How many inspection deficiencies does PIKETON NURSING CENTER have?

PIKETON NURSING CENTER has 48 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at PIKETON NURSING CENTER?

PIKETON NURSING CENTER has a two-star staffing rating from CMS with 0.41 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is PIKETON NURSING CENTER located?

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

How many beds does PIKETON NURSING CENTER have?

PIKETON NURSING CENTER has 46 certified beds.

Who owns PIKETON NURSING CENTER?

PIKETON NURSING CENTER is a for profit - corporation facility and is part of the AOM HEALTHCARE chain.

What questions should families ask when visiting PIKETON NURSING CENTER?

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

How does PIKETON NURSING CENTER compare to other nursing homes?

PIKETON NURSING CENTER has a 5-star overall rating, placing it above average compared to other nursing homes in OH. Higher-rated facilities typically have better inspection results and staffing levels.

PIKETON NURSING CENTER

Q: What is PIKETON NURSING CENTER's CMS rating?

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

Q: Is PIKETON NURSING CENTER safe?

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

Q: Do nurses at PIKETON NURSING CENTER stick around?

PIKETON NURSING CENTER has high staff turnover at 56%. High turnover can mean less continuity of care as staff change frequently.

Q: Was PIKETON NURSING CENTER ever fined?

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

Q: Is PIKETON NURSING CENTER on any federal watch list?

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

300 OVERLOOK DRIVE, PIKETON, OH 45661 · (740) 289-4074

For profit - Corporation 46 Beds AOM HEALTHCARE Data: November 2025

Trust Grade

70/100

#146 of 913 in OH

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PIKETON NURSING CENTER nursing home in PIKETON, OH - Photo 1 of 4

PIKETON NURSING CENTER nursing home in PIKETON, OH - Photo 2 of 4

Photo by amanda kinneman

Last Inspection: April 2025

Within standard 12-15 month inspection cycle. Federal law requires annual inspections.

Overview

Piketon Nursing Center has a Trust Grade of B, which means it is a good choice overall, ranking in the top half of Ohio facilities at #146 out of 913. Within Pike County, it ranks #2 out of 3, indicating that only one local option is better. The facility is improving, having reduced its issues from 11 in 2023 to just 3 in 2025. Staffing is a weaker area with a 2/5 rating and a turnover rate of 56%, which is about average for the state. Notably, there have been no fines recorded, which is a positive sign, and RN coverage is average, meaning that while there is some oversight, it could be better. However, there have been specific concerns noted in inspections, such as a serious incident where a resident did not receive the necessary bowel protocol treatment, and there was a failure to have RN coverage for eight hours, which could impact all residents. Additionally, one resident reported that hot food substitutions were not readily available unless requested. Overall, while there are strengths in the quality measures and no fines, the staffing challenges and specific incidents raise some concerns for families considering this facility.

Trust Score: B
In Ohio: #146/913
Safety Record: Moderate
Inspections: Getting Better
Staff Stability: 56% turnover. Above average. Higher turnover means staff may not know residents' routines.
Penalties: No fines on record. Clean compliance history, better than most Ohio facilities.
Skilled Nurses: Each resident gets only 24 minutes of Registered Nurse (RN) attention daily — below average for Ohio. Fewer RN minutes means fewer trained eyes watching for problems.
Violations: 48 deficiencies on record. Higher than average. Multiple issues found across inspections.

★★★★★

5.0

Overall Rating

★★☆☆☆

2.0

Staff Levels

★★★★★

5.0

Care Quality

★★★★☆

4.0

Inspection Score

↔

Stable

2023: 11 issues

2025: 3 issues

The Good

5-Star Quality Measures · Strong clinical quality outcomes
Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record

Facility shows strength in quality measures, fire safety.

The Bad

Staff Turnover: 56%

Near Ohio avg (46%)

Frequent staff changes - ask about care continuity

Chain: AOM HEALTHCARE

Part of a multi-facility chain

Ask about local staffing decisions and management

Staff turnover is elevated (56%)

8 points above Ohio average of 48%

The Ugly 48 deficiencies on record

1 actual harm

Apr 2025 3 deficiencies

CONCERN (D)

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

Deficiency F0699 (Tag F0699)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure a resident with Post Traumatic Stress Disorder (PTSD) was appropriately assessed to identify the cause of the residents PTSD and minimize triggers and/or re-traumatization. This affected two residents (#7 and #18) out of two residents identified by the facility as having PTSD/trauma. The facility census was 43. Findings include: 1. Record review for Resident #7 revealed the resident was admitted to the facility on [DATE] and had diagnoses including partial intestinal obstruction, edema, ilius, hypertension, atrial fibrillation, Parkinson's disease, depression, anxiety, chronic post-traumatic stress disorder(on admission date of 04/07/23), schizoaffective disorder, and chronic kidney disorder. Review of the admission Minimum Data Set (MDS) assessment, dated 03/11/25, revealed this resident was assessed to have intact cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 15 out of 15. This resident was assessed to have an active diagnosis of PTSD. Review of the active care plans for Resident #7 revealed no plan of care was in place addressing the cause of PTSD, triggers which may cause re-traumatization, or interventions to reduce the risk of re-traumatization and provide care for PTSD. Review of six Trauma Informed Care Evaluations revealed no determination had been completed to identify the cause of PTSD for Resident #7 and to identify potential triggers which may cause re-traumatization. Interview with Resident #7 on 04/22/25 at 02:09 P.M. revealed this resident has a history of post-traumatic stress disorder because she had been sexually abused as a child. Resident stated she cannot recall anyone ever asking her about this from the facility staff. Interview with Social Services #570 on 04/23/25 at 09:58 A.M. verified the assessments did not capture actual cause of trauma and care plan did not accurately reflect triggers for recurrence. 2. Record review for Resident #18 revealed the resident was admitted to the facility on [DATE] and had diagnoses including dementia, cognitive communication deficit, chronic obstructive pulmonary disease, hypertension, diabetes mellitus type II, hyperlipidemia, PTSD(active diagnosis since 08/18/22), edema, anxiety, depression, and unspecified psychosis. Review of the admission Minimum Data Set (MDS) assessment, dated 01/20/25, revealed this resident was assessed to have severely impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 7 out of 15. This resident was assessed to have an active diagnosis of PTSD. Review of the active care plans for Resident #18 revealed no plan of care was in place addressing the cause of PTSD, triggers which may cause re-traumatization, or interventions to reduce the risk of re-traumatization and provide care for PTSD. Review of two Trauma Informed Care Evaluations revealed no determination had been completed to identify the cause of PTSD for Resident #18 and to identify potential triggers which may cause re-traumatization. Interview with Social Services #570 on 04/23/25 at 11:00 A.M. verified the assessments did not capture actual cause of trauma and care plan did not accurately reflect triggers for recurrence.

CONCERN (D)

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

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interviews, the facility failed to ensure an order for the administration of as needed Ativan (an anti-anxiety medication) contained a stop date of 14 days or less. This affected one resident (#31) out of the five residents reviewed for unnecessary medications. The facility census was 43. Findings include: Record review for Resident #31 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included anxiety disorder, depression, and diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/27/25, revealed the resident was assessed to have intact cognition. The resident was assessed to have received anti-anxiety medications during the lookback period. Review of the active physicians order, dated 12/08/24, revealed Resident #31 was to be administered 0.5 milligrams (mg) of Ativan every two hours as needed for anxiety. The order did not contain a stop date. Review of the Medication Administration Records (MAR's) for Resident #31, dated 12/22/24 (14 days after the order for Ativan was implemented) through 04/22/25, revealed the resident was documented to have been administered 32 doses of as needed Ativan. Interview with Licensed Practical Nurse (LPN) #290 on 04/22/25 at 3:45 P.M. confirmed the Ativan ordered for Resident #31 was as needed and did not contain a date for which to stop the order.

CONCERN (D)

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

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews, and review of facility policy, the facility failed to ensure a medication was administered according to physicians order. This affected one resident (#31) out of the five residents reviewed for unnecessary medications. The facility census was 43. Findings include: Record review for Resident #31 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included chronic pain due to trauma, anxiety disorder, depression, and diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/27/25, revealed the resident was assessed to have intact cognition. Review of the active physicians order, dated 12/24/24, revealed Resident #31 was to be administered one milliliter (ml) of Morphine Sulfate (an opioid medication) Oral Suspension 20 milligrams (mg) per five ml's (which was equivalent to four mg's per dose administered) every two hours as needed for breakthrough pain. Review of the facility Controlled Drug Receipt Record/Disposition Forms, dated 12/24/24 through 04/22/25, revealed bottles of Morphine Sulfate Oral Suspension supplied to the facility for administration to Resident #31 were 100 mg's per five ml's (which was equivalent to 20 mg per one ml). One ml of Morphine Sulfate Oral Suspension 100 mg's per five ml's (equaling 20 mg) was documented to have been removed from the bottles by multiple nurses over 300 times for administration to Resident #31. Review of the Medication Administration Records (MAR's) for Resident #31, dated 12/24/24 through 04/22/25, revealed one ml of Morphine Sulfate Oral Suspension 20 mg's per five ml's (equaling four mg's) was documented to have been administered to Resident #31 at each dose. Further record review for Resident #31 revealed the resident had not experienced any episodes of respiratory depression, oversedating, or other adverse side effects of medications between 12/24/24 and 04/22/25. Observation and interview with Licensed Practical Nurse (LPN) #290 on 04/22/25 at 3:45 P.M. confirmed the bottle of Morphine Sulfate Oral Suspension contained in the narcotic lock box on the medication cart used for Resident #31 was a strength of 100 mg's per five ml's which was equal to 20 mg's per one ml. LPN #290 confirmed one ml of the Morphine Sulfate Oral Suspension was removed from the bottle at each dose and administered to Resident #31 so the resident received 20 mg each time. LPN #290 further confirmed the physicians order for Resident #31 was for one ml of Morphine Sulfate Oral Suspension at a strength of 20 mg's per five ml's which was only equivalent to four mg's to be administered at each dose. LPN #290 confirmed the amount administered to the resident at each dose did not match the amount ordered by the physician. Observation of Resident #31 on 04/22/25 at 4:05 P.M. revealed the resident was lying in bed eating grapes and watching television and did not appear to be exhibiting signs or symptoms of pain. Interview with Resident #31 at the time of the observation confirmed facility staff administered pain medication which kept the residents pain at a manageable level and denied any concerns with adverse side effects from medications. Review of the facility policy titled Administering Medications, revised 04/2019, revealed medications are administered in accordance with prescriber orders, including any required time frames. The individual administering the medication checks the label THREE times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.

Sept 2023 11 deficiencies

CONCERN (D)

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

Deficiency F0582 (Tag F0582)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interview, the facility failed to ensure a Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN) specified the type of skilled services being discontinued. This affected one resident (#33) out of the three residents reviewed for NOMNC and SNFABN notices during the annual survey. The facility census was 40. Findings include: Record review for Resident #33 revealed this resident was admitted to the facility on [DATE] and had diagnoses including dementia, glaucoma, and encephalopathy. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/21/23, revealed this resident was rarely/never understood. This resident was assessed to require extensive assistance from two staff members for bed mobility, transfers, and toileting. Review of the NOMNC and SNFABN, both signed on 01/20/23, revealed the type of service listed as ending had been written in as Skilled Services and did not specify the type of skilled services the resident was being cut from. Interview with the Administrator on 09/06/23 at 1:19 P.M. verified the NOMNC and SNFABN notices for Resident #33 did not specify the type(s) of skilled services the resident was being cut from.

CONCERN (D)

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, staff interviews and facility policy, the facility failed to develop resident centered care plans for behavioral interventions for three (Residents #2, #28 and #30) of the eight residents reviewed. The facility census was 40. Findings include: 1. Review of the medical record for Resident #2 revealed an admission date of 10/25/22. Diagnoses included: anxiety disorder, unspecified intellectual disabilities, unspecified mental disorder due to known physiological condition and schizoaffective disorder. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident is rarely/never understood. This resident was assessed to require extensive assistance with one-person physical assist with bed mobility, dressing, and toileting and extensive assistance with two-persons physical assist with transfers. The resident received antianxiety medication seven days. Review of Resident #2's physician orders dated for 10/25/22 revealed this resident was receiving the following medication: Haloperidol Decanoate 50 milligrams (mg) one time a day starting on the 28th and ending on the 28th every month by injection for schizoaffective disorder. Further review of this resident's physicians order dated for 07/31/23 revealed the following medication: Buspirone HCL 7.5 mg one tablet by mouth three times a day for anxiety disorder. Review of the physicians' orders for Resident #2 revealed no orders since admission on [DATE] for documentation of targeted behaviors as well as no non-pharmacological interventions for the facility staff to utilize. Review of the care plans for Resident #30 dated 08/01/23 revealed no evidence of a care plan containing non-pharmacological interventions as well as no target behaviors to be monitoring for. Interview with Licensed Practical Nurse (LPN) #130 on 09/07/23 at 10:44 A.M. revealed the care plans for each resident informs them of what target behaviors to look for as well as non-pharmacological interventions to use. Verified Resident #2's care plan does not have both non-pharmacological intervention and target behaviors. Interview with the Director of Nursing (DON) on 09/07/23 at 10:50 A.M. verified Resident #2's care plans do not include non-pharmacological interventions for behaviors and no target behaviors to observe for. 2. Review of the medical record for Resident #28, revealed an admission date of 03/10/21. Diagnoses included: dementia, major depressive disorder, weakness, anxiety disorder, and generalized anxiety disorder. Review of the most recent MDS 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 7 out of 15 indicating severe cognitive loss. This resident was assessed to require limited assistance with one-person physical assist with bed mobility and dressing and supervision with set up only for eating, toilet use and transfers. Further review of the MDS dated [DATE] revealed antianxiety and antidepressant medications seven out of seven days. Review of Resident #28's physician orders dated 05/25/22 revealed this resident was receiving Bupropion HCL 100 milligrams (mg) one tablet by mouth one time a day for behavior. Further review of Resident #28's physician orders dated 09/17/22 revealed this resident was receiving the follow medication: Buspirone HCL 10 mg one tablet orally a day for behavior. Review of the physicians' orders for Resident #28 revealed no orders since admission on [DATE] for documentation of targeted behaviors as well as no non-pharmacological interventions for the facility staff to utilize. Review of the care plans for Resident #28 dated 08/29/23 revealed no evidence of a care plan containing non-pharmacological interventions as well as no target behaviors to be monitoring for. Interview with LPN #130 on 09/07/23 at 10:45 A.M. revealed the care plans for each resident informs them of what target behaviors to look for as well as non-pharmacological interventions to use. Verified Resident #28's care plan does not have both non-pharmacological intervention and target behaviors. Interview with the DON on 09/07/23 at 10:51 A.M. verified Resident #28's care plans do not include non-pharmacological interventions for behaviors and no target behaviors to observe for. 3. Review of the medical record for Resident #30, revealed an admission date of 04/28/22. Diagnoses included: bipolar disorder, polyosteoarthritis, anxiety disorder, major depressive disorder, and atherosclerotic heart disease of native coronary artery without angina pectoris. Review of the most recent MDS 3.0 assessment dated [DATE] revealed a BIMS of 15 out of 15 indicating intact cognition. This resident was assessed to require supervision with set up only for: bed mobility, transfers, dressing and eating. Further review of the MDS dated [DATE] revealed antianxiety and antidepressant medications for seven out of seven days. Review of Resident #30's physician order dated 04/29/22 revealed Duloxetine 30 mg tablet, give 30 mg orally in the morning related to major depressive disorder. Further review for this resident's physician order dated 05/01/22 revealed Clonazepam 1 mg, give 1 tablet orally three times a day related to anxiety disorder. Review of the physicians' orders for Resident #30 revealed no orders since admission on [DATE] for documentation of targeted behaviors as well as no non-pharmacological interventions for the facility staff to utilize. Review of the care plans for Resident #30 dated 08/01/23 revealed no evidence of a care plan containing non-pharmacological interventions as well as no target behaviors to be monitoring for. Interview with LPN #130 on 09/07/23 at 10:46 A.M. revealed the care plans for each resident informs them of what target behaviors to look for as well as non-pharmacological interventions to use. Verified Resident #30's care plan does not have both non-pharmacological intervention and target behaviors. Interview with the DON on 09/07/23 at 10:52 A.M. verified Resident #30's care plans do not include non-pharmacological interventions for behaviors and no target behaviors to observe for. Review of the facility policy titled Behavioral Assessment, Intervention and Monitoring no dated stated the care plan will include as a minimum: non-pharmacological approaches will be utilized to the extent possible to avoid or reduce the use of antipsychotic medications to manage behavioral symptoms and specific target behaviors and expected outcomes.

CONCERN (D)

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility interviews, record reviews and Medscape, the facility failed to obtain orders, and/or create care plans, conduct assessments and conduct communications for the appropriate care for three (Resident #25, #37, and # 295) out of twenty five residents reviewed. The facility census was 40. Findings include: 1. Review of the medical record for Resident # 295, revealed an admission date of 08/24/23. Diagnoses included: acute osteomyelitis, essential hypertension, and type 1 Diabetes Mellitus (DM). Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15 out of 15 indicating intact cognition. This resident was assessed to require limited assistance with one-person physical assist for bed mobility, transfer, dressing and supervision with set up only for eating. Review of the physician's order dated 08/25/23 for Resident #295 revealed an order for an Omnipod 5 G6 Intro (Gen 5) Kit (Insulin Infusion Disposable Pump) 1 unit every 72 hours as needed for type 1 diabetes and insulin aspart 100unit/ml via insulin pump two times a day related to type 1 DM. Further review of the physician orders dated 08/25/23 to 09/06/23 for this resident did not reveal the following orders: -no order for blood glucose checks and/or an order for the Dexcom continuous glucose monitor (CGM) for the facility staff to be aware of the resident's blood glucose levels. -no order for the basal rate of this resident's Omnipod insulin infusion disposable pump. -no order for the sliding scale coverage for this resident for coverage for meals and if blood glucose level is high. -no order for a Glucagon Emergency kit to treat severe low blood glucose as needed -no order to care for the Dexcom CGM and when to renew it Review of the medication administration record (MAR) and treatment administration record (TAR) for Resident #295 from the dates of 08/25/23 to 09/06/23 revealed the following: -no documentation of blood glucose checks and/or the Dexcom CMG results for the facility staff to be aware of this resident's blood glucose levels. -no documentation of the basal rate of the Omnipod insulin infusion disposable pump -no documentation of the sliding scale coverage for this resident for coverage for meals and if blood glucose level is high. -no documentation for the use of a Glucagon Emergency kit to treat severe low blood sugar as needed. -no documentation to care for the Dexcom CGM, when to renew it and location. -no documentation to care for the Omnipod insulin infusion disposable pump, when to renew it and location. -insulin aspart 100unit/ml via insulin pump two times a day at 0800 and 2000 related to Type 1 DM. Review of care plans dated 08/24/23 for Resident # 295 revealed no diabetic care was initiated and implemented as of 09/06/23. Resident refused an interview on 09/06/23 at 10:22 A.M. and refused on 09/07/23 at 9:10 A.M. Interview with LPN #130 on 09/07/23 at 11:08 A.M. confirmed Resident #295 does not have a care plan for her diabetes care as well as no orders/documentation's for the following: -blood glucose checks and/or the Dexcom continuous glucose monitor (CGM). -the basal rate of the Omnipod insulin infusion disposable pump. -the sliding scale coverage for meals and if blood glucose level is high. -a Glucagon Emergency kit to treat severe low blood glucose as needed. -how to care for the Dexcom CGM and when to renew it and location. -how to care for the Omnipod insulin infusion disposable pump, when to renew it and location. Interview with LPN #130 also verified on 09/07/23 at 11:12 A.M. she was not aware of how the Omnipod insulin infusion disposable pump and a Dexcom CGM works, how to change them if needed, and their location on this resident. She was unsure of how the disease process is different from a Type 1 diabetic resident to a Type 2 diabetic resident. Interview with the Director of Nursing (DON) on 09/07/23 at 11:18 A.M. confirmed Resident #295 does not have a care plan for her diabetes care as well as no orders/documentation's for the following: -blood glucose checks and/or the Dexcom continuous glucose monitor (CGM). -the basal rate of the Omnipod insulin infusion disposable pump. -the sliding scale coverage for meals and if blood glucose level is high. -a Glucagon Emergency kit to treat severe low blood glucose as needed. -how to care for the Dexcom CGM and when to renew it and location. -how to care for the Omnipod insulin infusion disposable pump, when to renew it and location. The DON also confirmed the order: insulin aspart 100unit/ml via insulin pump two times a day at 0800 and 2000 related to type 1 DM was not correct as the Omnipod insulin infusion disposable pump continuously maintains this resident's blood glucose level and boluses for meals and if needed for high blood glucose control. Interview with the DON on 09/07/23 at 11:22 A.M. stated when the orders came with her, the hospital did not send the orders for her diabetic care. She has a Dexcom CGM, and we check on her to make sure she is ok. If she was to get low, we would give her orange juice. Verified the facility staff is unaware of this resident's blood sugar levels unless asking the resident so unaware if the residents blood sugar levels are safe and the facility nursing staff were never given education on how the Dexcom CGM and the Omnipod insulin infusion disposable pump function as well as the difference in care for a type 1 DM resident to a type 2 DM resident. According to Medscape, type 1 diabetes is a chronic illness characterized by the body's inability to produce insulin due to the autoimmune destruction of the beta cells in the pancreas. Type 1 diabetics require lifelong insulin therapy. Type 2 diabetes mellitus consists of an array of dysfunctions characterized by hyperglycemia and resulting from the combination of resistance to insulin action, inadequate insulin secretion, and excessive or inappropriate glucagon secretion. Type 2 diabetes care includes: appropriate goal setting dietary and exercise modifications, medications, appropriate self-monitoring of blood glucose (SMBG), regular monitoring for complications and laboratory assessment. According to Medscape, a Continuous subcutaneous insulin infusion (Omnipod): Rapid-acting insulin infused continuously 24 hours a day through an insulin pump at 1 or more basal rates, with additional boluses given before each meal and correction doses administered if blood glucose levels exceed target levels. It replaces the need for multiple injections for short acting and long-acting insulins. According to Medscape, a Continuous Glucose Monitors (CGMs like Dexcom) contain transcutaneous or subcutaneous sensors-depending on whether the devices are externally worn or fully implantable, respectively-that measure interstitial glucose levels every 1-5 minutes, providing alarms when glucose levels are too high or too low or are rapidly rising or falling. CGMs transmit to a receiver, which either is a pager like device or is integral to an insulin pump. Looking at the continuous glucose graph and responding to the alarms can help patients avoid serious hyperglycemia or hypoglycemia. It replaces the need to often obtain 2-4 blood glucose levels each day, including fasting levels and levels checked at various other times that are required. 2. Review of the medical record for Resident #25 revealed an admission date of 04/25/23 with diagnoses including Alzheimer's disease, hypertension, anxiety disorder and season allergies. Review of the quarterly MDS dated [DATE] revealed Resident #25 had severe cognitive impairment. Resident #25 had no impairment to range of motion to bilateral upper extremities, and received no therapy services. Review of the physician orders for 09/23 revealed Resident #25 did not have any orders for range of motion, or resting hand splint to right hand. Review of the plan of care for Resident #25 revealed no plan of care addressing the right hand impaired range of motion or resting had splint. Observation on 09/06/23 at 9:18 A.M. revealed Resident #25 had on a blue resting hand splint to her right hand. Observation on 09/07/23 at 9:10 A.M. revealed Resident #25 had a black soft brace to her right hand. Interview on 09/07/23 at 9:12 A.M. with State Tested Nursing Assistant (STNA) #165 revealed Resident #25 had two braces (splints) for her right hand: a blue one for night time and a black one for day time. STNA #165 stated it was not on the [NAME] (STNA care plan) for Resident #25 to wear the braces. STNA #165 stated the nurse (not identified) told the STNA to put the braces on the resident. STNA #165 stated she did not complete any type of range of motion on Resident #25's right hand. Interview on 09/07/23 at 10:15 A.M. with Certified Occupational Therapy Assistant (COTA) #166 revealed therapy was not providing any services for Resident #25 as she was on hospice care. COTA #166 observed and assessed Resident #25 right hand with surveyor. COTA #166 stated Resident #25 had decreased flexion in right wrist and thumb. The COTA observed the resting hand splint on Resident #25 bed side table and stated the device was used to prevent contracture's and was the correct splint for Resident #25 to wear. However, the therapy department did not provide the splint or any care and services to Resident #25. 3. Record review of Resident #37 revealed an admission date of 06/08/22 with pertinent diagnoses of: schizophrenia, major depressive disorder, shortness of breath, urinary tract infection, benign prostatic hyperplasia, protein calorie malnutrition, constipation, tremor, chest pain, asthma, hyperlipidemia, age related osteoporosis, schizoaffective disorder, dysphagia, Barrett's esophagus with dysplasia, hypertension, hyponatremia, dry mouth, iron deficiency anemia, chronic peptic ulcer, esophageal obstruction, polyp of colon, and nausea. Review of the 07/21/23 annual MDS assessment revealed the resident is cognitively intact and requires limited assistance for bed mobility, transfer, walk in room, dressing, toilet use, and personal hygiene. The resident uses a wheelchair to aid in mobility and is always incontinent of bladder and frequently incontinent of bowel. Review of the medical record on 09/05/23 revealed the resident was admitted to Hospice services on 08/02/22. There was no physicians order stating he was admitted to hospice in the electronic or paper record. Review of the medical record on 09/07/23 revealed there was no communication papers with the hospice company available. Interview with the Director of Nursing (DON) on 09/07/23 at 10:32 A.M. verified there was not a Physicians Order for Resident #37 to be on hospice services. The DON also verified they did not have communication from hospice readily available in the facility.

CONCERN (D)

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

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected 1 resident

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Based on observation, staff interview, and record review the facility failed to ensure medication error rates were not greater than five percent when Resident #95 did not receive their dose of Eliquis (an anticoagulant blood thinner medication) and gave Resident #37 the wrong dose amount of Vitamin D3. This affected two (Resident #37, and #95) of four residents reviewed for medication administration. The facility had two errors out of 25 opportunities for a medication error rate of eight percent. The facility census was 40. Findings include: 1. Record review of Resident #95 revealed an admission date of 09/01/23 with pertinent diagnosis of: cellulitis, cirrhosis of liver, thrombocytopenia, atherosclerotic heart disease of native coronary artery, atrial fibrillation, type two diabetes mellitus, anemia, and congestive heart failure. Review of a Physicians Order dated 09/01/23 revealed to give apixaban (Eliquis) five milligrams one half tab by mouth every 12 hours. Observation on 09/06/23 at 7:54 A.M. revealed Registered Nurse (RN) #138 administering medications to Resident #95 for morning medication pass. RN #138 administered nine medications but did not administer Eliquis. RN #138 verified she had given all the resident's morning medication and did not give anything earlier on 09/06/23 at 8:09 A.M. Interview with RN #138 on 09/06/23 at 10:20 A.M. verified she did not give Resident #95's morning Eliquis she had just missed the medication. 2. Record review of Resident #37 revealed an admission date of 06/08/22 with pertinent diagnosis of: schizophrenia, major depressive disorder, shortness of breath, urinary tract infection, benign prostatic hyperplasia, protein calorie malnutrition, constipation, tremor, chest pain, asthma, hyperlipidemia, age related osteoporosis, schizoaffective disorder, dysphagia, Barrett's esophagus with dysplasia, hypertension, hyponatremia, dry mouth, iron deficiency anemia, chronic peptic ulcer, esophageal obstruction, polyp of colon, and nausea. Review of the 07/21/23 annual Minimum Data Set (MDS) assessment revealed the resident is cognitively intact and requires limited assistance for bed mobility, transfer, walk in room, dressing, toilet use, and personal hygiene. The resident uses a wheelchair to aid in mobility and is always incontinent of bladder and frequently incontinent of bowel. Review of a Physicians Order dated 06/09/22 revealed to give cholecalciferol (vitamin D3) 1000 units one time a day for supplement. Observation on 09/06/23 at 8:13 A.M. revealed RN #138 administering medications to Resident #37 for morning medication pass. RN #138 administered cholecalciferol (vitamin D3) 400 units to Resident #37. Interview with RN #138 on 09/06/23 at 10:20 A.M. verified she gave Resident #37 the 400 units of cholecalciferol (vitamin D3) instead of 1000 units.

CONCERN (D)

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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Based on observation, staff interview, record review, and policy review the facility failed to to provide a sanitary environment to prevent the spread and development of communicable disease and infections when they did not cleanse blood glucose monitoring machines appropriately after resident use for Resident #95. The facility identified three Residents (#5, #9, #11) on the 19-27 hallway who received blood glucose monitoring checks. The facility census was 40. Findings include: Record review of Resident #95 revealed an admission date of 09/01/23 with pertinent diagnosis of: cellulitis, cirrhosis of liver, thrombocytopenia, atherosclerotic heart disease of native coronary artery, atrial fibrillation, type two diabetes mellitus, anemia, and congestive heart failure. Review of a Physicians Order dated 09/03/23 revealed to inject novolog insulin per sliding scale before meals and at bedtime. Observation on 09/06/23 at 7:54 A.M. revealed Registered Nurse (RN) #138 used the glucometer to check Resident #95 blood sugar level. RN #138 cleaned the glucometer with alcohol after she was done. Interview with RN #138 on 09/06/23 at 8:21 A.M. verified she cleaned the glucometer with alcohol and when questioned what she uses to clean the glucometer she stated alcohol or a bleach wipe. The Surveyor informed RN #138 that alcohol does not kill blood born pathogens such as human immunodeficiency virus, and hepatitis. RN #138 did not have any bleach containing wipes in her cart and they had to be retrieved out of the storage area. Review of the Assure Prism Multi Glucometer Reference Manual dated 03/01/21 revealed to minimize the risk of transmitting blood-borne pathogens, the cleaning and disinfection procedure should be performed as recommended. A variety of the most commonly used EPA-registered wipes have been tested and approved for cleaning and disinfecting of the Assure Prism multi Blood Glucose Monitoring System. The disinfectant wipes listed below have been shown to be safe for use with this meter. Please read the manufacturer's instructions before using their wipes on the meter: Clorox germicidal wipes, Dispatch hospital cleaner disinfectant towels and bleach, PDI Super Sani-Cloth germicidal disposable wipes, and Caviwipes1.

CONCERN (E)

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

Deficiency F0569 (Tag F0569)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interview, the facility failed to ensure spend down notices were provided timely and appropriately. This affected four residents (#17, #24, #28, and #31) out of the five residents whose facility fund accounts were reviewed during the annual survey. The facility census was 40. Findings include: 1. Record review for Resident #17 revealed this resident was admitted to the facility on [DATE] and had diagnoses including cerebral palsy, disorder of muscle, and spastic quadraplegia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/17/23, revealed this resident was rarely/never understood. This resident was assessed to be dependent upon two staff members for bed mobility, transfers, and toileting. Review of the facility Funds Balance Report, dated 09/06/23, revealed the balance in Resident #17's account was $2,021.58. Review of the facility Spend Down Notice for Resident #17 revealed the notice was not dated and did not provide evidence of how or when it was sent to the residents representative. Interview with the Administrator on 09/07/23 at 11:10 A.M. verified the spend down notice for Resident #17 did not provide evidence of the date it was issued or how or when it was provided to the residents representative. 2. Record review for Resident #28 revealed this resident was admitted to the facility on [DATE] and had diagnoses including unspecified dementia, major depressive disorder, and weakness. Review of the annual MDS assessment, dated 08/24/23, revealed this resident had moderately impaired cognition evidenced by a Brief interview for Mental Status (BIMS) assessment score of 07 out of 15. This resident was assessed to require limited assistance from one staff member for bed mobility and supervision for transfers and toileting. Review of the facility Funds Balance Report, dated 09/06/23, revealed the balance in Resident #17's account was $2,932.53. Review of the facility Spend Down Notice for Resident #28 revealed the notice was not dated and did not provide evidence of how or when it was sent to the residents representative. Interview with the Administrator on 09/07/23 at 11:10 A.M. verified the spend down notice for Resident #28 did not provide evidence of the date it was issued or how or when it was provided to the resident. 3. Record review for Resident #31 revealed this resident was admitted to the facility on [DATE] and had diagnoses including chronic obstructive pulmonary disease, dysphagia, and anemia. Review of the annual MDS assessment, dated 08/25/23, revealed this resident had intact cognition evidenced by a BIMS assessment score of 15 out of 15. This resident was assessed to require limited assistance from one staff member for bed mobility, transfers, and toileting. Review of the facility Funds Balance Report, dated 09/06/23, revealed the balance in Resident #17's account was $2,442.41 Review of the facility Spend Down Notice for Resident #31 revealed the notice was not dated and did not provide evidence of how or when it was sent to the residents representative. Interview with the Administrator on 09/07/23 at 11:10 A.M. verified the spend down notice for Resident #31 did not provide evidence of the date it was issued or how or when it was provided to the resident. 4. Record review for Resident #24 revealed this resident was admitted to the facility on [DATE] and had diagnoses including dementia, depressive disorder, and anxiety. Review of the quarterly MDS assessment, dated 07/14/23, revealed this resident had mildly impaired cognition evidenced by a BIMS assessment score of 10 out of 15. This resident was assessed to require supervision for bed mobility, transfers, and toileting. Review of the facility Funds Balance Report, dated 09/06/23, revealed the balance in Resident #17's account was $2,176.44. Review of the facility Spend Down Notice for Resident #23 revealed the notice was not dated and did not provide evidence of how or when it was sent to the residents representative. Interview with the Administrator on 09/07/23 at 11:10 A.M. verified the spend down notice for Resident #24 did not provide evidence of the date it was issued or how or when it was provided to the resident.

CONCERN (E)

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

Medication Errors (Tag F0758)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews and facility policy, the facility failed to identify target behaviors with documentation and/or provide an appropriate diagnosis for psychotropic medications for five (Resident #2, #11, #28, #30 and #41) of the eight residents reviewed. The facility census was 40. Findings include: 1. Review of the medical record for Resident #2 revealed an admission date of 10/25/22. Diagnoses included: anxiety disorder, unspecified intellectual disabilities, unspecified mental disorder due to known physiological condition and schizoaffective disorder. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident is rarely/never understood. This resident was assessed to require extensive assistance with one-person physical assist with bed mobility, dressing, and toileting and extensive assistance with two person physical assist with transfers. Further review of the MDS revealed resident received antianxiety medication seven out of seven days. Review of Resident #2's physician orders dated for 11/28/22 revealed this resident was receiving the following medication: Haloperidol Decanoate 50 milligrams (mg) one time a day starting on the 28th and ending on the 28th every month by injection for schizoaffective disorder. Further review of this resident's physicians order dated for 07/31/23 revealed the following medication: Buspirone HCL 7.5 mg one tablet by mouth three times a day for anxiety disorder. Review of the physicians' orders for Resident #2 revealed no orders since admission on [DATE] for documentation of targeted behaviors. Review of the progress notes for Resident #2 for the past thirty days starting on 09/06/23 revealed no documentation of target behaviors from the facility staff. Review of the behavioral task documentation for Resident #2 for the past thirty days starting on 09/06/23 revealed no documentation for target behaviors from the facility staff. Review of Resident #2's care plan dated 08/01/23 revealed no evidence of a care plan containing target behaviors to be monitoring for. Interview with Registered Nurse (RN) #146 on 09/07/23 at 9:29 A.M. revealed the progress notes are where the facility nurses document observed targeted behaviors and under the tasks are where the State Tested Nursing Aides (STNA) document targeted behaviors. Verified for the past thirty days starting on 09/06/23, Resident #2 did not have any documentation in the progress notes from the facility nurses for target behaviors and no documentation under tasks from the facility's STNAs for target behaviors. Interview with STNA #161 on 09/07/23 at 9:45 A.M. revealed the behavioral task charting is newer for the facility staff and stated We have only been doing this for about a month the computer charting, in the past I just tell the nurse about behaviors. I do not know where the target behaviors are, but the nurses tell me and if a resident is screaming or crying out that is a behavior. Verified STNA #161 is unsure of where the Resident #2's target behaviors are in the chart and the behavior tasks for the past thirty days since 09/06/23 were blank. Interview with Licensed Practical Nurse (LPN) #130 on 09/07/23 at 10:44 A.M. revealed the care plans for each resident informs them of what target behaviors to look for and in the progress notes are where the documentation of them go for nurses and the task section are for the STNA's. Verified Resident #2's care plan does not have target behaviors to observe for and the progress notes as well as the behavioral task notes for the past thirty days starting 09/06/23 does not have documentation of target behaviors. Interview with the Director of Nursing (DON) on 09/07/23 at 10:50 A.M. verified Resident #2's care plans do not include target behaviors to observe for and the progress notes as well as the behavioral task notes for the past thirty days starting 09/06/23 does not have documentation of target behaviors. 2. Review of the medical record for Resident #28, revealed an admission date of 03/10/21. Diagnoses included: dementia, major depressive disorder, weakness, anxiety disorder, and generalized anxiety disorder. Review of the most recent MDS 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 7 out of 15 indicating severe cognition. This resident was assessed to require limited assistance with one-person physical assist with bed mobility and dressing and supervision with set up only for eating, toilet use and transfers. Further review of the MDS revealed antianxiety and antidepressant medications were used seven out of seven days. Review of Resident #28's physician orders dated 05/25/22 revealed this resident was receiving Bupropion HCL 100 milligrams (mg) one tablet by mouth one time a day for behavior. Further review of Resident #28's physician orders dated 09/17/22 revealed this resident was receiving the follow medication: Buspirone HCL 10mg one tablet orally a day for behavior. Review of the physicians' orders for Resident #28 revealed no orders since admission on [DATE] for documentation of targeted behaviors for facility to observe. Review of the care plans for Resident #28 dated 08/29/23 revealed no evidence of a care plan containing target behaviors to be monitoring for. Interview with RN #146 on 09/07/23 at 9:30 A.M.,verified for the past thirty days starting on 09/06/23, Resident #28 did not have any documentation in the progress notes from the facility nurses for target behaviors and no documentation under tasks from the facility's STNAs for target behaviors. Interview with STNA #161 on 09/07/23 at 9:45 A.M. revealed the STNA #161 is unsure of where the Resident #28's target behaviors are in the chart and the behavior tasks for the past thirty days since 09/06/23 were blank. Interview with LPN #130 on 09/07/23 at 10:45 A.M. revealed Resident #28's care plan does not have target behaviors to observe for and the progress notes as well as the behavioral task notes for the past thirty days starting 09/06/23 does not have documentation of target behaviors. Interview with the DON on 09/07/23 at 10:51 A.M. verified Resident #28's care plans do not include target behaviors to observe for and the progress notes as well as the behavioral task notes for the past thirty days starting 09/06/23 does not have documentation of target behaviors. 3. Review of the medical record for Resident #30, revealed an admission date of 04/28/22. Diagnoses included: bipolar disorder, polyosteoarthritis, anxiety disorder, major depressive disorder, and atherosclerotic heart disease of native coronary artery without angina pectoris. Review of the most recent MDS 3.0 assessment dated [DATE] revealed resident was cognitively intact. This resident was assessed to require supervision with set up only for: bed mobility, transfers, dressing and eating. Review of Resident #30's physician order dated 04/29/22 revealed Duloxetine 30 mg tablet, give 30 mg orally in the morning related to major depressive disorder. Further review for this resident's physician order dated 05/01/22 revealed Clonazepam 1 mg, give 1 tablet orally three times a day related to anxiety disorder. Review of the physicians' orders for Resident #30 revealed no orders since admission on [DATE] for documentation of targeted behaviors for facility to observe. Review of the care plans for Resident #28 dated 08/01/23 revealed no evidence of a care plan containing target behaviors to be monitoring for. Interview with RN #146 on 09/07/23 at 9:31 A.M. verified for the past thirty days starting on 09/06/23, Resident #30 did not have any documentation in the progress notes from the facility nurses for target behaviors and no documentation under tasks from the facility's STNAs for target behaviors. Interview with STNA #161 on 09/07/23 at 9:47 A.M. revealed STNA #161 is unsure of where the Resident #30's target behaviors are in the chart and the behavior tasks for the past thirty days since 09/06/23 were blank. Interview with LPN #130 on 09/07/23 at 10:47 A.M. verified Resident #30's care plan does not have target behaviors to observe for and the progress notes as well as the behavioral task notes for the past thirty days starting 09/06/23 does not have documentation of target behaviors. Interview with the DON on 09/07/23 at 10:52 A.M. verified Resident #30's care plans do not include target behaviors to observe for and the progress notes as well as the behavioral task notes for the past thirty days starting 09/06/23 does not have documentation of target behaviors. 5. Record review for Resident #41 revealed this resident was admitted to the facility on [DATE] and had diagnoses including Schizophrenia, auditory hallucinations, and unspecified psychosis. Review of the quarterly MDS dated [DATE], revealed this resident had mildly impaired cognition evidenced by a BIMS assessment score of 12 out of 15. This resident was assessed to require extensive assistance from two staff members for bed mobility, to be dependent upon one staff member for toileting, to be dependent upon two staff members for transfers, and to require supervision with setup help only for eating. Review of the active care plan, dated 04/07/23, revealed this resident used anti-psychotic medication related to Schizophrenia. No target behaviors were specified in the care plan. Review of the active physicians order, dated 03/20/23, revealed this resident was ordered to be administered 50 milligrams (mg) of Seroquel (an anti-psychotic medication) once a day for a diagnosis of Schizophrenia. Review of the active physicians order, dated 03/21/23, revealed this resident was ordered to be administered two mg of Risperdal (an anti-psychotic medication) twice a day for a diagnosis of Schizophrenia. Interview with the Director of Nursing on 09/07/23 at 9:20 A.M. verified no target behaviors for Resident #41 had been identified in the residents plan of care. Interview with MDS Coordinator #121 on 09/07/23 at 9:30 A.M. revealed Resident #41 had not been referred to psychiatric services or had any behaviors since being admitted to the facility. Review of the facility policy titled Behavioral Assessment, Intervention and Monitoring no dated stated the care plan will include, as a minimum, a description of the behavioral symptoms (target Behaviors) in frequency intensity, duration, outcomes and location and the document any improvements or worsening in the individual's behavior, mood, and function. 4. Review of the medical record for Resident #11 revealed an admission date of 04/25/23 with diagnoses including Alzheimer's disease, Atrial Fibrillation, anxiety disorder, type two diabetes mellitus, and chronic obstructive pulmonary disorder. Review of the quarterly MDS dated [DATE] revealed Resident #11 had severe cognitive impairment with no behaviors noted. The assessment indicated Resident #11 had no psychiatric or mood disorder and did not receive any antipsychotic medications. Review of the physician orders for 09/23 revealed Resident #11 was ordered and received trazadone (antidepressant medication) 25 milligrams (mg) by mouth at bedtime for Alzheimer's disease. Review of the nursing progress notes from 08/08/23 through 09/07/23 revealed no documented behaviors. Review of the plan of care dated 02/13/23 revealed Resident #11 had a behavioral problem related to combative at times with the staff. Interventions included administer medication as ordered, monitor and document for side effects and effectiveness of medication and anticipate and meet the residents needs. Review of the plan of care dated 10/06/22 revealed Resident #11 received an antidepressant medication. Interventions included administer the antidepressant medication as ordered by the physician, monitor and document side effects and effectiveness every shift, monitor and report any adverse reactions to the antidepressant therapy. Review of the plan of care dated 10/06/22 revealed Resident #11 had a mood problem related to Alzheimer's disease. Interventions included administer medications as ordered, monitor and document for side effects and effectiveness, behavioral health consult as needed, monitor, record and report to the physician any acute episodes of feelings of sadness, loss of pleasure and other feelings of depression. Review of the task section of the STNA [NAME] revealed no abnormal behaviors documented for past 30 days. Observations of Resident #11 on 09/06/23 at 7:55 A.M., 09/07/23 at 8:45 A.M. revealed Resident #11 had no adverse behaviors. Interview on 09/07/23 at 9:15 A.M. with STNA #165 revealed Resident #11 yelled out at times but had no other adverse behaviors. STNA #165 stated behaviors would be documented on the task section of [NAME]. Interview on 09/07/23 at 9:31 with RN #138 revealed Resident #11 yelled out at night when the resident became anxious and confused but had no other behaviors. RN #138 stated all behaviors were documented in the nursing progress notes. Interview on 09/07/23 at 9:37 A.M. with the DON confirmed Alzheimer's disease was not a proper diagnosis for the use of trazadone an antidepressant medication. The DON stated the resident would hit her arms and hands against the wall in her room. The facility placed soft cushion like pads on the wall beside residents bed to help prevent injury.

CONCERN (E)

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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Based on observation and interview the facility failed to maintain a clean and sanitary kitchen. This had the potential to affect 39 residents who received meals from the kitchen. The facility census was 40. Findings include: Initial observation on 09/05/23 at 8:30 A.M. revealed the heating/air conditioning vents in the ceilings were rusty, with brown fuzzy like substance noted on the vents and around the vents on the ceiling. Observation on 08/07/23 at 10:30 A.M. revealed the heating/air conditioning vents in the ceiling remained soiled and blowed air over the food preparation and serving areas. The drain pipes under the sinks and dish tank were rusty, black and green like they leaked. The floor had black areas under the drains and the ice machine. Also the corners of the floor were dusty, dirty and black. The wall behind the steam/food holder was streaked with black and brown greasy like substance. The large plastic containers that contained flour and sugar were dusty on top with black like grime. Interview on 09/07/23 at 11:20 A.M. with the Regional Director (cook for the day) confirmed all areas that needed attention and cleaned.

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

Medical Records (Tag F0842)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility daily staffing sheets, and staff interviews, the facility failed to ensure resident medical records were maintained in an accurate manner and failed to ensure staff did not document the administration of medications using another staff members name and credentials. This affected the four residents (#2, #10, #28, and #295) reviewed for accurate documentation of medication and treatments. The facility census was 40. Findings include: 1. Record review for Resident #2 revealed this resident was admitted to the facility on [DATE] and had diagnoses including anxiety, depression, and delirium. Review of the annual Minimum Data Set (MDS) assessment, dated 08/06/23, revealed this resident was rarely/never understood. This resident was assessed to require extensive assistance from one staff member for bed mobility and toileting and to require extensive assistance from two staff members for transfers. Review of the Medication Administration Record (MAR) for 08/2023 revealed documentation Resident #2 had been administered medications by LPN #199 on 08/07/23, 08/11/23, 08/12/23, 08/13/23, 08/14/23, 08/16/23, 08/17/23, 08/18/23, 08/19/23, 08/20/23, 08/23/23, 08/26/23, 08/27/23, 08/28/23, 08/30/23, and 08/31/23. Review of the MAR for 09/2023 revealed documentation Resident #2 had been administered medications by LPN #199 on 09/01/23. Review of the facility daily staffing sheets from 08/01/23 through 09/05/23 revealed Licensed Practical Nurse (LPN) #199 was not documented to have worked at the facility. 2. Record review for Resident #10 revealed this resident was admitted to the facility on [DATE] and had diagnoses including Schizophrenia, hypothyroidism, and depressive disorder. Review of the quarterly MDS assessment, dated 07/16/23, revealed this resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 15. This resident was assessed to require supervision for bed mobility, transfers, and toileting. Review of the daily staffing sheets from 08/01/23 through 09/05/23 revealed LPN #199 was not documented to have worked at the facility. Review of the MAR for 08/2023 revealed documentation Resident #10 had been administered medications by LPN #199 on 08/06/23, 08/11/23, 08/12/23, 08/13/23, 08/16/23, 08/17/23, 08/21/23, 08/22/23, 08/25/23, 08/26/23, 08/27/23, 08/30/23, and 08/31/23. Review of the MAR for 09/2023 revealed documentation Resident #10 had been administered medications by LPN #199 on 09/01/23. 3. Record review for Resident #28 revealed this resident was admitted to the facility on [DATE] and had diagnoses including unspecified dementia, major depressive disorder, and weakness. Review of the annual MDS assessment, dated 08/24/23, revealed this resident had moderately impaired cognition evidenced by a BIMS assessment score of 07. This resident was assessed to require limited assistance from one staff member for bed mobility and supervision for transfers and toileting. Review of the daily staffing sheets from 08/01/23 through 09/05/23 revealed LPN #199 was not documented to have worked at the facility. Review of the MAR for 08/2023 revealed documentation Resident #28 had been administered medications by LPN #199 on 08/09/23, 08/11/23, 08/12/23, 08/13/23, 08/16/23, 08/19/23, 08/20/23, and 08/31/23. 4. Record review for Resident #295 revealed this resident was admitted to the facility on [DATE] and had diagnoses including acute osteomyelitis, hypertension, and depressive disorder. Review of the admission MDS assessment, dated 08/31/23, revealed this resident had intact cognition evidence by a BIMS assessment score of 15. This resident was assessed to require limited assistance from one staff member for bed mobility, transfers, and toileting. Review of the daily staffing sheets from 08/01/23 through 09/05/23 revealed LPN #199 was not documented ot have worked at the facility. Review of the MAR for 08/2023 revealed documentation Resident #295 had been administered medications by LPN #199 on 08/25/23, 08/26/23, 08/27/23, and 08/31/23. Review of the MAR for 09/2023 revealed documentation Resident #295 had been administered medications by LPN #199 on 09/01/23. Interview with Medical Records Employee #125 on 09/06/23 at 10:45 A.M. revealed LPN #199 worked at the facility through an agency but had not worked a shift in several months. Interview with the Director of Nursing (DON) on 09/06/23 at 2:15 P.M. verified LPN #199 had not worked at the facility in several months and other staff members had been using LPN #199's credentials to document medication administration to residents. The DON stated she just found out on 09/02/23 from an agency staff member that reported RN#134 was using LPN #199's badge. She verified that RN#134 did not report to her that her badge was not working The DON stated she was on vacation and when she returned on 09/06/23 she had a new badge delivered for Registered Nurse (RN) #134. The DON stated the process was to program badges for each separate staff member to identify each individuals name and license including agency staff. Telephone interview with RN #134 on 09/07/23 at 1:38 P.M. verified she had been using LPN #199's badge to document medication administration to residents as RN #134's badge was not working. She stated she had went prn (as needed) and returned to help out full time and when she returned to work on night shift her badge did not work so she grabbed an angency nurse badge to use. She verified she did not report her broken badge to the DON or Administrator. This deficiency represents non-compliance investigated under Complaint Number OH00146104.

CONCERN (E)

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

Deficiency F0847 (Tag F0847)

Could have caused harm · This affected multiple residents

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Based on record reviews and staff interview, the facility failed to ensure arbitration agreements provided to residents included written notice of the residents right to rescind the agreement within 30 days of signing. This affected the ten residents (#7, #8, #18, #21, #26, #30, #31, #34, #37, and #41) who the facility identified as having signed arbitration agreements. The facility census was 40. Findings include: Review of the facility provided list of residents who had signed arbitration agreements with the facility revealed there were ten residents ((#7, #8, #18, #21, #26, #30, #31, #34, #37, and #41) who had signed the agreements. Review of the facility Optional Arbitration Agreement form, revised 04/2017, revealed the agreement did not contain notice of the residents rights to rescind the arbitration agreement within 30 days of signing the agreement. Interview with the Administrator on 09/07/23 at 10:00 A.M. verified the facilities written arbitration agreement form did not contain notice of the residents right to rescind the arbitration agreement within 30 days of signing the agreement.

CONCERN (E)

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

Safe Environment (Tag F0921)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and observation the facility failed to provide a safe comfortable environment for residents when the wall was scratched in room [ROOM NUMBER] and 20. The toilet seat was soiled in room [ROOM NUMBER], and there was cracked floor tiles in room [ROOM NUMBER]. This affected seven residents (#10, #11, #17, #20, #23, #37, and #95) living in those rooms. The facility census was 40. Findings include: Observation with the Maintenance Director #122 on 09/07/23 from 2:19 P.M. to 2:26 P.M. revealed room [ROOM NUMBER], where Resident #17 and #23 resides, had wall scratches and missing caulking around the toilet. Observation of room [ROOM NUMBER], where Resident #95 resides, had wall scratches behind the resident's bed. Observation of room [ROOM NUMBER], where Resident #20 and #37 resides, had a dark brown substance dried on the the raised toilet seat. Observation of room [ROOM NUMBER], where Resident #10 and #11 resides, revealed a large crack in the floor covering multiple floor tiles. Interview with Maintenance Director #122 on 09/07/23 from 2:19 P.M. to 2:26 P.M. verified the observations and stated he was unaware of these items that needs fixing.

Dec 2021 34 deficiencies 1 Harm

SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Quality of Care (Tag F0684)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review for Resident #22 revealed this resident was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure, chronic pain disorder, and constipation. This resident had allergies to ibuprofen, levofloxacin, zosyn, vancomycin, amitriptyline, baclofen, tramadol, and effexor. Review of the quarterly MDS assessment, dated 10/13/21, revealed Resident #22 had intact cognition evidenced by a BIMS assessment score of 15. This resident was assessed to require limited assistance from one staff member for toileting and eating and to require supervision with set up assistance for bed mobility and transfers. Review of the care plan, dated 08/20/21, revealed Resident #22 was at risk for altered bowel elimination. Interventions included to provide medications as ordered. Review of Resident #22's active physicians orders revealed an order to implement the bowel protocol per facility policy if no bowel movement by the third day. Review of the facility Bowel and Bladder Elimination Pattern Evaluation for Resident #22 for 10/2021 revealed the resident was documented as not having a bowel movement from 10/01/21 through 10/09/21, 10/17/21 through 10/23/21, and 10/26/21 through 10/31/21. Review of Resident #22's Medication Administration Record (MAR) for 10/2021 revealed no documentation of the facility bowel protocol being implemented for Resident #22. Review of Resident #22's progress notes, dated 10/01/21 through 11/01/21, revealed an absence of documentation of Resident #22 not having a bowel movement or of the facility bowel protocol being implemented. Interview with Resident #22 on 11/30/21 at 2:30 P.M. revealed the resident had experienced episodes of constipation which had been reported to staff and had not received any additional medications or treatments for the constipation. Interview with the Director of Nursing on 11/30/21 at 4:45 P.M. verified Resident #22 had not been documented as having a bowel movement for more than three days on multiple occasions in 10/2021 and verified the MAR for 10/2021 contained no documentation of the facility bowel protocol being implemented. Based on medical record review, contract review, and staff interview the facility failed to provide necessary treatment and services to treat constipation, and hospice services. This affected three of three residents (Residents #15, #20, and #22) reviewed for constipation, one of one residents (Resident #15) reviewed for hospice services. Actual harm occurred to Resident #20 when the resident did not receive timely treatment for constipation that resulted in hospitalization of a bowel obstruction. Findings include: 1. Review of Resident #20's medical record revealed she was admitted on [DATE] with diagnoses that include: non displaced fracture of the right femur, cerebral palsy, paraplegia, contracture of left ankle, contracture of muscle multiple sites, post-surgical malabsorption, edema, anxiety disorder, disorder of psychological development, epilepsy, and constipation. Review of Resident #20's annual Minimum Data Set (MDS) 3.0 dated 04/06/21 revealed Resident #20 had no speech, was rarely understood and rarely understands others. Resident #20 had short-term and long-term memory impairment, had no recall, and severely impaired decision making. Resident #20 had no behaviors and did not reject care. Resident # 20 was dependent on two staff for bed mobility and transfers, did not walk, was dependent on two staff for toilet use, and personal hygiene. Review of Resident #20's physician orders revealed if Resident #20 had no bowel movement by the third day administer milk of magnesia (MOM) milliliters (ml) daily as needed on the third day at 7:00 A.M. If the MOM was ineffective, administer Dulcolax suppository via the rectum at 1:00 P.M. If the Dulcolax suppository was ineffective, administer one bottle of magnesium citrate at 5:00 P.M. If the magnesium citrate was ineffective, administer a Fleet enema at 10:00 P.M. If there was no bowel movement after the enema, abdominal pain or distention, bowel sounds increase/decrease at any time notify the physician. At any time do not administer the above medication if any if the following were present: abdominal pain, vomiting and/or rectal bleeding. Review of Resident #20's bowel records revealed on 09/23/21 Resident #20 had a bowel movement. No bowel movements were documented from 09/24/21 to 10/03/21. Review of the bowel record on 09/30/21 LAXED was documented. Review of Resident #20's medication administration record (MAR) for September 2021 revealed no evidence the bowel protocol was implemented. Review of Resident #20's October 2021 MAR revealed no evidence the bowel protocol was implemented. Review of Resident #20's progress notes dated 10/01/2021 revealed Resident #20 had a distended abdomen and was sent to the local hospital. Review of Resident #20's hospital Discharge summary dated [DATE] revealed on 10/01/21 Resident #20 went to the emergency room with reported abdominal distention. A computed tomography (CT) scan revealed bowel obstruction and severe constipation. Resident #20 was treated with magnesium citrate and soapsuds enema. Resident #20 had multiple extremely large bowel movements. Review of Resident #20's progress notes revealed on 10/03/21 Resident #20 returned from the hospital. Review of Resident #20's orders revealed magnesium citrate 296 ml every 72 hours was ordered and documented as administered as ordered. Interview with the Director of Nursing (DON) on 11/23/21 at 3:25 P.M. confirmed the bowel protocol was not implemented in September 2021 and October 2021 when Resident #20 had no bowel movement from 09/24/21 to 10/01/21. The DON confirmed Resident #20 was admitted to the local hospital and was diagnosed with a bowel obstruction and severe constipation. 2. Review of Resident #15's medical record revealed she was admitted on [DATE] with diagnoses that included: chronic obstructive pulmonary disease, heart failure, urinary incontinence, anxiety, hemiplegia and hemiparesis, right side, and psychosis. Review of Resident #15's annual MDS dated [DATE] revealed the following Resident #15's speech was clear, she was understood, understands others, and her cognition was intact. Resident #15 had no behaviors and did not reject care. Resident #15 required extensive assistance of two staff for bed mobility, to transfer, did not walk, no locomotion, extensive assistance of two staff for toilet use, and personal hygiene. Resident #15 had a life expectancy of six months or less and was on hospice. Review of Resident #15's quarterly MDS dated [DATE] revealed Resident #15 rejected care one to three days. Review of Resident #15's physician orders revealed if Resident #15 had no bowel movement by the third day, administer milk of magnesia (MOM) milliliters (ml) daily as needed on the third day at 7:00 A.M. If the MOM was ineffective, administer Dulcolax suppository via the rectum at 1:00 P.M. If the Dulcolax suppository was ineffective, administer one bottle of magnesium citrate at 5:00 P.M. If the magnesium citrate was ineffective, administer a Fleet enema at 10:00 P.M. If there was no bowel movement after the enema, abdominal pain or distention, bowel sounds increase/decrease at any time notify the physician. At any time do not administer the above medication if any if the following were present: abdominal pain, vomiting and/or rectal bleeding. Review of Resident #15's bowel records revealed no evidence Resident #15 had a bowel movement from 11/08/21 to 11/12/21 and 11/15/21 to 11/26/21. Review of Resident #15's MAR revealed the ordered bowel protocol was not initiated. Interview with Regional Director of Clinical Operations (RDCO) #77 on 11/30/21 at 1:18 P.M. confirmed there was no evidence Resident #15 had a bowel movement from 11/08/21 to 11/12/21 and 11/15/21 to 11/26/21 and the bowel protocol was not implemented as ordered. Review of Resident #15's record revealed no current hospice care plan and there was no information from hospice provided to the facility. Review of the hospice contract with the hospice service that provided services to Resident #15 dated 10/10/17 revealed hospice would maintain a complete medical record for the hospice recipient and documentation would be maintained in the recipient's nursing home medical record. Interview with DROC #77 on 11/30/21 at 3:50 P.M. revealed Resident #15's hospice provider maintained electronic documentation and previously their documentation was not shared with the facility.

CONCERN (D)

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

Deficiency F0561 (Tag F0561)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation the facility failed to provide personal materials of the resident's choice as requested. This affected one resident(Resident #28) out of two residents reviewed for personal choices. The facility census was 34. Findings include: Record review for Resident #28 revealed this resident was admitted to the facility on [DATE] with diagnoses including diabetes mellitis type II, myositis, muscle weakness, hypertension, anxiety, osteoarthritis, urinary tract infection, dyspnea, depression, cardiac arrhythmias, bipolar disorder, muscle spasms, pain, constipation, Vitamin D deficiency, hyperlipidemia, thyroid disorders, hyperlipidemia, depression, atherosclerotic heart disease, atrial fibrillation, chronic obstructive pulmonary disease, pain syndrome, and cystocele. This resident had allergies to Ibuprofen. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/03/21, revealed this resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 15. Interview with Resident #28 on 11/21/21 at 9:52 A.M. revealed she has asked repeatedly for wet wipes, and has been told none are available or in stock. Interview with Resident #28 on 11/22/21 at 3:55 P.M. revealed she has asked multiple staff members to obtain a package of wet wipes several times and has been told the facility is unable to obtain them. She stated she used wet wipes throughout the day at home before admission for personal use, and now cannot get them which are extremely important to her. Interview with State Tested Nursing Assistant #21 on 11/22/21 at 4:00 P.M. revealed Resident #28 had asked for a package of wet wipes about a week ago. This STNA stated she had told the resident the facility did not have any after looking for some. She stated she told the nurse on duty the resident wanted wet wipes but did not hear anything else about it. Interview with the Director of Nursing on 11/29/21 at 11:50 A.M. revealed she is unaware of this resident asking for personal wet wipes. She stated the facility does not have them, and does not think they have ever had them. She stated she is unsure about how to get them. Observation of Supply Room on 11/29/21 at 11:50 P.M. revealed no supply of wet wipes or cloths being stored in this room. This deficiency substantiates Complaint Number OH00114643.

CONCERN (D)

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

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to ensure residents who formulated an advance directive had the directive honored. This affected two of five sampled residents (Resident #15 and Resident #24) reviewed for advance directives. Findings include: 1. Review of Resident #15's medical record revealed she was admitted on [DATE] with diagnoses that included: chronic obstructive pulmonary disease, heart failure, urinary incontinence, anxiety, hemiplegia and hemiparesis of right side, and psychosis. Resident #15 requested a do not resuscitate-comfort care (DNR-CC) order on 09/26/19. Review of Resident #15's quarterly Minimum Data Set (MDS) dated [DATE] revealed the following. Resident #15's speech was clear, she was understood by others, understands others, her vision was adequate with no correction, and her cognition was intact. Resident #15 had a life expectancy of six months or less and she received hospice services. Review of Resident #15's signed October 2021 and November 2021 physician's orders revealed no DNR-CC order. Interview of Resident #15 on 11/21/21 at 2:26 P.M. revealed an advance directive for a DNR was in place and that was what she wanted. Interview of Regional Director of Clinical Operations (RDCO) #77 on 11/30/21 at 3:50 P.M. confirmed Resident #15 did not have an order for DNR-CC and without that order Resident #15 would be a full code. 2. Review of Resident #24's medical record revealed she was admitted on [DATE] with diagnoses that included: seizures, dementia, diabetes, and hypertension. On 10/07/2021 Resident #24's spouse elected an advance directive of DNR-CC. Review of Resident #24's significant change Minimum Data Set (MDS) dated [DATE] revealed the following. Resident #24's speech was clear, was rarely understood, rarely understands, she had short-term and long-term memory problems, no recall and her decision making was severely impaired. Resident #24 had a life expectancy of six months or less and received hospice services. Review of Resident #24's signed November 2021 physician's orders revealed no DNR-CC order. Interview of Regional Director of Clinical Operations (RDCO) #77 on 11/30/21 at 3:50 P.M. confirmed Resident #24 did not have an order for DNR-CC and without that order Resident #24 would be a full code.

CONCERN (D)

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

Deficiency F0582 (Tag F0582)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interview, and facility policy review, the facility failed to ensure a resident being discharged from a Medicare covered Part A stay with benefit days remaining was provided a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) form, and a Notice of Medicare Non-Coverage-Forms, Center for Medicare and Medicaid Services (CMS) 10123-(NOMNC) form. This affected one resident of the three residents reviewed for Beneficiary Notifications (Resident #13). The facility census was 34. Findings include: Review of the medical record for Resident #13 revealed an admission date of 09/24/20. Diagnoses included Parkinson's disease, acute and chronic respiratory failure, and drug induced acute dystonia (involuntary muscle contractions that cause repetitive or twisting movements). Review of Resident #13's Significant Change of Condition, Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #13 experienced long and short term memory problems and had moderately impaired cognition for daily decision making ability. Resident #13 required total dependence from one staff member for bed mobility, dressing, eating, toilet use, and personal hygiene, and total dependence from two staff members for bathing. Review of the Skilled Nursing Facility (SNF) Beneficiary Protection Notification review completed for Resident #13 revealed Medicare Part A skilled service episode start date was on 09/17/21 and the last covered day of Part A services was on 10/01/21. Resident #13 was noted on this form to have not received the SNF ABN form nor was the NOMNC form provided. Interview on 11/29/21 at 3:03 P.M. with MDS Coordinator #1 revealed Resident #13 was not provided either of these forms because he started receiving Hospice services. Interview on 11/29/21 at 5:00 P.M. with Regional Director of Clinical Operations #77 confirmed the facility did not provide Resident #13 with the required SNF ABN and NOMNC forms prior to his Skilled Part A services ending. Review of the facility policy titled Advance Beneficiary Notice-ABN, dated 11/30/14, revealed An ABN will be utilized to notify Residents of the possibility that Medicare will not pay for the item(s) or service(s) that are described on the form. The form will be reviewed with the Resident and/or authorized representative and a signature needs to be obtained. Review of the facility policy titled Notice of Medicare Provider Non-Coverage-Generic Notice, dated 11/30/14, revealed A notice of Medicare Provide Non-Coverage- Generic notice will be utilized to notify Residents of non-Medicare coverage. This form will be reviewed with the Resident and/or authorized representative and a signature needs to be obtained.

CONCERN (D)

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

Deficiency F0604 (Tag F0604)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and observation the facility failed to assess a resident's use of a specialty chair and failed to assure the resident's chair was not positioned to prevent the resident for getting out of the chair. This affected one of one residents (Resident #24) reviewed for restraints. Findings include: Review of Resident #24's medical record revealed she was admitted on [DATE] with diagnoses that included: seizures, dementia, diabetes, and hypertension. Review of Resident #24's significant change Minimum Data Set (MDS) dated [DATE] revealed the following. Resident #24's speech was clear, Resident #24 was rarely understood, rarely understands, she had short-term and long-term memory problems, no recall and her decision making was severely impaired. Resident #24 had no behaviors, she rejected care one to three days. Resident #24 was dependent on two staff for bed mobility, required extensive assistance of two staff to transfer, did not walk, and had no locomotion. Resident #24 used no restraints or alarms. Resident #24 received a specialty chair (Broda chair) on 11/04/21. There was no assessment of the Broda chair to determine whether it restricted Resident #24's freedom of movement. Observation of Resident #24 on 11/21/21 at 11:50 A.M. on 11/22/21 at 7:56 A.M., on 11/23/21 at 8:06 A.M., on 11/23/21 at 11:04 A.M., and 11/29/21 at 10:27 A.M. revealed she was in the Broda chair and it was reclined. Interview of the Director of Nursing (DON) on 11/29/21 at 10:15 A.M. revealed Resident #24 was placed in the Broda chair because the staff was afraid Resident #24 was unsafe in a wheel chair. She did not explain what was meant by unsafe. Interview of Licensed Practical Nurse (LPN) #32 on 11/29/21 at 12:46 P.M. revealed Resident #24 was able to walk and could get out of the Broda chair when it was upright, but not when it was reclined. Interview of State Tested Nursing Assistant (STNA) #18 on 11/30/21 at 8:30 A.M. revealed Resident #24 could walk. STNA #18 stated after Resident #24 had COVID-19 she was not herself, then one day it was like a light turned on and she got up and walked. STNA #18 stated Resident #24 was unsteady because she had not been up so much. STNA #18 stated Resident #24 could get out of the Broda chair when upright and she does, however when the Broda chair was reclined Resident #24 could not get out of the chair. Interview of Regional Director of Clinical Operations (RDCO) #77 on 11/30/21 at 11:16 A.M. confirmed no restraint/enabler assessment was conducted of Resident #24's use of a BRODA chair.

CONCERN (D)

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

Transfer Requirements (Tag F0622)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Review of resident medical record and staff interview, the facility failed to document a discharge for a resident returning to the community. This affected one (Resident #34) of the two residents reviewed for discharging from the facility. The facility census was 34. Findings include: Review of the closed medical record for Resident #34 revealed an admission date on 02/24/21 and a discharge date of 08/31/21. Diagnoses included, dementia without behavioral disturbances, hypertension, and muscle weakness. Review of the Resident #34's quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 07 indicating a severely impaired cognition for daily decision making abilities. Resident #34 required limited assistance from one staff member for bed mobility, transfers, ambulation, dressing, toilet use, and personal hygiene, and supervision with set up help only for eating. Review of Resident #34's MDS revealed Discharge, return not anticipated, dated 08/31/21. Review of Resident #34's physician orders for August 2021, revealed no order related to the resident's discharge. Review of Resident #34's nursing, dietary, and social services progress notes from 08/01/21 through 08/31/21, revealed no entries related to the resident's discharge from the facility or an overview of Resident #34's care received while at the facility. Continued review of Resident #34's medical record revealed no documented evidence a Discharge Summary was completed for the residents discharge from the facility. Interview on 11/30/21 at 2:20 P.M. with Regional Director of Clinical Operations #77 confirmed Resident #34's medical record did not reflect an accurate and complete discharge summary or documentation. Review of the facility policies revealed the facility was not able to provide a policy and/or procedure related to Residents Discharge.

CONCERN (D)

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

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview the facility failed to provide appropriate dental and nutritional assessments to appropriately represent the residents health status. This affected two residents (Resident #4 and Resident #20) of 21 residents reviewed for accurate assessments. The facility census was 34. Findings include: 1. Record review for Resident #4 revealed this resident was admitted to the facility on [DATE] with diagnoses including Huntington's disease, lack of coordination, muscle weakness, dementia, dysphagia, abnormal posture, peripheral vascular disease, delusional disorders, depression, unspecified psychosis, paranoid personality disorder, Vitamin D deficiency, and shortness of breath. This resident had no known allergies. Review of the quarterly Minimum Data Set (MDS) assessment, dated 09/17/21, revealed this resident had moderately impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 8. Review of Annual Minimum Data Set Assessment Section L 0200 completed on 05/07/21 revealed the resident had obvious or likely cavity or broken natural teeth. Review of dental assessments revealed a completion on admission of 10/26/16, where the resident was assessed to be missing teeth. Review of dental assessments on 4/4/19, 6/27/19, 9/26/19, 1/2/20, 3/26/20, 6/25/20 revealed no problems or concerns. On the assessment completed 5/25/21, Resident #4 was assessed to have missing/broken teeth. No other dental assessments were provided. Interview with the Regional Director of Clinical Services #77 on 11/30/21 at 10:00 A.M. verified Resident #4 had been provided with eight quarterly dental assessments since her admission to the facility on [DATE] with the most recent one being completed on 05/25/21. She also verified the Resident #4 was assessed to have broken or chipped teeth on this assessment with no further assessments being done. The Regional Director of Clinical Services #77 also verified Resident #4 should have been provided with proper dental assessments quarterly each year. 2. Review of Resident #20's medical record revealed she was admitted on [DATE] with diagnoses that include: non displaced fracture of the right femur, cerebral palsy, paraplegia, contracture of left ankle, contracture of muscle multiple sites, postsurgical malabsorption, edema, anxiety disorder, disorder of psychological development, epilepsy, and constipation. Review of Resident #20's annual Minimum Data Set (MDS) dated [DATE] revealed the following. Resident #20 had no speech, was rarely understood, rarely understands others. Resident #20 had short-term and long-term memory impairment, did not have recall, and had severely impaired decision making. Resident #20 had no behaviors and did not reject care. Resident #20 was dependent on two staff for bed mobility, to transfer, and was dependent on one staff to eat. Resident #20 had no swallowing problems, was 60 inches tall, 118 pounds, had no significant weight changes, and received 51% or more of calories and fluid intake via a tube feeding. Review of Resident #20's physician orders dated 10/06/21 revealed enteral feeding order (Jevity 1.5) with fiber, 8 ounce carton, administer with syringe 4:00 A.M., 10:00 A.M., 4:00 P.M., and 10:00 P.M. to total 1200 milliliters (ml) of feeding. Review of Resident #20's November 2021 physician orders signed 11/23/2021 revealed the following enteral feeding orders. A bolus tube feeding six times daily was ordered, as well as total tube feeding solution each shift 720 ml, and Jevity 1.5 ml to run at 70 cubic centimeters (cc) at noon daily. Review of Resident #20's medication administration record (MAR) revealed a continuous enteral feeding of Jevity 1.5 at 70 cc per hour (cc/hr) from 11:00 A.M. to 6:00 A.M. Review of Resident #20's nutrition assessment dated [DATE] revealed Resident #20 received Jevity 1.5 300 ml four times a day. There was no nutritional assessment reflecting the 19 hours of continuous feeding. Observation of Resident #20 on 11/23/21 at 8:05 A.M. revealed Resident #20 was in bed on her back and the enteral feeding was turn off. Observation of Resident #20's enteral feeding at 11:20 A.M. revealed it was administered by a pump at 70 ml/hr Interview of Registered Nurse (RN) #12 on 11/23/21 at 2:27 P.M. revealed Resident # 20 received a tube feeding from 11:00 A.M. to 6:00 A.M. administered at 70 ml/hr. Interview of the Director of Nursing (DON) on 11/23/21 at 3:25 P.M. revealed the 10/06/21 enteral feeding orders were Resident #20's feeding orders when she was in the hospital and were not to be implemented in the facility. The DON confirmed the nutritional assessment was not accurate related to Resident #20's enteral feeding.

CONCERN (D)

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

PASARR Coordination (Tag F0644)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to refer a resident for a level II pre-admission screening and resident review (PASRR) when the resident was newly diagnosed with a mental illness. This affected one of three sampled residents (Resident #24) reviewed for PASRR. Findings include: Review of Resident #24's medical record revealed she was admitted on [DATE] with diagnoses that included: seizures, dementia, diabetes, hypertension, schizoaffective disorder (10/26/21). Review of Resident #24's PASRR dated 03/17/21 revealed Resident #24 did not have any mental illness. Review of Resident #24's significant change Minimum Data Set (MDS) dated [DATE] revealed the following. Resident # 24 did not have a level II PASRR completed. There was no level II PASRR conducted after Resident #24 was newly diagnosed with a mental illness, schizoaffective disorder. Interview of Regional Director of Clinical Operations (RDCO) #77 on 11/30/21 at 11:16 A.M. confirmed no level II PASRR was conducted after Resident #24 was diagnosed with schizoaffective disorder.

CONCERN (D)

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

Deficiency F0646 (Tag F0646)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to notify the state mental health authority promptly after an significant change in a resident mental health, a resident with a newly diagnosed mental illness. This affected one of three sampled residents (Resident #24) reviewed for pre-admission screening and resident review (PASRR). Findings include: Review of Resident #24's medical record revealed she was admitted on [DATE] with diagnoses that included: seizures, dementia, diabetes, hypertension, schizoaffective disorder (10/26/21). Resident #24 received a new mental health diagnoses of schizoaffective disorder on 10/26/21. Resident #24 had no mental illness diagnoses identified prior. Interview of Regional Director of Clinical Operations (RDCO) #77 on 11/30/21 at 11:16 A.M. confirmed the state mental health authority was not notified of Resident #24's significant change in mental health.

CONCERN (D)

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

Deficiency F0661 (Tag F0661)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Review of resident medical record and staff interview, the facility failed to complete a discharge summary for a resident returning to the community. This affected one (Resident #34) of the two residents reviewed for discharge from the facility. The facility census was 34. Findings include: Review of the medical record for Resident #34 revealed an admission date on 02/24/21 and a discharge date of 08/31/21. Diagnoses included, dementia without behavioral disturbances, hypertension, and muscle weakness. Review of the Resident #34's quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 07 indicating a severely impaired cognition for daily decision making abilities. Resident #34 required limited assistance from one staff member for bed mobility, transfers, ambulation, dressing, toilet use, and personal hygiene, and supervision with set up help only for eating. Review of Resident #34's MDS revealed Discharge, return not anticipated, dated 08/31/21. Review of Resident #34's physician orders for August 2021, revealed no order related to the residents discharge. Review of Resident #34's nursing, dietary, and social services progress notes from 08/01/21 through 08/31/21, revealed no entries related to the resident's discharge from the facility or an overview of Resident #34's care received while at the facility. Continued review of Resident #34's medical record revealed no documented evidence a Discharge Summary completed for the residents discharge from the facility. Interview on 11/30/21 at 2:20 P.M. with Regional Director of Clinical Operations #77 confirmed Resident #34's medical record did not reflect an accurate and complete discharge summary or documentation. Review of the facility policies revealed the facility was not able to provide a policy and/or procedure related to Residents Discharge.

CONCERN (D)

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

Deficiency F0676 (Tag F0676)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure residents were provided with the necessary assistance to help maintain abilities in the area of eating and ambulation. This affected four of 22 residents (#7, #8, #12, and #24) reviewed for meal assistance. The facility census was 34. Findings include: 1. Record review for Resident #12 revealed this resident was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, hypertension, tremors, anxiety, depression, hypothyroidism, and malignant neoplasm of the breast. This resident had no known allergies. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 10/05/21, revealed this resident had moderately impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 06. This resident was assessed to require extensive assistance from two staff members for bed mobility, transfers, and toileting, and set-up assistance with supervision for eating. This resident was assessed to be 64 inches tall and weigh 189 pounds. Review of the care plan, dated 10/11/21, revealed this resident had imbalanced nutrition. Interventions included to assist with eating as needed. Review of the facility Vital Signs and Weight Record for Resident #12 revealed the resident's documented weight on 09/29/21 was 189 pounds, 189 pounds on 10/05/21, 186.2 pounds on 10/12/21, 187 pounds on 10/19/21, and 173 pounds on 11/23/21 with a recorded wheelchair weight of 35.4 pounds. Review of the facility Nurse Tech Information [NAME] revealed Resident #12 required set up and was dependent on staff for eating. Review of the facility CNA - ADL Tracking form for 10/2021 revealed there were no recorded meal intake percentages or amount of assistance the resident required for eating from 10/01/21 through 10/15/21. Documentation from 10/15/21 through 10/30/21 revealed the resident received set up assistance or limited assistance from one staff member and typically consumed 25 to 75 percent of meals. Review of the facility CNA - ADL Tracking form for 11/2021 revealed documentation the resident received limited to extensive assistance from one or two staff members and typically consumed 25 to 75 percent of meals. Observation on 11/21/21 at 11:36 A.M. revealed staff set-up the lunch tray of Resident #12 and left the room, leaving the resident unsupervised and without eating assistance. Observation on 11/21/21 at 12:01 P.M. revealed Resident #12 was reaching into an opened bag of Doritos chips and had consumed less than 25 percent of the bag. The remaining food items on the resident's tray had not been touched by the resident. Observation on 11/21/21 at 3:30 P.M. revealed the lunch meal tray for Resident #12 remained on the over the bed table in front of the resident. The remaining food items on the tray had been stacked on top of each other in the center of the tray. Interview with Licensed Practical Nurse (LPN) #88 on 11/21/21 at 3:35 P.M. verified Resident #12 received set up assistance for meals from staff in her room and typically ate by herself. LPN #88 verified Resident #12 had consumed less than 25 percent of her lunch meal which was usual for the resident. Interview with the Director of Nursing (DON) on 11/29/21 at 10:40 A.M. verified Resident #12 had a documented weight on 09/28/21 of 189.0 pounds and a documented weight on 11/23/21 of 173.0 pounds which was a 14.0 pound weight loss in 35 days. Observation of Resident #12 on 11/30/21 at 7:33 A.M. revealed Resident #12 was in bed with her tray set up on the overbed table. Resident #12 was feeding herself with a built up handle fork. The room door was shut. Resident #12 attempted to eat the scrambled eggs. At 7:50 A.M. Resident #12 was observed in bed, the room door was closed. Resident #12 stated she was done eating, but she might eat a little more. At 8:11 A.M. State Tested Nursing Assistant (STNA) #21 picked up Resident #12's tray. Resident #12 at 10% of her eggs, 25 % of her toast, 0% of cereal, 100 % juice, 0% milk. Interview with STNA #21 revealed Resident #12 does eat well on her own, but she did better with sandwiches and finger foods. Interview with STNA #18 on 11/30/21 at 8:25 A.M. revealed residents ate in their room as night staff did not get any resident's up because they were afraid day shift staff would not show up for work. Observation on 12/01/21 at 11:20 A.M. revealed Resident #12 was sitting her her wheelchair in the lobby with the lunch meal sitting in front of her on an over the bed table. Staff members were observed to be passing lunch meal trays to other residents and did not offer assistance or cueing to Resident #12 until 11:45 A.M. 2. Record review for Resident #7 revealed this resident was admitted to the facility on [DATE] and had diagnoses including unspecified dementia without behavioral disturbances, Alzheimer's disease, pulmonary fibrosis, and dysphagia. This resident had no known allergies. Review of the quarterly MDS assessment, dated 09/29/21, revealed this resident had mildly impaired cognition evidenced by a BIMS assessment score of 12. This resident was assessed to require extensive assistance from one staff member for bed mobility, transfers, and toileting and required set up assistance and supervision for eating. Review of the care plan, dated 07/24/20, revealed this resident had an Activities of Daily Living (ADL) self care deficit. Interventions included to monitor and report decline in abilities while eating. Review of the progress notes dated 10/11/21 through 11/20/21 revealed documentation on 11/30/21 of Resident #12 coughing. No other documentation of the resident coughing while consuming food or beverages was observed. Observation on 11/29/21 at 6:02 P.M. revealed Resident #7 was sitting at the table in the lobby consuming her dinner meal when she began coughing profusely. LPN #32 responded to assess the resident after being requested to three times by an STNA who was sitting at the table assisting another resident. Observation on 11/30/21 at 5:15 P.M. of Resident #12 revealed this resident was sitting at the table in the lobby consuming her dinner meal when she again began coughing profusely. LPN #4 responded to assist the resident and the resident stated It is stuck in my throat and I can't get it up. LPN #4 took Resident #12 to her room where she continued to cough and spit into the trash can. No food or debris were observed to come out while the resident was coughing. Interview with Registered Nurse (RN) #12 and LPN #36 on 11/30/21 at 9:35 A.M. verified Resident #12 had previously been prescribed a mechanical soft diet and had recently been upgraded to a regular diet. RN #12 stated Resident #12 had experienced episodes of coughing while eating and drinking over the previous week and had stated the food and beverages went down wrong while consuming them but had never lost consciousness. LPN #36 verified the resident continued to be prescribed a regular diet and had not received any new orders related to the resident coughing while eating and drinking. 3. Review of Resident #8's medical record revealed he was admitted on [DATE] with diagnoses that included: COVID-19, essential hypertension, altered mental status, legal blindness, major depressive disorder recurrent, and dysphagia oropharyngeal. Review of Resident #8's quarterly MDS dated [DATE] revealed his speech was clear, he makes self-understood, understands others, his vision was severely impaired and with no corrective lens, and his cognition was moderately impaired. Resident #8 did not reject care. Resident #8 required extensive assistance of one staff for bed mobility, transfers and eat.ing Resident #8 had no swallowing problems, was 66 inches, 179 pounds with no significant weight change. Review of Resident #8's plan of care for eating dated 06/30/21 revealed interventions to encourage the resident to eat, to keep needed items in easy reach, place food items in bowls, open and set up items, and provide positive feedback for efforts and accomplishments. Review of Resident #8's nutrition plan of care dated 06/29/21 revealed assist resident as needed to eat. Review of Resident #8's activities of daily living form for November 2021 revealed Resident #8 required supervision with set up help to eat. Observation of Resident #8 on 11/22/21 at 7:50 A.M. to 8:10 A.M. revealed STNA #16 served Resident #8 his meal tray. STNA #16 did not tell Resident #8 what foods he received or where they were located. Resident #8 received scrambled eggs, cereal, and toast each in a bowl and thickened milk, thickened juice, and thickened water. The beverages were not uncovered. At 7:56 A.M. Resident #8 stated he did not know where food was on his tray. Resident #8 was not told what food he had on his tray or where they were located to enable him to eat his meal. Interview with STNA #18 on 12/01/21 at 11:16 A.M. revealed Resident #8 received food in bowls, thickened liquids, and he did not like the thickened liquids. STNA #18 stated she would place a spoon in his right hand and a bowl of food in his left hand so he can hold it to eat. STNA #18 stated Resident #8 did not require assistance for eating just cueing. STNA #18 confirmed he had a difficult time locating food on tray. STNA #18 was supposed to be up in the chair to eat, he usually eats in the common area so they can keep an eye on him, but with short staffing he eats in his room sometimes. Interview with Registered Nurse (RN) #12 on 12/01/21 at 11:22 A.M. revealed Resident #8 received food in bowls and he did not require assistance to eat. Observation of Resident #8 on 12/01/21 at 11:26 A.M. revealed STNA #18 set Resident #8's tray up and handed him a bowl of meat and gravy and spoon to feed self. STNA #18 did not tell him the foods on his tray or where they were located. 4. Review of Resident #24's medical record revealed she was admitted on [DATE] with diagnoses that included: seizures, dementia, diabetes, and hypertension. Review of Resident #24's significant change Minimum Data Set (MDS) dated [DATE] revealed the following. Resident #24's speech was clear, she was rarely understood, she rarely understands others, she had short-term and long-term memory problems, no recall and her decision making was severely impaired. Resident #24 had no behaviors, she rejected care one to three days. Resident #24 was dependent on two staff for bed mobility, required extensive assistance of two staff to transfer, did not walk, had no locomotion, and was dependent on one staff to eat. Resident #24 had six months or less life expectancy, and was on hospice. Resident #24 received no restorative nursing services. Observation of Resident #24 on 11/21/21 at 11:50 A.M. on 11/22/21 at 7:56 A.M., on 11/23/21 at 8:06 A.M., on 11/23/21 at 11:04 A.M., and 11/29/21 at 10:27 A.M. revealed she was in a specialized chair (Broda chair) and it was reclined. Interview of Resident #24's spouse on 11/22/21 at 11:04 A.M. revealed Resident #24 needed services to help Resident #24 to walk. Interview of Licensed Practical Nurse (LPN) #32 on 11/29/21 at 12:46 P.M. revealed Resident #24 was able to walk and could get out of the Broda chair when it was upright, but not when it was reclined. LPN #32 stated Resident #24 was not steady on her feet because she did not walk that often. Interview of State Tested Nursing Assistant (STNA) #18 on 11/30/21 at 8:30 A.M. revealed Resident #24 could walk. STNA #18 stated after Resident #24 had COVID-19 she was not herself, then one day it was like a light turned on and she got up and walked. STNA #18 stated Resident #24 was unsteady because she has not been up so much. Interview of Regional Director of Clinical Operations (RDCO) #77 on 11/30/21 at 11:16 A.M. confirmed Resident #24 was not on a program to strengthen her ambulation abilities.

CONCERN (D)

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

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide Activities of Daily Living (ADL) assistance and care for one dependent resident (Residents #11) of 21 residents reviewed for ADL assistance. The facility census was 34. Findings include: Review of the medical record and face sheet revealed Resident #11 was admitted to the facility on [DATE] with the diagnosis of chronic kidney disease, difficulty walking, hemiplegia following cerebral vascular accident, dysphagia, peripheral vascular disease, and aphasia. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #11 was cognitively intact and was able to make needs known. Resident #11 required extensive assistance of one person assistance for personal hygiene care, including shaving and supervision for bathing. Review of the plan of care, revised on 10/07/21, identified Resident #11's need for extensive assistance of one staff with grooming. Interventions included explaining procedures prior to starting and providing items step by step. Resident #11 was observed on 11/29/21 at 10:00 A.M. through 12/01/21 at 3:00 P.M. to have beard growth. Resident #11 was interviewed on 11/29/21 at 10:00 A.M., 11/30/21 at 10:54 A.M. and 12/01/21 at 8:47 A.M. Resident #11 affirmatively nodded to interview questions he wanted to be showered and shaved and he had not refused showers and shaving on 11/29/21, 11/30/21 and 12/01/21. Review of the shower sheet schedule dated November 2021, revealed Resident #11 was scheduled for showers three times a week on day shift. Review of shower sheets dated 11/01/21 through 12/01/21 revealed Resident #11 did not receive showers three times a week. There was no shower sheets provided by Regional Clinical Nurse #77 for dates of 11/05/21, 11/12/21, 11/19/21, 11/24/21, 11/29/21 and 12/01/21. State tested nurse aide (STNA) #18 was interviewed on 12/01/21 at 11:42 A.M. She revealed Resident #11 was to be showered and shaved three times a week and documented on shower sheets. She verified Resident #11 had not been showered or shaved on 11/29/21, 11/30/21 or 12/01/21. STNA #18 stated she did not shave him unless he was scheduled a shower and had not provided a shower or shave on 11/30/21 or 12/01/21 due to insufficient staffing.

CONCERN (D)

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

Deficiency F0679 (Tag F0679)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Review of the medical record and face sheet revealed Resident #6 was admitted to the facility on [DATE] with a diagnosis of dementia, muscle weakness, unsteadiness on feet, hypertension, history of falls, and anxiety disorder. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #6 had moderately impaired cognition, and delusions. Resident #6 preferred activities of music, socialization, magazines to review, animals, religion interests and outside activities. Review of plan of care updated on 05/11/21 addressed Resident #6's impaired cognition, thought processes and potential for wandering behaviors due to dementia, anxiety and ineffective coping skills. Interventions included to provide activities of interest such as books and newspapers, and a wanderguard alert bracelet. Review of November 2021 physician orders revealed medications of Amlodipine 5 mg two tabs daily, Hydroxyzine HCC 25mg two times a day, Lisinopril and Rivastigmine 3 mg twice a day. A wander guard alert bracelet was ordered. Review of activity assessment dated [DATE] revealed Resident #6 was assessed to enjoy TV, music, activity groups and card games. Review of Activity Director #2 participation log revealed no documentation of any activities from 11/18/21 through 11/30/21. Review of posted activity calendar of November 2021 revealed three activities from 10:00 A.M. to 3:00 P.M. Sunday through Saturday, with exception of additional 9:00 A.M. activity on Tuesdays. Activities were repeated weekly with little variety in subject or activity level Random observations of Resident #6 from 11/21/21 2:25 P.M. through 11/29/21 6:15 P.M. revealed Resident was not involved in music, magazine review, or socializing game activities. Observation on 11/23/21 at 10:00 A.M. of posted activity of Coffee Cart revealed the activity started at 10:22 P.M. with 10 residents waiting in the main lounge. Activity Director #2 provided coffee, tea , pop, from a cart provided by the kitchen. Within five minutes, Activity Director #2 left the 10 residents in lounge and took cart down hallway to residents' rooms. There was no other staff providing activity after the Activity Director #2 left the lounge. There was no engagement of residents during the Coffee Cart activity. Interview on 11/22/21 at 8:07 A.M. Resident #6 stated there was nothing to do. She stated she liked magazines. Interview on 11/22/21 at 11:03 A.M. with Resident #6 Power of Attorney, stated Resident #6 enjoys animal activities, reading or reviewing magazines, and socializing in groups. The Activity Director #2 was interviewed on 11/30/21 at 9:03 AM and verified no activities had been documented as provided to Resident #6 from 11/18/21 through 11/29/21. Activity Director #2 stated she has been working as a direct care giver due to insufficient staffing and was unable to provide activities as posted on the November activity calendar. No individualized resident programming documentation was provided. Based on observation, medical record review, staff interview, resident group meeting, and resident council minute review the facility failed to provide residents with a meaningful, varied activity program, and ongoing activities program that was tailored to the wants and needs of the residents living in the facility. This affected three of three sampled residents (Resident #6, Resident #20, and Resident #24) and five of five residents (Resident #18, Resident #31, Resident #23, Resident #28, and Resident #29) who attended the resident group meeting. Findings include: 1. Review of Resident #20's medical record revealed she was admitted on [DATE] with diagnoses that include: non displaced fracture of the right femur, cerebral palsy, paraplegia, contracture of left ankle, contracture of muscle multiple sites, postsurgical malabsorption, edema, anxiety disorder, disorder of psychological development, epilepsy, and constipation. Review of Resident #20's annual Minimum Data Set (MDS) dated [DATE] revealed the following. Resident #20 had no speech, she rarely was understood, rarely understands others, had short-term and long-term memory impairment, had no recall, and severely impaired decision making. Resident #20 had no behaviors and did not reject care. Resident #20's staff activity preference revealed she did not like reading material, keeping up with news, group activities, and spending time away from nursing home. Resident #20's staff interview revealed she liked listening to music, being around animals, like participating in favorite activities, and religious activities. Resident #20 was dependent on two staff for bed mobility, to transfer, did not walk, and was dependent on one staff for locomotion. Review of Resident #20's activity assessment dated [DATE] revealed Resident #20 had a need for one to one activities and had a need for acoustic stimulation. Movies and music were good sources of stimulation for Resident #20. Resident #20 was nonverbal, unable to express feelings or anything for that matter. Resident #20 watches television and movies. Review of Resident #20's plan of care dated 11/13/14 for activities revealed the following interventions: porch sitting- sitting outside and people watching, one to one activities, in room visits, massage/therapeutic touch, loves music, religious services, small group activities, provide an activities calendar, thank resident for attending activities, female directed activities including nails, makeup, sensory, and [NAME] and cartoon channels. Review of Resident #20's activity participation records for Resident #20 revealed the following. Resident #20 received 15 minutes of one to one activities on 10/25/21 to 10/29/21, 11/01/21 to 11/02/21, on 11/04/21, 11/07/21 to 11/20/21, 11/22/21 to 11/26/21, and on 11/29/21. Resident #20 for the month of November 2021 Resident #20 had daily friend visits, and television that she actively participated in, music was provided 15 of 29 days, three days movies were provided, and sensory was provided 11 of 29 days. Observation of Resident #20 on 11/21/21 at 10:30 A.M. at 3:35 P.M. revealed Resident #20 was in bed, the television was on with children's programing, Resident #20 was not watching the television. There were toddler toys on Resident #20's night stand and they had not been moved from the first observation. Observation on 11/23/21 at 8:05 A.M. revealed Resident #20 was in bed, a child's program was on television and she was asleep. The toddler toys were on the night stand in the same location they were in on 11/21/21. Observation of Resident #20 on 11/22/21 at 10:01 A.M. revealed she was in bed, the privacy curtain pulled to end of bed, a child's program was on the television and Resident #20 was asleep. At 11:00 A.M. the privacy curtain was pushed to the head of the bed, and a child program was on the television, Resident #20 was not watching the television. Resident #20 was observed at 12:50 P.M. and 2:00 P.M. the television was on children's programs, the toddler toys were in the same place on the night stand and Resident #20 was not engaged in any activity. Interview of Activity Director (AD) #2 on 11/23/21 at 1:49 P.M. revealed she was familiar with Resident#20. AD #2 stated Resident #20 did not talk she only yells out if touch on her leg with a brace. AD #2 stated Resident #20 had baby toys at the bedside and AD #2 try to give them to her daily. AD #2 stated she provided one to one visits daily for 15 to 20 minutes, but they were short staffed and she could not always do the one to one visits. AD #2 stated she put cartoons on the television for Resident #20. AD #2 stated it took two staff and Hoyer lift to get her out of bed. AD #2 stated there was not enough staff to get up out of bed. AD #2 confirmed Resident #20 was not out of bed on 11/21/2021 or 11/22/2021. Interview of State Tested Nursing Assistant (STNA) #18 on 11/23/21 at 1:55 P.M. revealed she did not have a care plan or a care sheet for any resident. STNA #18 was always told not to get in the resident's chart for information, she asks the nurse what care Resident #20 needed including activities. STNA #18 stated Resident #20 only got up on shower days and staff do not take her out of her room due to COVID and the personal protective equipment she needed to wear when out of her room. Additional interview of AD #2 on 11/23/21 at 2:35 P.M. stated she wanted to do sensory and aroma therapy with Resident #20, but she was tactically defensive so AD #2 was not sure that would work for Resident #20. AD #2 revealed television meant the television was on in the resident's room, friend visits was staff going into the room during the day. 2. Review of Resident #24's medical record revealed she was admitted on [DATE] with diagnoses that included: seizures, dementia, diabetes, hypertension, and schizoaffective disorder (10/26/21). Review of Resident #24's significant change MDS dated [DATE] revealed the following. Resident #24's speech was clear, rarely understood, rarely understands, she had short-term and long-term memory problems, no recall and her decision making was severely impaired. Resident #24 had no behaviors, but she rejected care one to three days. Resident #24's staff assessment of activity preferences revealed she liked reading books, listening to music, being around pets, participating in favorite activities, spending time away from the nursing home, spending time outdoors, and participating in religious practices. Resident # 24 was dependent on two staff for bed mobility, required extensive assistance of two staff to transfer, did not walk, and had no locomotion. Resident #24's activities assessment dated [DATE] revealed Resident #20 was very confused and needed help with games. Review of Resident #24's activity care plan dated 04/02/21 revealed the following interventions: porch sitting- sitting outside and people watching, one to one activities, board games, celebrations/parties, coffee hour, cookouts, encourage exercise, engage in activities with available staff, food and snacks, massage/therapeutic touch, music, pet therapy, religious services, small group activities, invite to schedule activities, provide an activities calendar, thank resident for attending activities, and explain to the resident the importance of activity participation. Review of Resident #24's October 2021 activity participation record revealed six days of television, four days of family/friend visits, two days of social/parties, and on day of group discussion. Review of Resident #24's November 2021 activity participation record revealed daily family/friend visits, television, 12 of 29 days music, nine of 29 days of socials/parties, four of 29 days of radio and group discussion, and three of 29 days beauty/barber. Observation of Resident #24 on 11/23/21 at 9:06 A.M. to 11:04 A.M. revealed she was in a common area with no activity. Review of the Activity Calendar for 11/23/21 revealed at 9:00 A.M. BINGO was listed, this activity was not observed to occur. Observation on 11/29/21 from 7:42 A.M. to 10:27 A.M. Resident #24 was in a common area with no activity, no television or music on, and no staff in the area. On 11/29/21 at 10:27 A.M. the coffee cart was circulating. AD #2 offered resident's coffee or tea and the interaction was limited. Review of the Activity calendar for 11/29/21 revealed the activity of coffee cart at 8:45 A.M. Interview of AD #2 on 11/29/21 at 3:01 P.M. revealed Resident #24 liked nail care, television, music, social parties, small groups, and likes one to one visits. Further interview of AD #2 on 12/01/21 at 10:05 A.M. revealed television when the television was on, Resident #24's spouse visits almost daily. AD #2 stated she just got an activity assistant so more activities could be offered. AD #2 stated she got pulled to the floor so sometimes activities do not get done. 3. Review of Resident Council Meeting minutes dated 09/15/21 and 10/25/21 revealed no weekend activities, staff did not have time for activities, and activity staff were pulled from an activity and did not come back. A resident group meeting was held on 11/22/21 at 9:30 A.M. with Resident #18, #23, #28, #29, and #31. The residents stated there were no activities on the weekends and activities frequently did not happen or were interrupted due to Activity personnel being pulled to the floor to complete other tasks. The residents stated they would like activities other than BINGO. 4. Review of the Activity Calendar for October 2021 revealed on Sundays at 1:00 P.M. relaxation cloths were offered, on Mondays 6:00 P.M. world news, on Tuesday 9:00 A.M. BINGO at senior center, 1:30 P.M. manicures, 2:00 P.M. BINGO, 3:00 P.M. resident time, Wednesday no activity was listed, Thursdays 10:30 A.M. morning group and 1:00 P.M. store list run, Friday 10:00 A.M. morning group, 1:30 P.M. room visits, and 2:00 P.M. BINGO, and Saturday 2:00 P.M. BINGO. Review of the November 2021 activity calendar revealed Sundays, morning praise channel and 1:00 P.M. relaxation cloths, Monday 10:00 A.M. coffee cart, 1:00 P.M. a special activity, 6:00 P.M. world news, Tuesdays 9:00 A.M. BINGO at senior center, 1:30 P.M. manicures, 2:00 P.M. BINGO, 3:00 P.M. resident time, Wednesday, a special activity and a second special activity, Thursday 10:30 A.M. morning group, BINGO, and another activity, Fridays 10:30 A.M. morning group, 1:30 P.M. room visits, and 3:00 P.M. a food activity, and Saturday 10:00 A.M. movie and 3:00 P.M. activity cart. Interview of AD #2 on 12/01/21 at 10:05 A.M. revealed current events was the news or what they have on in the common room, relaxation clothes included warm, wet clothes on hands followed by lotion massaged onto hands. World news was watching the news on television, movie is a DVD put on, activity cart is taking a cart around with packets they can work on, and Sunday praise channel is a TV program. AD #2 confirmed there were no evening activities. AD #2 stated sometime activities did not occur because she was pulled to the floor, but that should be better now because she now had an activity aide.

CONCERN (D)

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

Deficiency F0685 (Tag F0685)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, medical record review, and staff interview the facility failed to assess and provide vision services and devices as needed. This affected one of one residents reviewed for vision (Resident #15). Findings include: Review of Resident #15's medical record revealed she was admitted on [DATE] with diagnoses that included: chronic obstructive pulmonary disease, heart failure, urinary incontinence, anxiety, hemiplegia and hemiparesis right side, and psychosis. Review of Resident #15's annual minimum Data Set (MDS) dated [DATE] revealed the following. Resident #15's speech was clear, she understood others, her vision was adequate with no correction, and her cognition was intact. Resident #15 had no behaviors and did not reject care. Resident #15 required extensive assistance of two staff for bed mobility and to transfer. Review of Resident # 15's quarterly MDS dated [DATE] revealed the following changes: rejected care one to three days, and for locomotion she required set up help with staff supervision. There was no comprehensive assessment of Resident #15's vision or need for glasses. Interview of Resident #15 on 11/21/21 at 2:42 P.M. revealed her vision was impaired and she needed glasses. Resident #15 stated and she had not seen the eye doctor in a long time. Interview of the Regional Director of Clinical Operations (RDCO) #77 on 11/30/21 at 3:50 P.M. revealed Resident #15 had no vision examination, she is scheduled for a vision examination next year.

CONCERN (D)

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review the facility failed to complete fall investigations and assessments of residents after falls with head injuries. This affected one of three residents reviewed for falls and after fall assessments (Resident #384). Findings Include: Review of the closed medical record for Resident #384 revealed an initial admission date of 10/09/13, re-entry date on 11/01/13, and a discharge date on 05/19/21. Diagnoses included difficulty in walking, unsteadiness on feet, repeated falls, muscle weakness, abnormal posture, stiffness of the knees, transient ischemic attack (TIA), concussion without loss of consciousness, injury of the head, and contusion of the scalp. Review of Resident #384's quarterly MDS assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating a moderately impaired cognition for daily decision making abilities. Resident #384 was noted to experience or express no behaviors. Resident #384 required extensive assistance from one staff member for bed mobility, transfers, dressing, and toilet use, and limited assistance from one staff member for ambulation, and personal hygiene. Resident #384 was noted with no impairments to bilateral upper or lower extremities, requires the use of a walker for ambulation, and was always continent of bowel and bladder function. Review of Resident #384's fall risk assessments dated 04/23/20 revealed a score of 19 indicating Resident #384 was at risk for falls. Assessments completed on 06/03/20 and 07/02/20 revealed a score of 11 indicating Resident #384 at risk for falls. Fall risk assessment completed on 01/04/21 revealed a score of 8 indicating Resident #384 was not at risk for falls. Review of Resident #384's physician orders for May 2021 included: -Vicodin (narcotic to treat pain) 5-325 milligram (mg) tablet, give one tablet twice a day, -Zestril (ACE inhibitor to treat high blood pressure) 2.5 mg tablet, give one tablet daily for hypertension, Metoprolol Succinate (Beta blocker to treat hypertension, and chest pain) 25 mg extended release (er) tablet, give one tablet daily for a-fib. Review of Resident #384's treatment orders for May 2021 included: -non-skid socks at night time -one side of bed against wall -non-skid strips in front to of high back chair, put non-skid strips in front of bed - dycem in chair due to falls and fall precautions. Review of Resident #384's nursing progress note dated 07/02/20, no time noted, revealed, Resident found laying on floor. Gash on top of her head. States she hit her head on the bedside table. Contacted doctor, sending resident to ER to be checked out. Continued review revealed at 9:02 A.M. Patient returned from ER. Nurse called ER for report who states patient CT scan came back normal. Patient has a laceration to left head and received 4 staples, new order to monitor staples for signs and/or symptoms of infection. Cleanse with soap and water if needed. Remove staples in 10 days. Review of Resident #384's nursing progress note dated 07/31/20 at 6:40 A.M. revealed, Resident fell at 6:40 A.M. from chair. Resident hit head on bed side table. Resident has knot on top of her head. Resident sent to the ER for evaluation. Continued review revealed at 9:15 A.M. Patient arrived back to the facility, no new complaints of pain. Review of Resident #384's nursing progress note dated 11/20/20 at 7:20 A.M. revealed, Resident slid and fell out of recliner. Resident stated that she hit her head on her walker. Sent to ER for a CT. Review of Resident #384's nursing progress note dated 12/19/20 at 8:00 A.M. revealed Resident sitting in chair, contusion on left side of forehead. When asked what happened, resident stated she fell at 3:00 A.M. on Friday morning. Doctor called and suggested getting a CT scan. Review of Resident #384's nursing progress note dated 04/08/21 at 9:15 A.M. revealed, Resident fell out of bed without shell helmet on. Resident stated she hit her head. A knot was noted on the top of her head. After getting resident in bed, she vomited, her pupils were sluggish but reactive. Resident had a bruise noted above the coccyx after the fall. Resident was sent to the ER for further evaluation. Review of Resident #384's fall investigation dated 03/12/21 revealed, fall, blood pressure (B/P) 135/71 millimeter of mercury (mmHg), pulse-71 beats per minute, respiration-18 breaths per minute, temperature 97.3 degrees Fahrenheit (F), and oxygen saturations at 98% with 2 liters of supplemental oxygen via nasal cannula, weakness, knot on left frontal lobe, moaning, grimacing, flinching. Skin tear to arm, right upper arm, interventions is a table with wheel locks with supervision as needed. No new fall interventions were noted in this investigation or report. Review of the Skin Evaluation form from fall, dated 03/15/21, revealed, Resident has a hematoma back of head at crown approximate tennis ball. Fall on 03/15/21- previous fall on 03/13/21. Vital Signs, B/P-176/85 mmHg, pulse- 63 beats per minute, respiration 20 breaths per minute, temperature 97.3 degrees F, and oxygen saturation at 98%. Increased confusion, needs more assistance with activities of daily living (ADL), more than one fall, pain to the back of head at a level of 5 out of 10 on the numeric pain scale. (Resident fell out of recliner onto floor, head impact on feet of bed, hematoma, emergency room (ER).). No new fall interventions were noted in this investigation or report. Review of Resident #384's fall investigation dated 04/08/21 revealed, Fall B/P-159/77 mmHg, pulse-74, respirations-14, and oxygen saturation 97%, decreased level of consciousness, resident had a small bruise on coccyx, head. No new fall interventions were noted in this investigation or report. Review of Resident #384's fall investigation dated 04/20/21 revealed, B/P-159/77, pulse-55, respirations- 18, and oxygen saturations 98% on 2 liters of oxygen via nasal cannula. No new fall interventions were noted in this investigation or report. Review of Resident #384's emergency room (ER) visit summary dated 04/22/21 revealed, Based on this patient's presentation and physical exam as well as lab values, and imaging, she does have a rather large contusion on the anterior forehead. However here in the ER, during ER course, her behaviors been normal. She slept some of which has been good, she is having pain under control, she has a closed head injury. Patient will be returned back to the nursing home. Computed Tomography (CT) of head was negative for any intracranial abnormalities. Continued review of Resident #384's medical record revealed neuro- checks had not been completed for fall where it was noted the Resident hit her head on 03/12/21, 03/15/21, and 04/08/21. Interview on 12/01/21 at 10:00 A.M. with Regional Director of Clinical Operations #77 confirmed fall investigations completed for Resident #384 were incomplete and did not include fall interventions. The Regional Director of Clinical Operations #77 confirmed neuro- checks were not completed for Resident #384 after multiple falls where it was indicated she hit her head. Review of the facility policy titled Accident and Incident-Investigating and Reporting, dated 07/2017, revealed The following data, as applicable, shall be included on the report form, any corrective actions taken., as well as the condition of the injured person, including his/her vital signs. This deficiency substantiates Complaint Number OH00111914.

CONCERN (D)

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

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, medical record review, and staff interview the facility failed to assess and provide treatment and care to treat a resident's incontinence. This affected one of one residents reviewed for bladder function (Resident #15). Findings include: Review of Resident #15's medical record revealed she was admitted on [DATE] with diagnoses that included: chronic obstructive pulmonary disease, heart failure, urinary incontinence, anxiety, hemiplegia and hemiparesis right side, and psychosis. Review of Resident #15 annual minimum Data Set (MDS) dated [DATE] revealed the following. Resident #15's speech was clear, she understood others, and her cognition was intact. Resident #15 had no behaviors and did not reject care. Resident #15 required extensive assistance of two staff for bed mobility and to transfer. Resident #15 was not on a toileting program and was always incontinent of bladder, There was no comprehensive assessment of Resident #15's bladder function or bladder retraining potential. Interview of Resident #15 on 11/21/21 at 2:42 P.M. revealed she was incontinent of urine and was supposed to be on a toileting plan. Interview of the Regional Director of Clinical Operations (RDCO) #77 on 11/30/21 at 3:50 P.M. revealed Resident #15 had no bladder assessment and currently was not on a toileting plan.

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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of pharmacy recommendations, and staff interview the facility failed to review a resident's drug regimen and make recommendations regarding drug irregularities. This affected one of six sampled residents (Resident #24) reviewed for unnecessary medications. Findings include: Review of Resident #24's medical record revealed she was admitted on [DATE] with diagnoses that included: seizures, dementia, diabetes, and hypertension. On 10/26/21 a diagnosis of schizoaffective disorder was added. Review of Resident #24's significant change Minimum Data Set (MDS) dated [DATE] revealed the following. Resident #24 received an antipsychotic medication, an antidepressant medication, and an anticoagulant, 6 of 7 day assessment period and there was no dose reduction of the antipsychotic medication. Review of Resident #24's monthly physician orders revealed on admission an order for an antipsychotic medication (Risperdal) one milligram (mg) at bedtime. Review of Resident #24's July 2021, August 2021, October 2021, and November 2021 drug regimen reviews revealed no irregularities. No drug regimen reviews were provided prior to July 2021. These reviews were requested by the surveyor but none were provided. Record review revealed Resident #24 did not have an indication for the use of the antipsychotic medication and there were no target behaviors identified or tracked. Interview of Director of Nursing (DON) on 11/30/21 at 11:06 A.M. revealed drug regimen reviews for Resident #24 were not available prior to the July 2021 reviews. The DON verified there were no recommendations from the pharmacist regarding Resident #24's usage of Risperdal.

CONCERN (D)

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

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to ensure a resident did not receive an antipsychotic medication without an indication for its use. This affected one of six sampled residents (Resident #24) reviewed for unnecessary medications. Findings include: Review of Resident #24's medical record revealed she was admitted on [DATE] with diagnoses that included: seizures, dementia, diabetes, and hypertension. On 10/26/21 a diagnosis of schizoaffective disorder was added. Review of Resident #24's significant change Minimum Data Set (MDS) dated [DATE] revealed the following. Resident #24 received an antipsychotic medication, an antidepressant medication, and an anticoagulant 6 of 7 day assessment period. There was no dose reduction of the antipsychotic medication. Review of Resident #24's monthly physician orders revealed on admission an order for an antipsychotic medication (Risperdal) one milligram (mg) at bedtime. Review of Resident #24's medical record revealed the resident did not have an indication for the use of the antipsychotic medication, there were no target behaviors identified or tracked. Interview Licensed Practical Nurse (LPN) #32 on 11/29/21 at 12:46 P.M. revealed Resident #24 had no behaviors and did not resist care. LPN #32 stated one time a hospice aid, who was trying to shower Resident #24 and the resident did not want showered, Resident #24 told her to stop or she would fist her. The aid did not stop and Resident #24 hit at the hospice aid. LPN #32 stated Resident #24 did not have delusions and she does not have mental illness like they to say she does. Resident #24 gets her words mixed up but that is dementia. Interview of State Tested Nursing Assistant (STNA) #18 on 11/30/21 at 8:30 A.M. revealed Resident #24 would resist care when staff tried to get her to do something she did not want to do. Resident #24 would resist care such as holding onto her brief when you go to change her if she did not know the aid. Interview of the Regional Director of Clinical Operations (RDCO) #77 on 11/30/21 at 11:16 A.M. confirmed no target behaviors were identified for Resident #24 and there was no tracking of behaviors for Resident #24.

CONCERN (D)

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

Dental Services (Tag F0791)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview the facility failed to provide routine dental services for two residents. This affected two residents (Resident #4 and Resident #15) of four residents reviewed for routine dental services. The facility census was 34. Findings include: 1. Record review for Resident #4 revealed this resident was admitted to the facility on [DATE] with diagnoses including Huntington's disease, lack of coordination, muscle weakness, dementia, dysphagia, abnormal posture, peripheral vascular disease, delusional disorders, depression, unspecified psychosis, paranoid personality disorder, Vitamin D deficiency, and shortness of breath. This resident had no known allergies. Review of the quarterly Minimum Data Set (MDS) assessment, dated 09/17/21, revealed this resident had moderately impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 8. Review of Annual Minimum Data Set Assessment Section L 0200 completed on 05/07/21 revealed the resident had obvious or likely cavity or broken natural teeth. Review of Resident #4's dental appointment log revealed the last dental appointment was on 01/20/21. A dentist recommendation was made to be seen in the office for her next appointment due to heavy plaque and gingivitis. No follow up appointments have been made for this resident since that time. Dentist last visit to the facility was on 06/21/21, with this resident not being seen from information provided. Facility provided the next appointment for this resident is currently scheduled for January 2022, with no appointment time provided, and to be seen in house. Facility provided no evidence of an outside dental appointment taking place following the recommendation on 01/20/21. Review of the Dental Summary Report completed on 01/20/21, stated Resident #4 has partial dentition and no dental x-rays were taken due to the resident being seen in their room. A recommendation was made to be brought to the dental clinic for their next visit. The notes reflect the dentist was unable to complete cleaning at the time of service as well. The dentist assessed the resident to have heavy plaque and gingivitis, and requires assistance for daily mouth care. Interview with the Director of Nursing on 11/23/21 at 2:25 P.M. verified Resident #4 had not been seen for a dental appointment since 1/20/21, even after receiving a recommendation by the dentist to be seen in the office on her next visit. She verified the last time the dentist was in the building was 06/21/21, and Resident #4 was not seen at that time. She verified Resident #4 has her next dental appointment for 360 care in January 2022 which she believes will be conducted in the facility. 2. Review of Resident #15's medical record revealed she was admitted on [DATE] with diagnoses that included: chronic obstructive pulmonary disease, heart failure, urinary incontinence, anxiety, hemiplegia and hemiparesis, right side, and psychosis. Review of Resident #15's annual minimum Data Set (MDS) dated [DATE] revealed the following. Resident #15 had no swallowing problems, no significant weight changes, and was edentulous. Review of Resident #15's quarterly MDS dated [DATE] revealed Resident #15 rejected care one to three days during the assessment period. Review of Resident #15's quarterly clinical health status dated 05/25/21 and 07/21/21 revealed she was edentulous and these documents did not identify that Resident #15 had dentures or not. Review of Resident #15's dental plan of care did not identify the resident as having dentures. There was no comprehensive assessment of Resident #15's dental status, no documentation of the resident having dentures or using dentures. There was no evidence in Resident #15's medical record of her having a dental appointment. Interview of Resident #15 on 11/21/21 at 2:36 P.M. revealed she had dentures that did not fit and she was supposed to see the dentist when he next comes to the facility. Observation of Resident #15 on 11/23/21 at 8:05 A.M. revealed she did not have dentures. Interview of State Tested Nursing Assistant (STNA) on 11/30/21 at 2:27 P.M. revealed Resident #15 had dentures but she did not wear them. Interview of the Regional Director of Clinical Operations (RDCO) #77 on 11/30/21 at 3:50 P.M. confirmed Resident #15 had no dental assessment, no evidence Resident #15 saw the dentist, and now Resident #15 was scheduled for dental appointment next year.

CONCERN (D)

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

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview, the facility failed to ensure resident medical records reflected an accurate code status and enteral nutrition orders. This affected two residents (Resident #383, and #20) of the 23 resident records reviewed. The facility census was 34. Findings include: 1. Review of the closed medical record for Resident #383 revealed an admission date of [DATE], and a discharge date of [DATE]. Diagnoses include chronic kidney disease stage 3, hypokalemia, and heart disease. Review of Resident #383's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating an intact cognition for daily decision abilities. Resident #383 required supervision with no set up for bed mobility, transfers, locomotion, dressing, and personal hygiene. Resident #383 required supervision with set up assist for eating and toilet use. Review of Resident #383's physician orders for [DATE] revealed Resident #383's code status indicated full code where all life sustaining measure are to be implemented. Review of Resident #383's nursing progress note dated [DATE] at 1:20 P.M. revealed, Resident expired at 1:20 P.M. was released to funeral home at 3:25 P.M. Review of Resident #383's code status form dated [DATE] revealed a physician signed form indicating Resident #383's desired to be a Do Not Resuscitate-Comfort Care (DNRCC). Interview on [DATE] at 4:00 P.M. with the Director of Nursing (DON) and the Regional Director of Clinical Operations #77 confirmed Resident #383's medical record did not accurately reflect Resident #383's DNRCC code status. 2. Review of Resident #20's medical record revealed she was admitted on [DATE] with diagnoses that include: non displaced fracture of the right femur, cerebral palsy, paraplegia, contracture of left ankle, contracture of muscle multiple sites, postsurgical malabsorption, edema, anxiety disorder, disorder of psychological development, epilepsy, and constipation. Review of Resident #20's annual Minimum Data Set (MDS) dated [DATE] revealed the following. Resident #20 had no swallowing problems, was 60 inches tall, weighed 118 pounds, had no significant weight changes, and received 51% or more of calories and fluid intake via a tube feeding. Review of Resident # 20's physician orders dated [DATE] enteral feeding order (Jevity 1.5) with fiber, 8 ounce carton, administer with syringe at 4:00 A.M., 10:00 A. M., 4:00 P.M., and 10:00 P.M. to total 1200 milliliters (ml) of formula. Review of Resident #20's [DATE] physician orders signed [DATE] revealed the following enteral feeding orders. A bolus tube feeding six times daily was ordered, as well as total tube feeding solution each shift 720 ml, and Jevity 1.5 ml to run at 70 cubic centimeters (cc) at noon daily. Review of Resident #20's medication administration record (MAR) revealed a continuous enteral feeding of Jevity 1.5 at 70 cc per hour (cc/hr) from 11:00 A.M. to 6:00 A.M. Review of Resident #20's nutrition assessment dated [DATE] revealed Resident #20 received Jevity 1.5, 300 ml four times a day. There was no nutritional assessment reflecting the 19 hours of continuous feeding. Observation of Resident #20 on [DATE] at 8:05 A.M. revealed Resident #20 was in bed on her back and the enteral feeding was turned off. Observation of Resident #20's enteral feeding at 11:20 A.M. revealed it was administered by a pump at 70 ml/hr Interview of Registered Nurse (RN) #12 on [DATE] at 2:27 P.M. revealed Resident # 20 received a tube feeding from 11:00 A.M. to 6:00 A.M. administered at 70 ml/hr. Interview of the Director of Nursing (DON) on [DATE] at 3:25 P.M. revealed the [DATE] enteral feeding orders were Resident #20's feeding orders when she was in the hospital and were not to be implemented in the facility. The DON confirmed the Resident #20's medical record did not contain the accurate enteral feeding order. This deficiency substantiates Master Complaint Number OH00114643.

CONCERN (E)

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

Resident Rights (Tag F0550)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review for Resident #26 revealed this resident was admitted to the facility on [DATE] with diagnoses including non-displaced transverse fracture of right fibula, falls, muscle weakness, urinary tract infection, anxiety, morbid obesity, chronic pain, acute kidney failure, hypertension, bimalleolar fracture, and hyperlipidemia. This resident had no known drug allergies. Review of Resident #26's quarterly Minimum Data Set (MDS) assessment, dated 11/19/21, revealed this resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 15. Resident #26 was admitted to the facility with a diagnosis of bilateral leg fractures and is currently in bed with a urinary catheter in place. Review of Resident #26's Physician Orders revealed an order was obtained on 11/03/21 for a urinary catheter due to recent acute kidney failure, resident request, and immobility. Order was obtained for 16 French urinary catheter with 10 ml balloon. Resident was explained risks and benefits. Review of Resident #26's care plan from 11/03/21 revealed catheter kept in place, catheter care each shift and change catheter tubing monthly. Observation of Resident #26 on 11/29/21 at 11:45 A.M. revealed this resident has a urinary catheter draining to a catheter bag that is not currently covered by a dignity bag. Interview with the DON and observation of Resident #26 on 11/29/21 at 11:50 A.M. verified this resident does not have a dignity bag in place as the facility does not have any in stock. Interview with Resident #26 on 11/29/21 at 12:00 P.M. revealed this resident stated it is a little embarrassing without having something to cover her catheter bag, as it can be seen from the hallway. Based on observation, resident interview, staff interview, medical record review, and policy review the facility failed to ensure residents were treated with dignity and respect regarding covering urinary catheter drainage bags and engaging with residents during meal time. This affected four of 22 sampled residents (Resident #7, Resident #24, Resident #26, and Resident #29). Findings include: 1. Review of Resident #24's significant change Minimum Data Set (MDS) dated [DATE] revealed the following. Resident #24's speech was clear, she rarely understood, rarely understands, she had short-term and long-term memory problems, no recall and her decision making was severely impaired. Resident #24 had no behaviors, she rejected care one to three days. Resident #24 was dependent on two staff for bed mobility, required extensive assistance of two staff to transfer, and dependent on one staff to eat, Observation of the common area by the nurses station on 11/21/21 at 11:36 A.M. revealed Resident #26 and Resident #29 were seated at the same table. Resident #26 was seated in a reclined specialized chair (Broda chair). At 11:54 A.M. Resident #29 was served her meal tray, Resident #24's tray was delivered at 11:47 A.M., but State Tested Nursing Assistant (STNA) #16 did not begin feeding Resident #26 until 12:00 P.M. STNA #16 did not talk with Resident #26 and was watching the television as she fed Resident #26. Resident #26 finished eating at 12:15 P.M., STNA #16 did not engage with Resident #26 during the time she fed her. Observation of Resident #26 on 11/23/21 at 8:06 A.M. revealed she was in a Broda chair that was laid back in a common area and STNA #18 was feeding Resident # 24. STNA #18 was standing next to Resident #26's feeding her and STNA #18 was talking with Resident #29. Observation of Resident #26 on 11/30/21 at 7:43 A.M. revealed Resident #26 was in bed and STNA #18 was feeding Resident #26. STNA #18 was standing next to Resident #26's bed holding a bowl of food feeding her. Resident #26's tray was placed in Resident #26's recliner chair, there was no overbed table in or chair in the room for STNA #18 to use. Interview of STNA #18 on 11/30/21 at 7:43 A.M. confirmed she was standing to feed Resident #26 and she should be seated, but there was no overbed table to put Resident #26's tray on and no chair for her to sit to fed her. STNA #18 stated she did not have time to find an over bed table and chair. Interview of the Director of Nursing (DON) on 12/01/21 at 2:30 P.M. confirmed staff should talk with the resident they were feeding and should be seated not stand over the resident they fed. Review of the facility's Quality of Life - Dignity policy dated April 2009 revealed residents would be treated with dignity and respect at all times. 2. Review of Resident #29's medical record revealed she was admitted on [DATE] with diagnoses that included: Alzheimer's disease, osteoarthritis, muscle weakness, difficult ambulation, COVID-19, irritable bowel syndrome, diabetes mellitis type II, depression, congestive heart failure, anxiety, dementia, urinary tract infection, anxiety, and hypertension. Review of Resident #29's quarterly MDS dated [DATE] revealed Resident #29's speech was clear sometimes she understands other, sometimes she was understood, and her cognition was severely impaired. Resident #29 required supervision with set-up help for bed mobility, to transfer, and to eat. Review of Resident #7's medical record reviewed she was admitted on [DATE] with diagnoses that included: pulmonary fibrosis, falls, dementia, and gastro-esophageal reflux disease. Review of Resident #7's quarterly MDS dated [DATE] revealed the following. Resident #7's speech was clear, she understands others, was understood, and her cognition was moderately impaired. Resident #7 did not reject care and she required extensive assistance of one staff for bed mobility to transfer and required supervision with set-up assistance to eat. Observation of the lunch meal on 12/01/2021 at 11:31 A.M. revealed Resident #7 and Resident #29 were seated at a table with two other residents who had received their meal trays and were eating. Resident #7 was served at 11:30 A.M. and Resident #29 was served her meal at 11:39 A M. Interview of the Director of Nursing (DON) on 12/01/21 at 2:30 P.M. confirmed resident's seated at the same table should be served at the same or very close time. Review of the facility's Quality of Life - Dignity policy dated April 2009 revealed residents would be treated with dignity and respect at all times.

CONCERN (E)

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

Deficiency F0567 (Tag F0567)

Could have caused harm · This affected multiple residents

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Based on record review and interview the facility failed to ensure Witnessed Authorization Forms were completed and available for residents whose personal funds were being managed by the facility. This affected two (Resident #4, and #5) of the four residents reviewed for personal funds. The facility census was 34. Findings include: Review of the resident personal funds account record for Resident #4 revealed the facility was managing a personal funds account for Resident #4, and failed to have a Witnessed Authorization Form on record for personal funds to be managed by the facility. Review of the resident personal funds account record for Resident #5 revealed the facility was managing a personal funds account for Resident #5, and failed to have a Witnessed Authorization Form on record for personal funds to be managed by the facility. Interview on 11/29/21 at 11:30 A.M. with Business Office Manager #76 confirmed Resident #4, and #5 did not have a Witnessed Authorization Form on record.

CONCERN (E)

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

Deficiency F0568 (Tag F0568)

Could have caused harm · This affected multiple residents

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Based on record review and interview the facility failed to provide receipts and/or book keeping records for all personal account activity. This affected three (Resident #4, #5, and #11) of the (4) four residents reviewed for personal funds. The facility census was 34. Findings include: Review of the resident personal funds revealed the facility failed to keep or provide records and/or receipts for purchases or withdrawals from resident personal funds accounts for Resident #4, #5, and #11 who were noted to have personal funds being managed by the facility. Interview on 11/29/21 at 11:30 A.M. with Business Office Manager #76 confirmed she was not able to locate any receipts for any purchases or cash withdrawals for Resident #4, #5, and #11.

CONCERN (E)

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

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

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Based on observation, resident interview, group resident interview, staff interview, and policy review the facility failed to provide an adequate dining space that was clean, comfortable, and homelike. This affected 11 residents who routinely ate in the common area by the nurses station (Resident #6, Resident #8, Resident #18, Resident #23, Resident #31, Resident #24, Resident #29, Resident #13, Resident #7, Resident #3, and Resident #26) and one resident ( Resident #12) who was observed eating in the common area. The facility census was 34 residents. Findings include: Observation on 11/21/21 at 8:15 A.M. revealed a large dining room with the doors closed. The room was brightly lit, had seven tables of differing sizes, and other dining room furnishings (sideboards, china cabinets, etc.). At the time of the observation, Dietary Manager (DM) #11 confirmed it was the resident dining room, but it was closed to the residents and she did not know why. DM #11 revealed the residents had not used the dining room since June 2021. Observation on 11/21/21 at 11:49 A.M. revealed residents eating in a common area by the nurses station. The area was furnished with a variety of chairs, a small round table and three over bed tables. The floor carpet was dirty and stained. The area was not a homelike environment. Resident #7, Resident #24, Resident #29, and Resident #18 were seated around the small table, when meal trays were served starting at 11:50 A.M. Resident #24 was moved back from the table to make room for Resident #7, Resident #29, and Resident #18's meal trays. Resident #18 stated the table was small and it was difficult for them to eat together. Residents eating in this area were less than six feet apart. A resident group meeting was held on 11/22/21 at 9:02 A.M. with Resident #18, Resident #31, Resident #23, Resident #28, and Resident #29 revealed they want to return to eating meals in the dining room. Interview of the Administrator on 11/30/21 at 7:20 A.M. revealed they were in outbreak status since last week due to one staff positive for COVID-19. The Administrator stated she was unclear about residents using the dining room. The Administrator stated the recommendations change all the time it was not clear if the residents could eat in the dining room. The Administrator stated residents have used it for Resident Council meetings. The Administrator confirmed the dining room was larger and better suited for social distancing of six feet between residents. The Administrator could not explain why residents could share a communal meal in the smaller space by the nurses station and were not permitted to share a communal meal in the designated dining room. Observation at lunch meal on 12/01/21 at 11:31 A.M. revealed three residents ( Resident #6, Resident #7, and Resident #29) , seated in wheel chairs at a small round table in the common area by the nurses station. Resident #29 stated the table was not large enough for them all to eat especially when Resident #18 returned from having her blood sugar checked. The table was not large enough to accommodate four meal trays. At 11:32 A.M. Resident #18 returned to the common area seated in a wheel chair. For Resident #18 to wheel herself to the small dining table Resident #8, who was in a wheel chair, had to be moved by staff. Resident #18 was not able to get around Resident #8. In the common area Resident #6, Resident #31, Resident #24, Resident #13, Resident #3, and Resident #12 were also in the common area. The facility identified Resident #6, Resident #8, Resident #18, Resident #31, Resident #24, Resident #29, Resident #13, Resident #7, Resident #3, and Resident #26 routinely ate in the dining room. The annual survey was conducted from 11/21/2021 to 12/01/2021 and no residents ate in the dining room.

CONCERN (E)

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

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide a therapeutic diet for three residents, (Residents #6, #12 and #30,) and accurately monitor weights for one resident (Resident #24), as ordered by the physician for 21 residents reviewed for nutritional status. The facility census was 34. Findings include: 1. Review of the medical record and face sheet revealed Resident #30 was admitted to the facility on [DATE] with the diagnoses of chronic obstructive pulmonary disease, (COPD), dementia, SOB, gastritis, peripheral vascular disease, depressive disorder, nausea, reflux disease, fatigue, and muscle weakness. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #30 was moderately cognitively impaired, received a mechanically altered diet, was edentulous without pain., and had no depression. Review of plan of care updated on 09/15/21, addressed Resident #30's nutritional risk due to dementia, COPD, and edentulous assessment. Interventions included provide food preferences, Registered Dietitian., (RD) to evaluate and make diet changes, dental consult as needed, keep snacks in room, resident prefers sweet snack foods, and fortified food program started 03/09/20. Review of November 2021 physician orders revealed diet order of dysphagia advanced texture, fortified meals, thin liquids, and nutritional health shake three times daily with meals. Review of RD #78's quarterly progress notes dated 10/19/21 revealed Resident #30 was to receive a dysphagia advanced texture diet with fortified foods and health shake supplement three times a day. Resident #30 meal intake was 50 to 75 %. Review of weight records revealed weights of 107 pounds on 04/08/21, 108 pounds on 05/03/21, 108 pounds on 06/01/21, 105 pounds on 07/05/21, 102 pounds on 08/02/21, 105 pounds on 09/16/21, 104 pounds on 10/07/21 and 99 pounds on 12/01/21. Resident #30 was 5 foot 11 inches tall. Review of nutritional laboratory value dated 07/01/21 revealed a slightly depleted protein value of 2.9, below normal value of 3.2 Review of Resident #30's breakfast, lunch and dinner meal tray cards listed dysphagia advanced texture diet with fortified foods, health shake at each meal, sweets at breakfast and two desserts at lunch and dinner. Resident #30's meals were observed on 11/23/21 at 7:40 A.M. breakfast, no health shake and no additional sweets were provided. On 11/29/21 at 11:55 A.M. at lunch meal, no health shake and no additional desserts were provided. State Tested Nurse Aide, (STNA) #18 verified no health shake was provided on 11/23/21 at breakfast. Resident #30 was interviewed on 11/23/21 at 7:40 A.M. He stated he liked the health shakes when he receives them. The Dietary Manager, (DM), #11 was interviewed on 11/30/21 at 10:24 A.M. and revealed she was unaware Resident #30 physician diet order included fortified foods and additional sweets at breakfast and additional desserts at lunch and supper. DM #11 further stated Resident #30 foods had not been prepared and served as fortified. DM #11 verified Resident #30 did not receive additional foods, as listed on the tray card, for meals served on 11/21/21 through 11/30/21. Review of facility policy titled Fortified Food Program undated, revealed the facility failed to implement the policy. 2 . Review of the medical record and face sheet revealed Resident #6 was admitted to the facility on [DATE] with a diagnosis of dementia, muscle weakness, unsteadiness on feet, hypertension, history of falls, and anxiety disorder. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #6 had moderately impaired cognition. Review of plan of care updated on 09/15/21, addressed Resident #6 nutritional risk for imbalanced nutrition due to varied intake and dementia diagnosis. Intervention, dated 05/11/21 , included ice cream added to lunch and dinner meal. Review of November 2021 physician orders revealed diet order of Regular diet with ice cream at lunch and dinner. Review of Resident #6's breakfast, lunch and dinner meal tray cards listed Regular diet with ice cream at lunch and dinner meals. Observation of lunch meals 11/23/21, 11/29/21 and 11/30/21 revealed no ice cream on Resident #6's meal tray. Observation of dinner meal on 11/29/21 at 5:41 P.M. revealed no ice cream on dinner meal tray. Interview on 11/29/21 at 5:41 P.M., Resident #6 stated she liked ice cream. The Diet Manager , (DM), #11 was interviewed on 11/30/21 at 10:24 A.M. and revealed she was unaware Resident #6's physician diet order included ice cream at lunch and supper. DM #11 verified Resident #6 did not receive ice cream as listed on the tray card, for lunch and dinner meals served on 11/21/21 through 11/30/21. 3. Record review for Resident #12 revealed this resident was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, hypertension, tremors, anxiety, depression, hypothyroidism, and malignant neoplasm of the breast. This resident had no known allergies. Review of the admission MDS assessment, dated 10/05/21, revealed this resident had moderately impaired cognition evidenced by a BIMS assessment score of 06. This resident was assessed to require extensive assistance from two staff members for bed mobility, transfers, and toileting, and set-up assistance with supervision for eating. This resident was assessed to be 64 inches tall and weigh 189 pounds. Review of the care plan, dated 10/11/21, revealed this resident had imbalanced nutrition. Interventions included to assist with feeding as needed and weigh per facility protocol. Review of the Hospice Initial Visit note, dated 09/12/21, revealed Resident #12 had a documented weight of 148.0 pounds. Review of the facility Vital Signs and Weight Record for Resident #12 revealed the resident's documented weight on 09/29/21 was 189 pounds, 189 pounds on 10/05/21, 186.2 pounds on 10/12/21, 187 pounds on 10/19/21, and 173 pounds on 11/23/21 with a recorded wheelchair weight of 35.4 pounds on 11/23/21. Review of the dietician progress note, dated 10/07/21, revealed Resident #12 was documented as weighing 189.4 pounds which put the residents Body Mass Index (BMI) at 32.5, indicating class one obesity. Interview with the Director of Nursing (DON) on 11/29/21 at 10:40 A.M. revealed the weight documented on the Hospice Initial Visit Note dated 09/12/21 was correct and the weights recorded by the facility on 09/29/21, 10/05/21, 10/12/21, and 10/19/21 were not documented accurately as they did not reflect the weight of the resident's wheelchair being subtracted. The DON verified the assessment completed by the Registered Dietician on 10/07/21 was also inaccurate due to the inaccurate documentation of Resident #12's weight by facility staff. The DON verified the MDS assessment completed on 10/05/21 was inaccurate as it listed the resident's weight as 189 pounds. Review of the facility policy titled Weighing and Measuring the Resident, revised 03/2011, revealed staff were to note and record the resident's weight and were to subtract the weight of the wheelchair prior to documenting the weight. 4. Review of Resident #24's medical record revealed she was admitted on [DATE] with diagnoses that included: seizures, dementia, diabetes, hypertension, schizoaffective disorder (10/26/21). Review of Resident #24's weights revealed on admission she weighed 188.4 pounds, on 08/09/21 she weighed 173 pounds, on 09/06/21 171 pounds, on 10/04/21 she weighed 152 pounds. Resident #24 was diagnosed with COVID-19 and sent to another facility on 09/09/21 and returned on 10/01/21. Review of Resident #24's significant change Minimum Data Set (MDS) dated [DATE] revealed the following. Resident #24's speech was clear, rarely understood, rarely understands, she had short-term and long-term memory problems, no recall and her decision making was severely impaired. Resident #24 had no behaviors, she rejected care one to three days. Resident #24 was dependent on two staff for bed mobility, required extensive assistance of two staff to transfer, and was dependent on one staff to eat. Resident #24 had no swallowing problems, was 62 inches tall, 152 pounds, had no weight loss, and was on hospice. Review of Resident #24's physician orders revealed a pureed diet and a liquid nutritional supplement (mighty shake) at each meal. On 11/28/21 Resident #24's diet was changed to a regular diet. Observation on 11/21/21 at 11:52 A.M. of Resident #24's lunch meal revealed she received mashed potatoes, pureed meat, pureed vegetable, and pureed fruit. There was no mighty shake on her tray. Observation of Resident #24's breakfast meal on 11/23/21 at 8:06 A.M. revealed she did not receive a mighty shake. Observation of Resident #24's breakfast tray on 11/30/21 at 7:43 A.M. revealed she did not receive a might shake. Interview of State Tested Nursing Assistant (STNA) #18 on 11/30/21 at 7:48 A.M. confirmed Resident #24 did not have mighty shake on her tray and did not receive one. Interview of Dietary Account Manager (DAM) #11 on 11/30/21 at 8:40 A.M. confirmed Resident #24 did not receive mighty shakes on her tray or from the kitchen. DAM #11 stated she was told since Resident # 24 was on hospice, hospice not the kitchen provided mighty shakes to the resident. Interview of Licensed Practical Nurse (LPN) #32 on 11/30/21 at 9:00 A.M. revealed the kitchen provided the mighty shake not nursing and nursing did not have mighty shakes in the medication refrigerator.

CONCERN (E)

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

Respiratory Care (Tag F0695)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of the medical record and face sheet revealed Resident #30 was admitted to the facility on [DATE] with the diagnosis of chronic obstructive pulmonary disease, (COPD), dementia, SOB, gastritis, peripheral vascular disease, depressive disorder, nausea, reflux disease, fatigue, and muscle weakness. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #30 was moderately cognitively impaired, and received oxygen per nasal cannula as needed. Review of plan of care updated on 09/15/21, addressed Resident #30 respiratory risk due to dementia, and COPD. Interventions included provide oxygen per nasal cannula as needed. Review of November 2021 physician orders revealed order of oxygen two liters per nasal cannula as needed to maintain 90% oxygen saturation. Change oxygen tubing every Sunday. Observation on 11/21/21 at 10:00 A.M. revealed oxygen tubing dated 11/12/21. Based on observation, interviews, and record reviews, the facility failed to obtain or implement physicians orders for oxygen therapy and failed to change tubing as ordered by the physician. This affected four residents (#12, #14,#24 and #30) of the five residents reviewed for respiratory services. The facility census was 34. Findings include: 1. Record review for Resident #12 revealed this resident was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, hypertension, depression, tremor, and hypothyroidism. This resident had no known allergies. Review of the admission Minimum Data Set (MDS) assessment, dated 10/05/21, revealed this resident had moderately impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 06. This resident was assessed to require extensive assistance from two staff members for bed mobility, transfers, and toileting and set-up help with supervision for eating. Review of the care plan, dated 10/11/21, revealed this resident had the potential for an ineffective breathing pattern. Interventions included to administer oxygen as ordered. Review of the active physicians orders, signed on 11/11/21 by the physician, revealed an order to administer oxygen by nasal cannula at two liters per minute by nasal cannula. Review of the Medication Administration Record (MAR) for 11/2021 revealed documentation oxygen had been administered by nasal cannula to Resident #12 from 11/01/21 through 11/22/21. Observation on 11/21/21 at 9:45 A.M. revealed Resident #12 was lying in bed with no oxygen being administered and no oxygen concentrator available in the room. Observation on 11/22/21 at 8:07 A.M. revealed Resident #12 was lying in bed with no oxygen being administered and no oxygen concentrator available in the room. Observation on 11/22/21 at 3:41 P.M. revealed Resident #12 was lying in bed with no oxygen being administered and no oxygen concentrator available in the room. Interview with Licensed Practical Nurse (LPN) #36 on 11/22/21 at 3:45 P.M. verified there was not an oxygen concentrator located in the room of Resident #12 and the resident was not receiving oxygen therapy. LPN #36 then verified Resident #12 had active physicians orders for oxygen to be delivered at two liters per minute which was documented as being administered on the MAR for 11/2021 every shift by licensed nurses employed at the facility. 2. Record review for Resident #14 revealed this resident was admitted to the facility on [DATE] with diagnoses including sepsis, difficulty walking, bipolar disorder, hypertension, and shortness of breath. Review of the quarterly Minimum Data Set (MDS) assessment, dated 09/30/21, revealed this resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 15. This resident was assessed to require set up assistance and supervision for bed mobility, transfers, and toileting. Review of the care plan, dated 07/14/20, revealed this resident had the potential for ineffective breathing patterns. Interventions included oxygen as ordered as needed. Review of the active physicians orders, signed by the physician on 11/11/21, revealed an absence of an order for oxygen administration for Resident #14. Review of the MAR for 11/2021 revealed an absence of documentation of oxygen administration to Resident #14. Observation on 11/21/21 at 12:09 P.M. revealed Resident #14 was lying in bed and had oxygen being administered by nasal cannula at a rate of two point five liters per minute. Observation on 11/29/21 at 3:53 P.M. revealed Resident #14 was lying in bed and had oxygen being administered by nasal cannula at a rate of two point five liters per minute. Interview with LPN #88 on 11/29/21 at 3:53 P.M. verified Resident #14 had oxygen being administered by nasal cannula at a rate of two point five liters per minute. LPN #88 verified Resident #14 did not have an order for oxygen administration or documentation of oxygen administration on the MAR. 3. Review of Resident #24's medical record revealed she was admitted on [DATE] with diagnoses that included: seizures, dementia, diabetes, hypertension, schizoaffective disorder (10/26/2021). Review of Resident #24's significant change Minimum Data Set (MDS) dated [DATE] revealed the following. Resident #24 used oxygen and on hospice. Review of Resident #24's monthly physician orders for November 2021 revealed oxygen at two liters per minute as needed for dyspnea and to change the oxygen tubing every week and as needed. Review of Resident #24's treatment administration record for November 2021 revealed oxygen ordered at two liters for per minute and to change the tubing every week. There was no evidence Resident #24's oxygen tubing was changed. Observation on 11/21/21 at 9:48 A.M. of Resident #24's room revealed an oxygen concentrator with tubing next to Resident #24's bed. The tubing attached to the concentrator was not dated. Observation of Resident #24's oxygen concentrator on 11/29/21 at 10:00 A.M. revealed the tubing on Resident #24's oxygen concentration was dated 11/21/21. Interview of the Director of Nursing (DON) on 11/29/21 at 10:15 A.M. confirmed Resident #24's oxygen tubing was dated 11/21/21 and was supposed to be changed on 11/28/21.

CONCERN (E)

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

Deficiency F0947 (Tag F0947)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and personnel file review, the facility failed to ensure direct care staff were provided dementia education. This affected one resident (Resident #24) of 11 residents with a dementia diagnosis. The facility census was 34. Findings include: Review of Resident # 24's medical record revealed she was admitted on [DATE] with diagnoses that included: seizures, dementia, diabetes, hypertension, schizoaffective disorder. Review of Resident #24's significant change Minimum Data Set (MDS) dated [DATE] revealed the following. Resident #24 had short-term and long-term memory problems, no recall and her decision making was severely impaired. Resident #24 had no behaviors, she rejected care one to three days. Resident #24 was dependent on two staff for bed mobility, required extensive assistance of two staff to transfer, did not walk, no locomotion, required extensive assistance of two staff for dressing, was dependent on one staff to eat, for toilet use, and required extensive assistance of one staff for personal hygiene. Resident #24 was dependent on two staff for showering and had no limitations in range of motion. Observation on 11/23/21 at 8:06 A.M. revealed Resident #24 received staff assistance for meal time while staff was noted standing, and not talking or interacting with Resident #24. Observation on 11/29/21 at 7:42 A.M. of Resident #24 revealed her sitting in a geri chair in the common area. Continued observation at 8:30 A.M. revealed Resident #24 continued to sit in the common area, no activity noted, no television, music, or staff in the area Interview 11/29/21 12:46 P.M. with Licensed Practical Nurse (LPN) #32 revealed Resident #24 does not experience or display behaviors. Resident #24 does not have delusions and does not have a mental illness they like to say she does. Resident #24 gets her words mixed up but that is dementia. Interview on 11/30/21 at 8:30 A.M. with State Tested Nursing Assistant (STNA) #32 revealed the facility had not provided staff with dementia education or training. Review of direct care staff personnel files for eight staff members revealed no evidence of staff receiving education and training related to dementia. Interview on 11/29/21 at 12:30 P.M. with the Administrator confirmed staff had not received dementia education or training.

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

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Based on staff interview, review of time punch cards, and review of direct care staff schedule revealed the facility failed to ensure the facility had Registered Nurse (RN) coverage for a consecutive eight hours. This had the potential to affect all 34 residents. Findings include: Review of the nursing staff schedule from 11/01/21 through 11/30/21 revealed the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) were scheduled on 11/25/21 day shift. Review of the time punch cards for the DON revealed zero accumulated hours for 11/25/21. Review of the time punch for the ADON revealed zero accumulated hours for 11/25/21. Interview on 12/01/21 at 3:00 P.M. with the Administrator and the Regional Director of Clinical Operations #77 confirmed there was no RN coverage for the facility on 11/25/21.

CONCERN (F)

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

Deficiency F0804 (Tag F0804)

Could have caused harm · This affected most or all residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review for Resident #22 revealed this resident was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, congestive heart failure, acute and chronic respiratory failure, difficult ambulation, parainfluenza, muscle weakness, lack of coordination, myocardial infarction, fatigue, shortness of breath, hypertension, anxiety, depression, asthma, fluid aspiration, diabetes mellitis type II, and hypertension. This resident had allergies to Ibuprofen, Levofloxicin, Zosyn, Vancomycin, Amytriptylline, Baclofen, Tramadol, and Effexor. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/13/21, revealed this resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 15. Interview with Resident #22 on 11/21/21 at 10:53 A.M. revealed the facility does not provide hot food substitutions, and you have to ask for them. 3. Record review for Resident #26 revealed this resident was admitted to the facility on [DATE] with diagnoses including non-displaced transverse fracture of right fibula, falls, muscle weakness, urinary tract infection, anxiety, morbid obesity, chronic pain, acute kidney failure, hypertension, bimalleolar fracture, and hyperlipidemia. This resident had no known drug allergies. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/19/21, revealed this resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 15. Interview with Resident #26 on 11/21/21 at 9:40 A.M. revealed the resident stated that some of the food is not very good, and is sometimes cold. This deficiency substantiates Master Complaint Number OH00114643. Based on resident interviews, group resident interview, review of Resident Council Meeting Minutes, and a test tray the facility failed to serve food that was palatable and at an acceptable temperature. This had the potential to affect 33 of 34 resident (Resident #15 receives nothing from the kitchen) and specifically affected Residents #26, #10, #22, #15, #18, #23, #26, #28, #29, and #31. Findings include: 1. Review of Resident Council meeting minutes revealed on 8/27/21 complaints of cold food, it was not the best food and the food was either over or under cooked. The 09/15/21 resident council minutes revealed the food was cold, the food tasted bad, the broccoli and cauliflower were overcooked, and served in big pieces. Interview of Resident #26 on 11/21/21 at 9:40 A.M. revealed sometimes the hot foods were served cold and were not good. Interview of Resident #10 on 11/21/21 10:30 A.M. revealed hot foods were served cold. Interview with Resident #22 on 11/21/21 at 10:53 A.M. revealed food was not served hot. Interview of Resident #15 on 11/21/21 at 2:35 P.M. revealed sometimes the hot food was not hot. A resident group meeting was held on 11/22/21 at 9:30 A.M. with Resident #18, #23, #28, #29, and #31 stated the hot foods were served cold and it did not taste good. A test tray was requested on 11/29/21. The cart containing the test tray arrived on the unit at 12:05 P.M. The last tray was delivered at 12:25 P.M. At 12:27 P.M. the following temperatures of the food items were obtained. The cheese pizza was 94 degrees Fahrenheit (F) it was cold to the taste, the cheese on the pizza was light brown, the sauce was absorbed by the crust, and the crust was tough and very dry. The green beans were 102 degrees F and cool to taste. The test tray was sampled by two surveyors.

CONCERN (F)

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

Deficiency F0806 (Tag F0806)

Could have caused harm · This affected most or all residents

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Based on observation, resident interview, resident group interview, resident council meeting minutes, and staff interview the facility failed to ensure accommodation of resident food preferences and failed to offer a food substitute when a resident did not like the food served. This affected 33 of 34 residents (except Resident #15 who received nothing from the kitchen) and specifically affected Residents #7, #18, #23, #28, #29, #30, and #31 . Findings include: Review of Resident Council meeting minutes revealed on 09/15/21 resident council minutes revealed staff never asked the resident's food preferences. The residents stated they never served what is on the menu, and the residents did not have a copy of the menu to ask for a substitution. Observation on 11/21/21 at 12:12 P. M. revealed Resident #18 did not eat her soup and State Tested Nursing Assistant (STNA) #16 did not offer Resident #18 a substitute for the food she did not like. Resident #31 did not eat her chips, sandwich, or fruit and ate 50% of her soup. STNA #16 did not offer Resident #31 an alternate for the food items she did not eat Resident #29 did not eat her soup, or her fruit, she at 50 % of her sandwich, and a few chips. STNA #16 did not offer Resident #29 food substitutes for the items she did not eat. Resident #30 was served his meal tray and refused it. STNA #21 told STNA #16 that Resident #30 refused his meal. STNA #16 told STNA #21 she had to ask Resident #30 if he wanted a substitute because he would not ask for one. A resident group meeting was held on 11/22/21 at 9:30 A.M. with Residents #18, #23, #28, #29, and #31 stated they were not offered food substitutes. Observation of Resident #12's breakfast meal on 12/01/21 at 7:56 A.M. revealed Resident #12 ate 10 % of her eggs, 25% of her toast, 0% cooked cereal and 0% of her milk. Interview of STNA #66 revealed she did not offer Resident #12 a replacement meal as the resident was not a big eater. Observation at lunch revealed 12/01/21 at 11:38 A.M. Resident #7 refused her meat and rice and Resident #29 refused her steak, rice, and cooked spinach. STNA #21 did not offer Resident #7 or Resident #29 alternate food for the food items refused. Interview of the Director of Nursing (DON) on 12/01/2021 at 11:40 A.M. confirmed staff should ask residents if they wanted food substitutions.

CONCERN (F)

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

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

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Based on observation, interview and record review, the facility failed to maintain a sanitary kitchen and ensure safe storage of foods served to residents. This had the potential to affect 33 of the 34 residents (Resident #15 does not receive nutrition from the facility kitchen) and specifically affected Residents #29 and #30. Facility census was 34. Findings include: The kitchen was observed on 11/21/21 at 8:20 A.M. with food debris noted on the bottom shelf of the reach in freezer. The hand washing station had missing cove base, missing and loose caulking seal around the sink and a wall gouge measuring eight inches by 10 inches long. At the time of the observation, Diet Manager, (DM )#11 verified the findings and verified the surfaces were unable to be cleaned and sanitized. Observation on 11/29/21 at 10:45 A.M. of the kitchen revealed the wall behind the stove had green drippings which had a greasy consistency when touched. Observation on 11/29/21 at 11:45 A.M. during preparation of puree foods by [NAME] #15, the attic entry door in the ceiling above the food preparation area had condensation of a clear fluid which dripped onto the food preparation area. [NAME] #15 was observed to touch her face with gloved hands during puree food preparation. DM #11 was observed to send soiled puree blender canister though dishwasher without changing gloves after blender canister was cleaned. At the time of the observation, Dietary Manager , (DM )#11 verified the observations. Observation on 11/29/21 at 11:45 A.M. of the ceiling above the dish machine revealed an unwashable surface and separation of the ceiling wall board resulting in a hole of two foot in length by one half inch wide. At the end of the dish machine clean dish rack, the wall had peeling paint which had fallen on the clean dish rack. At the time of the observation, Dietary Manager, (DM )#11 verified the observations. Observation on 11/29/21 at 11:55 A.M. revealed the four bulb ceiling fixture had no cover or light bulb tube covers above the tray line where food was open and being served onto trays for residents. At the time of the observation, Dietary Manager , (DM )#11 verified the observations. Observation on 11/21/21 and 11/30/21 revealed Resident #30 and Resident #29 had personal refrigerators in their rooms. Observation of Resident #30 and Resident #29 personal refrigerators revealed they had incomplete temperature monitoring logs for November 2021. Resident #29 did not have a thermometer inside her refrigerator. There was an eight ounce carton of milk with expiration date 11/12/21 , and a cottage cheese container with expiration date of 11/15/21. Observation on 11/30/21 at 9:15 A.M. of resident refrigerator, used for food storage by nurses and resident visitors, revealed no thermometer monitoring log, open liter of pop without name and no open date, thicken liquid dated 10/22/21, liquid creamer no open date and no name, ketchup bottle with no open date, frozen meal with no name listed, and an open bag of dry cereal dated 10/15/21 with no name. At the time of the observation, State Tested Nurse Aide, (STNA) #18 , verified the findings. The Dietary Manager, (DM )#11 was interviewed on 11/29/21 at 5:11 P. M and revealed work orders for the hand washing sink and light fixture had been submitted to the Maintenance Director #56 on 11/09/21 and no work had been completed. DM #11 revealed the policy for thickened juice disposal date is 10 days after the date marked on the container and foods stored in the refrigerator should be discarded after seven days or on or before expiration date. Interview on 11/30/21 at 3:25 P.M. with Maintenance Director #56 stated the nurses are responsible to monitor and document the resident refrigerator temperature onto monitoring sheets, and the STNA s are responsible to clean out resident refrigerators for expired or unlabeled foods. Review of policy titled, Food Preparation , dated September 2017, and Safe Handling for Foods from Visitors ,dated September 2017 verified the facility failed to follow the policies for food storage and sanitation. This deficiency substantiates Complaint Number OH00114643.

CONCERN (F)

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

Infection Control (Tag F0880)

Could have caused harm · This affected most or all residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, policy review, and review of Centers for Disease Control information, and record reviews, the facility failed to implement transmission based precautions to prevent the spread of COVID-19. This had the potential to affect the 34 residents residing in the facility and specifically affected Resident #135. The facility census was 34. Findings include: Record review for Resident #135 revealed this resident was admitted to the facility on [DATE] with diagnoses including cerebral infarction, dysphagia, restlessness and agitation, and history of falls. This resident had no known allergies. Review of the admission Minimum Data Set (MDS) assessment, dated 11/22/21, revealed this resident had severely impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 04. This resident was assessed to require extensive assistance from two staff members for bed mobility and transfers and extensive assistance from one staff member for toileting. Review of the physicians orders for Resident #135 revealed an absence of an order to be placed on transmission based precautions. Observation on 11/21/21 at 8:35 A.M. revealed no residents, including Resident #135, were currently on transmission based precautions for suspected or confirmed COVID-19. Interview on 11/21/21 at 8:37 A.M. with Licensed Practical Nurse (LPN) #88 verified the facility did not have any residents on transmission based precautions for COVID-19. Interview with the Director of Nursing (DON) on 11/30/21 at 9:33 A.M. verified Resident #135 did not have a physician order to be placed on transmission based precautions and was not fully vaccinated against COVID-19. The DON verified the facility policy was to place newly admitted , unvaccinated residents on isolation precautions for 14 days to prevent the spread of COVID-19. Review of the facility policy titled Piketon Nursing Center COVID-19 Policy and Procedure, updated on 08/30/21, revealed newly admitted or readmitted residents would be encouraged to self isolate in a room for a minimum of 14 days. Review of the Centers for Disease and Control (CDC) guidance, titled CDC Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes & Long-Term Care Facilities, updated 09/10/21, revealed if no additional cases are identified during the broad-based testing, room restriction and full Personal Protective Equipment (PPE) use by Health Care Personnel (HCP) caring for unvaccinated residents can be discontinued after 14 days and no further testing is indicated. This deficiency substantiates Complaint Number OH00114643.

CONCERN (F)

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

Deficiency F0919 (Tag F0919)

Could have caused harm · This affected most or all residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain the call light system in working order. This had the potential to affect the 34 residents residing in the facility. The facility census was 34. Findings include: Observation on 11/29/21 at 12:43 P.M. revealed the call light system located at the nurses station was beeping and the light for room [ROOM NUMBER] was lit up but no lights outside resident rooms were lit up. Licensed Practical Nurse (LPN) #88 responded to room [ROOM NUMBER] and found the call light system had not been activated in the room. LPN #88 then began going from room to room searching for the activated call light. Interview with LPN #88 on 11/29/21 at 12:50 P.M. verified the call light system located at the nurses station was beeping and the indicator for room [ROOM NUMBER] was lighting up indicating the resident residing in that room had activated the call light system. LPN #88 then verified no call lights outside the resident rooms had been lit up and the call light had actually been activated by the resident residing in room [ROOM NUMBER], not room [ROOM NUMBER]. Observation on 11/30/21 at 5:05 P.M. revealed the call light system located at the nurses station was beeping and the lights for multiple rooms were lit up on the system. No lights were observed flashing outside resident rooms. Interview with LPN #4 on 11/30/21 at 5:05 P.M. verified multiple lights were lit up on the call system board located at the nurses station and were beeping but no lights were lit up in the hallways outside resident rooms. LPN #4 stated the call light system had not been operating functionally for a while and staff had to go room to room at times to find out who activated the call light system.

CONCERN (F)

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

Safe Environment (Tag F0921)

Could have caused harm · This affected most or all residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, and review of facility policy, the facility failed to maintain tile flooring in a resident room in safe condition and to ensure residents and staff smoking area was free of fire hazards This had the potential to affect all 34 residents residing at the facility. Findings include: 1. Observation on 11/21/21 at 9:48 A.M. of room [ROOM NUMBER] revealed there were five tiles located in the center of the room which were cracked and had raised corners coming off of the floor. Observation on 11/29/21 at 3:11 P.M. of room [ROOM NUMBER] revealed there were five tiles located in the center of the room which were cracked and had raised corners coming off of the floor. Interview with Maintenance Supervisor #56 on 11/29/21 at 3:11 P.M. verified the five tiles located in the center of room [ROOM NUMBER] were cracked and had raised corners which needed to be replaced. 2. Observation on 11/30/21 between 4:15 P.M. and 4:22 P.M. State Tested Nursing Assistant (STNA) #18 entered the dining room banged on the kitchen door stating there was a fire and she needed a pitcher of water. This action was repeated twice. STNA #18 was questioned regarding the statement and she revealed there was a fire in the courtyard and there was smoke. The surveyors headed toward the courtyard, smoke was visible in the hallway as was an odor of burning debris. Upon exiting into the courtyard, the bottom of a smoking receptacle was smoldering. STNA #18 poured a pitcher of water on the smoldering cigarette butts. STNA #18 stated that was not enough water to put the fire out and she returned to the kitchen for a second pitcher of water. STNA #18 left the receptacle smoldering unattended. That pitcher was poured onto the smoldering cigarette butts. At 4:28 P.M. STNA #18 revealed the top was off the smoking receptacle and was smoldering when she went into the courtyard. The smoldering container was against the exterior wall of the building. There were dried leaves and cigarette butts on the ground around the receptacle. A fire extinguisher was mounted on the wall of the smoking [NAME] with a smoking apron draped over the fire extinguisher. On 11/30/21 observation of the courtyard between 4:28 P.M. and 4:40 P.M. revealed the courtyard densely littered with dried leaves, cigarette butts, cigarette ash, and paper products. The smoking [NAME] (a wooden structure with a wooden floor) had cigarette butts, ash, and paper cigarette cartoons on the floor. The waste can was over-flowing with paper waste. The wood brace above a smoking container had evidence of soot consistent with cigarette butts being snuffed out. The courtyard had a U shaped wooden raised flower bed with multiple cigarette buts and ash next to it. On 11/30/21 interview of STNA #18 at 4:40 P.M. revealed it was the responsibility of the maintenance staff to keep the smoking area clean and tidy. At 4:42 P.M. the Administrator stated it was the nursing assistants responsibility to keep the smoking area clean and tidy. Review of the facility policy titled Smoking Policy-Resident, dated 07/2017, revealed This facility shall establish and maintain safe resident smoking practices. Ashtrays are emptied only into designated receptacles.

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

"Why is there high staff turnover? How do you retain staff?"
"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• No fines on record. Clean compliance history, better than most Ohio facilities.

Concerns

• 48 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
• 56% turnover. Above average. Higher turnover means staff may not know residents' routines.

Bottom line: Mixed indicators with Trust Score of 70/100. Visit in person and ask pointed questions.

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About This Facility

What is Piketon Nursing Center's CMS Rating?

CMS assigns PIKETON NURSING CENTER an overall rating of 5 out of 5 stars, which is considered much above average nationally. Within Ohio, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.

How is Piketon Nursing Center Staffed?

CMS rates PIKETON NURSING CENTER's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 56%, which is 10 percentage points above the Ohio average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs.

What Have Inspectors Found at Piketon Nursing Center?

State health inspectors documented 48 deficiencies at PIKETON NURSING CENTER during 2021 to 2025. These included: 1 that caused actual resident harm and 47 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.

Who Owns and Operates Piketon Nursing Center?

PIKETON NURSING CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by AOM HEALTHCARE, a chain that manages multiple nursing homes. With 46 certified beds and approximately 45 residents (about 98% occupancy), it is a smaller facility located in PIKETON, Ohio.

How Does Piketon Nursing Center Compare to Other Ohio Nursing Homes?

Compared to the 100 nursing homes in Ohio, PIKETON NURSING CENTER's overall rating (5 stars) is above the state average of 3.2, staff turnover (56%) is near the state average of 46%, and health inspection rating (4 stars) is above the national benchmark.

What Should Families Ask When Visiting Piketon Nursing Center?

Based on this facility's data, families visiting should ask: "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's high staff turnover rate and the below-average staffing rating.

Is Piketon Nursing Center Safe?

Based on CMS inspection data, PIKETON NURSING CENTER has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 5-star overall rating and ranks #1 of 100 nursing homes in Ohio. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.

Do Nurses at Piketon Nursing Center Stick Around?

Staff turnover at PIKETON NURSING CENTER is high. At 56%, the facility is 10 percentage points above the Ohio average of 46%. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?

Was Piketon Nursing Center Ever Fined?

PIKETON NURSING CENTER has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.

Is Piketon Nursing Center on Any Federal Watch List?

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

Facility Details

Beds: 46
Avg. Residents: 45
Occupancy: 98.9%
Ownership: For profit - Corporation
Chain: AOM HEALTHCARE
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
5-Star Rating: +40
High Turnover: -5
1 Actual Harm citation: -5
48 Deficiencies: -10
Final Score: 70/100

Nearby Alternatives

NATIONAL CHURCH RESIDENCES BRI... 5-star THE PAVILION AT PIKETON 3-star

View all in PIKETON →

Check Bed Availability

Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 365961