speech was unclear, he sometimes understood, he sometimes understands, and his cognition was severely impaired. Resident # 50 had no indicators or psychosis, had physical behaviors one to three days that did not significantly impact the resident or other residents and he did not reject care. Review of the staff assessment of activity preferences revealed Resident #50 did not want reading material, he listened to music, liked being around animals, like keeping up with news, liked doing things with groups of people, liked favorite activities, liked spending time outdoors, and did not participate in religious activities. Resident # 50 required extensive assistance from two staff for bed mobility and to transfer. Review of Resident #50's activity participation logs revealed for December 2019 he participated in independent activities three times, conversing once, and television/movies three times. In January 2020 Resident #50 participated in independent activities nine times, sing-along once, mail once, and social twice. Review of Resident #50's activity reevaluation, dated 02/02/20, revealed the resident participated in social activities, sat in the common area throughout the day and liked games and exercise. The reevaluation indicated the resident declined the need for activity supplies such as crossword puzzles and coloring sheets. The activity staff would continue to engage him in activities as tolerated. There were no assessment of Resident #50's past or current activity interests. In February 2020 Resident #50 participated in busy hands three times, listened to music once, pamper me once, party/special event twice, sing-a-long/karaoke three times, and television/movies five times, conversing with others three times, cooking club twice, games four times, independent activities once, and radio/music once. From 03/01/20 to 03/04/20 Resident #50 participated in games twice, music once, sing-along/karaoke once, special interests once and television music once. Observation of Resident #50 on 03/02/20 at 10:30 A.M. revealed he was asleep in his wheelchair; the television was on and no other activity was occurring even though the activity calendar revealed a church service was scheduled. On 03/02/20 at 3:55 P.M. Resident #50 was in his wheelchair in the common area asleep. The television was on, music was playing and Activity Aide (AA) #133 was talking to residents. Review of the activity calendar revealed the scheduled activity was supposed to be karaoke at that time. Observation of Resident #50 on 03/03/20 at 10:23 A.M. revealed he was asleep in the common area, the television was on, music was playing, and four other residents were playing corn hole. On 03/03/20 at 2:57 P.M. Resident #50 was in the common area and the television was on The Talk. Resident #50 was not watching it. The activity calendar called for horse racing at that time. Observation on 03/03/20 from 4:15 P.M. until 4:26 P.M. revealed the window coverings were closed, the lights were out and AD #131, in a loud voice, was repeatedly telling the residents it was time to relax and unwind time. Resident #59 asked for the lights to be turned on. The environment was not calm and relaxing. On 03/04/20 from 10:13 A.M. until 10:44 A.M. Resident #50 was seated in the common area with no activity and no other resident or staff interactions occurring. Four other residents were bowling. Observation on 03/04/20 from 2:07 P.M. until 2:48 P.M. revealed Resident #50 was sitting in the common area with no activity while five other residents played charades with AA #133. Observation of Resident #50's room on 03/04/20 at 2:50 P.M. revealed he did not have a television or radio in his room. Interview with AD #131 on 03/05/20 at 2:27 P.M. confirmed Resident #50 did not actively participate in activities and he mostly just sat in the common area. AD #131 revealed the resident liked to watch television in his room. However, after making this statement, observation with AD #131 confirmed there was no television or radio in the resident's room. The AD was unable to explain why the activities listed on the calendar did not occur as planned based on the observations made. Interview with LPN #294 on 03/06/20 at 12:01 P.M. revealed Resident #50 talks but he does not make sense when he talks. 4. Review of Resident #83's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included ataxia, altered mental status, mild cognitive impairment, age related osteoporosis, dementia with behavior disturbance and constipation. Review of Resident #83's activity reevaluation dated 03/20/19 revealed there was no assessment of the resident's activity interests past or present. Review of Resident #83's care plan dated 04/26/19 revealed she liked independent activities in her room such as watching television and listening to music. Review of Resident #83's annual MDS 3.0 assessment, dated 11/27/19 revealed her speech was unclear, she usually understands, she usually was understood, her short and long term memory were impaired, she recalled her room location and that she was in a nursing home and her cognition was moderately impaired. Resident #83 had no behaviors, no indicators of psychosis, and rejected care daily. Review of Resident #83's self-assessment for activities reveled she liked to have reading materials, it was very important to listen to music, somewhat important to be around animals, to keep up with the news, do things with groups of people, to do favorite activities, go outside for fresh air, and participate in religious activities. Resident #83 required supervision of two staff for bed mobility and supervision of one staff to transfer. Review of Resident #83's quarterly MDS 3.0 assessment revealed the resident's speech was clear, she understands, she was understood and her cognition was moderately impaired. Resident #83 had no behaviors and did not reject care. Resident #83 required supervision of one staff for bed mobility and to transfer. Observation of Resident #83 on 03/02/20 at 10:30 A.M. revealed she was sitting in the common area not paying attention to the television that was on and no other activity was occurring at that time even though the activity calendar revealed a church service was scheduled. At 3:55 P.M. Resident #83 was in a chair in the common area. The television was on, music was playing and AA #133 was talking to residents. Review of the activity calendar revealed the scheduled activity was karaoke. Observation of Resident #83 on 03/03/20 at 10:23 A.M. revealed she was in her room and there was no television or music was playing. On 03/03/20 at 2:57 P.M. Resident #83 was in the common area and the television was on The Talk. Resident #83 was not watching it. The activity calendar called for horse racing. Observation on 03/03/20 from 4:15 P.M. until 4:26 P.M. revealed the window coverings were closed the lights were out and AD #131, in a loud voice, was repeatedly telling the residents it was time to relax and unwind time. Resident #59 asked for the lights to be turned on. The environment was not calm and relaxing. Observation on 03/04/20 from 10:13 A.M. until 10:44 A.M. revealed Resident #83 was in her room and there was no television or music playing. Observation on 03/04/20 from 2:07 P.M. until 2:48 P.M. revealed Resident #83 was sitting in the common area with no activity while five other residents played charades with AA #133. Interview with AD #131 on 03/04/20 at 4:23 P.M. revealed once Resident #83 moved to the secure unit she refused one to one visits. AD #131 stated Resident #83 was socializing more and out of her room almost all day. AD #131 stated Resident #83 used to look out the window, watch television, or came to music activities, but not now. However, no changes had been made to her activity plan. Interview with Resident #83 on 03/05/20 at 7:34 A.M. revealed she liked to watch television and listen to music in her room but did not have a TV or radio. Resident #83 stated mostly she liked to stay in her room. This deficiency substantiates Complaint Number OH00110812.

CONCERN (E)

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

Medication Errors (Tag F0758)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of Resident #67's medical record revealed an admission date on 09/14/19 with diagnoses including encephalopathy, muscle weakness, abnormalities of gait and mobility, cerebral infarction, stiffness of right shoulder, hyperlipidemia, obesity, stiffness of right elbow, major depressive disorder, atrial flutter, aphasia following cerebral infarction, cognitive communication deficit, unsteadiness on feet, atherosclerotic heart disease of native coronary artery without angina pectoris, history of falling, hypertension, insomnia, asthma, stiffness of right knee, stiffness of right hand and vascular dementia without behavioral disturbance. Review of Resident #67's physician's orders revealed an order for the antipsychotic medication, Aripiprazole (Abilify), 10 milligrams (mg) at night for depression. Review of Resident #67's care plan, dated 09/14/19 revealed the resident had potential for fluctuations in mood and behaviors related to cognitive communication deficit, mood disorder, vascular dementia, cerebral infarction, depression, and encephalopathy. Interventions included a quarterly psychotropic medication regimen review, attempted gradual dose reductions and behavior monitoring. Review of Resident #67's quarterly Minimum Data Set assessment dated [DATE] showed the resident had mild cognitive impairment and required extensive assistance from staff to complete activities of daily living (ADLs). Resident #67 received daily antipsychotic medication. Review of Resident #67's Psychoactive Medication Quarterly Evaluation assessment, dated 01/07/20 revealed the resident was taking Aripiprazole (Abilify) 10 mg daily for dementia and major depressive disorder. The behaviors associated with using the medication included: increased anxiety, depression, frustration while trying to find the appropriate words, and agitation. The assessment did not indicate any target behaviors that Resident #67 displayed to justify the usage of a psychotropic medication. Review of Resident #67's behavior monitoring task for the past 30 days revealed the resident had not displayed any behaviors during this time period. Interview with Registered Nurse (RN) #325 on 03/05/20 at 12:56 P.M. revealed Resident #67 was transferred to the 200 unit from the secured unit in October 2019. RN #325 stated Resident #67 had not displayed any behaviors toward staff or other residents. RN #325 stated Resident #67 did self-isolate and required encouragement to accept care. Interview with the Director of Nursing (DON) on 03/05/20 at 3:01 P.M. confirmed they facility had no evidence or documentation to support specific behaviors for Resident #67 during the given quarterly review period. The DON would expect the nursing staff (aides and nurses) to document in the electronic record when there was a behavior so they could accurately assess and monitor Resident #67's behaviors and continued medication justification. Based on observation, record review and staff interview the facility failed to ensure the necessary use of psychotropic medications including monitoring for symptoms for which the psychotropic medications were given and completion of gradual dose reduction attempts. This affected four residents (#50, #48, #102 and #67) of six residents reviewed for unnecessary medication use. Findings include: 1. Review of Resident #48's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including cerebral infarction, hypertension, chronic obstructive pulmonary disease, schizophrenia, dysphagia, malignant neoplasm if prostrate, dementia with behaviors, altered mental state, anxiety disorder, alcohol abuse, major depressive disorder and type two diabetes. Review of Resident #48's significant change Minimum Data Set (MDS) 3.0 assessment, dated 12/17/19 revealed the resident's speech was unclear, he usually understood, usually understands, and his cognition was severely impaired. Resident #48 had behaviors not directed toward others that did not significantly affect him or other residents and he did not reject care. Resident # 48 required extensive assistance of two staff for bed mobility and to transfer. Resident # 48 received antipsychotic medication, antianxiety medication, and antidepressant medication seven of the seven days during the assessment period and no gradual dose reduction had been attempted. Review of Resident #48's pharmacy review revealed on 12/17/19 a recommendation to attempt a dose reduction of Resident #48's psychotropic medications was made by the pharmacist. On 12/24/19 the physician declined a dose reduction but failed to give a rational as to why a dose reduction was clinically contraindicated. Review of Resident #48's physician's orders revealed the resident had orders for the antidepressant medication, Prozac 40 milligrams (mg) daily, the antipsychotic medication, Risperdal 0.25 mg twice daily and the antianxiety, Buspirone 5 mg three times a day. Review of Resident #48's plan of care dated 01/29/20 revealed target behaviors were related to the resident yelling, screaming out, hypersexuality, agitation, blowing kisses to staff, being verbally aggressive and difficulty with rational problems solving. However, the only target behavior the facility was monitoring was inappropriate sexual behavior toward females. Observation of Resident #48 on 03/02/20 at 11:09 A.M., and 3:58 P.M. revealed he was asleep in his wheelchair in the common area. At 1:02 P. M. after lunch the resident was awake. Interview with Activities Director (AD) #131 on 03/05/20 at 2:27 P.M. revealed Resident #48 slept a lot in the common area and she was not aware of him having any behaviors. Interview with Licensed Practical Nurse (LPN) #247 on 03/06/20 at 2:18 P.M. revealed Resident #48 did not usually have any behaviors. LPN #247 stated Resident #48 liked to talk to girls but that was about all. Interview with the Director of Nursing on 03/06/20 at 3:10 P.M. confirmed the facility was not monitoring all of Resident #48's behaviors and confirmed the physician did not give a rational why a gradual dose of the resident's psychotropic medication was contraindicated. 2. Review of Resident #50's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included syncope. dysphagia, hyperlipemia, gastro-esophageal reflux disease, depressive disorder, dementia with behavioral disturbance, atherosclerotic heart disease, obsessive compulsive disorder, anxiety disorder, sexual dysfunction, bipolar disorder and schizoaffective disorder. Review of Resident #50's significant change MDS 3.0 assessment, dated 12/20/19 revealed Resident #50's speech was unclear, he sometimes understood, sometimes understands and his cognition was severely impaired. Resident #50 had no indicators or psychosis, had physical behaviors one to three days that did not significantly impact the resident or other residents and he did not reject care. Resident #50 required extensive assistance from two staff for bed mobility and to transfer. Resident #50 received antipsychotic medication, antianxiety medication and antidepressant medication, seven of the seven days during the assessment period and no gradual dose reduction was attempted. Review of Resident #50's pharmacy reviews revealed on 02/17/20 a recommendation to attempt a dose reduction of Resident #50's psychotropic medications was made by the pharmacist. On 02/21/20 the physician declined a dose reduction but failed to give a rational as to why a dose reduction was clinically contraindicated. Review of Resident #50's March 2020 physician's orders revealed the resident had orders for the antipsychotic medication, Seroquel 12.5 mg in the morning and 37.5 mg at night, the antianxiety medication, Buspirone 15 mg three times a day, the antianxiety medication, Ativan 0.5 mg twice daily and the antidepressant medication, Prozac twice daily. Resident #50's plan of care identified target behaviors of wandering without purpose and delusions. The only target behavior the facility was monitoring wandering and in the past 30 days no episodes of wandering were documented to have occurred. Observation of Resident #50 on 03/04/20 from 10:13 A.M. to 10:44 A.M. and from 2:05 P.M. until 2:48 P.M. revealed he was seated in a wheelchair in a common area asleep. Interview with State Tested Nursing Assistant (STNA) #150 on 03/06/20 at 11:58 A.M. revealed Resident #50 had no behaviors. Interview with LPN #294 on 03/06/20 at 12:01 P.M. revealed Resident #50 did not have a lot of behaviors mostly he talked but did not make sense. Interview with the Director of Nursing on 03/06/20 at 3:10 P.M. confirmed the facility was not monitoring all of Resident #48's behaviors and confirmed the physician did not give a rational why a gradual dose was contraindicated for the resident's psychotropic medications. 3. Review of Resident #102's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included acute and chronic respiratory failure, obesity, chronic obstructive pulmonary disease, hypothyroidism, delirium, schizoaffective disorder, hypothyroidism, type two diabetes, anxiety, Meibomian gland dysfunction, acute embolism and thrombosis, psychosis, major depression, peripheral vascular disease, gout, xerosis cutis, acne vulgaris, hyperlipidemia and essential hypertension. Review of Resident #102's annual MDS 3.0 assessment, dated 01/07/2020 revealed Resident #102's speech was clear, he understands, was understood and his cognition was intact. Resident #102 had no behaviors and did not reject care. Resident #102 was independent with set up help for bed mobility and required supervision with set up help to transfer. The assessment revealed the resident received an antipsychotic medication, antianxiety medication and an antidepressant medication on seven of the seven days in the assessment period and no gradual dose reduction was attempted. Review of Resident #102's March 2020 physician's orders revealed the resident had an order for the antianxiety medication, Buspirone 5 mg twice daily, the antidepressant medication, Zoloft 100 mg daily and the antipsychotic medication, Abilify 5 mg daily. Resident #102's plan of care did not identify specific target behaviors for which he was receiving the psychoactive medication. And there was no evidence any behaviors were being monitored for the resident. Interview with STNA #146 on 03/04/20 at 8:36 A.M revealed sometimes Resident #102 refused care, his sheets to be changed or a shower. STNA #146 stated Resident #102 had no physical or verbal behaviors and he had no hallucinations or delusions. Interview with LPN #292 on 03/04/20 at 8:47 A.M. revealed the resident only refused showers sometimes and he had no hallucinations or delusions. Interview with LPN #322 on 03/04/20 at 9:49 A.M. confirmed Resident #102's target behaviors were not identified on his plan of care and there was no evidence of the facility was monitoring behaviors to ensure the psychoactive medications were necessary for the resident.

CONCERN (E)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

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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 medication carts were locked and secured when not within nurses view. This had the potential to affect all residents residing on the 400 and 500 halls. Findings include: Observation on 03/04/20 between 10:03 A.M. and 10:15 A.M. of Licensed Practical Nurse (LPN) #291 administering medication revealed the 400 hall medication cart was left unlocked while LPN #291 entered room [ROOM NUMBER] and 402 to administer medication to residents. The medication cart was not visible by LPN #291 during this time. Interview on 03/04/20 at 10:20 A.M. with LPN #291 confirmed she left the medication cart unattended and unlocked. Observation on 03/04/20 at 11:03 of LPN #348 administering medication on the 500 hall revealed the medication cart was left unlocked while LPN #348 entered a residents room to administer medication and the medication cart was not within the nurse's view. Interview on 03/04/20 at 11:10 A.M. with LPN #348 confirmed the medication cart was left unlocked and unattended in the hall. Review of the facility policy titled Medication Administration, revised October 2019 revealed for staff to make sure the medication cart was locked at all times when not in use or when not in (the nurses) constant vision.

CONCERN (E)

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

Menu Adequacy (Tag F0803)

Could have caused harm · This affected multiple residents

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Based on observation, record review and interview the facility failed to ensure the written menu for pureed diets was followed. This had the potential to affect eight residents (#15, #23, #149, #83, #50, #147, #139 and #146) who received pureed meal trays. Findings include: Review of the spreadsheet for the lunch meal on 03/20/20 revealed a #10 scoop was to be used to serve pureed green beans, a #20 scoop was to be used for the pureed bread and pureed macaroni and cheese was on the menu. Observation of tray line on 03/04/20 from 10:50 A.M. until 11:15 A.M. revealed staff were using a #8 scoop (instead of a #10 scoop) for the pureed green beans. Staff were using a #16 scoop (instead of a #20 scoop) for the pureed bread and there was no pureed macaroni and cheese on tray line. Interview with Dietary Aide #204 confirmed the pureed foods (beans and bread) had the wrong scoop sizes compared with the size listed on the menu/spreadsheet. Interview with [NAME] #210 at the time of tray line revealed she missedthe macaroni and cheese for the pureed diets. Interview with Dietary Staff #192 revealed she was going to serve the residents who had orders for pureed diets mashed potatoes instead of the pureed macaroni and cheese. The facility identified eight residents, Resident #15, #23, #149, #83, #50, #147, #139 and #146 who received pureed meal trays.

CONCERN (E)

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

Safe Environment (Tag F0921)

Could have caused harm · This affected multiple residents

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Based on observation and interview the facility failed to ensure resident rooms and bathrooms on the 300 and 400 units were maintained in a safe, sanitary and comfortable manner. This affected 13 residents (#183, #103, #175, #109, #143, #70, #23, #176, #6, #7, #201, #8 and #182) residing on the 400 unit, ten residents (#107, #146, #59, #142, #48, #87, #86, #50, #130 and #160) residing on the 300 unit and had the potential to affect all 82 residents who resided on the 300 and 400 units. Findings include: 1. On 03/02/20 at 10:38 A.M. a tour of the 400 unit revealed the following concerns: In Resident #183's room, the bathroom floor had a heavy buildup of a black substance especially around the edge of the room (six to eight inches wide) and the floors were sticky. In Resident #103 and Resident #175's room, the toilet was sitting sideways exposing a dark brown golden yellow thick rusty ring on floor. There was a heavy buildup of dirt around the edge of bathroom floor. In Resident #109 and Resident #143's room, the bathroom floor had a dark brown golden yellow thick rusty ring build up around the base of the toilet. There was a white towel folded in half on floor in front of toilet and was stuck to floor. There were multiple scrapes on wall behind the B bed approximately three to four-foot area in diameter. In Resident #70's room, the area around the toilet had a dark brown golden yellow thick rusty ring build up around the base of the toilet. The dresser in the room had the top layer of veneer chipping off exposing the rough wood underneath. In Resident #23's room, the call light had a broken clip, so it was unable to be secured to ensure the light kept from falling to the floor. There was brown matter splattered on the wall beside the toilet. There was a broken electric cover on the wall behind the B bed. In Resident #176's room, the bathroom floor had a buildup of black material. In Resident #6 and Resident #7's room, the bathroom floor was dirty with dark brown golden yellow thick rusty ring around the toilet on the floor. There was a two-foot piece of molding missing near floor under sink. In Resident #201's room, the dresser in the room had the top layer of veneer chipping off exposing rough wood underneath. The bathroom floor had a dark brown golden yellow thick rusty ring around the toilet and the floor was dirty. In Resident #8 and Resident #182's room, had a brown substance on the left side of toilet seat with an elevated toilet seat over top of it. The bathroom floor was dirty with a dark brown golden yellow thick rusty ring build up around the base of the toilet. In the 400 shower room, the toilet had dried fecal matter covering the left side of the inside of the toilet bowel. The light above the back-shower stall does not work leaving the shower stall area dark. A fan and a ceiling vent in the shower room covered with dust build up. The back shower had low water pressure coming out of the handheld shower wand. The entire shower room floor had dirt and paper scattered all over. On 03/03/20 from 2:50 P.M. through 3:40 P.M. a second tour of the 400 unit was conducted with Maintenance Supervisor #314. The areas identified by the facility tour at the 10:38 A.M., were still there during the second tour. The Maintenance Supervisor #314 verified all the areas of concern during the tour. The Maintenance Supervisor furthermore verified there were live wires behind the missing electric cover in Resident #23's room because the room use to be the ventilator room. 2. On 03/03/19 from 3:50 P.M. to 4:05 P.M. a tour of the 300 unit with Maintenance Supervisor #314 revealed the following: Observation of Resident #107 and #146's room revealed the wall by the door was patched but not painted, the telephone outlet cover did not cover the outlet. Observation of Resident #59 and #142's room revealed the floor in the bedroom floor was stained and the wall by the closet had cracked and missing dry wall patch. Observation of Resident #48 and #87's bathroom floor revealed it was dirty and the flooring had about a half inch gap around the edge which was dirty with a buildup of debris. Observation of Resident #86 and 50's bathroom revealed cove molding and tiles missing off the wall under the sink. Observation of Resident #130 and #160's room revealed cove molding and tiles missing off the wall under the sink. Maintenance Supervisor #314 verified the above findings at the time of the observations. The carpeting in the common area by the nurses' station had stains that were red and beige in color on all of the carpeting. This deficiency substantiates Complaint Number OH00110812 and OH00110377.

CONCERN (F)

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

Deficiency F0802 (Tag F0802)

Could have caused harm · This affected most or all residents

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Based on observation, record review and interview the facility failed to provide sufficient staffing to ensure residents received their meals in a timely manner. This had the potential to affect 186 of 186 residents who received meal trays with the exception of 11 residents (#56, #121, #123, #145, #42, #43, #49, #94, #69, #24, and #159) who received nothing by mouth. The facility census was 197. Findings include: 1. Review of the facility established mealtimes revealed breakfast was supposed to be served at 8:00 A.M., lunch in the dining room was supposed to be served at 12:00 P.M. On 03/02/20 at 2:19 P.M. observation on the 100 unit received the lunch meal cart and meals were delivered and meal service started at this time. Interview with Licensed Practical Nurse (LPN) #293 and LPN #350 on 03/02/20 at 2:14 P.M. confirmed meal served in this hallway varies (quite often) since it was the last hallway served. The LPNs revealed they were unsure why it took so long for the meal carts to be brought back, but nursing worked to get meals out as quickly as they could once the cart arrived. On 03/03/20 at 8:57 A.M., breakfast was observed being served to the residents on the 100 unit. The front hallway was completed at 9:03 A.M. and the back hallway was starting to be served. On 03/03/20 interview with Resident #162 at 9:23 A.M. and interview with Resident #54 at 9:46 A.M. revealed meals were always served later than scheduled. Both residents indicated they wished meals came sooner/on time because they get hungry. The residents also shared food items were sometimes cold when meals were served late and indicated they had both asked nursing staff about this previously. Interview with Dietary Manager #211 and Dietary Aide #204 on 03/04/20 at 11:41 A.M. revealed the reason the dining room meal service was late was because kitchen staff were dependent on the State tested nursing assistants (STNA) to serve the food when they come from they units. When the STNAs were late coming, the meal service was late and that spiraled out to the other hallways. They stated they will email the STNAs when they notice they are late. On 03/05/20 at 2:45 P.M., there were three residents being served their lunch in the common/dining area in the 100 unit. These residents had not received their lunch prior to this. 2. Observation of the main dining room on 03/02/20 at 11:56 A.M. revealed 16 residents were in the dining room waiting to be served. At 12:02 P.M. coffee was served. At 12:13 P.M. soup was served and at 12:19 P.M. entrées were served. As of 12:41 P.M., Resident #183, Resident #112, Resident t#35, and Resident #150, and Resident #37 were not served. Interview with STNA #180 revealed the STNA was not aware these residents had not been served as another staff was supposed to serve them. Observation of the 300-hall meal cart on 03/02/20 revealed the first cart did not arrive until 1:29 P.M. and the second cart arrived at 1:42 P.M. Observation of the breakfast meal in the dining room on 03/03/20 at 8:05 A.M. revealed the ice cart and beverage carts were out at this time. At 8:12 AM 21 residents were in the dining room and two STNAs were passing beverages and one STNA was passing condiments. At 8:24 A.M. packaged bowls of cereal were passed. At 8:27 A.M. the breakfast meal was passed. Review of the facility established mealtimes revealed breakfast was supposed to be served at 8:00 A.M., lunch in the dining room was supposed to be served at 12:00 P.M., and lunch on 300 halls was supposed to arrive at 12:55 P.M. and 1:10 P.M. Interview with Dietary Manager (DM) #500 on 03/04/20 at 11:41 A.M. revealed on 03/02/20 the trays were late due to staff calling off and the dietary aide on the line had family problems. DM #500 revealed the reason the dining room was served late was the kitchen staff were dependent on the STNA staff from the units to serve the food. DM #500 stated when the STNA's were late the meal service was late.

CONCERN (F)

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

Deficiency F0804 (Tag F0804)

Could have caused harm · This affected most or all residents

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2. On 03/02/20 at 1:35 P.M. Resident #109 was heard telling Registered Nurse (RN) #324 his food was not prepared correctly. Interview on 03/03/20 at 12:00 P.M. with Resident #109 revealed dietary concerns. The resident stated the food was horrible, there was no taste to it and it looked like cat food. The resident then reported fresh citrus fruits were rarely offered but sometimes you might get a banana. Observation on 03/03/20 at 12:00 P.M. revealed Resident #109 was served ground up chicken or turkey (could not be identified) with brown gravy, peas and carrots and mashed potatoes with gravy. The resident indicated the meal was not any good. On 03/02/20 at 10:44 A.M. an interview with Resident #183 revealed dietary concerns. The resident stated the food was horrible, everything was always served cold. The resident stated if you want anything else to eat (other than what was served) it takes a very long time for the substitution to come. The resident stated the meat was tough and many times you can't tell what vegetables you are eating because they all look the same and taste the same; no taste at all. 3. On 03/05/20 at 11:30 A.M. during a resident council group meeting, revealed four of the five residents present at the meeting voiced dietary concerns. The residents revealed food was often served late and cold. Resident #6 revealed the orange juice was never cold and actually hot when served. He further stated the hot items were served cold and the cold items were served hot. Resident #189 stated when Styrofoam was used, the residents were served cold meals like deli sandwiches. The problem was when they placed other things on the plate the bun or bread gets soaking wet and the sandwich turns to mush due to the runoff of the liquids from the sides. Resident #457 reported she refuses to drink the juice any longer do to it being sour and making her sick in the past. Based on observation, record review and interview the facility failed to ensure food served was appealing, appetizing and served at the proper temperature. This affected seven residents (#54, #162, #109, #6, #189, #457 and #183) and had the potential to affect all 186 of 186 residents who received meal trays with the exception of 11 residents (#56, #121, #123, #145, #42, #43, #49, #94, #69, #24, and #159) who received nothing by mouth. The facility census was 197. Findings include: 1. Interview with Resident #54 on 03/02/20 at 1:58 P.M. revealed dietary concerns. The resident indicated most meals were served late and when served they were often cold (no longer hot/warm enough). The resident revealed she tells the staff this and at times they will warm the meal up. Interview with Resident #162 on 03/02/20 at 3:26 P.M. revealed dietary concerns. The resident revealed meals were served to his room extremely late, and by the time it gets to his room, the food was cold. The resident revealed he will sometimes ask for it to be warmed up, and it typically will be; but there were times he doesn't say anything because he doesn't believe anything will be fixed. He definitely wanted his food to be much warmer when served to him. Observation of food service and test tray temperature on 03/04/20 from 1:17 P.M. to 1:46 P.M. revealed it too 29 minutes from the point the food was served onto the test tray plate, to when it was served to take the food temperatures. The temperature of the ham was 101.7 degrees Fahrenheit (F). When tasting the ham, it was luke warm, not warm enough for a preference for food to be served warm/hot. The temperature of the ham was confirmed by Dietary Aide #204. During a follow up interview with Resident #54 on 03/04/20 at 2:12 P.M. the resident revealed the ham she received for lunch on this date was not warm enough for her preference when it was served to her.

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

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Based on observation and staff interview the facility failed to store, prepare and distribute food under sanitary conditions to prevent contamination and potential food borne illness. This had the potential to affect 186 of 186 residents who received meal trays with the exception of 11 residents (#56, #121, #123, #145, #42, #43, #49, #94, #69, #24, and #159) who received nothing by mouth. The facility census was 197. Findings include: Initial tour of the kitchen on 03/02/20 from 8:30 A.M. to 08:45 A.M. revealed the following concerns: The plate warmer had bread crumbs on it. A plate with egg residue on the plate was in the plate warmer. Two covers for the plate warmers were dirty, one had bread crumbs in it and the other had dried food on it. The floor of the fridge under the shelves was dirty and lids to drinks (4) were on the floor. The storeroom floor under the rack and shelves was dirty with food packet and lids. Observation of the service hallway outside the kitchen revealed three serving carts in service hall with old food trays. The above observations were confirmed by Dietary Manager (DM) #500 during the initial tour. In addition DM #500 revealed the trays were from the evening before and would be washed this morning. There was dried juice on the floor. The floor had the same areas of dried juice on the service hall floor which DM #500 confirmed on 03/03/20 at 11:00 A.M.

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• 32% turnover. Below Ohio's 48% average. Good staff retention means consistent care.

Concerns

• Multiple safety concerns identified: 5 harm violation(s). Review inspection reports carefully.
• 73 deficiencies on record, including 5 serious (caused harm) violations. Ask about corrective actions taken.
• $10,980 in fines. Above average for Ohio. Some compliance problems on record.
• Grade F (23/100). Below average facility with significant concerns.

Bottom line: Trust Score of 23/100 indicates significant concerns. Thoroughly evaluate alternatives.

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About This Facility

What is The Laurels Of Walden Park's CMS Rating?

CMS assigns THE LAURELS OF WALDEN PARK an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Ohio, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.

How is The Laurels Of Walden Park Staffed?

CMS rates THE LAURELS OF WALDEN PARK's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 32%, compared to the Ohio average of 46%. This relatively stable workforce can support continuity of care.

What Have Inspectors Found at The Laurels Of Walden Park?

State health inspectors documented 73 deficiencies at THE LAURELS OF WALDEN PARK during 2020 to 2025. These included: 5 that caused actual resident harm and 68 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.

Who Owns and Operates The Laurels Of Walden Park?

THE LAURELS OF WALDEN PARK is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by CIENA HEALTHCARE/LAUREL HEALTH CARE, a chain that manages multiple nursing homes. With 225 certified beds and approximately 206 residents (about 92% occupancy), it is a large facility located in COLUMBUS, Ohio.

How Does The Laurels Of Walden Park Compare to Other Ohio Nursing Homes?

Compared to the 100 nursing homes in Ohio, THE LAURELS OF WALDEN PARK's overall rating (2 stars) is below the state average of 3.2, staff turnover (32%) is significantly lower than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.

What Should Families Ask When Visiting The Laurels Of Walden Park?

Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"

Is The Laurels Of Walden Park Safe?

Based on CMS inspection data, THE LAURELS OF WALDEN PARK has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Ohio. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.

Do Nurses at The Laurels Of Walden Park Stick Around?

THE LAURELS OF WALDEN PARK has a staff turnover rate of 32%, which is about average for Ohio nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.

Was The Laurels Of Walden Park Ever Fined?

THE LAURELS OF WALDEN PARK has been fined $10,980 across 1 penalty action. This is below the Ohio average of $33,189. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.

Is The Laurels Of Walden Park on Any Federal Watch List?

THE LAURELS OF WALDEN PARK is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

Facility Details

Beds: 225
Avg. Residents: 206
Occupancy: 91.8%
Ownership: For profit - Individual
Chain: CIENA HEALTHCARE/LAUREL HEALTH CARE
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
2-Star Rating: +10
5 Actual Harm citations: -25
73 Deficiencies: -10
Fines ($10,980): -2
Final Score: 23/100

Nearby Alternatives

WESTERWOOD REHABILITATION 5-star OHIO LIVING WESTMINSTER-THURBE... 5-star WESLEY GLEN HEALTH SERVICES CO... 5-star

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Check Bed Availability

Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 365379