How many inspection deficiencies does RIVERVIEW POST ACUTE have?

RIVERVIEW POST ACUTE has 52 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at RIVERVIEW POST ACUTE?

RIVERVIEW POST ACUTE has a two-star staffing rating from CMS with 0.71 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 RIVERVIEW POST ACUTE located?

RIVERVIEW POST ACUTE is located in SOUTH POINT, OH. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does RIVERVIEW POST ACUTE have?

RIVERVIEW POST ACUTE has 100 certified beds.

Who owns RIVERVIEW POST ACUTE?

RIVERVIEW POST ACUTE is a for profit - limited liability company facility and is part of the LEGACY HEALTH SERVICES chain.

What questions should families ask when visiting RIVERVIEW POST ACUTE?

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

How does RIVERVIEW POST ACUTE compare to other nursing homes?

RIVERVIEW POST ACUTE has a 4-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.

RIVERVIEW POST ACUTE

Name: RIVERVIEW POST ACUTE
Address: 7743 COUNTY ROAD 1, SOUTH POINT, OH, 45680, US
Telephone: (740) 894-3287
Rating: 4.0

7743 COUNTY ROAD 1, SOUTH POINT, OH 45680 · (740) 894-3287

For profit - Limited Liability company 100 Beds LEGACY HEALTH SERVICES Data: November 2025

Trust Grade

60/100

#330 of 913 in OH

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RIVERVIEW POST ACUTE nursing home in SOUTH POINT, OH

Last Inspection: December 2023

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

Overview

Riverview Post Acute in South Point, Ohio, has a Trust Grade of C+, which means it is slightly above average but not exceptional. It ranks #330 out of 913 facilities in Ohio, placing it in the top half, and is the best option among the four nursing homes in Lawrence County. The facility is improving, with a decline in issues from four in 2024 to just one in 2025. However, staffing is a concern, rated at 2 out of 5 stars, and while the turnover rate of 46% is better than the state average, there have been instances of inadequate RN coverage, with no RN on duty for 16 days over a month. Specific incidents include a resident not receiving necessary range of motion treatment, leading to physical decline, and another resident experiencing a fall and fracture possibly due to medication side effects that were not properly monitored. Overall, while Riverview has some strengths, such as good RN coverage and no fines, families should be aware of the staffing challenges and past serious incidents.

Trust Score: C+
In Ohio: #330/913
Safety Record: Moderate
Inspections: Getting Better
Staff Stability: 46% 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 42 minutes of Registered Nurse (RN) attention daily — more than average for Ohio. RNs are trained to catch health problems early.
Violations: 52 deficiencies on record. Higher than average. Multiple issues found across inspections.

★★★★☆

4.0

Overall Rating

★★☆☆☆

2.0

Staff Levels

★★★★★

5.0

Care Quality

★★★☆☆

3.0

Inspection Score

↔

Stable

2024: 4 issues

2025: 1 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: 46%

Near Ohio avg (46%)

Higher turnover may affect care consistency

Chain: LEGACY HEALTH SERVICES

Part of a multi-facility chain

Ask about local staffing decisions and management

The Ugly 52 deficiencies on record

2 actual harm

Sept 2025 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

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 observations, interviews, record reviews, and review of facility policy, the facility failed to ensure a resident who was dependent on staff for Activities of Daily Living (ADLs) received timely and appropriate nail care. This affected one (#6) of six residents reviewed for ADLs. The facility census was 79. Findings include:Record review for Resident #6 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included diabetes mellitus, heart failure, muscle wasting and atrophy, and vascular dementia. Review of the care plan, dated 02/21/24, revealed the resident had an ADL self-care/mobility/functional ability performance deficit. Interventions included nail care as needed. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 had impaired cognition and was dependent on staff with personal hygiene and bathing. Observations on 09/22/25 at 12:50 P.M. and 09/23/25 at 9:45 A.M. and 3:25 P.M. revealed Resident #6 was lying in bed. The resident's fingernails were extremely long and had dark-colored debris caked underneath them. Observation and interview with Registered Nurse (RN) #117 on 09/23/25 at 4:15 P.M. confirmed Resident #6's fingernails were extremely long with dark-colored debris caked underneath them and were in need of being trimmed and cleaned. RN #117 confirmed she was going to get nail clippers and was coming back to trim and clean the resident's nails. Review of the facility policy titled Fingernails/Toenails, Care of revised 02/2018 revealed the purpose of the procedure was to clean the nail bed, to keep the nails trimmed, and to prevent infections. Nail care included daily cleaning and regular trimming. This deficiency represents non-compliance investigated under Master Complaint Number 2608350 and Complaint Number OH00166779 (1282675).

Sept 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

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Based on medical record review, observation, and staff interview, the facility failed to ensure staff assisted residents with feeding in a dignified manner. This affected two (Residents #8 and #72) of five facility-identified residents who required assistance with eating. The facility census was 100 residents. Findings include: Review of the medical record for Resident #8 revealed an admission date of 04/30/21 with diagnoses including hemiplegia, frontal lobe deficit related to cerebrovascular accident, and dementia. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #8 dated 07/31/23 revealed the resident had impaired cognition and required moderate assistance with eating. Review of the nutritional assessment for Resident #8 dated 08/01/24 revealed the resident was on a regular diet with pureed textures. Observation on 09/16/24 at 11:43 A.M. revealed Resident #8 was seated in a wheelchair with an over the bed table across her lap. State Tested Nurse Aide (STNA) #114 delivered and set up Resident #8's meal tray. STNA #114 then fed Resident #8 her lunch meal while standing over the resident at the resident's side. Interview on 09/16/24 at 11:52 A.M. with STNA #114 confirmed she was standing over Resident #8 while feeding the resident. 2. Review of the medical record for Resident #72 revealed an admission date of 03/20/23 with diagnoses including Alzheimer's disease, diabetes mellitus type two, hypertension, and peripheral vascular disease. Review of the MDS assessment for Resident #72 dated 07/25/24 revealed the resident had cognitive impairment and required partial to moderate assistance with eating. Review of the nutritional assessment for Resident #72 dated 06/28/24 revealed the resident was on a pureed diet with regular textures. Resident #72 was a slow eater and required staff assistance as needed. Observation on 09/16/24 at 11:54 A.M. revealed Resident #72 was seated in her wheelchair with an over the bed tray table across her lap. STNA #117 delivered and set up the resident's meal tray. STNA #117 then fed Resident #72 her lunch meal while standing over the resident at the resident's side. Interview on 09/16/24 at 11:59 A.M. with STNA #117 confirmed she was standing over Resident #72 while feeding the resident. Interview on 09/17/24 at 10:45 A.M. with the Director of Nursing (DON) confirmed staff should sit down at eye level when feeding residents. The DON further confirmed that staff standing over a resident while feeding or assisting a resident did not provide the resident a dignified dining experience. This deficiency represents noncompliance investigated under Complaint Number OH00157601.

Jun 2024 3 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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Based on medical record review and staff interview, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and failed to ensure a residents received adequate supervision to prevent accidents. This affected one (Resident #87) of three residents reviewed for wandering behavior. The facility census was 89. Findings include: Review of the medical record for Resident #87 revealed an admission date of 04/26/21 with diagnoses including dementia, dysphagia (difficulty swallowing), and congestive heart failure. Review of the plan of care for Resident #87 dated 04/26/21 revealed the resident had exit seeking behavior and was an elopement risk. The resident wandered about the facility in her wheelchair looking for a way home. Interventions included the use of the alert bracelet to her ankle and to calmly redirect to an appropriate area. Review of the physician's orders for Resident #87 revealed an order dated 04/17/23 for a secure bracelet for the resident's ankle to prevent elopement form the facility and order dated 05/26/23 for a regular, soft and bite sized texture diet with minced meats. Interview on 06/24/24 at 1:17 P.M. with Licensed Practical (LPN) #100 confirmed she worked over until 2:00 A.M. on 05/20/24 which was the night Resident #87 was found in the unlocked facility kitchen unattended. LPN #100 confirmed on 05/20/24 around 1:50 A.M. she asked Nursing Assistant (NA) #115 if he had seen the resident, but the aide had not seen Resident #87. On 05/20/24 at approximately 2:00 A.M. NA #115 found Resident #87 in the kitchen with an opened bag of potato chips on her lap. LPN #100 confirmed the kitchen was usually locked and she was unsure why it had been left unlocked. LPN #100 confirmed she reported the incident to Registered Nurse (RN) #110 right after it happened. LPN #100 confirmed RN #100 told her that because Resident #87 did not leave the building, no documentation was necessary. Interview on 06/24/24 at 1:53 P.M. with NA #115 confirmed he worked on night shift on the night Resident #87 was found in the unattended facility kitchen. NA #115 stated Resident #87 was a wanderer and he and he went to look for her after he had not seen her for about 10 minutes. NA #115 confirmed he found Resident #87 eating potato chips in the unlocked and unattended kitchen. NA #115 confirmed when he found Resident #87, she had already consumed a whole snack size bag of baked chips when staff removed the resident from the kitchen. NA #115 further confirmed the kitchen was normally locked and he did not know how it was left unlocked. Interview on 06/24/24 at 1:50 P.M. with the Dietician confirmed Resident #87 was on a diet where all foods were to be soft and bite sized, except meats which were to be minced and moist. The Dietitian confirmed Resident #87 had dysphagia and should not eat potato chips because they not considered a safe texture in keeping with the resident's diet. Interview with on 06/24/24 at 1:35 P.M. with RN #100 confirmed LPN #100 called her on 05/20/24 and told her that Resident #87 had been gone for about 15 minutes when she was found in the unlocked and unattended facility kitchen. RN #100 stated she did not remember being told that she ate anything. RN #100 confirmed the kitchen is normally locked when unattended and residents are not normally allowed in the kitchen. RN #100 confirmed Resident #87 could have gotten hurt if she would have turned the stove on, got out a knife, or ate something not on her diet. RN #100 stated she never told LPN #100 not to document the incident. Interview on 06/24/24 at 2:40 P.M. with the Director of Nursing (DON) confirmed one nurse on night shift had a key to the kitchen and must have went in and failed to lock the kitchen. The DON confirmed Resident #87 had dysphagia and was not safe to eat potato chips, and staff had not informed her Resident #87 had eaten chips when she was found unattended in the facility kitchen on 05/20/24. This deficiency represents noncompliance investigated under Complaint Number OH00154534.

CONCERN (D) 📢 Someone Reported This

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

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

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

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Based on medical record review and staff interview, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and failed to ensure a residents received adequate supervision to prevent accidents. This affected one (Resident #87) of three residents reviewed for wandering behavior. The facility census was 89. Findings include: Review of the medical record for Resident #87 revealed an admission date of 04/26/21 with diagnoses including dementia, dysphagia (difficulty swallowing), and congestive heart failure. Review of the plan of care for Resident #87 dated 04/26/21 revealed the resident had exit seeking behavior and was an elopement risk. The resident wandered about the facility in her wheelchair looking for a way home. Interventions included the use of the alert bracelet to her ankle and to calmly redirect to an appropriate area. Review of the physician's orders for Resident #87 revealed an order dated 04/17/23 for a secure bracelet for the resident's ankle to prevent elopement form the facility and order dated 05/26/23 for a regular, soft and bite sized texture diet with minced meats. Interview on 06/24/24 at 1:17 P.M. with Licensed Practical (LPN) #100 confirmed she worked over until 2:00 A.M. on 05/20/24 which was the night Resident #87 was found in the unlocked facility kitchen unattended. LPN #100 confirmed on 05/20/24 around 1:50 A.M. she asked Nursing Assistant (NA) #115 if he had seen the resident, but the aide had not seen Resident #87. On 05/20/24 at approximately 2:00 A.M. NA #115 found Resident #87 in the kitchen with an opened bag of potato chips on her lap. LPN #100 confirmed the kitchen was usually locked and she was unsure why it had been left unlocked. LPN #100 confirmed she reported the incident to Registered Nurse (RN) #110 right after it happened. LPN #100 confirmed RN #100 told her that because Resident #87 did not leave the building, no documentation was necessary. Interview on 06/24/24 at 1:53 P.M. with NA #115 confirmed he worked on night shift on the night Resident #87 was found in the unattended facility kitchen. NA #115 stated Resident #87 was a wanderer and he and he went to look for her after he had not seen her for about 10 minutes. NA #115 confirmed he found Resident #87 eating potato chips in the unlocked and unattended kitchen. NA #115 confirmed when he found Resident #87, she had already consumed a whole snack size bag of baked chips when staff removed the resident from the kitchen. NA #115 further confirmed the kitchen was normally locked and he did not know how it was left unlocked. Interview on 06/24/24 at 1:50 P.M. with the Dietician confirmed Resident #87 was on a diet where all foods were to be soft and bite sized, except meats which were to be minced and moist. The Dietitian confirmed Resident #87 had dysphagia and should not eat potato chips because they not considered a safe texture in keeping with the resident's diet. Interview with on 06/24/24 at 1:35 P.M. with RN #100 confirmed LPN #100 called her on 05/20/24 and told her that Resident #87 had been gone for about 15 minutes when she was found in the unlocked and unattended facility kitchen. RN #100 stated she did not remember being told that she ate anything. RN #100 confirmed the kitchen is normally locked when unattended and residents are not normally allowed in the kitchen. RN #100 confirmed Resident #87 could have gotten hurt if she would have turned the stove on, got out a knife, or ate something not on her diet. RN #100 stated she never told LPN #100 not to document the incident. Interview on 06/24/24 at 2:40 P.M. with the Director of Nursing (DON) confirmed one nurse on night shift had a key to the kitchen and must have went in and failed to lock the kitchen. The DON confirmed Resident #87 had dysphagia and was not safe to eat potato chips, and staff had not informed her Resident #87 had eaten chips when she was found unattended in the facility kitchen on 05/20/24. The DON confirmed the incident on 05/20/24 involving Resident #87 should have been documented in the resident's medical record. This deficiency represents noncompliance investigated under Complaint Number OH00154534.

CONCERN (E) 📢 Someone Reported This

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

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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Based on medical record review, resident interview, staff interview and review of the facility policy, the facility policy failed to notify local health department and visitors to the facility of an outbreak of a stomach virus which infected residents and staff. This affected 19 of 19 residents reviewed for stomach virus symptoms. The facility census was 89 residents. Findings include: Review of the medical record for Resident #11 revealed an admission date of 06/18/24 with diagnoses including cellulitis in left lower extremity, diabetes mellitus type two, depression, morbid obesity, and gastrointestinal reflux disease. Review of the nursing progress notes for Resident #11 dated 06/18/24 to 06/26/24 revealed they did not include information regarding a stomach virus or documentation regarding notification to resident's representatives of an outbreak of a stomach virus. Review of the medical records for Residents #2, #18 and #38 revealed the residents had nausea, vomiting and or diarrhea from 06/15/24 through 06/19/24. There was no documentation regarding resident representative notification of an outbreak of stomach virus. Interview on 06/26/24 at 10:06 A.M. with Resident #2 confirmed she had been sick a couple of weeks ago along with other residents. Resident #2 stated her symptoms included nausea, vomiting and diarrhea. Interview on 06/26/24 at 10:03 A.M. with Resident #18 confirmed she had been sick a couple of weeks ago with nausea, vomiting and diarrhea. Interview on 06/27/24 at 9:15 A. M. with Licensed Practical Nurse (LPN) #156 confirmed she had a stomach virus a couple of weeks ago and she had to call off work due to her symptoms. Interview on 06/27/24 at 9:18 A.M. with State Tested Nursing Assistant (STNA) #145 confirmed she had a stomach virus a couple weeks ago and she had to call off work due to her symptoms. Interview on 06/27/24 at 9:22 A.M. with STNA #114 confirmed she had a stomach virus a couple weeks ago and was sent home from work when she developed symptoms. Interview on 06/26/24 at 2:41 P.M. with the Director of Nursing (DON) confirmed the facility had an outbreak of a stomach virus in early June 2024 which infected 19 residents and eight staff members. The DON further confirmed the facility did not notify the local health department of the outbreak of the virus with symptoms including nausea, vomiting and diarrhea, nor had the facility notified visitors and resident representatives of the outbreak. Review of the facility policy titled Outbreak Prevention and Intervention dated 11/23/23 revealed outbreak measures would be instituted whenever there was an incidence of infections above what was normally expected considering seasonal variation. Appropriate notifications would be issued to the medical director, the attending physician, administrator, all departments, and family members at a minimum and to appropriate state and local officials. The facility should determine that an outbreak existed when a commonality of symptoms was evident among residents and or staff with common person, place or time. The facility should educate the staff, residents and visitors of their individual responsibilities and importance of compliance with any isolation requirements. This deficiency represents noncompliance investigated under Complaint Number OH00155114.

Dec 2023 7 deficiencies

CONCERN (D)

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

PASARR Coordination (Tag F0644)

Could have caused harm · This affected 1 resident

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Based on medical record review and staff interview, the facility failed to ensure resident Pre-admission Screening and Resident Review (PASARR) documents accurately reflected resident current conditions and diagnoses. This affected one (Resident #54) of three residents reviewed for PASARR documents. The census was 93. Findings include: Review of the medical record for Resident #54 revealed an admission date of 10/02/20 with diagnoses including were non-Hodgkin's lymphoma, dysphagia, cognitive social or emotional deficits, dementia, anxiety, depression, hypertension, foot drop, suicidal ideations, noncompliance with medical treatment, traumatic brain injury, unspecified psychosis, and chronic pain syndrome. Review of the Minimum Data Set (MDS) assessment for Resident #54 dated 09/01/23 revealed the resident had severe cognitive impairment. Review of the PASARR document for Resident #54 dated 10/01/20 revealed it did not include any active psychiatric diagnoses. Interview on 11/30/23 at 11:42 A.M. with the Director of Nursing (DON) confirmed Resident #54 had a new diagnosis of unspecified psychosis which was added on 12/27/21. The DON confirmed an updated PASARR was not completed for this resident after the addition of a new mental health diagnosis in 2021.

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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Based on medical record review and staff interview the facility failed to ensure all significant mental health changes were communicated to the state mental health agency. This affected one (Resident #54) of three residents reviewed for Pre-admission Screening and Resident Review (PASARR) documents. The census was 93. Findings Include: Review of the medical record for Resident #54 revealed an admission date of 10/02/20 with diagnoses including were non-Hodgkin's lymphoma, dysphagia, cognitive social or emotional deficits, dementia, anxiety, depression, hypertension, foot drop, suicidal ideations, noncompliance with medical treatment, traumatic brain injury, unspecified psychosis, and chronic pain syndrome. Review of the Minimum Data Set (MDS) assessment for Resident #54 dated 09/01/23 revealed the resident had severe cognitive impairment. Review of the PASARR document for Resident #54 dated 10/01/20 revealed it did not include any active psychiatric diagnoses. Interview on 11/30/23 at 11:42 A.M. with the Director of Nursing (DON) confirmed Resident #54 had a new diagnosis of unspecified psychosis which was added on 12/27/21. The DON confirmed an updated PASARR was not completed for this resident after the addition of a new mental health diagnosis in 2021 and the state mental health agency was not notified of Resident #54's new diagnosis.

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** Based on medical record review and staff interview the facility failed to timely complete a discharge summary for residents upon discharge from the facility and failed to provide residents and their representatives with discharge instructions. This affected one (Resident #51) of three residents reviewed for discharge. The facility census was 93. Findings include: Review of the medical record for Resident #51 revealed an admission date of 10/25/23 and diagnoses including displaced intertrochanteric fracture of right femur, atrial fibrillation, atherosclerotic heart disease, heart failure, end stage renal disease, diabetes mellitus, obstructive sleep apnea, major depressive disorder, and a discharge date of 11/22/23. Review of the admission Minimum Data Set (MDS) assessment for Resident #51 dated 11/01/23 revealed the resident was moderately cognitively impaired and used a walker and wheelchair to aid in mobility. Review of the MDS for Resident #51 dated 11/22/23 revealed the resident was discharged from the facility with a return not anticipated. Review of the medical record for Resident #51 on 11/29/23 at 3:57 P.M. revealed it did not include a discharge summary or discharge instructions provided to the resident and/or the resident's representative upon discharge. Interview by phone on 11/30/23 at 2:18 P.M. with Registered Nurse (RN) #167 confirmed Resident #51 was discharged to home on [DATE] and the facility did not provide the resident with discharge instructions prior to him leaving. RN #167 further confirmed Resident #51's family came to the facility on [DATE] to obtain a list of the resident's medications because it had not been provided at discharge. RN #167 confirmed Resident #51's discharge paperwork was not finalized until 11/30/23.

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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Based on medical record review, observations, and staff interview the facility failed to provide timely and appropriate nail care for a resident who was dependent upon staff for assistance with activities of daily living (ADLs). This affected one (Resident #254) of two residents reviewed for ADLs. The facility census was 93. Findings include: Review of the medical record for Resident #254 revealed an admission date of 11/21/23 with diagnoses including Alzheimer's disease, acute cystitis without hematuria, retention of urine, and nondisplaced intertrochanteric fracture of right femur. Review of the care plan for Resident #254 dated 11/22/23, revealed the resident had an ADL self-care, mobility, and functional ability performance deficit. Interventions included staff should provide nail care as needed. Observation on 11/27/23 at 2:30 P.M. revealed Resident #254 was lying in bed and was alert and pleasantly confused. The resident fingernails were observed to be long and jagged and to have a layer of black debris caked underneath them. Observation on 11/28/23 at 10:34 A.M. revealed the fingernails of Resident #254 continued to be long and jagged and to have a layer of black debris caked underneath them. Observation on 11/28/23 at 12:15 P.M. revealed Resident #254 was consuming her lunch meal and used her hands to pick up food items off her tray to place them in her mouth. The resident's fingernails continued to be long and jagged and have a layer of black debris caked underneath them. Observation on 11/29/23 at 9:25 A.M. revealed Resident #254 was lying in bed and appeared to have received recent assistance with bathing and grooming. However, the resident's fingernails remained long and jagged and had a layer of black debris underneath them. Interview on 11/29/23 at 11:15 A.M. with State Tested Nursing Assistant (STNA) #292 confirmed Resident #254's fingernails were long and jagged and had a layer of black debris underneath them and were in need of being trimmed and cleaned. STNA #292 stated she would obtain the needed supplies and trim and clean them immediately.

CONCERN (D)

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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

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Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure pressure ulcer prevention interventions were in place per the plan of care. This affected one (Resident #25) of one resident who was reviewed for positioning during the annual survey. The facility identified two residents with pressure ulcers. The facility census was 93. Findings include: Review of the medical record for Resident #25 revealed an admission date of 04/08/20 with diagnoses including dementia, peripheral vascular disease, heart failure, and diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #25 dated 09/29/23 revealed the resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 15. The resident was assessed to require extensive assistance from staff for bed mobility and toileting and to be dependent upon staff for transfers. Review of the care plan for Resident #25 dated 01/25/22, revealed the resident was at risk for altered skin integrity. Interventions included the staff should apply a Prevalon boot to the left foot while in bed. Observation on 11/27/23 at 11:25 A.M., on 11/29/23 at 10:34 A.M. and on 11/30/23 at 1:08 P.M. revealed Resident #25 was lying in bed with his left leg was placed on a pillow with the heel lying directly on the mattress. There was no Prevalon boot in place to Resident #25's left foot or on the bed. Interview on 11/30/23 at 1:08 P.M. with State Tested Nursing Assistant (STNA) #222 confirmed Resident #25 was lying in bed with his left leg placed on a flattened pillow and the resident's left heel was positioned directly on the mattress with no Prevalon boot in place. STNA #222 stated she did not believe the resident needed to have a Prevalon boot and confirmed there was not a Prevalon boot present in the resident's room. Interview on 11/30/23 at 1:55 P.M. with Registered Nurse (RN) #188 on 11/30/23 at 1:55 P.M. verified Resident #25 did not have a Prevalon boot in place to his left foot per his care plan. Review of the facility policy titled Pressure Ulcer Prevention Protocols/Risk Assessment dated 06/08/22 revealed the facility would identify residents at risk for the development of pressure ulcers and would implement supportive/preventative precautions as appropriate.

CONCERN (D)

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

Deficiency F0757 (Tag F0757)

Could have caused harm · This affected 1 resident

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Based on medical record review and staff interview the facility to ensure antibiotic medications were prescribed and administered only when necessary. This affected one (Resident #10) of the three residents reviewed for antibiotic use. The facility census was 93. Findings include: Review of the medical record review for Resident #10 revealed an admission date of 06/07/23 with diagnoses including dementia, chronic kidney disease, diverticulosis of the large intestine, anxiety, and acquired absence of part of the stomach. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #10 dated 09/27/23 revealed the resident had mildly impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 12. The resident was assessed to require extensive assistance for bed mobility, transfers, and toileting. Review of the results of the urinalysis with culture and sensitivity (UA with C&S) for Resident #10 dated 11/22/23 revealed the presence of over 100,000 colony forming units per milliliter (CFU/ml) of mixed pathogens indicating probable contamination of the urine specimen. No further UA C&S testing was completed for Resident #10. Review of the physician's order for Resident #10 dated 11/25/23 revealed an order for 250 milligrams (mg) of vancomycin (an antibiotic medication) to be administered four times a day for five days for possible clostridium difficile (c-diff) infection. Review of the physician's order for Resident #10 dated 11/26/23, revealed an order for one gram of ertapenem Sodium Solution (an antibiotic medication) to be administered intravenously for three days for infection. Review of the results of the stool specimen for Resident #10 dated 11/28/23, revealed the specimen was negative for infection, including c-diff infection. Interview on 11/29/23 at 3:38 P.M with Medical Director (MD) #400 confirmed the antibiotic medication ertapenem was ordered and administered to Resident #10 for a possible urinary tract infection (UTI). MD #400 confirmed the results of the UA with C&S obtained on 11/22/23 revealed probable contamination and did not indicate that Resident #10 had an active UTI. Interview on 11/30/23 at 10:10 A.M. with Registered Nurse (RN) #189 confirmed antibiotic medication vancomycin was ordered and administered to Resident #10 for a possible c-diff infection. RN #189 confirmed results of the stool specimen obtained for Resident #10 on 11/28/23 revealed the resident did not have an infection.

CONCERN (D)

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

Deficiency F0773 (Tag F0773)

Could have caused harm · This affected 1 resident

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Based on medical record review, observation, staff interview, and review of facility policy the facility failed to ensure physician-ordered laboratory tests and specimens were obtained timely and as ordered. This affected two residents (#10 and #84) out of the eight residents reviewed for antibiotic use and unnecessary medications during the annual survey. The facility census was 93. Findings include: 1. Review of the medical record for Resident #10 revealed an admission date of 06/07/22 with diagnoses including dementia, chronic kidney disease, diverticulosis of the large intestine, anxiety, and acquired absence of part of the stomach. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #10 dated 09/27/23 revealed the resident had mildly impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 12. The resident was assessed to require extensive assistance for bed mobility, transfers, and toileting and to be independent for eating. The resident was assessed to have an indwelling foley catheter. Review of the physician's order for Resident #10 dated 11/17/23, revealed an order for a urinalysis with culture and sensitivity (UA with C&S) to be obtained stat (immediately). Review of the UA with C&S result for Resident #10 dated 11/22/23 revealed the specimen showed possible contamination. Review of the physician's order for Resident #10 dated 11/24/23 revealed an order for a stool sample to be obtained to rule out possible clostridium difficile (c-diff) infection and for a UA with C&S to be obtained on 11/27/23. Review of the care plan for Resident #10 dated 11/27/23 revealed the resident had possible clostridium difficile (c-diff) infection. Interventions included the following: follow facility protocols for contact isolation for duration of treatment, give medications per physician order, utilize personal protective equipment (PPE) as appropriate. Observation on 11/27/23 at 11:05 A.M. revealed Resident #10 was in isolation precautions for possible c-Diff infection. The resident was observed to have an indwelling foley catheter in place. Review of the laboratory record for Resident #10 revealed a stool specimen was obtained on 11/28/23, and the results were not yet available. Interview with Medical Director #400 on 11/29/23 at 3:38 P.M. confirmed the UA with C&S ordered for Resident #10 should have been obtained as ordered on 11/17/23 as the resident had an indwelling foley catheter. MD #400 confirmed a stool specimen for possible c-diff infection had been ordered to be obtained on 11/27/23 and he was still awaiting the results to review. Review of the facility policy titled Lab and Diagnostic Tests dated 06/08/22, revealed staff were to check physicians' orders for the test, specimen collection directions, and the date on which the test was due. Staff should mark the word stat on requisitions appropriately to bring the testing time frame to the attention of the laboratory. Stat requests would also be called to the laboratory as soon as ordered. 2. Review of the medical record for Resident #84 revealed an admission date of 10/19/23 with diagnoses including neutropenia due to infection, sepsis, myelodysplastic, atrial fibrillation, atherosclerotic heart disease, hyperlipidemia, generalized anxiety disorder, major depressive disorder, dysphagia, hypertension, and cognitive communication deficit. Review of the laboratory test results of the complete blood count (CBC) for Resident #84 dated 10/23/23 revealed the resident's hemoglobin (protein in red blood cells that delivers oxygen to tissues) was low at 8.6 g/dl (grams per deciliter) and the reference range was 14.0 to 18.0. Review of the physician's order for Resident #84 dated 10/24/23 revealed an order to obtain a weekly complete blood count (CBC). Review of the MDS for Resident #84 dated 10/26/23 revealed the resident was cognitively intact and required a walker and wheelchair for mobility. Review of the laboratory results for Resident #84 revealed a CBC was not completed for the resident until11/20/23. Review of the CBC results revealed the resident's hemoglobin level was 8.1 g/dl which was low. Interview with the Director of Nursing (DON) on 11/30/23 at 8:40 A.M. confirmed Resident #84 had an order for a weekly CBC dated 10/24/23, but the CBC was not completed until 11/20/23. Further interview with the DON confirmed the facility did not notify the attending physician of the abnormal lab result (low hemoglobin level) noted on 11/20/23.

Aug 2023 1 deficiency

CONCERN (F) 📢 Someone Reported This

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

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

Deficiency F0727 (Tag F0727)

Could have caused harm · This affected most or all residents

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Based on observation, interview, record review, and facility policy review the facility failed to ensure a Registered Nurse (RN) was providing services to the residents eight consecutive hours, seven days per week. This had the potential to affect all the residents residing in the facility. The facility census was 91. Findings include: Observation of the daily staff postings on 07/31/23 and 08/08/23 revealed no scheduled RN was working. Review of the staffing schedules and daily postings from 07/07/23 through 08/07/23 revealed 16 days without RN working hours: 07/08/23, 07/09/23, 07/10/23, 07/14/23, 07/16/23, 07/17/23, 07/18/23, 07/21/23, 07/22/23, 07/23/23, 07/25/23,07/30/23, 07/31/23, 08/04/23, 08/05/23 and 08/06/23. Interview on 08/07/23 at 1:56 P.M. with Registered Nurse (RN) #11 revealed the RN worked at the facility full time but did not usually work weekends. Interview on 08/07/23 at 2:06 P.M. with RN #69 revealed the RN worked the floor part time and did not work weekends. Interview on 08/07/23 at 3:35 P.M. with the Director of Nursing (DON) revealed the facility currently had two RN's on staff. The facility did not admit residents that required RN coverage and a RN (director of nursing and assistant director of nursing) were on call 24 hours a day, seven days a week. The DON confirmed the facility did not staff an RN seven days per week for eight consecutive hours. Review of the facility policy titled Staffing and Scheduling, dated 06/08/23, revealed the facility would follow the Centers for Medicare and Medicaid Services (CMS) staffing requirements. This deficiency represents non-compliance investigated under Complaint Number OH00145194, OH00144880 and OH00138034.

Dec 2022 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

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 incident report review the facility failed to ensure Resident #80's safety while using a mechanical lift to transfer the resident while providing care. This affected one (Resident #80) of the five residents reviewed for safe transfers. The facility census was 94. Findings include: Review of the medical record for Resident #80 revealed an admission date of 02/21/18. Diagnosis included altered mental status, dementia without behavioral disturbances, disorder of bone density and structure, osteoarthritis, and muscle wasting and atrophy. Review of Resident #80's significant change Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #80 experienced long and short-term memory problems as well as a severely impaired cognition for daily decision-making abilities. Resident #80 was noted to have difficulty focusing attention and noted to display an altered level of consciousness. No behaviors were noted during the assessment review. Resident #80 required extensive assistance from two staff members for bed mobility, dressing, toilet use, personal hygiene, and extensive assistance from one staff member for eating, and transfers were noted to have not occurred. Resident #80 was noted to have impairment to one upper and one lower extremity. Review of Resident #80's physician orders for November 2022 revealed, orders for staff to monitor Steri-strips to the left calf and to the left elbow until they fall off on their own. Review of the plan of care, dated 01/10/22 and revised on 05/03/22, revealed Resident #80 had a self-care deficit as evidenced by weakness related to disease process, cerebral vascular accident (CVA) with hemiparesis, Parkinson's, physical limitations, inability to ambulate, terminal prognosis. Interventions included to complete active range of motion (ROM) to upper extremities during activities of daily living (ADL), collaborate care with Hospice, and family and resident prefers bed baths and hair washed in bed, do not transfer with a mechanical lift per family request. Review of the plan of care dated 04/27/22 revealed Resident #80 was resistive/noncompliant with treatment/care, refusing geri-legs to protect skin to lower extremities related to a belief that the treatment was not needed/working. Interventions include to allow for flexibility in ADL, elicit family input for bed approaches, return later to attempt care again, and educate about risk of not complying with therapeutic regimen. Review of incident report dated 11/09/22 revealed, Resident #80 sustained a skin tear to the left calf while staff was giving her a shower. Staff went to lift her leg and her skin tore. When staff was putting the resident to bed with a Maxi (mechanical) lift, the resident grabbed the bar and refused to let go causing skin tear to left elbow. Action taken during investigation- Treatment completed for both areas, daughter notified and upset that mother sustained skin tears. Staff explained as we get older our skin gets thinner. Statements were obtained. Education was provided to staff on avoiding skin alterations. Conclusion- Resident #80 is an [AGE] year-old female with a diagnosis of cerebral vascular accident (CVA) disease, altered mental status (AMS), dementia, arthrodesis, of native arteries of right with ulceration of heel and mid foot. Polyosteoarthritis, neuropathy, and more. Resident #80's skin is thin and fragile; it tears very easily related to the aging process. The resident's daughter has requested not to use the Hoyer lift anymore and to complete bed baths for the resident and shampoo hair in bed. Skin tear was accident and defined not intentional. Review of the progress note dated 11/09/22 at 11:40 A.M. created by Licensed Practical Nurse (LPN) #201 revealed, while staff was giving Resident #80 a shower in the shower room, staff lifted her left leg causing a skin tear measuring 5.0 centimeters (cm) by 1.0 cm. When staff took the resident back to her room to put her back to bed using the mechanical lift, the resident refused to let go of the bar causing a skin tear measuring 2.0 cm by 1.0 cm. Both areas cleansed with wound cleanser and Steri-strips applied. The physician and family were notified. Review of the Braden Scale assessment completed for Resident #80 dated 10/08/22 revealed a score of 08 indicating the resident was at a very high risk of developing a skin injury, skin tear, or pressure wound. Review of Resident #80's Admission/readmission screening dated 01/08/22 revealed the resident came from an acute care hospital, noted to understand, and follows instructions. The resident was noted with weakness, clear speech, and able to understand verbal commands, able to express self. The resident was noted to display an unsteady balance, with sitting, standing, and gait, noted to be pleasant and cooperative. The resident was noted to have right lower left round raised bruising areas and an open area to the right buttocks and the right heel. Resident #80 required assistance/potential to restore function for transferring from one position to another, transfer with mechanical lift. Interview on 11/30/22 at 3:00 P.M. with the Director of Nursing (DON) revealed Resident #80 was noted to have fragile skin due to the diagnoses of peripheral vascular disease and atherosclerosis of the arteries of the legs, causing issues with circulation. The incident that occurred where Resident #80 received a skin tear to the left calf and left elbow was an accident. Education was provided to staff regarding the proper procedure when transferring residents with a mechanical lift. Review of the facility policies revealed the facility did not provide a policy regarding the allegation. This deficiency represents non-compliance investigated under Complaint Number OH00137500.

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0808 (Tag F0808)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interviews, menu spread sheet review, and moist and minced food procedure review the facility failed to ensure Resident #87 received the correct food consistency during mealtime. This affected one (Resident #87) of the five residents reviewed for food texture. The facility census was 94. Findings include: Review of the medical record for Resident #87 revealed an admission date of 04/30/21. Diagnoses included dementia without behavioral disturbances, seizures, hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, dysphagia, and cognitive communication deficit. Review of Resident #87's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a long- and short-term memory deficit and a severely impaired cognition for daily decision-making abilities. No behaviors were noted with this assessment review. Resident #87 required extensive assistance from two staff members for bed mobility, transfers, dressing, limited assistance from one staff member for eating, extensive assistance from one staff member for toilet use, and personal hygiene. Resident #87 was noted with impairment to one lower extremity and required the use of a wheelchair for mobility. Review of the care plan, dated 05/12/21 and revised on 07/09/21, revealed Resident #87 had a couple of natural teeth. Interventions include to report changes in chewing ability, and signs and symptoms of oral pain. Review of Resident #87's physician orders for November 2022 revealed the following diet order, No added salt diet, Minced and Moist textured food. Review of progress note date 11/19/22 at 1:36 P.M. created by Licensed Practical Nurse (LPN) #65 revealed, a nurse aide reported to this nurse during lunch the resident was eating her lunch and when the nurse aide walked by her room, she was noted to be having some trouble with her lunch. When the nurse aide approached the resident, she was noted to have her mouth open, and a French fry was sticking out of her mouth. She quickly did a finger sweep and obtained the food. When she looked at the tray, she had eaten a piece of cake and was eating French fries and discovered the resident had been given the wrong meal tray. The resident was on a puree diet and had a regular tray. LPN #65 went to assess the resident. Resident #87 was sitting upright in her bed with the head of bed elevated. Vital Signs- Temperature 97.6 degrees Fahrenheit, blood pressure - 126/68 milliliters of mercury (mmHg), respirations - 26 breaths per minute, and oxygen saturation was 97% on room air. Lungs sounds were diminished. The resident did not appear to be in any distress. Resident #87 was already eating the correct tray and was having no issues. Physician #243 was made aware. The resident's daughter was notified. Resident #87 was placed on alert charting and new orders were received to obtain vital signs every four hours for 24 hours. Interview on 11/29/22 at 1:48 P.M. with Dietary Manager #117 revealed each resident receiving a meal tray had a diet slip printed out in advance with menu items noted on it for that specific meal. Resident #87 was noted to receive a regular diet with minced and moist textured food. For the lunch meal on 11/19/22, Resident #87 should have received minced chicken with gravy on it and mashed potatoes instead of French fires. After lunch meal trays had been delivered, a staff member was walking by Resident #87 and noted she had a French fry sticking out of her mouth and intervened immediately by removing the French fry out of her mouth and requested a new meal tray with the appropriate textured food. After looking at the meal tray it was concluded that when staff members were passing out the lunch meal trays, one of the staff members gave Resident #87 the wrong meal tray. There were two residents in the same room that had the same first name and this caused the confusion. Interview on 11/29/22 at 2:30 P.M. with LPN #65 confirmed she was the nurse who was working on 11/19/22 when it was reported to her by a State Tested Nursing Assistant (STNA) that Resident #87 had received the incorrect meal tray. Resident #87 was assessed with no concerns noted. Resident #87 had not choked on any of the food and was noted to be at baseline. Resident #87 normally does very well at mealtime. Staff will set up her meal tray and monitor throughout the meal to ensure she is eating. Most of the time Resident #87 does not require encouragement or cueing. Review of the menu spread sheet for 11/19/22 for lunch revealed the following food items and textures to be served to a resident receiving a regular textured diet, BBQ chicken on a bun, seasoned potato wedges, green bean, bread, and a honey bun cake. Residents who required to receive a Moist and Minced textured food diet were to receive, minced BBQ chicken, mashed potatoes, green bean, and honey bun cake. Review of the facility policy titled Minced and Moist Diet -MM 5, dated 07/21 revealed, The diet consists of food that are soft and moist with pieces no bigger than 4 millimeter (mm) by 15 mm with no thin liquid or dripping from the food. The foods are not sticky because this can cause the food to stick to the cheeks, teeth, roof of mouth, or in the throat. Guideline: Meat if finely minced to 4 mm lump size serving in non-pouring sauces or gravy. Vegetables are cooked and blenderized into 4 mm lump sizes, excess liquid is drained. Bread and rice are pureed. This deficiency represents non-compliance investigated under Complaint Number OH00137764.

Oct 2021 19 deficiencies 2 Harm

SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Deficiency F0688 (Tag F0688)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview and review of the facility policy titled Restorative Nursing Guidelines the facility failed to ensure Resident #17 received the appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. Actual Harm occurred when Resident #17, who was cognitively impaired and required extensive assistance/dependence on staff for activities of daily living was identified to have a decline in range of motion of her neck and left wrist with new onset contractures resulting in the resident's neck being bent to the left side with her head touching her shoulder and her left hand being in a bent downward position from her wrist. There was no evidence of a comprehensive and individualized range of motion program being implemented following therapy recommendations in June 2021 to prevent the declines and new onset contractures from occurring. This affected one resident (#17) of one resident reviewed for range of motion. Findings include: Review of the medical record for Resident #17 revealed an admission date of 04/15/21. The resident was admitted from the hospital after treatment for a cerebral vascular accident. Review of an admission Minimum Data Set (MDS) 3.0 assessment, dated 04/22/21 revealed the resident had short and long term memory impairment, required extensive assistance from two staff with transfers, locomotion, dressing and hygiene. The resident required extensive assistance from one staff for eating. The MDS assessment revealed Resident #17 had impairment in range of motion of the upper and lower extremities on one side. Record review revealed the resident was provided physical therapy from 04/16/21 until 06/24/21. The physical therapy evaluation revealed the resident was exhibiting a new onset of decrease in functional mobility. Notes indicated the resident previously lived in an apartment independently. The notes indicated the resident's left lower extremity range of motion was impaired but without contractures. The physical therapy discharge summary on 06/24/21 revealed the resident required substantial/maximal assistance with transfers from chair to bed, was dependent for toilet transfer and no longer allowed attempts at walking. The discharge summary indicated follow up care was to include a restorative range of motion program. However, there was no evidence a restorative range of motion program was implemented. Record review revealed the resident was provided with occupational therapy from 04/16/21 until 06/24/21. The goal was for the resident to increase ability to engage in self care. The notes indicated the resident's right upper extremity range of motion was within normal limits. The left upper extremity range of motion was impaired but no muscle contraction was detected. Review of the occupational therapy Discharge summary, dated [DATE] revealed Resident #17 was demonstrating left neck flexion and at time of discharge had increased tightness of left upper extremity noted but the resident was unwilling to let the therapist position left upper extremity in any way. Recommendations included 24 hour care and assistance with all activities of daily living including self feeding. Chair with head/neck support recommended when out of bed to facilitate most appropriate positioning. There was no evidence any other treatment was recommended for the neck flexion or tightness in left upper extremity at the time of therapy discharge. Review of Resident #17's plan of care revealed the resident had an activity of daily living deficit as evidenced by muscle atrophy and weakness multiple sites related to recent cerebral vascular accident. The care plan was initiated 04/16/21. The goal was to improve activity of daily living self performance. The only intervention included was physical therapy (which was discontinued 06/24/21). There was no evidence of any interventions in place after therapy was discontinued to improve or maintain the resident's range of motion. Review of the quarterly MDS 3.0 assessment, dated 07/23/21 revealed the resident was totally dependent upon two staff for transfers, required extensive assistance from staff with dressing, eating, and hygiene, and now had impairments in range of motion on both sides including the upper and lower extremities. Record review revealed no evidence any treatment related to range of motion was provided between 06/24/21 and 10/05/21 for the resident. On 10/05/21 an occupational therapy evaluation was completed. The evaluation revealed the reason for the referral was due to worsening of range of motion. The resident's left wrist was noted to be at a 100 degree position relative to left radius and ulna, with increased tightness so much so that changes in range of motion during flexion/extension were not measurable. The evaluation indicated the resident had functional limitations due to contractures. The evaluation also revealed decreased range of motion of the left upper extremity and neck limited participation in self care without pain as well as increased risk for skin breakdown. Occupational therapy was initiated to address contracture impairment. The notes indicated Resident #17 demonstrated poor supine positioning with her head laterally flexed and rotated to left. Left upper extremity at risk for worsening contracture. Therapy to trial orthotic devices to manage decreased range of motion and increased tightness. Resident to participate in manual therapy to manage decreased range of motion. On 10/18/21 at 12:06 P.M. Resident #17 was observed in bed with her head bent to the left (touching her shoulder). The resident's left hand was contracted downward at the wrist. Staff were observed feeding the resident her lunch with her head bent completely to the left side. On 10/18/21 at 2:41 P.M. Resident #17 was observed in bed with her head bent to the left (touching her shoulder) and her left hand contracted downward at the wrist. On 10/19/21 at 7:48 A.M. Resident #17 was observed in bed with her head bent to the left (touching her shoulder) and her left hand contracted downward at the wrist. Staff were observed feeding the resident her breakfast with her head bent completely to the left side. On 10/19/21 at 9:50 A.M. interview with Resident #17's brother revealed when the resident was in the hospital her head was not leaning to the left and now it was. The brother indicated he felt this had been a decline for the resident since her admission to the facility. The resident's brother revealed about a week ago staff had talked to him about the resident wearing a collar on her neck but he was not aware if this had been implemented. On 10/19/21 at 1:34 P.M. and 4:41 P.M. Resident #17 was observed in bed with her head bent to the left (touching her shoulder) and her left hand contracted downward at the wrist. Resident #17 was not observed to be out of bed on 10/18/21 or 10/19/21. On 10/20/21 at 7:15 A.M. interview with Occupational Therapist (OT) #415 revealed he had provided occupational therapy for Resident #17 during the period of 04/16/21 to 06/24/21. OT #415 revealed the resident's left wrist was starting to contract during that time but that the resident would not allow him to work with her left arm. OT #415 also indicated the resident had some neck flexion starting at that time and she would allow him to provide range of motion for her neck but the neck had since worsened. OT #415 revealed he was not sure what had been done to prevent the resident's neck from further contracting after she was discontinued from therapy services on 06/24/21. OT #415 verified his discharge recommendations on 06/24/21 did not include any type of passive range of motion for her neck or left upper extremity. OT #415 verified both the resident's left wrist and neck had declined in range of motion. He stated since therapy restarted 10/05/21, she sometimes allowed him to provide range of motion and sometimes not. On 10/11/21 the resident allowed nine minutes of stretching of her neck. He stated her neck was at approximately 60 degrees laterally flexed and with range of motion he could get it to midline. The resident's left wrist was at approximately 90 degrees flexion and he could get it to about 30 degrees with range of motion now. OT #415 revealed he planned to attempt splinting for the resident's neck and wrist. On 10/20/21 at 8:40 A.M. observations of an occupational therapy session revealed Resident #17 was up in a chair with lateral neck support. The resident did allow intermittent stretching of her neck to almost midline. On 10/20/21 at 11:08 A.M. interview with MDS Coordinator #145 revealed when Resident #17 was first admitted she had limitations described as left sided weakness on one side. Then when she completed the quarterly MDS in July 2021, she noticed issues on the right side. MDS Coordinator #145 revealed she did not know what the issue was that prompted her to mark both sides as having limitations in range of motion as she made no notes. During the interview, MDS Coordinator #145 also confirmed there was no plan of care in place related to range of motion. She stated when range of motion was recommended by therapy, if it was done, it was documented by nursing assistant staff. MDS Coordinator #145 confirmed there was no evidence of any range of motion program being in place or provided for Resident #17 between 06/24/21 and 10/05/21. On 10/20/21 at 2:00 P.M. interview with Interim Director of Nursing #325 and Director of Rehab #125 confirmed there was no treatment provided for Resident #17 after her therapy was discontinued on 06/24/21. Review of the facility policy titled Restorative Nursing Guideline, dated 08/2019 revealed restorative nursing care included nursing interventions that help to maintain the patient's highest level of function and prevent unnecessary decline in function. Restorative nursing programs were individualized to specific patient needs and have many tangible positive effects including preventing further decline and reducing risk of complications related to immobility. Restorative nursing does not require a physician's order. Patients may enter a restorative nursing program in several ways including after discharge from a skilled physical, occupational, or speech rehabilitation program. Techniques include passive range of motion and active range of motion. Interventions were provided by nursing staff who have completed the appropriate competency evaluation.

SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Medication Errors (Tag F0758)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to adequately monitor and assess Resident #44 for adverse consequences following the initiation of the psychoactive medication, Ambien. The facility also failed to provide an appropriate diagnosis for the use of the antipsychotic medication, Risperidone for Resident #46. Actual harm occurred on 07/23/21 when Resident #44 sustained a fall resulting in a fractured arm (humerus) related to possible side effects of the new Ambien medication being prescribed for the resident without proper monitoring and notification of the physician of the presence of adverse side effects prior to the resident's fall/fracture. This affected one resident (#44) of three residents reviewed for falls and one resident (#46) of five residents reviewed for unnecessary medication use. Findings include: 1. Record review revealed Resident #44 was admitted to the facility on [DATE] with diagnoses including unspecified dementia, history of falls, anxiety, depression and cognitive communication deficit. Review of the care plan, revised 11/11/20 revealed the resident was at risk for falls. Interventions included to have bed in lowest position, non-skid socks or shoes on, leave bathroom light on and leave bathroom door ajar. Review of the physicians' orders for July 2021 revealed on 07/01/21 a new order was obtained for Ambien 10 milligrams (mg), one tablet every night for insomnia. Review of the nursing progress note, dated 07/02/21 at 3:41 A.M. revealed the resident was documented to have had an adverse reaction to Ambien as she had been excitable and yelling all night and had been attempting to wander into other resident's rooms. There was no evidence the physician was notified of the adverse reaction at that time. Review of the Treatment Administration Record (TAR) for 07/2021 revealed Resident #44 was documented to have received one Ambien 10 mg tablet every night from 07/02/21 through 07/23/21. There was no evidence the resident was assessed/monitored for side effects/additional adverse consequences of the medication during this time period. Review of a nursing progress note, dated 07/23/21 at 2:30 A.M. revealed Resident #44 was heard yelling out and was found lying on the floor of her room complaining of pain to her left arm. The Nurse Practitioner (NP) was notified of the fall and gave orders for the resident to be sent to the hospital where she was diagnosed with a fractured humerus. The resident was re-admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/27/21 revealed Resident #44 was assessed to have mildly impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 11. This resident was assessed to require extensive assistance from one staff member for bed mobility and toileting and limited assistance from one staff member for transfers. This resident was assessed to have suffered one fall without major injury since the prior assessment. Review of the facility list of resident falls from 10/01/20 through 10/18/21, provided by Registered Nurse (RN) #325, revealed Resident #44 was identified to have one fall during this time period, the fall on 07/23/21. On 10/20/21 at 10:30 A.M. interview with Interim Director of Nursing (IDON) #325 revealed she was not aware of any adverse side effects of the medication prior to the resident's fall/fracture on 07/23/21. IDON #325 verified the lack of evidence of monitoring of the medication between 07/02/21 and 07/23/21. IDON #325 started at the facility the beginning of July 2021. On 10/20/21 at 1:20 P.M. interview with Medical Director (MD) #675 verified he had ordered Ambien for Resident #44 but could not recall being notified of any adverse side effects of the medication by facility staff. MD #675 revealed if he had been notified of adverse side effects of the Ambien therapy, he would have placed the medication on hold until he could have reassessed Resident #44. Medication guidelines reveal Ambien is designed for short term use only and commonly prescribed for anxiety related insomnia and other sleeping difficulties. The medication may cause some people, especially older persons, to become drowsy, lightheaded, dizzy, unsteady, or less alert than they are normally, which may lead to falls as seniors are more likely to be more sensitive to the drugs' effects than younger adults. The medication can cause confusion and memory problems that more than double the risk for falls and fractures in the elderly. The recommended dose of Ambien in these patients is 5 milligrams once daily before bedtime. 2. Review of Resident #46's medical record revealed an original admission date of 09/25/15 with diagnoses including Alzheimer's disease, chronic pain, nonthrombocytopenia purpura, anxiety, atherosclerotic heart disease, cardiac pacemaker, bradycardia, diabetes mellitus type II, anorexia, dementia with behavioral disturbance, debility, dysphagia, cognitive communication deficit, depression, peripheral vascular disease, hyperlipidemia, COVID-19, muscle wasting and atrophy, hypertension and atrial flutter. Review of the resident's quarterly MDS 3.0 assessment, dated 08/31/21 revealed the resident had a BIMS score of 3, indicating severe cognitive impairments. Review of physician's orders revealed an order (dated 09/01/21) for Risperidone 1 mg by mouth daily at bedtime for dementia related to agitation/irritability. The resident also had an order (dated 09/02/21) for Risperidone 0.75 mg by mouth daily in the morning On 10/20/21 at 11:02 A.M. interview with the Director of Nursing verified the resident was currently receiving two doses of an antipsychotic medication, Risperidone for a diagnosis of dementia with behavioral disturbance. The Director of Nursing verified these were not appropriate medications for the resident's diagnoses. No additional information was provided during the survey to justify the use of the medication for Resident #46.

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 and interview the facility failed to ensure Resident #47 had the right to make choices about aspects of his/her life in the facility, including a change in rooms, that was significant to the resident. This affected one resident (#47) of two residents reviewed for choices. Findings include: Medical record review revealed Resident #47 was admitted to the facility on [DATE] and had a Brief Interview for Mental Status (BIMS) score of 11 on a Minimum Data Set (MDS) 3.0 assessment, dated 09/03/21, indicating the resident had moderately impaired cognition. However, there was no documentation in the resident's medical record the resident was unable to make decisions for herself. Review of a social service progress note, written by Social Service Aide #635 on 10/01/21 at 4:25 P.M. revealed Resident #47 was requesting to be moved with her friend across the hall. The note indicated the resident was advised she would be moved on Saturday when housekeeping staff returned. Review of a social service progress note, dated 10/01/21 at 4:27 P.M. revealed Resident #70 requested to have her friend across the hall as her roommate. She understands the move would happen on Saturday when housekeeping staff returned. On 10/18/21 at 10:41 A.M. interview with Resident #47 revealed she had wanted to change rooms and move across the hallway into a room with her friend. She stated the facility spoke with her son, who was her power of attorney and since he did not want her to move, she was not permitted to change rooms. The resident stated she wanted to make her own decisions. Interview with Social Service Aide (SSA) #635 on 10/20/21 at 3:15 P.M. confirmed she documented the notes indicating Resident #47 and #70 were notified Resident #47 would be moving into the room with Resident #70. She stated the room move did not occur because the healthcare team did not feel it would be ideal for them to be roommates and Resident #47's son did not want her to be moved. SSA #635 indicated the surveyor should discuss this further with the Interim Director of Nursing because she really only documented on the room move and was not involved with the decision not to move the resident. Interview with Interim Director of Nursing #325 on 10/20/21 at 3:20 P.M. revealed she did not know why Resident #47 was not moved to the room with her friend after she was told she would be moved. A copy of an email was provided to the surveyor which was sent from Environmental Services Director #100 to a group of staff including the Administrator, Social Service Aide #635, and Social Service Coordinator #860 which documented Resident #47's room was not changed because her son said no. There was no additional information provided to support the resident not being able to make this choice for herself or any follow up discussion regarding the resident's request.

CONCERN (D)

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

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

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Based on record review, interview and facility policy and procedure review the facility failed to notify Resident #15's family of a change in condition and new medication orders. This affected one resident (#15) of one reviewed for change in condition. Findings include: Review of Resident #15's medical record revealed an admission date of 09/19/17 with the admitting diagnoses of dementia, adult failure to thrive, anorexia, abnormal weight loss, personal history of COVID-19, seasonal allergic rhinitis, rosacea, major depressive disorder, glaucoma, peripheral vascular disease, dysphagia and age related debility. A physician's order, dated 04/21/21 revealed the resident was admitted to Hospice services. Review of the resident's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/23/21 revealed the resident had clear speech, sometimes understood others, sometimes made herself understood and had a severe cognitive deficit as indicated by a Brief Interview for Mental Status score of one. Review of the mood and behavior section of the MDS revealed the resident displayed verbal behaviors directed towards others, behaviors not directed towards others and wandered. The resident required supervision with bed mobility, transfers and ambulation. The MDS indicated the resident had less than six months life expectancy and received Hospice services. Review of the resident's monthly physician's orders for October 2021 revealed an order, dated 10/18/21 for oxygen at two liters per minute as needed for shortness of breath and an order for the antibiotic, Cefuroxime Axetil 500 milligrams (mg) by mouth one time daily for one day then give one tablet by mouth twice a day for four days for probable lower respiratory infection. Review of the medical record failed to provide any documented evidence of why the resident was placed on an antibiotic or evidence the resident's son was notified of the change in condition or new orders. On 10/19/21 at 9:27 A.M. a family interview conducted with Resident #15's son revealed he was not aware of any recent respiratory infections or recent medication changes for the resident. On 10/20/21 at 3:10 P.M. interview with Interim Director of Nursing (IDON) #235 verified the resident's son was not notified of the change in condition or new medication orders dated 10/18/21. Review of the facility policy titled, Change in Condition, dated 11/2016 revealed the facility must immediately inform the resident, consult with the resident's physician and notify the resident representative when there was a significant change or a need to alter treatment significantly.

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** 2. Record review revealed Resident #54 was admitted to the facility on [DATE] with diagnoses including anemia, depression, hyperlipidemia, diabetes mellitus, muscle weakness and need for assistance with personal care. Review of the quarterly MDS 3.0 assessment, dated 09/04/21 revealed Resident #54 had severely impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 00. This resident was assessed to require extensive assistance from two staff members for bed mobility, transfers, toileting and dressing and to require supervision with two person physical assist for eating and drinking. On 10/18/21 at 12:04 P.M. observation of the lunch meal revealed Resident #54's meal tray was set up by staff and the resident was observed to be feeding herself independently with staff supervision. Interview with Registered Nurse (RN) #325 on 10/20/21 at 3:15 PM verified Resident #54 was able to eat independently with supervision and set up from one staff member and the MDS assessment dated [DATE] was incorrect. Based on observation, record review and interview the facility failed to ensure Minimum Data Set (MDS) 3.0 assessments were complete and accurate. This affected two residents (#25 and #54) of 27 sampled residents whose MDS assessments were reviewed. Findings include: 1. Review of the medical record for Resident #25 revealed an admission date of 04/03/19 with diagnosis including mood disorder, depression and dementia with behavioral disturbance. Review of the physician's orders for 07/2021, 08/2021, 09/2021 and 10/2021 revealed Resident #25 was not receiving any medications for mood disorder, depression or behavioral disturbances. Review of Resident #25's quarterly MDS 3.0 assessment, dated 08/04/21 revealed the cognitive patterns, mood and behavior section of the assessment were incomplete. The answer boxes contained dashes for the interviewer and staff portion of the assessment. Review of the progress notes for the look back period of the quarterly assessment did not reveal any abnormal behaviors noted. Review of Resident #25's plan of care revealed a plan in place to address resisting care, refusal of care and inappropriate sexual behaviors. On 10/20/21 at 10:20 A.M. interview with Social Service Aide (SSA) #400 revealed she completed the sections for cognitive patterns, mood and behavior of the MDS. SSA #400 revealed she would insert dashes for the answer if the resident was discharged to the hospital before the assessment was completed, if the resident was non verbal or if the resident was in a vegetative state. SSA #400 confirmed she completed the MDS sections for cognitive patterns, mood, and behaviors for Resident #25 and had inserted dashes for the answers but stated this was because the resident refused to answer the questions. She also confirmed the staff assessment portion was not completed.

CONCERN (D)

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

PASARR Coordination (Tag F0644)

Could have caused harm · This affected 1 resident

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Based on record review, review of pre-admission screening review results and interview the facility failed to ensure Resident #67, a resident with a newly evident mental disorder was referred to the appropriate State-designated mental health authority for review for the need for level two services. This affected one resident (#67) of one resident reviewed for pre-admission screening and resident review (PASARR). Findings include: Medical record review revealed Resident #67 was admitted to the facility 02/25/20. Review of a pre-admission screening review, dated 02/25/20 revealed the resident had no indications of serious mental illness. Therefore, an in-person assessment was not required. A diagnosis of psychosis was added for the resident on 10/28/20. Review of nursing progress notes revealed on 10/26/20 at 3:28 P.M. Resident #67 had several behaviors on this date. The resident has been verbally aggressive towards staff. Resident has called family members making up stories on staff. Resident has yelled and screamed at this nurse and aide all day making negative comments and refusing care. Physician notified and received new order to give an extra one time dose of Ativan at 5:30 P.M. and change Ativan order to one milligram three times daily. A note on 10/27/21 at 1:47 A.M. revealed the resident was having increased agitation this shift. Yelling out for staff, refusing to use the call light and calling facility. Redirection ineffective. A note on 10/28/20 at 10:35 P.M. revealed resident had a very rough day. Resident has been yelling and screaming non stop all day at residents and staff. Resident has made several calls to family members and making up things that are not true. The family members have called back and spoke to this nurse stating they know the things she is saying are not true and are on our side but they want to know if she could possibly start some new and stronger medications for all these behaviors and lies she is calling them about daily. This nurse and aides have tried anything and everything to please her today and get her anything she needed or wanted but the resident wanted to cuss, scream, and was combative, argumentative, and disagreeable to nurses and aides today. A note on 10/29/20 at 8:15 A.M. revealed staff spoke with physician about resident's recent behaviors. New order was given for an antipsychotic (Risperdal 0.5 milligrams twice daily) for psychosis. Review of Minimum Data Set (MDS) 3.0 assessments, dated 10/30/20, 12/04/20, 03/04/21, 06/17/21, and 09/17/21 all indicated the resident had a psychotic disorder. The annual MDS 3.0 assessment, dated 03/04/21 indicated a level two review was not done. There was no evidence Resident #67, who had a newly evident mental disorder, was referred to the appropriate State-designated mental health authority for review for the need for level two services following the new diagnosis. On 10/19/21 at 8:40 A.M. interview with Interim Director of Nursing (DON) #325 confirmed the last resident review by the State authority was on 02/25/20 (at the time of the resident's admission). The Interim DON confirmed the resident was not referred to the State-designated mental health authority for review for the need for level two services after the new diagnosis of psychosis on 10/28/20.

CONCERN (D)

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

Deficiency F0655 (Tag F0655)

Could have caused harm · This affected 1 resident

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Based on obsesrvation, record review, interview and facility policy and procedure review the facility failed ensure baseline care plans for Resident #61 and Resident #226 included the use of oxygen. This affected two residents (#61 and #226) of 27 sampled residents whose care plans were reviewed. Findings include: 1. Review of Resident #61's medical record revealed an admission date of 09/10/21 with the admitting diagnoses of displaced spiral fracture of shaft of right femur, COVID-19, symbolic dysfunction, difficulty in walking, hypertension, gastro-esophageal reflux disease, hypothyroidism, major depressive disorder, neuromuscular dysfunction of bladder and muscle weakness. Review of the resident's admission Evaluation dated 09/10/21 revealed the resident was admitted with no special treatment and/or procedure. The resident had no baseline plan of care related to oxygen use. Review of the resident's comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 09/17/21 revealed the resident had clear speech, usually understood others, made herself understood and had a moderate cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of seven. The resident required extensive assistance of two staff for bed mobility, transfers and was dependent on two staff for bathing. The assessment indicated the resident had no natural teeth or fragments. The assessment revealed the resident received oxygen therapy. Review of the resident's progress notes revealed on 09/19/21, 09/20/21, 09/21/21, 09/22/21, 09/23/21, 09/24/21, 09/25/21, 09/26/21, 09/27/21, 09/28/21, 09/29/21, 09/30/21, 10/01/21, 10/02/21, 10/03/21, 10/04/21, 10/05/21, 10/10/21 and 10/12/21 the resident had received oxygen therapy. On 10/18/21 at 3:46 P.M. observation of the resident's room revealed an oxygen concentrator with undated oxygen tubing wrapped around the handle of the resident's night stand. On 10/20/21 at 10:45 A.M. interview with Interim Director of Nursing (IDON) #235 verified the resident utilized oxygen, had no order physician order for the oxygen and the baseline and/or comprehensive plan of care did not reflect the need for/use of oxygen for the resident. 2. Review of Resident #226's medical record revealed an admission dated of 10/13/21 with the admitting diagnoses of pneumonia due to COVID-19, symbolic dysfunction, hypertension, gastro-esophageal reflux disease, hypothyroidism, anxiety disorder and major depressive disorder. Review of the resident's discharge instructions from the acute care hospital stay revealed the resident's oxygen use had peaked at 11 liters but the resident now required oxygen at 3 to 5 liters per minute via nasal cannula to maintain oxygen saturations. Review of the resident's admission evaluation dated 10/13/21 identified the resident as having no special treatments/procedures for respiratory status. The resident had no baseline plan of care related to the resident's oxygen use. Review of the plan of care, dated 10/15/21 revealed the resident was at risk and/or has a respiratory impairment. Interventions included obtain pulse oximetry and report abnormal findings, administer medications/treatments as ordered per physician, elevate the head of the bed and evaluate lung sound and vital signs as needed. Review of the resident's monthly physician's orders for October 2021 identified no orders for oxygen or pulse oximetry. Review of the resident's comprehensive Minimum Data Set (MDS) 3.0 assessment with assessment reference date (ARD) of 10/20/21 was still in progress at the time of the survey. On 10/18/21 at 11:15 A.M. Resident #226 was observed with oxygen at two liters per minute per nasal cannula. On 10/19/21 at 1:57 P.M. interview with IDON #235 verified the resident had no plan of care for the roxygen use. Review of the facility policy titled Requirements and Guidelines for Clinical Record Content, dated 01/31/17 revealed upon admission, a care plan was developed to address the primary reason for admission and treatment of the resident's most immediate care needs. A comprehensive care plan was developed within seven days of completion of the comprehensive assessment.

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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Based on observation, record review, staff interview and facility policy and procedure review the facility failed to develop a comprehensive plan of care related to oxygen use for Resident #15. This affected one resident (#15) of 27 sampled residents whose care plans were reviewed. Findings include: Review of Resident #15's medical record revealed an admission date of 09/19/17 with the admitting diagnoses of dementia, adult failure to thrive, anorexia, abnormal weight loss, personal history of COVID-19, seasonal allergic rhinitis, rosacea, major depressive disorder, glaucoma, peripheral vascular disease, dysphagia and age related debility. Review of the resident's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/23/21 revealed the resident had clear speech, sometimes understood others, sometimes made herself understood and had a severe cognitive deficit as indicated by a Brief Interview for Mental Status score of one. The resident required supervision with bed mobility, transfers and ambulation. The MDS indicated the resident had less than six months life expectancy and received Hospice services. Review of the resident's plan of care revealed no care plan addressing the resident's respiratory status and oxygen use. On 10/19/21 at 2:20 P.M. observation of the resident's oxygen concentrator revealed it was powered on and set at two liters per minute. The resident's oxygen tubing was laying on the floor while the resident was sitting on her bed. On 10/20/21 at 3:10 P.M. interview with Interim Director of Nursing (IDON) #235 verified the resident had no comprehensive plan of care addressing the oxygen use. Review of the facility policy titled Requirements and Guidelines for Clinical Record Content, dated 01/31/17 revealed upon admission, a care plan was developed to address the primary reason for admission and treatment of the resident's most immediate care needs. A comprehensive care plan was developed within seven days of completion of the comprehensive assessment.

CONCERN (D)

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

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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Based on record review and interview the facility failed to revise Resident #17's plan of care related to range of motion following the discontinuation of therapy services. This affected one resident (#17) of 27 sampled residents whose care plans were reviewed. Findings include: Review of the medical record for Resident #17 revealed an admission date of 04/15/21. The resident was admitted from the hospital after treatment for a cerebral vascular accident. Review of an admission Minimum Data Set (MDS) 3.0 assessment, dated 04/22/21 revealed the resident had short and long term memory impairment, required extensive assistance from two staff with transfers, locomotion, dressing and hygiene. The resident required extensive assistance from one staff for eating. The resident was identified as having impairment in range of motion of the upper and lower extremities on one side. Record review revealed the resident was provided with physical therapy from 04/16/21 until 06/24/21. The physical therapy evaluation revealed the resident was exhibiting a new onset of decrease in functional mobility. Notes indicated the resident previously lived in an apartment independently. The notes indicated the resident's left lower extremity range of motion was impaired but without contractures. The physical therapy discharge summary on 06/24/21 revealed the resident required substantial/maximal assistance with transfers from chair to bed, was dependent for toilet transfer and no longer allowed attempts at walking. The discharge summary revealed follow up care was to include a restorative range of motion program. There was no evidence a restorative range of motion program was implemented. Review of Resident #17's plan of care (initiated 04/16/21) revealed the resident had an activity of daily living deficit as evidenced by muscle atrophy and weakness multiple sites related to recent cerebral vascular accident. The goal was to improve activity of daily living self performance. The only intervention included was physical therapy (which was discontinued 06/24/21). There was no evidence the plan of care was revised after therapy was discontinued 06/24/21. Review of a quarterly MDS 3.0 assessment, dated 07/23/21 revealed the resident was totally dependent upon two staff for transfers, required extensive assistance from staff with dressing, eating, and hygiene, and now had impairments in range of motion on both sides including upper and lower extremities. Interview with MDS Coordinator #145 on 10/20/21 at 11:09 A.M. confirmed there was no evidence the plan of care was revised related to range of motion after therapy was discontinued 06/24/21.

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** 2. Review of the medical record for Resident #48 revealed an admission date of 05/17/17 with diagnoses including legal blindness, peripheral vascular disease, assistance with personal care and muscle wasting. Review of the activities of daily living plan of care, dated 05/24/17 revealed Resident #48 required assistance with bathing. Review of MDS 3.0 assessment, dated 09/01/21 indicated the resident required extensive physical assistance of two persons for transfers and personal hygiene. Resident #48 required extensive physical assistance from one person for bathing. Review of the progress notes, dated 08/01/21 through 10/18/21 revealed no documentation of Resident #48 refusing a shower or bath. Review of the State Tested Nursing Assistant (STNA) task documentation revealed Resident #48 was to receive a shower on Monday and Thursday and as needed on the day shift. Review of the documentation for 08/2021, 09/2021 and 10/2021 revealed Resident #48 received a shower/bath on the following dates: 08/12/21, 08/16/21, 09/06/21, 09/09/21, 09/13/21, 09/23/21, 09/27/21, 10/04/21 and 10/14/21. There was no documentation of a shower/bath or reason why a shower/bath was not provided as scheduled on 08/02/21, 08/05/21, 08/09/21, 08/23/21, 08/26/21, 08/30/21, 09/02/21, 09/30/21, 10/07/21 or 10/18/21. An interview on 10/18/21 at 10:14 A.M. with Resident #48 revealed she requested to be showered two times per week and had only received one or two showers here and there. An interview on 10/21/21 at 9:22 A.M. with Resident #48 revealed she was waiting on the STNA to take her to the shower room. An interview on 10/20/21 at 7:40 A.M. with STNA #420 revealed Resident #48 would often say she does not want a shower or bath. STNA #420 said a resident who refused shower or bath would be offered two times, and if the resident continued to refuse, she would notify the nurse. The STNA stated she would document the refusal in the task section of the care plan. An interview on 10/20/21 at 11:30 A.M. with Interim Director of Nursing (IDON) #325 revealed a resident who refused a bath or shower would be offered two times and the STNA would notify the nurse. The nurse would attempt and if the resident continued to refuse, the STNA would document in the task section the refusal. IDON DON #325 reviewed the task documentation and confirmed no refusals were documented for Resident #48. IDON #325 could not answer why Resident #48 did not receive showers as scheduled/requested. Based on observation, record review and interview the facility failed to ensure Resident #48 and Resident #61, who required extensive assistance/dependence on staff for activities of daily living received adequate and routine showers to maintain proper hygiene. This affected two residents (#48 and #61) of two residents reviewed for activities of daily living. Findings include: 1. Review of Resident #61's medical record revealed an admission date of 09/10/21 with the admitting diagnoses of displaced spiral fracture of shaft of right femur, COVID-19, symbolic dysfunction, difficulty in walking, hypertension, gastro-esophageal reflux disease, hypothyroidism, major depressive disorder, neuromuscular dysfunction of bladder and muscle weakness. Review of the plan of care, dated 09/13/21 revealed the resident had a self-care deficit as evidenced by weakness and limited mobility related to physical limitations due to a femur fracture with surgical repair. Interventions included to transfer with mechanical lift with large size sling with two person assist, assist to bathe/shower as needed, assist with daily hygiene, grooming, dressing, oral care and eating as needed, set up assist with meal trays by offering to open packages and containers, cutting up meat/vegetables, use assuasive/adaptive equipment wheelchair and non-weight bearing to right lower extremity. Review of the resident's comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 09/17/21 revealed the resident had clear speech, usually understood others, made herself understood and had a moderate cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of seven. The resident required extensive assistance of two staff for bed mobility and transfers and was dependent on two staff for bathing. Review of the resident's activities daily preference revealed it was very important to choose between a tub bath, shower, bed bath or sponge bath. Review of the task bar revealed the resident's scheduled showers were Monday, Wednesday and Friday evenings. Review of the resident's shower documentation for September 2021 revealed no evidence the resident received a shower and/or bed bath on the scheduled days of 09/10/21, 09/13/21, 09/15/21, 09/17/21, 09/20/21, 09/22/21, 09/24/21, 09/27/21 and 09/29/21. Review of the resident's shower documentation for October 2021 revealed no evidence the resident received a shower and/or bed bath on the scheduled days of 10/04/21, 10/08/21, 10/11/21 and 10/18/21. On 10/18/21 at 3:39 P.M. interview with the resident revealed he had not received any showers since being admitted to the facility on [DATE]. On 10/19/21 at 8:45 A.M. observation of the resident revealed the resident's hair was greasy and unkempt. On 10/20/21 at 8:25 A.M. observation of the resident revealed the resident's hair was greasy and unkempt. On 10/20/21 at 11:25 A.M. interview with Registered Nurse (RN) #540 verified the resident had not had a shower since admission because the nursing assistant staff had reported the resident preferred a bed bath. The RN revealed she had not confirmed with the resident the preference for bathing.

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 record review and interview the facility failed to ensure collaborative and coordinated care with Hospice to meet the total care needs of Resident #15. The facility failed to maintain any documentation from Hospice with regards to care or services provided in the resident's medical record. This affected one resident (#15) of one resident reviewed for Hospice services. Findings include: Review of Resident #15's medical record revealed an admission date of 09/19/17 with the admitting diagnoses of dementia, adult failure to thrive, anorexia, abnormal weight loss, personal history of COVID-19, seasonal allergic rhinitis, rosacea, major depressive disorder, glaucoma, peripheral vascular disease, dysphagia and age related debility. Review of the resident's physician's orders revealed an order, dated 04/21/21 to admit resident for Hospice services. Review of the plan of care, dated 04/23/21 revealed the resident had a terminal prognosis related to dementia with restlessness and increased agitation. Interventions included to encourage support system of family and friends. Allow compassionate immediate family visits per facility policy, Hospice and team to ensure the resident's spiritual, emotional, intellectual, physical and social needs were met. Review of the plan of care, dated 05/04/21 revealed hospice/palliative care need due to terminal illness. Interventions included to administer medications per physician orders, allow patient/family to discuss feelings, assist to reposition, assist with activities of daily living (ADL) care and pain management as needed, collaborate care with hospice, dietary to evaluate and modify meal and snack plan as needed, encourage to participate in activities as able, honor advanced directives, Hospice services with with Hospice staff to visit to provide care, assistance and/or evaluation due to terminal illness; will collaborate all care/plan of care with Hospice. Review of the resident's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had clear speech, sometimes understood others, sometimes made herself understood and a severe cognitive deficit as indicated by a Brief Interview for Mental Status score of one. The MDS indicated the resident had less than six months life expectancy and received Hospice services. Review of the resident's medical record failed to provide any documentation or evidence of coordination of care from Hospice for Resident #15. On 10/19/21 at 2:23 P.M. interview with Licensed Practical Nurse (LPN) #900 revealed Resident #15 had been admitted to Hospice on 04/22/21. However, Hospice staff had their own charting system and doesn't leave any documentation with the facility. On 10/20/21 at 2:49 P.M. interview with Medical Records #215 verified the facility had no documentation from the resident's Hospice company. Review of the facility Hospice contract, dated 11/30/17 revealed the facility and hospice would prepare and maintain a complete medical record for Hospice residents receiving facility services in accordance with the agreement and would include all treatments, progress notes, authorizations, physician's orders and other pertinent information. Documentation of care and services provided by Hospice would be filed and maintained in the facility chart.

CONCERN (D)

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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure Resident #54's left hip was comprehensively assessed prior to implementing a skin treatment and failed to ensure a physician order was in place for the treatment. This affected one resident (#54) of three sampled residents reviewed for skin/wound care. Findings include: Record review revealed Resident #54 was admitted to the facility on [DATE] with diagnoses including anemia, depression, hyperlipidemia, diabetes mellitus, muscle weakness and need for assistance with personal care. Review of the care plan, revised 08/12/21 revealed Resident #54 was at risk for alteration in skin integrity and had a history of scratching arms and legs. Interventions included a low air loss (Hospice) mattress. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 09/04/21 revealed Resident #54 had severely impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 00. This resident was assessed to require extensive assistance from two staff members for bed mobility, transfers, toileting and dressing and required supervision with two person physical assist for eating and drinking. On 10/19/21 at 2:20 P.M. Resident #54 was observed with a foam border dressing located on her left hip which was dated 10/13/21. At the time of the observation, interview with State Tested Nursing Assistant (STNA) #150 and STNA #335 verified Resident #54 had a foam border dressing on her left hip which contained the date 10/13/21. No additional information was provided related to why the dressing was in place at that time. On 10/20/21 at 4:15 P.M. Resident #54 was observed to continue to have a foam border dressing on her left hip which contained the date 10/13/21. At the time of the observation, interview with Registered Nurse (RN) #120 and Licensed Practical Nurse (LPN) #160 verified Resident #54 had a foam border dressing to her left hip which contained the date 10/13/21. No additional information was provided by the RN or LPN related to why the dressing was in place. Review of the active physician's orders for October 2021 revealed no current order for a treatment to the resident's left upper hip. In addition, review of the resident's assessments and progress notes from 10/13/21 through 10/20/21 revealed no assessment of the resident's left hip or information related to why the foam border dressing was applied on 10/13/21.

CONCERN (D)

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure fall risk interventions were in place as care planned to prevent falls for residents. This affected three residents (#24, #44 and #54) of three residents reviewed for falls. Findings include: 1. Record review revealed Resident #44 was admitted to the facility on [DATE] with diagnoses including unspecified dementia, history of falls, anxiety, depression, and cognitive communication deficit. Review of the care plan, revised 11/11/20 revealed Resident #44 was at risk for falls. Interventions included to have bed in lowest position, non-skid socks or shoes on, leave bathroom light on, and leave bathroom door ajar. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/27/21 revealed Resident #44 was assessed to have mildly impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 11. This resident was assessed to require extensive assistance from one staff member for bed mobility and toileting and limited assistance from one staff member for transfers. The resident was assessed to have suffered one fall without major injury since the prior assessment. On 10/20/21 at 9:40 A.M. Resident #44 was observed in bed. The resident's bed was not in the lowest position at the time of the observation as care planned. Interview with State Tested Nursing Assistant (STNA) #212 at the time of the observation, verified Resident #44's bed was not in the lowest position. 2. Record review revealed Resident #24 was admitted to the facility on [DATE] with diagnoses including cerebral infarction, hemiplegia and hemiparalysis following cerebral infarction affecting the right dominant side, muscle wasting and atrophy and need for assistance with personal care. Review of the care plan, revised 08/12/20 revealed Resident #24 was at risk for falls. Interventions included bed in low position, low bed, air mattress with bolsters to bed and implement use of grabbing assist tool. Review of the annual MDS 3.0 assessment, dated 08/03/21 revealed Resident #24 had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 15. This resident was assessed to require extensive assistance from two staff members for bed mobility, toileting, dressing and personal hygiene. On 10/18/21 at 2:41 P.M. Resident #24 was observed in bed with the bed in a high position. No bolsters were observed to the resident's mattress and no grabbing assist tool was observed within the resident's reach or in the room. On 10/19/21 at 8:57 A.M. Resident #24 was observed in bed with the bed in a high position. No bolsters were observed to the resident's mattress and no grabbing assist tool was observed within the resident's reach or in the room. On 10/19/21 at 2:05 P.M. Resident #24 was observed in bed with the bed in a high position. No bolsters were observed to the resident's mattress and no grabbing assist tool was observed within the resident's reach or in the room. On 10/19/21 at 2:05 P.M. interview with STNA #360 verified Resident #24 was in bed and the bed was in a high position, there were no bolsters located on the side of the resident's mattress and no grabbing assist tool was observed in the resident's reach or in the resident's room. On 10/20/21 at 8:50 A.M. Resident #24 was observed in bed with the bed in a high position. No bolsters were observed to the resident's mattress and no grabbing assist tool was observed within the resident's reach or in the resident's room On 10/20/21 at 8:50 A.M. interview with Registered Nurse (RN) #975 verified Resident #24 was in bed with the bed in a high position, there were no bolsters located on the side of the resident's mattress, and no grabbing assist tool in the resident's reach or in the resident's room as per the resident's fall risk plan of care. 3. Record review revealed Resident #54 was admitted to the facility on [DATE] with diagnoses including anemia, depression, hyperlipidemia, diabetes mellitus, muscle weakness and need for assistance with personal care. Review of the care plan, revised 04/27/21 revealed Resident #54 was at risk for falls. Interventions included non-skid socks on when in bed, scoop/perimeter mattress, staff education on low bed, implement use of hipsters and mattress on floor at bedside. Review of the quarterly MDS 3.0 assessment, dated 09/04/21 revealed Resident #54 had severely impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 00. This resident was assessed to require extensive assistance from two staff members for bed mobility, transfers, toileting and dressing and to require supervision with two person physical assist for eating and drinking. This resident was not assessed to have had any falls since the prior assessment. Review of the nursing progress note, dated 09/29/21 at 9:15 A.M. revealed Resident #54 was found lying on the floor next to her bed which had been elevated for the breakfast meal and not been placed back down in low position afterward. On 10/18/21 at 10:10 A.M. Resident #54 was observed lying on a mattress on the floor beside her bed and was not wearing hipsters. On 10/18/21 at 2:33 P.M. Resident #54 was observed lying on a mattress on the floor beside her bed and was not wearing hipsters. On 10/19/21 at 8:53 A.M. Resident #54 was observed in bed. The resident's bed was in a high position and the resident was not observed to be wearing hipsters. On 10/19/21 at 2:20 P.M. Resident #54 was observed in bed and not observed to have hipsters on. On 10/19/21 at 2:20 P.M. interview with STNA #335 verified Resident #54 did not have hipsters on but was supposed to according to the [NAME] and care plan for the resident.

CONCERN (D)

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

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Based on observation, record review and interview the facility failed to ensure pharmacy services met the needs of Resident #4 when insulin was not available in the emergency supply stock. This affected one resident (#4) of seven residents observed for medication administration. Findings include: Record review revealed Resident #4 had a physician's order for Novolin N insulin 16 units daily (scheduled at 8:00 A.M.) for a diagnosis of diabetes mellitus. On 10/20/21 at 8:30 A.M. Registered Nurse (RN) #510 was observed administering medications for Resident #4. During the observation, RN #510 revealed the Novolin N insulin was not available for Resident #4. Staff then called the physician and got a physician's order to substitute Humulin N insulin, as the Novolin N insulin was not available in the facility stock medications. However, when RN #510 went to the stock medication, Humulin N insulin was not available either. Therefore, Resident #4 was unable to receive her scheduled insulin at that time. RN #510 indicated the pharmacy was notified and the insulin would be sent at a later time. Review of the facility list of emergency stock medications to be available revealed it included Novolin N and Humulin N insulin. Interview with Interim Director of Nursing #325 on 10/21/21 at 11:01 A.M. revealed she did not know why the insulin was not available in the emergency stock as it should have been. At 11:45 A.M. she revealed the facility did not have a policy on emergency stock medications, just a list of medications to be available.

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, record review, interview, and review of the facility policy and procedure for medication administration the facility failed to maintain a medication error rate less than five (5) percent (%). The medication error rate was calculated to be 8.33% and included three medication errors of 36 medication administration opportunities. This affected two residents (#4 and #70) of seven residents observed for medication administration. Findings include: 1. Review of the medical record for Resident #70 revealed a physician's order dated 12/28/20 for Miralax 17 grams one time a day (scheduled for 8:00 A.M.) for constipation. On 10/19/21 at 8:05 A.M. Licensed Practical Nurse (LPN) #160 was observed to administer medications to Resident #70. During the administration, the LPN was not observed to administer Miralax (a laxative medication). However, the LPN signed off she administered the medication on 10/19/21 at 8:00 A.M. On 10/19/21 at 10:00 A.M. interview with LPN #160 verified she had forgotten to administer the Miralax medication to the resident but had documented it had been administered. 2. Review of the medical record for Resident #4 revealed a physician's order for Eliquis 5 mg two times daily (scheduled for 8:00 A.M. and 8:00 P.M.) for atrial fibrillation. On 10/20/21 at 8:30 A.M. Registered Nurse (RN) #510 was observed to administer medications to Resident #4. RN #510 revealed he was administering nine pills. The pills observed included Mucus Relief 400 milligrams (mg), Ferrous Sulfate 325 mg, Omeprazole 20 mg, Senna S 8.6 mg, Allopurinol 100 mg, Atorvastatin 20 mg, Benztropine 0.5 mg, Buspirone 5 mg and Lasix 40 mg. The RN verified these medications and was observed to administer them to the resident. At the time of the observation, Resident #4 was not observed to receive Eliquis 5 mg. However, review of the medication administration record revealed the Eliquis was documented as being given on 10/20/21 at 8:29 A.M., the same time the nine observed medications were signed off as given. On 10/20/21 at 10:05 A.M. interview with RN #510 revealed he administered the Eliquis medication to the resident at a later time after the surveyor was no longer watching. Review of the facility policy on Medication Administration, dated 3/2010 revealed the nurse was to remain with the resident until administration of medication was complete, then document their initials on the medication administration record for each medication administered. Interview with Interim Director of Nursing #325 on 10/20/21 at 10:40 A.M. confirmed the Eliquis was documented as given at 8:29 A.M. She confirmed RN #510 stated he gave the medication after it was documented as given. In addition, Resident #4 had a physician's order for Novolin N insulin 16 units daily (scheduled at 8:00 A.M.) for diabetes mellitus During the observation of the medication administration on 10/20/21 at 8:30 A.M. RN #510 revealed the Novolin N insulin was not available for Resident #4. Staff then called the physician and got a physician's order to substitute Humulin N insulin, as the Novolin N insulin was not available in the facility stock medications. However, when RN #510 went to the stock medication, Humulin N insulin was not available either. Therefore, Resident #4 was unable to receive her scheduled insulin at that time. RN #510 revealed the pharmacy was notified and the insulin would be sent at a later time.

CONCERN (D)

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

Antibiotic Stewardship (Tag F0881)

Could have caused harm · This affected 1 resident

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Based on record review, interview and facility policy and procedure review the facility failed to ensure laboratory testing was obtained for Resident #61 as ordered by the physician to ensure proper and justified use of antibiotic treatment for a urinary tract infection. This affected one resident (#61) of six residents reviewed for laboratory testing and unnecessary medication use. Findings include: Review of Resident #61's medical record revealed an admission date of 09/10/21 with the admitting diagnoses of displaced spiral fracture of shaft of right femur, COVID-19, symbolic dysfunction, difficulty in walking, hypertension, gastro-esophageal reflux disease, hypothyroidism, major depressive disorder, neuromuscular dysfunction of bladder and muscle weakness. Review of the resident's comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 09/17/21 revealed the resident had clear speech, usually understood others, made herself understood and had a moderate cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of seven. The assessment indicated the resident had no natural teeth or fragments. The resident received oxygen therapy. Review of the progress note, dated 9/18/2021 at 8:22 P.M. revealed new orders were received to obtain a urine specimen on 09/19/20, get a urinalysis and a culture and sensitivity (UA/C&S) on 09/20/21 and start Cipro (a medication used to treat infection) 500 milligrams (mg) twice daily for three days. Review of the resident's September 2021 Medication Administration Record (MAR) revealed the resident received a dose of Cipro 500 mg by mouth on 09/18/21 and twice daily on 09/19/21, 09/20/21 and 09/21/21. Review of the resident's medical record failed to provide UA/C&S results for the resident. On 10/20/21 at 1:27 P.M. interview with Interim Director of Nursing (IDON) #325 verified the UA/C&S was not completed and resulted in the antibiotic being administered to the resident without proper/adequate justification. Review of the facility policy titled Antibiotic Stewardship, dated 09/2017 revealed the antibiotic stewardship program would assist centers to manage and ensure the appropriate use of antibiotics while minimizing resistance to unnecessary antibiotic therapy.

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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5. Review of the medical record for Resident #328 revealed an admission date of 10/15/21 with diagnosis including pneumonia unspecified organism, anxiety and chronic obstructive pulmonary disorder. Review of the physician's orders for 10/2021 revealed the resident had an order for oxygen at two liters per minute via nasal cannula. Review of the progress notes from 10/15/21 through 10/20/21 revealed Resident #328 received a respiratory assessment three times daily. The assessment revealed the resident was on oxygen at two liters per minute via nasal cannula and oxygen saturations were in the mid 90's. Review of the respiratory care plan dated 10/16/21 revealed Resident #328 was to receive oxygen as ordered. An interview on 10/19/21 at 3:40 P.M. with Resident #328 revealed he was on three liters of oxygen at home prior to admission to hospital. An observation on 10/18/21 at 11:25 A.M. of Resident #328 revealed the oxygen tubing was not dated, the oxygen was set at three liters per minute via nasal cannula but was not hooked up to the humidification bottle on the concentrator. An interview on 10/18/21 at 11:25 A.M. with Licensed Practical Nurse (LPN) #900 confirmed the oxygen tubing was not dated or hooked up to the humidification bottle on the concentrator. An interview on 10/19/21 at 8:25 A.M. with LPN #420 confirmed the physician's order for Resident #328 was for oxygen at two liters per minute via nasal cannula. LPN #420 confirmed Resident #328 was receiving oxygen at three liters per minute via nasal cannula. Review of the facility policy titled Oxygen Administration, dated 07/2017 revealed the purpose of the policy was to describe the method of delivering oxygen in order to improve tissue oxygenation, reduce risk for hypoxia, decrease work of breathing and reduce shortness of breath with activity. The procedure included to verify the physician's order. The application of a nasal cannula included to ensure that tubing and cannula or mask was labeled with date and time (it was first opened/used). Based on observation, record review, interview and facility policy and procedure review the facility failed to ensure residents were assessed for oxygen use, had physician's orders in place for oxygen and/or failed to ensure oxygen tubing was dated and stored in a sanitary manner. This affected five residents (#15, #61, #226, #228 and #328) of six residents reviewed for oxygen therapy. Findings include: 1. Review of Resident #15's medical record revealed an admission date of 09/19/17 with the admitting diagnoses of dementia, adult failure to thrive, anorexia, abnormal weight loss, personal history of COVID-19, seasonal allergic rhinitis, rosacea, major depressive disorder, glaucoma, peripheral vascular disease, dysphagia and age related debility. Review of the resident's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/23/21 revealed the resident had clear speech, sometimes understood others, sometimes made herself understood and had a severe cognitive deficit as indicated by a Brief Interview for Mental Status score of one. The assessment indicated the resident had not used oxygen. Review of the resident's monthly physician's orders for October 2021 revealed an order, dated 10/18/21 for oxygen at two liters per minute (LPM) as needed for shortness of breath. Review of the resident's plan of care revealed no care plan addressing the resident's respiratory status and oxygen use. On 10/19/21 at 2:20 P.M. observation of the resident's oxygen concentrator revealed it was powered on and set at two LPM. The resident's oxygen tubing was laying on the floor and had no date identifying the date the tubing was opened for use. On 10/18/21 at 11:21 A.M. interview with Licensed Practical Nurse (LPN) #900 verified the resident's oxygen tubing had no date identifying when it had been opened and was not being stored in a sanitary manner. Review of the facility policy titled Oxygen Administration, dated 07/2017 revealed the purpose of the policy was to describe the method of delivering oxygen in order to improve tissue oxygenation, reduce risk for hypoxia, decrease work of breathing and reduce shortness of breath with activity. The procedure included to verify the physician's order. The application of a nasal cannula included to ensure that tubing and cannula or mask was labeled with date and time (it was first opened/used). 2. Review of Resident #61's medical record revealed an admission date of 09/10/21 with the admitting diagnoses of displaced spiral fracture of shaft of right femur, COVID-19, symbolic dysfunction, difficulty in walking, hypertension, gastro-esophageal reflux disease, hypothyroidism, major depressive disorder, neuromuscular dysfunction of bladder and muscle weakness. Review of the resident's admission Evaluation, dated 09/10/21 revealed the resident was admitted with no special treatment and/or procedure. The resident had no baseline plan of care related to oxygen use. Review of the resident's comprehensive MDS 3.0 assessment, dated 09/17/21 revealed the resident had clear speech, usually understood others, made herself understood and had a moderate cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of seven. The assessment indicated the resident received oxygen therapy. Review of the resident's monthly physician's orders for October 2021 identified no orders for oxygen. Review of the resident's plan of care failed to identify a care plan related to oxygen use. On 10/18/21 at 3:46 P.M. observation of the resident's oxygen tubing revealed the tubing had no date identifying when the tubing was opened. The tubing was wrapped around the handle on the resident's night stand. On 10/18/21 at 3:50 P.M. interview with LPN #900 verified the resident's oxygen tubing was not dated identifying when it was opened and was not stored in a sanitary manner. On 10/20/21 at 10:45 A.M. interview with Interim Director of Nursing (IDON) #325 verified the resident had no physician order for oxygen. Review of the facility policy titled Oxygen Administration, dated 07/2017 revealed the purpose of the policy was to describe the method of delivering oxygen in order to improve tissue oxygenation, reduce risk for hypoxia, decrease work of breathing and reduce shortness of breath with activity. The procedure included to verify the physician's order. The application of a nasal cannula included to ensure that tubing and cannula or mask was labeled with date and time (it was first opened/used). 3. Review of Resident #226's medical record revealed an admission dated of 10/13/21 with the admitting diagnoses of pneumonia due to COVID-19, symbolic dysfunction, hypertension, gastro-esophageal reflux disease, hypothyroidism, anxiety disorder and major depressive disorder. Review of the resident's discharged instructions from acute care hospital stay revealed the resident's oxygen use had peaked at 11 liters but the resident now required oxygen at 3 to 5 liters per minute via nasal cannula to maintain oxygen saturations. Review of the resident's admission evaluation, dated 10/13/21 identified the resident as having no special treatments and/or procedures for respiratory status. Review of the plan of care, dated 10/15/21 revealed the resident was at risk and/or has a respiratory impairment. Interventions included obtain pulse oximetry and report abnormal findings, administer medications/treatments as ordered per physician, elevate the head of the bed and evaluate lung sound and vital signs as needed. Review of the resident's monthly physician's orders for October 2021 identified no orders for oxygen or pulse oximetry. Review of the resident's comprehensive MDS 3.0 assessment with assessment reference date (ARD) of 10/20/21 was still in progress. Review of the resident's respiratory surveillance assessments from 10/14/21 to 10/19/21 revealed the resident's oxygen saturation rate was 100% on room air. The assessment failed to identify the resident's oxygen use. Review of the resident's progress notes from 10/13/21 through 10/19/21 revealed no documentation regarding the resident's use of oxygen. On 10/18/21 at 11:15 A.M. observation of the resident revealed she had oxygen at two LPM via nasal cannula. Further observation revealed the resident's oxygen tubing had no date identifying when it had been opened. On 10/18/21 at 11:20 A.M. interview with the LPN assigned to care for Resident #226 verified the oxygen tubing had not been dated to indicate when it had been opened. On 10/19/21 at 1:57 P.M. interview with IDON #325 verified the resident had no order for oxygen use and had not been assessed for oxygen use. Review of the facility policy titled Oxygen Administration, dated 07/2017 revealed the purpose of the policy was to describe the method of delivering oxygen in order to improve tissue oxygenation, reduce risk for hypoxia, decrease work of breathing and reduce shortness of breath with activity. The procedure included to verify the physician's order. The application of a nasal cannula included to ensure that tubing and cannula or mask was labeled with date and time (it was first opened/used). 4. Review of Resident #228's medical record revealed an admission date of 10/12/21 with the admitting diagnoses of atrial fibrillation, chronic obstructive pulmonary disease, congestive heart failure, severe morbid obesity, hypertension, anxiety disorder, asthma and major depressive disorder. Review of the resident's admission Evaluation dated 10/12/21 revealed the resident required oxygen therapy. Review of the resident's plan of care, dated 10/14/21 revealed the resident had a respiratory impairment related to asthma and congestive heart failure. Interventions included evaluate lung sounds, vital signs as needed, obtain labs as ordered and notify physician of results, provide assistance with activities of daily living to conserve energy, obtain pulse oximetry and report abnormal findings, administer medications/treatments per physician orders, elevate the head of bed, administer oxygen as per physician's orders at 2 liters per minute via nasal cannula and reports signs of infection or edema. Review of the resident's monthly physician's orders for October 2021 identified orders dated 10/12/21 for oxygen at two LPM via nasal cannula continuously. Review of the resident's Treatment Administration Record (TAR) revealed the resident received oxygen at two LPM via nasal cannula. Review of the resident's comprehensive MDS 3.0 assessment with assessment reference date (ARD) of 10/19/21 revealed it was still in progress. On 10/18/20 at 11:09 A.M. observation of the resident's oxygen tubing revealed no date identifying when the tubing had been opened. On 10/18/21 at 11:20 A.M. interview with LPN #900 verified the resident's oxygen tubing was not dated identifying when it had been opened. Review of the facility policy titled Oxygen Administration, dated 07/2017 revealed the purpose of the policy was to describe the method of delivering oxygen in order to improve tissue oxygenation, reduce risk for hypoxia, decrease work of breathing and reduce shortness of breath with activity. The procedure included to verify the physician's order. The application of a nasal cannula included to ensure that tubing and cannula or mask was labeled with date and time (it was first opened/used).

CONCERN (E)

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

Deficiency F0804 (Tag F0804)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview and review of the facility policy and procedure the facility failed to ensure each resident received food that was palatable and failed to ensure meals were served at appetizing temperatures. This affected seven residents (#12, #28, #47, #48, #67, #70, and #75) of 27 sampled residents. The facility census was 87. Findings include: The following food/meal concerns were identified during the annual survey: a. Record review revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including repeated falls, anxiety disorder, and rheumatoid arthritis. Review of the annual Minimum Data Set (MDS) 3.0 assessment, dated 10/01/21 revealed Resident #12 had slightly impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 11. The 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. Interview with Resident #12 on 10/18/21 at 10:44 A.M. revealed the resident voiced concerns the food/meals served was often cold and tasted badly. b. Review of a MDS 3.0 assessment, dated 09/03/21 revealed Resident #47 had a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. Interview with Resident #47 on 10/18/21 at 10:51 A.M. revealed concerns the food in general was not good and was not hot enough when served. c. On 10/18/21 at 11:21 A.M. interview with a resident who wished to remain anonymous revealed concerns the food was not good and was sometimes cold when served. d. Record review revealed Resident #75 was admitted to the facility on [DATE] with diagnoses including hypertension, obstructive and reflux uropathy and chronic obstructive pulmonary disease. Review of the admission MDS 3.0 assessment, dated 09/14/21 revealed Resident #75 had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 14. The resident was assessed to require extensive assistance from two staff members with bed mobility, transfers, and toileting and was independent for eating with setup help only. Interview with Resident #75 on 10/18/21 at 11:49 A.M. revealed the resident voiced concerns the food was often cold. e. Review of a MDS 3.0 assessment, dated 08/07/21 revealed Resident #28 had a BIMS score of 15, indicating intact cognition. Interview with Resident #28 on 10/18/21 at 12:08 P.M. revealed the food was awful and had no taste. f. Observations of the lunch meal on the 200 hall on 10/18/21 revealed the unheated cart containing the resident lunch trays arrived on the hall at 11:43 A.M. The lunch meal consisted of fish, noodles, spinach, bread, and a lemon bar. On 10/18/21 at 12:14 P.M. Resident #48, who had not received her tray yet, was asking if lunch had been served. Her lunch tray remained on the cart in the hall. On 10/18/21 at 12:15 P.M. (32 minutes after they were delivered) there were still three trays remaining on the lunch cart in the hall (Resident #32, #48, and #67). State Tested Nursing Assistant #555 revealed at that time, that those three residents needed assistance with eating and there were only two nursing assistants on the hall at that time and they were both assisting other residents to eat. Resident #48 was served her lunch at 12:23 P.M. (40 minutes after the trays were delivered to the hall). The surveyor was unable to ask Resident #48 about the temperature of the food when it was served as Resident #48 refused to even taste the food and requested a sandwich instead. Resident #67 was served her lunch at 12:30 P.M. (47 minutes after the trays were delivered to the hall). On 10/18/21 at 12:30 P.M. temperatures were taken of the tray remaining on the cart belonging to Resident #32. (It was determined at that time that Resident #32 was out for an appointment). The food temperatures were taken by Registered Dietician (RD) #565 at 12:30 P.M. on 10/18/21. The fish was 110 degrees, the noodles were 103 degrees, and the spinach was 114 degrees. The fish, noodles, and spinach were tasted by RD #565, who stated the food was not hot enough and should be at least 120 degrees when served. She stated the food should be served within 20-30 minutes of arriving on the hall. The surveyor also tasted the fish, noodles, and spinach. The food was cool to taste. Review of the facility policy titled Food Temperatures at Point of Service, dated 11/2020 revealed trays were to be delivered promptly after arriving in patient care areas. The policy further revealed the regulation that addressed food temperatures at point of service to the patient was Ftag 804. Proper temperature means both appetizing to the resident and minimizing the risk for scalding and burns.

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** 3. Record review revealed Resident #75 was admitted to the facility on [DATE] with diagnoses including enterolcolitis due to clostridium difficile, hypertension, obstructive and reflux uropathy, chronic obstructive pulmonary disease, type two diabetes mellitus, and muscle wasting and atrophy. Review of the admission MDS 3.0 assessment, dated 09/14/21 revealed Resident #75 had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 14. This resident was assessed to require extensive assistance from two staff members for toileting, bed mobility and transfers. Review of the care plan, dated 09/30/21 revealed Resident #75 had an infection of the gastrointestinal tract. Interventions included contact isolation, maintain precautions as indicated and record temperature as clinically indicated. Review of the physician's orders, dated 09/30/21 revealed an order for contact isolation related to clostridium difficile (C-Diff). On 10/18/21 at 12:05 P.M. Human Resource Director (HRD) #640 was observed to remove the lunch tray for Resident #75 from the meal cart, walked into the room of Resident #75 wearing only a surgical mask and face shield, delivered and set up the meal tray for Resident #75, then returned to her office. Interview with HRD #640 on 10/18/21 at 12:38 P.M. verified she had entered the room of Resident #75 and set up his lunch meal tray only wearing a surgical mask and face shield. HRD #640 revealed she performed hand hygiene with alcohol based hand santizer located by the resident's door on her way out of the room. Review of information from the mayoclinic (www.mayoclinic.org) related to C-Diff dated 08/27/21 revealed health care workers should practice good hand hygiene before and after treating each person in their care. In the event of a C. Diff outbreak, using soap and warm water was a better choice for hand hygiene, because alcohol-based hand sanitizers did not effectively destroy C. Diff spores. The information also indicated health care workers and visitors should wear disposable gloves and isolation gowns while in the room. 4. On 10/18/21 at 11:30 A.M. State Tested Nursing Assistant (STNA) #655 was observed to exiting Resident #62's room wearing an N95 face mask and a face shield. Resident #62 was observed to be on transmission based droplet precautions due to displaying respiratory symptoms. Upon exiting the resident's room, STNA #655 did not remove her face shield and was not observed to clean the face shield with a recommended disinfectant. The STNA was then observed to walk down the hallway and outside the double closed doors to obtain a clean sheet from the linen cart located just outside the doors. An interview on 10/18/21 at 11:33 A.M. with STNA #655 confirmed she did not properly clean her face shield upon exiting Resident #62's room. The STNA verified the resident was on transmission based droplet precautions. The STNA then indicated there were no cleaning wipes available in the personal protective equipment (PPE) cart outside Resident #62's room. Review of the CDC recommendations titled Strategies for Optimizing the Supply of Eye Protection updated 09/13/21 revealed when manufacturer instructions for cleaning and disinfection are unavailable, such as for single use disposable face shields or goggles, consider: While wearing a clean pair of gloves, carefully wipe the inside, followed by the outside of the face shield or goggles using a clean cloth saturated with neutral detergent solution or cleaner wipe. Carefully wipe the outside of the face shield or goggles using a wipe or clean cloth saturated with EPA approved hospital disinfectant solution. Wipe the outside of face shield or goggles with clean water or alcohol to remove residue. Fully dry (air dry or use clean absorbent towels). Remove gloves and perform hand hygiene. Cleaned and disinfected eye protection can be stored onsite, in a designated clean area within the facility. 5. On 10/18/21 at 12:03 P.M. observation of the lunch meal revealed STNA #245 delivered a meal tray to Resident #25's room. The resident was observed to be on transmission based droplet precautions due to displaying respiratory symptoms. The STNA exited the resident's room wearing an N95 mask, face shield and disposable gown to request a drink for the resident from another STNA. An interview on 10/18/21 at 12:03 P.M. with STNA #245 confirmed she stepped out in to the hallway without properly removing the PPE gown she was wearing. 6. On 10/18/21 at 12:20 P.M. STNA #245 was observed entering Resident #329's room. Resident #329 was on transmission based droplet precautions due to being a new admission to the facility. The STNA was observed wearing an N95 mask, face shield and disposable gown. The STNA entered the room without first applying gloves. An interview on 10/18/21 at 12:21 P.M. with STNA #245 confirmed she had entered Resident #329's without gloves as she indicated there were no gloves in the PPE cart outside of the resident's room that fit her. The STNA then informed the nurse of the need for larger gloves on the PPE cart. 7. On 10/20/21 at 8:05 A.M. observation of Resident #70 room revealed a soiled incontinence brief (Depend), wet with a strong odor was observed directly on the floor beside the bed of Resident #70. An interview on 10/20/21 at 8:06 A.M. with Resident #70 revealed she could smell the odor but did not know how or when the soiled Depend was put on the floor. An interview on 10/20/21 at 8:08 A.M. with STNA #67 confirmed the soiled depend was directly on the floor beside Resident #70's bed. STNA #67 then removed the soiled Depend from the floor and discarded it properly. The STNA did not state how or why the incontinence brief was directly on the floor. 2. Review of Resident #61's medical record revealed an admission date of 09/10/21 with the admitting diagnoses of displaced spiral fracture of shaft of right femur, COVID-19, symbolic dysfunction, difficulty in walking, hypertension, gastro-esophageal reflux disease, hypothyroidism, major depressive disorder, neuromuscular dysfunction of bladder and muscle weakness. Review of the resident's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had clear speech, usually understood others, made herself understood and had a moderate cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of seven. Review of the resident's monthly physician's orders for October 2021 identified an order dated 10/15/21 for contact isolation related to shingles and Acyclovir 800 milligrams (mg) by mouth four times a day for shingles for seven days. Review of the progress note, dated 10/15/21 revealed staff observed a small fluid filled pustules with a small reddened area around the pustules. The physician was notified and ordered Acyclovir 800 milligrams by mouth four times a day for seven days for shingles. Review of the resident's plan of care dated 10/15/21 revealed the resident had infection of the skin related to shingles to left side of coccyx. Interventions included to administer medications per physician's orders, contact isolation related to shingles, maintain precautions as indicated, obtain labs as ordered and notify physician of results and record temperature as clinically indicated. On 10/18/21 at 3:39 P.M. observation of the resident revealed she was sitting in her room watching television. There was no evidence the resident was in isolation at that time. On 10/19/21 at 8:45 A.M. observation of the resident revealed she had been placed in contact isolation. On 10/19/21 at 8:45 A.M. interview with State Tested Nursing Assistant (STNA) #245 revealed the resident was on contact isolation for shingles and confirmed the resident had not been in contact isolation prior to 10/19/21. On 10/20/21 10:06 AM interview with Registered Nurse (RN) #540 verified the resident was to be placed on contact isolation on 10/15/21. Review of the facility policy titled, Contact Precautions, dated 07/2021 revealed in addition to standard precautions, the following measures were necessary for contact precautions: wear gloves for any interactions with patient or the environment, wear gloves when in direct contact with a resident who was infected or colonized with organisms that were transmitted by direct contact, change gloves after contact with infective material, avoid contaminating other surfaces with gloved hands, apply gloves before entering and remove gloves before leaving the resident's room and immediately wash hands with an antimicrobial agent or use alcohol-based hand sanitizer, wear gown when clothing anticipated to come in contact with the resident, environmental surfaces or items in room contaminated and apply gown upon entry and remove gown before leaving room and immediately wash hands with an antimicrobial agent or use alcohol-based sanitizer. Based on observation, record review, review of the Centers for Disease Control (CDC) guidelines, interview and facility policy and procedure review the facility failed to maintain acceptable infection control practices, including the proper use of personal protective equipment (PPE), proper isolation procedures and during blood glucose monitoring to prevent the spread of infection inlcuding COVID 19. This affected eight residents (#62, #25, #329, #70, #61, #14, #28 and #75) and had the potential to affect all 87 residents residing in the facility. Findings include: 1. Review of the medical record for Resident #14 revealed a physician's order on 08/16/21 to perform a finger stick blood sugar test before meals and at bedtime. On 10/19/21 at 11:00 A.M. Registered Nurse (RN) #975 was observed to perform a finger stick blood sugar test for Resident #14. RN #975 used a lancet to obtain a drop of blood from the resident's finger. The drop of blood was applied to a test strip which had been inserted into the blood glucose meter to measure the resident's blood glucose. The resident's blood sugar was 351. RN #975 was not observed to sanitize the blood glucose meter prior to using it on Resident #14. RN #975 was not observed to sanitize the blood glucose meter after using it on Resident #14. She then took the same blood glucose meter and performed a finger stick blood sugar test for Resident #28 on 10/19/21 at approximately 11:10 A.M. Resident #14's blood sugar was 198. Medical record review revealed Resident #14 had a physician's order on 09/22/21 to have a finger stick blood sugar test before meals. Interview with RN #975 on 10/19/21 at approximately 11:15 A.M. confirmed she did not sanitize the blood glucose meter after using it on Resident #14 or prior to using it on Resident #28. She confirmed she was supposed to clean the blood glucose meter between residents using a germicidal wipe. The facility identified nine residents, Resident #14, #24, #28, #44, #45, #57, #68, #72, and #75 who received blood sugar monitoring using this blood glucose meter. None of those residents were noted to have any blood bourne diseases such as HIV/Aids, Hepatitis B or C. Review of the facility policy on Glucose Blood Monitoring dated 03/2001 and updated 1/2010, 7/2010, 2/2011 and 8/2014 revealed after performing a blood glucose test, the blood glucose meter was to be cleaned with an EPA approved bleach wipe or approved germicidal disinfectant per manufacturer instructions.

May 2019 18 deficiencies

CONCERN (D)

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

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

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2. Review of Resident #350's medical record revealed an admission date of 04/24/19 with the admitting diagnoses of generalized muscle weakness, hypothyroidism and urinary retention. Review of the resident's admission screening dated 04/05/19 revealed the resident was admitted with an indwelling urinary catheter. The resident had clear speech, understood others and able to communicate her needs. Review of the resident's plan of care dated 04/25/19 revealed she used an indwelling urinary catheter due to neurogenic bladder. Interventions included, maintain drainage bag below bladder level, report to physician signs of urinary tract infection, secure catheter with securement device, and report any changes in amount, color or odor of urine. Review of the resident's monthly physician's orders for May, 2019 revealed orders dated for 04/25/19 to maintain Foley catheter with 16 FR 10 milliliter (ml) balloon for neurogenic bladder and 04/30/19 to change urinary catheter as needed for neurogenic bladder. On 04/29/19 at 4:15 P.M. observation of Resident #350 revealed she was sitting in the lounge at the nurses station with her indwelling urinary catheter collection bag secured to a bar under her wheelchair. Further observation revealed the resident's urine was visible to other residents and visitors. Interview with Registered Nurse (RN) #98 verified the resident's urine was visible to others at the time of the observation. Review of the facility's Indwelling Catheter Care policy and procedure, dated 04/19 revealed catheter collection bags should be covered with a catheter dignity bag to preserve the dignity of the resident. Based on observations, medical record review, and staff interview, the facility failed to ensure each resident was treated with respect and dignity and was cared for in a manner and in an environment that promotes enhancement of quality of life. This affected two of four residents reviewed for dignity (Residents #79 and #350). Findings include: 1. Observations on 05/01/19 at 10:50 A.M. revealed Registered Nurse (RN) #30 to be standing at the medication cart which was sitting by the nurses station. Resident #79 propelled herself in her wheelchair up to RN #30 and started talking to her about the fact that she was going home on Friday. RN #30 ignored Resident #79 and continued what she was doing at the medication cart. RN #30 did not look at the resident or say anything to the resident. After Resident #79 did not get any response from RN #30, she stated I better leave you alone and left the area. Interview with Licensed Practical Nurse (LPN) #92 on 05/01/19 at 11:30 A.M. (who was standing nearby when the interaction occurred between Resident #79 and RN #30) revealed she did not see what happened but confirmed this was not unusual behavior for RN #30. She stated RN #30 had a very dry, flat personality. Interview with the Administrator on 05/01/19 at 2:30 P.M. confirmed this was not an appropriate interaction from RN #30. Review of the medical record for Resident #79 revealed a diagnosis of dementia and a Minimum Data Set assessment completed 04/19/19 revealed a brief interview for mental status score of 3, indicating severe cognitive impairment.

CONCERN (D)

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

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

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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 the resident's attending physician was notified when an intravenous (IV) medication was not available. This affected one of six residents reviewed for medication (Resident #303). Findings include: Review of Resident #303's medical record revealed she was admitted on [DATE] with diagnoses that included: acute respiratory failure, pneumonia, malignant neoplasm of lung, chronic pulmonary disease, and altered mental status. Review of Resident #303's admission Minimum Data Set (MDS) dated [DATE] revealed her speech was clear, understood others, understands, she had moderately impaired cognition. Resident #303 received IV medication. Review of Resident #303's physician orders revealed on 04/20/19 an IV antibiotic (Piperacillin) was ordered twice daily for pneumonia. Review of Resident #303's April, 2019 medication administration record (MAR) and 04/28/19 progress note revealed the resident did not receive the Piperacillin as it was not available until the morning. There was no evidence Resident #303's attending physician was notified the medication was not available for administration. Interview of the Director of Nursing on 05/02/19 at 4:01 P.M. confirmed there was no evidence Resident #303's attending physician was notified when the Piperacillin was not available for administration.

CONCERN (D)

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

Deficiency F0583 (Tag F0583)

Could have caused harm · This affected 1 resident

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Based on resident record review, observation, and staff interview, the facility failed to provide privacy during an eye exam for Resident #30. This affected one of one resident reviewed for privacy (Resident #30). Findings include: Review of Resident #30's medical record revealed an admission date of 10/17/17, with diagnoses of cerebral infraction (stroke) and generalized weakness. Observation on 04/29/19 at 12:07 P.M. revealed Resident #30 sitting in the dining room, along with other residents, eating lunch. Resident #30 had turned her wheelchair around toward the dining room exit door when she was approached by a person claiming to be the eye doctor. While Resident #30 was still in the dining room where other residents were still eating lunch, the eye doctor placed a patch on Resident #30's left eye and proceeded to back up slowly while asking Resident #30 to identify letters on a board she was holding. Then the patch was moved to the right eye and the test was completed once more. After completing, the eye doctor removed the eye patch and exited the dining room. Interview on 04/29/19 at 12:30 P.M. with the Administrator revealed a confirmation the eye exam should not have been completed in the dining room and was to be conducted in a private area.

CONCERN (D)

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

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, review of the facility's Abuse policy, review of a facility self-reported incident (SRI) and review of the facility abuse investigation notes, the facility failed to prevent staff to resident physical abuse. This affected one resident (Resident #24) of one resident reviewed for abuse. Findings Include: Record review revealed Resident #24 was admitted to the facility on [DATE] with diagnoses including left above the knee amputation on 11/01/18, respiratory failure, anxiety, stage IV kidney disease, paralytic syndrome, diabetes mellitus Type II, and chronic pain. Review of the quarterly Minimum Data Set (MDS) 3.0 completed on 02/15/19 revealed Resident #24 had no cognitive delay. Resident #24 was assessed as requiring extensive assistance of two plus staff for all activities of daily living, including personal hygiene, was totally dependent for 2+persons physical assistance for bathing, had an urinary catheter and was always incontinent of bowel. Review of the physician orders included an order for a #16 french foley catheter in place with a 10 cc balloon due to neurogenic bladder. Review of the SRI filed on 04/15/19 revealed State Tested Nursing Assistant (STNA) #176 threw a catheter bag against Resident #24's leg causing a bruise. During an interview with the Administrator and the Director of Nurses (DON) on 05/02/19 the DON reported an allegation of abuse was reported to Licensed Practical Nurse (LPN) # 83 on 04/15/19 after Physical Therapy Assistant (PTA) #55 reported she was in the room when she heard a conversation between Resident #24 and STNA#176 and then Resident #24 stated her leg hurt after STNA #176 threw a catheter bag against her leg. The DON reported the facility immediately sent STNA #176 home and completed an investigation into the incident. The DON stated they determined abuse did occur towards Resident #24 when STNA #176 threw the catheter bag on her leg and STNA #176 was terminated. Review of the incident report investigation indicated the facility interviewed Resident #24 who stated STNA #176 was rough with her and threw a catheter bag on her leg. STNA#176's statement dated 04/15/19 indicated Resident #24 was not ready to get up when approached for care and stated she would have another STNA get her out of bed at a later time. STNA #176 documented she had no recall of putting the foley catheter bag on the bed. A statement obtained from Resident #24 on 04/15/19 indicated she felt STNA #176 was jerking her around and when she told her to stop, STNA #176 threw the catheter bag on her leg. A statement by Activity Staff # 121 reported she entered the room towards the end of Resident #24 and STNA #176's conversation. Activity Staff #121 reported she heard Resident #24 state 'ouch that hurt me' and when she turned around, STNA #176 was leaving the room. Activity Staff # 121 reported the catheter bag was on Resident #24's leg, however, she did not see any bruising at that time. Review of a statement by Physical Therapy Assistant (PTA) #55 she reported she was in the room at the time of the incident and had finished instructing STNA#176 how to assist Resident #24 put her shrinker on. PTA #55's statement indicated she returned to assist Resident #24's roommate when she heard Resident #24 telling STNA #176 how to position the wheelchair and STNA #176 got huffy with her and then she heard Resident #24 state ouch, that hurts and told STNA #176 to get out of the room. PTA #55 reported she assessed Resident #24 leg and noted the starting of a bruise and she notified LPN #83. LPN #83 alerted the Assistant Director of Nurses (ADON) and the DON, and STNA #176 was removed from the facility pending investigation. Review of a skin assessment dated [DATE] indicated a one centimeter (cm) by one cm bruise to Resident #24's right lower leg. Review of an incident report dated 04/15/19 at 3:11 P.M. indicated LPN #83 was notified by a staff member that STNA#176 who was on duty was rough with Resident #24 and tossed the Foley catheter bag on the resident's leg. LPN #83 assessed Resident #24 and Resident #24 stated that the aide was rough with her care and spoke to her in a rough manner. Resident #24 reported STNA #176 got upset and just threw the bag on her leg. An assessment was completed at that time and Resident #24 had a 1 cm x 1 cm bruise to her right leg with no other injuries noted at this time. The physician present in the building and was notified on 04/15/19 at 3:11 P.M. The physician assessed the resident and made note of a bruise to right leg measuring 1 cm x 1 cm found at this time. The area blue/grey in color and the physician deemed it was not necessary to transport the resident to the hospital for further evaluation. The guardian was notified of the incident. STNA #176 was terminated from the facility. Staff education was provided to all employees regarding the facility Abuse/Neglect policy on 04/15/19 through 04/18/19. Review of medical record progress noted dated 04/15/19 at 3:21 P.M. indicated LPN #83 assessed Resident #24 and the resident had a 1cm by 1cm bruise to her right leg. The area was blue and grey in color. Resident #24 reported no pain to the area and no other injuries were noted at this time. A progress note on 04/15/19 at 5:19 P.M. indicated the resident's physician was in to assess the resident. A progress note on 4/17/19 at 11:29 A.M. completed by the ADON indicated Resident #24 was resting in bed in the supine position, denied pain to the bruise on her right lower shin, except when it is touched. The bruise was described as flat and purple in color with no increase in size noted. During an interview on 04/29/19 at 3:17 P.M. Resident #24 reported a STNA had thrown a catheter bag on her leg while providing care. Resident #24 reported the facility had terminated the STNA and she did not wish to press charges. On 05/02/19 at 2:58 P.M., during interview, LPN #83 reported she recalled the incident between STNA #176 and Resident #24. LPN #83 stated she was the nurse who PTA #55 reported the incident to and she immediately notified the ADON who removed STNA #176 from the building. LPN #83 stated when she went to the room and assessed resident a bruise was noted to the leg. LPN #83 reported the bruise was measured at that time. Review of the facility policy Abuse, Neglect, Exploitation, Mistreatment and Misappropriation Prevention dated 11/08/16 indicated the resident had the right to be free from abuse and the facility would not tolerate any type of physical abuse.

CONCERN (D)

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

Abuse Prevention Policies (Tag F0607)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, self reported incident (SRI) review, policy review, and interview, the facility failed to implement their abuse policy and procedure in regards to reporting or investigating an incident of family to resident abuse. This affected one resident (Resident #199) of two residents reviewed for abuse. Findings Include: Review of Resident #199's medical record revealed an admission date of 01/25/19 and discharged on 02/20/19 to the community. Diagnoses included fracture of the left femur, Alzheimer's disease, generalized muscle weakness and dysphagia. Review of the resident's comprehensive MDS 3.0 assessment dated [DATE] revealed the resident had clear speech, usually understood others, made herself understood and had a severe cognitive deficit as indicated a Brief Interview for Mental Status (BIMS) score of zero. The resident required extensive assistance of two staff for activities of daily living. Review of the resident's progress note dated 2/14/19 at 1:42 P.M., authored by the Director of Nursing (DON) revealed facility staff reporting the resident's son was verbally and physically aggressive with the resident during his visits. The Former Administrator spoke with the son regarding the allegations and explained until an investigation was completed the facility would supervise the visit for the resident's safety. Review of the Self-Reported Incident (SRI) dated 02/14/19 at 11:33 A.M. revealed staff reported that during a visit by the resident's son on 02/14/19 his comments to her were verbally inappropriate. The SRI documented two staff nurses were outside the door of the resident's room and heard the resident's son state, who was feeding her, Open your damn mouth or I'm going to let you starve. and It's over for you girl, I can't take care of you. Further review of the SRI revealed an incident reported by State Tested Nurse Aide (STNA) #154 was not addressed in the SRI. On 05/02/19 05:16 PM interview with the DON revealed the Former Administrator completed the SRI as one incident instead of three separate incidents. Review of the facility's Abuse, Neglect, Exploitation, Mistreatment and Misappropriation Prevention, dated 11/08/16 revealed the resident has the right to be free from abuse, neglect, misappropriation of resident's property and exploitation. The facility must have evidence that all alleged violations are thoroughly investigated and must prevent further abuse while the investigation is in progress. The facility must ensure that all violations involving abuse, neglect, exploitation or mistreatment, including injury of unknown source and misappropriation of resident property are reported immediately. The facility must have evidence that all alleged violations are thoroughly investigated.

CONCERN (D)

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

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, self reported incident (SRI) review, interview, and facility policy and procedure review, the facility failed to thoroughly investigate an allegation of verbal and physical abuse. This affected one resident (Resident #199) of two residents reviewed for abuse. Findings Include: Review of Resident #199's closed medical record revealed an admission date of 01/25/19 and discharged on 02/20/19 to the community. Diagnoses included fracture of the left femur, Alzheimer's disease, generalized muscle weakness and dysphagia. Review of the resident's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had clear speech, usually understood others, made herself understood and had a severe cognitive deficit as indicated a Brief Interview for Mental Status (BIMS) score of zero. The resident required extensive assistance of two staff for activities of daily living. Review of the resident's progress note dated 2/14/19 at 1:42 P.M., authored by the Director of Nursing (DON) revealed facility staff reported the resident's son was verbally and physically aggressive with the resident during his visits. The Former Administrator spoke with the son regarding the allegations and explained until an investigation was completed the facility would supervise the visit for the resident's safety. Review of the staff statement dated 02/15/19 at 11:20 A.M. revealed Licensed Practical Nurse (LPN) #85 reported on 02/14/19 during the breakfast meal the resident's son was in the room feeding the resident and she was standing outside the resident's room and heard the resident's son tell her, Open your damn mouth or I am going to let you starve. The LPN looked in the room and no one else was in the room but the resident and her son. She reported the incident to Registered Nurse (RN) #100. Further review of the LPN's statement revealed the date of occurrence was documented as 02/13/19 with no time specified. Review of the staff statement dated 02/15/19, at 11:30 A.M., revealed RN #97 was working outside the resident's room on 02/13/19, no time given, when she heard the resident's son say, It's over for you girl. I can't take care of you. The RN looked into the room and made sure the resident was safe. The RN then went to the DON and notified her of what had happened. Review of the staff statement dated 02/15/19 and not timed, revealed State Tested Nursing Assistant (STNA) #154 reported the resident was crying when she came out of the shower as normal. The resident's son was in the resident's room on his phone and he told her, shut up, I'm on the phone. The statement documented the resident did not stop crying so he put his hand over her mouth to try to get her to stop crying. STNA #154 said it happened so quickly the resident's head went backwards. STNA #154 said she didn't know if it was from the force of him putting his hand on her mouth or she just jerked because she saw his hand coming towards her. The STNA reported the situation to an unspecified nurse and she told her to keep checking on the resident. The STNA documented she was walking by the resident's room, no time given and the son was standing by her wheelchair when she heard the resident's son state, you can be such a b**ch sometimes. The statement did not specify if the STNA reported the incident to a supervisor. Review of the Self-Reported Incident (SRI) dated 02/14/19 at 11:33 A.M. revealed staff reported that during a visit by the resident's son on 02/14/19 his comments to her were verbally inappropriate. The SRI documented two staff nurses were outside the door of the resident's room and heard the resident's son state, who was feeding her, Open your damn mouth or I'm going to let you starve. and It's over for you girl, I can't take care of you. Further review of the SRI revealed the incident reported by STNA #154 was not addressed in the SRI. The SRI documented the resident's son would be supervised during visits with the resident. On 05/02/19 at 5:16 PM interview with the DON revealed the Former Administrator completed the SRI as one incident instead of three separate incidents. The DON said the facility supervised the resident's visits with her son by having the nurse park her medication administration cart outside the resident's room. The DON verified the facility had no documented evidence the facility provided supervision during the visits. Review of the facility's Abuse, Neglect, Exploitation, Mistreatment and Misappropriation Prevention, dated 11/08/16 revealed the resident has the right to be free from abuse, neglect, misappropriation of resident's property and exploitation. The facility must have evidence that all alleged violations are thoroughly investigated and must prevent further abuse while the investigation is in progress. The facility must ensure that all violations involving abuse, neglect, exploitation or mistreatment, including injury of unknown source and misappropriation of resident property are reported immediately. The facility must have evidence that all alleged violations are thoroughly investigated.

CONCERN (D)

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

Deficiency F0679 (Tag F0679)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide an ongoing activity program. This affected one resident (Resident #80) of three residents reviewed for activities. Findings Include: Record review revealed Resident #80 was admitted to the facility on [DATE] with diagnoses including cognitive communication deficit, dysphagia following a stroke, acute kidney failure, hypertension, and diabetes mellitus Type II. Resident #80 was hospitalized from [DATE] to 3/25/19 and readmitted to the facility after a significant decline in her health condition. A review of the Minimum Data Set (MDS) 3.0 completed on 04/20/19 indicated Resident #80 had severe cognitive impairment and required extensive assistance with bed mobility, dressing and total dependence for personal hygiene, toilet use, eating, dressing and transfer. The activity evaluation available for review was completed on 02/26/19 and indicated Resident #80 enjoyed leisure activities, group activities, outdoor activities, animals/pets, coloring, games, cooking and baking, and comedy movies. No further activity evaluation was available for review. A review of Resident #80's activity Plan of Care (POC) dated 04/23/19 indicated Resident #80 needed bed-side sensory/activity stimulation, however, enjoyed activities such as animals, music, art, cards/games, children, computer, cooking, current events, exercises, outdoors, parties, word searches, religious involvement, socializing with others, travel, movies and watching television. A goal included would respond with eye contact, facial expressions, and some verbal responses within activity visits or sensory programs three times per week. Interventions included to allow time for responses, individualized visit program, activity program directed toward specific interests/needs, one to one activity visits provided three times weekly, and sensory stimulation three times per week. Review of the Daily Recreation/Activity Participation Documentation from 03/26/19 through 04/23/19 revealed Resident #80 did not participate in any type of recreation/activity program. An activity progress note on 04/23/19 indicated Resident #80 was transferred to a one to one activity program and was to receive stimulation three times per week. Observation of Resident #80 on 04/29/19 between 11:00 AM and 1:20 P.M. and between 2:00 P.M. and 3:57 P.M. did not reveal participation in an activity program. On 05/01/19 at 10:41 A.M. during an interview with Activity Staff #121 she reported Resident #80 had been active in activities prior to her medical decline in March, however, since this time, they had been trying to identify what types of one to one may work best for her. Activity Staff #121 reported she had tried activities with a ball and she did not respond, and was currently thinking being read to may be something she would enjoy. The Activity Director (AD) #123 reported during interview on 05/02/19 at 8:14 A.M. Resident #80 had been very involved in activities, however, after her recent hospitalization, she had not participated in any group activities and was recently transferred to the one to one activity program. AD #123 reported an activity assessment had not been completed after returning to the facility on [DATE]. AD #123 confirmed the activity participation sheet from 03/26/19 through 04/23/19 indicated Resident #80 was not provided any activities other than television and socializing. When asked what types of activities would be included in socializing, she stated this would be when any staff member, family, visitor would enter the residents room and talk to the resident. AD #123 stated socializing was something that happened daily for all residents.

CONCERN (D)

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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and staff interview, the facility failed to ensure accurate assessment and treatment for a resident admitted with a Stage II pressure ulcer (partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial & presents clinically as an abrasion, blister, or shallow crater). This affected one (Resident #92) of two residents reviewed for pressure ulcers. The facility identified five residents with pressure ulcers. Findings Include: Review of Resident #92's medical record revealed an admission date of 04/05/19 with the admitting diagnoses of congestive heart failure, atrial fibrillation, diabetes mellitus, chronic pain syndrome and hypothyroidism. Review of the resident's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident had clear speech, understood others, made herself understood and had no cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of 14. The resident required extensive assistance of two for activities of daily living and was occasionally incontinent of bladder and always continent of bowel. The facility assessed the resident at being at risk for skin breakdown and had two unhealed Stage II pressure ulcers present on admission. The facility implemented the interventions, pressure reducing device to the bed/chair and pressure ulcer care. Review of the resident's admission screen dated 04/05/19 revealed the resident was admitted with a pressure ulcer to her right and left buttocks. The admission screen did not stage, measure or describe the pressure ulcers to her right and left buttocks. Review of the resident's admission Braden Scale dated 04/05/19 revealed a score of 18 indicating the resident was at risk for skin breakdown. Review of the resident's plan of care dated 04/06/19 revealed the resident had a pressure ulcer to her right and left buttocks related to immobility. Interventions included, administer analgesia per physician orders and offer prior to treatment/therapy, administer treatment per physician orders, encourage and assist as needed to turn and reposition, follow up care with physician as ordered, pressure reducing surface, alternating air mattress, report evidence of infection and side to side turns, toileting program as indicated and use pillows and/or positioning devices as needed. Review of the resident's monthly physician orders for May, 2019 revealed orders dated 04/30/19 to cleanse upper left buttock with in house wound cleanser, apply prisma to fit the wound and cover with a foam dressing, 04/09/19 cleanse the pressure ulcer to mid right buttock with in house wound cleanser, fit to prisma to wound and cover with a foam dressing. Review of the resident's progress note dated 04/09/19 at 1:57 P.M. authored by Registered Nurse (RN) #67 indicated the resident was admitted with two pressure ulcers to the right and left buttocks. The stage II to her left buttocks measured 1.0 centimeter (cm) by 0.9 cm and was 20% slough (dead tissue with a yellow or white appearance) in the wound bed with epithelial tissue. The Stage II pressure ulcer to her right buttocks measured 1.2 cm by 1.0 cm with epithelial tissue and no drainage. Review of the resident's progress note dated 04/10/19 at 2:50 P.M. authored by RN #67 revealed the depth to both pressure ulcer to the left and right buttocks were less than 0.1 cm and the treatment included to cleanse the wounds with in house wound cleanser, apply prisma to fit and cover with foam dressing. Review of the resident's progress note dated 04/16/19 at 1:45 P.M. authored by RN #67 revealed the Stage II pressure ulcer to the resident's left buttocks measured 1.3 cm by 0.9 cm by 0.1 cm with epithelial tissue. The Stage II pressure ulcer to the right buttocks measured 0.4 cm by 0.4 cm by 0.1 cm with epithelial tissue. Review of the progress notes revealed the resident's Stage II pressure ulcers were not assessed on 04/23/29. Review of the progress note dated 04/30/19 at 1:40 P.M. authored by RN #67 revealed the Stage II pressure ulcer to the resident's left buttocks measured 1.0 cm by 0.9 cm by 0.1 cm with epithelial tissue. The pressure ulcer to the right buttocks had resolved. Review of the resident's April, 2019 Treatment Administration Record (TAR) revealed the resident's physician ordered treatment was not provided on 04/20/19, 04/24/19 and on 04/29/19. On 05/02/19 at 10:30 A.M. observation of the physician ordered treatment to the Stage II pressure ulcer to her left buttocks by Licensed Practical Nurse (LPN) #87 revealed the LPN had the required supplies set up on a barrier on the resident's bedside table. The LPN washed her hands and donned a clean pair of disposable gloves. The LPN measured the wound to her left buttocks as 2.0 cm by 2.4 cm by 0.1 cm. The LPN sanitized her hands and donned a clean pair of disposable gloves and cleansed the wound with wound cleanser using a 4X4, she sanitized her hands and donned a clean pair of disposable gloves and applied the Prisma and covered with a foam dressing. The wound was dark pink in color and without drainage. On 05/01/19 at 12:19 P.M. interview with RN #67 verified the Stage II pressure ulcers were not assessed until 04/08/19. RN #67 also verified the resident's medical record contained no documented assessment for 04/23/19 for the Stage II pressure ulcer.

CONCERN (D)

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

Deficiency F0688 (Tag F0688)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, review of the facility policy and restorative nursing practice guide, and staff interview, the facility failed to ensure a resident with limited range of motion received the appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. This affected one of two residents reviewed for range of motion (Resident #45). The facility identified 37 of 95 residents with contractures. Findings include: Review of the medical record for Resident #45 revealed an admission date of 08/31/18 and diagnoses including paraplegia and morbid obesity. Review of Minimum Data Set assessments completed on 09/13/18 and 02/27/19 revealed the resident had a brief interview for mental status score of 15 indicating intact cognition, required extensive assistance from two staff for transfers and personal hygiene, and had impairment in range of motion of both lower extremities. Review of a physical therapy Discharge summary dated [DATE] revealed after discharge from physical therapy, Resident #45's prognosis to maintain current level of functioning was good with consistent staff follow through. Discharge recommendations were for restorative nursing for passive range of motion of the bilateral lower extremities with daily care. The discharge plan was not specific as to how long range of motion was to be provided and/or how many repetitions to lower extremity joints were to be provided. Interview with Occupational Therapist #31 on 05/01/19 at 3:30 P.M. revealed she was filling in for the therapy director. She confirmed Resident #45's physical therapy was discontinued on 12/08/18 and the resident was supposed to get passive range of motion of both lower extremities during care. She confirmed a specific number of repetitions per joint was not specified but stated it should be more that just the one or two bends of the legs it would take to get dressed. Interview with Resident #45 on 05/02/19 at 8:30 A.M. revealed she had fallen at home while caring for her grandchildren. She stated she instantly became paralyzed from the waist down. She stated that, although she felt like her legs were starting to get stiff, staff were not providing her with any range of motion of her legs. She stated that she wanted staff to provide range of motion of her legs so she did not decline. Review of the plan of care for Resident #45 dated 09/04/18 revealed the resident had a self care deficit due to paraplegia related to a fall with compression fractures to the spine with cord compression. The plan of care stated the resident was total assist of two staff for daily hygiene, grooming, and dressing. The plan of care stated the resident would receive passive range of motion of upper and lower extremities during activities of daily living to assist with maintaining current level of activity. The plan of care did not specify how long and/or how many repetitions of joints were to be completed with the range of motion. Interview with State Tested Nursing Assistant (STNA)#26 on 05/02/19 at 8:45 A.M. revealed she provides care for Resident #45 including bathing, dressing, and getting her up with the hoyer lift in the morning. She stated she does not provide any range of motion for the resident. She stated if a resident was to get range of motion, it would be on the [NAME]. STNA #26 then showed the surveyor the [NAME] for Resident #45. The [NAME] for Resident #45 stated PROM with upper/lower extremities. At first, STNA #26 stated she did not know what PROM meant. She then stated it meant range of motion but did not know it was on Resident #45's [NAME]. Interview with Registered Nurse #67 on 05/02/19 at 9:00 A.M. confirmed the plan of care for Resident #45 was not specific to ensure enough range of motion was provided to prevent decline. Review of the facility Activity of Daily Living/Functional Restorative Nursing Practice Guide dated 07/2011 revealed residents may enter a restorative nursing program in several ways including after discharge from a skilled physical, occupational, or speech rehabilitation program. Restorative nursing programs are individualized to specific patient needs. The practice guide stated the comprehensive care plan should include individualized patient interventions including measurable objectives or goals. It stated objectives are measurable when a form of measurement is attached to it, such as a distance, amount, percentage or time frame. Review of the facility policy on active/passive range of motion updated 02/29 revealed it did not include how long range of motion was to be provided and/or the number of repetitions to be provided to each joint.

CONCERN (D)

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and interview, the facility failed to implement one resident's fall interventions, who had a recent fall. This affected one (Resident #50) of three residents reviewed for falls. Findings Include: Review of Resident #50's medical record revealed an original admission date of 05/08/14 with the admitting diagnoses of atrial fibrillation, difficulty walking, generalized weakness, peripheral vascular disease and diabetes mellitus. Review of the resident's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had clear speech, understood others, made herself understood and had a moderate cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of 12. The resident required extensive assistance of two staff for bed mobility, transfers, dressing and was non-ambulatory. Review of the resident's plan of care dated 05/08/14 revealed the resident is at risk for falls due to unsteady gait, history of cerebrovascular accident with left sided weakness, congestive heart failure, anemia, atrial fibrillation, lower extremity edema, requires assistance with transfers, diuretic use and history of falls. Interventions included, bed in low position, defined perimeter mattress, encourage non-skid footwear, encourage to transfer and change positions slowly, encourage to lock brakes to wheelchair prior to transfers or ask for assistance, have commonly used articles within easy reach, reinforce need to call for assistance, resident re-educated on calling for assistance while being treated for acute illness or tasks she feels she can do on her own. Review of the incident report, not dated, revealed the resident was found in her room on the floor by the bed's foot board. The incident report documented the resident stated she had fallen out of her wheelchair and the fall was unwitnessed. Review of the resident's progress note dated 04/28/19 at 6:32 P.M., authored by Registered Nurse (RN) #99 revealed at 10:50 A.M. the resident had fallen in her room from her wheelchair. The fall was unwitnessed and the resident was found on the floor by her footboard. She stated she hit her head on the footboard of the bed. Review of the resident's progress note dated 04/30/19 at 5:27 P.M., authored by RN #67 revealed the Interdisciplinary Team met and discussed the resident's fall that occurred on 04/28/19. During the time of the fall the resident was found on the floor by the footboard stating that she had fallen out of her wheelchair. The fall was unwitnessed and neurochecks were started. The resident sustained a skin tear to the right side of her forehead measuring 0.6 centimeters (cm) by 0.7 cm, to her right elbow measuring 1.3 cm by 0.4 cm and one to her right forearm measuring 1.5 cm by 0.5 cm. The resident was also noted to have bruising to her face and both arms. The facility implemented the intervention to encourage the resident to wear non-skid footwear. On 04/30/19 at 4:10 P.M. interview with the resident revealed she had a fall from her wheelchair. She said she was trying to go to the bathroom and fell from her wheelchair. On 05/01/19 at 9:28 A.M. observation of Resident #50 revealed she was sitting in her wheelchair in the doorway of her room and she asked for assistance to the restroom. She said she had been waiting for some time and needed to go badly. On 05/01/19 at 9:31 A.M. interview with RN #30 revealed she was notified the resident was requesting to use the restroom and the RN stated Well, it will be a little while. She said everyone is busy and they would get her when they could. RN #30 failed to identify Resident #50 had fallen recently and was at high risk for falls.

CONCERN (D)

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

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

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Based on observation, medical record review, staff interview and facility policy and procedure review, the facility failed to ensure appropriate treatment for one resident (Resident #350) in the area of indwelling urinary catheter. This affected one of one resident reviewed for catheter usage. The facility identified eights residents having catheters. Findings Include: Review of Resident #350's medical record revealed an admission date of 04/24/19 with the admitting diagnoses of generalized muscle weakness, hypothyroidism and urinary retention. Review of the resident's admission screening dated 04/05/19 revealed the resident was admitted with an indwelling urinary catheter. The resident had clear speech, understood others and was able to communicate her needs. Review of the resident's plan of care dated 04/25/19 revealed she used an indwelling urinary catheter due to neurogenic bladder. Interventions included, maintain drainage bag below bladder level, report to physician signs of urinary tract infection, secure catheter with securement device, and report any changes in amount, color or odor of urine. Review of the resident's monthly physician's orders for May, 2019 revealed orders dated for 04/25/19 to maintain Foley catheter with 16 FR 10 ml balloon for neurogenic bladder and 04/30/19 for change urinary catheter as needed for neurogenic bladder. On 05/01/19 at 12:45 P.M. observation of Resident #350 revealed the resident's catheter collection bag and tubing was laying on the floor. On 05/01/19 at 12:47 P.M. interview with State Tested Nursing Assistant (STNA) #28 verified the indwelling urinary collection bag and tubing was laying on the floor. Review of the facility's Indwelling Catheter Care policy and procedure, dated 04/19 revealed the indwelling catheter tubing is not kinked, looped, clamped or positioned above the level of the bladder and off the floor.

CONCERN (D)

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

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview the facility failed to identify a resident with weight loss was not consuming nutritional interventions used to help prevent additional weight loss. This affected one of two sampled residents reviewed for nutrition (Resident #77). Findings include: Review of Resident #77's medical record revealed he was admitted on [DATE] with diagnoses that included; encephalopathy, dysphagia, benign prostatic hyperplasia, essential hypertension, Parkinson's disease, and chronic kidney disease. Review of Resident #77's 60-day Medicare Minimum Data Set (MDS) dated [DATE] revealed his speech was clear, he understands, was understood, and his cognition was intact. Resident #77 was independent with set up help to eat. Resident #77 had a significant weight loss that was not planned. Review of Resident #77 plan of care dated 02/04/19 revealed staff were to provide his diet as ordered and encourage him to accept and consume his meal and supplements. Review of Resident #77's weights revealed on 02/04/19 he weighed 167 pounds, on 02/21/19 he weighed 146 pounds, on 04/28/19 he weighed 138 pounds. Review of Resident #77's nutrition note dated 02/21/19 revealed the resident had lost 21 pounds since admission and recommended the addition of a nutritional supplement twice daily. Review of Resident #77's April, 2019 physician orders revealed a nutrition supplement twice daily. Review of Resident #77's nutritional supplement revealed only that he accepted the supplements. There was no documentation of how much of the supplement the resident consumed. Observation of Resident #77 on 05/01/19 at 1:25 P.M. revealed a house supplement on his bedside table that was opened with a straw in it. The container felt almost full and the resident was asleep in bed. Interview of Registered Dietitian (RD) #56 on 05/02/19 at 8:02 A.M. revealed the State Tested Nursing Assistants (STNAs) document if the resident takes the supplement, but not how much he takes of it. RD #56 stated she asks the STNA's how much he takes of the supplement. RD #56 was not aware Resident #77 had lost eight pounds and was going to request a reweigh as the staff who weighed him on 04/28/19 was not the usual staff. Interview of STNA #165 on 05/02/19 at 8:02 A.M. revealed Resident #77 had not been eating so well lately and taking about maybe 25% of the supplement since he has been ill. STNA #165 stated since he was ill he took 25% to 50%, it just depended and some residents do not like them.

CONCERN (D)

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

Tube Feeding (Tag F0693)

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 resident record review, the facility failed to ensure a resident's tube feeding was administered according to physician order. This affected one of three residents reviewed for tube feeding (Resident #80). Findings Include: Record review revealed Resident #80 was admitted to the facility on [DATE] with diagnoses including cognitive communication deficit, dysphagia following a stroke, acute kidney failure, hypertension, and diabetes mellitus Type II. A review of the Minimum Data Set 3.0 completed on 04/20/19 indicated Resident #80 had severe cognitive impairment and required extensive assistance with bed mobility and was totally dependent on staff for nutrition. Resident #80's physician orders included to have nothing by mouth, and enteral feeding every 24 hours of continual Jevity 1.5 at 75 milliliters (ml) per hour, to start at 12 noon and run until 1500 ml had infused. Resident #80 was also to receive water at 60 ml per hour plus 30 ml water flush before and after medication administration and 5-10 ml of water between medications. Resident #80's plan of care (POC) indicated at risk for alteration in hydration related to decreased independence and receives all hydration by feeding tube. Interventions included to maintain adequate hydration, enteral feeding and water flushes as ordered, report changes related to signs of fluid deficit and report changed related to signs of fluid overload such as shortness of breath, edema and changes in mental status. The POC identified the need for a feed tube and potential for complications of feeding tube related to dysphagia. Interventions included to provide feeding as ordered and monitor for side effects. Review of the electronic Treatment Administration Record (eTAR) indicated treatments per order by staff checking the tube feeding was provided. Observation on 04/29/19 at 3:00 P.M. revealed Resident #80's feeding tube pump had a hold error and the pump was alarming. On 04/29/19 at 3:37 P.M. Resident #80's feeding tube pump was observed to be beeping/alarming and the hold error light was flashing. On 04/29/19 at 3:51 P.M. Resident #80's tube feeding was infusing at 75 ml per hour and the date of the Jevity 1.5 indicated was hung at 3:30 P.M. On 05/01/19 at 9:34 A.M. the tube feeding was observed to be infusing at 75ml per hr. The tube feeding indicated it was hung at 9:00 P.M. on 04/30/19. During an interview on 05/01/19 at 10:36 A.M. with Licensed Practical Nurse (LPN) #82, he confirmed the tube feeding for Resident #80 was infusing at 75 ml per hour per physician order. LPN #82 reported they did not document the actual amount of tube feeding recorded in the medical record, they just checked the box indicating the feeding was administered per order. On 05/01/19 at 4:55 P.M. the Director of Nurses (DON) and Assistant Director of Nurses (ADON) reported the facility did not maintain a record of the ml of enteral feedings a resident received during a shift nor for a 24 hour period. The DON stated the feeding was infused per physician order and 1500 ml was administered during 24 hours, with the feeding turned off for four hours every day. When questioned at what time period the feeding was turned off, the DON reported she had no record of when the feeding was turned off, just that it was to be started at 12:00 P.M. The DON stated the feeding would most likely be off between 8:00 A.M. to 12:00 noon when care would be provided. When the DON was informed of observations of the feeding running at 9:35 A.M. and off at 3:00 P.M. the DON had no explanation for why that would be occurring. During an interview on 05/02/19 at 7:45 A.M. with the Registered Dietician, she reported the nutritional assessment was based off of the ordered amount of fluid/nutrition to be provided to a resident. The RD confirmed no actual amount was documented in the medical record of nutritional and water intake a resident received during a 24 hour period. The RD confirmed the amount of Jevity 1.5 and water could be different than the prescribed amount. Review of the facility policy Enteral Tubes: Continuous pump feedings dated 12/2009 included suggested documentation would include the volume and water administered.

CONCERN (D)

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

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review revealed Resident #80 was admitted to the facility on [DATE] with diagnoses including cognitive communication deficit, dysphagia following a stroke, acute kidney failure, hypertension, and diabetes mellitus Type II. Review of a general progress note dated 3/26/19 at 1:09 P.M. indicated Resident #80 was re-admitted to the facility and had oxygen at two liters per minute (LPM) per nasal cannula. The physician orders from 03/26/19 through 04/29/19 did not include an order for oxygen. Review of Resident #80's plan of care included to administer oxygen per physician order related to edema related to cardiac disease/pulmonary edema. Observation of Resident #80 on 04/29/19 at 3:57 P.M. revealed oxygen at 2 LPM per nasal cannula. During an interview with Licensed Practical Nurse (LPN) #85 on 04/29/19 at 4:00 P.M., she reported she was familiar with Resident #80 and the resident had oxygen per nasal cannula at all times due to history of shortness of breath. LPN #85 confirmed Resident #80 had oxygen on and was set at 2 LPM per nasal cannula. LPN #85 confirmed there was no physician order for Resident #80 to receive oxygen and stated would contact the physician to obtain an order for the oxygen. Review of the facility policy Oxygen Administration date 07/2017 indicated physician order would be verified prior to oxygen administration. Based on observation, medical record review, and staff interview the facility failed to ensure a resident received oxygen with a physician's order, at the correct level, humidified, and the tubing and humidification bottles were dated. This affected three of four sampled residents reviewed for respiratory care (Resident #72, #77, and #80). Findings include: 1. Review of Resident #72's medical record revealed she was admitted on [DATE] with diagnoses that included; acute respiratory failure with hypoxia, diabetes, and major depressive disorder recurrent. Review of Resident #72's 5-day Minimum Data Set (MDS) dated [DATE] revealed her speech was clear, she understands, she understood, her cognition was intact. Resident #72 had no shortness of breath and used oxygen. Review of Resident #72's April 2019 physician orders revealed oxygen continuously at three liters per minute (LPM) per nasal cannula. Observation of Resident #72's oxygen on 04/29/19 at 4:25 P.M. revealed it was set at five LPM and there was no water in the humidification bottle. Interview of Licensed Practical Nurse (LPN) #85 on 04/29/19 at 4:36 P.M. confirmed Resident #72's oxygen was set at five LPM not three as ordered and there was no water in the humidification bottle. 2. Review of Resident #77's medical record revealed he was admitted on [DATE] with diagnoses that included; encephalopathy, dysphagia, benign prostatic hyperplasia, essential hypertension, Parkinson's disease, and chronic kidney disease. Review of Resident #77's 60-day Medicare Minimum Data Set (MDS) dated [DATE] revealed his speech was clear, he understands, was understood, and his cognition was intact. Resident #77 did not use oxygen. Review of Resident #77's April, 2019 physician orders revealed on 04/30/19 oxygen at two LPM continuously was ordered. Observation of Resident #77 on 04/30/19 at 10:48 A.M. revealed the resident had oxygen at two LPM that was humidified, however there was no date on the tubing or the humidification bottle. Resident #77 was observed on 04/30/19 at 11:02 A.M., 3:47 P.M., on 05/01/19 at 8:17 A.M. 9:48 A.M., 10:45 A.M., and 12:12 P.M. and oxygen was on, but the tubing and humidification bottle were not dated. Interview of LPN #85 on 05/01/19 at 4:25 P.M. confirmed Resident #77's oxygen tubing and humidification bottle were not dated.

CONCERN (D)

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

Deficiency F0773 (Tag F0773)

Could have caused harm · This affected 1 resident

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Based on medical record review and staff interview, the facility failed to promptly notify the physician of laboratory results that fell outside of clinical reference ranges. This affected two of five residents reviewed for unnecessary medications (Residents #4 and #18). Findings include: 1. Review of the medical record for Resident #4 revealed an admission date of 01/08/18 and diagnoses including diabetes, peripheral vascular disease, and hypertension. Review of physician's orders revealed the resident received two types of insulin routinely every day and sliding scale insulin before meals as needed. Review of laboratory results revealed on 02/01/19 Resident #4's hemoglobin A1C level was 10.9 (normal listed as 4.1-6.1). A mean glucose level was 266 (normal listed as 70-120). There was no evidence the physician was notified promptly of the results. Interview with Registered Nurse #67 on 05/01/19 at 9:30 A.M. confirmed there was no evidence the physician was made aware of the lab results of 02/01/19 promptly. 2. Review of the medical record for Resident #18 revealed an admission date of 10/28/15 and diagnoses including hypertension, seizure disorder, and dementia with behavioral disturbances. The resident received an antiseizure medication (depakote) daily since 04/14/18 and had physician's orders for laboratory testing of a complete blood count and a depakote level every three months. Review of laboratory testing revealed a complete blood count and a depakote level were done on 02/25/19. The depakote level was 49 (normal listed as 50-100) and the complete blood count had results outside of the normal range listed: white blood count 3.3 (normal listed as 4.5-10.8), hemoglobin 13.8 (normal listed as 14-18), hematocrit 41 (normal listed as 42-54), platelets 109 (normal listed as 150-450). There was no evidence the physician was made aware of the results promptly. Interview with Registered Nurse #67 on 05/02/19 at 1:45 P.M. confirmed there was no evidence the physician was notified of the 02/25/19 lab results promptly.

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 interview and record review, the facility failed to ensure accurate documentation of oral intake. This affected one resident (Resident #80) of 20 residents reviewed for accuracy of medical records. Findings Include: Record review revealed Resident #80 was admitted to the facility on [DATE] with diagnoses including cognitive communication deficit, dysphagia following a stroke, acute kidney failure, hypertension, and diabetes mellitus Type II. A review of the Minimum Data Set 3.0 completed on 04/20/19 indicated Resident #80 had severe cognitive impairment and required extensive assistance with bed mobility and was totally dependent on staff for nutrition. The physician orders for Resident #80 included to have nothing by mouth, and enteral feeding every 24 hours of continual Jevity 1.5 at 75 milliliters (ml) per hour, to start at 12 noon and run until 1500 ml had infused. Resident #80 was also to receive water at 60 ml per hour plus 30 ml water flush before and after medication administration and 5-10 ml of water between medications. Resident #80's plan of care (POC) indicated she was at risk for alteration in hydration related to decreased independence and receives all hydration by feeding tube. The POC identified the need for a feeding tube and potential for complications of feeding tube related to dysphagia and Resident #80 was to have nothing by mouth. A medical progress note dated 04/24/19 indicated Resident #80 had regained weight in the past 60 days and received all hydration and nutrition per enteral feeding. Review of State Tested Nursing Assistant (STNA) documentation for 04/2019 indicated Resident #80 was offered and consumed oral fluids on one shift on 04/05, 04/08, 04/12, 04/14, 04/15, 04/24, 04/27, 04/28, and 04/29/19. The STNA documentation indicated oral fluids were offered and consumed on two shifts on 04/01, 04/02, 04/10, 04/16, 04/18, 04/20, 04/21, 04/22, 04/23, 04/25, 04/26, 04/30/19, and on three shifts 04/04, 04/06, 04/07, 04/09, 04/17/19. On 05/01/19 at 12:42 P.M. during an interview with STNA #154 she reported Resident #80 did not receive any fluids by mouth. During an interview with the Director of Nurses (DON) on 05/01/19 at 4:55 P.M. she confirmed the STNA documentation indicated Resident #80 was offered and consumed fluids by mouth, however, this documentation was incorrect.

CONCERN (E)

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

ADL Care (Tag F0677)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Record review revealed Resident #80 was admitted to the facility on [DATE] with diagnoses including cognitive communication deficit, dysphagia following a stroke, acute kidney failure, hypertension, and diabetes mellitus Type II. A review of the Minimum Data Set (MDS) 3.0 completed on 04/20/19 indicated Resident #80 had severe cognitive impairment and required extensive assistance with bed mobility, dressing and total dependence for personal hygiene, toilet use, eating, dressing and transfer. Resident #80 was identified at risk for pressure ulcer and had a pressure reducing device to bed and chair. Review of the Plan of Care (POC) revised 04/24/19 indicated Resident #80 had a self care deficit as evidenced by weakness and would receive assistance necessary to meet activity of daily living needs. The POC indicated Resident #80 would receive assistance transfer with maxi lift with large sling and two person assist, bathe/shower as needed, extensive assistance with daily hygiene, grooming, dressing and oral care. On 04/29/19 at 3:45 P.M. Resident #80 was observed with long nails with red/brown debris noted under the nail. On 05/01/19 at 9:40 A.M. Resident #80 was observed with long nails and brown debris noted under the nail. Interview on 05/01/19 at 12:42 P.M. with State Tested Nursing Assistant (STNA) #154 confirmed Resident #80 nails were long and some brown debris was noted under the nail. STNA #154 reported Resident #80 was total care and received a bed bath daily and nail care was to be performed during bathing. Review of the facility policy 'AM Care' dated 12/2009 indicated to clean area under finger nails and maintain nails at a smooth/safe length. 3. Review of the medical record for Resident #18 revealed an admission date of 10/28/15 and diagnoses including Alzheimer and dementia with behavioral disturbances. Review of a quarterly Minimum Data Set assessment completed 02/04/19 revealed the resident had short and long term memory impairment and required extensive assistance from two staff for personal hygiene. Review of the plan of care for Resident #18 revealed the resident required extensive assistance from staff with activities of daily living and would receive the assistance necessary to meet activity of daily living needs including daily grooming and hygiene. Observations on 04/29/19 at 12:08 P.M., 04/30/19 at 8:35 A.M., 10:50 A.M., 4:40 P.M., and 05/01/19 at 7:35 A.M., 9:55 A.M. and 1:35 P.M. revealed Resident #18 needed to be shaved. Interview with Registered Nurse #67 on 05/02/19 at 1:45 P.M. revealed male residents are usually only shaved on shower days twice weekly. She confirmed there was no evidence Resident #18 refused to be shaved on 04/29/19, 04/30/19, or 05/01/19. When the surveyor asked the Director of Nursing for a facility policy on how often male residents are to be shaved, she provided a nursing procedure on how to shave a male resident. The procedure did not include how often male residents are to be shaved. Based on observation, staff interview, and medical record review the facility failed to ensure dependent residents received the needed assistance for shaving and nail care. This affected four of six residents reviewed for activities of daily living (Resident #18, #77, #80, and #346). Findings include: 1. Review of Resident #77's medical record revealed he was admitted on [DATE] with diagnoses that included; encephalopathy, dysphagia, benign prostatic hyperplasia, essential hypertension, Parkinson's disease, and chronic kidney disease. Review of Resident #77's 60-day Medicare Minimum Data Set (MDS) dated [DATE] revealed his speech was clear, he understands, was understood, and his cognition was intact. Resident #77 required extensive assistance of two staff for bed mobility, transfer, and required extensive assistance of one staff for personal hygiene. Review of Resident #77's plan of care dated 02/04/19 revealed staff were to assist the resident daily with hygiene, grooming, and dressing. Review of Resident #77's bathing/showering records revealed the resident's last shower, or bed bath was 04/25/19. There was no assessment of Resident #77's grooming preferences. Observation of Resident #77 on 04/30/19 at 10:48 A.M. revealed the resident had greater than a day's growth of facial hair. Resident #77 was observed on 04/30/19 at 11:02 A.M., and 3:47 P.M. and he was not shaved. On 05/01/19 at 8:17 A.M. the resident was observed in bed asleep not shaved and drooling on his shirt. On 05/01/19 the resident was the same at 9:48 A.M. and at 10:45 A.M On 05/01/19 at 12:12 P.M. Resident #77 was shaved and his clothing was changed. Interview of State Tested Nursing Assistant (STNA) #167 on 05/01/19 at 4:10 P.M. revealed Resident #77 was a little more lethargic lately. STNA #167 revealed the resident received showers twice weekly, but today he gave him a bed bath because Resident #77 was not feeling well. STNA #167 stated the resident did not resist care and was shaved at least on bath days. Interview of the Director of Nursing (DON) on 05/02/19 at 7:06 A.M. confirmed Resident #77 was last bathed on 04/25/19 and no assessment of the resident's preference was completed. 2. Review of Resident #346's medical record revealed he was admitted on [DATE] with diagnoses that included; heart failure, difficulty walking, acute myocardial infarction, cerebral infraction, dementia with our behavioral disturbance and major depressive disorder recurrent. Review of Resident #346's admission assessment date dated 04/25/19 revealed his speech was clear, he usually understands, required substantial/maximal assistance with bathing and dressing. Review of his baseline care plan dated 04/26/19 revealed staff were to assist Resident #346 daily with hygiene and grooming. Observation of Resident #346 on 04/29/19 at 10:55 A.M. revealed a long scruffy growth of facial hair. Resident #346 had long scruffy facial hair on 04/30/19 at 11:16 A.M., on 05/01/19 at 3:15, and on 05/02/19 at 1:25 P.M. Resident #346 still had long scruffy growth of facial hair. Review of Resident #346's bathing records revealed he was bathed on 04/29/19 and 05/01/19. Interview of State Tested Nursing Assistant (STNA) #167 on 05/02/19 at 3:00 P.M. confirmed Resident #346 needed shaved and men were shaved on shower days.

CONCERN (E)

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

Quality of Care (Tag F0684)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Review of Resident #30's medical record revealed an admission date of 10/17/17, with diagnoses of cerebral infraction, right sided hemiplegia, and generalized muscle weakness. Review of Resident #30's Minimum Data Set (MDS) dated for 02/21/19 revealed Resident #30 required an extensive, two person staff assist for bed mobility and transfers along with right sided upper and lower extremity impairment. Resident #30's means of locomotion on and off the unit was via wheelchair with one person staff assist or supervision. Review of Resident #30's Plan of Care dated for 08/11/15 with a revision date of 12/29/17 and a target date of 06/13/19, revealed an intervention for a right leg foot rest/peddle to the resident's wheelchair. Observation made of 04/29/19 at 12:07 P.M., on 04/30/19 at 4:09 P.M., 5:41 P.M., and 6:16 P.M. and 05/01/19 at 10:12 A.M. revealed Resident #30 seated in a wheelchair without a right leg foot rest, propelling herself on the unit while using her left leg to hold up her right leg. Interview on 05/01/19 at 9:20 A.M. with Resident #30 revealed no knowledge of having a right leg foot peddle placed on her wheelchair. When asked if a right leg foot rest could be placed on the wheelchair, Resident #30 stated that it would be ok. Interview on 05/01/19 at 9:30 A.M. with STNA #28 revealed Resident #30 was not noted to have any behaviors where care was refused. When asked about the right leg foot peddle, STNA #28 confirmed Resident #30's wheelchair did not have a right left foot rest on it, nor was there a foot peddle located in Resident #30's room. 2. Record review revealed Resident #24 was admitted on [DATE] with diagnoses including left above the knee amputation, respiratory failure, stage IV kidney disease, paralytic syndromes, kidney failure, heart failure, anemia, diabetes mellitus Type II, and chronic pain. Review of the Minimum Data Set (MDS) 3.0 completed on 02/15/19 revealed Resident #24 had no cognitive delay and required extensive assistance for activities of daily living. Resident #24 had a Foley catheter. Review of physician orders included body audit every day shift every seven days for skin observation. Review of nursing progress notes by Licensed Practical Nurse (LPN) #83 dated 04/15/19 at 3:21 P.M. indicated Resident #24's assessment was completed and Resident #24 had a one centimeter (cm) by one cm bruise to her right leg. The area was described as blue and gray in color and Resident #24 did not report any pain at this time. A nursing progress note on 04/17/19 at 11:29 A.M. by the Assistant Director of Nurses (ADON) revealed Resident #24 denied pain to the bruise on her right lower shin, except when touched. The bruise was noted to be flat and purple in color and no increase size was noted. No further documentation regarding the bruised area to the right leg was assessed. During an interview with LPN #83 on 05/02/19 at 2:58 P.M. she reported she recalled the incident regarding Resident #24's bruise to the leg. LPN #83 confirmed she documented the bruise at the time it was discovered and stated no further documentation regarding the bruise to the leg was completed. LPN #83 stated the facility did not document or monitor bruising once it was identified. On 05/01/19 at 4:09 P.M. during an interview with the Director of Nurses (DON) she reported weekly skin assessments were completed on all residents at the facility and staff initialed on the electronic Treatment Administration Record (eTAR) the assessments were completed. The DON stated further documentation would be noted in the progress notes if any new areas or changes to previous skin issues were identified. The DON stated the facility did not monitor bruising at any other location than the eTAR and no weekly monitoring for changes in bruises or when resolved was located in the medical record. The DON stated the weekly skin assessment was completed by the nurse on duty and confirmed no documentation from the previous week to ensure no increase in number or location of bruising. No further documentation regarding Resident #24's bruising was noted in the progress notes. 3. Record review revealed Resident #80 was admitted to the facility on [DATE] with diagnoses including cognitive communication deficit, dysphagia following a stroke, acute kidney failure, hypertension, and diabetes mellitus Type II. A review of the Minimum Data Set (MDS) 3.0 completed on 04/20/19 indicated Resident #80 had severe cognitive impairment and required extensive assistance with bed mobility, dressing and total dependence for personal hygiene, toilet use, eating, dressing and transfer. Resident #80 was identified at risk for pressure ulcer and had a pressure reducing device to bed and chair. Review of physician orders included body audit every day shift every seven days for skin observation. Review of the plan of care (POC) for Resident #80 identified self care deficit with activities of daily living with interventions including transfer with maxi lift with large size sling and two person assist, extensive assistance with daily hygiene, grooming, dressing and oral care. The POC identified Resident #80 at risk for alteration in skin integrity with interventions including to observe skin condition with activity of daily living care and report abnormalities. Review of the electronic Treatment Administration Record (eTAR) revealed Resident #80's skin condition was monitored weekly. A general progress note on 3/26/2019 at 1:09 P.M. indicated Resident #80 was readmitted to the facility. The progress note stated a second skin assessment was completed with the following findings: right upper chest with a dark scab measuring 5 centimeters (cm) x 3.2 cm. Bilateral arms and hands were noted to be bruised from needle sticks and blood draws, the right and left abdomen was bruised due to injections. The progress note indicated discolored areas and bruising were noted bilaterally from the knees down the shins. On 05/01/19 at 4:09 P.M. during an interview with the Director of Nurses (DON) she stated skin assessments were documented as completed weekly per physician order on the eTAR. The DON verified the medical record did not contain monitoring of bruising for Resident #80. The DON reported a complete assessment for Resident #80 was done at the time of admission and addressed bruising (03/26/19). The DON reported if any changes in the bruising was noted, the changes would be identified in the progress notes, however, no weekly monitoring of bruising to indicate when resolved or if a new area was noted was in the medical record. The DON reported the weekly monitoring was completed by the nurse on duty that shift and confirmed they may not have previous knowledge of the resident's skin condition. 4. Review of Resident #50's medical record revealed an original admission date of 05/08/14 with the admitting diagnoses of atrial fibrillation, difficulty walking, generalized weakness, peripheral vascular disease and diabetes mellitus. Review of the resident's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had clear speech, understood others, made herself understood and had a moderate cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of 12. The resident required extensive assistance of two staff for bed mobility, transfers, dressing and was non-ambulatory. Review of the resident's plan of care dated 05/08/14 revealed the resident required anticoagulant treatment for atrial fibrillation and is at risk for adverse effects. Interventions include, administer medications per physician's order, monitor and report signs and symptoms of bleeding and increased bruising and use a soft toothbrush for oral care. Review of the resident's monthly physician's orders for May, 2019 failed to provide an order to monitor the extensive bruising to the resident's face. Review of the resident's progress note dated 04/30/19 at 5:27 P.M., authored by Registered Nurse (RN) #67 revealed the Interdisciplinary Team met and discussed the resident's fall that occurred on 04/28/19. During the time of the fall the resident was found on the floor by the footboard stating that she had fallen out of her wheelchair. The fall was unwitnessed and neurochecks were started. The resident sustained a skin tear to the right side of her forehead measuring 0.6 centimeters (cm) by 0.7 cm, to her right elbow measuring 1.3 cm by 0.4 cm and one to her right forearm measuring 1.5 cm by 0.5 cm. The resident was also noted to have bruising to her face and both arms. The facility implemented the intervention to encourage the resident to wear non-skid footwear. Further review of the resident's progress notes on 05/01/19 revealed no documentation regarding the extensive bruising to the resident's face. On 04/29/19 at 4:10 P.M. observation of Resident #50 revealed she had bruising to her right eye, right cheek and the right side of her forehead that was dark purple in color. On 04/30/19 at 8:39 A.M. observation of the resident revealed the bruising to the right side of her face remained and now had bruising to the left eye and cheek that was park purple in color. On 05/01//19 at 2:45 P.M. observation of Resident #50 revealed the dark purple bruising had spread to both sides of her face and forehead. On 05/02/19 at 8:37 AM interview with Registered Nurse (RN) #67 verified the resident had no monitoring or documentation of extensive dark purple bruising to her face. Based on medical record review, observation, and staff interview the facility failed to ensure residents were provided needed care in the areas of treatment of pneumonia, monitoring of bruising, and mobility devices equipped as needed. This affected five of 20 sampled residents (Resident #24, #30, #50, #80, and #303). Findings include: 1. Review of Resident #303's medical record revealed she was admitted on [DATE] with diagnoses the included: acute respiratory failure, pneumonia, malignant neoplasm of lung, chronic pulmonary disease, and altered mental status. Review of Resident #303's admission Minimum Data Set (MDS) dated [DATE] revealed her speech was clear, understood others, understands, she had moderately impaired cognition. Resident #303 received IV medication. Review of Resident #303's physician orders revealed on 04/20/19 an IV antibiotic (Piperacillin) was ordered twice daily for treatment of pneumonia. Review of Resident #303's April medication administration record (MAR) and 04/28/19 progress note revealed the resident did not receive the 12:00 A.M. does of Piperacillin as it was not available until the morning. Interview of Resident #303 on 04/30/19 at 9:54 A.M. revealed the past weekend she did not get her IV antibiotics and that is why she was here. Interview of the Director of Nursing (DON) on 05/02/19 at 4:01 P.M. confirmed Resident #303 did not receive her 12:00 A.M. dose of Piperacillin medication used in the treatment of the resident's pneumonia. The DON stated she did not know why the medication was not available for administration.

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

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

Our Honest Assessment

Strengths

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

Concerns

• 52 deficiencies on record, including 2 serious (caused harm) violations. Ask about corrective actions taken.

Bottom line: Mixed indicators with Trust Score of 60/100. Visit in person and ask pointed questions.

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About This Facility

What is Riverview Post Acute's CMS Rating?

CMS assigns RIVERVIEW POST ACUTE an overall rating of 4 out of 5 stars, which is considered 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 Riverview Post Acute Staffed?

CMS rates RIVERVIEW POST ACUTE's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 46%, compared to the Ohio average of 46%.

What Have Inspectors Found at Riverview Post Acute?

State health inspectors documented 52 deficiencies at RIVERVIEW POST ACUTE during 2019 to 2025. These included: 2 that caused actual resident harm and 50 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.

Who Owns and Operates Riverview Post Acute?

RIVERVIEW POST ACUTE 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 LEGACY HEALTH SERVICES, a chain that manages multiple nursing homes. With 100 certified beds and approximately 84 residents (about 84% occupancy), it is a mid-sized facility located in SOUTH POINT, Ohio.

How Does Riverview Post Acute Compare to Other Ohio Nursing Homes?

Compared to the 100 nursing homes in Ohio, RIVERVIEW POST ACUTE's overall rating (4 stars) is above the state average of 3.2, staff turnover (46%) is near the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.

What Should Families Ask When Visiting Riverview Post Acute?

Based on this facility's data, families visiting should ask: "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?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the below-average staffing rating.

Is Riverview Post Acute Safe?

Based on CMS inspection data, RIVERVIEW POST ACUTE 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 4-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 Riverview Post Acute Stick Around?

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

Was Riverview Post Acute Ever Fined?

RIVERVIEW POST ACUTE 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 Riverview Post Acute on Any Federal Watch List?

RIVERVIEW POST ACUTE 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: 100
Avg. Residents: 84
Occupancy: 84.4%
Ownership: For profit - Limited Liability company
Chain: LEGACY HEALTH SERVICES
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
4-Star Rating: +30
2 Actual Harm citations: -10
52 Deficiencies: -10
Final Score: 60/100

Nearby Alternatives

SANCTUARY AT OHIO VALLEY 4-star HARBOR HEALTHCARE OF IRONTON 3-star CRYSTAL CARE OF COAL GROVE 3-star

View all in SOUTH POINT →

Check Bed Availability

Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 365620