What is GARDEN COURT NURSING AND REHABILITATION CENTER's CMS rating?

GARDEN COURT NURSING AND REHABILITATION CENTER has a two-star overall rating from CMS (Centers for Medicare & Medicaid Services), based on health inspections, staffing levels, and quality measures.

How many inspection deficiencies does GARDEN COURT NURSING AND REHABILITATION CENTER have?

GARDEN COURT NURSING AND REHABILITATION CENTER has 92 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at GARDEN COURT NURSING AND REHABILITATION CENTER?

GARDEN COURT NURSING AND REHABILITATION CENTER has a one-star staffing rating from CMS with 0.57 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

How many beds does GARDEN COURT NURSING AND REHABILITATION CENTER have?

GARDEN COURT NURSING AND REHABILITATION CENTER has 67 certified beds.

Who owns GARDEN COURT NURSING AND REHABILITATION CENTER?

GARDEN COURT NURSING AND REHABILITATION CENTER is a for profit - individual facility and is part of the HILLSTONE HEALTHCARE chain.

Was GARDEN COURT NURSING AND REHABILITATION CENTER ever fined?

Yes, GARDEN COURT NURSING AND REHABILITATION CENTER has been fined $144,171 by federal regulators. Fines are issued for serious violations of Medicare and Medicaid requirements.

Is GARDEN COURT NURSING AND REHABILITATION CENTER on any federal watch list?

No, GARDEN COURT NURSING AND REHABILITATION CENTER is not on any federal watch list. It is not designated as a Special Focus Facility or SFF Candidate by CMS.

What have inspectors found at GARDEN COURT NURSING AND REHABILITATION CENTER?

Medicare inspectors have found 92 deficiencies at GARDEN COURT NURSING AND REHABILITATION CENTER: 3 serious, 89 moderate. Each deficiency represents a violation of federal nursing home requirements.

What questions should families ask when visiting GARDEN COURT NURSING AND REHABILITATION CENTER?

Families visiting GARDEN COURT NURSING AND REHABILITATION CENTER should ask about staff retention and training programs, what corrective actions were taken after fines. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does GARDEN COURT NURSING AND REHABILITATION CENTER compare to other nursing homes?

GARDEN COURT NURSING AND REHABILITATION CENTER 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.

GARDEN COURT NURSING AND REHABILITATION CENTER | 10/100 (Grade F)

Aug 2025 2 deficiencies

CONCERN (F) 📢 Someone Reported This

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

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

Safe Environment (Tag F0584)

Could have caused harm · This affected most or all residents

Based on observation, resident interview, staff interview and review of facility policy, the facility failed to maintain comfortable temperatures. This affected 16 (#27, #28, #29, #30, #31, #32, #33, ...

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Based on observation, resident interview, staff interview and review of facility policy, the facility failed to maintain comfortable temperatures. This affected 16 (#27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, and #42) of 16 residents who resided on the 400 and 500 halls. Additionally, the facility failed to ensure residents had access to comfortable water temperatures. This affected 26 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25 and #26) residents who resided on the 100, 200 and 300 halls. The facility census was 42.Findings include:1. Interview on 08/18/25 at 12:07 P.M. with the Administrator revealed the facility's air conditioner was not working on the 400 and 500 halls. The Administrator stated companies had been out to evaluate the system, but it had not yet been repaired. The Administrator stated the system needed to be replaced. Observation on 08/18/25 from 1:15 P.M. through 2:00 P.M., with Maintenance Director (MD) #255, revealed Resident #28's room was 83.3 degrees Fahrenheit (F), Resident #33's room was 82.3 degrees F, and Resident #38's room was 82.6 degrees F. MD #255 stated that Resident #38's room was hot because the window was cracked. MD #255 proceeded to check the air temperature at the window, which was 71.0 degrees F. MD #255 verified all of the room temperatures exceeded 81 degrees F. Interview on 08/18/25 at 1:18 P.M. with Resident #39 revealed she removed her clothing before going to bed because it was too hot. Resident #39 also stated she used cold water to cool off when it was hot at night. Interview on 08/18/25 at 1:44 P.M. with Resident #38 revealed his window was cracked open because it was so hot last night in his room. Resident #38 stated that it was cooler outside, so he cracked the window. Interview on 08/18/25 at 2:44 P.M. with Resident #27 revealed her room was hot because there was no air conditioning and she sometimes she slept with no clothing on to help keep her cooler. Interview on 08/18/25 at 3:18 P.M. with Maintenance Assistant (MA) #202 revealed the air conditioner chiller had gone out on the unit that cooled the 400 and 500 halls at the end of July 2025 and it had not been repaired yet. Interview on 08/19/25 at 2:55 P.M. with Resident #30 revealed his room was very hot and he was not offered an air conditioner for his room. Resident #30 stated the air conditioning had been broken for weeks. Interview on 08/19/25 at 4:49 P.M. with Certified Nursing Assistant (CNA) #266 revealed the air conditioning did not work on the 400 and 500 halls. CNA #266 stated that the air conditioner had gone out about a month ago, then worked, then stopped again. Review of the facility policy titled, Loss of Heating or Cooling, dated 2024, revealed the policy of the facility was to take immediate actions when the facility's heating or cooling was inoperable in order to maintain temperatures within the facility at 71to 81 degrees Fahrenheit. Review of the facility policy titled Extreme Heat, dated 2024, revealed the policy was to ensure that during times of extreme heat, mitigation strategies were implemented to protect residents, staff, and visitors from extreme heat events. 2. Interview on 08/18/25 at 11:49 A.M. with the Administrator revealed the 100, 200 and 300 halls did not have hot water available for the residents in their rooms. The Administrator stated there was hot water available on the 400 and 500 halls, including the 500-hall shower room. The Administrator stated several companies had been out to look at the hot water issue, but it had not been fixed yet. Interview on 08/18/25 at 1:30 P.M. with MD #255 revealed that around 08/01/25, he was told by a CNA that there was no hot water in the 200-hall shower room. MD #255 stated he went down to the shower room and confirmed the water was cold. Interview on 08/19/25 at 8:53 A.M. with Resident #22 revealed the hot water in her bathroom sink had been out for three weeks or more. Resident #22 stated she was not able to take bed baths or wash up if she wanted to. Resident #22 stated the shower room was busy, and she needed assistance to take showers. Observation of water temperatures on 08/19/25, beginning at 11:40 A.M. with the Administrator, revealed Resident #22's bathroom sink hot water temperature was 73.5 degrees F, Resident #23's bathroom sink hot water temperature was 66.0 degrees F, the 200-hall shower room hot water temperature was 72.5 degrees F, Resident #31's bathroom sink hot water temperature was 69.8 degrees F, Resident #9's bathroom sink hot water temperature was 68.0 degrees F, and Resident #2's bathroom sink hot water temperature was 65.0 degrees F. The Administrator verified the water temperatures. Review of an estimate for the replacement of the hot water heater revealed it was dated 07/23/25. Further review revealed no evidence the facility took action related to the acceptance of the estimate to make needed repairs. This deficiency represents noncompliance investigated under Master Complaint Number 2589044 and Complaint Number 2566950.

CONCERN (F) 📢 Someone Reported This

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

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

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, review of food delivery invoices and review of facility policy, the facility failed to en...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, review of food delivery invoices and review of facility policy, the facility failed to ensure foods were properly stored and further failed to ensure dishes were clean and sanitized in a manner to prevent foodborne illness. This had the potential to affect all 42 residents residing in the facility. The facility census was 42. Finding include:1. Interview on 08/18/25 at 10:13 A.M. with the Administrator revealed the facility's freezer did not work. The Administrator stated an air compressor was received to repair the freezer, but the repair did not fix it. The Administrator stated the facility did not use frozen food at this time. Observation on 08/18/25 at 10:18 A.M. of the freezer revealed that it was empty and contained no food items. Further observation of refrigerator number two revealed foods that should have been stored in the freezer, including eight 32-ounce bags of carrots, one 40 count box of sausage patties, one 12-pound box of sliced beef, 12 pounds of turkey meat, a 10-pound box of fish patties, and three 40-ounce bags of corn.Interview on 08/18/25 at 10:19 A.M. with [NAME] #245 confirmed the fish patties, corn, carrots, sausage patties, turkey and beef were stored in the refrigerator and should have been stored in the freezer until they were pulled for use. [NAME] #245 stated all of those foods were delivered to the facility on [DATE] and had been in the refrigerator since delivery because the freezer did not work.Interview on 08/18/25 at 11:25 A.M. with Public Health Department (PHD) #303 revealed they inspected the facility last week and found that both of the facility's refrigerators exceeded the recommended maximum temperature of 41 degrees F. PHD #303 stated that dietary staff were making homemade pizzas that included eggs, cheese and sausage and the refrigerator that the pizzas were being held in prior to baking had a temperature of 50 degrees F. Observation on 08/18/25 at 12:32 P.M. of refrigerator number one revealed an internal temperature of 47 degrees F. The refrigerator contained a large box of ground beef and a large box of French toast. Further observation of refrigerator number two revealed an internal temperature of 43 degrees F. The refrigerator contained eggs, milk, fresh fruit, bread, fresh vegetables and the frozen food items identified above. Concurrent interview with [NAME] #245 verified the temperatures of refrigerator number one and two. Additionally, [NAME] #245 confirmed the boxes of ground beef and French toast should have been stored in a freezer.Review of the food vendor invoice, dated 08/14/25, confirmed the facility had sausage patties, sliced beef, and breaded fish delivered on that date. Review of the facility policy titled, Date Marking for Food Safety, undated, revealed that refrigerated, ready-to-eat, time/temperature control for food safety (for example, perishable food) foods should be held at a temperature of 41 degrees F or less. Review of the facility policy titled, Food Safety Requirements, undated, revealed the facility policy was to procure food from sources approved or considered satisfactory by federal, state and local authorities. Food would be stored in accordance with professional standards for food service safety. Foods that required refrigeration should be refrigerated immediately upon receipt or placed in the freezer, whichever was applicable. 2. Interview on 08/18/25 at 11:49 A.M. with the Administrator revealed the hot water in the kitchen had been turned off due to the ventilation. The Administrator verified there was no hot water available in the kitchen, but there was hot water on the 400 and 500 halls of the facility. The Administrator stated dietary staff boiled water to sterilize the pots and pans. Observation on 08/19/25 at 8:57 A.M. of the water temperatures in the kitchen with the Administrator revealed the sink near the coffee machine was 74.4 degrees Fahrenheit (F), the sink across from the stove was 74.9 degrees F, the three compartment sink had two faucets, with the one closest to the refrigerator being 74.9 degrees F and the second faucet water temperature being 70.4 degrees F. The Administrator verified the water temperatures. Observation on 08/18/25 from 12:31 P.M. through 12:50 P.M. revealed [NAME] #220 prepared the three-compartment sink to wash dishes. The first sink held water poured from a 33 gallon pan that had boiling water from the stove. [NAME] #220 poured pot and pan detergent directly from a one-gallon jug into the water in the first sink, without measuring the amount. The second sink contained plain hot water for rinsing. The third sink had cold water. [NAME] #220 proceeded to pour just under one-half of a full gallon sized jug of sanitizer into the water in the third sink. Further observation revealed [NAME] #220 tested the sanitation level in the third sink and the test strip read 400 parts per million (ppm), which was a dark blue color on the test strip. [NAME] #220 verified there was too much sanitizer in the water, noting the color on the test strip should be more of a green color, and stated he had no measuring devices to ensure appropriate chemicals were used to ensure safe sanitation of the dishes. Interview on 08/22/25 at 3:50 P.M. with Dietary Manager (DM) #944 revealed the hot water in the kitchen went out approximately one month ago. DM #944 stated the device to measure the chemical solutions for the three-compartment sink had been broken for a long time and staff did not have a way to measure cleaning or sanitation solutions to ensure safe and effective cleaning of the dishes. DM #944 confirmed dietary staff washed dishes in the three-compartment sink since the kitchen had no hot water to use the dishwasher. This deficiency represents noncompliance investigated under Master Complaint Number 2589044.

Jun 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

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and resident and staff interviews, the facility failed to ensure residents were treated with dign...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and resident and staff interviews, the facility failed to ensure residents were treated with dignity and respect. This affected one (#10) out of three reviewed for dignity and respect. The facility census was 49. Findings include: Review of the medical record for Resident #10 revealed an admission date of 05/30/25 with diagnoses of chronic obstructive pulmonary disease, edema, post-traumatic stress disorder, and essential (primary) hypertension. Review of the Discharge Return Anticipated Minimum Data Set (MDS) dated [DATE] revealed resident was cognitively intact. Resident required supervision assistance with all activities of daily living (ADL's). Review of the care plan dated 06/09/25 revealed resident had a potential for behavior problems related to anxiety and depression with interventions of administer medication as ordered, allow resident to discuss feelings, and approach/speak to resident in a calm voice. Interview on 06/10/25 at 2:23 P.M. with Resident #10 stated Certified Nursing Assistant (CNA) #235 was disrespectful while she was on the phone yesterday, 06/09/25. Resident #10 stated CNA #235 kept insisting she had to take a shower right then. Resident #10 told CNA #235 should would take a shower later. CNA #235 left and came back yelling at her again to take a shower. Resident #10 told CNA #235 she wanted to take her shower at a later time because she was on the phone. Resident #10 stated CNA #235 yelled at her to get off the phone, because it wasn't important. Resident #10 stated CNA #235 continued to yell and tell her to get a shower, so Resident #10 stated she started yelling back. Resident #10 stated Resident #10 tried to tell the Administrator but he said he would come and talk to her later. Resident #10 sated the Administrator never did talked to her about the incident. Interview on 06/10/25 at 3:15 P.M. with the Administrator stated he was not aware of Resident #10's accusations of a CNA #235 being rude, yelling and disrespectful to her. The Administrator stated Resident #10 did ask to speak with him earlier in the day and he told her not right now, that he would talk to her later. The Administrator stated Resident #10's case manager was in the facility and she didn't report any concerns during the meeting. Interview on 06/11/25 at 8:35 A.M. with CNA #235 confirmed she was yelling at Resident #10 on 06/09/25 because she was far away from Resident #10 and wanted to know about her shower. CNA #235 stated she did tell Resident #10 to hang up the phone. CNA #235 confirmed she didn't believe Resident #10, so she told Resident #10 to get off the phone and told Resident #10 that the phone call wasn't important. This deficiency represents non-compliance investigated under Complaint Number OH00166394.

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medication record review, staff interview, and policy review, the facility failed to ensure a resident's pain was adequ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medication record review, staff interview, and policy review, the facility failed to ensure a resident's pain was adequately control. This affected one (#19) out of three residents reviewed for pain. The facility census was 49. Findings include: Review of the medical record for Resident #19 revealed an admission date of 05/22/25 with diagnoses of quadriplegia, essential (primary) hypertension, type 2 diabetes mellitus with hypoglycemia without coma, polyneuropathy and chronic obstructive pulmonary disease. Review of the care plan dated 05/22/25 revealed resident is at risk for pain related to diagnoses of polyneuropathy, history of displaced Bimalleolar fracture of the right lower extremity with interventions of administer medication as ordered, monitor for pain every shift, and notify physician as needed. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #19 had moderate cognitive impairment. Resident required supervision assistance with eating, oral hygiene, wheelchair mobility, required substantial assistance with bathing, personal hygiene, bed mobility, and transfers and resident was dependent on staff assistance with toileting hygiene and dressing. Review of Resident #19's physician order dated 05/22/25 revealed an order for Acetaminophen Tablet 325 mg give 2 tablet by mouth every 6 hours as needed for pain/discomfort. Review of Resident #19's physician order dated 05/23/25 revealed an order for Aspirin Oral Tablet 325 mg give 1 tablet by mouth one time a day for pain. Review of Resident #19's physician order dated 06/04/25 revealed an order for an appointment with the Pain Center on 06/26/25 at 2:15 P.M. for pain. Review of the progress note dated 06/04/25 at 3:57 P.M. revealed the Pain Center called facility stating Resident #19 has been accepted as a new patient and may now be scheduled. Appointment scheduled for 06/26/25 at 2:15 P.M. Review of the pain levels revealed on 06/09/25 at 9:51 A.M. revealed Resident #19 reported a pain level of a seven out of 10. On 06/10/25 at 8:11 A.M. Resident #19 reported a pain level of eight out of 10. Review of the Medication Administration Record (MAR) for June 2025 revealed Resident #19 did not receive any pain medication on 06/09/25 at 9:51 A.M. and resident did not received pain medication 06/10/25 at 8:11 A.M. Further review of Resident #19's medical record revealed there was no documentation on non-pharmacological pain interventions being offered/implemented. Interview on 06/11/25 at 1:28 P.M. with the Director of Nursing (DON) confirmed Resident #19 had a pain level on 06/09/25 at 9:51 A.M. of seven and did not receive any pain medication. The DON also confirmed on 06/10/25 at 8:11 A.M. had a pain level of eight and did not receive any pain medication. The DON confirmed there was no documentation on non-pharmacological pain interventions being offered/implemented. The DON confirmed Resident #19 is receiving a daily Aspirin 325 mg but that is not for pain and should not be listed with a diagnoses of pain. The DON confirmed Resident #19 has not received any pain medication since admission. The DON confirmed Resident #19 has pain and is going to be seen at the pain clinic on 06/26/25. Review of the Pain Assessment and Management Policy dated March 2015 revealed the purposes is to help the staff identify pain in the resident, and to develop interventions to meet the resident's goals. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

CONCERN (D) 📢 Someone Reported This

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

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interviews, and policy review, the facility failed to ensure Resident #10's medications we...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interviews, and policy review, the facility failed to ensure Resident #10's medications were administered as ordered and failed to ensure Resident #46's pain medication was timely reordered/available for administration. This affected two (#10 and #46) out of six residents reviewed for medication administration. The facility census was 49. Findings include: 1. Review of the medical record for Resident #10 revealed an admission date of 05/30/25 with diagnoses of chronic obstructive pulmonary disease, edema, post-traumatic stress disorder, and essential (primary) hypertension. Review of the care plan dated 05/30/25 revealed Resident #10 is at risk for altered cardiac output related to diagnosis of hypertension with interventions of administer medication as ordered and obtain Vital signs as ordered and as needed (PRN). Notify physician as needed. Review of the Discharge Return Anticipated Minimum Data Set (MDS) dated [DATE] revealed Resident #10 was cognitively intact. Resident required supervision assistance with all activities of daily living (ADL's). Review of Resident #10's hospital Continuity of Care form for discharge back to the facility dated 06/05/25 revealed and order for Olmesartan Medoxomil Oral Tablet 20 mg give 1 tablet by mouth one time a day for hypertension hold for systolic blood pressure of 100 or less. Review of Resident #10's physician orders revealed an order dated 06/06/25 at 6:00 A.M. for Olmesartan Medoxomil Oral Tablet 20 mg give 1 tablet by mouth one time a day for hypertension hold for systolic blood pressure of 100 or less. Review of the documented blood pressures for Resident #10 revealed on 05/30/25 at 12:52 P.M. the resident's blood pressure was 129/75, on 06/06/25 at 4:42 A.M. the resident's blood pressure was 136/73, and on 06/10/25 at 11:11 A.M. the resident's blood pressure was 136/73. Review of the medication administration record for June 2025 revealed on Resident #10's Olmesartan Medoxomil Oral Tablet 20 mg 1 tablet was administered to the resident with no blood pressure listed on 06/06/25 at 6:00 A.M., on 06/07/25 at 6:00 A.M., on 06/08/25 at 6:00 A.M., on 06/09/25 at 6:00 A.M. and on 06/10/25 at 6:00 A.M. Interview on 06/11/25 at 1:28 P.M. with the Director of Nursing (DON) confirmed Resident #10 had an order when she returned from the hospital dated 06/06/25 for Olmesartan Medoxomil Oral Tablet 20 mg give 1 tablet by mouth one time a day for hypertension hold for systolic blood pressure of 100 or less. The DON confirmed that blood pressures were not monitored when medication was administered. 2. Review of the medical record for Resident #46 revealed a re-admission date of 05/31/25 with diagnoses of right lower quadrant pain, schizoaffective disorder, bipolar type, anxiety disorder, and essential (primary) hypertension. Review of the care plan dated 04/18/24 revealed Resident #46 was at risk for pain related to hemiplegia with interventions of administer medication as ordered monitor for pain every shift, and notify physician as needed. Review of the Discharge Return Anticipated MDS dated [DATE] revealed Resident #46 was independent regarding tasks of daily life. Resident #46 required supervision assistance with eating, oral hygiene, bed mobility, transfers, and wheelchair mobility and required partial assistance with toileting hygiene, bathing, dressing, and personal hygiene. Resident #46 received scheduled pain medication regimen and received as needed pain medications. Review of Resident #46's physician order dated 05/21/25 revealed an order for Norco Oral Tablet 5-325 mg give one tablet by mouth every six hours for Pain. Review of the progress notes revealed a note dated 06/06/25 at 1:52 P.M. revealed Tylenol Oral Capsule 325 mg two tablets given due to complaints of pain in back. Review of the progress notes revealed a note dated 06/06/25 at 6:41 P.M. revealed Norco Oral Tablet 5-325 mg medication on order, contacted physician and pharmacy for estimated time of arrival (ETA). Review of the progress notes revealed a note dated 06/06/25 at 10:38 P.M. revealed Tylenol Oral Capsule 325 mg two tablets given for pain. Ineffective, follow-up pain level six out of 10. Review of the progress notes revealed a note dated 06/06/2025 at 11:00 P.M. revealed Norco Oral Tablet 5-325 mg medication not available. Review of the progress notes revealed a note dated 06/07/25 at 05:11 A.M. revealed Norco Oral Tablet 5-325 mg medication not available. Review of the progress notes revealed a note dated 06/09/25 at 12:28 P.M. regarding Norco Oral Tablet 5-325 mg, left a message for physician regarding the need for a new script. Review of the progress notes revealed a note dated 06/09/25 at 1:24 P.M. revealed Tylenol Oral Capsule 325 mg two tablets given for complaints of pain. Review of the progress notes revealed a note dated 06/09/25 at 4:52 P.M. revealed Tylenol Oral Capsule 325 mg two tablets given was effective with a follow up pain level of three out of 10. Review of the progress notes revealed a note dated 06/09/25 at 5:00 P.M. regarding Norco Oral Tablet 5-325 mg, awaiting new order from the physician. Review of the progress notes revealed a note dated 06/10/25 at 2:58 A.M. regarding Norco Oral Tablet 5-325 mg, awaiting medication delivery. Review of the progress notes revealed a note dated 06/10/25 at 6:34 A.M. regarding Norco Oral Tablet 5-325 mg, awaiting medication delivery. Review of the progress notes revealed a note dated 06/10/25 at 1:07 P.M. regarding Norco Oral Tablet 5-325 mg, medication unavailable awaiting delivery from pharmacy. Review of the Controlled Drug Record for Resident #46 revealed the last Norco 5-325 mg tablet was last administered on 06/05/25 at 12:21 P.M. Interview on 06/10/25 at 1:38 P.M. with Registered Nurse (RN) #293 confirmed Resident #46 has been without Norco 5-325 mg for a week and the resident has stomach pain. Interview on 06/10/25 at 1:40 P.M. with Nurse Practitioner (NP) #289 confirmed she was not aware of Resident #46 being out of Norco 5-325 mg tablets since 06/05/25. Review of the Administering Medications policy dated 12/2012 revealed medications will be administered in a safe and timely manner, and as prescribed. This deficiency represents non-compliance investigated under Master Complaint OH00166390 and Complaint OH00166394.

CONCERN (E) 📢 Someone Reported This

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

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

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

Based on observations, resident and staff interviews, and policy review, the facility failed to maintain a comfortable and home-like environment by ensuring heating/air conditioning units in resident ...

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Based on observations, resident and staff interviews, and policy review, the facility failed to maintain a comfortable and home-like environment by ensuring heating/air conditioning units in resident rooms were properly functioning. This affected five (#10, #12, #35, #36, and #43) out of ten residents reviewed for complaints of air conditioning not working. The facility census was 49. Findings include: Interview on 06/10/25 at 8:36 A.M. with Resident #12 stated the heating/air conditioner unit does not work in her room. Interview on 06/10/25 at 9:25 A.M. with Maintenance Supervisor (MS) #212 stated the heating/air conditioning units in all residents rooms are working. MS #212 confirmed resident could control the heating/air conditioning in their rooms. Interview on 06/10/25 at 9:31 A.M. with Resident #35 stated the heating/air conditioner unit does not work in his room. Interview on 06/10/25 at 9:43 A.M. with Resident #10 stated the heating/air conditioner unit does not work in her room. Interview on 06/10/25 at 10:04 A.M. with Resident #36 stated the heating/air conditioner unit does not work in his room. Interview on 06/10/25 at 10:46 A.M. with Resident #43 stated the heating/air conditioner unit does not work in her room. Observations and interview on 06/11/25 at 11:53 A.M. with MS #212 confirmed the heating/air unit conditioning units in the Resident #10, #12, #35, and #43's room was not properly functioning. MS #212 confirmed the heating/air conditioning unit in Resident #36's room is working but not blowing strong enough and needs repaired as well. Review of the Room Temperatures policy dated 07/2020 revealed air conditioning repairs and/or modifications will be completed as soon as possible. This deficiency represents non-compliance investigated under Master Complaint Number OH00166394 and Complaint Number OH00166394. This deficiency represents ongoing noncompliance from the survey dated 06/04/25.

Jun 2025 1 deficiency

CONCERN (E) 📢 Someone Reported This

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

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

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

Based on medical record review, observation, resident interview, and staff interview the facility failed to ensure the building and furnishings were in good repair. This affected Resident #43 and the ...

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Based on medical record review, observation, resident interview, and staff interview the facility failed to ensure the building and furnishings were in good repair. This affected Resident #43 and the 19 residents residing in the in the 300/400 hall (#2, #3, #8, #10, #11, #14, #18, #21, #23, #28, #32, #37, #39, #41, #42, #43, #44, #45, and #46). The facility census was 47 residents. Findings include: 1.Review of the medical record for Resident #43 revealed an admission date of 02/17/25 with diagnoses including chronic obstructive pulmonary disease and bipolar disorder. Review of the Minimum Data Set (MDS) assessment for Resident #43 dated 05/21/25 revealed the resident had intact cognition and required assistance with activities of daily living (ADLs). Observation on 06/04/25 at 9:10 A.M. of Resident #43's room revealed there was a hole in the wall approximately 18 inches above the baseboard which measured approximately nine inches in diameter. Interview on 06/04/25 at 9:10 A.M. with Resident #43 confirmed the hole in his wall had been there when he was admitted to the facility in February 2025. Resident #43 confirmed he asked facility staff if they would repair the hole, but it had not yet been repaired. Resident #43 confirmed overall the facility was in poor repair. Interview on 06/05/25 at 9:25 A.M. with Licensed Practical Nurse (LPN) # 605 confirmed there was a hole in the wall of Resident #43's room which should be repaired. Interview on 06/04/25 at 3:40 P.M. with the Administrator confirmed there was a hole in the wall of Resident #43's room which was caused by a power wheelchair. 3. Observation on 06/04/25 at 10:00 A.M. of the resident lounge area near the 400 hall revealed a built-in buffet cabinet which measured approximately 12 feet in length. Each end of the buffet had open areas below the counter measuring approximately three feet in diameter. There were missing baseboards, chipped wood, and multiple scuff marks to the buffet cabinet. Further observation revealed the drawers in the center of the buffet area were cracked and off-center. Interview on 06/04/25 at 10:00 A.M. with LPN #605 confirmed the built-in buffet area in the resident lounge was not in good repair and the cabinets looked like they were moldy. Interview on 06/05/25 at 10:48 A.M. with Maintenance Director (MD) #510 confirmed the cabinets needed some upkeep and had been in that poor condition since January 2025. Interview on 06/04/25 at 3:35 P.M. with the Administrator confirmed the cabinet/buffet area in the resident lounge was in disrepair and he considered closing the lounge to residents as an alternative to making the repairs or replacing the run-down furnishings in the lounge. 4.Observation on 06/04/25 at 3:30 P.M. revealed the walls of the 300 and 400 halls had numerous areas of broken trim near the baseboards of the hall and doorways of resident rooms. Several resident room doors were noted to be scuffed and had chipped paint. Interviews on 06/04/25 at 9:02 A.M. with Resident #19 and at 10:15 A.M. with Resident #7 confirmed the facility was in bad repair. Interview on 06/04/25 at 3:32 P.M. with the Administrator confirmed the broken trim and scuffed doors on the 300/400 hall. The administrator confirmed the trim was last repaired in January and if they repaired the trim, it would just be damaged again, so there was no point in repairing the areas. Interview on 06/04/25 at 4:50 P.M. with Administrator at 4:50 PM confirmed the facility did not have a policy regarding the physical environment. This deficiency represents noncompliance investigated under Complaint Number OH00164677.

Mar 2025 3 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected 1 resident

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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to administer medications per physicians orders. There were two medication errors out of 31 opportunities resulting in a 6.45 percent (%) medication error rate. This affected two (Residents #40 and #47) of three residents reviewed for medication administration. The facility census was 45. Findings include: 1. Review of the medical record for Resident #40 revealed an admission date of 09/14/23. Diagnoses included chronic obstructive disease, cystocele, overactive bladder, depression, cognitive communication, and anxiety disorder. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #40 was cognitively intact. Resident #40 required setup or clean up assistance for meals, and oral care. Resident #40 required supervision or touching assistance for bathing, dressing upper and lower body, toilet hygiene, personal hygiene, and placing shoes on and off feet. Review of physician orders for Resident #40 revealed there was no current order for medication Pyridium 100 mg. Review of the medication administration record for March 2025 revealed Resident #40 had a discontinued order for Phenazopyridines 100 mg take three times a day. The end date was 03/04/25. Observation and interview on 03/26/25 at 7:58 A.M. revealed Licensed Practical Nurse (LPN) #252 administered Pyridium 100 mg to Resident #40. Interview on 03/26/25 at 11:42 A.M. with LPN #252 verified no active order for Pyridium 100 mg. Interview on 03/26/25 at 1:00 P.M. with Regional Nurse (RN) #300 verified Resident #40 had an older order of Pyridium 100 mg. RN #300 stated it should not have been administered. 2. Review of the medical record for Resident #47 revealed an admission date of 09/10/15. Diagnoses included chronic kidney disease, paranoid schizophrenia, major depressive disorder, type diabetes, and asthma. Review of the MDS assessment dated [DATE] revealed Resident #47 was cognitively intact. Resident #47 required supervision or touching assistance meals, dress upper body, and oral care. Resident #47 required partial moderate assistance, dress lower body, putting on and off shoes, and bathing. Resident #47 required substantial to maximal assistance for toileting hygiene, and personal hygiene, and toileting hygiene. Review of physician orders revealed an order for Linagliptin 5 mg take one tablet for diabetes at 8:00 A.M. Observation on 03/26/25 at 8:05 A.M. with LPN #252 did not administer Lingliptin 5 mg during medication administration. Interview on 03/26/25 at 11:42 A.M. LPN #252 verified she did not administer Lingliptin 5 mg as ordered. Review of facility document titled, Medication Administration-General Guidelines, dated 11/2018 revealed medication is administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. This deficiency represents non-compliance investigated under Master Complaint Number OH00163987 and Complaint Number OH00163208.

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, interview, and policy review, the facility failed to ensure medications were stored...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, interview, and policy review, the facility failed to ensure medications were stored in a safe manner. This affected one (Resident #19) of one resident observed for medication storage. The facility census was 45. Findings include, Medical record review for Resident #19 revealed he was admitted to the facility on [DATE]. His diagnoses included alcohol dependent withdrawal, emphysema, anxiety disorder, major depressive disorder, polycythemia, chronic obstructive pulmonary disease (COPD), asthma, hypokalemia, foot drop, irritable bowel syndrome, delusional disorder, acute respiratory failure, acute kidney failure, pleural effusion, and acute respiratory failure with hypoxia. Review of Minimum Date Set (MDS) assessment, dated 03/18/25, revealed Resident #19 had a Brief Interview for Mental Status (BIMS) of 15 and this indicated he was cognitively intact. Resident #19 required set up, clean up assistance for meals, and oral care. Resident #19 required supervision or touching with dressing upper and lower body, placing shoes on and off feet, bathing, personal hygiene, and toileting. Resident #19 was dependent on staff for medication administration. Interview and observation on 03/26/25 at 8:43 A.M. with Resident #19 in his room revealed he was seated in his wheelchair. Resident #19 had the following bottles of medication in his room; milk [NAME], St. [NAME]- [NAME], two bottles of zinc, a large bottle of B Vitamins, and a large container of soy lectin. Interview and observation on 03/26/25 at 8:53 A.M. with Registered Nurse (RN) #213 confirmed Resident #19 had the following medications and fertilizer in his room; Resident #19 had the following bottles of medication in his room; milk [NAME], St. John's-[NAME], two bottles of zinc, a large bottle of B Vitamins, and a large container of soy lectin. Review of the facility policy titled, Storage Medications, dated 2001, confirmed the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Drugs and biologicals shall be stored in the packaging, containers, or other dispensing systems in which they are received. Further review of the policy confirmed the nursing staff shall be responsible for maintain medication storage.

CONCERN (F) 📢 Someone Reported This

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

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

Safe Environment (Tag F0921)

Could have caused harm · This affected most or all residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility policy review, the facility failed to provide a clean, homelike environment with w...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility policy review, the facility failed to provide a clean, homelike environment with working showers. This had the potential to affect all residents. The facility also failed to provide a clean floor for Resident #36. The facility census was 45. Findings include: 1. Interview and observation on 03/26/25 at 9:00 A.M. with Licensed Practical Nurse (LPN) #255 confirmed the 500-hallway shower room was the only shower room used by all residents in the facility. LPN #255 confirmed the first two shower room stalls were not functioning. She confirmed the dirt, debris, and trash scattered all over the floor of the shower room. LPN #255 confirmed the lights in the 500-hall shower room contained multiple brown items that appeared to be bugs. LPN #255 confirmed the bathroom stall had a sign that read, Do Not Use, dated 01/22/25. LPN #255 opened the bathroom stall door next to the shower stall and the toilet had various pieces of colored tape on it. The toilet contained black water. Interview and observation on 03/26/25 at 9:05 A.M. with the Maintenance Supervisor (MS) #231 confirmed the first shower room on the 200-hall did not have a handle on it and was unlocked. The sign on the door read, Out of Order-Use 500 hall shower. He confirmed when you opened the shower door, a bag with trash all around it was lying on the floor in water. The floor was approximately 50% covered with a foot of stagnated water. Across from the shower stall a fountain of running water from the ceiling was running down. The wall was covered with a brown stain and black dotted substance all along the wall. Active gnats were flying around the water. Water was pouring from the ceiling and down the wall. The ceiling had brown stains and black dotted substance all over it. MS #231 confirmed the second 200-hallway bathroom had lights; however, the electric was turned off. MS #231 used a flashlight to confirm the bathroom was full of various chairs and the walk-in tub had dried brown debris and dirt all over it. MS #231 confirmed the 200-hall bathroom had the water turned off all the equipment in the bathroom. Review of the facility policy titled, Maintenance Policy and Procedure, dated 01/01/18, confirmed all maintenance repairs and request need a work order filled out and submitted to maintenance. Maintenance will attempt to make repairs and if unable will use an outside contractor. Maintenance will follow up on the status of repairs. 2. Review of the medical record revealed Resident #36 was admitted [DATE]. Diagnoses included type two diabetes, major depressive disorder, chronic obstructive pulmonary disease, anxiety disorder, and adjustment disorder with depressed mood. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 was cognitively impaired. Resident #36 required supervision or touching assistance for meals, oral care, dress upper body, and personal hygiene. Resident #36 required partial moderate assistance toileting hygiene, personal hygiene, bathing, dressing lower body, and putting on and off shoes. Observation on 03/26/25 at 8:45 A.M. with Resident #36 during a medication pass, revealed Licensed Practical Nurse (LPN) #252 was walking around in the resident's room, shoes were sticking to the floor, and made a very loud sticking noise. Interview on 03/26/25 at 8:50 A.M. with LPN #252 verified her shoes were sticking to Resident's #36 floor. LPN #252 stated she will let someone know. Interview and observation on 03/26/25 at 5:30 P.M. with Regional Nurse (RN) #300 verified Resident #36's floor was was sticky and made a loud noise when walking on. RN #300 walked around the bed, and the room to understand why floor was so sticky. RN #300 stated it was possibly the chemical cleaner. Review of the facility document, CDC Environment Checklist for Monitoring Terminal Cleaning, undated, revealed facility check off list required floor to be cleaned and disinfection by sweeping the floor before wet mopping, then with wet mop, start to the furthest from the door, half of room first, then the other half to complete. This deficiency represents non-compliance investigated under Master Complaint Number OH00163987.

Feb 2025 3 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of facility policy, the facility failed to ensure a comfortable environment. This af...

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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 a comfortable environment. This affected one (Resident #46) of three residents reviewed for comfortable temperatures. The facility census was 48. Findings include: Review of medical records for Resident #46 revealed the resident admitted to the facility on [DATE]. Diagnoses included psychosis, anxiety disorder, type two diabetes, and schizoaffective disorder bipolar type. Review of annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #46 had a Brief Interview of Mental Status (BIMS) score of three, indicating he was severely cognitively impaired. Resident #46 required supervision and touching for meals, personal hygiene, toileting, bathing, placing shoes on and off, dressing upper and lower body, and oral care. Observation on 02/26/25 from 9:53 A.M. through 10:20 A.M. of Resident #46's room revealed the door was open and the temperature was 66 degrees Fahrenheit. There was a heater outside the door set to 103 degrees. Interview on 02/26/25 at 10:01 A.M. with Housekeeping Technician (HT) #212 stated the facility installed the new heating and a/c units in the rooms and had not finished the final connection to the outside condenser because the facility had to find a drill bit that would break through to the outside throw steel in the wall to connect to the outdoor condenser. At this time the new units were not working and still using the old heater in the hallways to heat resident rooms. Interview on 02/26/25 at 10:15 A.M. with Certified Nurse Aide (CNA) #319 verified Resident #46's room was very cold, and was not sure why the heat was not working. CNA #319 stated that the residents keep their doors open to hallway for the heat to go in their room. Interview on 02/26/25 at 10:17 A.M. with the Administrator verified with a laser thermometer that Resident #46's room was 66 degrees Fahrenheit. The Administrator stated he would have it fixed by the end of the day. Review of the facility policy titled, Extreme Cold Policy and Procedure, dated 01/01/16 revealed when facility internal temperature drops below 71 degrees, the facility will implement procedure due to residents had a higher risk for hypothermia when the environment temperature was below 65 degrees for four consecutive hours. This deficiency represents non-compliance investigated under Master Complaint Number OH00162643 and Complaint Number OH00161961.

CONCERN (D) 📢 Someone Reported This

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

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

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

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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 ensure medications were administered as ordered. This affected one (Resident #44) of three residents reviewed for medication administration. The facility census was 48. Findings include: Review of medical records for Resident #44 revealed an admission date on 08/24/21. Diagnoses included chronic obstructive pulmonary disease, heart disease, delusional disorder, and chronic pain. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #44 had a Brief Interview of Mental Status (BIMS) score of 15 indicating he was cognitively intact. Resident #44 had required extensive bed mobility assistance, one-person physical assist for bed mobility, transfers in bed mobility, and toileting hygiene. Review of the plan of care dated 12/18/24 revealed Resident #44 was at risk for pain related to muscle spasm, post procedural pain, and chronic pain. Interventions included to administer medication as ordered. Review of physician order dated 12/13/24 revealed Resident #44 had an order for Oxycodone Hcl 5 milligram (mg) take one tablet two times a day. Review of the Medication Administration Record (MAR) for month of February 2025 revealed Resident #44 did not receive Oxycodone Hcl 5 mg on 02/19/25 at 9:00 A.M. and 9:00 P.M. Review of progress note dated 02/19/25 by Licensed Practical Nurse (LPN) #259 revealed awaiting Oxycodone 5 mg delivery from pharmacy. Review of progress note dated 02/19/25 revealed Resident #44 currently out of Oxycodone 5 mg supply, pharmacy awaiting new script, provider made aware. Interview on 02/26/25 at 10:59 A.M. with the Director of Nursing (DON) verified on 02/19/25, Resident #44 had run out of Oxycodone Hcl 5 mg and this was placed in the book for the physician to review on 02/18/25. The DON reported the new prescription was ordered timely. The DON also verified the emergency drug kit supply could not be pulled to administer pain medication on 02/19/25. Review of the facility policy titled, Medication Administration General Guidelines, dated 01/2018 revealed medications are administered as prescribed in accordance with good nursing practices and only by persons legally authorized to do so. This deficiency represents non-compliance investigated under Complaint Number OH00161961.

CONCERN (D) 📢 Someone Reported This

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

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

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected 1 resident

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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, staff interview, and review of facility policy, the facility failed to ensure the facility was free from medication error rate less than 5%. A total of 30 opportunities were observed with two errors observed, resulting in a 6.6% medication error rate. This affected one resident (#44) of three residents reviewed for medication administration. The facility census was 48. Findings include: Review of medical records for Resident #44 revealed an admission date on 08/24/21. Diagnoses included chronic obstructive pulmonary disease, heart disease, delusional disorder, and chronic pain. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #44 had a Brief Interview of Mental Status (BIMS) score of 15, indicating he was cognitively intact. Resident #44 required extensive bed mobility assistance, one-person physical assist for bed mobility, transfers in bed mobility, and toileting hygiene. Review of physician order dated 08/20/24 revealed Resident #44 had an order for Magnesium Hydroxide oral suspension take 10 milliliter (ml) one time a day for laxative. Review of physician order dated 08/20/24 revealed Resident #44 had an order for folic acid 1 milligram (mg) take one tablet by mouth one time a day. Observation 0n 02/27/25 at 9:09 A.M. revealed Licensed Practical Nurse (LPN) #288 administered one Magnesium Oxide 400 mg tablet and one Folic Acid 400 micrograms (mcg) tablet to Resident #44. Interview on 02/27/25 at 12:20 P.M. with LPN #288 verified she administered Magnesium Oxide 400 mg in tablet form and Resident #44 had an order for liquid form. Furthermore, LPN #288 verified Resident #44 had Folic Acid 400 mcg administered in pill form and should have had Folic Acid 1 mg in tablet form. Observation on 02/27/25 at 12:20 P.M. with LPN #288 and the Director of Nursing (DON) revealed Magnesium Hydroxide oral suspension in liquid was found in the medication cart and should have been given to Resident #44. Review of the facility policy titled, Medication Administration General Guidelines, dated 01/2018 revealed medications are administered as prescribed in accordance with good nursing practices and only by persons legally authorized to do so. This deficiency represents non-compliance investigated under Complaint Number OH00161961.

Jan 2025 1 deficiency

CONCERN (E) 📢 Someone Reported This

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

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

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interviews, review of the facility census and review of facility policy, the facility f...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interviews, review of the facility census and review of facility policy, the facility failed to ensure air temperatures were maintained within comfortable ranges for residents residing on the secure behavioral unit (100 hall). This had the potential to affect 13 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, and #13) residents who resided on the secure behavior unit (100 hall). The census was 49. Findings include: Observation of the secure behavioral unit (100 hall) on 01/21/25 from 4:16 P.M. to 4:30 with Maintenance Director (MD) #110 and the Administrator revealed air temperatures were below 71 degrees Fahrenheit (F). A check of room air temperatures revealed room [ROOM NUMBER] was at 43.6 degrees F, room [ROOM NUMBER] was at 55 degrees F, and room [ROOM NUMBER] was at 51.1 degrees F. The air temperature in all 12 rooms ranged from 43.6 F to 55 F. Two portable heating units were present in the hallway. Residents were observed in the secure behavioral unit and no residents were observed in distress. Interview with MD #110 and the Administrator during tour confirmed air temperatures were not at comfortable levels MD #110 stated resident room heater were working, but not able to keep up with current low outside temperatures. MD #110 and the Administrator confirmed there are 13 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10,#11, #12, and #13) residents residing on the secure behavioral unit (100 hall) that could potentially be affected by the temperatures. During an interview on 01/21/25 at 4:23 P.M. Resident #4 stated it's cold in here. Review of facility census revealed 13 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10,#11, #12, and #13) residents reside on the secure behavioral unit (100 hall). Review of the facility's policy titled Room Temperature dated revised July 2020 revealed it is the policy of this procedure to maintain safe and comfortable room temperatures in all resident rooms and resident areas. Every reasonable attempt will be made to maintain room temperatures in all resident rooms between 71-81 degrees F. This deficiency represents non-compliance investigated under Complaint Number OH00161777.

Dec 2024 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0745 (Tag F0745)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and resident, staff and physician office staff interviews, the facility failed to provide medical...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and resident, staff and physician office staff interviews, the facility failed to provide medically-related social services by failing to provide assistance with a resident's medical appointments to an outside provider. This affected one (#21) of three residents reviewed for medical appointments. The facility census was 51. Findings include Medical record review for Resident #21 revealed an admission on [DATE] with diagnoses including but not limited to congestive obstructive pulmonary disease, chronic pain, hypertension, and depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #21 revealed the resident had intact cognition. Resident #21 required set up or clean up assistance for eating, supervision or touching assistance for toileting, bed mobility and transfers. Review of the Resident Appointment Sheet for Resident #21 revealed an appointment for unknown physician on 10/17/24 with a pickup time scheduled for 1:45 P.M. Review of the Resident Appointment Sheet for Resident #21 revealed an appointment for heart and vascular physician on 10/28/24 with a pickup time scheduled for 11:02 A.M. Review of the progress notes for Resident #21 dated 10/13/24 to 10/30/24 was silent for any appointment documentation for 10/17/24 or 10/28/24 related to departures, returns or order changes. Review of the after-visit summary for Resident #21 dated 11/04/24 revealed the resident was seen for a follow-up appointment related to post aortic aneurysm repair and to discuss next surgical procedure for a thoracic nonvascular aortic repair. Further review of the document for Resident #21 revealed the physician reviewed the computed tomography (CT) scan completed on 10/17/24. Interview on 11/12/24 at 9:47 A.M. with Facility Administrative Staff #122 assigned to complete transportation arrangements states Resident #21 went to his appointment on 10/17/24, but the physician rescheduled the appointment on 10/28/24 to 11/04/24. Interview on 11/12/24 at 12:20 P.M. with Resident #21 stated he must have another surgery, and the facility is messing up the appointments that need to take place before he can have his next surgery for his aneurysm repair. Interview on 11/12/24 at 1:38 P.M. with Transportation Staff #206 verified transportation was scheduled for 10/28/24 for Resident #21. Transportation Staff #206 stated the appointment was not completed as scheduled and was canceled by transportation staff on 10/29/24. Transportation Staff #206 was unable to provide any additional documentation for the cancellation as none was listed in their system regarding a reason for the cancellation. Interview on 11/12/24 at 1:59 P.M. with Registered Nurse (RN) #208 verified she was the Office Manager for the cardiologist that Resident #21 was scheduled to seen on 10/28/24. RN #208 stated she called the facility on 10/23/24 for Resident #21 to verify the appointment on 10/28/24 as they have had problems in the past with no calls and no shows. RN #208 verified the appointment was not canceled by the office or the physician and Resident #21 was a no call or no show for the appointment on 10/28/24. Interview on 11/12/24 at 4:25 P.M. with Administrator and the Director of Nursing (DON) verified the facility did not have any documentation in the medical record for the scheduled appointments for Resident #21 and should have. The Administrator and DON could not provide information as to why Resident #21's cardiologist appointment scheduled for 10/28/24 was canceled. This deficiency represents non-compliance investigated under Complaint Number OH00159497.

CONCERN (D) 📢 Someone Reported This

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

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, staff and pharmacist interviews and policy review, the facility failed to ensure m...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, staff and pharmacist interviews and policy review, the facility failed to ensure medications were administered according to physicians orders, failed to ensure licensed nursing staff accurately documented the administration of medications in the medical record and failed to ensure medications were re-ordered/available from the pharmacy. This affected two (#52 and #21) of three reviewed for medication administration. The facility census was 51. Findings include 1. Medical record review for Resident #52 revealed an admission on [DATE]. Diagnoses include hydronephrosis, anemia, gastroesophageal reflux disease, benign prostatic hyperplasia, obstructive uropathy, thyroid disorder, anxiety, and schizophrenia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #52 revealed the resident had impaired cognition. Resident #52 required maximum assistance for eating, toileting, and moderate assistance for transfers and bed mobility. Review of the plan of care for Resident #52 revealed resident has potential for behavior problems related to anxiety and schizoaffective disorder (bipolar type). Interventions include administer medication as ordered, allow resident to discuss feelings, approach/speak to resident in a calm voice, encourage resident to attend activities of choice, and psych/counseling services as needed. Review of the hospital discharge medication orders for Resident #52 dated 10/02/24 revealed an order for Clonazepam one milligram (mg) take two tablets by mouth at bedtime. Additionally, the orders revealed a second order for clonazepam one mg take two tablets by mouth two times a day dated 10/02/24. Review of the facility's medication administration record (MAR) for Resident #52 for the month of October 2024 revealed an order dated 10/02/24 for Clonazepam 0.5 mg give two tablets by mouth at bedtime to treat seizures. Review of the controlled drug record for Resident #52 revealed an order for Resident #52 revealed the facility received ten tablets of clonazepam 1 mg tablets with written instructions stating to take two tablets by mouth at bedtime for five days on 10/03/24. Further review of the controlled drug record for Resident #52 revealed on 10/03/24 at 9:00 A.M., and 10/07/24 at 9:00 P.M. Resident #52 received only one tablet instead of the two prescribed for administration. Interview on 11/07/24 at 12:20 P.M. with Pharmacist #200 verified the facility was only sent ten tablets of Clonazepam on 10/03/24. Pharmacist #200 stated the pharmacy did not receive any request to remove the prescribed medication from the emergency box. Interview on 11/07/24 at 3:30 P.M. with the Director of Nursing (DON) verified the admission orders for Resident #52 were not transcribed as ordered on the day of admission for the clonazepam. DON verified Resident #52 did not receive his clonazepam as ordered two times a day and only the nighttime dose was administered by the facility. DON further verified Resident #52 did not receive the correct dose of clonazepam on 10/03/24 and 10/07/24 as only one tablet was signed off on the controlled drug record. DON verified the medication administration record for Resident #52 was signed off as given eleven times, and the signatures for the nurse's documenting medication was administered on 10/05/24 at 9:00 A.M., 10/05/24 at 9:00 A.M., 10/06/24 at 9:00 A.M., 10/07/24 at 9:00 P.M., 10/08/24 at 9:00 A.M., 10/08/24 at 9:00 P.M., 10/09/24 at 9:00 A.M., 10/09/24 at 9:00 P.M., 10/10/24 at 9:00 A.M. and 10/10/24 at 9:00 A.M. were not located on any controlled drug record for Resident #52. DON verified the pharmacy sent 10 tablets of clonazepam on 10/11/24 and thirty tablets on 10/15/24 to the facility that were destroyed. DON verified the facility nurses did not contact the pharmacy for authorization for the clonazepam to be removed from the facility emergency box. Review of the facility policy titled Adverse Consequences and Medication Errors', dated 04/2014 stated a medication error is defined as the preparation or administration of drugs which is not in accordance with physicians' orders. 2. Medical record review for Resident #21 revealed an admission on [DATE] with diagnoses including but not limited to congestive obstructive pulmonary disease, chronic pain, hypertension, and depression. Review of the quarterly MDS assessment dated [DATE] for Resident #21 revealed the resident had intact cognition. Resident #21 required set up or clean up assistance for eating, supervision or touching assistance for toileting, bed mobility and transfers. Resident #21 is on scheduled pain medications and received as needed pain medication during the assessment period. Review of the plan of care dated 08/29/2023 and revised 08/21/24 for Resident #21 revealed resident is at risk for addiction and drug seeking behaviors related to history of polysubstance abuse. Interventions include administer medication as ordered, administer Narcan as ordered, notify physician of suspected drug or alcohol use, observe resident for signs and symptoms opioid overdose. Review of the active physician's orders for Resident #21 revealed an order dated 08/18/24 for oxycodone oral tablet five mg, give one tablet by mouth every six hours as needed for pain and methocarbamol oral tablet 750 mg give one tablet by mouth every eight hours as needed for muscle spasms. Review of the November 2024 medication administration record for Resident #21 revealed the resident received oxycodone oral tablet five mg, give one tablet by mouth every six hours as needed for pain on ten occasions starting on 11/01/24 to 11/12/24. Resident #21 received methocarbamol 750 mg one time. Review of the controlled drug record for Resident #21 dated 11/01/24 to 11/12/24 revealed resident had received oxycodone oral tablet five mg, give one tablet by mouth every six hours as needed for pain revealed facility staff signed out thirty-one oxycodone tablets. Interview with the DON on 11/07/24 at 3:30 P.M. verified facility staff failed to document the administration of the oxycodone oral tablet five mg on 11/01/24 at 2:37 A.M., 11/01/24 at 9:00 P.M., 11/02/24 at 4:20 A.M., 11/02/24 at 9:00 A.M., 11/02/24 at 11:00 P.M., 11/03/24 at 9:30 P.M., 11/04/24 at 9:00 A.M., 11/05/24 at 8:00 A.M., 11/05/24 at 2:00 P.M., 11/05/24 at 9:30 P.M., 11/06/24 at 9:00 A.M., 11/06/24 at 2:40 P.M., 11/06/24 at 9:30 P.M., 11/08/24 at 10:55 P.M., 11/09/24 at 7:46 A.M., 11/09/24 at 2:46 P.M., 11/09/24 at 9:00 P.M., 11/10/24 at 7:46 A.M., 11/10/24 at 2:40 P.M., 11/10/24 at 9:00 P.M., 11/11/24 at 7:19 A.M., 11/11/24 at 2:22 P.M., and 11/11/24 at 9:00 P.M. in the electronic health record and should have. The DON further verified the staff should be documenting all medication administered in the electronic health record. Interview on 12/03/24 at 2:15 P.M. with LPN #67 verified the facility does not have any methocarbamol for Resident #21 at this time. LPN #67 stated if Resident #21 would ask for it they can get it from the emergency box. LPN #67 stated a refill request was sent to the pharmacy and staff was notified that insurance was not filling it for lack of coverage. LPN #67 was unable to provide documentation of non payment. LPN #67 verified he had administered the methocarbamol previously and did not document it on the MAR. Interview on 12/03/24 at 2:22 P.M. with Pharmacist #156 verified insurance would pay for Resident #21's methocarbamol medication as it was covered previously. Pharmacist #156 further stated there have not be any requests to refill Resident #21's methocarbamol from the facility or facility notification of non payment. Pharmacist #156 stated the facility was sent 90 tablets of the methocarbamol on 08/18/24. Interview on 12/03/24 at 2:26 P.M. with Corporate Registered Nurse (RN) #154 advised that insurance communication would trigger an email to the facility staff responsible to monitoring medications and she was not sure who was receiving it at this time. RN #154 stated the medication would be paid for by insurance. RN #154 verified the facility did not have the medication available at this time and if requested the nurse would be able to pull medication from the emergency box for administration. RN #154 verified the facility MAR for Resident #21 for the months of August 2024, September 2024, October 2024 and November 2024 only contained documentation of methocarbamol being administered four times and should have been 90 times. RN #154 verified the nurses were not documenting the administration of medication correctly. Review of the facility policy titled Adverse Consequences and Medication Errors, dated 04/2014 stated a medication error is defined as the preparation or administration of drugs which is not in accordance with physicians' orders and administration documentation per accepted professional standards. This deficiency represents non-compliance investigated under Complaint Numbers OH00159863, OH00159497 and OH00158906.

Jul 2024 19 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

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, staff interview, and review of facility policy, the facility failed to ensure residents were provided with dignity and respect. This affected two (#17 and #33) residents of the five residents reviewed for dignity and respect. The facility census was 52. Findings included: 1. Review of the medical record for Resident #33 revealed the resident was admitted on [DATE]. Diagnoses included type two diabetes, schizophrenia, candidiasis, cerebral infarction, and overactive bladder. Review of the plan of care dated 05/06/24, revealed Resident #33 had an indwelling catheter related to obstructive and reflux uropathy. Interventions included change catheter bag as needed, document urine output, observe catheter for any kinks, and staff to provide catheter care every shift. Review of Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #33 had Brief Interview Mental Status (BIMS) of 15 which indicated he was cognitively intact. Observation of Resident #33 in his bed on 07/08/24 at 1:50 P.M., revealed a very full urinary Foley bag hanging on right side of bed and visible from the hallway where other residents were walking by. Interview State Tested Nursing Assistant (STNA) #308 on 07/08/24 at 1:58 P.M., verified Resident #33's urinary catheter Foley bag was full, was visible by other residents and it did not have a dignity bag covering it. 2. Review of medical record for Resident #17 revealed the resident was admitted on [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), paranoid schizophrenia, major depression, and schizoaffective disorder. Review of MDS assessment dated [DATE] revealed Resident #17 had a BIMS of 10 which indicated she was cognitively impaired. Resident #17 required substantial maximal assistance for activities of daily living (ADLs). Review of the plan of care for Resident #17 dated 06/20/24, revealed the resident had a risk for decline in ADLs related to paranoid schizophrenia, COPD, heart disease, and osteoarthritis. Interventions included allowing time for rest breaks, encourage resident to participate while performing ADLs, staff to anticipate needs, and encourage the resident to attend activities and assist as needed. Observation of Resident #17 on 07/11/24 at 1:47 P.M., revealed the resident was seated in a wheelchair talking on the phone at the nurse's station with a blue hospital type gown on and it was not tied at the neck. Resident #17's hospital gown was draped low on her shoulders revealing her entire bare back. Resident #17's buttocks were also exposed and sticking out the back open side of the wheelchair. Other residents were observed passing by the nurse's station. Interview with Licensed Practical Nurse (LPN) #385 on 07/11/24 at 1:50 P.M., verified Resident #17 was seated in her wheelchair in the common area with her back and buttocks exposed. LPN #385 she would get an Aide to assist Resident #17. Continued observation of Resident #17 on 07/11/24 at 2:00 P.M., revealed the resident was seated in a wheelchair in the hallway with her back and buttocks still exposed as LPN #385 was brushing the resident's hair. Interview with LPN #385 at the same time, revealed she was waiting on an Aide to get Resident #17 and take her back to her room to get her dressed. Review of the facility document titled Residents Rights dated 10/03/23 revealed that the resident had the right to be treated at all times with courtesy, respect, dignity and individuality. This deficiency represents non-compliance investigated under Complaint Numbers OH00155134, OH00155040 and OH00154641. .

CONCERN (D)

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

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure the physician was notified of a resident's weight loss. This affected one (Resident #4...

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Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure the physician was notified of a resident's weight loss. This affected one (Resident #40) of two residents reviewed for nutrition. The facility census was 52. Findings include: Review of the medical record for Resident #40 revealed an admission date of 09/13/23. Diagnoses included type two diabetes, emphysema, hypertensive heart disease, hyperlipidemia, peripheral vascular disease, congestive heart failure, anxiety, major depressive disorder, and spinal stenosis. Review of the Minimum Data Set (MDS) assessment for Resident #40 dated 06/20/24 revealed the resident had intact cognition, weighed 151 pounds, and had experienced a significant weight loss. Review of the medical record for Resident #40 revealed the following weights: 179.6 pounds on 12/04/23, 167.7 pounds on 02/01/24, 172 pounds on 03/06/24, 164.2 pounds on 04/01/24, 151.4 pounds on 06/07/24. Resident #40 experienced a weight loss of 15.7 percent (%) in six-month period and an 11.9 % weight loss in a three month period. Review of the dietary progress note for Resident #40 dated 06/13/24 revealed the resident had a significant weight loss and was recommended to receive a house supplement twice per day. There was no documentation of physician notification of the significant weight loss. Review of the medical record for Resident #40 revealed it did not include documentation of physician notification of the resident's significant weight loss Interview on 07/15/24 at 1:30 P.M. with the Director of Nursing (DON) confirmed Resident #40 had experienced a significant weight loss but the resident's record did not include documentation of physician notification of the resident's significant weight loss Review of the facility policy titled Notification dated 01/11/20, revealed a nurse should notify the physician of a significant change in a resident's status which included unplanned significant weight loss which was defined as a loss of 5 % in 30 days or 10 % in 180 days.

CONCERN (D) 📢 Someone Reported This

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

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

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff and Guardian interview, observations, review of emergency room (ER) records, review of wit...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff and Guardian interview, observations, review of emergency room (ER) records, review of witness statements, review of Self-Reported Incidents (SRI's) and review of the facility policy, the facility failed to provide adequate supervision to prevent resident-to-resident sexual abuse. This affected two (#29 and #43) of the ten residents reviewed for abuse. The facility census was 52 residents. Findings include: 1. Review of the medical record for Resident #29 revealed the resident was admitted on [DATE]. Diagnoses included, but not limited to, hemiplegia and hemiparesis following a cerebrovascular disease, paranoid schizophrenia, schizoaffective disorders old myocardial infarction, seizure disorder, Bechet's disease, generalized anxiety, insomnia, bipolar disorder and major depression. Review of 2018 court documents titled Appointment of Guardian for Incompetent Person revealed Resident #29 was identified by the [NAME] County Probate Court as being incompetent of person and had a court appointed Guardian. Review of a behavior note for Resident #29 dated 03/08/24 at 2:30 A.M. and recorded as a late entry by an unknown nurse, revealed the Director of Nursing (DON) was notified that a male resident (facility identified Resident #42) was in Resident #29's room. The male resident was caught in the resident's room again while the nurse was passing medications in another hall. Resident #29's dentures were out and attempting to give oral sex to the male resident. Resident #29 progress notes revealed no documented evidence that the resident's guardian and the physician were notified. Review of facility document, titled Am I Ready for Sex signed by Resident #29 on 03/11/24 and witnessed by Social Services Designee (SSD) #376 indicated sex is a choice and, revealed some residents are not able to give informed consent, which means they do not understand the potential risks of the behavior. If a resident is not able to give informed consent, you are not permitted to be intimate with a resident, including hugging kissing or any other type of intimacy. If you continue to be intimate with such a resident, even after you have been informed, it's not appropriate and you may be given a discharge notice and assisted to find another facility. It is also possible the family or legal representative of the other resident will notify the police that they believe you are taking advantage of the other resident. Review of plan of care for Resident #29 revised on 04/06/24, revealed the resident has potential for behavior problems related to preferred to engage in sexual activity with other male residents and the resident makes false allegations against staff and other residents at times. Resident #29 has history of stripping clothing in the common area and the resident will perform oral stimulation to male residents in exchange for money and cigarettes. Interventions in place for staff to redirect resident as able, one-on-one (1:1) observation as needed, and educate the resident to remain clothed in common areas. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #29 had a Brief Interview Mental Status (BIMS) score of 11 indicating cognitive impairment. The assessment revealed no physical behavior symptoms, verbal behavior symptoms, or other behavior symptoms were indicated. Interview with Resident #29's Guardian on 07/11/24 at approximately 12:37 P.M., revealed after the resident had an acute illness, it caused damage to the resident's brain, and the resident was left with the inability to make or understand decisions about her care or her body. Resident #29's Guardian stated she had concerns with the facility allowing Resident #29 to have sexual encounters with other residents on a regular basis and the lack of investigating those incidents. Resident #29's Guardian stated the resident could not make sexual decisions with other residents, nor did he want her to have any sexual contact with any other persons because of her inability to make the appropriate decisions which was determined by the court. Interview with SSD #376 on 07/15/24 at approximately 1:00 P.M., revealed after the sexual incident between Residents #42 and #29 on 03/08/24, she provided Resident #29 with a guide titled, Am I ready for sex to which she had Resident #29 sign. SSD #376 verified Resident #29's guardian did not want her to have any sexual contact with any resident. SSD #376 also verified she witnessed the document. Interview with State Tested Nursing Assistant (STNA) #332 on 07/16/24 at 8:54 A.M., revealed Resident #29 had multiple sexual encounters with a variety of different residents. STNA #332 stated that almost on a weekly basis, Resident #29 was caught or suspected of a sexual encounter with other residents. STNA #332 stated she has even caught Resident #42 back in Resident #29's room after he was placed off of the secured unit because he knew the code to the door. STNA #332 stated she reports the incidents every time to the nurse as required to do per policy. Interview with the Director of Nursing (DON) on 07/16/24 at approximately 1:35 P.M., revealed the police were never notified of the sexual incident between Residents #29 and #42 on 03/08/24. The DON stated Resident #29 had the mental capacity of a [AGE] year old girl and she could not consent to sexual activities. The DON stated they could not watch Resident #29 all the time and she has had previous sexual encounters with other Residents. The DON verified the investigation subsequent to SRI #245069 created on 03/11/24 as physical abuse, did not contain police notification or sexual assault assessment, or investigation consisting of sexual in nature to like residents. The DON also verified an SRI was not created until 03/11/24 despite the incident on 03/08/24. Interview with the Administrator on 07/16/24 at approximately 2:40 P.M., revealed any allegations of abuse should be reported and investigated immediately, and that any allegation of sexual abuse should have law enforcement notified, other residents questioned and provide safety to the residents as well as creating an SRI. Review of the medical record for Resident #42 revealed the resident was admitted on [DATE]. Diagnoses included but were not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non- dominate side, major depressive disorder, major depressive disorder, muscle weakness, type two diabetes mellitus, alcohol abuse, adult failure to thrive, hypertension, depression, alcohol abuse and anemia. Review of the plan of care for Resident #42 dated 02/26/24 revealed the resident was at risk for behavior problems, resident will touch himself inappropriately in public areas, around other residents for other people to see. Resident #42 will accept oral stimulation from other female residents in exchange for cigarettes and/or money. Resident #42 makes poor decisions regarding sexual behaviors. Interventions in place include staff to redirect resident as able, staff to perform 15-minute checks on resident, staff to give 1:1 as needed and a goal to have fewer episodes of behavior though the next review. Review of a progress note for Resident #42 dated 03/08/24 revealed no documented evidence of an incident involving Resident #29. Review of a progress note for Resident #42 dated 03/11/24 at 10:24 A.M., revealed the team met for a behavior follow up. Resident #42 has been smoking in his room and common area. Resident #42 has been argumentative and still displays sexual behaviors. Review of a Social Services note for Resident #42 dated 03/12/24, revealed SSD #376 met with the resident to discuss his sexual behaviors and to talk about the pros and cons of having unprotected sex. Resident #42 stated he knew what he was doing and signed the paper. Review of a Social Services note for Resident #42 dated 03/14/24 at 5:00 P.M. and recorded as a late entry by SSD #376, revealed the resident was moved back to the Memory Care Unit because of sexual behavior. The resident was threatening to knock everybody's head off. Review of a quarterly MDS assessment for Resident #42 dated 05/06/24 revealed a BIMS score of 15 indicating cognitively intact and no behaviors were assessed. 2. Review of a closed record for Resident #43 revealed admission date of 04/25/24. Diagnoses included, but not limited to, schizoaffective disorder bipolar type, spinal stenosis, intracranial injury with loss of consciousness, anxiety disorder, depression, mild neurocognitive disorder, hyperlipidemia and post cholecystectomy syndrome. Resident #43 was discharged home on [DATE]. Review of a nursing progress note for Resident #43 dated 05/10/24 at 10:44 A.M. and authored by the DON, revealed the DON was notified from Human Resources (HR) that Resident #43's power of attorney (POA) called the facility and stated she was notified by and an unnamed source that Resident #43 was witnessed by an STNA in another male resident's room (facility identified as Resident #42) and inappropriately touching one another in a sexual manner. Resident #43 was immediately removed from the room, her hands were washed and taken back to room. Review of the ER records for Resident #43 dated 05/10/24 revealed the resident presented to the ER at 1:37 P.M. per Emergency Medical Services (EMS), for complaints of possible sexual assault. According to the EMS, Resident #43 was found having sexual intercourse with another resident. the resident's family was contacted, and they wanted a sexual assault kit to be done as they do not think patient could consent. Resident #43 denied having intercourse. Resident #43 states that she was there to get food from the restaurant for her brother. Resident #43 does have a history of traumatic brain injury (TBI), some chronic problems with memory and dementia as well as a history of agitation. The resident does not provide a reliable history as she was pleasantly confused. The ER called the nursing home, and they reported the resident was found a lot in other resident's beds. There is no documented evidence that Resident #43 had any sexual intercourse due to no one at the facility visualizing anything. No pelvic examination was completed due to history of dementia and agitation, and it was in the best interest of the resident to not put the resident through this examination with a low suspicion and the family members were in agreement. A urinalysis, chlamydia, and gonorrhea test were documented as being provided and the resident returned to the facility. The final impression included worried well examination and a possible STD exposure. Review of the SRI (tracking #247360) created 05/10/24 at 11:36 A.M., revealed Resident #43 and Resident #42 were found inappropriately touching each other while visiting together. The residents were immediately separated and head to toe assessments were completed. Resident #43 was placed on 1:1 supervision to ensure the residents remained separated. The DON notified the physician and the resident's family. Resident #43 has a baseline behavior of wandering in and out of other resident's rooms due to her history of a TBI. Resident #43 is easily redirected by staff. No other residents were involved in the incident. The physician was notified. The residents were interviewed with no recall of the event and no further incident noted between the residents. Staff reported no changes in residents' daily function. The staff were in-serviced on the abuse policy and the procedures. The facility unsubstantiated the allegations of sexual abuse due Resident #43 not able to understand that she is not to go into other resident's room at night or have inappropriate contact with the residents. Also, Resident #42 did not mind Resident #43 coming in his room. Resident #43's family requested for the resident to be sent to the hospital for further evaluation. The resident returned with no clinical concerns. Review of a witness statement dated 05/10/24 authored by STNA #398, revealed she had Resident #43 sitting in the common area. STNA #398 went to get briefs to change another resident and noticed Resident #43 was not located in the common area. STNA #398 went to look for Resident #43 and started in room [ROOM NUMBER], where she found Resident #43 sitting in a chair next to Resident #42 and inappropriately touching Resident #42. STNA #398 removed Resident #43 from Resident #42's room, washed her hands and took Resident #43 back to her room. Review of nursing progress notes for Resident #42 dated 05/10/24, revealed no documentation regarding an incident with Resident #43. Review of Social Services note for Resident #43 dated 5/14/24 at 4:06 P.M. and authored by SSD #376, revealed Resident #43 was found in a male resident's rooms. Resident #43 was asked to come out of the room, she states that her momma drop her off here and where is she supposed to stay. SSD #376 took the resident for a walk and tried explaining that Resident #43 was not allowed to go into male rooms under no circumstance. Resident #43 states that she can go where she wants and proceeded to try to enter another male patient's room, but the resident was able to be redirected. Review of the quarterly MDS dated [DATE] revealed Resident #43 had a BIMS score of 08 indicating severe cognitive impairment. Interview with SSD #376 on 07/15/24 at approximately 1:00 P.M. verified Resident #43 was found going in other male rooms after the incident on 05/10/24. Resident#43 was not placed on 1:1 observation after the incident on 05/10/24. SSD #376 noted Resident #43's responsible party expressed concerns before the incident on 05/10/24, of her being on a unit with predominately male residents, and placement on the unit was continued because of a previous elopement. SSD #376 verified Resident #43 would not have been able to consent to any sexual encounters because of her cognition. Interview with STNA #332 on 07/16/24 at 8:54 A.M., revealed a concern over the lack of investigations/care provided after incidents involving abuse allegations were made. STNA #332 stated she reports all incidents of abuse to the nurse but knows nothing about them after that because they never fill out a witness statement about what happened. Interview with the DON on 07/16/24 at approximately 1:35 P.M., verified that Resident #43 was placed back on the secured unit after she returned from the hospital on [DATE]. The DON verified Resident #43's behavior of wandering into others room continued throughout her stay. The DON stated Resident #42 was placed on the secured unit because of a sexual abuse allegation from another resident. The DON stated the secured unit was for increased supervision but was unable to always provide 1:1 to make sure Resident #43 did not go back into Resident #42's room or other residents rooms. Review of Residents #43's progress notes and physician orders revealed no documented evidence of any increased supervision such as 1:1 supervision, or other safety measures provided immediately following the sexual abuse incident on 05/10/24. Review of facility policy abuse neglect exploitation and misappropriation of resident's property dated 08/10/23 defines sexual abuse as non-consensual sexual contact of any type with a resident. Further review states staff should report all incidents/allegations immediately to the administrator or designee. Residents will be free from sexual abuse. The residents will be assessed and documented of incident in the resident's record. Review of the facility document titled Residents Rights dated 10/03/23 revealed that the resident had the right to be free from physical, verbal, mental, and emotional abuse and to be treated at all times with courtesy, respect, dignity and individuality. This deficiency represents non-compliance investigated under Complaint Number OH00155040.

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

Abuse Prevention Policies (Tag F0607)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident interview, staff interviews, review of witness statements and policy review, the ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident interview, staff interviews, review of witness statements and policy review, the facility failed to timely implement their abuse policy during allegations of staff-to-resident verbal abuse. This affected one (#18) of the 10 residents sampled for abuse. The facility census was 52. Findings include: Review of the medical record for Resident #18 revealed the resident was admitted to the facility on [DATE]. Diagnoses included unspecified bipolar disorder, unspecified hemiplegia affecting left dominant side, unspecified anxiety disorder, uncomplicated opioid dependence and marijuana abuse, and unspecified Chronic Obstructive Pulmonary Disease (COPD). Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 was cognitively intact, had verbal behaviors, did not wander, and occasionally rejected care. Review of a witness statement dated 07/17/24 and authored by State Tested Nurse Aide (STNA) #360, revealed she went into Resident #18's room at 5:47 A.M. to change Resident #46 (roommate of Resident #18). Resident #18 began cursing and yelling at State Tested Nursing Assistant (STNA) #360 to get out because she was too loud. Resident #18 got out of bed, tried to hit STNA #360, and continued yelling racial slurs. STNA #360 said something back to Resident #18 and reported the incident to the nurse. Resident #18 kept cursing and making racial slurs. STNA #360 said something to her again. Review of a witness statement dated 07/17/24 at 8:30 A.M., revealed Registered Nurse (RN) #406 stated around 6:00 A.M., STNA #360 went into Resident #46 and Resident #18's room for patient care. STNA #360 was loud and rude waking up Resident #46. Resident #18 told STNA #360 she was tired of her being rude and told her to shut up. STNA #360 responded by telling Resident #18 not to disrespect her and to shut up. Resident #18 began name-calling. STNA #360 name-called back. Resident #18 tried to hit STNA #360. STNA #360 pushed Resident #18's chair aggressively. In the process, RN #406 asked STNA #360 to calm down and leave the room. RN #406 removed Resident #18 from the room and asked her if she was ok. STNA #360 proceeded to threaten Resident #18 and stated something about losing her job. RN #406 again asked STNA #360 to leave. STNA #360 insisted on writing a witness statement before she left. Resident #18 threatened to report the incident to the State. STNA #360 reported the incident as she was leaving. RN #406 reported the incident to the DON and explained to STNA #360 how to handle the situation in the future, but STNA #360 was not receptive and threatened to quit. Observation of Resident #18 on 07/17/24 at 6:38 A.M., revealed the resident appeared visibly upset. Interview with Resident #18 at the same time, revealed STNA #360 came into her room, turned the lights on and started yelling at her roommate, Resident #46, about being dirty. STNA #360 stated to Resident #46 I just changed you at midnight, why are you dirty again? Resident # 18 stated she got out of bed and confronted STNA #360. Resident #18 stated STNA #360 cursed at her, threatened her, and kept pushing her wheelchair aggressively when the nurse came in the room and pulled Resident #18 out of the room. Interview with STNA #360 on 07/17/24 at 7:07 A.M., revealed she went into the room to do patient care on Resident #46. The STNA turned the light on. Resident #18 was yelling, started cussing at her for being too loud, and told her to get out of the room. Resident #18 jumped out of bed, came over, and started swinging at her. STNA #360 indicated she was in the middle of a total bed change and could not leave Resident #46 covered in poop. STNA #360 stated she had last changed Resident #46 at midnight, and when she checked on her at 2:00 AM, Resident #46 was dry. STNA #360 stated she was explaining this to Resident #46. STNA #360 stated her voice is loud and it carries but denied yelling at either resident. STNA #360 stated Resident #18 always jumped in and did this during resident care for Resident #46, like she was being protective of her mother. Resident #18 did this before when STNA #360 worked with her at another facility. Interview with RN #406 on 07/17/24 at 7:18 A.M., revealed she witnessed the entire incident which happened around 6:00 A.M. STNA #360 went into the shared room to give care to Resident #46. STNA #360 went in, turned the light on, and Resident #46 was completely dirty. Resident #46 had not been changed all night long. STNA #360 was changing Resident #46, and her voice was kind of loud. RN #406 stated she had many patient complaints about an STNA but never knew who they were talking about until now. RN #406 stated this night was her first night meeting STNA #360. RN #406 stated Resident #18 was half asleep. Resident #18 was very rude and said, I don't like the way you're talking to her and shut the expletive up. STNA #360 said something back along the lines of ,I was not talking to you. Resident #18 then called her foul names. STNA #360 responded and called Resident #18 foul names back. RN #406 stated she told STNA #360 not to respond to the Resident #18 and offered to take her place to take over care when STNA #360 refused. RN #406 stated she stayed there at the medication cart outside of the room to supervise. Resident #18 got in her chair to go to the bathroom. Resident #18 swung at the STNA but made no physical contact. STNA #360 said, I don't care about my job, I will beat your expletive. At that point RN #406 asked STNA #360 to step out of the room and clock out, which she refused to do. STNA #360 wanted to tell her side of the story. As she was telling her side of the story, STNA #360 threatened Resident #18 again. STNA #360 said to the Resident #18, You are too young to be in the nursing home, you are a crackhead, and no one wants to take care of you. That upset Resident #18 and she started yelling at STNA #360 and calling her names. RN #406 asked STNA #360 to leave again when the STNA said, that isn't right how Resident #18 talked to her. RN #406 stated she educated STNA #360 about her responsibility to remain professional and not participating in verbal abuse. STNA #360 was not receptive. STNA #360 asked if it was ok to write her statement before she left, and RN #406 asked her to write it in her car. RN #406 verified she did not intervene to remove Resident #18 from the room promptly after initially identifying verbal abuse had occurred when STNA #360 responded to Resident #18 with name-calling and profanity. RN #406 verified she did not remove Resident #18 from the room until after Resident #18 tried to make physical contact with STNA #360 and after STNA #360 aggressively pushed Resident #18's wheelchair. RN #406 verified she took no further actions to remove STNA #360 from the property after Resident #306 refused twice to leave or notify the Administration of the abuse situation. Review of policy titled Abuse, Neglect, Exploitation & Misappropriation of Resident Property dated 08/10/23 revealed: the facility provided supervision of staff to identify inappropriate behaviors such as using derogatory language, immediately remove from the building any staff member who was accused or suspected of abuse of a resident and would respond to protect the resident. This deficiency represents non-compliance investigated under Complaint Number OH00155040.

CONCERN (D) 📢 Someone Reported This

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

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

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, observation, review of witness statements, review of the facility policy, and review of...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, observation, review of witness statements, review of the facility policy, and review of Self-Reported Incident (SRI), the facility failed to thoroughly investigate allegations of sexual abuse. This affected one (#29) of the ten residents reviewed for abuse. The facility census was 52. Findings included: Review of the medical record for Resident #29 revealed the resident was admitted on [DATE]. Diagnoses included, but not limited to, hemiplegia and hemiparesis following a cerebrovascular disease, paranoid schizophrenia, schizoaffective disorders old myocardial infarction, seizure disorder, Bechet's disease, generalized anxiety, insomnia, bipolar disorder and major depression. Review of 2018 court documents titled Appointment of Guardian for Incompetent Person revealed Resident #29 was identified by the [NAME] County Probate Court as being incompetent of person and had a court appointed Guardian. Review of a behavior note for Resident #29 dated 03/08/24 at 2:30 A.M. and recorded as a late entry by an unknown nurse, revealed the Director of Nursing (DON) was notified that a male resident (facility identified Resident #42) was in Resident #29's room. The male resident was caught in the resident's room again while the nurse was passing medications in another hall. Resident #29's dentures were out and attempting to give oral sex to the male resident. Resident #29 progress notes revealed no documented evidence that the resident's guardian and the physician were notified and the allegations were investigated. Review of facility document, titled Am I Ready for Sex signed by Resident #29 on 03/11/24 and witnessed by Social Services Designee (SSD) #376 indicated sex is a choice and, revealed some residents are not able to give informed consent, which means they do not understand the potential risks of the behavior. If a resident is not able to give informed consent, you are not permitted to be intimate with a resident, including hugging kissing or any other type of intimacy. If you continue to be intimate with such a resident, even after you have been informed, it's not appropriate and you may be given a discharge notice and assisted to find another facility. It is also possible the family or legal representative of the other resident will notify the police that they believe you are taking advantage of the other resident. Review of plan of care for Resident #29 revised on 04/06/24, revealed the resident has potential for behavior problems related to preferred to engage in sexual activity with other male residents and the resident makes false allegations against staff and other residents at times. Resident #29 has history of stripping clothing in the common area and the resident will perform oral stimulation to male residents in exchange for money and cigarettes. Interventions in place for staff to redirect resident as able, 1:1 observation as needed, and educate the resident to remain clothed in common areas. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #29 had a Brief Interview Mental Status (BIMS) score of 11 indicating cognitive impairment. The assessment revealed no physical behavior symptoms, verbal behavior symptoms, or other behavior symptoms were indicated. Interview with Resident #29's Guardian on 07/11/24 at approximately 12:37 P.M. revealed after the resident had an acute illness, it caused damage to the resident's brain, and the resident was left with the inability to make or understand decisions about her care or her body. Resident #29's Guardian stated she had concerns with the facility allowing Resident #29 to have sexual encounters with other residents on a regular basis and the lack of investigating those incidents. Resident #29's Guardian stated the resident could not make sexual decisions with other residents, nor did he want her to have any sexual contact with any other persons because of her inability to make the appropriate decisions which was determined by the court. Interview with SSD #376 on 07/15/24 at approximately 1:00 P.M., revealed after the sexual incident between Residents #42 and #29 on 03/08/24, she provided Resident #29 with a guide titled, Am I ready for sex to which she had Resident #29 sign. SSD #376 verified Resident #29's guardian did not want her to have any sexual contact with any resident. SSD #376 also verified she witnessed the document. Interview with State Tested Nursing Assistant (STNA) #332 on 07/16/24 at 8:54 A.M., revealed Resident #29 had multiple sexual encounters with a variety of different residents and there was a lack of investigations after the incidents. STNA #332 stated that almost on a weekly basis, Resident #29 was caught or suspected of a sexual encounter with other residents. STNA #332 stated she has even caught Resident #42 back in Resident #29's room after he was placed off of the secured unit because he knew the code to the door. STNA #332 stated she reports the incidents every time to the nurse as required per policy but unknown if the allegations were investigated because the facility never fills out a witness statement about what happened. Interview with DON on 07/16/24 at approximately 1:35 P.M., revealed the police were not notified of the sexual incident between Residents #29 and #42 on 03/08/24. The DON stated Resident #29 had the mental capacity of a [AGE] year old girl and she could not consent to sexual activities. The DON stated they could not watch Resident #29 all the time and she has had previous sexual encounters with other residents. The DON verified the investigation subsequent to SRI #245069 created on 03/11/24 as physical abuse, did not contain police notification or sexual assault assessment, or investigation consisting of sexual abuse in nature to like residents. The DON also verified an investigation, and an SRI was not started until 03/11/24 and should have been started immediately. Interview with the Administrator on 07/16/24 at approximately 2:40 P.M. revealed any allegations of abuse being reported should be investigated immediately, and that any allegations of sexual abuse should have law enforcement notified, resident's representatives/Guardians notified, other residents questioned and ensure safety to the residents as well as creating an SRI. Review of the facility policy dated Abuse, Neglect, Exploitation and Misappropriation of Resident Property dated 08/10/23 revealed that all incident and allegations of abuse, neglect, exploitation, mistreatment of a resident, or misappropriation of resident property and all injuries of unknown source must be reported immediately to the Administrator or designee. The investigation must be started immediately and completed within five working days, if there are special circumstances causing the investigation to continue beyond five working days. This deficiency represents non-compliance investigated under Complaint Number OH00155040.

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 F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interviews, staff interviews, review of the medical record, and policy review, the facility failed to hold qua...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interviews, staff interviews, review of the medical record, and policy review, the facility failed to hold quarterly care conferences with residents and/or resident's representatives. This affected three (#29, #49 and #51) of the three residents sampled for care conferences. The facility census was 52. Findings include: 1. Review of medical record for Resident #29 revealed the resident was admitted on [DATE]. D diagnoses included, but were not limited to, hemiplegia and hemiparesis following a cerebrovascular disease, paranoid schizophrenia, schizoaffective disorders old myocardial infarction (heart attack), seizure disorder, Bechet's disease, generalized anxiety, insomnia, bipolar disorder and major depression. Review of 2018 court documents titled Appointment of Guardian for Incompetent Person revealed Resident #29 was identified by the [NAME] County Probate Court as being incompetent of person and had a court appointed Guardian. Review of the Minimum Data Set (MDS) assessment for Resident #29 dated 05/08/24 revealed a Brief Interview Mental Status (BIMS) score of 11 indicating cognitive impairment. Further review of the medical record of Resident #29 revealed the last Interdisciplinary Team (IDT) care conference was held with Resident #29's and Guardian on 03/30/22. Resident #29 medical record revealed no documented evidence a care conferences were completed for the years of 2023 and 2024. There was no documented evidence of notification of scheduled care conferences, refusals to participate in care conferences and /or resident assessments. Interview with Resident #29's Guardian on 07/11/24 at approximately 12:37 P.M., revealed care conferences had not been held for years. Resident #29's Guardian stated he had requested care conferences on multiple occasions to multiple different facility personnel, that he wanted to participate, and schedule a care conference so that he could help to dictate Resident #29's plan of care, but all requests went unanswered. Resident #29's Guardian stated he was unaware of what Resident #29's plan of care said. Interview with Social Services Designee (SSD) #376 on 07/15/24 at approximately 1:00 P.M. verified the only documented care conference with Resident #29 and Guardian was on 03/30/22. SSD #376 verified that Resident #29 and/or her Guardian had not been scheduled or contacted for a care plan conference since she had begun working at the facility, which is about six months. SSD #376 further verified care plan conferences should be held quarterly with each resident's quarterly MDS assessment or as needed as per policy. 2. Review of the medical record for Resident # 49 revealed an admission date of 03/07/23 with diagnoses including morbid obesity with alveolar hypoventilation, moderate persistent asthma, and acute diastolic heart failure. Review of the medical record for Resident #49 revealed the resident had a care conference during which the resident's family was present by telephone. There were no other care conferences documented for Resident #49 from 03/07/23 to 07/11/24. Review of the MDS assessment for Resident #49 dated 06/07/2024 revealed the resident was cognitively intact. Interview on 07/11/24 at 2:00 P.M. with Social Services Designee (SSD) #376 confirmed Resident #49 had only one care conference from 03/07/23 to 07/11/24. 3. Review of the medical record for Resident #51 revealed an admission date of 09/07/2023 with diagnoses including chronic obstructive pulmonary disease (COPD), type two diabetes, mild protein calorie malnutrition, ischemic cardiomyopathy, unspecified anxiety disorder, and adjustment disorder with depressed mood. Review of the MDS assessment for Resident #51 dated 06/14/2024 revealed the resident had moderately impaired cognition. Review of the medical record for Resident #49 revealed the resident had care conferences on 10/11/23 and 04/15/24. There were no other care conferences documented for Resident #49 from 09/07/23 to 07/11/24. Review of the medical record revealed Resident #51 had care conferences documented on 10/11/2023 and 04/15/2024. Interview on 07/11/2024 at 2:02 P.M. with SSD #376 confirmed resident care conferences should be held at least quarterly and further confirmed Resident #51 had not received quarterly care conferences. His next care conference was scheduled to occur August 2024. Review of facility policy, Resident participation-assessment/care plans dated 2001 states, social services is responsible for notifying the resident/representative and maintaining records of such notices. Further stated resident or representative's right to participate in the development and implantation of the plan of care including, request meetings, participate in the planning process, be informed in advance of the risks and benefits of care or treatment proposed and have access to and review the care plan.

CONCERN (D)

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

Deficiency F0685 (Tag F0685)

Could have caused harm · This affected 1 resident

Based on medical record review, resident interview, staff interview, and review of the facility policy, the facility failed to provide services to maintain resident vision. This affected one (Resident...

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Based on medical record review, resident interview, staff interview, and review of the facility policy, the facility failed to provide services to maintain resident vision. This affected one (Resident #46) of eight residents sampled for vision services. The facility census was 52 residents. Findings include: Review of the medical record for Resident #46 revealed an admission date of 10/02/23 with diagnoses including type two diabetes, unspecified visual loss, chronic obstructive pulmonary disease, and chronic kidney disease. Review of the physician orders for Resident #46 revealed an order dated 03/21/24 for the resident to be referred to an ophthalmologist for decreased vision. Review of the Minimum Data Set (MDS) assessment for Resident #46 dated 04/09/2024 revealed the resident had moderately impaired cognition, had highly impaired vision, and had no corrective lenses. Review of care plan for Resident #46 dated 06/06/2024 revealed the resident had an alteration in visual function related to low vision abilities. Interventions included to obtain eye exam consultations to ensure appropriate medications and compensatory mechanisms. Interview on 07/09/24 at 10:47 A.M. with Resident #46 confirmed her vision was impaired and she was going blind. Resident #46 stated she had prescription glasses at home, but she needed a new pair. Resident #46 confirmed she was supposed to have her eyes examined at the facility about six months ago, but the appointment was canceled and was never rescheduled. Interview on 07/11/24 at 2:08 P.M. with Social Service Designee (SSD) #376 confirmed she was unaware of Resident #46's referral for ophthalmology and further confirmed the resident had not been seen by the facility eye doctor. Review of policy titled Ancillary Services dated September 2019 revealed the facility worked to assist and coordinate routine and emergency vision services, including prompt referrals, scheduling appointments, and arranging transportation as needed.

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure dietary supplements were administered per the ...

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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 ensure dietary supplements were administered per the physician's order. This affected one (#106) of two residents reviewed for nutrition. The facility census was 52. Findings include: Review of the medical record of Resident #106 revealed an admission date of 06/02/24. The resident transferred to the hospital on [DATE] and did not return. Diagnoses included acute gastroenteritis and colitis, post-traumatic stress disorder (PTSD), major depressive disorder, cerebral infarction, adult failure to thrive, colon cancer, diabetes mellitus, emphysema, mild protein-calorie malnutrition. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #106 had adequate short and long-term memory. The resident required supervision or touching assistance for eating, weighed 103 pounds, had no known significant weight changes, and received a mechanically altered diet. Review of the physician orders for Resident #106 dated 06/02/24 revealed the resident was ordered Boost (oral supplement) three times a day. Review of the June 2024 Medication Administration Record (MAR) for Resident #106 revealed the resident received Boost three times a day beginning on 06/02/24. The MAR indicated the resident did not receive the Boost as ordered twice on 06/03/24 and once on 06/07/24. Review of the medical record revealed no progress notes on 06/03/24 nor 06/07/24 regarding the administration of the Boost supplement. Interview on 07/17/24 at 9:39 A.M., the Director of Nursing (DON) verified there were holes in the MAR of Resident #106 for Boost administration twice on 06/03/24 and once on 06/07/24. The DON further verified there were no progress notes regarding the Boost administration for the aforementioned dates. The DON confirmed Resident #106's medical record lacked evidence of Resident #106's Boost being administered per the physician's order. This deficiency represents non-compliance investigated under Complaint Number OH00154796.

CONCERN (D) 📢 Someone Reported This

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

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to ensure residents received medications...

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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 residents received medications as ordered. This affected one (#39) of four residents reviewed for pain. The facility census was 52. Findings include: Review of the medical record of Resident #39 revealed an admission date of 08/24/21. Diagnoses included chronic obstructive pulmonary disease (COPD), constipation, insomnia, hypertension, pain, emphysema, anxiety disorder, major depressive disorder, polycythemia vera, alcohol dependence with withdrawal delirium. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 had intact cognition. The resident did not display behaviors during the assessment period. Review of the physician orders for Resident #39 dated 10/23/23 revealed the resident was ordered to receive Celebrex 100 milligrams (mgs) two times a day for pain. Physician orders dated 10/24/23, revealed Aspirin 81 mgs daily for prevention, folic acid 1 mg daily for supplement, omeprazole 20 mg daily for heartburn and indigestion, multi-vitamins daily for supplement, thiamine 100 mg daily for supplement, metoprolol tartrate 25 mg twice daily for hypertension, Seroquel 25 mg twice a day for behaviors related to anxiety and depression. Physician orders dated 02/17/24 revealed Norco 5-325 mg twice daily for pain. Physician orders dated 02/20/24 revealed promethazine 25 mg daily for nausea. Physician orders dated 06/03/24 re revealed lorazepam 0.5 mg twice daily for anxiety. Review of the June 2024 medical Medication Administration Record (MAR) for Resident #39 revealed no documentation to support Resident #39 received aspirin, folic acid, omeprazole, multivitamin, thiamine, lorazepam, and Seroquel as ordered on 06/19/24, promethazine as ordered on 06/25/24 and 06/28/24, and Celebrex, metoprolol, and Norco as ordered on 06/19/24 and 06/25/24. Review of Resident #39's progress notes revealed no documentation regarding the administration of the medications on 06/19/24, 06/25/24, nor 06/28/24. Interview on 07/15/24 at 1:30 P.M., the Director of Nursing (DON) verified the medical record for Resident #39 did not contain documentation to support the medications were administered as ordered on 06/19/24, 06/25/24, and 06/28/24. Review of the facility policy titled, Medication Administration-General Guidelines, dated 01/2018, revealed medications are administered as prescribed. The individual who administers the medication records the administration on the resident's MAR directly after the medication is given by initialing the MAR in the space provided. If a dose of a regularly scheduled medication is withheld, refused, not available, or given at a time other than the scheduled time, it is documented on the MAR and an explanatory note is also entered in the medical record. This deficiency represents non-compliance investigated under Complaint Number OH00155040. This deficiency is a recite to complaint surveys dated 04/11/24, 05/13/24, and 06/06/24.

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 F0776 (Tag F0776)

Could have caused harm · This affected 1 resident

Based on medical record review, resident interview, and staff interview, the facility failed to obtain radiology services per physician's order. This affected one (Resident #107) of one reviewed for c...

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Based on medical record review, resident interview, and staff interview, the facility failed to obtain radiology services per physician's order. This affected one (Resident #107) of one reviewed for constipation. The facility census was 52 residents. Findings include: Review of the medical record of Resident #107 revealed an admission date of 06/17/24 with diagnoses including humerus fracture, major depressive disorder, low back pain, chronic bronchitis, suicidal ideations, nicotine dependence, age-related osteoporosis, and hypocalcemia and a discharge date of 07/11/24. Review of the Minimum Data Set (MDS) assessment for Resident #107 dated 06/25/24 revealed the resident had intact cognition and required partial/moderate assistance for transfers. Review of the medical record revealed Resident #107's last bowel movement was a medium, formed stool on 07/04/24. Review of a progress note for Resident #107 dated 07/08/24 timed at 9:56 P.M. revealed the resident complained of lower abdominal pain and stated he had not had a bowel movement in five days. The physician was notified and ordered an x-ray of the kidneys, ureters, and bladder (KUB.) Review of physician's orders for Resident #107 revealed an order dated 07/09/24 timed at 6:56 A.M. for the resident to have a KUB x-ray. Review of the medical record for Resident #107 revealed it did not include documentation of KUB x-ray being completed or KUB x-ray results. Interview on 07/08/24 at 11:22 A.M. with Resident #107 confirmed the resident had not had a bowel movement in six days although he had been given medications to promote bowel movements with no results. Resident #107 complained of stomach cramping. Interview on 07/15/24 at 1:30 P.M. with the Director of Nursing (DON) confirmed the KUB x-ray was not completed for Resident #107 and the chart did not include documentation regarding the rationale for not completing the KUB x-ray.

CONCERN (D)

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

Dental Services (Tag F0791)

Could have caused harm · This affected 1 resident

Based on medical record review, resident interview, staff interview, and review of the facility policy, the facility failed to ensure residents received follow up care to dental visits. This affected ...

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Based on medical record review, resident interview, staff interview, and review of the facility policy, the facility failed to ensure residents received follow up care to dental visits. This affected two (Residents #46 and #49) of three residents sampled for dental care. The facility census was 52 residents. Findings include: 1. Review of the medical record for Resident #46 revealed an admission date of 10/02/23 with diagnoses including type two diabetes, unspecified visual loss, unspecified chronic obstructive pulmonary disease, and chronic kidney disease. Review of care plan for Resident #46 dated 10/02/2023 revealed the resident was at risk for oral /dental problems related to having natural teeth. Interventions included the following: administer medications as ordered, assist with lip balm for dry/cracked lips, arrange for dental care/transportation as needed, observe/report dental abnormalities, assist with oral care as needed. Review of the Minimum Data Set (MDS) assessment for Resident #46 dated 04/09/2024 revealed the resident had moderately impaired cognition. Interview on 07/09/24 at 10:46 A.M. with Resident #46 confirmed she needed to see the dentist for fillings that had fallen out a while ago and needed be refilled and the facility was aware of the concern. Resident #46 further confirmed she had not been seen by a dentist since admission to the facility. Interview on 07/11/24 at 2:11 P.M. with Social Service Designee (SSD) #376 confirmed she was unaware Resident #46 had any dental concerns. SSD #376 further confirmed Resident # 46 had not been seen by the facility dentist since admission to the facility in October 2023. 2. Review of the medical record for Resident # 49 revealed an admission date of 03/07/23 with diagnoses including morbid obesity with alveolar hypoventilation, moderate persistent asthma, and acute diastolic heart failure. Review of the MDS assessment for Resident #49 dated 06/07/2024 revealed Resident #49 was cognitively intact. Review of the care plan for Resident #49 dated 03/08/203 revealed the resident was at risk for oral/dental problems related to having natural teeth. Interventions included the following: administer medications as ordered, assist with applying lip balm as needed, coordinate dental care/transportation, observe oral cavity for abnormalities (redness, swelling, pain, sores, coating on tongue, chewing problems, and cracked/bleeding lips), assist with mouth care as needed. Review of dentist note for Resident #49 dated 03/27/2024 revealed the resident was examined by the facility dentist who determined the resident needed dental extractions in four to six areas of the oral cavity. An internal case review was needed to determine if the resident needed to consult with an oral surgeon or if the work could be completed in the facility. Interview on 07/08/24 at 1:57 P.M. with Resident #49 confirmed a dentist came to the facility clean his teeth about four to five months ago, and they were supposed to pull some back teeth. Resident #49 stated the dentist recommended dentures and he frequently experienced pain in the gums. Interview on 07/11/24 at 2:23 P.M. with SSD #376 confirmed she was unaware of Resident #49's dental follow-up recommendations. SSD #376 further confirmed the dentist faxed the visit notes to her attention, and she uploaded them into the charts without reading them. Interview on 07/11/24 at 2:25 P.M. with the Director of Nursing (DON) confirmed she did not review Resident #49's dental visit note dated 03/27/24 and was unaware of recommendations that the resident needed to consult an oral surgeon for dental extractions and possible dentures. Review of policy titled Ancillary Services dated September 2019 revealed the facility assisted residents in obtaining timely routine and emergency dental services including scheduling and transportation as needed for any problem requiring the immediate attention of a dentist.

CONCERN (D) 📢 Someone Reported This

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

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

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview, the facility failed to ensure resident records adequately refl...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview, the facility failed to ensure resident records adequately reflected resident status. This affected one (Resident #107) of one resident reviewed for constipation. The facility census was 52 residents. Findings include: Review of the medical record of Resident #107 revealed an admission date of 06/17/24 with diagnoses including right humerus fracture, major depressive disorder, low back pain, chronic bronchitis, suicidal ideations, nicotine dependence, age-related osteoporosis, and hypocalcemia and a discharge date of 07/11/24. Review of the Minimum Data Set (MDS) assessment for Resident #107 dated 06/25/24 revealed the resident had intact cognition and required partial/moderate staff assistance for transfers. Observation on 07/15/24 at 9:00 A.M. revealed Resident #107 was not in his room and was unable to be located by the Surveyor. Review of the medical record for Resident #107 revealed it did not include documentation of resident's location. Interview on 07/15/24 at 1:30 P.M. with the Director of Nursing (DON) confirmed Resident #107 was sent to the hospital on [DATE] and had not returned to the facility, but this was not documented in the resident's medical record. The DON further confirmed staff should document resident transfers to the hospital in the medical record.

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 F0919 (Tag F0919)

Could have caused harm · This affected 1 resident

Based on medical record review, observation, and staff interview, the facility failed to ensure residents had functioning call lights. This affect three (Residents #2, #47, #53) of three residents rev...

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Based on medical record review, observation, and staff interview, the facility failed to ensure residents had functioning call lights. This affect three (Residents #2, #47, #53) of three residents reviewed for call lights. The facility census was 52 residents. Findings include: 1. Review of the medical record for Resident #2 revealed an admission date of 08/25/23 with diagnoses including schizophrenia, dementia, chronic pulmonary disease, and delusional disorder. Review of care plan for Resident #2 dated 05/06/24 revealed that the resident was at risk for falls and interventions included keeping the call light within reach. Review of the Minimum Data Set (MDS) assessment for Resident #2 dated 05/16/24 revealed the resident was cognitively intact and required supervision with light touch assistance for transfers, bathing, meals, personal hygiene, dressing, and oral care. Observation on 07/08/24 at 10:05 A.M. through 10:35 A.M. revealed Resident #2 was in bed and the call light was sounding. There was no call light cord in the resident's room for the resident to summon assistance and for the staff to turn off the call light. Interview on 07/08/24 at 10:36 A.M. with State Tested Nursing Assistant (STNA) #341 confirmed Resident #2 did not have a call light in the room to summon assistance and there was no way to turn off the call light. Interview on 07/08/24 at 11:55 A.M. with Maintenance Supervisor (MS) #363 confirmed Resident #2 did not have a functional call light to summon staff assistance. Observation on 07/09/24 at 11:18 A.M. revealed Resident #2 did not have a functional call light or alternate means such as a bell to summon assistance. Interview on 07/09/24 at 11:19 A.M. with MS #363 confirmed Resident #2 did not have a functional call light or other means to summon staff assistance. 2. Review of the medical record for Resident #53 revealed an admission date 05/20/24 with diagnoses including schizoaffective bipolar disorder, and anxiety disorder. Review of the MDS assessment for Resident #53 dated 06/08/24 revealed the resident was severely cognitively impaired and required supervision and touch assistance with transfers, toileting, dressing and bathing. Review of plan of care for Resident #53 dated 06/19/24 revealed that resident was at risk for falls related to medications and interventions included keeping the call light within reach. Observation on 07/09/24 at 11:17 A.M. revealed Resident #53's room had a call light cord wrapped around the call light box on the wall. The call light was not plugged into the hole for the call light box on the wall. Interview on 07/09/24 at 11:20 A.M. with MS #363 confirmed Resident #53's room did not have a functional call light or means to summon staff assistance. 3. Review of the medical record for Resident #47 revealed an admission date of 12/26/23 with diagnoses including Huntington's disease, mood disorder, anxiety disorder, and dementia. Review of the MDS assessment for Resident #47 dated 06/05/24 revealed the resident was severely cognitively impaired required substantial assistance with transfers, dressing, bathing, personally hygiene, and toileting. Review of plan of care for Resident #47 dated 06/24/24 revealed the resident at risk for falls related to decreased mobility, medications, and Huntington's disease and interventions included keeping the call light within reach. Observation on 07/09/24 at 10:59 A.M. revealed Resident #47 was in bed and the call light cord was wrapped around the box on the wall, and the call light was not functional. Interview on 07/09/24 at 11:00 A.M. with MS #363 confirmed Resident #47's room did not have a functional call light or means to summon staff assistance. This deficiency is a recite to complaint surveys completed 05/13/24 and 06/06/24.

CONCERN (E) 📢 Someone Reported This

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

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

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

3. Observation of the facility's outdoor environment on 07/11/24, 07/15/2024 and 07/16/24, revealed unkept lawn, patio (smoking area), empty plastic bottles, black plastic/fabric pieces strewn across ...

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3. Observation of the facility's outdoor environment on 07/11/24, 07/15/2024 and 07/16/24, revealed unkept lawn, patio (smoking area), empty plastic bottles, black plastic/fabric pieces strewn across the patio area, decaying tree branches above the patio and seating area with residents wheeling/walking across areas of tree bark on the concrete of the patio area. Overgrown landscaping with tall weeds making the pathway difficult to navigate because of the height, and the vegetation in the pathway of the walking path. Interview on 07/16/24 at approximately 1:48 P.M. with STNA #341, revealed concerns over the lack of landscaping and lawn care provided to the outdoor space for the residents. STNA #341 verified that the vegetation from overgrown grass, weeds and decaying tree branch materials covered areas on the walking pathways. Further verified a large dead tree branch that was over top of the seating area for residents. Stated a concern for branch to fall and cause injury to residents or staff. STNA #341 stated the lawn was about a foot high and did not know the last time it was mowed. Interview with Resident #29 on 07/16/24 at 10:40 A.M. stated that when she is outside on the smoking area (outdoor patio), she is unable to propel herself around the outdoor space because of the weeds and grass covering the pathway. While looking out the window to the patio area, Resident #29 gestured towards the grass, and vegetation covering the sidewalks. Further pointing to the trash allover gesturing toward empty plastic bottles, back plastic/fabric pieces laying in the sidewalk areas and non-organic debris in landscaping and in grass. Interview with administrator on 07/16/24 at approximately 2:40 P.M., verified the conditions outside and stated the facility should provide a safe and homelike environment for all their residents. Review of the facility policy titled Housekeeping Services Policy & Procedure, dated 01/01/16, revealed residents would be provided with housekeeping services on a regularly scheduled basis. This deficiency is a recite to complaint surveys completed on 04/11/24 and 06/06/24. This deficiency represents non-compliance investigated under Complaint Numbers OH00155134 and OH00154641. Based on observations, resident and staff interviews, and review of facility policy, the facility failed to ensure a clean, safe, comfortable environment for all residents. This affected 32(#01, #02, #03, #05, #06, #08, #09, #10, #12, #17, #18, #19, #22, #23, #27, #29, #30, #31, #32, #35, #36, #37, #41, #42, #44, #46, #47, #49, #50, #51, #53, and #54) of the 52 residents observed for environment. The facility census was 52. Findings include: 1. Observation of the secured Memory Care Unit (MCU) on 07/08/24 at 10:20 A.M. with State Tested Nursing Assistant (STNA) #341, revealed a very dirty, upswept, light brown laminate wood floors that were 80 percent (%) stained with black coloring throughout the middle of the hall. The entire floor had food crumbs scattered throughout the halls, soda cans and other trash debris in the floor. Interview with STNA #341 on 07/08/24 at 10:28 A.M., verified the environmental conditions of the secured MCU. 2. Observation of Resident #44's room on 07/08/24 at 11:40 A.M., revealed the resident's room felt warm. Interview with Resident #44 at the same time, stated her room had been warm for a few days. Resident #44 stated there was no air conditioning in her room and woke up that morning and her head was soaked from sweat. Resident #44 was observed laying on her bed. Observation on 07/08/24 at 12:54 P.M., Housekeeping Assistant (HA) #306 utilized a hand-held thermometer to check the temperature of Resident #44's room. The room temperature was observed to be 82 degrees Fahrenheit (F) by the resident's bed and the ceiling vent in the center of the room was observed at 83 degrees Fahrenheit. HA #306 adjusted the thermostat in the resident's room, stating it was set at 75 degrees Fahrenheit and he turned it down to 50 degrees Fahrenheit. A second check of the ceiling vent was conducted immediately following and the room was observed at 85 degrees Fahrenheit. Interview on 07/08/24 at 12:55 P.M., HA #306 confirmed the temperature in Resident #44's room felt warm and the temperature should be maintained between 71 and 81 degrees Fahrenheit. HA #306 further stated he checked the temperature in Resident #44's room earlier that day and it was 76 degrees Fahrenheit. Observation of the common area between the 400 and 500 halls on 07/16/24 at 8:00 A.M. with Licensed Practical Nurse (LPN) #385, revealed five large buckets on the floor, all containing water. The ceiling panels above the buckets were observed to be brown-stained, bulging, and actively leaking water into the buckets. Further observation revealed the open room adjacent to the common area had two trash cans sitting on top of the table. Both trash cans contained water and the ceiling panels directly above the trash cans were brown-stained, bulging, and actively leaking water into the trash cans. Interview with LPN #385 at the same time stated the ceiling had been leaking for several months and the trash cans collected the water. LPN #385 stated it always leaked following a rain. LPN #385 affirmed the room adjacent to the common area where trash cans were sitting on the tables, was a common area for residents to congregate as desired. Observation on 07/16/25 at 8:05 A.M., STNA #332 walked by the common area, observed the buckets and trash cans, and stated, Oh, that's leaking again, and continued to walk down the hall. Interview on 07/16/24 at 8:09 A.M., Maintenance Supervisor (MS) #363 confirmed the ceiling in the common area and adjacent room was brown stained, bulging, and actively leaking water into the buckets and trashcans. MS #363 stated the observed areas had been leaking for approximately one to two weeks. MS #363 stated he had been chasing leaks throughout the building and the areas in the roof needed to be repaired.

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, resident interview, staff interview, and policy review, the facility failed to ensu...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, resident interview, staff interview, and policy review, the facility failed to ensure residents did not have access to knives, razors, and smoking materials and smokers were supervised while smoking. This affected Residents #50, #29, #48 and #107. The facility identified 28 Residents (#01, #03, #04, #07, #09, #16, #18, #19, #20, #21, #22, #24, #27, #30, #31, #34, #35, #37, #38, #40, #41, #42, #44, #48, #50, #51, #53, and #54) who smoked. The facility census was 52. Findings include: 1. Review of the medical record of Resident #50 revealed an admission date of 09/14/23. Diagnoses included alcoholic cirrhosis of liver with ascites, chronic obstructive pulmonary disease, anxiety, hypertension, and cognitive communication deficit. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #50 had intact cognition and was independently mobile. Review of the Smoking Assessment for Resident #50 dated 06/12/24 revealed the resident needed the facility to store her lighter and cigarettes. Review of the care plan for Resident #50 dated 09/17/23, revealed the resident was at risk for injury and health risks related to smoking. Interventions included for staff to keep cigarettes, lighters, and matches in a designated area. Review of the medical record of Resident #29 revealed an admission date of 04/24/17. Diagnoses included hemiplegia and hemiparesis following cerebrovascular disease affecting the right dominant side, nicotine dependence, paranoid schizophrenia, conversion disorder with seizures or convulsions, behcet's disease, anxiety, cerebral infarction, depression, and bipolar disorder. Review of the quarterly MDS assessment dated [DATE] revealed Resident #29 had moderately impaired cognition and was independently ambulatory. Review of the Smoking Assessment, dated 08/16/23 revealed Resident #29 was unable to light her own cigarette, required supervision, and needed the facility to store lighters and cigarettes. Review of the plan of care for Resident #29 dated 11/19/21, revealed the resident was at risk for injury related to smoking. Interventions included providing supervision while smoking and for staff to keep cigarettes lighter and matches in a designated area. Observation on 07/08/24 at 3:17 P.M. revealed Resident #50 was observed lighting a cigarette for Resident #29 on the facility's smoking patio. Resident #50 then placed the lighter in her walker basket and entered the building. Further observation revealed there were no staff present in the facility's smoking patio to supervise the residents who were smoking. Interview with the Director of Nursing (DON) on 07/08/24 at 3:20 P.M., verified Resident #50 had two lighters and two empty packs of cigarettes in her walker basket. The DON further verified there was no staff present on the facility's smoking patio to supervise residents who were smoking. 2. Review of the medical record of Resident #48 revealed an admission date of 02/09/24. Diagnoses included repeated falls, bradycardia, chronic obstructive pulmonary disease, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, senile degeneration of brain, and type 2 diabetes mellitus. Review of the quarterly MDS assessment dated [DATE] revealed Resident #48 had severely impaired cognition and was independently mobile. Review of the Smoking Assessment for Resident #48 dated 05/25/24 revealed the resident required supervision and required the facility to store his lighter and cigarettes. Review of the plan of care for Resident #48 dated 02/12/24, revealed the resident was at risk for injury related to smoking. Interventions included providing supervision at all times for smoking and keeping smoking items at the nurse's station. Observation on 07/11/24 at 8:45 A.M. revealed Resident #48 standing inside the common area next to the outdoor smoking patio. Resident #48 reached in his walker basket and took a cigarette out of a pack he had in the basket and placed it in his mouth. Interview on 07/11/24 at 8:47 A.M. Housekeeping Assistant (HA) #325 verified Resident #48 had cigarettes in his walker basket. Further observation revealed Resident #48 had an additional pack of cigarettes in his walker basket. HA #325 verified Resident #48 was not supposed to carry his own cigarettes. 3. Review of the medical record of Resident #107 revealed an admission date of 06/17/24. The resident transferred to the hospital on [DATE] and did not return to the facility. Diagnoses included right humerus fracture, major depressive disorder, low back pain, chronic bronchitis, suicidal ideations, nicotine dependence, age-related osteoporosis, and hypocalcemia. Review of the comprehensive MDS assessment dated [DATE] revealed Resident #107 had intact cognition. The resident exhibited verbal behavioral symptoms directed towards others during the assessment period. The resident had impaired range of motion on one side of his upper extremities and utilized a wheelchair for mobility. The resident required partial/moderate assistance for transfers. Review of the care plan for Resident #107 dated 06/26/24, revealed the resident was at risk for suicide related to a history of suicidal ideation. Interventions included to allow the resident to express his feelings and offer support. Review of the care plan for Resident #107 dated 06/18/24 revealed the resident was at risk for injury related to smoking. Interventions included for staff to keep cigarettes, lighters, and matches in a designated area. Review of the Smoking Assessment for Resident #107 dated 07/05/24, revealed the resident needed the facility to store his lighter and cigarettes. Review of a progress note for Resident #107 dated 06/26/24, revealed the resident voiced concerns of feeling down and depressed. Psychiatric (psych) services had been consulted. The DON and physician were notified, and no new orders were received. Interview on 07/09/24 at 11:06 A.M., Resident#107 stated he smoked cigarettes and kept his cigarettes in his drawer. Resident #107 stated his daughter brought him his cigarettes. Observation on 07/09/24 at 11:09 A.M., State Tested Nursing Assistant (STNA) #354 opened Resident #107's dresser drawers and found a large pocketknife, three razors, and a carton of cigarettes, which contained nine packs of cigarettes. Interview with STNA #354 at the same time, verified Resident #107 had a large pocketknife, three razors, and nine packs of cigarettes in his drawers. Interview on 07/09/24 at 11:10 A.M., Resident #107 stated he used his pocketknife to open milk cartons and cut the meat on his meal tray. Resident #107 further stated, What am I going to do? Slit my neck with the razors? Review of the facility policy titled, Smoking, dated 11/04/22, revealed any resident with supervised smoking privileges requiring monitoring shall always have the supervision of a staff member, family member, visitor, or volunteer worker while smoking. Supervision shall be direct supervision with the person providing the supervision in the direct vicinity of the resident. All smoking materials will be stored in a secure location by facility staff. The staff member providing the supervision will distribute the material, while maintaining control of the lighting device. At the end of the smoke break, all material distributed will be collected by the staff member and returned to the secure location. Residents who are assessed and demonstrate the ability to smoke independently must keep smoking materials secured with the nurse in a locked container. Residents are not permitted to supervise or assist other residents with smoking. 4. Review of medical record revealed Resident #21 was admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease, major depressive disorder, seizures, and bipolar disorder. Review of MDS assessment dated [DATE] revealed Resident #21 had a BIMS of 12 that indicated he was cognitively intact. Review of plan of care for Resident #21 dated 04/15/24, revealed the resident did not have a smoking care plan. Resident #21 was at risk for activity of daily living related to episodes of depression severe, with psychotic features, and major depressive disorder. interventions included allow time for rest breaks, encourage resident participation in care, encourage activities, and encourage resident to participate in care. Observation on 07/12/24 at 10:00 A.M. through 10:20 A.M. revealed Resident #21 was smoking outside of the designated smoking area. Resident #21 was alone and had a cigarette, and a lighter in his hand. Interview on 07/12/24 at 10:01 A.M. with Resident #21 who stated he was leaving today and was not going to be at the facility any longer. Resident #21 stated he had his lighter since he had got to the facility on admission day. Resident #21 stated he was upset someone was taking his lighter away. Interview on 07/12/24 at 10:10 A.M. with DON, revealed Resident #21 was not leaving the facility for a discharge. The DON verified Resident #21 was a supervised smoker and was not to have a lighter without staff supervising the lighter. This deficiency represents non-compliance investigated under Complaint Number OH00154641. This deficiency is a recite to the complaint surveys dated 05/13/24 and 06/06/24.

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

Based on observation, staff interview, and review of the dishwasher manual, the facility failed to ensure the dishwasher was functioning to clean and sanitize dishes appropriately. This had the potent...

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Based on observation, staff interview, and review of the dishwasher manual, the facility failed to ensure the dishwasher was functioning to clean and sanitize dishes appropriately. This had the potential to affect 51 of 52 residents in the facility. The facility identified one resident (#15) who did not receive food from the kitchen. The facility census was 52. Findings include: Interview on 07/11/24 at 8:51 A.M. with Dietary Supervisor (DS) #502 confirmed she had called for the dishwasher to be serviced on 07/08/24 and the sanitizer concentration levels had read 0 parts per million (ppm) for a few weeks. DS #502 further confirmed the dishwasher remained in use during the time the sanitizer levels read 0 ppm. DS #502 stated the sanitizer level should be at 50 ppm for safe use. Observation on 07/11/24 at 9:00 A.M. revealed there was a sign on the dish machine indicating the sanitizer level should be 50 ppm for proper use. Observation on 07/11/24 at 9:01 A.M. revealed DS #502 tested the sanitizer level with a test strip and the test strip did not change color indicating the machine did not contain the proper level of sanitizer. Interview on 07/11/24 at 9:02 A.M. with DS #502 confirmed the sanitizer level tested at 0 ppm and should test at 50 ppm for proper use. Interview on 07/11/24 at 2:03 P.M. with Service Technician (ST) #507 confirmed he came to the facility to service the dishwasher because the sanitizer was not testing at the appropriate level. ST #507 verified the sanitizer was reading 0 ppm and stated the bucket of sanitizer was empty, causing the sanitizer levels to read at 0 ppm. ST #507 stated the machine should run with a sanitizer level of 50 ppm to ensure proper cleaning and sanitation of dishes. Observation on 07/11/24 at 2:05 P.M. revealed the sanitizer bucket was empty. Further observation revealed the sanitizer bucket had a delivery date of 02/12/24. There was no date observed on the bucket to indicate when the bucket was opened. Interview on 07/11/24 at 2:09 P.M. with DS #502 confirmed the sanitizer bucket that was being used for the dishwasher was empty and had a delivery date of 02/12/24. DS #502 stated she was unsure when the bucket had been opened and stated [NAME] #334 managed all of the chemicals in the kitchen. DS #502 stated when chemicals in the kitchen needed refilled [NAME] #334 was responsible for ordering the chemicals. DS #502 stated [NAME] #334 had been off since 07/08/24 and would not return to work until 07/25/24. DS #502 estimated the sanitizer needed to be replaced every 45-60 days. DS #502 confirmed she was unable to locate any invoices showing when sanitizer for the dish machine had last been ordered. Review of the manufacturer's instructions for the dish machine dated 06/07/13 provided by ST #507 revealed sanitizer concentrations should be 50 ppm for safe and proper use.

CONCERN (E) 📢 Someone Reported This

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

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of medical record for Resident #33 revealed an admission date of 04/22/24 with diagnoses including type two diabetes, ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of medical record for Resident #33 revealed an admission date of 04/22/24 with diagnoses including type two diabetes, morbid obesity, other sites of candidiasis, carrier of suspected carrier of methicillin resistant staphylococcus aureus, and chronic kidney disease. Review of physician orders for Resident #33 revealed an order dated 04/22/24 revealed for the resident to have catheter care every shift. There were no orders for EBP. Review of the plan of care for Resident #33 dated 04/23/24 revealed the resident had an indwelling catheter related to obstructive and reflux uropathy. Interventions included the resident should be placed in EBP. Review of the Minimum Data Set (MDS) assessment for Resident #33 dated 06/21/24 revealed the resident #33 was cognitively intact and required staff assistance with activities of daily living (ADLs.) 5. Review of medical record for Resident #16 revealed an admission date 04/16/24 with diagnoses including mood disorder, schizophrenia, presence of artificial hip, Huntington's disease, and dementia. Review of MDS for Resident #16 dated 04/23/24 revealed the resident severely cognitively impaired and required moderate assistance with ADLs. Review of physician orders for Resident #16 revealed an order dated 06/25/24 revealed to cleanse the left hip wound, apply Santyl and cover with moistened gauze and a border dressing. There were no physician orders for EBP. Review of the wound progress note for Resident #16 dated 07/09/24 revealed the resident had a full thickness wound with slough tissue which showed clinical signs of infection. Observations on 07/09/24 at 9:55 A.M. revealed Residents #16 and #33 had no signs posted indicating they were in EBP and there was no personal protective equipment (PPE) available outside the residents' rooms. Interview on 07/09/24 at 10:00 A.M. with the Director of Nursing (DON) confirmed Residents #16, and #33 were not in EBP but both residents should have been placed in EBP. The DON further confirmed Resident #16 should have been in EBP because of his full thickness hip wound, and Resident #33 should have been in EBP because he had an indwelling catheter. Review of the facility policy titled Enhanced Barrier Precautions dated 04/01/24 revealed the facility would utilize EBP to prevent broader transmission of multidrug-resistant organisms and to help protect patients with chronic wounds and indwelling devices. EBP was described as the use of gowns and gloves during high contact resident care activities. Residents who required EBP included residents with open wounds and indwelling medical devices. Physician orders would be obtained and reflected in the resident's medical record. Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure residents with wounds and indwelling medical devices were placed in enhanced barrier precautions (EBP). This affected five (#14, #15, #16, #28, and #33) of five residents reviewed for EBP. The facility census was 52 residents. Findings include: 1. Review of the medical record for Resident #14 revealed an admission date of 01/20/22 with diagnoses including congestive heart failure, osteomyelitis, alcohol dependence, open wound right ankle, systemic lupus, schizoaffective disorder, major depressive disorder. Review of the quarterly Minimum Data Set (MDS) for Resident #14 assessment dated [DATE] revealed the resident had intact cognition, refused care daily, and required supervision or touching assistance with activities of daily living (ADLs.) Review of the non pressure skin grid for Resident #14 dated 07/05/24 revealed the resident had an unstageable vascular ulcer to his right lower extremity. Review of the medical record for Resident #14 revealed no physician orders for EBP. Observations on 07/08/24 at 10:49 A.M. and 07/09/24 at 10:25 A.M. revealed the door to Resident #14's room did not contain any type of notification of the resident being in EBP. There was no personal protective equipment (PPE) observed outside of Resident #14's room. Interview on 07/09/24 at 10:30 A.M. with Registered Nurse (RN) #368 confirmed Resident #14 had a wound and the door to his room did not contain any signage for EBP. RN #368 further confirmed there were no gowns or gloves outside Resident #14's room for staff to utilize when necessary. 2. Review of the medical record for Resident #15 revealed an admission date of 03/12/14 with diagnoses including hemiplegia, chronic obstructive pulmonary disease (COPD), bladder neoplasm, congestive heart failure, bipolar disorder, cerebral infarction, gastrostomy status. Review of the MDS assessment for Resident #15 dated 06/10/24 revealed the resident had severely impaired cognition and was dependent on staff for ADLs. Review of the physician orders for Resident #15 revealed the resident had an enteral feeding tube with physician orders to verify tube placement prior to medication administration, flush the tube with water before and after each med pass, flush tube with water every four hours, and to administer tube feeding from 6:00 P.M. to 10:00 A.M. daily. There were no physician orders for EBP. Observations on 07/08/24 at 10:39 A.M. and 07/09/24 at 8:20 A.M. revealed the door to Resident #15's room did not contain any signage to indicate Resident #15 was on EBP. There was no personal protective equipment (PPE) observed outside of Resident #15's room. Interview on 07/09/24 at 8:23 A.M. with RN #368 confirmed Resident #15 had a feeding tube and did not have any orders for isolation precautions, nor did Resident #15's door contain any signage for EBP nor were any gowns or gloves available outside the room for staff use. 3. Review of the medical record of Resident #28 revealed an admission date of 07/26/22 with diagnoses including COPD, peripheral vascular disease, chronic venous hypertension with ulcer of right lower extremity. Review of the MDS assessment for Resident #28 dated 05/16/24 revealed the resident had intact cognition. Review of the non pressure skin grid for Resident #28 dated 07/09/24 revealed the resident had vascular ulcers to his right and left lower extremities. Review of the medical record for Resident #28 revealed no physician orders for EBP. Observations on 07/08/24 at 10:11 A.M. and 07/09/24 at 10:25 A.M. revealed the door to Resident #28's room did not contain any type of notification of the resident being in EBP. There was no personal protective equipment (PPE) observed outside of Resident #28's room. Interview on 07/09/24 at 10:30 A.M., Registered Nurse (RN) #368 confirmed Resident #28 had a wound and the door to his room did not contain any signage for EBP. RN #368 further verified there were no gowns or gloves outside Resident #28's room for staff to utilize when necessary.

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 F0883 (Tag F0883)

Could have caused harm · This affected multiple residents

Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure residents were offered pneumococcal and influenza vaccinations. This affected five (Re...

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Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure residents were offered pneumococcal and influenza vaccinations. This affected five (Resident #2, #5, #16, #33, and #47) of five residents reviewed for vaccinations. The facility census was 52 residents. Findings include: Review of the medical record for Resident #2 revealed an admission date of 08/25/23. Further review of the record revealed it did not include documentation regarding receipt or refusal of the pneumococcal or influenza vaccines. Review of the medical record for Resident #5 revealed an admission date of 11/06/23. Further review of the record revealed it did not include documentation regarding receipt or refusal of the pneumococcal or influenza vaccines. Review of the medical record for Resident #16 revealed an admission date of 04/16/24. Further review of the record revealed it did not include documentation regarding receipt or refusal of the pneumococcal or influenza vaccines. Review of the medical record for Resident #33 revealed an admission date of 04/22/23. Further review of the record revealed it did not include documentation regarding receipt or refusal of the pneumococcal or influenza vaccines. Review of the medical record for Resident #47 revealed an admission date of 12/26/23. Further review of the record revealed it did not include documentation regarding receipt or refusal of the pneumococcal or influenza vaccines. Interview on 07/13/24 at 8:45 P.M. with the Administrator confirmed the facility had no documentation of receipt or refusal of pneumococcal or influenza vaccines for Residents #2, #5, #16, #33, and #47.

CONCERN (F)

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

Deficiency F0727 (Tag F0727)

Could have caused harm · This affected most or all residents

Based on review of nursing schedules and staff interview, the facility failed to ensure the supervision by a Registered Nurse (RN) for eight consecutive hours daily. This had the potential to affect a...

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Based on review of nursing schedules and staff interview, the facility failed to ensure the supervision by a Registered Nurse (RN) for eight consecutive hours daily. This had the potential to affect all of the residents residing in the facility. The facility census was 52 residents. Findings include: Review of nursing schedule dated 06/16/24 revealed there was no RN scheduled. Interview on 07/17/24 at 9:43 A.M. with the Director of Nursing (DON) confirmed the facility did not have an RN work on 06/16/24.

Jun 2024 7 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review observations, staff and resident interviews, and policy review, the facility failed to ensure the call li...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review observations, staff and resident interviews, and policy review, the facility failed to ensure the call light was within a resident's reach. This affected one (#47) out of three residents reviewed for call lights. The facility census was 55. Findings include: Review of the medical record for Resident #47 revealed an admission date of 10/02/23 with medical diagnoses of diabetes mellitus with chronic kidney disease, chronic obstructive pulmonary disease (COPD), depression, dementia with behavioral disturbances. Review of the medical record revealed a quarterly Minimum Data Set (MDS) assessment dated [DATE] which indicated Resident #47 had moderately impaired cognition and required substantial staff assistance with toilet hygiene, bathing, and bed mobility. The MDS also noted Resident #47 had highly impaired vision. Observation and interview on 06/04/24 at 10:34 A.M. of Resident #47 revealed the call light was resting on the headboard of Resident #47's bed and was not within her reach or line of vision. Interview with Resident #47 stated she was not able to reach her call light and that her call light did not work. Observation and interview on 06/04/24 at 10:36 A.M. with Licensed Practical Nurse (LPN) #277 confirmed Resident #47's call light was not within reach and not in her line of vision. LPN #277 confirmed Resident #47 did not have any other means to notify staff if she needed assistance. Review of the facility policy titled, Call Light, dated December 2020 stated the facility would ensure timely response to resident's call light to ensure needs are being met. The policy stated the call light is used by a resident to notify staff of the nursing facility that the resident has a need that they would like addressed. The policy further stated that the call light would be left within the reach of the resident before leaving the resident's room. This deficiency represents non-compliance investigated under Complaint Numbers OH00154373 and OH00153975.

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, staff and resident interviews, and policy review, the facility failed implement th...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, staff and resident interviews, and policy review, the facility failed implement their smoking policy to ensure a resident who smokes was assessed upon admission. Additionally, the facility failed to provide adequate interventions and/or supervision to ensure resident's smoking materials were properly secured per the facility smoking policy. This affected two (#51 and #46) out of three residents reviewed for smoking. The facility census was 55. Findings include: 1. Review of the medical record for Resident #51 revealed an admission date of 05/14/24 with medical diagnoses of paraplegia, anxiety, bipolar disorder, chronic hepatitis C, schizoaffective disorder, and congestive heart failure. Review of the medical record for Resident #51 revealed an admission Minimum Data Set (MDS) assessment dated [DATE] which indicated Resident #51 was cognitively intact and was dependent upon staff for toilet hygiene, requires substantial staff assistance for bathing and moderate staff assistance for bed mobility and transfers. The MDS indicated Resident #51 used tobacco. Review of the medical record for Resident #51 revealed a care plan dated 05/15/24 which stated resident was at risk for injury related to smoking and that resident had history of burning himself with cigarettes. The care plan indicated an intervention for staff to keep cigarettes, lighters, and matches in designated area. Review of the medical record for Resident #51 revealed a nurse progress note dated 05/25/24 at 2:26 A.M. stated at approximately 11:30 P.M., the fire alarm was activated. This nurse followed fire protocol to ensure the safety of residents by checking all rooms for visible smoke or fire. Visible smoke observed from resident's room. Doors were closed per fire alarm activation. Upon entering the room, Resident #51's bed linen had a small flame upon it with resident's hand within reach. Resident #51 admitted to this nurse that he had been smoking in room but forgot cigarette was still lit. This nurse removed linen with flames to floor and smothered object until State Tested Nursing Assistant (STNA) retrieved fire extinguisher to further douse flame. Resident #51 observed sleeping, unaware of flames in bed. Resident #51 had no obvious sign/symptoms of injury or inhalation during this event. Resident #51 transferred self into wheelchair but adamantly refused to leave smoke-filled room until obtaining other objects needed to smoke. Emergency Medical Services (EMS) notified, and fire EMS arrived to further evaluate and make scene safe. Director of Nursing (DON) notified. Resident #51 unwilling to cooperate with fire EMS to ensure safety of room. Fire EMS notified police to help further secure the scene. This nurse confiscated smoking objects from the resident and put them away for safe keeping. Resident #51 transferred to a new room due to smoke. Review of the medical record for Resident #51 revealed no documentation to support the facility completed a smoking assessment upon admission on [DATE]. Review of the medical record revealed a smoking assessment, dated 05/25/24, which indicated Resident #51 was a supervised smoker and the facility was to store Resident #51's cigarettes and lighters. Review of the medical record revealed a Social Service note dated 05/27/24 at 12:45 P.M. which stated the nurse notified her that Resident #51 had a lighter. The note stated the Social Service staff recovered the lighter and had the nurse to secure. Observation on 06/05/24 at 10:15 A.M. revealed Resident #51 had a cigarette in his hand and was entering his room. Interview on 06/05/24 at 12:18 P.M. with Administrator and Director of Nursing (DON) confirmed there was a fire in Resident #51's room on 05/25/24. DON stated staff and resident education was done on 05/25/24 on the smoking policy and procedures, stated the rooms of the residents who smoke were searched smoking materials and any items found were confiscated, and staff were notified that all smokers were to be supervised during designated smoking times. The Administrator and DON confirmed Resident #51 should not have any smoking materials in his possession per the facility smoking policy. DON stated Resident #51's mother would bring him in cigarettes and lighters without notifying the staff. Administrator stated Resident #51's mother was educated on the smoking policy and procedures and the facility issued Resident #51 a 30-day discharge notice. Interview on 06/05/24 at 1:50 P.M. with Resident #51 confirmed he smoked in his room on 05/25/24 and a washcloth caught on fire. Resident #51 stated he thought he put the lite cigarette out in the washcloth, and he fell asleep. Resident #51 stated he was awakened by a nurse and notified him the washcloth was on fire. Resident #51 stated the nurse was able to put out the small flame and he did not sustain any injuries. Resident #51 stated the facility provided education on smoking policy and procedures. Resident #51 confirmed the facility confiscated a lighter from his room on 05/27/24. 2. Review of the medical record for Resident #46 revealed an admission date of 09/14/23 with medical diagnoses of anxiety, depression, hypertension and hyperlipidemia. Review of the medical record for Resident #46 revealed a quarterly MDS assessment dated [DATE] which indicated the resident was cognitively intact and was independent with mobility. Further review of Resident #46's medical record revealed the resident was identified as a supervised smoker and smoking material was to be in a secured in a designated area. Observation on 06/05/24 at 12:39 P.M. noted that Resident #46 was observed placing cigarette packs into the basket of her walker. Interview on 06/05/24 at 12:42 P.M. with Maintenance #201 confirmed Resident #46 had packs of cigarettes stored in the basket portion of her walker. Maintenance #201 confirmed Resident #46 was a supervised smoker and all smoking materials should be kept in a designated area per the facility policy. Review of the facility policy titled, Smoking,, revised 11/04/22 stated the facility would make every best effort to establish and maintain safe resident smoking practices that accommodate the resident's needs. The policy stated residents would be evaluated upon admission and routinely to determine if he or she is able to smoke safely with or without supervision (per smoking assessment). The policy also stated smoking is only permitted in designated smoking areas and all smoking materials, including e-cigarettes would be stored in a secure location by the facility staff. This deficiency is based on incidental findings discovered during the course of this complaint investigation. This deficiency represents ongoing noncompliance from the survey dated 05/13/24.

CONCERN (D) 📢 Someone Reported This

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

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record reviews, staff interviews, and policy review, the facility failed to ensure residents were free from sig...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record reviews, staff interviews, and policy review, the facility failed to ensure residents were free from significant medication errors. This affected two (#23 and #47) residents out of the three residents reviewed for medications administered as ordered. The facility census was 55. Findings include: 1. Review of the medical record for Resident #23 revealed an admission date of 08/24/21 with medical diagnoses of COPD, hypertension (HTN), convulsions, anxiety, liver disease, and depression. Review of the medical record for Resident #23 revealed a quarterly Minimum Data Set (MDS) assessment dated [DATE] which indicated Resident #23 was cognitively intact and was independent with toileting, bed mobility, transfers, and required supervision with showers. Review of the medical record for Resident #23 revealed physician orders dated 10/23/23 for Celebrex 100 milligram (mg) one capsule by mouth two times per day and for Elavil sleep tablet 25 mg one tablet by mouth at bedtime, orders dated 10/24/23 for melatonin 3 mg one tablet by mouth at bedtime, metoprolol 25 mg one tablet by mouth two times per day, and Seroquel 25 mg one tablet by mouth two times per day and an order dated 02/17/24 Norco 5-325 mg one tablet by mouth two times per day. Review of the medical record for Resident #23 revealed the May 2024 Medication Administration Record did not contain documentation to support Resident #23 received Celebrex, Elavil, melatonin, metoprolol, Seroquel, or Norco as ordered on 05/08/24. 2. Review of the medical record for Resident #47 revealed an admission date of 10/02/23 with medical diagnoses of diabetes mellitus with chronic kidney disease, chronic obstructive pulmonary disease (COPD), depression, dementia with behavioral disturbances. Review of the medical record revealed a quarterly MDS assessment dated [DATE] which indicated Resident #47 had moderately impaired cognition and required substantial staff assistance with toilet hygiene, bathing, and bed mobility. The MDS also noted Resident #47 had highly impaired vision. Review of the medical record for Resident #47 revealed physician orders dated 10/02/23 for Dorzolamide-timolol ophthalmic solution 22.3-6.6 mg per milliliter (ml) to install one drop in both eyes two times per day, fluticasone-salmeterol inhalation 250-50 microgram per actuation one puff every 12 hours, carvedilol 3.125 mg one tablet by mouth two times per day, pregabalin 75 mg one capsule by mouth two times per day, Brimonidine Tartrate Ophthalmic solution 0.2% instill one drop to both eyes three times per day, Tylenol 650 mg one tablet by mouth every eight hours, physician orders dated 10/03/23 for cholecalciferol 25 micrograms (mcg) one tablet by mouth daily, duloxetine 60 mg one tablet by mouth daily, escitalopram oxalate 10 mg one tablet by mouth daily and to take with 5 mg tablet for total of 15 mg, escitalopram oxalate 5 mg one tablet by mouth daily and to take with 10 mg tablet for total of 15 mg, and folic acid 1 gram by mouth daily, orders dated 10/16/23 for cefadroxil 500 mg one capsule by mouth two times per day and furosemide 20 mg one tablet by mouth two times per day, an order dated 01/24/24 for metformin 1000 mg one po two times per day, and an order dated 02/17/24 Basaglar Kwikpen (insulin) 100 unit/ml to inject 18 units subcutaneously every morning at 6:00 A.M. Review of the medical record for Resident #47 revealed the May 2024 MAR revealed Resident #47 did not contain documentation to support Resident #47 received the dorzolamide-timolol ophthalmic solution eye drops, fluticasone-salmeterol inhaler, carvedilol, pregabalin, brimonidine tartrate eye drops, Tylenol, cholecalciferol, duloxetine, escitalopram, folic acid, cefadroxil, furosemide, metformin, and Basaglar Kwikpen as ordered on 05/21/24. Interview on 06/05/24 at 10:30 A.M. with Director of Nursing (DON) confirmed the medical record for Resident #23 did not contain documentation to support medications were administered as ordered on 05/08/24 and the medical record for Resident #47 did not contain documentation to support medications were administered as ordered on 05/21/24. Review of the facility policy titled, Medication Administration, revised November 2018, the policy stated medications are to be administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. This deficiency represents non-compliance investigated under Complaint Number OH00153942. This deficiency represents ongoing noncompliance from the survey dated 04/11/24 and 05/13/24.

CONCERN (D) 📢 Someone Reported This

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

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

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview, the facility failed to ensure resident's medications were admi...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview, the facility failed to ensure resident's medications were administered as ordered resulting in two medication errors out of 30 opportunities or a 6.66 percent (%) medication error rate. This affected one (#53) out of two residents observed for medication administration. The facility census was 55. Findings include: Review of the medical record for Resident #53 revealed an admission date of 04/24/17 with medical diagnoses of cerebral infarction, right sided hemiparesis, paranoid schizophrenia, and bipolar disorder. Review of the medical record for Resident #53 revealed a quarterly Minimum Data Set (MDS) assessment dated [DATE] which indicated Resident #53 had moderate cognitive impairment and was independent with eating, toileting, transfers, and bed mobility and required supervision with bathing. Review of the medical record for Resident #53 revealed a physician order dated 09/22/23 for Gabapentin 300 milligram (mg) one tablet by mouth daily, orders dated 09/23/23 for Gabapentin 600 mg one tablet by mouth daily, Azathioprine 50 mg three tablets by mouth daily, Colcrys 0.6 mg one tablet by mouth daily, and Cymbalta 60 mg one tablet by mouth daily, an order dated 09/26/23 for Ziprasidone 80 mg one tablet by mouth two times per day, orders dated 09/29/23 for Buspirone 5 mg one tablet by mouth two times per day and Clonidine 0.1 mg one tablet by mouth two times per day, an order dated 09/29/23 for Keppra 1000 mg by one tablet by mouth two times per day, orders dated 09/30/23 for Prednisone 10 mg one tablet by mouth daily and Budesonide inhalation aerosol powder 90 micrograms per actuation for one puff orally two times per day, an order dated 09/30/23 for Vitamin D3 one tablet by mouth daily, an order dated 10/24/23 for Lidocaine 4% patch one apply to right shoulder topically daily, an order dated 04/06/24 for MiraLAX 17 gram/scoop one scoop mix with water by mouth daily and an order dated 06/01/24 for hydrochlorothiazide 12.5 mg one tablet by mouth daily. Observation on 06/05/24 at 8:15 A.M. of Licensed Practical Nurse (LPN) #229 administer medications to Resident #53. The observation revealed LPN #229 did not apply Lidocaine patch or administer MiraLAX as ordered. Interview on 06/05/24 at 8:20 A.M. with LPN #229 confirmed she had not applied Resident #53's Lidocaine patch and had not administered MiraLAX as ordered. This deficiency represents non-compliance investigated under Complaint Number OH00153942.

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

Laboratory Services (Tag F0770)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and policy review, the facility failed to obtain laboratory work as ordered. Thi...

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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 obtain laboratory work as ordered. This affected one (#65) out of the three residents reviewed for nutrition. The facility census was 55. Findings include: Review of the medical record for Resident #65 revealed an admission date of 05/06/22 with medical diagnoses of depression, rhabdomyolysis, severe protein calorie malnutrition, dementia, and schizophrenia. Review of the medical record revealed Resident #65 discharged to the hospital on [DATE]. Review of the medical record for Resident #65 revealed a quarterly Minimum Data Set (MDS) assessment, dated 02/01/24, which indicated Resident #65 had severe cognitive impairment and was independent with transfers and bed mobility but required substantial staff assistance for toileting hygiene and bathing. Review of the medical record for Resident #65 revealed a physician order dated 04/30/24 for the following blood work to be done: comprehensive metabolic panel (CMP), complete blood count (CBC), and thyroid stimulating hormone (TSH). Review of the medical record revealed a lab report dated 04/30/24 which stated the lab was unable to obtain the specimen and on the first attempt the phlebotomist was unable to obtain an adequate sample. The form stated a second phlebotomist would be sent out. Further review of the lab report revealed documentation that the facility nurse was to call the lab to schedule the date for redraw. Review of the medical record for Resident #65 revealed no documentation to support the lab work was drawn as ordered. Interview on 06/05/24 at 10:30 A.M. with Director of Nursing (DON) stated Resident #65 readmitted to the facility from the hospital on [DATE]. DON stated Resident #65 was lethargic and was not eating well upon readmission. DON stated the facility notified the physician of Resident #65's condition and lab work was ordered on 04/30/24. DON stated Resident #65 did not have a guardian or power of attorney in place to make medical decisions. Interviews on 06/05/24 at 12:30 P.M. with Administrator and DON confirmed the medical record for Resident #65 did not contain documentation to support the facility obtained the lab work that was ordered on 04/30/24. DON stated she was not aware that the nurse was to call to schedule a date and time for the lab company to redraw the labs for Resident #65. DON stated Resident #65 was sent back out to the hospital on [DATE] due to change in medical condition and for poor intake and the hospital was able to get emergency guardianship for Resident #65. DON stated the hospital inserted a gastrointestinal tube (g-tube) to provide Resident #65 with enteral nutrition. Review of the facility policy titled, Lab and Diagnostic Test Results- Clinical Protocol, revised November 2018 stated the physician would identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs, staff would process test requisitions and arrange for test. This deficiency represents non-compliance investigated under Complaint Number OH00153991.

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 F0919 (Tag F0919)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, staff and resident interviews, and policy review, the facility failed to ensure the call l...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, staff and resident interviews, and policy review, the facility failed to ensure the call light system was functioning properly. This affected two (#23 and #47) out of the three residents reviewed for call lights not functioning properly. The facility census was 55. Findings include: 1. Review of the medical record for Resident #47 revealed an admission date of 10/02/23 with medical diagnoses of diabetes mellitus with chronic kidney disease, chronic obstructive pulmonary disease (COPD), depression, dementia with behavioral disturbances. Review of the medical record revealed a quarterly Minimum Data Set (MDS) assessment dated [DATE] which indicated Resident #47 had moderately impaired cognition and required substantial staff assistance with toilet hygiene, bathing, and bed mobility. The MDS also noted Resident #47 had highly impaired vision. Observation and interview on 06/04/24 at 10:34 A.M. of Resident #47 revealed the call light was resting on the headboard of Resident #47's bed and was not within her reach or line of vision. Interview with Resident #47 stated she was not able to reach her call light and that her call light did not work. Observation and interview on 06/04/24 at 10:36 A.M. with Licensed Practical Nurse (LPN) #277 confirmed Resident #47's call light was not within reach and not in her line of vision. LPN #277 was observed to press Resident #47's call light button and the call light signal box in Resident #47's room indicated the call light had been turned on. Observation with LPN #277 revealed the call light located outside of Resident #27's room above the door did not indicate the call light had been turned on. LPN #277 confirmed Resident #47 did not have any other means to notify staff if she needed assistance. 2. Review of the medical record for Resident #23 revealed an admission date of 08/24/21 with medical diagnoses of COPD, hypertension (HTN), convulsions, anxiety, liver disease, and depression. Review of the medical record for Resident #23 revealed a quarterly MDS assessment dated [DATE] which indicated Resident #23 was cognitively intact and was independent with toileting, bed mobility, transfers, and required supervision with showers. Observation and interview on 06/04/24 at 11:49 A.M. with Resident #23 stated the call in his room did not work and had not worked for a long time. Resident #23 was observed pressing the call light button in his room. The call light signal box on the wall in Resident #23's room did not indicate the call light had been turned on. Observation of the call light outside of Resident #23's room above the door did not indicate the call light had been turned on. The observation did not reveal any other means for Resident #23 to notify staff if he needed assistance. Interview on 06/04/24 at 12:02 P.M. with Registered Nurse (RN) #236 confirmed the call light for Resident #23's room did not work, and that Resident #23 did not have any other means to notify staff if he needed assistance. Review of the facility policy titled, Call Light, dated December 2020 stated the facility would ensure timely response to resident's call light to ensure needs are being met. The policy stated the call light is used by a resident to notify staff of the nursing facility that the resident has a need that they would like addressed. The policy further stated if a resident's call light is not functioning it should be replaced with an alternative device to notify staff unit it is repaired. This deficiency represents non-compliance investigated under Complaint Numbers OH00154373 and OH00153975. This deficiency represents ongoing noncompliance from the survey dated 05/14/24.

CONCERN (E) 📢 Someone Reported This

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

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

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

Based on observations and staff interviews, the facility failed to provide a comfortable, clean, and homelike environment by not ensuring comfortable air temperatures on 100 Hall. This had the potenti...

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Based on observations and staff interviews, the facility failed to provide a comfortable, clean, and homelike environment by not ensuring comfortable air temperatures on 100 Hall. This had the potential to affect 11 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10 and #11) residents residing on the 100 Hall. Additionally, the facility failed to ensure the facility was free of pervasive odors on 500 Hall. This had the potential to affect 10 (#46, #47, #48, #49, #50, #51, #52, #53, #54, and #55) residents residing on the 500 Hall. The facility census was 55. Findings include: Observation on 06/04/24 at 8:26 A.M. of 500 Hall revealed the pervasive urine odor. Observation on 06/04/24 at 1:21 P.M. revealed the air temperature on 100 Hall to feel very warm. The observation revealed multiple residents walking in the hallways and into rooms on the unit. None of the residents observed appeared to be in any distress. The observation revealed one portable air conditioning unit which was pumping cool air on to the unit. Observation with interview on 06/04/24 at 1:24 P.M. with Maintenance #201 revealed Maintenance #201 used the facility's handheld digital thermometer to take the temperature of the air on 100 Hall. The observation revealed the thermometer read 85.5 degrees Fahrenheit (F). Interview with Maintenance #201 confirmed the 100 Hall's temperature felt very warm and the thermometer read 85.5 degrees F on the unit. Maintenance #201 confirmed the facility had multiple portable air conditioning units in the facility to help keep the temperatures comfortable for staff and residents in the facility. The facility confirmed 11 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10 and #11) residents reside on the 100 Hall. Observation and interview on 06/05/24 at 8:12 A.M. with Licensed Practical Nurse (LPN) #229 revealed 500 Hall to have a pervasive urine odor. LPN #229 confirmed 500 Hall had a pervasive odor and stated the hall usually had a strong urine odor. The facility confirmed 10 (#46, #47, #48, #49, #50, #51, #52, #53, #54, and #55) residents reside on the 500 Hall. This deficiency represents non-compliance investigated under Complaint Number OH00154503. This deficiency represents ongoing noncompliance from the survey dated 04/11/24.

May 2024 3 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interviews, and policy review, the facility failed to provide adequate interventions and/o...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interviews, and policy review, the facility failed to provide adequate interventions and/or supervision to ensure a resident who was assessed as being at risk for elopements did not elope from the facility. This affected one (#26) out of three residents reviewed for elopement. The facility census was 58. Findings included: Review of the medical record for Resident #26 revealed an admission date of 04/25/24 with medical diagnoses of chronic obstructive pulmonary disease, schizoaffective disorder, spinal stenosis, psychosis, and mild neurocognitive disorder. Review of the admission Minimum Data Set (MDS) assessment, dated 05/02/24, indicated Resident #26 had moderate cognitive impairment, had delusions, and had verbal behavioral symptoms towards others. The MDS indicated Resident #26 required set-up assistance with eating, moderate staff assistance with toilet hygiene and dressing, and maximum staff assistance with bathing. The MDS indicated Resident #26 required supervision with transfers and bed mobility. Review of the medical record for Resident #26 revealed an Elopement Risk Screen, completed 04/26/24 at 10:25 A.M. which indicated Resident #26 was at high risk for elopement. Review of the medical record for Resident #26 revealed a nurse progress note dated 04/25/24 at 7:55 P.M. which stated resident was walking around and trying to leave the facility, agitation, having word salad, and flight of ideas. The note stated the physician was notified and an order was received for Haldol 1 milligram (mg) intramuscular every two hours as needed and the Director of Nursing (DON) was notified. Review of the medical record revealed a Social Service note, dated 04/26/24 at 5:17 P.M. which stated met with the resident, daughter, and son upon admission. The note stated Resident #26 did not want to be in the facility and was a flight risk. The note stated Resident #26 was to be one-on-one observation for the weekend. Further review of the medial record revealed a nurse progress note dated 04/26/24 at 11:00 P.M. which stated Resident #26 had an elopement and the DON, Administrator, and Assistant Director of Nursing (ADON) were notified immediately by staff. The note stated the police notified to assist with the search and family were notified. The note stated the Administrator located Resident #26 at a nearby store/gas station and was returned to the facility. The note continued to state Resident #26 was placed back on one-on-one observation. Review of the medical record for Resident #26 revealed a Interdisciplinary Team (IDT) note dated 04/29/24 at 2:48 P.M. which stated IDT met for follow up to Resident #26's elopement on 04/26/24. Resident #26 was admitted on [DATE]. Resident #26 was able to get a ride from another visitor to go to the nearby store/gas station. Staff immediately identified that the resident was missing. Staff notified DON, ADON and Administrator. Police and family were notified. Resident #26 was found at the store/gas station. Resident #26 agreed to get in the car with the Administrator and returned to facility. A head-to-toe assessment was completed, no marks, bruises or scratches identified. The IDT note stated Resident #26 was happy with her return, however, still did not want to be placed in a nursing home. Facility staff discussed with family the need to be placed on a secured unit, family okay with placement. Physician aware of elopement, referral made to psychiatric services for medication management. Resident #26 remained on one-on-one observation as the facility helped the resident adjust to her new placement in a nursing facility. The IDT note stated Resident #26 was placed on the secured unit. Interview on 05/13/24 at 8:10 A.M. with State Tested Nursing Assistant (STNA) #131 confirmed Resident #26 eloped from the facility on 04/26/24 and was found at a nearby store/gas station. STNA #131 stated the nurse who was responsible for providing the one-on-one supervision for Resident #26 left her unattended for a short period of time and Resident #26 eloped from the facility. Interview on 05/13/24 at 8:30 A.M. with DON confirmed Resident #26 had an elopement from the facility on 04/26/24 when the resident was to be on one-on-one observation by staff. The DON stated Resident #26 asked a visitor for a ride. The DON stated Resident #26 did not receive any injuries or had any negative effects from the elopement. DON stated the employee who was responsible for providing the one-on-one supervision was terminated. Review of the facility policy titled, Elopement, revised 09/03/19, stated the facility was to ensure that a resident's environment was safe while using the least restrictive measures possible. The policy also stated if a resident was at risk for elopement, an individualized care plan would be implemented to prevent elopement. The deficiency is based on incidental findings discovered during the course of this complaint investigation.

CONCERN (D) 📢 Someone Reported This

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

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure proper disposal of medications after a residen...

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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 ensure proper disposal of medications after a resident was discharged from the facility. This affected one (#60) out of three residents reviewed for medication disposition after discharge from the facility. The facility census was 58. Findings include: Review of the medical record for Resident #60 revealed an admission date of 07/10/23 with medical diagnoses of pneumonia, severe protein calorie malnutrition, Human Immunodeficiency Virus (HIV), Hepatitis C, and asthma. Review of the medical record revealed Resident #60 was discharged to the hospital on [DATE] and did not return to the facility. Review of the medical record for Resident #60 revealed an admission Minimum Data Set (MDS) assessment, dated 07/17/23, which indicated Resident #60 was cognitively intact and required supervision with bed mobility, transfers, toileting, and bathing. The MDS indicated Resident #60 required extensive staff assistance with eating. Review of the medical record for Resident #60 revealed a physician order dated 08/30/23 for hydroxyzine 25 milligram (mg) tablet give one tablet via gastrostomy tube (g-tube) three times per day for anxiety; physician orders dated 08/31/23 for Bictegravir-emtricitab-Tenofov oral tablet 50-200-25 mg give one tablet via g-tube daily for HIV; sertraline 25 mg tablet give 0.5 tablet via g-tube daily for depression; and a physician order dated 09/15/23 for doxycycline hyclate 100 mg tablet give one tablet by mouth two times per day for pneumonia. Review of the Medication Administration Record (MAR) for September 2023 revealed Resident #60 received his medications as ordered. Review of the MAR revealed Resident #60 refused to take his medications often. Review of the medical record for Resident #60 revealed no documentation related to the disposition of the Resident #60's medications upon discharge to the hospital and not returning to the facility. Interview on 05/09/24 at 10:22 A.M. with Director of Nursing (DON) stated when a resident discharged to the hospital and did not return to the facility, the resident's medications are sent back to the pharmacy and the narcotics are destroyed by two licensed nurses. Interview on 05/13/24 at 2:00 P.M. with DON confirmed the facility did not have any documentation to support Resident #60's medications were sent back to the pharmacy, or any documentation related to the disposition of Resident #60's medications upon discharge. DON stated the facility did not have a policy for the disposition of a resident's medications upon discharge from the facility. This deficiency represents non-compliance investigated under Complaint Number OH00153557. This deficiency represents ongoing noncompliance from the survey dated 04/11/24.

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 F0919 (Tag F0919)

Could have caused harm · This affected 1 resident

Based on record review, observations, staff and resident interviews, and facility policy review, the facility failed to ensure a resident's call light was functioning properly. This affected one (#02)...

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Based on record review, observations, staff and resident interviews, and facility policy review, the facility failed to ensure a resident's call light was functioning properly. This affected one (#02) out of the three residents reviewed for call lights. The facility census was 58. Findings include: Review of the medical record for Resident #02 revealed an admission date of 08/03/21 with medical diagnoses of chronic respiratory failure, cirrhosis of the liver, cerebral infarction, and anemia. Review of the medical record for Resident #02 revealed an annual Minimum Data Set (MDS) assessment, dated 04/15/24, which indicated Resident #02 had moderate cognitive impairment and required supervision with eating, toilet hygiene, transfer, bed mobility, and bathing. Interview and observation on 05/09/24 at 9:10 A.M. with Resident #02 revealed his call light had not worked for a few weeks. Resident #02 was observed to press his call light button. The observation revealed the call light indication box in Resident #02's room signaled the call light turned on, but the call light located outside Resident #02's room above his door did not turn on and there was no sound alerting staff the call light had been turned on. Resident #02 stated the facility had not provided him with alternate device to use to notify staff he needed assistance. Interview and observation on 05/09/24 at 9:11 A.M. with State Tested Nursing Assistant (STNA) #101 confirmed Resident #02's call light signaled as on in the room, but the light located outside of Resident #02's room above the door was not signaling the call light as on. STNA #101 stated Resident #02's call light had not been working for a while and that maintenance was aware of the issue. STNA #101 stated the facility's call light system does not sound but the light outside of Resident #02's rooms turn on when the resident pushes the call light button. STNA #101 confirmed Resident #02 did not have an alternate device to notify staff he needed assistance. Interview on 05/09/24 at 10:09 A.M. with Maintenance Director #124 stated he had not received any work orders recently for call light repair. Maintenance Director #124 stated he was not aware the call light in Resident #02's room was not working properly. Interview on 05/09/24 at 10:21 A.M. with Director of Nursing (DON) confirmed she was aware the facility had issues with the call light system and stated a new call light system was to be placed soon. DON stated all residents were to be given a bell to use to call staff for assistance when needed if their call light was not working. Review of the facility policy titled, Call light, dated December 2023, stated the facility would ensure timely response to resident's call light to ensure needs are being met. The policy stated the call light was to be used by a resident to notify the nursing facility that the resident has a need that they would like addressed. The policy also stated that if a resident's call light was not functioning it should be replaced with an alternative device to notify staff until it was repaired. The deficiency is based on incidental findings discovered during the course of this complaint investigation.

Apr 2024 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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

Based on medical record reviews, staff interview, and policy review, the facility failed to administer medications as ordered. This affected three (#31, #37, and #42) out of the three residents review...

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Based on medical record reviews, staff interview, and policy review, the facility failed to administer medications as ordered. This affected three (#31, #37, and #42) out of the three residents reviewed for medication administration. The facility census was 50. Findings include: 1. Review of the medical record for resident #31 revealed an admission date of 01/20/22 with medical diagnoses of congestive heart failure (CHF), hypertension (HTN), hyperlipidemia, glaucoma in the right eye, and convulsions. Review of the medical record for Resident #31 revealed a quarterly Minimum Data Set (MDS) assessment, dated 03/14/24, which indicated Resident #31 was cognitively intact and was independent with bed mobility, required supervision with toilet hygiene and transfers and moderate staff assistance with bathing. Review of the medical record for Resident #31 revealed physician orders dated 02/04/24 for meclizine 12.5 milligram (mg) one tablet by mouth three times per day, carvedilol 3.125 mg one tablet by mouth two times per day, Tylenol extra strength 500 mg two tablet by mouth every eight hours, gabapentin 100 mg two tablet by mouth three times per day, and atorvastatin 10 mg one tablet by mouth every evening and physician orders dated 02/05/24 for Mobic 15 mg one tablet by mouth two times per day, ferrous sulfate 325 mg one tablet by mouth daily, multivitamin one tablet by mouth daily, and Lasix 20 mg one tablet by mouth daily. Further review revealed physician orders dated 02/06/24 for hydralazine 50 mg one tablet by mouth two times per day, physician orders dated 02/07/24 for acetazolamide 250 mg two tablets by mouth three times per day and brimonidine tartrate ophthalmic solution 0.2% instill one drop to right eye three times per day, and a physician order dated 02/13/24 for norco 5-325 mg one tablet every 6 hours and gabapentin 300 mg two capsules three times per day. Review of the medical record for Resident #31 revealed the Medication Administration Record (MAR) for February 2024 did not contain documentation to support the following medications were administered as ordered on 02/09/24: ferrous sulfate, Lasix, multivitamin, acetazolamide, brimonidine tartrate ophthalmic solution, gabapentin, meclizine, hydralazine, and Tylenol extra strength. Further review revealed the March 2024 MAR did not contain documentation to support the following medication were administered as ordered on 03/08/24 and 03/15/24: brimonidine tartrate ophthalmic solution 0.2%, gabapentin, meclizine, and Norco. 2. Review of the medical record for Resident #37 revealed an admission date of 09/04/18 with medical diagnoses of diabetes mellitus with polyneuropathy, chronic kidney disease, anemia, and right hemiplegia. Review of the medical record for Resident #37 revealed a quarterly MDS assessment, dated 03/04/24, which indicated Resident #37 had severe cognitive impairment and was dependent for toilet hygiene, required maximum staff assistance for transfers and bed mobility and was set-up only for eating. Review of the medical record for Resident #37 revealed a physician order dated 08/18/23 for Novolog injection solution 100 units per milliliter (ml), inject subcutaneous (SQ) with meals per sliding scale: 0-49 no insulin and notify physician, 50-199= zero units, 200-249 = two units, 250-299= four units, 300-349= six units, 350-399= eight units, 400-450= ten units, and 451-600= 12 units and notify the physician, an order dated 02/21/23 for metoprolol 50 mg one tablet by mouth two times per day, an order dated 03/12/23 for atorvastatin 10 mg one tablet by mouth daily, physician orders dated 10/23/23 for amlodipine desylate 10 mg one tablet by mouth every evening, Prazosin 1 mg one capsule by mouth every evening, oxcarbazepine 300 mg one tablet by mouth two times per day, oxcarbazepine 150 mg one tablet by mouth two times per day, neudexta 20-10 mg one capsule by mouth two times per day, lorazepam 0.5 mg one tablet by mouth two times per day, buspirone 10 mg one tablet by mouth two times per day, and Seroquel 200 mg one tablet by mouth four times per day, physician orders dated 10/24/23 for aspirin 81 mg one tablet by mouth daily and docusate sodium 100 mg one tablet by mouth daily. Further review revealed physician orders dated 10/25/23 for Norco 5-325 mg one capsule by mouth two times per day, an order dated 11/23/23 for Vistaril 25 mg one capsule by mouth two times per day, an order dated 12/07/23 for Zoloft 25 mg one tablet by mouth every evening, and order dated 12/24/23 for Lantus 100 units per ml, inject 40 units SQ every evening, and an order dated 02/06/24 for glipizide 5 mg one tablet by mouth every morning. Review of the medical record for Resident #37 revealed MAR for March 2024 did not contain documentation to support the following medications were administered as ordered on 03/12/24: Lantus, Zoloft, buspirone, ferrous sulfate, metoprolol, Norco, neudexta, oxcarbazepine, Vistaril, amlodipine, atorvastatin, Prazosin, and lorazepam. Further review revealed no documentation to support Isosorbide was administered as ordered on 03/08/24, 03/13/24, 03/15/24, and 03/22/24. Review of the March 2024 MAR revealed no documentation to support Seroquel was administered as ordered on 03/13/24, 03/15/24, 03/22/24, and 03/24/24. Review of the April 2024 MAR revealed no documentation to support the following medications were administered as ordered on 04/05/24: aspirin, Isosorbide, and Seroquel. Further review of the April 2024 MAR revealed no documentation to support the following medications were administered as ordered on 04/09/24: docusate sodium, glipizide, buspirone, ferrous sulfate, lorazepam, metoprolol, Norco, neudexta, oxcarbazepine, Vistaril, Isosorbide, Seroquel, and Novolog per sliding scale. 3. Review of the medical record for Resident #42 revealed an admission date of 09/13/23 with medical diagnoses of diabetes mellitus with neuropathy, hypertensive heart disease with heart failure, anemia, and chronic pain. Review of the medical record for Resident #42 revealed a quarterly MDS assessment, dated 03/20/24, which indicated Resident #42 was cognitively intact and required supervision with bed mobility, showers, transfers, and toilet hygiene. Review of the medical record for Resident #42 revealed physician orders dated 09/13/23 for tamsulosin 0.4 mg one capsule by mouth every evening, atorvastatin 20 mg one tablet by mouth every evening, metformin 500 mg one tablet by mouth two times per day, melatonin 10 mg one tablet by mouth every evening, orders dated 09/14/23 for meloxicam 7.5 mg one tablet by mouth daily, citalopram 20 mg one tablet by mouth daily, glipizide 5 mg one tablet by mouth daily, clopidogrel bisulfate 75 mg one tablet by mouth daily, ferrous sulfate 325 mg one tablet by mouth daily, an order dated 09/15/23 for Jardiance 10 mg one tablet by mouth daily, and an order dated 01/25/24 for gabapentin 400 mg two capsules by mouth every six hours. Further review of the physician orders revealed an order dated 03/27/24 for duloxetine 30 mg one tablet by mouth daily. Review of the medical record for Resident #42 revealed the MAR for February 2024 did not contain documentation to support the following medications were administered as ordered on 02/07/24: citalopram, clopidogrel bisulfate, ferrous sulfate, gabapentin, glipizide, Jardiance, or meloxicam. Further review of the February 2024 MAR revealed no documentation to support Resident #42's metformin was administered as ordered on 02/24/24 or gabapentin was administered as ordered on 02/04/24, 02/09/24, 02/10/24, and 02/22/24. Review of the Resident #42's March 2024 MAR revealed no documentation to support the following medications were administered as ordered on 03/12/24 and 03/18/24: atorvastatin, melatonin, tamsulosin, and metformin. Further review of the March MAR revealed no documentation to support gabapentin was administered as ordered on 03/08/24, 03/13/24, 03/15/24, 03/19/24, and 03/22/24. Review of Resident #42's April MAR revealed no documentation to support the following medications were administered on 04/09/24: clopidogrel bisulfate, duloxetine, ferrous sulfate, glipizide, Jardiance, meloxicam, metformin, and gabapentin. Interview on 04/11/23 at 1:32 P.M. with Director of Nursing (DON) confirmed the medical records for Residents #31, #37, and #42 did not contain documentation that the medications stated above where administered as ordered. Review of the facility policy titled, Medication Administration, revised November 2018, stated medications are to be administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. This deficiency represents non-compliance investigated under Complaint Numbers OH00152180 and OH00151636.

CONCERN (E) 📢 Someone Reported This

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

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

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

Based on observations, resident and staff interviews and review of Resident Council Meeting minutes, the facility failed to ensure the 200 Hall shower was in good working condition for resident use. T...

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Based on observations, resident and staff interviews and review of Resident Council Meeting minutes, the facility failed to ensure the 200 Hall shower was in good working condition for resident use. This affected one (#31) out of the residents reviewed for functioning shower and also had the potential to affect nine (#26, #28, #30, #31, #32, #33, #34, #35 and #36) residents who reside on the 200 hallway that utilize the shower room. Additionally, the facility failed to ensure the roof did not leak onto the resident hallway on the 500 hall. This had the potential to affect 10 (#55, #56, #57, #58, #59, #60, #61, #62, #63 and #64) residents who reside on the 500 hallway where the room was leaking. The facility census was 50. Findings include: Observation on 04/11/24 at 7:21 A.M. revealed water was leaking from the ceiling onto the hallway floor, into a large trash can, a small bucket, and onto a large white towel on the 500 Hall. The observation revealed the area of the floor with water was three feet wide by two feet long and there was not a wet floor sign present. Observation on 04/11/24 at 8:35 A.M. of the shower room on the 200 Hall revealed the shower head was missing from the shower, eight areas of a black substance, about the size of a dime, was observed on the ceiling tiles above the shower, and several areas of black substances, about the size of a pencil eraser, were observed on the grout near the bottom of the shower. The observation revealed the shower faucet worked but the water pressure was poor. Interview on 04/11/24 at 7:24 A.M. with Director of Nursing (DON) confirmed that ceiling was leaking water onto the 500 Hall hallway floor, into a large trash can, a small bucket, and onto a large white towel. DON confirmed the hallway did not contain a wet floor sign to caution staff or residents of the water on the floor. The facility confirmed there are 10 (#55, #56, #57, #58, #59, #60, #61, #62, #63 and #64) residents who reside on the 500 hallway where the room was leaking. Interview on 04/11/24 at 8:25 A.M. with State Tested Nursing Assistant (STNA) #103 confirmed the shower for the 200 Hall had not been in proper working condition for a while. STNA #103 stated the 200 Hall shower was missing a shower head and the water did not have much pressure. STNA #103 confirmed the 200 Hall shower contained a black substance on the ceiling tiles over the shower and grout at the bottom of the shower. Interview on 04/11/24 at 8:30 A.M. with Resident #31 confirmed he resided on the 200 Hall and stated the shower on 200 Hall did not have any water pressure, was missing a shower head, and he believed there was mold in the shower. Resident #31 stated staff offered to give him a shower in the 500 Hall shower but Resident #31 stated too many residents took showers in that shower room and it was hard to get a time to shower. Interview on 04/11/24 at 11:50 A.M. with Administrator confirmed the shower in the 200 Hall shower room was missing a shower head. Administrator stated she was not sure how long the 200 Hall shower had been missing a shower head. The facility confirmed there are nine (#26, #28, #30, #31, #32, #33, #34, #35 and #36) residents who reside on the 200 hallway that utilize the shower room. Review of the Resident Council Meeting minutes for January 2024 and March 2024 revealed residents voiced concerns related to the shower not working properly and only having one working shower. The January 2024 note also stated residents voiced concerns related to the showers not being properly cleaned. This deficiency represents non-compliance investigated under Complaint Number OH00151636.

Jan 2024 1 deficiency

CONCERN (E) 📢 Someone Reported This

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

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected multiple residents

Based on observation and staff interview the facility failed to ensure the facility failed to ensure portable space heaters were not used in resident accessible areas. This had the potential to affect...

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Based on observation and staff interview the facility failed to ensure the facility failed to ensure portable space heaters were not used in resident accessible areas. This had the potential to affect all residents residing in the facility with the exception of two facility-identified residents (#33 and #44) who did not leave their rooms. The facility census was 47. Findings include: Tour of the facility on 01/10/24 at 7:55 A.M. revealed there were portable electric space heaters observed in the facility hallways and common areas which were accessible to residents. The following space heaters were observed during the tour: one small heater on the 100 hall, one small heater between the 100 and the 200 hall, one large heater on the 200 hall, one large heater on the 300 hall, one small heater in the chapel, one small heater in the dining room, one large heater in the lobby. The surface area of the front of the units where the heat was generated were uncovered and could have potentially caused a burn if touched. Interview on 01/09/24 at 9:10 A.M with Maintenance Director (MD) #26 confirmed there were portable space heaters in the halls and common areas throughout the facility which were accessible to residents. Interview on 01/09/24 at 2:12 P.M. with MD #26 confirmed the facility placed the small space heaters in the halls and common areas on 11/01/23 and the larger units were purchased and placed on 11/06/24. Interviews on 01/09/24 between the hours of 1:47 P.M. and 3:14 P.M. with Licensed Practical Nurses (LPNs) #18 and #20 and State Tested Nurse Aide (STNA) #60 confirmed the space heaters had been present in the facility in common areas accessible to residents since November 2023. LPN #20 and STNA #60 confirmed the front of the heaters where the heat came out was hot and a resident could have possibly gotten burned if that area were touched. Interview on 01/09/24 at 4:58 P.M. with the Administrator and the Director of Nursing (DON) confirmed portable space heaters had been in place in the hallways and common areas of the facility since November 2023. Further interview confirmed the facility did not have a policy regarding the use of portable space heaters.

Oct 2023 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

Accident Prevention (Tag F0689)

A resident was harmed · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, hospital documentation review, staff interview, and review of facility policies, the facility fa...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, hospital documentation review, staff interview, and review of facility policies, the facility failed to follow facility procedures for leave of absences (LOAs), failed to implement interventions and provide education to residents and family members to reduce falls and incidents while on LOAs, and failed to investigate causative factors and determine a root cause analysis of repeated fall incidents while on LOA from the facility. This resulted in actual harm when Resident #100 left the facility for LOAs with family and had repeated fall incidents and injuries during the LOAs. Resident #100 was seen in the emergency room on multiple occasions for fractures and dislocation of the left hip and fracture of the left femur which required hospitalization and surgical intervention. This affected one (#100) of two residents reviewed for falls. The census was 40. Findings include: Review of the medical record for Resident #100 revealed an admission date of 04/22/22. Diagnoses included alcohol abuse, weakness with unspecified symptoms and signs involving cognitive functions and awareness, major depressive disorder, aortic aneurysm, diabetes type two, hypoglycemia, diabetic neuropathy, hypertension, and cerebral infarct. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #100 was assessed with no cognitive impairment, no behavioral symptoms, no wandering, and no rejection of care indicated. Further review revealed the resident required limited assistance for bed mobility, transfers, walking in the room, dressing, and personal hygiene, required supervision only for eating, toilet use, and locomotion on and off the unit. Review of a nursing progress note dated 07/05/23 at 3:42 P.M. revealed Resident #100 was on a LOA with a family member when a facility staff member contacted the family member to inquire about Resident #100's whereabouts. Further review of the nursing progress note revealed the nurse educated Resident #100's family that the resident needed to be properly signed out of the facility during LOAs. Review of a nursing progress note dated 07/16/23 at 11:21 A.M. revealed Resident #100 was on a LOA until the next Monday. Review of a nursing progress note dated 07/17/23 at 3:23 P.M. revealed a facility nurse spoke to the hospital and informed the nurse Resident #100 was admitted to the hospital with a closed fracture of the left hip sustained when the resident was drunk and fell at home. Review of a nursing progress note dated 07/25/23 at 6:19 P.M. revealed Resident #100 returned to the facility. Review of a nursing progress note dated 08/10/23 revealed Resident #100 was out to an appointment with his daughter and had not returned. Review of a nursing progress note dated 08/11/23 at 3:15 A.M. revealed the facility received a telephone call from the hospital indicating Resident #100 fell from his daughter's truck approximately seven hours earlier that day and the resident's left hip was dislocated. The resident's left hip was put back into place and was on his way back to the facility. Review of a nursing progress note dated 08/11/23 at 3:40 P.M. revealed Resident #100 arrived to the facility, was alert and oriented, and had an abduction wedge (a padded device used to separate the legs) between the legs. Review of a nursing progress note dated 08/14/23 at 3:56 P.M. revealed a nurse was alerted that Resident #100 popped his hip out. Resident #100 stated he was trying to stand and sat down too hard in the chair and noticed his hip was out of place. A nurse practitioner was notified and Resident #100 was sent to the hospital for treatment. Review of a nursing progress note dated 08/22/23 at 4:12 P.M. revealed Resident #100 was picked up by a daughter for a LOA. Review of a nursing progress note dated 08/24/23 at 6:08 P.M. revealed, on 08/23/23, while on a LOA with a family member, Resident #100 experienced a closed dislocation of the left hip. Review of a nursing progress note dated 09/11/23 at 10:59 A.M. revealed a nurse at the facility received a telephone call from the hospital that Resident #100 was admitted for a closed fracture of the left hip. The hospital reported Resident #100 was drunk and fell at home and was brought to the facility by emergency medical services (EMS). Review of a fall risk assessment dated [DATE] revealed Resident #100 was assessed at high risk for falls with a history of multiple falls in the last six months. The resident was assessed to be confined to a chair and oriented, and was unable to independently come to a standing position, required hands on assistance to move from place to place, utilized an assistive device, and exhibited loss of balance while standing. Review of a nursing progress note dated 10/03/23 at 12:36 P.M. revealed the facility was not able to contact Resident #100's family regarding the resident's return to the facility. Review of hospital documentation dated 10/04/23 revealed Resident #100 was seen in the emergency room for complaints of hip pain and altered mental status. Resident #100 had a leg deformity on assessment, and per the resident's daughter, Resident #100 did not have the leg deformity the previous night. The resident was found to have a left femur fracture and per report did not remember how it occurred. A urine drug screen was tested and positive for amphetamines and benzodiazepines. Review of an x-radiation (x-ray) image of Resident #100's left femur dated 10/04/23 confirmed a displaced fracture of the proximal femur. Resident #100's hospital care plan timeline dated 10/05/23 included consideration of a left femur open reduction internal fixation (placing pieces of broken bone together using surgery often using screws, plates, sutures, or rods to put together) versus revision hip arthroplasty (total hip replacement). Review of the facility plan of care dated 04/22/22 for Resident #100 lacked documented evidence of any interventions during LOAs and did not address any safety for hip precautions from recent hip surgery or dislocation of hip. Review of Resident #100's fall plan of care dated 04/22/22 lacked documented evidence of any change to interventions for documented falls sustained on 07/17/23, 08/11/23, 08/23/23 and 10/04/23. Review of Resident #100's medical record had no documentation of any investigation for falls sustained while on LOA from the facility on 07/17/23, 08/11/23, 08/23/23 and 10/04/23. Review of Resident #100's medical record lacked any evidence of education for safety interventions during LOAs from the facility, and had no evidence for any release of responsibility forms for LOAs. Interview on 10/25/23 at 1:45 P.M. with the Director of Nursing (DON) verified the lack of documentation for Resident #100's LOA forms, verified there were no investigations completed for falls on 07/17/23, 08/11/23, 08/23/23 and 10/04/23, verified there was no documented education provided to Resident #100 or family for safety precautions while on LOAs, verified the lack of interventions implemented for Resident #100's hip fracture and dislocation, and verified there was no documentation of fall interventions implemented following Resident #100's repeated falls while on LOAs from the facility. Interview on 10/25/23 at 1:50 P.M. with Administrator #203 verified the facility leave of absence policy was not followed in accordance with the written policy for Resident #100's LOAs, and verified the lack of safety and/or oversight provided during Resident #100's LOAs with family. Review of a policy titled, Fall Response Policy and Procedure, dated 01/01/16, revealed the facility is to insure, to the best of its ability, the safety and well-being of residents who are at risk for falls and implement actions. The facility should implement an intervention to guard against another fall of the same type and initiate an investigation. Review of an undated policy titled, Change in Condition and Physician Notification, revealed the nurse will notify the physician and the resident when there is a need to alter medications or treatments or a significant change in the resident's physical, mental, or psychosocial status. Review of an undated policy titled, Leave of Absence, revealed the resident or person assuming responsibility will complete and sign the release of responsibility form prior to leaving. The nurse will document the LOA and relevant information. This deficiency represents non-compliance investigated under Complaint Number OH00147185.

CONCERN (F) 📢 Someone Reported This

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

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

Infection Control (Tag F0880)

Could have caused harm · This affected most or all residents

Based on employee personnel record review, staff interview, and policy review, the facility failed to test employees for tuberculosis per the facility policy. This affected five (State Tested Nurse Ai...

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Based on employee personnel record review, staff interview, and policy review, the facility failed to test employees for tuberculosis per the facility policy. This affected five (State Tested Nurse Aide (STNA) #104, STNA #131, STNA #128, Licensed Practical Nurse (LPN) #156, and LPN #162) of five employee personnel records reviewed. This had the potential to affect all 50 residents. The census was 50. Findings include: 1. Review of the personnel file for STNA #104 revealed a hire date of 09/27/23. Further review revealed no evidence of STNA #104 having a Mantoux test (a skin test used to screen for tuberculosis) completed. 2. Review of the personnel file for STNA #131 revealed a hire date of 08/14/23. Further review revealed no evidence of STNA #131 having a Mantoux test completed. 3. Review of the personnel file for STNA #128 revealed a hire date of 04/25/23. Further review revealed no evidence of STNA #128 having a Mantoux test completed. 4. Review of the personnel file for LPN #156 revealed a hire date of 06/06/23. Further review revealed no evidence of LPN #156 having a Mantoux test completed. 5. Review of the personnel file for LPN #162 revealed a hire date of 09/13/23. Further review revealed no evidence of LPN #162 having a Mantoux test completed. Interview on 10/23/23 at 10:20 A.M. with Business Office Staff #209 confirmed STNA #104, STNA #131, STNA #128, LPN #156, and LPN #162 did not have evidence of Mantoux testing completed in their personnel files, and verified it the facility policy to have Mantoux testing completed on the first day of employment. Review of the undated facility policy titled, Tuberculosis (TB) Infection Control Program, revealed all new hire employees will be administered a two-step Mantoux skin test and records are to be kept and updated annually per facility Mantoux risk assessment. This deficiency represents an incidental finding discovered during investigation of Complaint Number OH00147532.

Sept 2023 4 deficiencies 1 Harm

SERIOUS (G) 📢 Someone Reported This

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

Actual Harm - a resident was hurt due to facility failures

Deficiency F0692 (Tag F0692)

A resident was harmed · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff and family interviews, and review of facility policy and procedures, the facility failed t...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff and family interviews, and review of facility policy and procedures, the facility failed to ensure nutritional interventions were initiated and sustained to prevent unplanned weight loss for one (#52) of three residents reviewed for weight loss. This resulted in actual harm for Resident #52 who experienced a severe unplanned weight loss of 25.9 percent (%) in less than a one-month period of time. The facility census was 51 residents. Findings include: Review of the medical record for Resident #52 revealed an admission date of 07/10/23 with diagnoses including bacteremia, cannabis abuse, cocaine abuse, pneumonia, protein calorie malnutrition, human immunodeficiency virus (HIV), and major depressive disorder. Review of the care plan for Resident #52 dated 07/11/23 revealed resident was at risk for nutrition/hydration problems related to mechanically altered diet, need for tube feed, underweight body mass index (BMI) noted, noncompliant with obtaining weights, prefers to stop and start tube feeding on own at times, non-compliant with wearing tube feed continuously and/or letting staff know when he disconnects from it. Interventions included the following: administer medications as ordered, allow resident to make choices/preference of food as able, dietary consult as needed, obtain weight as ordered, and provide diet as ordered. Review of the Minimum Data Set (MDS) assessment for Resident #52 dated 07/17/23 revealed the resident was cognitively intact and required supervision and set up help with eating. Review of the weight record for Resident #52 revealed the resident's height upon admission was 68 inches. On 07/10/23, the resident weighed 86.4 pounds. On 07/13/23, the resident weighed 87.1 pounds. On 07/28/23, the resident weighed 84.1 pounds. On 08/15/23, the resident weighed 79.8 pounds and on 08/31/23, the resident weighed 87.8 pounds. There were no weights recorded in the month of September. Review of the hospital progress notes dated 08/24/23 revealed Resident #52 weighed 85 pounds in the hospital. Review of the dietitian progress note for Resident #52 dated 08/31/23 revealed the resident's most recent weight was 87.8 pounds which represented a low BMI of 13.3. The resident consumed a mechanical soft diet by mouth for comfort and food drained into a stoma due to esophagus not attached. Resident #52 received feedings via a percutaneous endoscopic gastrostomy (PEG) tube for nutritional needs: Isosource 1.5 at 60 milliliters per hour via continuous pump. Resident #52 had been refusing tube feeding, disconnecting at times. The resident was educated and encouraged to accept tube feeding as ordered. The resident showed a slight weight gain which was desirable due to low BMI. Dietitian would continue to monitor the resident's weight. Review of the nurses progress notes for Resident #52 dated 09/01/23 to 09/16/23 revealed there were no recorded weights or refusal of weights for Resident #52 during this time. Review of nurses progress notes dated 09/03/23, 09/04/23, 09/05/23, 09/08/23, 09/10/23, 09/13/23, 09/14/23, and 09/16/23 revealed Resident #52 was found to have disconnected his continuous tube feeding himself and gone outside to smoke or to wander about the facility and staff educated the resident of the importance of allowing his tube feeding as ordered and to notify the nurses when he disconnected the tube feeding. Review of the nurse's progress note dated 09/16/23 revealed Resident #52 was sent to the hospital emergency room per ambulance due to difficulty breathing and decline in functioning. Review of the MDS for Resident #52 dated 09/16/23 revealed the resident was discharged from the facility with return not anticipated. Review of section K for Resident #52 revealed no weight was recorded and it was unknown if resident had experienced weight loss. Review of the hospital admission note for Resident #52 dated 09/16/23 revealed the resident's admitting weight to the hospital was 65 pounds. Review of the admitting physician's note revealed the resident was markedly malnourished and looked to have lost significant weight since the last time the physician saw the resident in the hospital on [DATE] (when resident's weight was 85 pounds). Review of nurse's progress note dated 09/17/23 revealed Resident #52's representative, Resident Representative (RR) #500, called the facility and shared the resident's weight upon admission to the hospital was 65 pounds, which was a 20-pound weight loss from his last hospital weight in August 2023. Further review of the note revealed the Mobile Director of Nursing (MDON) #365 would reach out to RR #500 to discuss her concerns. Interview by phone on 09/21/23 at 2:13 P.M. with RR #500 confirmed Resident #52 had been admitted to the hospital on [DATE], and the admitting doctor told her the resident weighed 65 pounds upon admission, which represented a 20 pound weight loss since his last hospital weight on 08/24/23 of 85 pounds. RR #500 confirmed no one from the facility had informed her of the resident's severe weight loss. Interview on 09/25/23 at 1:53 P.M. with MDON #365 confirmed Resident #52 was at nutritional risk due to tube feeding and noncompliance with feeding. MDON #365 verified the resident should be weighed weekly. Interview with MDON #365 confirmed Resident #52 frequently disconnected his tube feeding, which was his sole source of nutrition during the month of September 2023, and the facility did not obtain the resident's weight during the month of September. MDON #365 confirmed Resident #52 was admitted to the hospital on [DATE] and on 09/18/23, he spoke with RR #500 regarding her concerns about the resident's severe weight loss. MDON #365 confirmed the facility was not aware of Resident #52's weight loss until RR #500 brought the concern to the facility's attention. MDON #365 confirmed the facility learned the resident had experienced a weight loss of 22.8 pounds, representing a 25.9% weight loss from the last recorded facility weight on 08/31/23 of 87.8 pounds to the hospital admission weight on 09/16/23 of 65 pounds. MDON #365 confirmed the facility did not implement any new interventions regarding the severe weight loss for Resident #52 because they were not aware he had lost so much weight. Interview by phone on 09/26/23 at 11:28 A.M. with the Administrator confirmed neither the physician nor the Nurse Practitioner (NP) examined Resident #52 from 09/01/23 to 09/16/23. Review of the facility policy titled, Weight Change, dated 01/01/16 revealed a weight loss of five % or greater in 30 days was considered to be a significant weight loss. Review of the facility policy titled, Weight Protocol, dated 01/01/16 revealed residents at risk for unintended weight loss will be weighed weekly and nursing staff will document attempts and refusals. Weight was an important factor used in determining the nutritional status of every resident. Weight was needed to complete the nutritional assessment of the resident as well. The Physician should acknowledge non-compliance with weights in the progress notes and recommend other methods of nutritional assessment when indicated. This deficiency represents non-compliance investigated under Complaint Number OH00146569.

CONCERN (D) 📢 Someone Reported This

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

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure medications were available for administration as ordered by the physician. This affected one (Resident #14) of four residents reviewed for medications. The facility census was 51 residents. Findings include: Review of the medical record for Resident #14 revealed an admission date of 09/13/23 with diagnoses including diabetes, emphysema, hypertension (HTN), and chronic pain. Review of the Minimum Data Set for Resident #14 dated 09/20/23 revealed resident was cognitively intact and required limited assistance of one staff with activities of daily living (ADLs). Review of the admission physician orders for Resident #14 revealed an order dated 09/13/23 for the resident to receive metformin twice daily for treatment of diabetes. Observation of medication administration on 09/25/23 at 8:49 A.M. for Resident #14 per Licensed Practical Nurse (LPN) #190, revealed metformin was not available in the cart for the resident. Further observation revealed LPN #190 called the pharmacy on her cell phone and ordered the medication over the phone. Interview on 09/25/23 at 8:53 A.M. of LPN #190 confirmed Resident #14's medication was not available in the cart so she ordered the medication from pharmacy, and they said it would be delivered in the evening on 09/25/23. Review of the September 2023 Medication Administration Record (MAR) for Resident #14 revealed the morning dose of metformin was documented as not administered due to medication was on order. Review of the pharmacy delivery receipt dated 09/13/23 revealed six 500 milligram (mg) metformin tablets, a 3-day supply was delivered for resident. Interview on 09/25/23 at 1:53 P.M. with Mobile Director of Nursing (MDON) #365 confirmed Resident #14 was admitted on [DATE] with an order for metformin 500 mg twice daily for treatment of DM. MDON #365 confirmed the pharmacy delivered a three-day supply of metformin in the evening on 09/13/23 so the resident should have received his metformin on 09/14/23, 09/15/23, and 09/16/23. MDON #365 confirmed the facility had received no further deliveries of metformin for Resident #14 after the delivery on 09/13/23. MDON #365 confirmed he called the pharmacy on 09/25/23 and the pharmacy confirmed they only sent a three-day supply on 09/13/23. MDON #365 confirmed the pharmacy representative did not provide an explanation as to why additional doses of metformin were not sent. MDON #365 confirmed the facility had no evidence that doses of metformin were retrieved from the facility's emergency supply and given to the resident. Resident #14 would have missed doses of metformin on 09/17/23, 09/18/23, 09/19/23, 09/20/23, 09/21/23, 09/22/23, 09/24/23, and 09/25/23 due to medication not being available for the resident. Review of the facility policy titled, Preparation and General Guidelines: Medication Administration, dated 11/2018 revealed medications are administered in accordance with written orders of the prescriber. If a medication with a current, active order cannot be located in the medication cart/drawer, other areas of the medication cart, medication room, and facility (e.g., other units) are searched, if possible. If the medication cannot be located after further investigation, the pharmacy is contacted, or medication may be removed from the emergency drug supply. This deficiency represents non-compliance investigated under Complaint Number OH00146569.

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 F0679 (Tag F0679)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, resident interview, staff interview, review of the Activity Director (AD) job description, ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, resident interview, staff interview, review of the Activity Director (AD) job description, and review of the facility activity calendar, the facility failed to ensure the activities program was implemented as scheduled. This affected five (Residents #13, #16, #34, #56, #57) and had the potential to affect all the residents in the facility with the exception of the following 29 facility-identified (Residents #2, #3, #4, #5, #8, #9, #10, #11, #12, #13, #17, #21, #24, #25, #27, #29, #31, #32, #36, #37, #38, #40, #41, #43, #45, #46, #48, #50, #51) who did not participate in activities. The facility census was 51. Findings include: 1. Review of the medical record for Resident #16 revealed an admission date of 09/07/23 with diagnoses including chronic obstructive pulmonary disease (COPD), catatonic disorder, metabolic encephalopathy, osteoarthritis (OA), congestive heart failure (CHF), and paranoid schizophrenia. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #16 was cognitively intact and required limited assistance with activities of daily living (ADLs). Review of the care plan dated 09/08/23 revealed Resident #16 had the potential for activity deficit related to behavior problems, decreased mobility, and mood problems. Interventions included the following: assist resident to activities as needed, encourage resident to come to group activities, staff to provide one on one as needed. Observation on 09/21/23 at 8:00 A.M. of Resident #16 revealed the resident had a September 2023 activity calendar posted in her room. Interview on 09/21/23 at 8:00 A.M. of Resident #16 confirmed she participated in the activity programs provided by the facility, and she referred to the activity calendar posted in her room. Resident #16 confirmed she planned to participate in following activities on 09/21/23: Breakfast Club, Exercise, Sip and Paint, and Resident Council. Interview on 09/25/23 at 9:00 A.M. with Resident #16 confirmed the facility did not have Breakfast Club, Exercise, Sip and Paint, and Resident Council on 09/21/23 and she was unsure why they didn't occur. Resident #16 confirmed she was disappointed the activities had not occurred as scheduled. 2. Review of the medical record for Resident #13 revealed an admission date of 09/13/23 with diagnoses including diabetes mellitus (DM), CHF, hemiplegia and hemiparesis, atherosclerotic heart disease, and peripheral vascular disease (PVD.) Review of the MDS for Resident #13 dated 09/20/23 revealed the resident was cognitively intact and required extensive assistance of one staff with ADLs. Review of the care plan dated 09/15/23 revealed Resident #13 had the potential for activity deficit related to anxiety disorder and major depressive disorder. Interventions included the following: assist resident to activities as needed, encourage resident to come to group activities, staff to provide one on one as needed. Observation on 09/25/23 at 3:16 P.M. revealed Resident #13 was sitting in the activity room waiting for the 3:00 P.M. activity to begin. Interview on 09/25/23 at 3:16 P.M. of Resident #13 confirmed he participated in the facility activity programs and enjoyed them when they occurred as scheduled. Resident #13 confirmed activities were often canceled at the last minute, and they didn't have any activities last Thursday. 3. Review of the medical record for Resident #34 revealed an admission date of 12/20/18 with diagnoses including emphysema, seizures, dysphagia, paranoid schizophrenia, and major depressive disorder. Review of the MDS for Resident #34 dated 08/28/23 revealed the resident was cognitively impaired and required extensive assistance of one to two staff with ADLs. Review of the care plan dated 03/20/20 revealed Resident #34 preferred to participate in a combination of organized as well as self-directed activities of interest. A source of strength for resident was her faith. Resident enjoys going outdoors, watching television, and socializing with her peers. Interventions included the following: give daily reminders of activities of interest, encourage participation and assist with transportation as needed, offer supplies for independent pursuits, give resident opportunity to express opinion of activities attended. Observation on 09/25/23 at 3:18 P.M. revealed Resident #34 was sitting in the doorway of the activity room waiting for the 3:00 P.M. activity to begin. Interview on 09/25/23 at 3:18 P.M. of Resident #34 confirmed she enjoyed the activities, but they didn't always occur as scheduled and sometimes they started late. 4. Review of the medical record for Resident #56 revealed an admission date of 07/25/23 with diagnoses including dry eye, dysphagia, disorder of adrenal gland, malignant neoplasm of skin, and cerebral infarction. Review of the MDS for Resident #56 dated 09/08/23 revealed the resident was cognitively intact and required limited assistance of one staff with ADLs. Review of the care plan dated 09/11/23 revealed Resident #56 had the potential for activity deficit related to mood problems. Interventions included the following: encourage resident to come to group activities, provide resident access to activity calendar. Observation on 09/25/23 at 3:19 P.M. revealed Resident #56 was sitting at a table in the activity room waiting for the 3:00 P.M. activity to begin. Interview on 09/25/23 at 3:19 P.M. of Resident #56 confirmed he participated in most group activities, but they seemed to get canceled a lot due to scheduling conflicts. 5. Review of the medical record for Resident #57 revealed an admission date of 09/16/21 with diagnoses including hemiplegia and hemiparesis, paranoid schizophrenia, schizoaffective disorder, and cerebral infarction. Review of the MDS for Resident #57 dated 09/07/23 revealed the resident was cognitively intact and required limited assistance of one staff with ADLs. Review of the care plan dated 09/13/23 revealed Resident #57 preferred to participate in a combination of self-directed as well as organized activities of interest. Resident enjoyed going outdoors, bingo, happy hour, journaling, socials. Strengths included the resident attends activities regularly, has a strong support system in place, and is very sociable and enjoys being around others. Interventions included the following: hang monthly activity schedule in room, keep informed of daily activities of interest, and offer supplies for self-directed activities as requested. Observation on 09/25/23 at 3:20 P.M. revealed Resident #57 was sitting at a table in the activity room waiting for the 3:00 P.M. activity to begin. Interview on 09/25/23 at 3:20 P.M. of Resident #57 confirmed she enjoyed participating in the facility activities and she was frustrated when the activity didn't occur. Resident #57 confirmed they didn't have activities at all on 09/21/23 and three of the four activities scheduled for 09/25/23 (Breakfast Club, Exercise, Resident's Choice) did not occur. Observation of the posted activity calendar for September 2023 revealed the following activities were scheduled to occur in the facility activity room on 09/21/23: 9:45 A.M. Breakfast Club, 10:45 A.M. Exercise, 1:30 P.M. Sip and Paint, 3:00 P.M. Resident Council. Observations on 09/21/23 at 9:50 A.M., 10:50 A.M., 1:35 P.M. and 3:00 P.M. revealed the activity room was empty. There were no staff or residents present. There was no notification posted to indicate a change in the activity programming for the day. Interview on 09/21/23 at 3:05 P.M. with Activities Assistant (AA) #445 confirmed she was an aide and was pulled to work on the floor on 09/21/23 so none of the scheduled activities occurred. AA #445 confirmed there was no notification made to the residents of the change to the activity calendar. Observation of the posted activity calendar for September 2023 revealed the following activities were scheduled to occur in the facility activity room on 09/21/23 9:45 A.M. Breakfast Club, 10:45 A.M. Exercise, 1:30 P.M. Residents' Choice, 3:00 P.M. Room Visit. Observations on 09/25/23 at 9:50 A.M. 10:50 A.M., and 1:37 P.M. revealed the activity room was empty. There were no staff or residents present. There was no notification posted to indicate a change in the activity programming for the day. Interview on 09/25/23 at 1:57 P.M. of AA #445 confirmed she was pulled to work on the floor on 09/25/23 in the morning and Breakfast Club and Exercise did not occur as scheduled. Interview of AA #445 confirmed no residents came to the activity room for the Residents' Choice activity scheduled at 1:30 P.M. so she took her break at that time. AA #445 confirmed they were going to have Resident Council at 3:00 P.M. on 09/25/23 because they didn't get to have it on 09/21/23 as scheduled. AA #445 confirmed there was no notification made to the residents of the changes to the activity calendar on 09/25/23. Review of the Activity Director job description undated revealed the AD would plan, organize, develop, and supervise the overall operation of the Activities Department in accordance with current federal, state, and local standards, guidelines and regulations, or established policies and procedures governing the facility, and as may be directed by the Administrator and/or Activity Consultant to assure that the on-going program of activities is designed to meet in accordance with the assessment the interests and physical, mental, and psychosocial well-being of each resident. This deficiency represents non-compliance investigated under Complaint Number OH00146009.

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 F0680 (Tag F0680)

Could have caused harm · This affected multiple residents

Based on review of activity calendar, review of personnel files, staff interview, and review of job description, the facility failed to ensure the services of a qualified Activity Director (AD). This ...

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Based on review of activity calendar, review of personnel files, staff interview, and review of job description, the facility failed to ensure the services of a qualified Activity Director (AD). This had the potential to affect all residents residing in the facility with the exception of the 29 residents (#2, #3, #4, #5, #8, #9, #10, #11, #12, #13, #17, #21, #24, #25, #27, #29, #31, #32, #36, #37, #38, #40, #41, #43, #45, #46, #48, #50, #51) identified by the facility as not participating in activities. The facility census was 51. Findings include: Review of the posted facility activity calendar dated September 2023 revealed there were resident activities scheduled seven days per week. Review of the personnel record for Activities Director (AD) #460 revealed the employee was a State Tested Nursing Assistant (STNA) and had a hire date of 05/24/23. Further review revealed AD #460 had no qualifications to be an AD. Interview on 09/21/23 at 8:59 A.M. with AD #460 confirmed she was hired on 05/24/23 to be the AD for the facility. AD #460 confirmed she developed the activity calendar for September 2023 and Activity Assistant (AA) #445 was also an aide who carried out the activities. AD #460 confirmed she was an STNA and had no additional training, education, or background which qualified her to serve as an AD. Interview on 09/21/23 at 10:04 A.M with the Administrator confirmed AD #460 was hired 05/24/23 prior to her coming to work for the facility. The Administrator confirmed AD #460 was not a qualified AD and the facility did not have a qualified AD to oversee the activities department. Review of the Activity Director job description undated revealed the AD would plan, organize, develop, and supervise the overall operation of the Activities Department in accordance with current federal, state, and local standards, guidelines and regulations, or established policies and procedures governing the facility, and as may be directed by the Administrator and / or Activity Consultant to assure that the on-going program of activities is designed to meet in accordance with the assessment the interests and physical, mental, and psychosocial well-being of each resident. Further review of the job description revealed the AD must be a qualified therapeutic recreation specialist or an activities professional who is licensed by this state and is eligible for certification as recreation specialist or as an activities professional or you must have, as a minimum, two years of experience in a social or recreation program within the last five years, one of which was full-time in a patient activities program in a health care setting; or must have completed a training course approved by the state. Education requirement was the AD must possess as a minimum two years of college with an associate degree preferred, but not required. This deficiency represents non-compliance investigated under Complaint Number OH00146009.

Aug 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interviews, and review of the facility policy, the facility failed to administer medicatio...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interviews, and review of the facility policy, the facility failed to administer medications per physician orders to a resident. This affected one (Resident #57) of four residents reviewed for medication administration. The facility census was 52. Finding include: Review of the medical record for Resident #57 revealed an admission date 07/21/23. Resident #57 discharged from the facility on 07/22/23. Diagnoses included infection and inflammatory reaction due to internal right knee prosthesis. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #57 was cognitively intact. Review of the medication administration record (MAR) revealed Resident #57 did not receive her medication for dates 07/22/23. On 07/22/23, the MAR had an X in all the squares. There were no licensed nurse's signature on the MAR indicating any medications were administered to Resident #57 during her stay at the facility. All medications were due starting on 07/22/23. Review of the physician orders and MAR dated July 2023 revealed Resident #57 did not receive the following six medications in the morning on 07/22/23: Allopurinol (can treat gout and kidney stones) 300 milligram (mg) one time a day, due at 6:00 A.M.; Atorvastatin Calcium (reduces cholesterol) 20 mg one tablet every morning, due 6:00 A.M. to 9:00 A.M.; Losartan Potassium-HCTZ (treats high blood pressure) 100-25 mg give one tablet, due at 6:00 A.M. to 9:00 A.M.; Pantoprazole Sodium (treats acid reflux) 20 mg one tablet at 6:00 A.M. to 9:00 A.M.; Spiriva Respimat inhalation (treats chronic obstructive pulmonary disease) 2.5 microgram (mcg)/act two puff inhale one time a day at 6:00 A.M.; and Aspirin (nonsteroidal anti-inflammatory) 81 mg one tablet at 9:00 A.M. Interview on 08/04/23 at 2:50 P.M. with Licensed Practical Nurse (LPN) #200 stated he did not give any medications to Resident #57 because he did not complete putting the physicians' orders in the electronic medical record, because it required to have allergies filled out. LPN #200 stated Resident #57's admission was not complete and no medications were listed to be administered the morning of 07/22/23. LPN #200 stated he was a new nurse and he had little experience to completing the admission process. Interview on 08/04/23 at 3:05 P.M. with the Director of Nursing (DON) verified LPN #200 did not administer any medications to Resident #57 the morning of 07/22/23 and verified the medications were Allopurinol, Atorvastatin Calcium, Losartan Potassium-HCTZ, Pantoprazole Sodium, Spiriva Respimat inhalation, and Aspirin. The DON stated she gave education to LPN #200 when he notified the DON that he did not give any medications to Resident #57. Review of the facility policy titled Preparation and General Guidelines, date 11/2018, revealed the facility had sufficient personnel and a medication distribution system to ensure safe administration of medication without unnecessary interruptions. This deficiency represents non-compliance investigated under Complaint Number OH00144932.

Jun 2023 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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility self-reported incidents (SRI's), staff interviews and policy review, the facility fai...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility self-reported incidents (SRI's), staff interviews and policy review, the facility failed to report allegations of sexual abuse to the State Survey Agency. This affected one (#10) of three residents reviewed for sexual abuse. The facility census was 52. Findings include: Review of medical record for Resident #10 revealed admission date of 01/18/17. Diagnoses include paranoid schizophrenia, type two diabetes mellitus and chronic obstructive pulmonary disease (COPD). The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #10 had a Brief Interview Mental Status (BIMS) score of 00 indicating significantly impaired cognition. She required supervision to limited assistance for her activities of daily living. Delusions were documented during the lookback period for potential indicators of psychosis as well as rejection of care four to six days. Review of Resident #10's care plan revealed the resident had potential for behavioral problems related to paranoid schizophrenia, makes false allegations that she is being raped. The care plan was updated on 05/17/23 that invisible people try to solicit her for sex with interventions which included administer medications as ordered, allow resident to discuss feelings, psychological counseling as needed and redirect as possible. Review of the electronic charting for Resident #10 revealed documentation on 03/07/23 revealed Company #1 psychiatric note documented Resident #10 reported she was surrounded by men at the facility and all they did was beat and rape her. Further review of a second note dated 04/28/23 revealed Resident #10 reported she was raped, and all the men want her. Documentation revealed the Director of Nursing (DON) was contacted and the writer was informed Resident #10 was care planned for the behavior. Review of facility SRI's revealed there was no incidents regarding Resident #10's sexual abuse allegations dated 03/07/23 or 04/28/23. Interview on 06/14/23 at 11:43 A.M. revealed the DON stated she had not been informed of Resident #10's allegation of sexual abuse on 04/28/23 and she was not at the facility. The DON also confirmed she was not aware of the 03/07/23 sexual allegation voiced by Resident #10. The DON verified the documentation was in the electronic charting regarding Resident #10's sexual abuse allegations. The DON verified the facility did not report Resident #10's sexual abuse allegations via a SRI to the State Survey Agency and the facility did not complete an investigation. Review of the facility policy for Abuse, Neglect and Exploitation last reviewed 01/27/23 revealed it was the facility policy to report and investigate all alleged violations/allegations of sexual abuse. This deficiency represents non-compliance investigated under Complaint Number OH00143393.

CONCERN (D) 📢 Someone Reported This

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

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

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility self-reported incidents (SRI's), staff interviews and policy review, the facility fai...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility self-reported incidents (SRI's), staff interviews and policy review, the facility failed to investigate sexual abuse allegations. This affected one (#10) of three residents reviewed for sexual abuse. The facility census was 52. Findings include: Review of medical record for Resident #10 revealed admission date of 01/18/17. Diagnoses include paranoid schizophrenia, type two diabetes mellitus and chronic obstructive pulmonary disease (COPD). The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #10 had a Brief Interview Mental Status (BIMS) score of 00 indicating significantly impaired cognition. She required supervision to limited assistance for her activities of daily living. Delusions were documented during the lookback period for potential indicators of psychosis as well as rejection of care four to six days. Review of Resident #10's care plan revealed the resident had potential for behavioral problems related to paranoid schizophrenia, makes false allegations that she is being raped. The care plan was updated on 05/17/23 that invisible people try to solicit her for sex with interventions which included administer medications as ordered, allow resident to discuss feelings, psychological counseling as needed and redirect as possible. Review of the electronic charting for Resident #10 revealed documentation on 03/07/23 revealed Company #1 psychiatric note documented Resident #10 reported she was surrounded by men at the facility and all they did was beat and rape her. Further review of a second note dated 04/28/23 revealed Resident #10 reported she was raped, and all the men want her. Documentation revealed the Director of Nursing (DON) was contacted and the writer was informed Resident #10 was care planned for the behavior. Review of facility SRI's revealed there was no incidents regarding Resident #10's sexual abuse allegations dated 03/07/23 or 04/28/23. Interview on 06/14/23 at 11:43 A.M. revealed the DON stated she had not been informed of Resident #10's allegation of sexual abuse on 04/28/23 and she was not at the facility. The DON also confirmed she was not aware of the 03/07/23 sexual allegation voiced by Resident #10. The DON verified the documentation was in the electronic charting regarding Resident #10's sexual abuse allegations. The DON verified the facility did not report Resident #10's sexual abuse allegations via a SRI to the State Survey Agency and the facility did not complete an investigation. Review of the facility policy for Abuse, Neglect and Exploitation last reviewed 01/27/23 revealed it was the facility policy to report and investigate all alleged violations/allegations of sexual abuse. This deficiency represents non-compliance investigated under Complaint Number OH00143393.

Apr 2023 3 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and policy review, the facility failed to notify resident representative of a resident's...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and policy review, the facility failed to notify resident representative of a resident's change in condition and transfer to the hospital. This affected one (#62) resident out of the four residents reviewed for change of condition and resident representative notifications. The facility census was 58. Findings include: Review of the medical record for the Resident #62 revealed an admission date of 05/03/21 with medical diagnoses of Parkinson's disease, alcohol-induced dementia, major depression, adult failure to thrive, and cerebrovascular disease. Review of the medical record for Resident #62 revealed Resident #62 discharged from the facility on 02/06/23. Review of the medical record for Resident #62 revealed a quarterly Minimum Data Set (MDS), dated [DATE], which indicated Resident #62 had severely impaired cognition and required limited staff assistance with bed mobility, transfers, ambulation, eating, and bathing and extensive staff assistance with toileting and grooming. Review of the medical record for Resident #62 revealed a nurse's note, dated 02/06/23 at 1:33 P.M., which stated Resident #62 was noted with some mottling to his legs below the knee and to his arm. The note stated the nurse could not get a complete set of vital signs on Resident #62 because the resident would not sit still when the nurse attempted to get the vital signs. The note continued to state the nurse notified the Nurse Practitioner of Resident #62's change in condition and an order was received to send Resident #62 to the hospital for evaluation. Review of the medical for Resident #62 did not have documentation to support Resident #62's representative was notified of Resident #62's change in condition or transfer to the hospital. Interview on 04/11/23 at 9:22 A.M. with Interim Director of Nursing (DON) confirmed the facility did not notified Resident #62's family/resident representative of Resident #62's change of condition and or that Resident #62 was sent to the hospital for evaluation on 02/06/23. Review of facility policy titled Change in Condition and Physician Notification, revised 09/2019, stated the facility was to notify the physician and resident representative if the nurse discovers an injury of unknown source, need to alter mediation or treatment, significant change in resident's physical and/or mental needs or need to transfer, discharge from the facility. This deficiency represents non-compliance investigated under Complaint Number OH00141547.

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0661 (Tag F0661)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review, the facility failed to complete a discharge recapitulation of stay. ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review, the facility failed to complete a discharge recapitulation of stay. This affected one (#70) out of the three residents reviewed for discharges. The facility census was 58. Findings include: Review of the medical record for Resident #70 revealed an admission date of 11/12/22 with medical diagnoses of bradycardia, diabetes mellitus, hypertension, and left sided hemiparesis. Review of the medical record for Resident #70 revealed a discharge date of 04/08/23. Review of the medical record for Resident #70 revealed a quarterly MDS, dated [DATE], which indicated Resident #70 had moderate cognitive impairment and required limited assistance with bed mobility, transfers, dressing, toileting, and extensive assistance with bathing. Review of the medical record for Resident #70 revealed a Social Service note, dated 04/05/23 at 12:54 P.M. which stated the Social Service Director (SSD) met with resident to plan his discharge. The note stated Resident #70 would discharge home to his brother's house and Resident #70 did not want any medical equipment. Review of the medical record for Resident #70 revealed no documentation to support the facility completed a discharge recapitulation of stay or discharge summary upon Resident #70's discharge on [DATE]. Interview on 04/11/23 at 1:36 P.M. with Interim Director of Nursing (DON) confirmed the facility did not complete a discharge recapitulation of stay for Resident #70. Review of the policy titled, Resident Discharge, dated 03/2022, stated the facility was to provide the resident with a thorough and seamless discharge. The policy stated the facility would provide all pertinent medical information, including reconciliation of medications, to the resident upon discharge. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

CONCERN (D) 📢 Someone Reported This

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

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

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, staff and resident interviews, and policy review, the facility failed to provide care and s...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, staff and resident interviews, and policy review, the facility failed to provide care and services to maintain good grooming and personal hygiene for the residents. This affected two (#62 and #40) out of the four residents reviewed for grooming and hygiene assistance. The facility census was 58. Findings include: 1. Review of the medical record for the Resident #62 revealed an admission date of 05/03/21 with medical diagnoses of Parkinson's disease, alcohol-induced dementia, major depression, adult failure to thrive, and cerebrovascular disease. Review of the medical record for Resident #62 revealed Resident #62 discharged from the facility on 02/06/23. Review of the medical record for Resident #62 revealed a quarterly Minimum Data Set (MDS), dated [DATE], which indicated Resident #62 had severely impaired cognition and required limited staff assistance with bed mobility, transfers, ambulation, eating, and bathing and extensive staff assistance with toileting and grooming. Review of the medical record for Resident #62 revealed an Activity of Daily Living (ADL) care plan, dated 05/03/21, which stated Resident #62 required staff assistance with all ADL's. The interventions included staff were to provide extensive assistance with dressing, bathing, toileting, and personal hygiene. The ADL care plan did not contain documentation to support Resident #62 refused cares. Review of the medical record for Resident #62 revealed Resident #62 received a shower on 01/06/23, 01/17/23, 01/27/23, and 02/02/23. The medical record revealed Resident #62 refused a shower on 01/10/23. The medical record did not have any documentation to support Resident #62 received or refused a shower from 01/18/23 to 01/26/23. Interview on 04/11/23 at 1:36 P.M. with Interim Director of Nursing (DON), confirmed the medical record for Resident #62 did not contain documentation to support Resident #62 received or refused showers from 01/18/23 to 01/26/23. 2. Review of the medical record for Resident #40 an admission date of 12/27/22 with medical diagnoses of anemia, depression, hypertension, schizoaffective disorder, bipolar disorder, and diabetes mellitus. Review of the medical record for Resident #40 revealed an admission MDS, dated [DATE], which indicated Resident #40 was cognitively intact and required limited staff assistance with bed mobility, transfers, personal hygiene, and supervision with bathing and toileting. Review of the medical record for Resident #40 revealed an alteration in ADL performance care plan related to behavioral problems. The interventions included staff to assist with ADL's as needed. Observation with interview on 04/10/23 at 10:33 A.M. with Resident #40 revealed the resident was sitting in a common area near the nurse's station dressed in clean, odor free clothes. The observation revealed Resident #40 had black and gray facial hair on her chin. Resident #40 stated staff must assist her with shaving her facial hair because she is not allowed to have a razor. Resident #40 stated she did not like having facial hair and has asked staff to assist with grooming needs. Resident #40 unable to state the last time staff shaved her facial hair. Interview on 04/10/23 at 10:37 A.M. with Licensed Practical Nurse (LPN) #72 confirmed Resident #40 had gray and black facial hair on her chin. LPN #72 stated she did not know the last time staff assisted Resident #40 with grooming needs. Review of a policy titled, Activity of Daily Living, revised 03/2018, sated appropriate care and services would be provided for residents who were unable to carry out ADL's independently, with the consent of the resident and in accordance with the place of care for hygiene (bathing, grooming, dressing, and oral cares), bed mobility, and toileting. This deficiency represents non-compliance investigated under Complaint Number OH00141547.

Mar 2023 3 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Laboratory Services (Tag F0770)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, Certified Nurse Practitioner and staff interviews, the facility failed to follow physician orders to tim...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, Certified Nurse Practitioner and staff interviews, the facility failed to follow physician orders to timely obtain laboratory test. This affected one (#12) of 12 resident reviewed for laboratory services. The facility census was 49. Findings include: Review of Resident #12's medical record revealed an admission date of 02/02/22, with medical diagnoses including congestive heart failure, cardiomegaly, depression, anxiety and morbid obesity. The resident remains in the facility. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition and required extensive two-person assistance for bed mobility, one person assistance for dressing total dependence for toileting and supervision for eating. Interview on 03/13/23 at 2:07 P.M., with Certified Nurse Practitioner (CNP) #18 revealed he had received an update on Resident #12 on 03/11/23, of increased shortness of breath and requesting an iron level check. CNP #18 stated he ordered a chest x-ray, Complete Blood Count (CBC) and a Basic Metabolic Panel (BMP). During the interview he verified he was unable to find the orders in the electronic charting system. Record review of the physician orders for Resident #12 revealed no orders for chest x-ray, CBC, or a BMP on or since 03/11/23. Interview on 03/13/23 at 3:35 P.M., with Licensed Practical Nurse (LPN) #19 revealed Resident #12 complained of being cold and short of breath. Resident #12 told LPN #19 she usually she felt that way when her iron was low and wanted her level checked. LPN #19 stated she contacted CNP #17 to provide the update and received an order for a chest x-ray, CBC, and BMP. LPN #19 stated she was unaware of how to put in the chest x-ray order and was going to have the day nurse assist her at the end of her shift, but she forgot and verified none of the orders were placed.

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 F0776 (Tag F0776)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, Certified Nurse Practitioner and staff interviews, the facility failed to follow physician orders to tim...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, Certified Nurse Practitioner and staff interviews, the facility failed to follow physician orders to timely obtain radiology test. This affected one (#12) of 12 resident reviewed for radiology services. The facility census was 49. Findings include: Review of Resident #12's medical record revealed an admission date of 02/02/22, with medical diagnoses including congestive heart failure, cardiomegaly, depression, anxiety and morbid obesity. The resident remains in the facility. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition and required extensive two-person assistance for bed mobility, one person assistance for dressing total dependence for toileting and supervision for eating. Interview on 03/13/23 at 2:07 P.M., with Certified Nurse Practitioner (CNP) #18 revealed he had received an update on Resident #12 on 03/11/23, of increased shortness of breath and requesting an iron level check. CNP #18 stated he ordered a chest x-ray, Complete Blood Count (CBC) and a Basic Metabolic Panel (BMP). During the interview he verified he was unable to find the orders in the electronic charting system. Record review of the physician orders for Resident #12 revealed no orders for chest x-ray, CBC, or a BMP on or since 03/11/23. Interview on 03/13/23 at 3:35 P.M., with Licensed Practical Nurse (LPN) #19 revealed Resident #12 complained of being cold and short of breath. Resident #12 told LPN #19 she usually she felt that way when her iron was low and wanted her level checked. LPN #19 stated she contacted CNP #17 to provide the update and received an order for a chest x-ray, CBC, and BMP. LPN #19 stated she was unaware of how to put in the chest x-ray order and was going to have the day nurse assist her at the end of her shift, but she forgot and verified none of the orders were placed.

CONCERN (D) 📢 Someone Reported This

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

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews and review of the Centers for Disease Control (CDC) Prevention website, the facility fail...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews and review of the Centers for Disease Control (CDC) Prevention website, the facility failed to ensure proper infection control procedures were followed for hand hygiene. This affected one ( #19)of one resident for incontinence care. The facility census was 59. Findings include: Review of medical record for Resident #19 revealed admission date of 03/18/21, with medical diagnoses included hemiparesis right dominant side, stroke, and incontinence. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed moderately impaired cognition. He was totally dependent for bed mobility, transfers, dressing, eating and toileting. He was always incontinent of bowel and bladder. Review of the care plan last revised 01/13/23, for incontinence of bowel and bladder with interventions which included observe skin and intervene when needed, provide incontinence care every two hours and as needed. Observation was made on 03/08/23 at 11:28 A.M. of State Tested Nursing Assistant (STNA) #12 providing incontinence care for Resident #19, who was incontinent of urine and stool. STNA #12 cleansed the peri and genital area with soap and water and dried the area. STNA #12 was observed to covered Resident #19 with the bed linens, removed his gloves, and left the room without using hand cleanser. STNA #12 returned to the room with more towels and grabbed another pair of gloves. After STNA #12 applied the gloves, he turned Resident #19 onto his left side and proceeded to clean stool from his buttocks with a soapy towel. STNA #12 rinsed the area with another wet towel and patted the area dry. STNA #12 placed a folded depends under Resident #19 and then rolled him onto his back. STNA #12 then proceeded to clean the stool which had spread to the peri area, without changing his gloves STNA #12 moved Resident #19's genitals from side to side, and again cleaned the area. STNA #12 rolled Resident #19 towards him and straightened the depends under Resident #19. After rolling Resident #19 onto his back, STNA #12 fastened the depends, covered him and restarted the tube feeding without removing the soiled gloves. STNA #12 then removed his soiled gloves and grabbed the bags of linens and dirty depends, without providing hand hygiene, and went into the hall. STNA #12 verified he did change his gloves after cleaning stool and he did not use hand hygiene after the removal of his gloves. Interview with the DON on 03/15/23 at 4:15 P.M., with the Director of Nursing (DON) verified the policy provided to the surveyor was for incontinence management and did not address the procedure for incontinence care including hand hygiene. The DON stated incontinence care was part of the training of STNA and verified it was the expectation of the facility, hand hygiene would be performed after the removal of gloves, and gloves would be changed after direct contact with one area before providing care to another. Review of the CDC website at https://www.cdc.gov/handhygiene/providers/index.html, under the category for Healthcare Providers and sub category of Hand Hygiene Guidance revealed hand hygiene would be expected immediately after glove removal and to change gloves and perform hygiene when moving from a soiled site to clean site.

Jan 2023 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

Abuse Prevention Policies (Tag F0607)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, review of facilities Self-Reported Incidents (SRIs) and policy review, the faci...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, review of facilities Self-Reported Incidents (SRIs) and policy review, the facility failed to ensure their abuse policy was implemented when a resident-to-resident sexual abuse allegation occurred. This impacted one (Resident #25) of three residents reviewed for abuse but had the potential to affect all resident in the facility. The facility census was 51. Findings include: Review of the medical record of Resident #25 revealed and admission date of 04/24/17. Diagnoses included, but not limited to, paranoid schizophrenia, unsteadiness on feet, hemiplegia/hemiparesis following the cerebral accident (stroke), and bipolar disorder. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #25 dated 10/07/22 revealed the resident had intact cognition. The resident was assessed as having no delirium and no short-term memory loss. Record review of Resident #10 revealed the resident was admitted to the facility on [DATE] and had a room change on 12/03/22. Diagnoses included, but not limited to, dementia, adult failure to thrive, psychotic disturbance and diabetes. There was no diagnosis of sexual aggressiveness. Review of the comprehensive MDS assessment dated [DATE], revealed Resident #10 had impaired cognition. The resident required limited assistance for walking, transferring and hygiene assistance. Review of facility investigation revealed an allegation of sexual abuse (witnessed by staff) which occurred on 12/01/22 at 2:35 A.M. between Resident #10 (Perpetrator) and Resident #25. Review of facilities investigation revealed the incident between Resident #25 and Resident #10 was not reported to the Administrator until the morning meeting on 12/02/22. Review of the reported SRI number (229723), for sexual abuse indicated the incident occurred on 12/01/22 at 2:35 A.M. when Resident #10 was observed fondling Resident #25's breast while masturbating. The SRI indicated the Administrator was notified during the morning meeting on 12/02/22. Review of the SRI Report, indicated the Administrator created the SRI on 12/02/22 at 4:21 P.M. Review of a nursing progress note dated 12/02/22 at 11:25 A.M. for Resident #25, revealed the Administrator was notified during the morning meeting of a sexual misconduct allegation between Resident #25 and Resident #10. Notes indicated Resident #25's guardian was notified of the incident and denied having the local police involved. Notes indicated the Nurse Practitioner was notified. Interview on 12/29/22 at 1:38 P.M. with Regional Clinical Nurse, (RCN) #48 verified the facility did not implement their abuse policy when the incident between Resident #25 and Resident #10 occurred on 12/01/22 at 2:35 A.M. RCN #48 verified the allegation was not reported to the Administrator until 12/02/22 during the morning meeting around 9:00 A.M. RCN #48 also verified the SRI was not created until 12/02/22 at 4:21 P.M. RCN #48 stated the incident constituted abuse and staff should have implemented their abuse policy and should have been reported immediately. Review of the facility policy titled, Abuse, Neglect, Exploitation, and Misappropriation of Resident Property, dated 2016, revealed facility staff should immediately report all allegations of abuse or mistreatment to the administrator and the allegations of abuse shall be reported to the state agency immediately, but not later than two hours after to the allegation is made. This deficiency represents non-compliance investigated under Complaint Number OH00138251.

CONCERN (D) 📢 Someone Reported This

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

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, review of facilities Self-Reported Incidents (SRIs) and policy review, the faci...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, review of facilities Self-Reported Incidents (SRIs) and policy review, the facility failed to timely report an allegation of sexual abuse to the state agency. This impacted one (Resident #25) of three residents reviewed for abuse. The facility census was 51. Findings include: Review of the medical record of Resident #25 revealed and admission date of 04/24/17. Diagnoses included, but not limited to, paranoid schizophrenia, unsteadiness on feet, hemiplegia/hemiparesis following the cerebral accident (stroke), and bipolar disorder. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #25 dated 10/07/22, revealed the resident had intact cognition. The resident was assessed as having no delirium and no short-term memory loss. Record review of Resident #10 revealed the resident was admitted to the facility on [DATE] and had a room change on 12/03/22. Diagnoses included, but not limited to, dementia, adult failure to thrive, psychotic disturbance and diabetes. There was no diagnosis of sexual aggressiveness. Review of the comprehensive MDS assessment dated [DATE], revealed Resident #10 had impaired cognition. The resident required limited assistance for walking, transferring and hygiene assistance. Review of facility investigation revealed an allegation of sexual abuse (witnessed by staff) which occurred on 12/01/22 at 2:35 A.M. between Resident #10 and Resident #25. Review of facilities investigation revealed the incident between Resident #25 and Resident #10 was not reported to the Administrator until the morning meeting on 12/02/22. Review of a nursing progress note dated 12/02/22 at 11:25 A.M. for Resident #25, revealed the Administrator was notified during the morning meeting of a sexual misconduct allegation between Resident #25 and Resident #10. Notes indicated Resident #25's guardian was notified and denied police involvement. Notes indicated the Nurse Practitioner was notified. Review of the reported SRI number (229723), for sexual abuse indicated the incident occurred on 12/01/22 at 2:35 A.M. when Resident #10 was observed fondling Resident #25's breast while masturbating. SRI indicated the Administrator was notified during the morning meeting on 12/02/22. Review of the SRI Report, indicated the Administrator created the SRI on 12/02/22 at 4:21 P.M. Interview on 12/29/22 at 1:38 P.M. with Regional Clinical Nurse, (RCN) #48 verified the facility did not implement their abuse policy when the incident between Resident #25 and Resident #10 occurred on 12/01/22 at 2:35 A.M. RCN #48 verified the allegation was not reported to the Administrator until 12/02/22 during the morning meeting around 9:00 A.M. RCN #48 also verified the SRI was not created until 12/02/22 at 4:21 P.M. RCN #48 stated the incident constituted abuse and staff should have implemented their abuse policy and should have been reported immediately. Review of the facility policy titled, Abuse, Neglect, Exploitation, and Misappropriation of Resident Property, dated 2016, revealed facility staff should immediately report all allegations of abuse or mistreatment to the administrator and the allegations of abuse shall be reported to the state agency immediately, but not later than two hours after to the allegation is made. This deficiency represents non-compliance investigated under Complaint Number OH00138251 and is an example of continued noncompliance from the survey dated 11/07/22.

Dec 2022 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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

Based on medical record review and staff and resident interviews, the facility failed to reorder an as needed medication for Resident #13 resulting in the medication being unavailable. This affected o...

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Based on medical record review and staff and resident interviews, the facility failed to reorder an as needed medication for Resident #13 resulting in the medication being unavailable. This affected one (#13) of three residents reviewed for medication administration. The facility census was 51. Findings include: Review of the medical record for Resident #13 revealed an admission date of 08/24/21. Diagnosis included chronic obstructive pulmonary disease (COPD), anxiety and depressive disorders, pain, insomnia, polycythemia vera (blood cancer), hypokalemia, hypomagnesemia, alcoholic liver disease, tachycardia, and hearing loss. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/14/22, revealed the resident had intact cognition. Resident #13 was independent for all activities of daily living. Review of Resident #13's behavior revealed the resident had rejection of care. Review of the plan of care dated 05/17/22 revealed the resident has potential for behavior problems related to diagnosis of anxiety. Interventions included to administer medication as ordered. Allow resident to discuss feelings. Approach/speak to resident in a calm voice. Encourage resident to attend activities of choice. Psychiatry/counseling services as needed. Staff to anticipated resident's needs. Staff to give resident one on one as needed. Staff to redirect resident as able. Interview with Resident #13 on 12/01/22 at 8:50 A.M. revealed the facility has been out of his Zofran as needed medication for months so its not available when he needs it. Further review of the physician orders dated 11/2022 and 12/2022 revealed an order for Zofran Tablet four milligrams (Ondansetron HCl), give one tablet by mouth every six hours as needed for nausea. Review of the Medication Administration Record (MAR) 11/01/22 revealed Resident #13's medication Zofran was last administered on 10/31/22. Review of Resident #13's medications revealed the facility was out of this medication since 10/31/22 and had not reordered it. Interview with the Corporate Nurse #9 on 12/01/22 at 1:27 P.M. confirmed Resident #13's as needed Zofran was not reordered and not available for administration since his last dose on 10/31/22. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

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 F0776 (Tag F0776)

Could have caused harm · This affected 1 resident

Based on medical record review and staff and resident interviews, the facility failed to obtain radiology and/or other diagnostic services when the facility failed to make a pulmonary referral for a r...

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Based on medical record review and staff and resident interviews, the facility failed to obtain radiology and/or other diagnostic services when the facility failed to make a pulmonary referral for a resident to have a sleep study and failed to obtain a ultrasound of a resident's kidney/bladder. This affected one (#13) of three resident reviewed for diagnostic services. The facility census was 51. Findings include: Review of the medical record for Resident #13 revealed an admission date of 08/24/21. Diagnosis included chronic obstructive pulmonary disease (COPD), anxiety and depressive disorders, pain, insomnia, polycythemia vera (blood cancer), hypokalemia, hypomagnesemia, alcoholic liver disease, tachycardia, and hearing loss. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/14/22, revealed the resident had intact cognition. Resident #13 was independent for all activities of daily living. Review of Resident #13's behavior revealed the resident had rejection of care. Review of the plan of care dated 05/17/22 revealed the resident has potential for behavior problems related to diagnosis of anxiety. Interventions included to administer medication as ordered. Allow resident to discuss feelings. Approach/speak to resident in a calm voice. Encourage resident to attend activities of choice. Psychiatry/counseling services as needed. Staff to anticipated resident's needs. Staff to give resident one on one as needed. Staff to redirect resident as able. Interview with Resident #13 on 12/01/22 at 8:50 A.M. revealed he was supposed to have an ultrasound of his kidney and bladder and that has not happened yet. Resident #13 also revealed he was supposed to have a sleep study done and that also has not happened yet. Further review of the facility's Clinical Nurse Practitioner (CNP) note dated 06/06/22 revealed a referral for Resident #13 to pulmonary for a sleep study to be completed. On 08/06/22, Resident #13 was ordered a ultrasound of kidney and bladder. Review of Resident #13's medical record revealed there was no evidence of a sleep study or ultrasound of the kidney and bladder. Interview with the Corporate Nurse #9 on 12/01/22 at 1:27 P.M. confirmed the sleep study order and the kidney/bladder ultrasound for Resident #13 were not completed. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Nov 2022 14 deficiencies 1 Harm

SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Pressure Ulcer Prevention (Tag F0686)

A resident was harmed · This affected 1 resident

Based on record review, observation, staff, family, and Wound Physician (WP) #315 interviews, review of facility policy, review of wound physician notes, and review of guidelines from the National Pre...

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Based on record review, observation, staff, family, and Wound Physician (WP) #315 interviews, review of facility policy, review of wound physician notes, and review of guidelines from the National Pressure Injury Advisory Panel (NPIAP), the facility failed to implement interventions/treatments to prevent the development of pressure ulcers and/or aid in the healing of existing pressure ulcers as ordered by the physician. This resulted in Actual Harm when Resident #35 was found to have avoidable pressure ulcers which were first identified as a stage III pressure ulcer on his right heel on 09/21/22 and an avoidable unstageable pressure ulcer in the palm of his left hand discovered at the time of the survey on 11/02/22. This affected one resident (#35) of two residents reviewed for pressure ulcers. The census was 48. Findings include: Review of the medical record for Resident #35 revealed an admission date of 01/08/14. Diagnoses included, left sided hemiplegia and hemiparesis following a cerebral infarction, peripheral vascular disease (PVD), aphasia, dysphagia, and congestive heart failure. Review of the Minimum Data Set (MDS) for Resident #35 dated 10/02/22 revealed the resident was cognitively impaired. Resident #35 was totally dependent on staff with all areas of activities of daily living (ADLs). Further review of the MDS assessment revealed the resident was coded as being at risk for the development of pressure ulcers and positive for the presence of a Stage III pressure ulcer on the right heel. Review of the care plan for Resident #35, revised on 10/02/22, revealed the resident was at risk for decreased skin integrity related to his weakness from left side hemiparesis and PVD diagnosis and resident was incontinent. Interventions included the following: diets and supplements per order, monitor skin weekly and as needed (PRN), pressure reducing cushion to the wheelchair, pressure reducing mattress, and treatments per order. Further review of the care plan revealed there were no specific interventions to reduce pressure to Resident #35's heels, such as elevation or floating of the heels. Review of the care plan revealed there was no care plan in place from 10/01/21 through 10/01/22 regarding the use of a carrot splint (wedge splint for contractures to keep hand open) or other pressure relieving interventions for resident's contracted left hand. Review of physician orders, dated 11/15/19, revealed Resident #35 was ordered to have weekly skin assessments to document skin integrity. Review of the Resident #35's most recent, Braden Scale for Predicting Pressure Sore Risk, dated 06/14/20, revealed resident was at low risk for developing pressures ulcers. Review of Occupational Therapy (OT) notes, dated 10/11/2021, revealed Resident #35, was totally dependent for all ADLs, had a contracture of the left hand, and would benefit from splinting of the left hand with carrot splint. Assessment summary indicated Carrot splint/orthotic device to be implemented. Review of physician orders from 10/2021 through 10/2022 for Resident #35 revealed no ordered carrot splint or other interventions to prevent the development of pressure ulcers for the contracted left hand. Review of the shower sheets dated 08/31/22, 09/14/22, 09/21/22, 09/27/22, and 10/25/22 revealed Resident #35 had no documented skin impairments. Review of the weekly skin assessment, dated 09/14/22, for Resident #35 revealed the resident was assessed to have no pressure areas and the resident's skin was intact. Additional review of weekly skin assessments prior to 11/02/22 revealed no documented skin assessments being completed. Review of the nurse progress notes for Resident #35, dated 09/21/22, revealed Nursing Assistant (NA) #500 identified an open wound on the right heel of Resident #35's foot. Further review of the note revealed the nurse cleaned and dressed the resident's wound. Review of Resident #35's, Skin Grid Pressure 3.0, dated 09/22/22, revealed a newly identified pressure area, on the resident's right heel, which measured 2.0 centimeters (cms) (length) by 3.3 cms (width) by 0.2 cm (depth), and categorized as a Stage III Pressure ulcer (full thickness tissue loss), with moderate drainage and notes indicated the physician was notified. Review of Skin Grid Pressure 3.0, dated 09/29/22, revealed the right heel pressure ulcer measured, 1.3 cms by 2.1 cms by 0.1 cm, was categorized as a Stage III pressure ulcer, and had a moderate amount of drainage. Review of Skin Grid Pressure 3.0, dated 10/06/22, revealed the right heel pressure ulcer measured, 1.2 cms by 2.4 cms by 0.1 cm, was categorized as a Stage III pressure ulcer, and had a moderate amount of drainage. Review of Skin Grid Pressure 3.0, dated 10/13/22, revealed the right heel pressure ulcer measured 1.4 cms by 1.1 cms by 0.1 cm, was categorized as a Stage III pressure ulcer, and had a moderate amount of drainage. Review of the WP #315 progress note for Resident #35, dated 09/22/22, revealed the physician classified the open area to the right heel as a Stage III pressure wound. Notes indicated the wound measured 2.0 cms by 3.3 cms by 0.2 cm, tissue bed at 75 percent (%) granular, 25 % slough, and a moderate amount of serous drainage was noted. Notes indicated the resident reported pain at the wound site as a three (zero indicated no pain and 10 indicated severe pain). Further review of the note revealed the wound was debrided to promote healing and prevention of infection, off-loading recommendations for resident to off-load heels from bed with pillow(s) or offloading boots, and antibiotics were ordered with fair prognosis. Review of WP #315 progress note, dated 10/27/22, revealed the resident's right heel pressure wound was healed and covered with stable wound scab. Plan noted for staff to use Betadine solution to wound, then leave open to air and continue to off-load heels and resident was discharged from the wound clinic. Review of the active monthly physician orders, dated October 2022, for Resident #35 revealed there were no orders for pressure relieving heel boots, heel protection, or orders to offload resident's heels or pressure relieving interventions for resident's contracted left hand. Review of the physician orders, dated 10/27/22, revealed an order for Resident #35 to receive Betadine applied to the right heal daily and to leave open to air. Review of the October 2022 Treatment Administration Record (TAR) for Resident #35 revealed the treatment to Resident #35's right heel was not completed on 10/28/22, 10/29/22, 10/30/22, or 10/31/22 per physician's order. Further review of the October TAR revealed skin assessments were documented as being completed on 10/07/22, 10/14/22, 10/21/22 and 10/28/22. Review of the physician orders, dated 10/27/22, revealed Resident #35 was ordered to receive Betadine applied to the right heal daily and leave open to air. Interview on 10/31/22 at 11:05 A.M. with Resident #35's representative revealed they had a concern with staff not utilizing the carrot splint to resident's left contracted hand. Resident #35's representative stated the splint was not able to be located in the room. Observation on 10/31/22 at 11:25 A.M. revealed a typed sign over Resident #35's bed that read carrot splint to the left hand Further review of the medical record revealed no documented evidence a carrot splint or other palm protector intervention was being utilized on Resident 35's contracted left hand. Interview on 10/31/22 at 3:56 P.M. with Licensed Practical Nurse (LPN) #75 confirmed there was a sign hanging over Resident #35's bed, which indicated resident was to have the carrot splint in place and verified Resident #35 did not have the carrot splint in place for his left hand contracture. Observation revealed LPN#75 searched Resident #35's room and verified the carrot splint was not able to be located in the resident's room. LPN #75 verified the resident's contracture of the left hand and verified the carrot split was to be utilized to keep fingers off of his palmar area. Interview on 11/01/22 at 3:21 P.M. with LPN #75 confirmed Resident #35 was capable of sitting in his wheelchair. LPN#75 confirmed she was on duty when facility discovered Resident #35 had a wound to the right heel. LPN #75 stated Resident #35 had moon boots in place prior to identifying the Stage III wound on his right heel, however, Resident #35 would kick them off and the staff would not put them back on him once he kicked them off. Observation of wound care provided to Resident #35 by LPN #75 on 11/02/22 at 10:09 A.M. revealed LPN #75 washed her hands and donned gloves. Continued observation revealed LPN #75 removed the old dressing, cleansed her hands, applied clean gloves, cleaned the wound, applied Mupirocin ointment, and wrapped the right heel with a dressing and placed the boot over the dressing. Interview on 11/02/02 at 11:05 A.M. with LPN #75 verified the observed wound treatment to Resident #35's right heel. LPN #75 verified the observed wound treatment was ordered on 09/27/22 and discontinued on 11/01/22. LPN #75 indicated the physician orders, dated 10/27/22, to apply Betadine to right heal everyday and leave open to air, was the current ordered wound treatment and verified she should have provided this wound treatment to Resident #35's right heel. LPN #75 verified she provided the incorrect wound treatment to Resident #35's right heel. Observation on 11/02/22 at 5:15 P.M. of wound care treatment for Resident #35 revealed the Director of Nursing (DON) assessed Resident #35's left contracted hand. Observation revealed the DON pulled the resident's contracted fingers away from the resident's palm and the resident was observed with thick long fingernails and his nails appeared to be imbedded into the skin of his left palm area. Continued observation revealed Resident #35 had an open wound identified in the resident's palm area of the left hand. Interview with DON at that time verified the open wound in the left palm and indicated she was not aware of the wound. Review of nurse's progress notes, dated 11/02/22 at 10:01 P.M., revealed staff cleansed palm of right hand with soap and water, applied dry gauze, notified facility physician of changes, notified wound physician regarding long nails, and resident's wife made aware. Nurse's progress notes, dated 11/03/22 at 2:35 A.M., indicated resident's nails were cut down, normal saline was applied, and hand wrapped with kerlix. Nurse's progress notes, dated 11/03/22 at 4:37 A.M., indicated the resident's fingernails were cut, cleansed with normal saline, and then the left fingernail was wrapped with kerlix. Further review of the medical record revealed no documented assessment of the left hand wound for Resident #35. Review of physician orders, dated 11/03/22, revealed the resident was ordered to have the left hand/palm cleaned with soap and water, a dry four by four (4 x 4) applied to inside of hand each shift and as needed (PRN) every shift, and to report changes to the wound doctor. Review of 11/03/22 WP #315 progress notes for Resident #35 revealed the resident was assessed to have a healed Stage III pressure injury to right heel (Wound #1) and a new open wound to left palmar surface in webspace between the left thumb and index finger (Wound #2). Notes indicated the right heel was healed and covered with stable wound scab. Notes indicated left hand webspace wound was facility acquired, non-pressure, and classified as a skin tear with unknown date of onset, had moderate amount of serous drainage, measured 1.3 cms by 1.8 cms by 0.1 cm depth, with subcutaneous area exposed. Notes indicated wound was cleansed, flushed, and irrigated and debrided to reduce the risk of infection and improve wound healing. Plan was for nursing to institute pressure injury prevention protocol for left hand, including physical therapy for range of motion exercises across joints and prevention of limb contracture, as well as improve overall patient's personal hygiene, and residents progress was diagnosed as fair and to follow in one week. Interview on 11/03/22 at 10:49 A.M. with the facility WP #315 confirmed he was not aware of the wound on Resident #35's left palm/hand. WP #315 stated he did not have Resident #35 on his list to be seen since the Stage III pressure wound on Resident #35's right heel had been considered healed. WP #315 additionally stated he was not aware the facility had not been completing the correct order to the right heel, which was ordered on 10/27/22. WP #315 confirmed, if proper nursing procedures had been followed, the pressure ulcer on Resident #35's right heel could have been avoidable and identified prior to the wound being identified as a Stage III on 09/22/22. Interview on 11/03/22 at 11:02 A.M. with Occupational Therapist (OT) #505 revealed he was met with resistance from facility staff when he recommended for Resident #35 to utilize the carrot splint in the resident's contracted left hand as tolerated. OT #505 insisted that he wrote an order for the treatment and even educated the staff, however, he could not explain why there was no order identified in Resident #35's record for the carrot splint. OT #505 stated, once he screened a resident for the need of a device, he educated the staff and then washed his hands of it. Follow up interview with WP #315 on 11/03/22 at 2:23 P.M. confirmed he assessed the wound located on the palm of the left contracted hand of Resident #35 on 11/03/22. WP #315 stated this was an avoidable, unstageable pressure wound and consisted of two separate wounds on the palm of the hand separated by an open area. The total size of the wound was 1.3 cms length by 1.8 cms width by 0.1 cm depth and considered it a trauma wound caused by pressure. WP #315 stated the right foot was very dry, however, he considered the right heel to be healed even with the scabbed area on the heel. WP #315 confirmed the importance of Resident #35 having clean skin and how it could affect the healing process. WP #315 stated a concern with the staffing at the facility, including the staff turning over and not having proper nursing care could affect the healing of Resident #35's skin. Interview on 11/03/22 at 3:08 P.M. with Nursing Assistant (NA) #500 confirmed she was the NA that discovered the wound on Resident #35's right heel on 09/21/22. NA #500 stated she was cleaning Resident #35 and identified red blood on the sheet under the right heel and NA #500 stated she told LPN #75. NA #500 stated she did not mark the shower sheet, dated 09/21/22, for a wound because it was the responsibility of the nurse on duty. Follow up interview on 11/04/22 at 8:46 A.M. with LPN #75 confirmed she could not remember notifying the physician or the resident representative of Resident #35's of the open area to his heel when it was found on 09/21/22. Attempted follow-up interview with WP #315 on 11/14/22 at 2:45 P. M to clarify 11/03/22 physician's wound notes was unsuccessful. Review of 11/01/18 facility policy Titled Wound Care indicated the facility would provide therapeutic treatments to heal wounds, treatments implemented by a nurse required a physician's order, and wounds be evaluated when they are noted and weekly until resolved. Review of the NPIAP guidelines, dated 2014, pages 70-71 at https://npiap.com/general/custom.asp?page=2014Guidelines, revealed facilities should educate health professionals on how to undertake a comprehensive skin assessment that includes the techniques for identifying blanching response, localized heat, edema, and induration. Further review of the guidelines revealed ongoing assessment of the skin was necessary in order to detect early signs of pressure damage. Visual assessment for erythema (redness of the skin) was the first component of every skin inspection. Skin redness and tissue edema resulting from capillary occlusion was a response to pressure, especially over bony prominences. Staff should conduct a head-to-toe assessment with particular focus on skin overlying bony prominences including the sacrum, ischial tuberosities, greater trochanters and heels and each time the patient was repositioned was an opportunity to conduct a brief skin assessment.

CONCERN (D)

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

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

Based on observation, resident interview, and staff interviews, the facility failed to ensure the dining room was available for accommodate resident preferences. This affected two (Residents #09 and #...

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Based on observation, resident interview, and staff interviews, the facility failed to ensure the dining room was available for accommodate resident preferences. This affected two (Residents #09 and #40) of three residents reviewed for accommodations of needs. The facility's census was 48. Findings include: Interview on 10/31/22 at 12:30 P.M. with Resident #09 revealed the facility did not enough staff to serve meals in the dining room. Interview on 10/31/22 at 12:45 P.M. with State Tested Nurse Aide (STNA) #170 revealed the facility removed an aide from the overall schedule, so there was no staff available to assist with the dining room. Observation with interview on 10/31/22 at 2:09 P.M. of Resident #09 revealed the resident was eating his meal in his room. Resident #09 stated the dining room was open about one month ago and he liked to socialize in the dining room. Resident #09 stated he was informed the dining room was closed due to not having enough staff to watch the residents in the dining room. Interview on 10/31/22 at 1:59 P.M. with Resident #40 stated she was told the residents do not eat in the dining room because of staffing. Resident #40 stated she was told the census was low, which causes low staffing. Resident #40 stated she was told the low staffing causes an issue because no staff was available to monitor the dining room. Interview on 11/03/22 at 3:52 P.M. with the Administrator confirmed the facility had been forced to close the dining rooms because of staffing. The Administrator stated the census had been low, creating a lower need for staffing. The Administrator stated they do not have enough staff to supervise the dining rooms.

CONCERN (D)

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

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff and family interviews, and review of facility policy, the facility failed to notify a resi...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff and family interviews, and review of facility policy, the facility failed to notify a resident's representative and resident's physician when resident had a change in condition. This affected one (Resident #35) of the three residents reviewed for notifications. The facility's census was 48. Findings include: Review of the medical record for Resident #35 revealed an admission date of 01/08/14. His diagnoses included, hemiplegia and hemiparesis following a cerebral infarction, peripheral vascular disease (PVD), aphasia, dysphagia, and congestive heart failure. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35 was cognitively impaired. Resident #35 was totally dependent upon staff for all activities of daily living (ADLs). Review of the progress note dated 09/21/22 revealed Resident #35 had a Stage III pressure ulcer (full thickness tissue loss) to his right heel. There was no documentation the resident's representative or physician was notified of the discovered wound. Interview on 10/31/22 at 11:27 A.M. with Resident #35's representative revealed she felt Resident #35 may have had pressure issues but could not say for sure because she did not always receive updates or notifications regarding changes with Resident #35. Interview on 11/04/22 at 8:46 A.M. with Licensed Practical Nurse (LPN) #75 confirmed she did not remember notifying Resident #35's representative or physician of the open area found of Resident #35's heel on 09/21/22. Review of the facility policy titled, Change of Condition and Notification to Physician Policy, dated 09/2019 revealed the facility would promptly identify, respond to, and report changes in a resident's condition to the resident's physician and representative.

CONCERN (D)

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, review of facilities Self-Reported Incidents (SRIs) and policy review, the faci...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, review of facilities Self-Reported Incidents (SRIs) and policy review, the facility failed to timely report an allegation of sexual abuse to the state agency. This impacted one (Resident #26) of three residents reviewed for abuse. The facility census was 48. Findings include: Review of the medical record of Resident #26 revealed and admission date of 07/21/17. The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]. Diagnoses included human immunodeficiency virus (HIV) disease, unspecified intellectual disabilities (ID), major depressive disorder, schizoaffective disorder, bipolar disorder, anxiety disorder, high risk bisexual behavior, and unspecified mood disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident was assessed as exhibiting hallucinations and delusions during the assessment period. Review of a nursing progress note dated 09/08/22 at 12:25 P.M. revealed Resident #26 was yelling out that two people raped him and to call the police. Resident #26 was noted slamming his door multiple times, would not calm down, and was refusing medications. Review of the reported SRI number (226633) for sexual abuse indicated the incident occurred on 09/08/22 at 12:25 P.M. SRI indicated facility created the SRI on 09/12/22 at 11:57 A.M. Review of facilities SRI revealed Resident #26's report of two people raping him was not reported to facilities administration until 09/12/22. Interview on 11/02/22 at 2:40 P.M. the Administrator verified Resident #26's allegation of sexual abuse was not reported until four days after the incident. The Administrator stated she created an SRI when she became aware of the incident, however there must have been a delay in reporting the incident to her. The Administrator further verified the incident should have been reported to her immediately. Review of the facility policy titled, Abuse, Neglect, Exploitation, and Misappropriation of Resident Property, dated 2016, revealed facility staff should immediately report all allegations of abuse or mistreatment to the administrator and state agency.

CONCERN (D)

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

Deficiency F0625 (Tag F0625)

Could have caused harm · This affected 1 resident

**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 a resident and/or resident's r...

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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 a resident and/or resident's representative were notified of the facility's bed hold policy upon being transferred to the hospital. This impacted one (Resident #26) of two residents reviewed for hospitalization. Facility census was 48. Findings include: Review of the medical record of Resident #26 revealed and admission date of 07/21/17. The resident was transferred to the hospital on [DATE] and returned to the facility on [DATE]. The resident transferred to the hospital again on 10/14/22 and returned to the facility on [DATE]. Diagnoses included human immunodeficiency virus (HIV) disease, unspecified intellectual disabilities (ID), major depressive disorder, schizoaffective disorder, bipolar disorder, anxiety disorder, and unspecified mood disorder. Review of the quarterly MDS assessment dated [DATE] revealed the resident had intact cognition. The resident was assessed as exhibiting hallucinations and delusions during the assessment period. Review of the electronic (Einteract) transfer form dated 09/09/22 revealed Resident #26 transferred to the hospital on [DATE] at 9:35 A.M. for behavioral symptoms. Review of the progress note dated 10/14/22 at 8:28 A.M. revealed Resident #26 was observed ambulating down the hallway with an unsteady gait, holding the handrails, and almost falling several times. The resident was assisted to a chair. The resident's speech was slurred and incoherent. Vitals were obtained and the resident requested to be sent to the hospital. Review of the medical record revealed no evidence of the resident nor resident representative being notified of the bed hold policy upon transferring to the hospital. Interview on 11/02/22 at 5:26 P.M., the Administrator verified there was no evidence of the resident nor resident's representative being notified of the bed hold policy upon transferring to the hospital on [DATE] and 10/14/22. Review of the facility policy titled, Bed Hold Notice Upon Transfer, dated 10/27/22, revealed, in the event of an emergent transfer, within 24 hours, the facility will provide the resident and/or resident representative with written notice specifying the duration of the bed hold policy. Further review revealed the facility will maintain a signed and dated copy of the bed-hold notice information given to the resident and/or representative in the resident's record.

CONCERN (D)

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

Deficiency F0637 (Tag F0637)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #35 revealed an admission date of 01/08/14. His diagnoses included, hemiplegia and ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #35 revealed an admission date of 01/08/14. His diagnoses included, hemiplegia and hemiparesis following a cerebral infarction, peripheral vascular disease (PVD), aphasia, dysphagia, and congestive heart failure. Review of the MDS for Resident #35 dated 10/02/22 revealed the resident was cognitively impaired. Resident # 35 was totally dependent on staff with all areas of activities of daily living (ADLs). Further review of the MDS assessments prior to the 10/02/22 revealed no MDS assessments for significant changes in the past year. Record review for Resident #35 revealed he was discharged to the hospital on [DATE] for a planned feeding tube placement scheduled on 03/16/22. Resident readmitted to the facility on [DATE] with a new feeding tube being placed. Interview on 11/03/22 at 2:21 P.M. with the MDS/LPN #245 confirmed the facility failed to complete a significant change MDS review when resident had a feeding tube placed on 03/16/22. 3. Review of the medical record of Resident #34 revealed an admission date of 03/27/19. Diagnoses included schizoaffective disorder, polyneuropathy, peripheral vascular disease, unspecified mood disorder, restlessness and agitation, violent behavior, major depressive disorder, auditory hallucinations, somnolence, anxiety disorder, bipolar disorder, and conduct disorder. Review of the quarterly MDS assessment dated [DATE] revealed the resident had moderately impaired cognition. The resident required supervision or limited assistance for ADLs. Further review of MDS assessments revealed a significant change had not been completed in the prior six months. Review of the medical record revealed Resident #34 was sent to psychiatric hospitals for stays on 06/25/22 through 07/06/22, 07/17/22 through 08/01/22, 09/18/22 through 09/26/22, and 10/13/22 through 10/19/22. Review of the Psychiatry Progress Note dated 07/07/22 revealed Resident #34 was assessed as having chronic unstable bipolar disorder, chronic stable major depressive disorder, chronic unstable schizoaffective disorder, chronic unstable conduct disorder, and chronic stable insomnia. Orders were given to adjust medications. Review of the Psychiatry Progress Note dated 08/04/22 revealed Resident #34 was assessed as having chronic unstable bipolar disorder, chronic stable major depressive disorder, chronic unstable schizoaffective disorder, chronic unstable conduct disorder, and chronic stable insomnia. Orders were given to adjust medications. Review of the Psychiatry Progress Note dated 08/29/22 revealed Resident #34 was assessed as having guarded bipolar disorder, chronic stable major depressive disorder, chronic unstable schizoaffective disorder, and chronic stable insomnia. Orders were given to adjust medications. Interview on 11/03/22 at 2:15 P.M., MDS/LPN #245 verified there was not a significant change MDS completed on Resident #34. MDS/LPN #245 stated she did not think it was necessary to do a significant change MDS. Review of the RAI revealed guidelines for determining a significant change in a resident's status should be based on the judgement of the clinical staff and a decline in two areas, including the emergence of anxious mood pattern as a problem that is not easily altered and the emergence of a condition in which a resident is judged to be unstable. Based on medical record review, staff interview, observations, and review of the Resident Assessment Instrument (RAI) version 3.0, the facility failed to develop a significant change Minimum Data Set (MDS) when indicated. This affected three (Residents #1, #34, and #35) of three residents reviewed for MDS completion. The facility census was 48. Findings included: 1. Medical record review for Resident #01 revealed and admission on [DATE] with diagnoses that included, but not limited to, terminal encephalopathy, cerebral vascular attack (CVA/stroke), and seizure disorder. Review of the most recent quarterly MDS assessment dated [DATE] for Resident #01 revealed the resident was severely cognitively impaired and required total care for bed mobility, transfers, toileting and eating. Further review of MDS assessments revealed no significant change MDS was noted when resident was admitted with hospice services. Review of the physician orders dated 09/23/20 for Resident #01 revealed an order for Hospice services. Review of the plan of care for Resident #01 dated 09/23/20 revealed the resident required Hospice services for end of life, Observation on 11/01/22 1:20 P.M. of Resident #01 revealed the resident was in bed with a Hospice Nursing Assistant (NA) assisting her with her meal. Interview on 11/01/22 at 2:00 P.M. with Licensed Practical Nurse (LPN) #75 verified Resident #01 received Hospice services. Interview on 11/01/22 at 2:30 P.M. with LPN # 245 verified a significant change MDS was not completed when Resident #01 was admitted with Hospice services.

CONCERN (D)

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

PASARR Coordination (Tag F0644)

Could have caused harm · This affected 1 resident

**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 a new Preadmission Screening a...

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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 a new Preadmission Screening and Resident Review (PASARR) was completed following a psychiatric hospitalization. This affected two (Residents #26 and #34) of five residents reviewed for PASARR. The facility census was 48. Findings include: 1. Review of the medical record of Resident #26 revealed and admission date of 07/21/17. The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]. Diagnoses included human immunodeficiency virus (HIV) disease, unspecified intellectual disabilities (ID), major depressive disorder, schizoaffective disorder, bipolar disorder, anxiety disorder, and unspecified mood disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident was assessed as exhibiting hallucinations and delusions during the assessment period. The resident was assessed has rejecting care daily during the assessment period. Review of the electronic (eInteract)Transfer form dated 09/09/22 revealed Resident #26 transferred to the hospital on [DATE] at 9:35 A.M. for behavioral symptoms. Resident #26 was noted to be at risk of harm to self or others. Review of the progress note dated 09/22/22 at 5:45 P.M. revealed Resident #26 returned to the facility from the local psychiatric hospital. Review of the medical record revealed the most recent PASARR for Resident #26 was completed on 07/18/17. Interview on 11/01/22 at 1:12 P.M., Social Services Designee (SSD) #145 stated a new PASARR was required when a resident had a psychiatric hospitalization. Interview on 11/02/22 at 12:05 P.M., SSD #145 verified a new PASARR was not completed following Resident #26's psych hospitalization from 09/09/22 to 09/22/22. 2. Review of the medical record of Resident #34 revealed an admission date of 03/27/19. Diagnoses included schizoaffective disorder, polyneuropathy, peripheral vascular disease, unspecified mood disorder, restlessness and agitation, violent behavior, major depressive disorder, auditory hallucinations, somnolence, anxiety disorder, bipolar disorder, and conduct disorder. Review of the quarterly MDS assessment dated [DATE] revealed the resident had moderately impaired cognition. The resident was assessed as exhibiting fluctuating inattention, disorganized thinking, and delusions during the assessment period. Review of the medical record revealed Resident #34 was sent to psychiatric hospitals for stays on 06/25/22 through 07/06/22, 07/17/22 through 08/01/22, 09/18/22 through 09/26/22, and 10/13/22 through 10/19/22. Review of PASARR results revealed the most recent PASARR was completed on 06/14/22. Interview on 11/02/22 at 12:05 P.M., SSD #145 verified a new PASARR was not completed following any of Resident #34's psych hospitalizations on 06/25/22 through 07/06/22, 07/17/22 through 08/01/22, 09/18/22 through 09/26/22, and 10/13/22 through 10/19/22. Review of the facility policy titled, Pre-admission Screening, undated, revealed a new PASARR is required if an individual's mental health status has changed since the last PASARR determination. Further review revealed, in general, a PASARR remains valid as long as an individual does not have a significant change in condition related to serious mental illness.

CONCERN (D)

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

Deficiency F0679 (Tag F0679)

Could have caused harm · This affected 1 resident

Based on observation, record review, and interviews the facility failed to provide therapeutic activities to meet the needs and preferences of the resident population. This affected two (Residents #09...

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Based on observation, record review, and interviews the facility failed to provide therapeutic activities to meet the needs and preferences of the resident population. This affected two (Residents #09 and #40) out of two residents reviewed for activities. The facility census was 48. Findings include: 1. Record review for Resident #09 revealed an admission date of 04/22/22. His diagnoses included, transient cerebral ischemic attack, cerebral infarction, essential primary hypertension, diabetes mellitus 2, major depressive disorder, hypoglycemia, hepatitis-C, dysphagia, atrial fibrillation (A-fib), and chronic obstructive pulmonary disease. Review of the minimum data set assessment (MDS) assessment dated , 07/30/22, revealed resident had mildly impaired cognition. Further review of the MDS assessment revealed Resident #09 required limited assistance or supervision for activities of daily living (ADLs). Interview on 10/31/22 at 12:27 P.M. with Resident #09 revealed he only attended bingo because there was not much to do. 2 Record review for Resident #40 revealed an admission date of 12/03/21. Her diagnoses included, essential primary hypertension, anemia, acute kidney failure, cellulitis of right lower limb, gastro-esophageal reflux disease, constipation, hypokalemia, and chronic obstructive pulmonary disease. Review of the quarterly MDS assessment dated , 10/07/22, revealed Resident #40 was cognitively intact. Further review of the MDS assessment revealed Resident #40 required supervision from staff with eating, personal hygiene, bathing, walking, and toilet use. Interview on 10/31/22 at 12:08 P.M. with Resident #40 revealed the facility only offered Bingo for activities. Observation on 11/01/22 on 8:22 A.M. in Resident #26's room revealed an activity calendar on the back of the bathroom door. The activity calendar was dated May 2022. Interview on 11/01/22 at 8:23 A.M., Registered Nurse (RN) #300 verified the activity calendar posted on Resident #26's bathroom door was dated May 2022. Interview on 11/01/22 at 8:26 A.M., Resident #26 stated the calendar was really old and he needed an updated calendar. Observation on 11/01/22 at 8:28 A.M., in Resident #46's room revealed an activity calendar on the back of the bathroom door. The activity calendar was dated May 2022. Interview on 11/01/22 at 8:32 A.M., State Tested Nursing Assistant (STNA) #170 verified the activity calendar posted on Resident #46's bathroom door was dated May 2022. Review of the Resident Council Meeting dated, 08/25/22 revealed the residents requested a corn hole game, more outside activities, and games available for the evening and weekends. Review of the Activity Calendar for September 2022 and October 2022 had activities available Monday through Friday until 2:30 P.M. The facility did not offer any weekend activities for the month of September 2022 and October 2022. Interview on 11/01/22 at 4:52 P.M. with the Activity Assistant (AA) # 10 confirmed she is the only person that works in activities. AA #10 confirmed the September and October calendars had activities ending daily at 2:30 P.M. AA #10 confirmed the facility did not have any activities for any weekend during the month of September 2022 or October 2022. AA #10 confirmed she could not explain why the activities calendars hanging on the behavior unit are dated May 2022. AD #10 confirmed the November calendars are not printed.

CONCERN (D)

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

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to implement physician orders following ...

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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 implement physician orders following a pharmacy medication review. This affected one (Resident #31) of five residents reviewed for unnecessary medications. The facility census was 48. Findings include: Review of the medical record of Resident #31 revealed an admission date of 09/26/13. Diagnoses included chronic obstructive pulmonary disease (COPD), type II diabetes mellitus with diabetic polyneuropathy, nicotine dependence, personal history of traumatic brain injury (TBI), bipolar disorder, disorganized schizophrenia, gastro-esophageal reflux disease (GERD), insomnia, pseudobulbar affect, and anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 had intact cognition. The resident was assessed as exhibiting physical and verbal behaviors directed towards others, other behavioral symptoms not directed towards others, and rejection of care one to three days during the assessment period. The resident required supervision for bed mobility and eating, and limited assistance of one for transfers and toileting. Review of the pharmacist note to Attending Physician/Prescriber dated 03/02/22 revealed the resident was receiving Risperdal (antipsychotic) one milligram (mg) twice per day, Oxcarbazepine (mood stabilizer) 600 mg twice per day, Restoril (insomnia) 15 mg at bedtime, Depakote (mood stabilizer/seizures) 250 mg twice per day, and Trazodone (antidepressant) 150 mg at bedtime. Pharmacy recommendations were made to consider a medication reduction, along with suggestions for reductions. The provider signed and dated the form on 03/07/22 and selected to reduce Restoril to 7.5 mg at bedtime, and reduce Trazodone to 100 mg at bedtime. Review of current physician orders dated 09/03/21 for Resident #31 revealed orders for Trazodone HCl 150 mg tablet at bedtime for insomnia and Restoril capsule 15 mg at bedtime. There were no updated orders reflecting the decrease in doses for both medications, as recommended by the physician on 03/07/22. Interview on 11/02/22 at 5:08 P.M. with Regional Nurse #310 verified the pharmacy monthly regimen review dated 03/02/22 was signed and dated by the practitioner on 03/07/22, with new orders for decreased in dose for Trazodone and Restoril, and the orders still had not been changed. Review of the facility policy titled, Consultant Pharmacist Reports, dated 11/2018, revealed recommendations are to be acted upon and documented by the facility personnel.

CONCERN (D)

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

Laboratory Services (Tag F0770)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to complete laboratory (lab) orders per pharmacy recomme...

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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 complete laboratory (lab) orders per pharmacy recommendations and physician's orders. This affected one (Resident #8) of one resident reviewed for lab orders. The facility's census was 48. Findings include: Review of the medical record for Resident #8 revealed an admission date of 10/18/13 with medical diagnoses of left hemiparesis, hypertensive retinopathy, polyneuropathy, hyperlipidemia, atherosclerotic heart disease, unspecified convulsions, epilepsy, anxiety, and hypertension. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 had moderate cognitive impairment. Resident #8 was dependent upon staff for bed mobility, transfers, dressing, toileting, and bathing and the resident did not ambulate. Review of Resident #8's physician orders revealed an order dated 01/20/22 for Divalproex Sodium (generic form of Depakote) (mood stabilizer/seizures) tablet 500 milligram (mg) by mouth two times per day and an order dated 09/01/17 for Levetiracetam (generic form of Keppra) (seizures) 500 mg one tablet by mouth two times per day for epilepsy. Review of Resident #8's Medication Administration Record (MAR) for February 2022, March 2022, September 2022, and October 2022 confirmed Resident #8 received Divalproex Sodium and Levetiracetam daily as ordered. Review of the pharmacy's Medication Recommendation Review Form titled Note to Attending Physician/Prescriber completed on 02/02/22 by the facility's consultant pharmacist revealed the pharmacist recommended Keppra and Depakote levels on next convenient lab day and every six months thereafter for Resident #8. Further review of the form revealed the physician signed the order on 03/31/22 for the Keppra and Depakote levels to be drawn as recommended by the pharmacist. Review of the Medication Recommendation Review Form Titled Note to Attending Physician/Prescriber completed on 09/05/22 by the facility's consultant pharmacist revealed the pharmacist recommended Basic Metabolic Panel (BMP), Depakote, and Oxcarbazepine levels on next convenient lab day and every six months thereafter for Resident #8. Further review of the form revealed the physician signed the order on 09/07/22 for the BMP, Depakote, and Oxcarbazepine levels to be drawn as recommended by the pharmacist. Further review of Resident #8's medical record revealed no documentation to support Keppra and Depakote levels were completed as ordered on 03/31/22. Further review revealed the BMP, Valproic acid and Keppra levels were completed on 10/06/22, a month after the ordered date. Interview on 11/02/22 at 5:20 P.M. with Regional Nurse #310 revealed the facility was to complete labs on Tuesdays and Thursdays for labs ordered to be drawn on the next convenient day. Regional Nurse #310 confirmed Resident #8's Keppra and Depakote levels recommended to be done by the pharmacist on 02/02/22 and ordered by the physician on 03/31/22, were not completed. Regional Nurse #310 confirmed Resident #8's BMP, Valproic acid and Keppra levels were recommended to be done and ordered the physician on 09/07/22 and were not completed until 10/06/22.

CONCERN (D)

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

Safe Environment (Tag F0921)

Could have caused harm · This affected 1 resident

2. Observation on 10/31/22 at 10:12 A.M. revealed Resident #35 was lying in bed with the television on. A tube feed was running at bedside. Further observation revealed dried, light brown substance sp...

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2. Observation on 10/31/22 at 10:12 A.M. revealed Resident #35 was lying in bed with the television on. A tube feed was running at bedside. Further observation revealed dried, light brown substance splattered all over the wall on the side of the bed and the wall behind Resident #35's headboard. Observation on 11/01/22 at 7:18 A.M. revealed Resident #35 lying in bed with the television on. The dried, light brown substance remained splattered all over the wall to the side of Resident #35's bed and on the wall behind the headboard. Observation on 11/02/22 at 9:10 A.M. revealed Resident #35 was lying in bed with the television on. The dried, light brown substance remained splattered all over the wall to the side of Resident #35's bed and on the wall behind the headboard. Interview on 11/01/22 with State Tested Nurse Aide (STNA) #215 confirmed the dried, light brown substance splattered all over the wall to the side of Resident #35's bed and on the wall behind his headboard. Interview on 11/02/22 at 2:30 P.M. with Regional Nurse (RN) #310 confirmed the dried, light brown substance splattered all over the wall to the side of Resident #35's bed and on the wall behind his headboard. Observation at the time of the interview also revealed Resident #35's carpet was soiled and stained, including a white unknown substance and various debris. RN #310 verified Resident #35's carpet was soiled and stained. Based on observation and staff interview, the facility failed to maintain a clean and sanitary environment. This affected two (Residents #46 and #35) of three residents reviewed for environment. The facility census was 48. Findings include: 1. Observation on 10/31/22 at 10:32 A.M. revealed the wall directly next to Resident #46's bed, which was positioned against the wall, had approximately 10 brown, raised spots of an unidentified substance on the wall, measuring approximately dime to half-dollar size. Further observation revealed the ceiling above the window had a large area, measuring approximately two feet by one foot, with peeling paint, four clusters of black spots, and a grey fibrous material. Interview on 10/31/22 at 10:35 A.M., with State Tested Nursing Assistant (STNA) #135 verified the spots on Resident #46's wall. STNA #135 stated she had not noticed the spots on the wall the last time she worked, three days prior. STNA #135 further verified the condition of the ceiling and stated she thought it was related to something leaking. STNA #135 stated the ceiling had been like that for, awhile. Observations on 10/31/22 at 4:19 P.M., 11/01/22 at 8:28 A.M., and 11/02/22 at 10:39 A.M. and 3:04 P.M. revealed the condition of the wall and ceiling in Resident #46's room remained unchanged. Interview on 11/02/22 at 3:04 P.M. the Administrator stated the spots on Resident #46's wall had been there for a few months and needed sanded and painted. The Administrator further stated she had not noticed the condition of the ceiling. Interview on 11/02/22 at 3:07 P.M. Maintenance Director (MD) #65 stated the condition of the ceiling was caused by condensation from the pipes of the boiler system, which were directly above the area on the ceiling.

CONCERN (E)

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

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews, medical record review and policy review, the facility failed to conduct quarterly care c...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews, medical record review and policy review, the facility failed to conduct quarterly care conferences. This affected four (Residents #08, #09, #27, and #40) out of the four residents sampled for care conferences. Facility census was 48. Findings include: 1. Review of the medical record for Resident #08 revealed an admission date of 10/18/13 with medical diagnoses of left hemiparesis, hypertensive retinopathy, polyneuropathy, hyperlipidemia, atherosclerotic heart disease, anxiety, and hypertension. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #08 had moderate cognitive impairment. Further review of MDS revealed Resident #08 was dependent on staff for activities of daily living (ADLs). Review of the medical record for Resident #08 revealed a care conference note written by Social Service dated 10/21/22 at 12:00 P.M. The care conference note stated Resident #08's Power-of-Attorney (POA) attended the care conference via phone. Further review of the care conference note revealed the resident declined to attend the conference. Review of the medical record for Resident #8 did not contain documentation to support the facility conducted a quarterly care conference in 2021 or from January 2022 to September 2022. Interview with Resident #08 on 10/31/22 at 11:27 A.M. revealed resident stated he was not invited to his care conferences and had not attended any care conferences in 2022 Interview on 11/02/22 at 11:38 A.M. with the Administrator confirmed the medical record for Resident #08 did not contain documentation to support the resident or POA were invited or attended quarterly care conferences between October 2021 to September 2022. 2. Review of medical record for Resident #27 revealed an admission date of 8/24/21 with medical diagnoses of chronic obstructive pulmonary disease (COPD), insomnia, major depression, convulsions, and alcoholic liver disease. Review of MDS assessment dated [DATE] revealed Resident #27 was cognitively intact. The MDS stated Resident #27 was independent or required supervision for ADLs Review of the medical record for Resident #27 revealed it did not contain documentation to support the facility conducted a care conference for Resident #27 since his admission date of 08/24/21. Interview on 10/21/22 at 12:28 P.M. with Resident #27 revealed he had not attended or been invited to attend a care conference meeting for 2022. Interview on 11/02/22 at 9:00 A.M. with the Administrator confirmed Resident #27's the medical record did contain any documentation to support the facility conducted quarterly care conferences since Resident #27's admission date. 3. Record review for Resident #09 revealed an admission date of 04/22/22. His diagnoses included, transient cerebral ischemic attack, cerebral infarction, essential primary hypertension, diabetes mellitus, major depressive disorder, hypoglycemia, hepatitis-C, dysphagia, atrial fibrillation (A-fi), and COPD. Review of the MDS assessment dated , 07/30/22, revealed resident had mildly impaired cognition. Further review of the MDS assessment revealed Resident #09 required supervision or limited assistance for ADLs. Record review for Resident #09 did not reveal a care conference documented for his stay. Interview on 10/31/22 at 12:32 P.M. with Resident #09 revealed he had never had a care conference with the interdisciplinary team (IDT) and never had the opportunity to review his plan of care. 4. Record review for Resident #40 revealed an admission date of 12/03/21. Her diagnoses included, essential primary hypertension, anemia, acute kidney failure, cellulitis of right lower limb, gastro-esophageal reflux disease, constipation, hypokalemia, and COPD. Review of the quarterly MDS assessment dated , 10/07/22, revealed Resident #40 was cognitively intact. Further review of the MDS assessment revealed Resident #40 required supervision for ADLs. Record review for Resident #40 did not reveal a care conference documented for his stay. Interview on 10/31/22 at 12:13 P.M. with Resident #40 revealed she had never had care conference with the IDT team to review her plan of care. Interview on 11/02/22 at 8:57 A.M. with the Administrator confirmed there was no documented care conferences for Resident #40. Review of the facility care conference policy revealed care conferences would be scheduled to include resident, resident representative, and interdisciplinary team as soon as possible after admission, routinely, and with a change in condition. The policy continued to state the resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development and revisions to the resident's care plan. The policy stated the facility will provide resident and/or representative advanced notice of care conference.

CONCERN (E)

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

Deficiency F0868 (Tag F0868)

Could have caused harm · This affected multiple residents

Based on record review, staff interview, and policy review, the facility failed to maintain evidence the Quality Assessment and Assurance (QAA) committee held quarterly Quality Assurance and Process I...

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Based on record review, staff interview, and policy review, the facility failed to maintain evidence the Quality Assessment and Assurance (QAA) committee held quarterly Quality Assurance and Process Improvement (QAPI) meetings. This had the potential to affect all 48 residents in the facility. Findings include: Review of QAPI meetings revealed meetings were held in September 2022 and May 2022. There was no documentation or evidence of any additional QAPI meetings taking place during 2022 and 2021. Interview on 11/03/22 at 5:45 P.M. the Administrator verified there was no evidence of any additional QAPI meetings. The Administrator stated she held a QAPI meeting when she started working at the facility in September 2022, and was unable to locate any additional QAPI information (with the exception of May 2022), in the available records. The Administrator affirmed QAPI meetings should be held at least quarterly. Review of the facility policy titled, Quality Assurance and Process Improvement (QAPI) Plan, undated, revealed QAPI meetings will be held at least quarterly and a record of all dates of meetings and the participants attending are maintained. Minutes of the meetings are to be accessible to surveyors in order to demonstrate compliance with the regulatory requirements.

CONCERN (F)

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

Deficiency F0727 (Tag F0727)

Could have caused harm · This affected most or all residents

Based on record review and staff interview, the facility failed to ensure a Registered Nurse (RN) worked at least eight consecutive hours a day, seven days a week as required. This had the potential t...

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Based on record review and staff interview, the facility failed to ensure a Registered Nurse (RN) worked at least eight consecutive hours a day, seven days a week as required. This had the potential to affect all 48 residents residing in the facility. Findings include: Review of the facility staffing records from 10/24/22 to 10/31/22 revealed the facility did not have RN coverage for eight consecutive hours on 10/30/22. Interview on 11/03/22 at 3:51 P.M. with the Administrator verified on 10/30/22, the facility did not have RN coverage for eight consecutive hours.

Dec 2019 11 deficiencies

CONCERN (D)

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

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to properly document advanced directives. This affected ...

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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 properly document advanced directives. This affected one (#23) out of 24 advanced directives reviewed during the annual survey. The facility census was 61. Findings include: Review of the medical record revealed Resident #23 was admitted to the facility on [DATE] with diagnosis including stage four pressure ulcer of the sacral region, anxiety disorder, major depressive disorder, multiple sclerosis, and need for personal assistance. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #23 was cognitively intact with no noted behaviors. Review of Section G- Functional Status revealed the resident required extensive one-person assistance with dressing, personal hygiene, supervision and setup with eating, extensive two-person assistance with bed mobility, toileting, and transfer/walking/locomotion did not occur. Review of the medical record revealed Physician Orders dated [DATE] for Resident #23's code status to be a Do Not Resuscitate (DNR) code status. Order dated [DATE] to admit Resident #23 into the local hospice services. Further review of the electronic and hard medical records contained no documentation of the required signed DNR form. Interview conducted on [DATE] at 9:54 A.M. with Licensed Practical Nurse (LPN) #301 verified she was the nurse caring for Resident #23. LPN #301 stated she was looked on the Electronic Health Record resident information line and face sheet, and she was unable to verify what Resident #23's code status was. LPN #301 stated if Resident #23 coded at that time, she would do Cardiopulmonary Resuscitation (CPR). LPN #301 verified Resident #23's medication record did not contain the required signed DNR forms.

CONCERN (D)

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

Abuse Prevention Policies (Tag F0607)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility record review, review of Self-Report Incidents (SRI), resident and staff interviews, an...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility record review, review of Self-Report Incidents (SRI), resident and staff interviews, and review of facility policy, the facility failed to implement their abuse policy to ensure the staff thoroughly investigated an allegation of resident to resident sexual abuse. This affected one (#23) out of one reviewed for abuse during the investigation stage of the annual survey. The facility census was 61. Findings include: Review of the medical record revealed Resident #23 was admitted to the facility on [DATE] with diagnosis including stage four pressure ulcer of the sacral region, anxiety disorder, major depressive disorder, multiple sclerosis, and need for personal assistance. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #23 was cognitively intact with no noted behaviors. Review of Section G- Functional Status revealed the resident required extensive one-person assistance with dressing, personal hygiene, supervision and setup with eating, extensive two-person assistance with bed mobility, toileting, and transfer/walking/locomotion did not occur. Review of the facility SRI's revealed an SRI dated 10/27/19 was sent to the state survey agency involving sexual abuse allegation from Resident #23 against Resident #10 and was found to be unsubstantiated by the facility. Interview conducted on 12/16/19 at 9:10 A.M., Resident #23 stated a little over a month ago Resident #10 came into her room and was rubbing between her legs, in the area near her vagina, stating how does that feel. Resident #23 stated she had blankets over top of her at the time and he was rubbing against the blanket. Resident #23 stated she told the resident to leave her room. Resident #23 stated it took her about a week to report it to staff because she was new to the facility and she didn't expect them to believe her, and he would come in to help her if she needing something. Resident #23 stated she reported it to an aid that she trusted, and the managers came back and talked to her about the incident. Interview and facility record review conducted on 12/17/19 at 3:54 P.M. with the facility Administrator revealed he conducted the investigation regarding the sexual abuse allegations by Resident #23. Administrator stated Resident #23 stated Resident #10 was visiting her as he usually did, and while talking to her he put his hand on her legs. Resident #23 stated it made her uncomfortable and so she reported it. Administrator stated he interviewed Resident #10 whom denied the allegation, so he educated Resident #10 due to the allegation he should no longer visit Resident #23 alone. Administrator stated he got statements from both resident, the nurse working with the residents, the aide, and placed Resident #10 on 15 minute checks. The Administrator stated there were no other residents, family, and/or staff interviewed and/or observed regarding the allegation of abuse. Review of the facility investigation revealed interviews/statements from Resident #10, and the nurse and aide, however no other interviews were noted. The Administrator verified no other residents were interviewed regarding the allegation, and he was unable to provide written verification of the statement from Resident #23. Review of the facility provided policy titled, Abuse, Neglect, Exploitation and Misappropriation of Resident Property dated 2016 revealed if an allegation of abuse was brought forward the facility would notify the resident physician, notify social services to care for the residents psychosocial needs, perform an initial assessment of the resident, interview anyone who may have heard and/or came in contact with the residents including other residents, family members and other employees on duty and prior shifts as well. Follow-up should be conducted with the case being reported to the interdisciplinary team to determine the appropriate interventions.

CONCERN (D)

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

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility record review, review of Self-Report Incidents (SRI), resident and staff interviews, an...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility record review, review of Self-Report Incidents (SRI), resident and staff interviews, and review of facility policy, the facility failed to thoroughly investigate an allegation of resident to resident sexual abuse. This affected one (#23) out of one reviewed for abuse during the investigation stage of the annual survey. The facility census was 61. Findings include: Review of the medical record revealed Resident #23 was admitted to the facility on [DATE] with diagnosis including stage four pressure ulcer of the sacral region, anxiety disorder, major depressive disorder, multiple sclerosis, and need for personal assistance. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #23 was cognitively intact with no noted behaviors. Review of Section G- Functional Status revealed the resident required extensive one-person assistance with dressing, personal hygiene, supervision and setup with eating, extensive two-person assistance with bed mobility, toileting, and transfer/walking/locomotion did not occur. Review of the facility SRI's revealed an SRI dated 10/27/19 was sent to the state survey agency involving sexual abuse allegation from Resident #23 against Resident #10 and was found to be unsubstantiated by the facility. Interview conducted on 12/16/19 at 9:10 A.M., Resident #23 stated a little over a month ago Resident #10 came into her room and was rubbing between her legs, in the area near her vagina, stating how does that feel. Resident #23 stated she had blankets over top of her at the time and he was rubbing against the blanket. Resident #23 stated she told the resident to leave her room. Resident #23 stated it took her about a week to report it to staff because she was new to the facility and she didn't expect them to believe her, and he would come in to help her if she needing something. Resident #23 stated she reported it to an aid that she trusted, and the managers came back and talked to her about the incident. Interview and facility record review conducted on 12/17/19 at 3:54 P.M. with the facility Administrator revealed he conducted the investigation regarding the sexual abuse allegations by Resident #23. Administrator stated Resident #23 stated Resident #10 was visiting her as he usually did, and while talking to her he put his hand on her legs. Resident #23 stated it made her uncomfortable and so she reported it. Administrator stated he interviewed Resident #10 whom denied the allegation, so he educated Resident #10 due to the allegation he should no longer visit Resident #23 alone. Administrator stated he got statements from both resident, the nurse working with the residents, the aide, and placed Resident #10 on 15 minute checks. The Administrator stated there were no other residents, family, and/or staff interviewed and/or observed regarding the allegation of abuse. Review of the facility investigation revealed interviews/statements from Resident #10, and the nurse and aide, however no other interviews were noted. The Administrator verified no other residents were interviewed regarding the allegation, and he was unable to provide written verification of the statement from Resident #23. Review of the facility provided policy titled, Abuse, Neglect, Exploitation and Misappropriation of Resident Property dated 2016 revealed if an allegation of abuse was brought forward the facility would notify the resident physician, notify social services to care for the residents psychosocial needs, perform an initial assessment of the resident, interview anyone who may have heard and/or came in contact with the residents including other residents, family members and other employees on duty and prior shifts as well. Follow-up should be conducted with the case being reported to the interdisciplinary team to determine the appropriate interventions.

CONCERN (D)

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

Deficiency F0655 (Tag F0655)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Medical record review for Resident #47 revealed an admission date on 07/05/19 with diagnosis that include but not limited to ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Medical record review for Resident #47 revealed an admission date on 07/05/19 with diagnosis that include but not limited to dementia with behaviors, lung disease, adult failure to thrive, high blood pressure, high cholesterol, chest pain, depressive disorder, diabetes, kidney failure, paralysis of left side of body, respiratory failure, stroke and chronic abnormal heart rate. Review of quarterly Minimum Date Set (MDS) dated [DATE] for Resident #47 revealed impaired cognition. Resident requires extensive assist for bed mobility, transfers, dressing, toileting, and personal hygiene. Review of plan of care for Resident #47 dated 10/08/19 revealed there was no 48 hour or baseline care plan. Review of nurse's progress notes for Resident #47 dated 07/05/19 through 07/07/19 revealed no documentation that a 48 hour or baseline plan of care was provided to resident. Interview with Resident #47 on 12/17/19 at 2:17 P.M. stated he did not receive any plan of care documentation from the facility. Interview with DON on 12/18/19 at 2:59 P.M., verified the facility did not completing a 48 hour plan of care for Resident #47. Based on medical record review and resident and staff interview, the facility failed to develop the required 48 hour care plans for newly admitted residents. This affected three (#23, #35, and #47) of 17 residents reviewed during the investigation stage of the annual survey. The facility census was 61. Findings include: 1. Review of the medical record revealed Resident #23 was admitted to the facility on [DATE] with diagnosis including stage four pressure ulcer of the sacral region, anxiety disorder, major depressive disorder, multiple sclerosis, and need for personal assistance. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #23 was cognitively intact with no noted behaviors. Review of Section G- Functional Status revealed the resident required extensive one-person assistance with dressing, personal hygiene, supervision and setup with eating, extensive two-person assistance with bed mobility, toileting, and transfer/walking/locomotion did not occur. Further review of Resident #23's medical record revealed the record contained no documentation of the required 48 hour care plan. 2. Review of the medical record revealed Resident #35 was admitted to the facility on [DATE] with diagnoses including vascular dementia without behaviors, anxiety disorder, major depressive disorder, bariatric surgery, post-traumatic stress disorder, borderline personality disorder, and tobacco use. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35's preference for routine and activities noted it was very important to the resident to be able to choose her clothes, care for personal belongings, choose between showers/bath, have snacks between meals, choose bedtime, be around animals, use phone in private, do favorite activities, keep things safe, get fresh air, it was somewhat important to listen to music, do things with groups, and not important at all for family/friends involved in care, have books/newspapers/magazines to read, keep up with the news, participate religious services. Review of quarterly MDS dated [DATE] revealed the resident was cognitively intact. Further review of Resident #35's medical record revealed the record contained no documentation of the required 48 hour care plan. Interview conducted on 12/18/19 at 2:56 P.M. with the facility Director of Nursing (DON) stated she was new to the facility, and prior to her arrival they were not doing 48 hour care plans. The DON verified Resident #23 and #35 did not have a 48 hour or baseline care plan in place as required.

CONCERN (D)

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

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Medical record review for Resident #47 revealed an admission date on 07/05/19 with diagnosis that include but not limited to ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Medical record review for Resident #47 revealed an admission date on 07/05/19 with diagnosis that include but not limited to dementia with behaviors, lung disease, adult failure to thrive, high blood pressure, high cholesterol, chest pain, depressive disorder, diabetes, kidney failure, paralysis of left side of body, respiratory failure, stroke and chronic abnormal heart rate. Review of quarterly Minimum Date Set (MDS) dated [DATE] for Resident #47 revealed an impaired cognition. Resident requires extensive assist for bed mobility, transfers, dressing, toileting, and personal hygiene. Review of plan of care for Resident #47 revealed no documentation related to care conferences being completed. Review of multidisciplinary progress notes for Resident #47 from admission [DATE]) through 12/15/19 revealed no documentation that a care conference was conducted. Interview with Resident #47 on 12/17/19 at 2:30 P.M. stated that he was not been to a care conference since he has been here. Interview with Social Service Director #343 on 12/18/19 at 11:17 A.M. verified care conferences have not been conducted for resident. Further verified advance notice has not been provided to the resident or the family. 3. Review of medical record of for Resident #57 revealed an admission date of 01/18/17 with diagnosis that include but limited to chronic breathing disorder, high cholesterol, need for personal assistance, repeated falls, depression, borderline personality disorder, impulse disorder, mental disorder, anxiety, high blood pressure, acid reflux disease, and dementia. Review of quarterly Minimum Data Set (MDS) dated [DATE] for Resident #57 revealed impaired cognition. Resident requires extensive assist for bed mobility, transfers, dressing, personal hygiene and toileting with two staff members. Resident requires supervision for eating. Review of plan of care dated 10/10/18 for Resident #57 revealed no documentation related to care conferences being completed. Review of multidisciplinary progress notes for Resident #57 from admission [DATE] through 12/15/19 revealed no documentation that a care conference was conducted. Interview with Social Service Director #343 on 12/18/19 at 11:17 A.M. verified care conferences have not been conducted for resident. Further verified advance notice has not been provided to the resident or the family. Review of facility policy titled Resident Participation-Assessment/Care Plans, dated 12/2016, revealed the facility did not follow policy regarding care conferences. Number four documents the care planning process will facilitate the inclusion of the resident and or representative, include an assessment of the resident's strengths and needs and incorporate the resident's personal and cultural preferences in establishing goals of care. Number seven documents a seven day notices of the care planning conference is provided to the resident and his or her representative. Such notice is made by mail or telephone. Based on medical record review, staff and resident interviews and policy review, the facility failed to conduct and/or include the appropriate staff in the development of resident care plan and care planning conferences. This affected three (#35, #47 and #57) of 17 residents reviewed during the investigation stage of the annual survey. The facility census was 61. Findings include: 1. Review of the medical record revealed Resident #35 was admitted to the facility on [DATE] with diagnoses including vascular dementia without behaviors, anxiety disorder, major depressive disorder, bariatric surgery, post-traumatic stress disorder, borderline personality disorder, and tobacco use. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35's preference for routine and activities noted it was very important to the resident to be able to choose her clothes, care for personal belongings, choose between showers/bath, have snacks between meals, choose bedtime, be around animals, use phone in private, do favorite activities, keep things safe, get fresh air, it was somewhat important to listen to music, do things with groups, and not important at all for family/friends involved in care, have books/newspapers/magazines to read, keep up with the news, participate religious services. Review of quarterly MDS dated [DATE] revealed the resident was cognitively intact. Review of Resident #35's Interdisciplinary Care Plan Conference Summary dated 10/18/19 revealed the only staff and/or individuals involved in the residents care plan conference was Resident #35 and Social Services (SS) #343. Interview conducted on 12/16/19 at 11:41 A.M., Resident #35 stated that she had never been invited to attend a care conference with members of the staff (interdisciplinary team), to discuss her care needs. Interview conducted on 12/17/19 at 1:52 P.M. with SS #343 stated she was new to the facility and at the time of Resident #35's Care Conference, and it was done with just her and the resident due to the facility was going through a lot of change over, and they had no interdisciplinary team.

CONCERN (D)

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

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview and policy review the facility failed to ensure nail care was provi...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview and policy review the facility failed to ensure nail care was provided to a resident who required assistance with personal hygiene. This affected one (#57) reviewed for personal hygiene. The facility census was 61. Findings included: Review of medical record of for Resident #57 revealed an admission date of 01/18/17 with diagnosis that include but limited to chronic breathing disorder, high cholesterol, need for personal assistance, repeated falls, depression, borderline personality disorder, impulse disorder, mental disorder, anxiety, high blood pressure, acid reflux disease, and dementia. Review of quarterly Minimum Data Set (MDS) dated [DATE] for Resident #57 revealed impaired cognition. Resident requires extensive assist for bed mobility, transfers, dressing, personal hygiene and toileting with two staff members. Resident requires supervision for eating. Review of plan of care dated 10/10/18 for Resident #57 needs assistance for completion of Activities of Daily Livings (ADL) related to weakness, cognitive impairment associated with dementia and poor decision making skills due to mental illness. Interventions include assist in choosing appropriate clothing, encourage and allow the resident to complete self care as able, set up and assist as needed for completion and therapy as ordered. Review of facility shower sheet for Resident #57 dated 12/10/19 revealed fingernails were cleaned and trimmed on that date. Document was signed by Licensed Practical Nurse (LPN) #24. Observation on 12/16/19 at 5:28 P.M. of Resident #57 fingernails on both hands that were long (extending past tip of fingers), cracked, jagged and had dark material under nails. Interview with the Director of Nursing (DON) at 5:35 P.M. verified Resident #57's nails were not trimmed and had dark material under nails. The DON further stated the State Tested Nursing Assistants should be providing nail care when he gets his showers. Review of facility policy titled Activities of Daily Living, dated 03/2018, revealed the facility did not follow the policy in regards to nail care. Number two documents appropriate care and services will be provided for residents who are unable to carry out activities of daily living including hygiene.

CONCERN (D)

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

Deficiency F0679 (Tag F0679)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medication record review, observation, staff, family and resident interviews, the facility failed to provide activities...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medication record review, observation, staff, family and resident interviews, the facility failed to provide activities to meet the needs of the residents. This affected three (#14, #24, and #35) out of three residents reviewed for activities during the investigation stage of the annual survey who resided on the locked unit. This facility census was 61. Findings include: 1. Review of the medical record revealed Resident #14 was admitted to the facility with diagnoses including schizophrenia, hepatitis C, major depressive disorder, anxiety disorder, and post-traumatic stress disorder. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #14 was moderately cognitively impaired, with verbal behaviors occurred one to three days during the lookback period, other behaviors not directed toward others four to six days during the lookback period, and wandering behaviors occurring one to three days during the lookback period. Review of MDS dated [DATE] section F- Preferences for routine and activities revealed it was very important for family to be involved in care, hold private phone conversations, listen to music, news, and get fresh air, it was somewhat important to have books/newspapers/magazines, be around pets, do things with groups of people, do favorite activities, and participate in religious services. Review of Resident #14 Activity Participation Review date 11/16/18 revealed the resident prefers to participate in a combination of organized and self-directed activities, including but not limited to being outdoors, watching television, listening to music, and reading. Interview conducted on 12/18/19 at 10:42 A.M. Resident #14 stated he would like to do activities but they don't do them or they don't invite him. Resident #14 stated depending on the activity, he would like to go. Resident #14 stated he enjoys going to crafts, bingo, and any activity with snacks. 2. Review of the medical record revealed Resident #24 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease, anxiety disorder, bipolar, major depressive disorder, paranoid schizophrenia, and dementia with behaviors. Review of quarterly MDS dated [DATE] revealed Resident #15 was cognitively intact with rejection of care behaviors noted daily. Review of the annual MDS dated [DATE] section F-Preferences for Routine and Activities revealed it was very important for the resident to have snacks provided, have close family and friends involved in discussions about care, talk on the phone in private, have books/newspapers/magazines to read, listen to music, be around pets, go outside, and some what important to do things in groups and do favorite activities. Review of Resident #24's Care Plan revised on 09/24/19 revealed the resident enjoys arts and crafts, exercise, sports, listening to music, reading the news paper, spending time outside, and attending socials/parties. Observation and interview conducted on 12/15/19 at 11:33 A.M. with Resident #24's family member revealed no activities had been observed throughout the morning in the locked unit. Resident #24's family member stated he comes in on the weekends and visits, and activities isn't open on the weekends. 3. Review of the medical record revealed Resident #35 was admitted to the facility on [DATE] with diagnoses including vascular dementia without behaviors, anxiety disorder, major depressive disorder, bariatric surgery, post-traumatic stress disorder, borderline personality disorder, and tobacco use. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35's preference for routine and activities noted it was very important to have snacks between meals, be around animals, use phone in private, do favorite activities, get fresh air, and it was somewhat important to listen to music, do things with groups, and not important at all for family/friends involved in care, have books/newspapers/magazines to read, keep up with the news, participate religious services. Review of quarterly MDS dated [DATE] revealed Resident #35 was cognitively intact. Interview conducted on 12/15/19 upon initial tour of the locked unit revealed, Resident #35 was observed sitting in the common area watching television. The resident stated they put activities sheets on the wall, but they never come to get them and do activities. Resident #35 stated she was bored just sitting and watching television all the time and would like to do activities, but they are never invited. Interview conducted on 12/17/19 at 4:25 P.M. and again on 12/18/19 at 7:41 A.M. with Social Services (SS) #343 stated she was currently the Social Services person for the facility along with being the Activities Director. SS #343 stated there had been problems in the past that the staff in the locked unit were not providing activities for residents. SS #343 stated with a facility of this size and clientele behaviors, sometimes activities get put on the back burner trying to ensure social services is provided. SS #343 verified the facility currently had no activities scheduled in the evening for residents, and she currently only had one other employee doing activities. SS #343 verified activities are currently only scheduled until 4:00 P.M. SS #343 stated in the locked unit, the aid is responsible to provide care needs(baths, toilet, dressing, transfer assistance, ect.), serve meals, take residents out to smoke at smoking times, and do activities. SS #343 stated she was in the process for putting together a program to get more activities in the evening, and she just implemented activities on the weekends, however she has only worked in the facility for a short period of time and it takes some time and staff to get everything accomplished. Interview conducted on 12/18/19 at 10:47 A.M., State Tested Nursing Assistant (STNA) #12 stated there are activities posted in the locked unit, however no specific times they are scheduled, just when the staff can get to them. STNA #12 stated the staff in the locked unit have resident to care for, take the smokers out to smoke, provide meals, and deal with all the behaviors on the unit, so sometimes there is no time or they do them when they can. STNA #12 stated the facility needs to hire more staff for activities. Interview conducted on 12/18/19 at 2:56 P.M. with the Director of Nursing (DON). The DON stated she was aware of the issues involving resident activities, and they are trying to resolve some issues. DON stated the residents would benefit from having more activity involvement. DON stated the social services has a lot to deal with in the facility, and they would benefit from hiring more staff for activities.

CONCERN (D)

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

Deficiency F0914 (Tag F0914)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff and resident interviews, the facility failed to ensure residents were aff...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff and resident interviews, the facility failed to ensure residents were afforded with full visual privacy. This affected two (#14 and #35) of two reviewed for Privacy during the investigation stage of the annual survey. The facility census was 61. Finding include: 1. Review of the medical record revealed Resident #14 was admitted to the facility with diagnoses including schizophrenia, hepatitis C, major depressive disorder, anxiety disorder, and post-traumatic stress disorder. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #14 was moderately cognitively impaired, with verbal behaviors occurred one to three days during the lookback period, other behaviors not directed toward others four to six days during the lookback period, and wandering behaviors occurring one to three days during the lookback period. Review of MDS dated [DATE] section F- Preferences for routine and activities revealed it was very important to-choose clothes to wear, taking care of personal belongings, bathing, meals, bedtime, family involved in care, phone conversations, place to lock things up, listen to music, news, get fresh air, somewhat important to-have books/newspapers/magazines, be around pets, do things with groups of people, do favorite activities, and participate in religious services. Observation and interview conducted on 12/18/19 at 10:42 A.M. with Resident #14 was observed residing in a room shared with another resident with no privacy curtain on his side of the room, and the curtain track had been removed. Resident #14 stated he would like to have a curtain for privacy, he had never had one since being in the room. Observation and interview conducted on 12/18/19 at 10:46 A.M. with the facility Administrator verified the resident had no privacy curtain in his room. 2. Review of the medical record revealed Resident #35 was admitted to the facility on [DATE] with diagnoses including vascular dementia without behaviors, anxiety disorder, major depressive disorder, bariatric surgery, post-traumatic stress disorder, borderline personality disorder, and tobacco use. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35's preference for routine and activities noted it was very important to the resident to be able to choose her clothes, care for personal belongings, choose between showers/bath, have snacks between meals, choose bedtime, be around animals, use phone in private, do favorite activities, keep things safe, get fresh air, it was somewhat important to listen to music, do things with groups, and not important at all for family/friends involved in care, have books/newspapers/magazines to read, keep up with the news, participate religious services. Review of quarterly MDS dated [DATE] revealed the resident was cognitively intact. Observation and interview conducted on 12/16/19 at 11:39 A.M., Resident #35 stated her privacy curtain was taken down about a month ago to be washed, and the staff never brought it back. Observation revealed Resident #35 did not have a privacy curtain, in her shared resident room. Observation and interview conducted on 12/16/19 at 5:36 P.M. with State Tested Nursing Assistant (STNA) #335 verified Resident #35 had no privacy curtain in her room. STNA #335 stated some times they will take them down to clean then, and then when they are done they will put them back up. STNA #35 was unable to verify how long resident curtain had been missing.

CONCERN (E)

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

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interviews, and review of facility policy, the facility failed to maintain the building...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interviews, and review of facility policy, the facility failed to maintain the building and equipment in a clean and homelike manner. This had the potential to affect 14 (#2, #14, #20, #24, #27, #30, #35, #39, #40, #46, #51, #55, #58, #60) residents residing in the 100 hall lock unit and three (#23, #53, and #57) residents residing in the unlocked areas out of 61 total residents residing in the facility. Facility census was 61. Findings include: Initial tour of the facility conducted on 12/15/19 throughout the day revealed Resident #53 was observed with an outlet box cover missing and wires exposed behind her bed; Resident #23 was observed with boxes on the floor next to her bed with personal belongings, and Resident #57 was observed with a broken off dresser drawer and his television was noted hanging to the left wall behind is head. Further observation conducted of the locked 100 hall revealed multiple rooms with chipped paint, broken/empty hand sanitizer canisters, broken dressers/night stand drawers, dirty carpet/floors, urine and foul odors, broken blinds, doors missing handles, missing privacy curtains, and holes in doors. Interview conducted on 12/15/19 at 4:18 P.M. with Maintenance Supervisor (MS) #375 verified Resident #53's over was missing from the outlet box, exposing wires behind her bed. MS #375 stated he was not aware of the missing cover on the outlet box. Observation and interview conducted on 12/16/19 at 8:56 A.M. Resident #23 stated she stuff has been in boxes on the floor and in her closet since her admission, on 10/04/19. Resident #23 stated she would like them to hang up her clothes and put up her pictures. Resident #23 stated she was lucky is housekeeping would come in and clean her room once a week, and the aids will usually pick up the trash. Observation and interview conducted on 12/16/19 at 10:08 A.M., Resident #57 stated staff only clean his room about once every week. Resident #57's room was observed with with shoes scattered on floor and in corner of the room, pieces of trash on floor, and his dresser was broken. Resident #57 stated his dresser drawer has been broken for months, and the staff moved his bed recently where his television is behind his head where he can't see. Interview conducted on 12/18/19 at 11:12 A.M. State Tested Nursing Assistant (STNA) #12 stated when maintenance issues arise, staff are to fill out tickets and put them in the box in the maintenance mans office. STNA #12 stated the facility had just recently hired a maintenance man, but it had only been about a month ago, and that has contributed to why things are not fixed. STNA #12 stated the facility only currently has about two to three cleaning people, so resident rooms do not get cleaned very often, usually housekeeping consist of them cleaning the resident bathroom about twice a week. Observations and interviews conducted on 12/18/19 at 11:32 A.M. with MS #375 and Housekeeping Supervisor (HSK) #350. Walk through was conducted at that time. During walk through with the staff of the locked unit revealed Resident #14 and #27, had splattered food on the walls/floor/dresser, paint chipped throughout the room and bathroom down to exposed drywall, only one privacy curtain in a double occupancy room, and both resident night stands had drawers broken completely off. Resident #35's room was noted with a paint chipped down to exposed drywall, and the night stand drawer was broken off. Resident #58's room was observed with food and orange peels scatter covering entire room floor, clothes scattered throughout the room, and paint chipped exposing the dry wall. Resident #30's room was observed with a strong foul [NAME] like odor, stained carpet throughout the room, and chipped pain exposed to the drywall. Resident #24's room was noted with a strong urine odor, and what appeared to be dried urine running from out of the residents bathroom to underneath his bed. Resident #20's room was noted with strong [NAME] like odor, black film covering the inside of the sink, and string broken off the bathroom call light. Resident #40's room was observed with a broken sanitizer canister and broken call light string in the bathroom. Resident #55's room was observed with a broken/stained toilet seat. Further review of the locked 100 unit with MS #375 and HSK #350 verified the resident shared dining room was observed with two broken blinds, holes in the dining room door, and two additional doors in the dining room were observed with handles broken off. Observations conducted of Resident #23's room revealed her personal belongings were still noted sitting in boxes next to her bed. Resident #57 room was observed sticky floor, dresser drawer was still noted broken, and television was again noted out of view of the resident on the wall behind his head. MS #375 stated he was new to the facility and was not prior aware to the issues observed in the walk through. MS #375 stated since starting in the facility, he had not conducted a walk through of the lock unit to observe for any maintenance issues. HSK #350 stated there was only currently two full-time housekeepers and one part-time housekeeper on the weekends. HSK #350 stated she was also new to the position and she was in the process of putting together a deep cleaning schedule for resident rooms, and obtain approval to hire another housekeeper for the facility. HSK #350 stated her current positions include central supply ordering, housekeeping supervisor, and medical records. HSK #350 stated at that time, and with the staff they have, housekeeping is only able to clean approximately 10-15 room daily, of the facilities 52 rooms, along with common areas and dining rooms with every meal. The facility confirmed the identified concerns had the potential to affect 14 (#2, #14, #20, #24, #27, #30, #35, #39, #40, #46, #51, #55, #58, #60) residents residing in the 100 hall lock unit and three (#23, #53, and #57) residents residing in the unlocked areas out of 61 total residents residing in the facility Review of the facility policy titled, Quality of Life-Homelike Environment dated 05/17 revealed the facility would provide a clean and comfortable homelike environment and encourage residents to use their personal belongings to the extent possible, including personalized furniture arrangement and pleasant odors. Review of the facility policy titled, Maintenance Services dated 12/09 revealed the maintenance would maintain the building and equipment in a safe and operable manner at all times.

CONCERN (E)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and review of the facility policy, the facility failed to securely store medication in lo...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and review of the facility policy, the facility failed to securely store medication in locked medication carts. This had the potential to affect 16 (#4, #11, #13, #15, #21, #25, #26, #31, #33, #42, #44, #45, #54, #57, #62, and #63) residents the facility identified as cognitively impaired and independently mobile. The facility census was 61. Findings include: Observation and interview conducted upon entrance to the facility on [DATE] at 8:18 A.M. revealed the medication cart in the 200/300 hall was observed to be left unlocked and unattended by staff. Licensed Practical Nurse (LPN) #301 arrived back to the cart after several minutes, and verified the cart had been left unlocked and unattended, and locked the cart. Observation and interview conducted on 12/16/19 at 4:18 P.M., while walking down the 300 hall with the Director of Nursing (DON) revealed a medication cart was observed to be left unlocked and unattended by staff. DON verified the medication cart was left unlocked and unattended and locked the cart. DON stated she would expect staff lock medication carts when they are not attended. The DON confirmed the unlocked/unsecured medication carts had the potential to affect 16 (#4, #11, #13, #15, #21, #25, #26, #31, #33, #42, #44, #45, #54, #57, #62, and #63) residents who are cognitively impaired, independently mobile and had the ability to access an unlocked/unsecured medication cart. Review of the facility policy titled, Medication Storage in the Facility dated 11/18 revealed the facility would safely store medication to ensure the medication is only accessible to those staff whom are lawfully authorized to administer medication. Medication rooms, carts and supplies are to be kept locked up when not attended by the person authorized to administer.

CONCERN (F)

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

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

Based on observation and staff interview, the facility failed to ensure the facility kitchen was clean and food items were being properly stored. This affected 60 out of 61 residents who receive meals...

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Based on observation and staff interview, the facility failed to ensure the facility kitchen was clean and food items were being properly stored. This affected 60 out of 61 residents who receive meals from the facility kitchen. The facility identified one (#47) resident who receive nothing by mouth (NPO). The facility census was 61. Findings include: 1. Tour of dry food storage area on 12/15/19 at 9:22 A.M. with Dietary Manager #459 revealed one bag of chocolate devils cake mix; one bag of powdered sugar; one bag of coffee cake mix; one bag of walnuts and one bag of raisins that was stored in the original plastic packaging. These items were opened and placed into a second plastic storage bag that was undated. Dietary Manager #459 confirmed the observation. 2. Tour of walk in refrigerator on 12/15/19 at 9:49 A.M., with the Dietary Manager #459 revealed an opened 128 ounce tub of banana peppers; a 128 ounce tub of thousand island salad dressing; a 128 ounce tub of teriyaki sauce; a 128 ounce tub of honey mustard salad dressing; a 128 ounce tub of Italian dressing and a 20 ounce bottle of sweet pickle relish without an opened on date. Dietary Manager #459 confirmed the observation. 3. Tour of the walk in freezer on 12/15/19 at 10:20 P.M. with the Dietary Manager #459 revealed a bag of open and undated asparagus. Additionally a box of frozen cinnamon rolls was opened not sealed exposing the product. Dietary Manager #459 confirmed the observation. Interview with the Dietary Manager #459 immediately following the observation verified the identified items were not correctly labeled with an opened on date or stored in plastic bags with a date identified when the product was initially opened for use. 4. Observation of the kitchen area on 12/15/19 at 10:47 A.M. revealed the floor was sticky and had multiple unidentified food particles/spills throughout the serving areas. Dark unidentified liquid drippings were noted on the doors of the walk in refrigerators and the legs of the stream table. Three ceiling light coverings directly over the steam table were noted to have multiple dark unidentified spots through out the covering. Two food carts were noted to have a multiple spots of thick dark unidentified material on the ledges of the tray supports. Walls behind the three compartment sink had multiple brown spattered material on them and unknown food particles were noted on the bottom ledge of food service prep area tables. Interview with Dietary Manager #459 on 12/15/19 at 11:40 A.M. revealed no cleaning schedule was available for review. Additionally stated dietary staff clean as they go, and sweep and mop at the end of each shift. 5. Tour of the kitchen area on 12/18/19 at 11:20 A.M. with the Corporate Registered Nurse #99 verified the floors though out the food service area was sticky and had multiple unidentified food particles and spills, the ceiling light coverings directly over the steam table area were broken and contained multiple spots of unidentified dark material the entire length of the covering; food delivery carts had thick dark unidentified material on the ledges of the tray supports; walls behind the three compartment sink had multiple unidentified food splattering and the legs of the food prep tables had multiple discolored food particles and spills on them. During the survey Dietary Manager #459 confirmed the identified dietary/kitchen concerns had the potential to affect 60 out of 61 residents in the facility who receive there meals from the kitchen and that one (#47) resident was ordered to be NPO. Request for dietary department cleaning and food storage was unavailable for review during the survey.

GARDEN COURT NURSING AND REHABILITATION CENTER

The Good

The Bad

The Ugly 92 deficiencies on record

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Do Nurses at Garden Court Stick Around?

Was Garden Court Ever Fined?

Is Garden Court on Any Federal Watch List?

GARDEN COURT NURSING AND REHABILITATION CENTER

Strengths

Concerns