How many inspection deficiencies does Alpine Nursing and Rehabilitation Center have?

Alpine Nursing and Rehabilitation Center has 62 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at Alpine Nursing and Rehabilitation Center?

Alpine Nursing and Rehabilitation Center has a two-star staffing rating from CMS with 0.59 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 Alpine Nursing and Rehabilitation Center located?

Alpine Nursing and Rehabilitation Center is located in XENIA, OH. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does Alpine Nursing and Rehabilitation Center have?

Alpine Nursing and Rehabilitation Center has 99 certified beds.

Who owns Alpine Nursing and Rehabilitation Center?

Alpine Nursing and Rehabilitation Center is a for profit - limited liability company facility and operates independently (not part of a chain).

Alpine Nursing and Rehabilitation Center

Q: What is Alpine Nursing and Rehabilitation Center's CMS rating?

Alpine Nursing and Rehabilitation Center has a two-star overall rating from CMS (Centers for Medicare & Medicaid Services), based on health inspections, staffing levels, and quality measures.

Q: Do nurses at Alpine Nursing and Rehabilitation Center stick around?

Alpine Nursing and Rehabilitation Center has average staff turnover at 48%, which is typical for the nursing home industry.

Q: Was Alpine Nursing and Rehabilitation Center ever fined?

Yes, Alpine Nursing and Rehabilitation Center has been fined $64,816 by federal regulators. Fines are issued for serious violations of Medicare and Medicaid requirements.

Q: Is Alpine Nursing and Rehabilitation Center on any federal watch list?

No, Alpine Nursing and Rehabilitation Center is not on any federal watch list. It is not designated as a Special Focus Facility or SFF Candidate by CMS.

164 OFFICE PARK DRIVE, XENIA, OH 45385 · (937) 419-4500

For profit - Limited Liability company 99 Beds Independent Data: November 2025

Trust Grade

20/100

#618 of 913 in OH

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Last Inspection: May 2025

Inspected within the last 6 months. Data reflects current conditions.

Overview

Alpine Nursing and Rehabilitation Center has received a Trust Grade of F, indicating significant concerns about its care quality and operations. Ranking #618 out of 913 facilities in Ohio puts it in the bottom half, and #7 out of 10 in Greene County means only three local options are worse. The facility's condition is worsening, with issues increasing from 5 in 2024 to 14 in 2025. Staffing is a relative strength, with a turnover rate of 48%, slightly below the state average, but RN coverage is only average, which may not ensure optimal resident care. However, there are serious concerns raised by recent inspections. For example, a resident went five days without a bowel movement and had to be hospitalized for fecal impaction, while another resident showed signs of a urinary tract infection but was not treated for six days, leading to significant complications. Additionally, residents with pressure ulcers were not given timely care, resulting in advanced stages of these injuries. Overall, while there are some strengths in staffing, the serious deficiencies in care raise red flags for families considering this facility.

Trust Score: F
In Ohio: #618/913
Safety Record: High Risk
Inspections: Getting Worse
Staff Stability: 48% turnover. Above average. Higher turnover means staff may not know residents' routines.
Penalties: $64,816 in fines. Lower than most Ohio facilities. Relatively clean record.
Skilled Nurses: Each resident gets 35 minutes of Registered Nurse (RN) attention daily — about average for Ohio. RNs are the most trained staff who monitor for health changes.
Violations: 62 deficiencies on record. Higher than average. Multiple issues found across inspections.

★★☆☆☆

2.0

Overall Rating

★★☆☆☆

2.0

Staff Levels

★★★★☆

4.0

Care Quality

★★☆☆☆

2.0

Inspection Score

↔

Stable

2024: 5 issues

2025: 14 issues

The Good

4-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

2-Star Overall Rating

Below Ohio average (3.2)

Below average - review inspection findings carefully

Staff Turnover: 48%

Near Ohio avg (46%)

Higher turnover may affect care consistency

Federal Fines: $64,816

Above median ($33,413)

Moderate penalties - review what triggered them

The Ugly 62 deficiencies on record

4 actual harm

Aug 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

Deficiency F0602 (Tag F0602)

Could have caused harm · This affected 1 resident

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.THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff interview, review of Self-Reported Incidents (SRIs), and review of the facility policy, the facility failed to prevent the misappropriation of resident medications. This affected one (Resident #35) of three residents reviewed for misappropriation. The facility census was 72 residents.Findings include: Review of the medical record for Resident #35 revealed an admission date of 10/31/22 with diagnoses including congestive heart failure, schizoaffective disorder bipolar type, generalized anxiety disorder, and chronic pain syndrome.Review of the Minimum Data Set (MDS) assessment for Resident #35 dated 07/18/25 revealed the resident was cognitively intact and required staff assistance with activities of daily living (ADLs.) Review of the controlled substance administration record for Resident #35 revealed 30 hydrocodone-acetaminophen 5-325 milligrams (mg) tablets were dispensed on 05/16/25. The administration record indicated there should be 19 doses remaining.Review of the record of disposal for controlled substances revealed the hydrocodone-acetaminophen tablets dispensed for Resident #35 on 05/16/25 with an original quantity of 30 tablets indicated 15 tablets had been destroyed on 06/13/25.Review of the facility SRI regarding Resident #35 dated 06/13/25 revealed a blister pack of the resident's hydrocodone-acetaminophen which was scheduled to be destroyed had gone missing. The facility began an investigation, and the blister pack was found in Resident #18's room with 15 pills remaining. Resident #18 reported he was unaware how the medication ended up in his room. The SRI indicated the Director of Nursing (DON) had removed multiple controlled substances from a locked drawer and had them on her desk to destroy when Housekeeping Supervisor (HS) #300 came to the office to vacuum. The DON walked to the front side of the desk while HS #300 vacuumed. The DON and additional nursing staff then began wasting the controlled substances and discovered the blister pack was missing.Interview on 08/05/25 at 10:33 A.M. via telephone with HS #300 confirmed she had been terminated because of a failed drug test. HS #300 stated she found a plastic bag in the conference room with the blister packs of medication and removed one from the plastic bag. HS #300 reported she opened four pills from the pack and took them before discarding the blister pack with the remaining pills in Resident #18's room because it was across the hall from the conference room. HS #300 stated she then pretended to have found the blister pack in Resident #18's room.Interview on 08/05/25 at 3:04 P.M. with Human Resources Director (HRD) #12 confirmed HS #300 admitted to taking Resident #35's medication. HRD #12 confirmed HS #300 was terminated. Review of the undated facility policy titled Abuse, Neglect, Exploitation and Misappropriation of Resident Property undated revealed the facility would not tolerate the misappropriation of resident property.The deficient practice was corrected on 06/19/25 when the facility implemented the following corrective actions: On 06/13/25, the DON and/or designee investigated and determined Resident #35 had not missed any doses of medication as the medication had been discontinued. On 06/13/25, the DON and/or designee completed initial audits of residents on controlled substances with no other discrepancies identified. By 06/19/25, the Administrator, the DON, and Assistant Director of Nursing (ADON) #14 educated all staff on the abuse, neglect, exploitation, and misappropriation policy. On 06/19/25, HS #300 was terminated. Starting on 08/05/25, the DON and/or designee will monitor/audit residents on controlled substances once weekly as an ongoing part of the facility's performance improvement plan.This deficiency represents noncompliance investigated under Self-Reported Incident Control Number OH00167073 (iQIES Number 1359708.)

May 2025 10 deficiencies

CONCERN (D)

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

Deficiency F0637 (Tag F0637)

Could have caused harm · This affected 1 resident

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Based on record review, staff interview, and review of the facility policy, the facility failed to complete significant change Minimum Data Set (MDS) assessments in a timely manner. This affected one (Resident #7) of 17 residents reviewed for MDS assessments. The facility census was 69 residents. Findings include: Review of the medical record for Resident #7 revealed an admission date of 11/21/21 with diagnoses including multiple sclerosis, cerebral infarction, and vascular dementia. Review of the physician's orders for Resident #7 revealed an order dated 03/04/25 for the resident to be admitted to hospice. Review of the significant change MDS assessment for Resident #7 dated 05/01/25 revealed the resident had severely impaired cognition and was dependent on staff for assistance with ADLs. Interview on 05/21/25 at 12:35 P.M. with MDS Coordinator #208 confirmed the facility had not completed the significant change MDS assessment for Resident #7 within 14 days as required. Review of the facility policy titled Comprehensive Assessments dated March 2022 revealed comprehensive assessments should be conducted in accordance with criteria and timeframes established in the Resident Assessment Instrument (RAI) manual.

CONCERN (D)

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

MDS Data Transmission (Tag F0640)

Could have caused harm · This affected 1 resident

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Based on record review and staff interview, the facility failed to submit Minimum Data Set (MDS) assessments in a timely manner. This affected one (Resident #59) of 17 residents reviewed for assessments. The facility census was 69 residents. Findings include: Review of the medical record for Resident #59 revealed an admission date of 10/03/23 with diagnoses including aphasia, dementia, and atrial fibrillation. Review of the MDS assessment for Resident #59 revealed the MDS for January had a target date of 01/06/25 and a completion date of 01/27/25, and the MDS for April had a target date of 04/07/25 and a completion date of 04/29/25. Interview on 05/21/25 at 01:33 PM with MDS Coordinator #208 confirmed the Resident #59's January 2025 MDS was late and not completed until 01/27/25, and the April 2025 MDS was late and not completed until 04/29/25. MDS Coordinator #208 further confirmed neither of Resident #59's assessments had been transmitted within 14 days as required.

CONCERN (D)

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

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure Minimum Data Set (MDS) assessments were coded accurately. This affected one (Resident #66) of 17 residents reviewed for MDS assessments. The facility census was 69 residents. Findings include: Review of the medical record for Resident #66 revealed an admission date of 03/13/25 with diagnoses including cerebral infarction, chronic obstructive pulmonary disease (COPD), dementia, and anxiety disorder. Review of the physician's orders for Resident #66 dated 03/16/25 revealed an order for oxygen two liters per minute (LPM) via nasal cannula (NC) as needed to keep oxygen saturation above 92 percent (%). Review of the Minimum Data Set (MDS) assessment for Resident #66 dated 04/04/25 revealed the resident had severe cognitive impairment and required staff supervision and assistance with activities of daily living (ADLs.) Review of section O for special treatments and procedures for the MDS assessment for Resident #66 dated 04/04/25 revealed the resident was not coded for use of oxygen therapy. Interview on 05/21/25 at 12:50 P.M. with MDS Coordinator #208 confirmed section O of Resident #66's MDS assessment dated [DATE] was not coded correctly as it did not reflect the resident's use of oxygen therapy. Review of the facility policy titled MDS Assessment Coordinator dated November 2019 revealed a licensed nurse should be responsible for conducting and coordinating the development and completion of the resident assessment (MDS). Each individual who completed a portion of the assessment (MDS) must certify the accuracy of that portion of the assessment by dating and signing the assessment and identifying each section completed.

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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Based on medical record review, staff interview, and review of the facility, the facility failed to ensure staff monitored tube feeding residuals. This affected one (Resident #40) of one resident reviewed for tube feeding. The facility census was 69 residents. Findings include: Review of the medical record for Resident #40 revealed an admission date of 08/23/24 with diagnoses including dysphagia following cerebral infarction, atherosclerotic heart disease, chronic obstructive pulmonary disease, and type two diabetes mellitus. Review of the Minimum Data Set (MDS) assessment for Resident #40 dated 04/02/25 revealed the resident had severely impaired cognition and required substantial staff assistance with activities of daily living (ADLs.) Review of the physician's orders for Resident #40 revealed an order dated 04/30/25 to check tube for residual before each feeding with instructions: if residual is above 60 milliliters (ml) hold for one hour and recheck, and if still above 60 ml to call the doctor. Review of the care plan for Resident #40 revised 05/07/25 revealed the resident required a feeding tube related to dysphagia. Interventions included administering enteral feedings and fluids as ordered, checking placement of tube, flushing tube as ordered, and notifying physician for increased amounts of residual. Review of the Medication Administration Record (MAR) for Resident #40 dated 05/01/25 to 05/21/25 revealed there was no documentation of monitoring the resident for tube feeding residuals. Interview on 05/21/25 at 12:30 P.M. with Assistant Director of Nursing (ADON) #207 confirmed there was no documentation of tube feeding residuals being checked for Resident #40 for 05/01/25 to 05/21/25. ADON #207 confirmed Resident #40 had a physician's order to the check the residual before each feeding. Review of the facility policy titled Checking Gastric Residual Volume (GRV) dated November 2018 revealed staff should measure GRV to assess the resident's tolerance of enteral feeding and minimize the potential for aspiration. The person performing the procedure should record completion of the task on the administration record.

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 review of the medical record review, observation, staff interview, and review of manufacturer's guidelines, the facility failed to ensure the medication error rate was below five percent (%). There were two errors out of 29 medication opportunities resulting in a medication error rate of 6.9%. This affected one (Resident #17) of seven residents reviewed for medication administration. The facility census was 69 residents. Findings include: Review of the medical record for Resident #17 revealed an admission date of 07/08/24 with diagnoses including type two diabetes mellitus, generalized anxiety disorder, and peripheral vascular disease. Review of the Minimum Data Set (MDS) assessment for Resident #17 dated 04/15/25 revealed the resident had intact cognition and required staff assistance with activities of daily living (ADLs.) Review of the physician's orders for Resident #17 revealed an order dated 05/02/25 Humalog insulin 22 units subcutaneously before meals and an order dated 05/06/25 for Glargine insulin 54 units subcutaneously in the morning. Observation on 05/20/25 at 7:45 A.M. revealed Licensed Practical Nurse (LPN) #245 administered 22 units of Humalog insulin and 54 units of Glargine insulin to Resident #22 with priming the insulin pens prior to administration. Interview on 05/20/25 at 7:47 A.M. with LPN #245 confirmed she did not prime the insulin pens prior to administration to Resident #17. Review of the manufacturer's guidelines for Glargine insulin revised November 2018 revealed a safety test should always be performed prior to each injection. After applying a needle to the pen, the nurse should select a dose of two units by turning the dosage selector and hold the pen with the needle pointing upwards. The nurse should then tap the insulin reservoir so that any air bubbles rise up towards the needle and then press the injection bottom all the way in and ensure insulin came out of the needle tip. Review of the manufacturer's guidelines for Humalog insulin revised 2023 revealed priming the pen meant removing the air from the needle and cartridge that might collect during normal use and ensure the pen was working correctly. If you did not prime before each injection, you might get too much or too little insulin. To prime the pen, turn the dose knob and select two units. Hold the pen with the needle pointing up, tap the cartridge holder gently to collect air bubbles at the top. Push the dose knob in until it stops and zero was seen in the dose window.

CONCERN (D)

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

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected 1 resident

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Based on review of the medical record review, observation, staff interview, and review of manufacturer's guidelines, the facility failed to ensure residents were free from significant medication errors. This affected one (Resident #17) of seven residents reviewed for medication administration. The facility census was 69 residents. Findings include: Review of the medical record for Resident #17 revealed an admission date of 07/08/24 with diagnoses including type two diabetes mellitus, generalized anxiety disorder, and peripheral vascular disease. Review of the Minimum Data Set (MDS) assessment for Resident #17 dated 04/15/25 revealed the resident had intact cognition and required staff assistance with activities of daily living (ADLs.) Review of the physician's orders for Resident #17 revealed an order dated 05/02/25 Humalog insulin 22 units subcutaneously before meals and an order dated 05/06/25 for Glargine insulin 54 units subcutaneously in the morning. Observation on 05/20/25 at 7:45 A.M. revealed Licensed Practical Nurse (LPN) #245 administered 22 units of Humalog insulin and 54 units of Glargine insulin to Resident #22 with priming the insulin pens prior to administration. Interview on 05/20/25 at 7:47 A.M. with LPN #245 confirmed she did not prime the insulin pens prior to administration to Resident #17. Review of the manufacturer's guidelines for Glargine insulin revised November 2018 revealed a safety test should always be performed prior to each injection. After applying a needle to the pen, the nurse should select a dose of two units by turning the dosage selector and hold the pen with the needle pointing upwards. The nurse should then tap the insulin reservoir so that any air bubbles rise up towards the needle and then press the injection bottom all the way in and ensure insulin came out of the needle tip. Review of the manufacturer's guidelines for Humalog insulin revised 2023 revealed priming the pen meant removing the air from the needle and cartridge that might collect during normal use and ensure the pen was working correctly. If you did not prime before each injection, you might get too much or too little insulin. To prime the pen, turn the dose knob and select two units. Hold the pen with the needle pointing up, tap the cartridge holder gently to collect air bubbles at the top. Push the dose knob in until it stops and zero was seen in the dose window.

CONCERN (D)

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure staff completed proper hand hygiene during medication administration. This affected one (Resident #30) of seven residents observed for medication administration. The facility also failed to ensure staff cleaned glucometers as appropriate after use. This affected one (Resident #3) of one resident with orders for blood sugar checks. Based on medical record review, observation, staff interview, review of the facility policy, and review online guidance per the Centers for Disease Control (CDC) the facility also failed to ensure staff disposed of personal protective equipment (PPE) properly. This affected one (Resident #123) of 15 residents with orders for enhanced barrier precautions (EBP.) The facility census was 69 residents. Findings include: 1. Review of the medical record for Resident #30 revealed an admission date of 10/31/22 with diagnoses including schizoaffective disorder, type two diabetes mellitus, and anxiety disorder. Review of the Minimum Data Set (MDS) assessment for Resident #30 dated 03/06/25 revealed the resident had intact cognition and required setup and supervision with activities of daily living (ADLs.) Observation on 05/19/25 at 7:41 A.M. revealed Licensed Practical Nurse (LPN) #219 did not perform hand hygiene before or after medication administration to Resident #30. Interview on 05/19/25 at 7:41 A.M. with LPN #219 confirmed she did not perform hand hygiene before or after medication administration for Resident #30. Review of the facility policy titled Hand Washing Guidelines dated August 2019 revealed staff should perform hand hygiene before and after providing routine resident care. 2. Review of the medical record for Resident #3 revealed an admission date of 12/07/23 with diagnoses including chronic obstructive pulmonary disease (COPD), type two diabetes mellitus, and congestive heart failure (CHF). Review of the MDS assessment for Resident #3 dated 03/07/25 revealed the resident had moderate cognitive impairment and required staff assistance with ADLs. Observation on 05/19/25 at 7:45 A.M. revealed LPN #219 did not clean the glucometer after use for Resident #3. Interview on 05/19/25 at 7:47 A.M. with LPN #219 confirmed she did not clean the glucometer after use for Resident #3 and she should have done so. Review of the facility policy titled Medication Administration dated 2001 revealed staff should follow established facility infection control procedures when administering medications. 3. Review of the medical record for Resident #123 revealed an admission date of 05/07/25 with diagnoses including type two diabetes mellitus, CHF, and COPD. Review of the care plan for Resident #123 dated 05/19/25 revealed the resident had two venous/stasis ulcers to the right leg and was placed in enhanced barrier precautions. Observation on 05/21/25 at 11:00 A.M. revealed there was a used yellow disposable gown on an entry table in Resident #123's room. Interview on 05/21/25 at 11:02 A.M. with LPN #238 confirmed Resident #123 was on EBP, and she had used a disposable gown for the resident's care earlier in the day but had not discarded the disposable gown after use and instead left the contaminated gown inside the resident's room. Interview on 05/21/25 at 01:19 P.M. with Assistant Director of Nursing (ADON) #207 confirmed that gowns were to be disposed of after each use and not left anywhere in a resident's room for reuse. Review of the facility policy titled Personal Protective Equipment (PPE) revised May 2023 revealed gowns should be removed and discarded in a dedicated container for waste or linen before leaving the resident room or care area. Review of online guidance per the Centers for Disease Control (CDC) titled Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) on 05/21/25 at https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/ppe.html?CDC_AAref_Val=https://www.cdc.gov/hai/containment/PPE-Nursing-Homes.html revealed for residents on EBP revealed staff should position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room.

CONCERN (D)

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

Deficiency F0925 (Tag F0925)

Could have caused harm · This affected 1 resident

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Based on medical record review, observation, resident interview, staff interview, and policy review, the facility failed to ensure resident rooms were free from pests. This affected one (Resident #23) of 17 residents reviewed for the physical environment. The facility census was 69 residents. Findings include: Review of the medical record for Resident #23 revealed an admission date of 01/17/25 with diagnoses including e muscular dystrophy, depression, and opioid dependence. Review of the Minimum Data Set (MDS) assessment for Resident #23 dated 04/23/25 revealed the resident #23 had intact cognition and required set up and supervision with activities of daily living (ADLs.) Observation on 05/18/25 at 2:46 P.M. of Resident #23's room revealed there were five ants on bedside table and four ants on windowsill and wall. Observation on 05/20/25 at 9:45 A.M. of Resident #23's room revealed there were 10 ants in total on the bedside table, wall, and windowsill. Interview on 05/20/25 at 9:46 A.M. with Resident #23 confirmed he had ants present in his room for weeks, he had reported it, but the facility had not responded to his concern. Interview on 05/20/25 at 9:49 A.M. with Maintenance Director (MD) #360 confirmed the presence of ants in Resident #23's room. MD #360 further confirmed he would have to call the pest control come out and spray, because he was not allowed to do so. Review of the facility policy titled Pest Control/Pest Surveillance dated 01/03/25 revealed the facility had a policy which promoted pest eradication and the factility would use an outside pest control company for monthly and emergency treatments.

CONCERN (E)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure medications were dated upon opening and discarded on or before the expiration date. This affected eight (Residents #6, #8, #10, #24, #28, #44, #49, and #122) and had the potential to affect all of the residents residing in the facility. The facility census was 69 residents. Findings include: 1.Review of the medical record for Resident #28 revealed an admission date of [DATE] with diagnoses including type two diabetes mellitus, chronic kidney disease, and heart failure. Review of the physician's orders for Resident #28 revealed an order dated [DATE] for artificial tears eye drops to both eyes twice daily. Review of the Minimum Data Set (MDS) assessment for Resident #28 dated [DATE] revealed the resident had intact cognition and required staff assistance with activities of daily living (ADLs.) Review of the physician's orders for Resident #28 revealed orders dated [DATE] for prednisone eye drops to the left eye twice daily and bromfenac solution eye drops to the left eye at bedtime. Observation on [DATE] at 10:36 A.M. revealed the prednisone eye drops, artificial tears eye drops, and bromfenac eye drops were opened and had not been dated upon opening. Interview on [DATE] at 10:38 A.M. with Licensed Practical Nurse (LPN) #219 confirmed the prednisone eye drops, the artificial tears eye drops, and the bromfenac eye drops for Resident #28 had been opened but had not been dated upon opening. 2.Review of the medical record for Resident #6 revealed an admission date of [DATE] with diagnoses including major depressive disorder, type two diabetes mellitus, and chronic obstructive pulmonary disease (COPD). Review of the physician's orders for Resident #6 revealed an order dated [DATE] for Refresh liquid gel eye drops to the left eye once daily. Review of the MDS assessment for Resident #6 dated [DATE] revealed the resident had intact cognition and required staff assistance with ADLs. Observation on [DATE] at 10:40 A.M. revealed the Refresh liquid gel eye drops for Resident #6 were opened on [DATE]. Interview on [DATE] at 10:41 A.M. with LPN #219 confirmed the Refresh liquid gel eye drops for Resident #6 were expired and should have been discarded. 3.Review of the medical record for Resident #24 revealed an admission date of [DATE] with diagnoses including chronic kidney disease, type one diabetes mellitus, and bipolar disorder. Review of the MDS assessment for Resident #24 dated [DATE] revealed the resident had severe cognitive impairment and required substantial staff assistance with ADLs. Review of the physician's orders for Resident #24 revealed an order dated [DATE] for insulin glargine inject 28 units subcutaneously at bedtime. Observation on [DATE] at 10:42 A.M. revealed Resident #24's bottle of glargine insulin was opened but had not been dated. Interview on [DATE] at 10:43 A.M. with LPN #219 confirmed the bottle of insulin for Resident #24 had been opened but had not been dated. 4. Review of the medical record for Resident #122 revealed an admission date of [DATE] with diagnoses including COPD, type two diabetes mellitus, and glaucoma. Review of the MDS assessment for Resident #122 dated [DATE] revealed the resident had intact cognition and required set up and supervision with ADLs. Review of the physician's orders for Resident #122 revealed an order dated [DATE] latanoprost eye drops to both eyes once daily. Observation on [DATE] at 10:50 A.M. revealed the latanoprost eye drops for Resident #122 were opened but had not been dated. Interview on [DATE] at 10:51 A.M. with LPN #239 confirmed the latanoprost eye drops for Resident #122 were opened but had not been dated. 5.Review of the medical record for Resident #8 revealed an admission date of [DATE] with diagnoses including cerebral infarction, major depressive disorder, and dry eye syndrome. Review of the physician's orders for Resident #8 revealed an order dated [DATE] revealed artificial tears eye drops to both eyes three times daily. Review of the MDS assessment for Resident #8 dated [DATE] revealed the resident had intact cognition and required staff assistance with ADLs. Observation on [DATE] at 11:01 A.M. revealed the bottle of artificial tears eye drops for Resident #8 were opened but had not been dated. Interview on [DATE] at 11:02 A.M. with LPN #245 confirmed the artificial tears eye drops for Resident #8 were opened but had not been dated. 6. Observation on [DATE] at 11:03 A.M. of the north hall medication cart revealed a bottle of docusate sodium with an expiration date of [DATE]. Interview on [DATE] at 11:04 A.M. with LPN #245 confirmed the docusate sodium in the north hall medication cart had expired and should have been discarded. LPN #245 further confirmed Residents #10, #44, and #49 had orders for docusate sodium. Review of the facility policy titled Administering Medications dated 2001 revealed medications should be administered in a safe and timely manner, and as prescribed. The expiration/beyond use date on the medication label should be checked prior to administering. When opening a multi-dose container, staff should record the date opened on the container.

CONCERN (F)

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

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

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Based on observation, staff interview, and review of the facility policy, the facility failed to ensure foods were labeled and dated properly. This had the potential to affect all of the residents residing in the facility. The facility census was 69 residents. Findings include: 1.Observation on 05/18/25 at 9:09 A.M. of the walk-in refrigerator revealed it contained four pre-made salads and one pitcher of orange liquid which were not labeled or dated. Interview on 05/18/25 at 9:15 A.M. with Dietary [NAME] (DC) #342 confirmed the salads and the pitcher of orange liquid were unlabeled and undated. DC #342 confirmed foods should be labeled and dated upon opening. 2.Observation on 05/20/25 at 10:47 A.M. of the walk-in refrigerator revealed it contained two trays of cups filled with orange liquid which were unlabeled and undated. Interview on 05/20/25 at 10:47 A.M. with Kitchen Manager (KM) #334 confirmed the trays of cups filled with orange liquid were unlabeled and undated. KM #334 confirmed foods should be labeled and dated upon opening. Review of facility policy titled Food Receiving and Storage dated November 2022 revealed dry foods and refrigerated/frozen foods should be labeled and dated.

Apr 2025 3 deficiencies 2 Harm

SERIOUS (G) 📢 Someone Reported This

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

Actual Harm - a resident was hurt due to facility failures

Quality of Care (Tag F0684)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THIS DEFICIENCY REPRESENTS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, review of physician standing orders, review of hospital records, staff interview, and policy review, the facility failed to ensure residents were free from constipation and had interventions to prevent constipation on the care plan. This resulted in Actual Harm when Resident #75 did not have a bowel movement for five days before a stool softener was prescribed and was transferred out to the hospital and diagnosed with a fecal impaction. This affected one (Resident #75) of three residents reviewed for constipation. The census was 73. Findings include: Record review revealed Resident #75 was admitted on [DATE] and discharged on 03/15/25. Diagnoses included metabolic encephalopathy, coronary artery disease, heart failure, hypertension, peripheral vascular disease, thyroid disorder and osteoporosis. Review of the baseline care plan dated 01/18/25 for Resident #75 revealed she was at risk for bowel and bladder and was continent of bowel. There were no further updates to the care plan. Review of the admission Minimum Data Set (MDS) assessment, dated 01/24/25, revealed she was moderately cognitively impaired. She required supervision/touching assistance for eating, substantial/maximal assistance for toileting, bed mobility, and transfers. She was always continent of bowel. Review of the facility's standing physician orders for constipation, not dated, revealed to give Milk of Magnesia 30 milliliters (ml) by mouth once as needed for constipation and call the physician if there wasn't a bowel movement. Review of the Medication Administration Record (MAR) from 01/18/25 through 03/06/25 revealed no standing orders or stool softeners ordered for Resident #75. Review of the bowel tracker dated 03/07/25 through 03/11/25 revealed no bowel movement documented for Resident #75. Review of therapy notes dated 03/10/25 documented Resident #75 complained of stomach pain, and it was reported to the nursing staff. Review of therapy notes dated 03/11/25 documented Resident #75 had a stomach ache and the family reported constipation issues prior. Therapy staff reported the issue again to the nursing staff. Review of the physician progress note dated 03/11/25 for Resident #75 documented the physician came into the facility and determined the chief complaint was an overall decline. There were also concerns of constipation and straining with bowel movements. There was an order for Sennosides-Docusate Sodium 8.6-50 milligrams (mg) to give two tablets one time a day for constipation. Review of the MAR for Resident #75 from 03/12/25 through 03/15/25 revealed the Senna was given to the resident. Review of the bowel tracker on 03/12/25 revealed Resident #75 had a small bowel movement, on 03/13/25 she had two small bowel movements, and on 03/14/25 she had two large bowel movements. Review of the progress notes from 03/12/25 through 03/15/25 revealed there were no further bowel assessments completed. Review of progress note dated 03/15/25 at 10:00 A.M. documented Resident #75's breathing had increased. Her respirations were 22 breaths per minute, blood pressure 140/80 millimeters of mercury (mmHg), pulse 110 beats per minute, and oxygen saturation was 83 percent (%). Oxygen was applied. The family was notified and wanted the resident sent out to the hospital for evaluation. Review of the hospital records dated 03/15/25 revealed a rectal fecal impaction with thickening of the rectal wall extending proximately into the splenic flexure suggestive of superimposed colitis. Liquefied small bowel enteric content with foci of air in the nondependent bowel right upper quadrant. A soap suds enema was ordered. During an interview on 04/08/25 at 9:45 A.M., the Director of Nursing (DON) and Assistant Director of Nursing (ADON) stated they knew about the unconfirmed impacted bowel from the family, and they started an action plan. They confirmed something happened between 03/11/25 when the doctor reported she had normal bowel sounds and a soft abdomen until 03/15/25 when the resident went out to the hospital. They confirmed there weren't any bowel assessments completed after 03/11/25 since the resident was having bowel movements. They confirmed the only bowel protocol the facility had in place was for milk of magnesia and Resident #75 wasn't given any of that before letting the doctor know on 03/11/25. They confirmed Resident #75 wasn't getting any stool softeners before 03/11/25. During an interview on 04/08/25 at 12:47 P.M., Medical Director (MD) #200 stated she had been notified of Resident #75's constipation but didn't know the constipation had been going on for five days. She stated when she saw Resident #75 on 03/11/25 she assessed her bowel sounds and abdomen and didn't find anything abnormal. She stated she ordered a stool softener and didn't hear back from the facility. She did not know the resident was found to be impacted on 03/15/25 at the hospital and stated the symptoms the resident had upon leaving for the hospital on [DATE] with an increased heart rate could have been from her bowel impaction. She stated she would expect to see nursing doing bowel assessments to ensure there wasn't any problems from 03/11/25 through 03/15/25 and not just think because the resident was having bowel movements she was ok. Review of the policy titled Constipation Management Policy, dated 09/10/24 revealed to provide guidelines for the prevention, identification, and management of constipation to ensure patient comfort and health. Prevention 1. Hydration: Encourage patients to drink fluids with each meal/Med pass on an as needed basis, unless contraindicated. 2. Exercise: Recommend regular physical activity to stimulate bowel function as able 3. Routine: Establish regular bowel habits by encouraging patients to use the restroom as able Identification 1. Monitor: Regularly assess patients for signs of constipation. 2. Documentation: Record bowel movement in the patient's medical record, plan of care or activities of daily living flowsheets. Management 1. Initial Interventions: Increase fluid intake with meals/Med Pass, unless contraindicated Encourage physical activity as able 2. Medications: standing orders to be implemented per each facility protocol Bulk-forming agents: e.g., psyllium Osmotic laxatives: e.g., polyethylene glycol Stimulant laxatives: e.g., Bisacodyl (use sparingly) Monitoring and Follow-Up 1. Regular Monitoring: Track patient progress and adjust treatment plans as necessary. Each facility may implement a system for monitoring that best suits their workflow. 2. Patient Education: Provide education on lifestyle modifications and the importance of adherence to treatment plans. The deficient practice was corrected on 04/02/25 when the facility implemented the following corrective actions: • On 03/17/25 and 04/01/25, all resident records were audited to see if they had a bowel movement documented and if not, they initiated their bowel protocol which was to give milk of magnesia 30 ml and if no bowel movement, then call the doctor. Auditing is still in progress. • Review of the medical records for Residents #18, #4, and #51 revealed they had a bowel tracker in place since 03/17/25 and they didn't have any concerns for constipation in the progress notes. They all had a care plan in place for bowels. • On 03/26/25, the nursing staff were educated on abdominal assessment and bowel documentation and there was a video to watch on bowel assessment. • During an interview on 04/08/25 at 11:20 A.M., Licensed Practical Nurse (LPN) #122 stated she had been educated on bowel assessment which was a video and on documentation of the bowel tracker. • During an interview on 04/08/25 at 11:23 A.M., LPN #201 stated she had been educated on bowel assessment which was a video and on documentation of the bowel tracker. This deficiency represents non-compliance investigated under Complaint Number OH00163923.

SERIOUS (G) 📢 Someone Reported This

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

Actual Harm - a resident was hurt due to facility failures

Incontinence Care (Tag F0690)

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, review of hospital records, staff interview, and review of facility policy, the facility failed to ensure residents were treated timely for a urinary tract infections (UTI). This resulted in Actual harm when Resident #75 developed signs and symptoms of a UTI and wasn't treated for the UTI for six days. She transferred out to the hospital and it was discovered the resident had a significant distention in the bladder with renal pelvictasis, (renal pelviectasis, is when urine gathers in the center of the kidney, called the pelvis. This makes the kidney larger than normal. This condition can affect one or both kidneys.) This affected one (Resident #75) of one resident reviewed for UTI. There were no other residents in the facility with a UTI. The census was 73. Findings include: Record review revealed Resident #75 was admitted on [DATE] and discharged on 03/15/25. Diagnoses included metabolic encephalopathy, coronary artery disease, heart failure, hypertension, peripheral vascular disease, thyroid disorder and osteoporosis. Review of the baseline care plan dated 01/18/25 for Resident #75 revealed she was at risk for bladder incontinence and was incontinent of bladder. There were no further updates to the care plan. Review of the admission Minimum Data Set (MDS) assessment, dated 01/24/25, documented Resident #75 was moderately cognitively impaired. She required supervision/touching assistance for eating, substantial/maximal assistance for toileting, bed mobility, and transfers. She was always continent for bowel and incontinent for bladder. Review of progress note dated 03/07/25 at 6:13 A.M. revealed Resident #75 had foul-smelling urine, burning while urinating, and pain in the abdominal region. The physician was called and made aware with new orders for a urinalysis (UA) with Culture and Sensitivity (C&S). The order was put in the computer system at 8:59 P.M. Review of progress notes dated 03/08/25 at 2:31 P.M. documented the UA and C&S were obtained and the order was changed to STAT (immediate) pickup. At 3:19 P.M. a call was made to the laboratory (lab) to make sure the urine sample was going to be picked up on this day and the lab assured the facility that a representative would be at the facility on that evening to pick up the sample. Review of the pickup time revealed it was 3:19 P.M. The lab results were not reported back to the facility until 03/12/25 at 1:48 P.M. Review of the physician orders dated 03/13/25 at 5:53 A.M. revealed Macrobid 100 milligrams (mg) to give one two times a day for five days. This was started on 03/13/25. The resident was sent to the hospital on [DATE] for a fecal impaction. Review of the hospital records dated 03/15/25 revealed Resident #75 had a significant distention in the bladder with renal pelvictasis left greater than the right and no obstruction was noticed. She also tested positive for Influenza A. During an interview on 04/08/25 at 9:45 A.M. the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) stated they thought the facility executed the orders for the UA and C&S in a timely manner even though it took six days to get the resident an antibiotic and she was exhibiting signs and symptoms of a UTI. They confirmed there wasn't any interventions for the incontinence of bladder. They also confirmed there wasn't any documentation or monitoring of the resident for bladder issues from 03/11/25 through 03/15/25. During an interview on on 04/08/25 at 12:47 P.M., Medical Director (MD) #200 revealed she had no idea the hospital found a significant distention of Resident #75's bladder. She reported it could take up to four days to get the result of a UA and C&S because the UA was just a dip and the C&S was what took the longest to get a result. She revealed when she saw the resident on 03/11/25 she did an assessment on her abdomen and flanks, but there wasn't anything abnormal. She reported the expectation of the nursing staff would be do an assessment on the resident for a distended bladder between 03/11/25 through 03/15/25. She revealed just because the resident was urinating, had a UTI and was on antibiotics for the UTI didn't mean she was ok. She revealed the increased heart rate upon discharge to the hospital on [DATE] could have been from the distension of the bladder. Review of policy titled Urinary Tract Infection/Bacteremia, dated 2001, revealed: Assessment and Recognition 1. The physician and staff will identify individuals with a history of symptomatic urinary tract infections, and those who have risk factors (for example, an indwelling urinary catheter, kidney stones, urinary outflow obstruction, etc.) for UTl. 2. The staff and practitioner will identify individuals with possible signs and symptoms of a UTI. a. Signs and symptoms of a UTI may be specific to the urinary tract and/or generalized. The presentation of symptomatic UTl varies. b. Nurses should observe, document, and report signs and symptoms (for example, fever or hematuria) in detail and avoid premature diagnostic conclusions. c. New onset of nonspecific or general symptoms alone (change in mental status, decline in appetite, etc.) is not enough to diagnose a UTI. Urine odor, color and clarity also are not adequate to indicate bacteruria or a UTI. d. Acute deterioration in previously stable chronic urinary symptoms may indicate an acute infection. Multiple concurrent findings such as fever with hematuria or catheter obstruction are more likely to be due to a urinary source. e. A positive urine culture in someone with chronic genitourinary symptoms is not enough to diagnose a symptomatic UTI. The presence of either pyuria or a positive leukocyte esterase test alone are not enough to prove that the individual has a UTI, but the absence of pyuria or a negative leukocyte esterase test is fairly strong evidence that a UTI is not present. Cause Identification 1. The physician will help nursing staff interpret any signs, symptoms, and lab test results. Diagnosis must be based on the entire picture and not just on one or several findings in isolation. a. Before diagnosing a UTI or urosepsis and ordering antibiotics, the physician should consider a resident's overall picture including specific evidence that helps confirm or refute the diagnosis of a UTI (as discussed above). 2. The physician will help identify causes of, and factors contributing to, bacteruria or UTl such as bladder outlet obstruction, kidney stones, neurological impairments, and medications that can cause urinary retention. 3. Because nonspecific or systemic symptoms can be due to diverse factors either instead of or along with a UTI, the staff and practitioner will also consider additional or alternative causes regardless of whether bacteruria or urinary symptoms is present. a. For example, a patient with a UTI could also have confusion caused by fluid and electrolyte imbalance such as hypernatremia as a result of several days of inadequate food and fluid intake. Treatment/Management 1. The physician will order appropriate treatment for verified or suspected UTl and/or urosepsis based on a pertinent assessment. a. Empirical treatment should be based on a documented description of an individual's symptoms and on consideration of relevant test results, co-existing illnesses and conditions, and pertinent risk factors. b. Generally, symptomatic UTl should be treated. Bacteruria alone (an asymptomatic UTI) should not be treated routinely, because treating it does not materially change outcomes, improve longevity, or correct underlying problems. c. In select situations, empirical antimicrobial therapy may be warranted if urosepsis or other complications are suspected. d. In select situations, empirical antimicrobial therapy may be warranted for afebrile individuals with non-specific symptoms. 2. The physician will not treat asymptomatic individuals whose urine is colonized with yeast or with multi-resistant organisms such as methicillin-resistant Staphylococcus aureus or Enterococcus without careful review and clinical rationale. 3. The physician should consider stopping antibiotics or switching parenteral to oral antibiotics in individuals with uncomplicated UTl who have been afebrile and asymptomatic for at least 48 hours. 4. The physician will help the staff identify suspected sepsis related to a UTI and identify whether hospitalization may be warranted. 5. Fever and change in mental status alone do not automatically warrant hospitalization, nor is there compelling evidence that hospitalization improves the ultimate outcomes in individuals with symptomatic UTl. Sepsis, however, may sometimes warrant more aggressive inpatient treatment. Monitoring 1. The physician and nursing staff will review the status of individuals who are being treated for a UTI and adjust treatment accordingly. a. Decisions should be made primarily on the basis of clinical signs and symptoms. The goal of treatment in most cases is to control signs and symptoms of infection, not to eliminate bacteruria. b. Follow-up urine cultures after antibiotic treatment are not indicated routinely, but may be helpful if the symptoms are not resolving or complications are present. 2. When a resident has a persistent or recurrent urinary tract infection after treatment with antibiotics, the physician will review the situation carefully with the nursing staff and consider other or additional issues (such as urinary obstruction or indwelling catheter change or removal) before prescribing additional courses of antibiotics. a. Physicians should justify continuing or resuming antibiotic treatment beyond an initial course. This deficiency represents non-compliance investigated under Complaint Number OH00163923.

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 F0804 (Tag F0804)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff and resident interviews and policy review, the facility failed ensure meals were palatable. This affected three (Residents #31, #59 and #57) of three residents reviewed for food. The facility identified two residents who couldn't eat anything by mouth. The census was 73. Findings include: Review of the menu dated 04/07/25 revealed lunch consisted of a peppered hamburger patty, buttered noodles, green beans, and white cake. A test tray was obtained on 04/07/25 at 11:50 A.M. The meat was crispy around the edges and was tough. The noodles were over cooked and tasted mushy and the green beans were bland. During an interview on 04/07/25 at 11:55 A.M., Dietary Manager (DM) #171 stated if she cooks the noodles el [NAME], the residents complain they are too hard. This is the way the residents like the noodles. Se said to get the beef pepper patties done and up to temperature they had to be cooked this way. She admitted the foods were over cooked. During an interview on 04/07/25 at 12:55 P.M., Resident #57 stated the buttered noodles and the peppered beef patty were too done at lunch time. During an interview on 04/07/25 at 1:07 P.M., Resident #21 at 1:07 P.M. stated she had a chef salad for lunch but didn't like the food. The food was processed, tough, and didn't taste very good. During an interview on 04/07/25 at 1:15 P.M., Resident #39 stated the food sucked. She said the meat was tough and she called it the mystery meat because it was processed. She stated the noodles for lunch were mushy. She stated when fish was served, it was hard. Review of policy titled Food Palatability, not dated, revealed the facility was committed to serving nutritious, safe, and palatable meals to residents that reflect their choices, cultural backgrounds, and dietary restrictions. Meals will be served in a manner that promotes dignity, socialization, and enjoyment of the dining experience. Palatability is food that is acceptable in taste, appearance, and texture to the resident. This deficiency represents non-compliance investigated under Complaint Number OH00164115.

Nov 2024 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interviews, and policy / procedures the facility failed to perform incontinence care in a sanitary manner. This affected one (#19) out of three residents reviewed for incontinence care. The facility census was 67. Findings include: Review of the medical record for Resident #19 revealed an admission date of 04/11/28 with diagnoses of cerebral infarction due to unspecified occlusion or stenosis of unspecified carotid artery, hypertensive heart disease with heart failure, and obesity. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had moderate cognitive impairment. Resident #19 required setup assistance with eating, substantial assistance with personal hygiene, and was dependent on staff assistance with oral hygiene, toileting hygiene, bathing, dressing, bed mobility. Review of the care plan dated 06/24/22 revealed Resident #19 had bladder and bowel incontinence, with interventions to assist resident to the bathroom as needed and to provide peri care after each incontinence episode. Review of the Auarterly Bowel & Bladder Assessment completed on 10/09/24 revealed resident was incontinent of bladder and bowel. Observation on 11/07/24 at 8:38 A.M. with Certified Nursing Assistant (CNA) #130 and CNA #790 performing incontinence care on Resident #19 revealed the CNA's entered the resident's room, washed their hands, prepared a water basin with wet washcloths, soap, and dry washcloths. CNA #130 and CNA #790 explained the procedure to Resident #19. CNA #130 and CNA #790 washed their hands, applied clean clothes and approached Resident #19. Resident #19's attend was opened in the front and rolled down between her legs. CNA #790 used a clean washcloth with soap to wash Resident #19's right peri-fold, left peri-fold outer labia, and the inner-labia with a clean section of the washcloth with each stroke. CNA #790 used a clean washcloth to rinse Resident #19's right peri-fold, left peri-fold outer labia, and the inner-labia with a clean section of the washcloth with each stroke. CNA #790 used a dry washcloth to dry Resident #19's peri-area. CNA #790 changed her gloves. Resident #19 was positioned onto her right side. CNA #790 used a clean washcloth with soap to wash Resident #19's buttocks/sacrum area. CNA #790 used a clean washcloth to rinse Resident #19's buttocks/sacrum area. CNA #790 used a dry washcloth to dry Resident #19's buttocks/sacrum area. A clean attends was applied, Resident #19 was repositioned in bed, her call light was handed to her, and her oxygen tubing was picked up by the nasal cannula area and handed to her by CNA #790. CNA #130 and CNA #790 removed their gloves and washed their hands prior to exiting the room. Interview on 11/07/24 at 8:48 A.M. with CNA #790 confirmed during incontinence care on Resident #19 she did not change her gloves after performing incontinence care to the resident's buttocks/sacrum area. Interview also confirmed the resident was repositioned, the blankets were placed on the resident, the call light was handed to the resident, and the oxygen tubing was picked up by the nasal cannula area all while continuing to wear the same gloves she used while performing incontinence care. Interview also confirmed she should have removed her soiled gloves and washed her hands prior to covering the resident up, prior to repositioning the resident, prior to handing the call light to the resident, and prior to picking up the nasal cannula for oxygen and handing it to Resident #19. Interview on 11/07/24 at 8:56 A.M. with CNA #130 confirmed while performing incontinence care with CNA #790 they did not change their gloves after incontinence care was complete. Interview also confirmed they should have removed their soiled gloves and washed their hands prior to covering the resident up, prior to repositioning the resident, prior to handing the call light to the resident, and prior to picking up the nasal cannula for oxygen and handing it to Resident #19. Review of the Incontinence Management Standard of Care policy, undated revealed It is the policy of this facility to promote intact skin, maintain dryness and respect the resident's standard and individualized interventions. Review of the Perineal Care procedure, undated revealed the procedure of for providing perineal care is Washes hands, applies disposable gloves, explains procedure to resident. And Cleanse skin folds thoroughly, rinses, and pats dry. And Removes and appropriately discards soiled gloves. Repositions and covers patient. Places call light in reach. This deficiency represents non-compliance investigated under Complaint Number OH00159419.

MINOR (C) 📢 Someone Reported This

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

Minor Issue - procedural, no safety impact

Abuse Prevention Policies (Tag F0607)

Minor procedural issue · This affected most or all residents

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Based on employee record review, review of the facility Bureau of Criminal Investigation (BCI) log, staff interview, and policy review, the facility to implement their abuse policy to ensure an employee had a background check completed with the results received timely. The had the potential to affect all 67 residents residing in the facility. The facility census was 67. Findings include: Review of the employee record for Certified Nursing Assistant (CNA) #120 was hired on 04/03/24. CNA #120's fingerprint background check was completed on 05/03/24, with facility receiving the results on 05/13/24. Review of the BCI log for the facility revealed CNA #120 was hired on 04/03/24, fingerprints were completed on 05/03/24 and the results were received on 05/13/24. Interview on 11/12/24 at 2:00 P.M. with Human Resource Director #680 confirmed CNA #120 was hired on 04/03/24 and her fingerprint results were not received at the facility until 05/13/24. Interview also confirmed CNA #120 was not terminated and continued to work for the facility after 05/03/24, which was 30 days from her hire date. Interview also confirmed CNA #120 continued to work hours at the facility from 05/03/24 through 05/13/24. Review of the Abuse, Neglect, Exploitation & Misappropriation of Resident Property policy, dated 08/10/23 revealed it is the policy of Facility to undertake background checks of all employees and to retain on file applicable records of current employees regarding such checks. The facility will conduct a criminal background check in accordance with State law and Facilities policy. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

May 2024 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0558 (Tag F0558)

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, review of the facility policy, and resident and staff interview the facility failed to ensure the residents had access to their call light. This affected one (Resident #200) of two residents reviewed for call light accessibility and functioning. The facility census was 71. Findings include: Review of the medical record for Resident #200 revealed an admission date of 07/25/19. Diagnoses included right hip fracture, seizure disorder, left below the knee amputation, traumatic brain injury, and vascular dementia. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #200 had intact cognition. Resident #200 required partial/moderate assistance from staff with oral hygiene and substantial/maximal assistance to dependent on staff for toileting, bathing/shower, upper body dressing, and lower body dressing. Review of the plan of care dated 06/14/22 revealed Resident #200 was at increased for risk for falls with interventions to have commonly used articles within easy reach: water, call light, remote control, and telephone. Interview and observation on 05/16/24 at 8:50 A.M. with Resident #200 in his room stated he was unable to find his television remote and could not call for help because he did not have his call light. No observation of call light within reach of Resident #200. During the interview with Resident #200, Registered Nurse (RN) #31 entered the room. Resident #200 told RN #31 that he was unable to locate his remote and his call light. RN #31 located the call light behind Resident #200's bed approximately five foot up the wall was a light bar and located on top of the light bar was Resident #200 call light. RN #31 removed the call light from above the light bar and gave it to Resident #200. Interview with RN #31 on 05/16/24 at 8:55 A.M. verified call lights were to be within reach of residents, including Resident #200. RN #31 verified Resident #200's call light was not within reach and was unable to call for assistance to find his remote. Review of the facility policy titled Call Lights, revision date 01/2020, revealed the call light is used by a resident to notify staff of the nursing facility that the resident has a need that they would like addressed. Staff will ensure that the resident is in a safe and comfortable position and that the call light is within reach of the resident before leaving the resident's room. This deficiency represents non-compliance investigated under Complaint Number OH00153796.

CONCERN (E) 📢 Someone Reported This

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

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

Safe Environment (Tag F0921)

Could have caused harm · This affected multiple residents

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Based on observations and staff interviews, the facility failed to provide a safe environment for the residents when a window air-conditioning unit in the dining room had exposed wires and coils. This had the potential to affect 41 residents (#102, #107, #109, #110, #112, #116, #118, #119, #120, #122, #125, #126, #127, #128, #129,#130, #131, #134, #135, #136, #138, #139, #142, #143, #144, #145, #146, #147, #149, #151, #152, #153, #154, #156, #158, #159, #161, #162, #163, #164, and #167) who the facility identified who were cognitively impaired and mobile. The facility census was 71. Findings include: Observations on 05/15/24 at 10:20 A.M. in the dining room, was a window air conditioning unit plugged into electrical outlet. The air conditioning unit had exposed coils, wires, and a thick layer of dust with debris and cobwebs covering the exposed internal components of the unit. On the wall in the dining room was a thermostat with no dial with a typed note Do not change setting on the thermostat, and fan, doing so can cause the system to overheat and could cause a fire. For residents rooms the settings must stay on 'cool'. Do not turn the thermostat up, our air conditioner unit is now on, and the system is based on water and not cooled air. Interview on 05/15/24 at 10:25 A.M. with Housekeeping Staff #40 verified the air conditioning unit located in the window of the dining room was plugged into the electrical outlet with the cover that had been broken for a long time. Housekeeping Staff stated, don't touch because she was unsure of the hazard risk because of the layer of dust, grass, and cobwebs on the coils and wires. Housekeeping Staff #40 was unsure when it was cleaned or when it was maintained last. Interview with the Administrator on 05/16/24 at 1:15 P.M. verified the typed letter hanging above thermostat in dining room indicating not to change the thermostat and fan, because of overheating and cause a fire. The Administrator stated she was unsure when or why this letter was placed and removed the letter from the wall. The Administrator stated there was no facility policy regarding the air conditioning system functioning and thermostat controls. Interview with Maintenance Staff #42 on 05/16/24 at 2:30 P.M. verified the air conditioning unit located in the dining room was non-functioning, missing a plastic surround which exposed electrical wires and coils. He verified the unit posed an electrical risk if exposed wires/coils were touched because the unit was plugged into the electrical outlet. He verified that all air conditioning units were to be maintained though the maintenance department but was unsure when that unit was last functioning or maintained. This deficiency represents non-compliance investigated under Complaint Number OH00153796.

Feb 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

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 medical record review, staff interviews, and policy review, the facility failed to complete an assessment and implement a treatment for a newly developed pressure ulcer. This affected one (#43) out of three residents reviewed for pressure ulcers. The facility census was 65. Findings included: Review of the medical record Resident #43 revealed an admission date of 09/01/16 with medical diagnoses of chronic obstructive pulmonary disease, chronic respiratory failure, peripheral vascular disease, and hypertension. Review of the medical record for Resident #43 revealed an annual Minimum Data Set (MDS), dated [DATE], which indicated Resident #43 was cognitively intact and required substantial/maximum staff assistance for bed mobility, bathing, transfers, and toileting. The MDS indicated Resident #43 was always incontinence of bladder and frequently incontinent of bowel. The MDS indicated Resident #43 did not have any pressure ulcers. Review of the medical record for Resident #43 revealed a nurse's note dated 02/15/24 at 5:50 P.M., written by Registered Nurse (RN) #217 which stated the nurse observed small pressure sore to the residents buttocks. The note continued to state the State Tested Nursing Assistant (STNA) informed her the area was present last week but had opened since then. The note stated the area was cleaned, ointment was applied, and the Assistance Director of Nursing (ADON) was notified. Further review of the medical record revealed a nurse's note, dated 02/16/24 at 11:40 A.M. which stated the nurse assessed the open area to resident's sacrum which measured 1.1 centimeters (cm) by 1.4 cm by 0.1 cm. The note stated the wound bed was dark red in the center and pink toward the outer edges and no drainage or odor was noted. The note continued to state the Physician Assistant, the wound Nurse Practitioner (NP), resident's power of attorney, and the dietician were notified. Review of the medical record for Resident #43 revealed a physician order dated 02/16/24 to cleanse sacrum with wound cleanser, pat dry, apply medi-honey to wound bed, cover with bordered gauze and to change daily and as needed. The medical record did not contain documentation to support a treatment to the sacrum was ordered prior to 02/16/24. Review of the medical record for Resident #43 revealed weekly skin assessments dated 02/05/24 and 02/12/24 which stated Resident #43 had no skin issues. The weekly skin assessment dated [DATE] stated Resident #43 had a small pressure sore to buttocks. Further review of the medical record revealed a pressure skin grid assessment dated [DATE] which stated Resident #43 was noted to have a Stage II pressure ulcer to the sacrum area on 02/15/24. The wound measured 1.1 cm by 1.4 cm by 0.1 cm. The medical record for Resident #43 revealed a pressure skin grid assessment, dated 02/27/24, which indicated the Stage II pressure ulcer to Resident #43's sacrum was healing and measured 1.0 cm by 1.5 cm by 0.1 cm. Review of the medical record for Resident #43 revealed wound NP note, dated 02/20/24 which stated Resident #43 was evaluated for Stage II pressure ulcer to sacrum which was found on 02/16/24. The note indicated the wound measured 1.8 cm by 1.8 cm by 0.1 cm and was debrided during the evaluation. Review of the wound NP note, dated 02/27/24, stated the Stage II pressure ulcer to the sacrum had improved and measured 1 cm by 1.5 cm by 0.1 cm. Interview on 02/29/24 at 12:48 P.M. with RN #217 confirmed she was the nurse who took care of Resident #43 when the pressure ulcer to the sacrum was found on 02/15/24. RN #217 stated STNA #204 informed her the pressure ulcer was present the week before but was not open at that time. RN #217 stated she notified the Assistant Director of Nursing (ADON) #233 of the area to the sacrum for further assessment. RN #217 stated ADON #233 completed the pressure skin grid and notified physician for treatment orders. Interview on 02/29/24 at 2:09 P.M. with STNA #204 confirmed she informed RN #217 that the pressure ulcer to Resident #43's sacrum was present a week prior to 02/15/24. STNA #204 stated she notified Licensed Practical Nurse (LPN) #211 on 02/09/24 that Resident #43 had a small area to the sacrum. STNA #204 stated she was not aware if LPN #217 assessed the area or notified the physician for treatment orders. Interview on 02/29/24 at 2:25 P.M. with LPN #217 confirmed he was notified by STNA #204 that Resident #43 had an area on her sacrum. LPN #217 stated he assessed the area to Resident #43's sacrum and the area was red, was not open, and was not blanchable. LPN #217 stated he applied barrier cream and a bordered gauze and informed STNA #204 to notify the ADON the next day of the area to Resident #43's sacrum. LPN #217 confirmed he did not measure the area or notify the physician of the area for treatment orders. Review of the facility policy titled, Wound Care, revised November 2018, stated wounds would be monitored for location, size (measure length, width, and depth), undermining, tunneling, exudates, necrotic tissue, and the presence or absence of granulation tissue and epithelialization. The policy also stated to notify the physician upon discovery of new skin area and when delay in healing is noted and to obtain physician orders for treatment to begin at the time of discovery. This deficiency represents non-compliance investigated under Complaint Number OH00150850.

Jun 2023 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and resident and staff interviews, the facility failed to ensure residents were treated with dignity by ensuring the residents indwelling (Foley) urinary catheter collection bag was covered. This affected one (#11) of three residents reviewed for indwelling (Foley) urinary catheters. The facility census was 71. Findings include: Review of medical record for Resident #11 revealed admission date of. 10/31/22. Diagnoses included depression, schizophrenia, Crohn's disease and ulcerative colitis. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #11 had Brief Interview Mental Status (BIMS) score of 15 out of 15 indicating intact cognition. Resident #11 required extensive two person transfers, toileting, one person assistance for bed mobility and supervision for eating. Resident #11 had an indwelling (Foley) urinary catheter. Observation and interview on 06/07/23 at 10:14 A. M with Resident #11 revealed he was sitting just inside the doorway to his room with the collection bag for his indwelling (Foley) urinary catheter hooked to his wheelchair. Resident #11's collection bag was observed to be uncovered and contain approximately 100 milliliters of urine. Resident #11 verified he would like the indwelling (Foley) urinary catheter it to be covered. Interview on 06/07/23 at 10:14 A.M. with Physical Therapy Assistant (PTA) #13 verified the collection bag for Resident #11's indwelling (Foley) urinary catheter bag was uncovered. Interview on 06/07/23 at 9:47 A.M. with State Tested Nursing Assistant #12 and on 06/08/23 at 10:52 A.M. with STNA #22 revealed they were unaware the facility had covers for residents indwelling (Foley) urinary catheter collection bags. STNA #12 and #22 both stated they sometimes use a pillowcase. This deficiency represents non-compliance investigated under Complaint Number OH00143060.

CONCERN (D) 📢 Someone Reported This

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

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

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and resident and staff interviews, the facility failed to ensure a resident's privacy curtain was clean and/or free of stains. This affected one (#78) of three residents reviewed for the physical environment. The facility census was 71. Findings include: Review of medical record for Resident #78 revealed admission date of 07/06/20. Diagnoses included paraplegia, neuromuscular dysfunction of bladder, hepatitis C, contracture of left lower leg, anxiety, depression and insomnia. The five-day Minimum Data Set (MDS) dated [DATE] revealed Resident #78's Brief Interview Mental Status (BIMS) score of 15 indicating intact cognition. Resident #78 was independent for bed mobility, transfers, eating and total dependence for toileting. Observation and interview on 06/07/23 at 9:02 A.M. revealed Resident #78's privacy curtain had a dark, brown stain towards the head of the bed and was approximately 12 inches by (x) eight inches at bed level. Resident #78 revealed he was unsure what was on the curtain and stated it may be barbecue sauce, but he did not know if the curtain had been cleaned since he had been there. Resident #78 stated he would like to have it cleaned. Interview on 06/07/23 at 9:14 A.M. with Housekeeper #10 revealed she cleans rooms daily including Resident #78's room. Housekeeper #10 verified there was an unsightly stain on the privacy curtain in Resident #78's room and stated she was unsure the last time it had been cleaned. This deficiency represents non-compliance investigated under Complaint Number OH00143060.

Jan 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of a facility self-reported incident (SRI), staff interviews and policy review, the facility failed to ensure a resident was free from sexual abuse. This affected one (#57) out of three reviewed for abuse. Facility census was 85. Findings include: Review of medical record for Resident #57 revealed admission date of 01/16/20. Diagnoses include stroke, hypertension, vascular dementia, and type two diabetes mellitus. The resident remains in the facility. Review of Resident #57's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview Mental Status (BIMS) score of four out of 15 indicating severely impaired cognition. Resident #57 required extensive one person assistance for dressing, toileting, and personal hygiene, limited assistance for bed mobility, transfers, walking and supervision for eating. No behaviors were documented in MDS lookback period. A care plan created 01/22/20 revealed Resident #57 was at risk for exhibiting sexually inappropriate behavior. Individualized interventions included medications as ordered and monitor when in common areas with others. Review of the progress note dated 12/13/22 revealed Resident #57 was found being touched inappropriately by Resident #10. Notifications were made to management, physician, police and a message was left for his guardian. Resident #57 acknowledged he was fine and is in no need of assistance or support. Review of medical record for Resident #10 revealed admission date of 11/24/21. Diagnoses include stroke, traumatic brain injury with loss of consciousness for unknown duration, and type two diabetes mellitus. Resident #10 was discharged on another skilled facility on 12/13/22. Review of Resident #10's discharge MDS dated [DATE] revealed the resident had a BIMS score of three out 15 indicating severely impaired cognition. Resident #10 was independent for activities of daily living. A care plan initiated 12/01/22 revealed a potential for behavioral problems related to dementia with schizoaffective disorder and history of traumatic brain injury which revealed individualized interventions to administer medications as ordered, allow resident to discuss feelings, approach/speak in a calm voice, and staff to redirect as able and provide one on one care as needed. Potential for mood changes related to chronic pain, conversion disorder with seizures, anxiety, hallucinations/delusions, stroke and traumatic brain injury created 07/25/22 with interventions to introduce to residents on unit of similar status and capability, monitor mental status/mood with medication changes, observe and report any change. Review of Resident #10's physician orders revealed an order for Medroxyprogesterone Acetate tablet 100 milligrams (mg) daily for sexual aggression with a start date of 12/02/22 and a discontinue date of 12/07/22. Review of Resident #10's the progress note dated 12/07/22 for Resident #10 documented Medroxyprogesterone Acetate order was clarified and updated due to incorrect dose written in system. Review of Resident #10's physician orders revealed an order for Medroxyprogesterone Acetate tablet 10 milligrams (mg) daily for sexual aggression with a start date of 12/07/22. Review of Resident #10's December 2022 Medication Administration Record (MAR) revealed the Medroxyprogesterone Acetate 100 mg was documented as given 12/02/22 through 12/06/22 and Medroxyprogesterone Acetate 10 mg documented as given 12/07/22 through 12/12/22. Review of Resident #10's progress note dated 12/12/22 at 12:03 P.M. revealed Licensed Practical Nurse (LPN) #30 documented Resident #10 had inappropriate behaviors on the shift and statements were written and given to the Director of Nursing (DON). Staff to be on alert for close monitoring. Review of Resident #10's progress note dated 12/12/22 at 11:02 P.M. revealed Resident #10 had to be redirected several times throughout the shift to keep his clothes on. Resident #10 was documented to take off his clothes and sit in his wheelchair and stare at his roommate (Resident #57). Resident #10 was educated on the importance of being courteous to Resident #57 and placed on 15-minute checks for noted behaviors. Review of Resident #10's progress note dated 12/13/22 at 1:31 A.M. revealed Resident #10 was found hovering over Resident #57 starring at him, Resident #10 was redirected back to bed and educated on personal space. Review of Resident #10's progress note dated 12/13/22 at 5:00 A.M. revealed the resident was found by a State Tested Nursing Assistant (STNA) sitting next to his roommate's bed, with his hands in his roommate's pants. Resident #10 removed Resident #57's penis and began fondling it. Resident #10 was immediately removed from the room and placed in the common area where he proceeded to masturbate in front of staff and another resident. Resident #10 was redirected and placed on one-on-one care. Management, family representatives of both parties and police were notified. Review of a facility SRI titled Sexual Abuse dated 12/13/22 revealed Resident #10 was observed inappropriately touching Resident #57. Resident #57 was assessed and no injuries were noted. Interview on 01/10/23 at 12:33 P.M. with Regional Director of Clinical Operation (RDCO) #3 revealed the police were contacted regarding sexual abuse of Resident #57 by Resident #10 on 12/13/22. RDCO #3 stated three staff statements were obtained by the police, the residents were not able to provide dependable accounts of the encounter. RDCO #3 reviewed the SRI dated 12/13/22 during the interview and verified she was unable to provide the documentation of one-on-one observation as stated in the SRI. A interview on 01/10/23 with the DON at 2:35 P.M. revealed she was unaware Resident #57's plan of care revealed the resident had sexual inappropriateness prior to moving Resident #10 into his room. The DON confirmed Resident #10 was observed inappropriately touching Resident #57. The DON confirmed the staff were documenting Resident #10 was receiving Medroxyprogesterone Acetate 100 mg; however, on 12/07/22 the facility discovered there was a discrepancy with the dose and they updated the order to 10 mg which was the correct dose. Follow up interview on 01/10/23 at with DON at 4:30 P.M. revealed she was unable to find the staff statements regarding documented behavior on 12/12/22 for Resident #10, as well as any one-on-one or 15-minute checks provided for Resident #10. Review of facility policy titled Abuse, Neglect, Exploitation and Misappropriation, dated 2016, revealed the facility policy does not specify how to handle abuse where another resident was the perpetrator. The policy revealed for third party perpetrators, to contact them to discuss the allegation and prevent access to the resident during the investigation and document resident assessment and any treatments provided as well as appropriate quality assurance documentation should be provided. Related to follow up for a resident to resident assessment, interventions would be determined by the interdisciplinary team. This deficiency substantiates Complaint Number OH00138470.

Dec 2022 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

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 medical record review, staff interview, observation, law enforcement interview, review of the self-reported incident (SRI), review of the increased supervision check log, and policy review, the facility failed to ensure residents were protected from potential further abuse during the investigation of an alleged resident to resident sexual assault. This affected one resident (#82) out of three residents reviewed for abuse. The facility census was 82. Findings include: Review of the medical record for the Resident #82 revealed an admission date of 11/20/20. Diagnoses included Alzheimer's disease, depression, anxiety, and cognitive communication deficit. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #82 was cognitively impaired and required extensive assistance of one staff member for bed mobility and limited assistance from staff for transfers and was independent with walking. Review of the plan of care dated 11/23/20 revealed Resident #82 had potential for changes in moods and behaviors related to Alzheimer's dementia. The resident was at risk for wandering and elopement related to Alzheimer's diagnosis with interventions to redirect, follow facility procedures, and resident resided on the secure unit for safety. Review of the progress note dated 12/01/22 at 2:30 A.M. revealed the nurse was informed by a State Tested Nursing Assistant (STNA) of a male resident in her room with his pants down and penis exposed with vaseline on the bed. When the nurse entered the room, the male resident was wheeling himself out of the room. Resident #82 was laying on her left side with her brief opened and vagina exposed laying in the fetal position crying. Resident #82 was unable to give a description of what happened. Resident #82 was sent to the hospital for an evaluation and the family and the physician were notified. Progress note dated 12/01/22 revealed Resident #82 returned to the facility, a head to toe assessment had been completed with no visible injuries noted. The local hospital reported to the facility nurse that no obvious assault had occurred according to the hospital physician, but a rape kit was completed and results were still pending. Review of the hospital discharge summary for Resident #82 revealed the resident was seen for a reported sexual assault. Review of the medical record for the Resident #47 revealed an admission date of 02/14/20. Diagnoses included dementia with behavioral disturbances, chronic obstructive pulmonary disease, diabetes, cerebral infarction, conversion disorder with seizures, anxiety, and schizoaffective disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 was cognitively impaired and required supervision set up assistance only. Review of the care plan dated 02/07/20 revealed Resident #47 had alteration in neurological status with interventions to assess for effectiveness of psychotropic medications, bowel and bladder program to improve or maintain continence, cueing and reorientation as needed. Resident had potential for behavior problems related to dementia and schizoaffective disorder with a history of a traumatic brain injury with history of sexual behaviors toward female residents with interventions to administer medication as ordered, allow the resident to discuss feelings, encourage resident to participate in activities, and staff to provide one-to-one observation as needed. (dated 12/01/22). Resident was at risk for wandering or elopement related to dementia with interventions to assess risk factors, redirect as needed, and resident resided on secure unit. Review of progress note dated 12/01/22 at 2:30 A.M., revealed Resident #47 was found in a female residents room with his pants down and penis exposed. Resident #47 had petroleum jelly by his side. The female resident had her brief opened and pulled down to expose the vaginal area and was crying. Resident #47 pulled his pants up when the STNA walked into the room. Resident #47 was taken to the common area and placed on 15 minute safety checks. Resident #47 was unable to recall and said he did not know when asked what happened. Review of physician order dated 12/02/22 revealed Resident #47 had an order for medroxyprogesterone acetate tablet with instructions to give 100 milligram (mg) by mouth once daily for sexual aggression. Interview on 12/06/22 at 11:59 A.M., with the Licensed Practical Nurse (LPN) #105 revealed she typically worked on the memory care unit. She revealed Resident #47 would wander in the halls and into resident rooms typically looking to take snacks and food. The LPN revealed Resident #47 lived in the room next to Resident #82. Resident #47 had his room moved to the opposite end of the memory care unit after the incident occurred and had 15 minute checks and the one-to-one checks initiated but was unsure when each type of monitoring was used. The LPN #105 revealed the results of the rape kit had not yet returned from the laboratory. Observation on 12/06/22 at 12:19 P.M. with the Administrator and the Director of Nursing (DON) asking LPN #105 to sign off on the one-to-one supervision logs for Resident #47. LPN #105 told the Administrator she was unsure who was working those days, do you want me to sign it? and the Administrator said yes. Observation of the LPN #105 initialing sections on three separate pages of the one-to-one documentation from the incident on 12/01/22. Interview on 12/06/22 at 2:22 P.M., with STNA #135 revealed Resident #47 had both one-to-one supervision and 15-minute checks when she worked after the incident occurred. STNA #135 revealed Resident #47 had moved rooms and Resident #82 went to the hospital for an evaluation. STNA #135 revealed Resident #47 was sneaky and would go in other resident rooms but typically it was to take food and snacks or use the bathroom. STNA #135 revealed the one-to-one supervision and 15 minute checks ended after a few days. Interview on 12/06/22 at 2:12 P.M., with STNA #145 revealed Resident was on one-to-one checks and switched to 15-minute checks at some point but was unsure when this occurred. Interview on 12/06/22 at 4:20 P.M., with the DON revealed she was first notified of the alleged sexual incident between Resident #47 and Resident #82 on 12/01/22 around 8:00 A.M. by the Administrator. She reported she came to the facility shortly after being notified and the interdisciplinary team was looking at options for a room move for Resident #47. She revealed Resident #47 was monitored but was unable to explain the type of monitoring (one-to-one, 15-minute checks, or standard observation). The DON estimated Resident #47 had his room moved around 9:00 A.M. and after the interdisciplinary team (IDT) met and discussed the incident, Resident #47 was placed on one-to-one checks. The DON reported residents were kept safe by staff walking the halls and doing their rounding as one-to-one observations or 15-minute checks were not determined for several hours (after IDT team met). The DON reported after 72 hours post incident the one-to-one monitoring stopped. Resident #47 had not exhibited any new or ongoing behaviors and had his medication reviewed and changed. The DON verified her and the Administrator spoke with LPN #105 on 12/06/22 regarding the one-to-one monitoring sheets and requested she complete the forms by filling in the open sections from the dates 12/01/22, 12/02/22, and 12/03/22 that had not been completed by previous staff. The DON acknowledged LPN #105 signed as requested on the dates and the times she was not working. The DON reported she had not looked at the schedule prior to asking LPN #105 to complete this documentation to ensure accuracy. Interview on 12/07/22 at 7:50 A.M., with STNA #110 revealed staff sent Resident #47 to his room while Resident #82 was assessed and staff remained with Resident #82 until she transferred to the hospital for evaluation. STNA #110 believed Resident #47 was on 15-minute checks during this time. STNA #110 said she had not seen any sexual act and had just saw Resident #47 within 10 minutes out in the common area of the unit. Interview on 12/07/22 at 10:03 A.M., with the police detective (PD) #200 revealed the local police were dispatched on 12/01/22 at 2:40 A.M. and believed the incident occurred between 2:00 and 2:15 A.M. The PD #200 reported the sexual assault nurse examiner (SANE) nurse (a nurse trained to perform rape examinations for forensic evidence) who completed the rape kit and examined Resident #82 reported to the police there was no evidence of trauma including redness, bruising or injuries and had not thought any assault or penetration occurred. The PD #200 reported it remained an open investigation until the laboratory results come back, but he did not believe it would be followed up on with charges due to the dementia diagnosis of both residents. The PD #200 reported the rape kit deoxyribonucleic acid (DNA) testing typically takes about four to eight weeks and reported the laboratory was backed up. Interview on 12/07/22 at 10:11 A.M., with the Administrator revealed she was first notified of the incident between Resident #47 and Resident #82 around 2:30 A.M. on 12/01/22. The Administrator informed staff to place Resident #47 on 15-minute checks and monitor behaviors. The Administrator revealed the 15-minute checks stopped around mid-day and Resident #47 was switched to one-to-one checks after the interdisciplinary team met to discuss a plan. Interview on 12/07/22 at 11:15 A.M., with LPN #150 revealed the observation status of one-to-one or 15-minute checks were given from staff to staff in a verbal report or handoff with limited direction. A follow-up interview on 12/07/22 at 2:14 P.M., with the Administrator revealed the abuse policy would include resident suspected perpetrators as third party accused or suspected as this should include any non-staff members. Interview on 12/08/22 at 3:50 P.M., with LPN #120 revealed she was informed on 12/01/22 around 2:15 A.M. of Resident #47 being in Resident #82's room with their pants down and briefs not securely fastened. LPN #120 revealed when she entered the room Resident #47 was wheeling himself out in his wheelchair and Resident #82 was curled up and crying in her bed. She reported she called either the DON or the Assistant DON and was instructed to contact the Administrator which she did. LPN #120 revealed Resident #47 was placed on one-to-one checks and remained on them through the weekend. LPN #120 revealed the facility management and administration had not spoken with her regarding the incident since it occurred. Review of facility policy titled Abuse, Neglect, Exploitation and Misappropriation, dated 2016, revealed the facility policy does not specify how to handle abuse where another resident was the perpetrator. The policy revealed for third party perpetrators, to contact them to discuss the allegation and prevent access to the resident during the investigation and document resident assessment and any treatments provided as well as appropriate quality assurance documentation should be provided. Related to follow up for a resident to resident assessment, interventions would be determined by the interdisciplinary team. Review of the SRI investigation number 229671 revealed staff statements were taken by the police and both resident's care plans were reviewed. Resident #47 had 15-minute checks and one-to-one documentation in the investigation file for approximately 72 hours post incident. The investigation was still pending final determination during the complaint investigation. Review of the increased supervision check logs revealed 15-minute logs and one-to-one logs were kept on the same form with no delineation of when the observation levels changed. LPN #105 signed off on the forms on 12/01/22 from 6:15 P.M. to 9:30 P.M., on 12/02/22 from 2:15 P.M. to 9:45 P.M., and 12/03/22 from 6:15 A.M. to 7:30 A.M. and 3:15 P.M. to 9:45 P.M. Review of the staff schedule revealed LPN #105 had not worked on 12/01/22, LPN #105 worked from 6:00 A.M. to 6:00 P.M. on 12/02/22 and LPN #105 worked from 6:00 A.M. to 6:00 P.M. on 12/03/22. This deficiency represents non-compliance investigated under Complaint Number OH00138071 and OH00138077.

Nov 2022 8 deficiencies 2 Harm

SERIOUS (G) 📢 Someone Reported This

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

Actual Harm - a resident was hurt due to facility failures

Pressure Ulcer Prevention (Tag F0686)

A resident was harmed · This affected 1 resident

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Based on record review, observation, resident and staff interviews, review of facility policy, and review of guidelines from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to implement physician-ordered interventions for residents with pressure ulcers, failed to thoroughly assess resident's skin and failed to identify pressure ulcers until they had already reached an advanced stage. This resulted in Actual Harm when Resident #76 developed an avoidable unstageable pressure ulcer to the left heel on 09/16/22 and Resident #55 developed an avoidable unstageable pressure ulcer to the right heel on 11/17/22. This affected two (#55 and #76) of three residents reviewed for pressure ulcers. The facility census was 84. Findings include: 1. Review of the medical record for Resident #55 revealed an admission date of 08/26/22 with a diagnoses including vascular dementia, hypertension, and Alzheimer's disease. Review of the Minimum Data Set 3.0 (MDS) for Resident #55 dated 09/04/22 revealed the resident was cognitively impaired and required extensive assistance of two staff with activities of daily living (ADL's). Further review of the MDS revealed Resident #55 was coded as negative for the presence of pressure ulcers and was coded as being at risk for the development of pressure ulcers. Review of the pressure ulcer risk assessment for Resident #55 dated 08/26/22 revealed the resident was at risk for the development of pressure ulcers. Review of the admission skin assessment for Resident #55 dated 08/26/22 revealed resident's skin was intact. Review of the care plan for Resident #55 initiated 08/31/22 revealed the resident was at risk for skin breakdown due to decreased mobility and incontinence. Interventions included the following: administer medication as ordered, assist resident to the bathroom as needed, provide peri care after each incontinence episode, apply barrier cream after incontinence care, assist the resident with turning and repositioning, pressure redistribution mattress to bed. Review of the care plan for Resident #55 dated 09/14/22 revealed the resident has an actual pressure wound to the coccyx. Interventions included: administer medications as ordered, administer treatment as ordered, assist resident with turning and repositioning, measure wounds weekly as ordered, observe for signs of infection: redness, purulent drainage, warmth, foul odor, obtain lab work as ordered, notify physician of abnormal lab values. Review of the pressure ulcer assessment for Resident #55 dated 09/15/22 revealed the resident developed a Stage I pressure ulcer to her coccyx which measured 2.1 centimeters (cm) in length by 0.6 cm in width and 0.1 cm in depth which was first identified on 09/09/22. Review of the pressure ulcer assessment for Resident #55 dated 09/22/22 revealed the pressure ulcer to the coccyx now measured 2.3 cm in length by 0.9 cm in width and 0.2 cm in depth and was now classified as a Stage III pressure ulcer. Review of the weekly skin assessments per licensed nurses for Resident #55 revealed the facility had completed one skin assessment for the resident on 09/16/22 which indicated the weekly skin assessment included previously identified pressure areas and no new areas of skin impairment. Review of the shower sheets for Resident #55 completed by the state tested nursing assistants (STNAs) and signed by licensed nurses for the following dates revealed there were no new areas of skin impairment notes for Resident #55: 09/02/22, 09/09/22, 09/16/22, 09/23/22, 09/30/22, 10/07/22, 10/14/22, 10/23/22, 10/28/22, 11/04/22, 11/11/22. Review of the nurse progress note for Resident #55 dated 11/12/22 revealed the STNA notified the nurse the resident had a black blister to her right heel. The nurse went into the resident's room and checked the resident's heel. A large black blister was noted to right heel. Area was cleansed gently, patted dry, skin prep applied, and heel was placed in a heel cup. Review of the pressure ulcer assessment for Resident #55 dated 11/17/22 revealed the resident had an unstageable pressure ulcer to her right heel which was purple in color and measured 6.0 cm in length by 2.7 cm in width. Review of a wound physician note for Resident #55 dated 11/17/22 revealed the resident had a new onset wound to the right heel which was classified as a deep tissue injury (DTI) which measured 6.0 cm in length by 2.7 cm in width. Review of the November 2022 monthly physician orders for Resident #55 revealed orders dated 11/17/22 for the resident to wear moon boots while in bed and an order to cleanse the right heel with normal saline (NS), pat dry, apply Betadine, apply heel cup, and apply the moon boots once daily and as needed. Review of the November 2022 Treatment Administration Record (TAR) for Resident #55 revealed the treatment to the right heel and the order for the moon boots was not implemented until 11/19/22. Observation on 11/21/22 at 2:18 P.M. revealed Resident #55 was resting in bed and was not wearing moon boots. One moon boot was observed in the resident's room resting on the windowsill. Resident #55 was not interviewable. Interview on 11/21/22 at 2:20 P.M. with STNA #370 confirmed Resident #55 did not have a pair of moon boots. STNA #370 further confirmed Resident #55 was not able to don or doff the moon boot herself. STNA #370 confirmed she had not placed the moon boot on the resident's right foot when she put the resident in bed after lunch because she thought the moon boot was only supposed to be placed when the resident was in bed for the night. Observation on 11/22/22 at 9:34 A.M. revealed Resident #55 was up in a geri chair and had a moon boot on the right foot. Interview on 11/22/22 at 9:34 A.M. with Licensed Practical Nurse (LPN) #200 confirmed the facility only had one moon boot for Resident #55 which they applied to the right foot because she had a pressure ulcer on that foot. Observation on 11/22/22 at 10:15 A.M. with LPN #200 revealed Resident #55 had a blackened area to the medial aspect of her right heel which was the size of two quarters placed next to one another. There was no drainage and the wound appeared to be covered with eschar. Interview on 11/22/22 at 10:15 A.M. with LPN #200 confirmed Resident #55 had an unstageable pressure ulcer to her right heel which was first identified on 11/17/22. LPN #200 further confirmed licensed nurses were supposed to conduct a head-to-toe skin assessment for each resident weekly. LPN #200 further confirmed the facility had not conducted regular weekly skin assessments for Resident #55. Interview on 11/22/22 at 1:08 P.M. with the Director of Nursing (DON) confirmed the facility staff first identified an area of impaired skin integrity to Resident #55's heel on 11/11/22. The DON confirmed the facility, and the wound physician identified a DTI to resident's right heel on 11/17/22. The DON confirmed the treatment to the wound was not implemented until 11/19/22. The DON further confirmed the licensed nurses were supposed to conduct weekly skin assessments and document them in the electronic medical record and there was only one weekly skin assessment for Resident #55 which was dated 09/16/22. The DON further confirmed the pressure ulcer to Resident #55's heel was avoidable. 2. Review of the medical record for Resident #76 revealed an admission date of 01/17/22 with diagnoses including atherosclerotic heart disease, anemia, chronic kidney disease and hypertension. Review of the MDS for Resident #76 dated 11/10/22 revealed the resident was cognitively impaired and required extensive assistance of one staff with activities of daily living (ADLs). Review of the care plan for Resident #76 initiated 02/18/22 revealed the resident was at risk for the development of pressure ulcers due to decreased mobility and incontinence. Interventions included the following: administer medication as ordered, apply lotion to dry skin as needed, assist resident to the bathroom as needed, provide peri care after each incontinence episode and wheelchair cushion as ordered. Review of the weekly skin assessments per licensed nurses for Resident #76 revealed the most recent skin assessment for the resident was conducted on 07/07/22 and indicated the resident had no areas of impaired skin integrity. Review of the care plan for Resident #76 dated 09/16/22 revealed the resident has an actual pressure wound to the left heel. Interventions included: administer medications as ordered, administer treatment as ordered, assist resident with turning and repositioning, measure wounds weekly as ordered, observe for signs of infection: redness, purulent drainage, warmth, foul odor, obtain lab work as ordered, notify physician of abnormal lab values. Review of the shower sheets for Resident #76 completed by the STNAs and signed by licensed nurses for the following dates revealed there were no new areas of skin impairment notes for the resident on 09/01/22 and 09/08/22. Shower sheet dated 09/15/22 revealed heels were soft and were an abnormal color (purple). Review of the pressure ulcer assessment for Resident #76 dated 09/16/22 revealed the resident had a pressure ulcer to her left heel that measured 2.5 cm in length by 2.0 cm in width. Review of the September 2022 monthly physician orders for Resident #76 revealed orders dated 09/16/22 for moon boots while in bed and to apply Betadine to left heel every shift. Review of a wound physician note for Resident #76 dated 09/29/22 revealed the resident had an unstageable pressure injury to the left heel, covered with dark colored eschar and had no drainage which measured 4.8 cm in length by 2.5 cm in width. The physician recommended boots for offloading the wound. Review of the wound physician note for Resident #76 dated 11/17/22 revealed the pressure ulcer to the resident's left heel was now classified as a Stage III and had 25 percent (%) yellow slough to the wound bed with a moderate amount of serous drainage. The wound measured 1.0 cm in length by 0.3 cm in width by 0.1 cm in depth. The physician recommended boots for offloading the wound. Review of the November 2022 monthly physician orders for Resident #76 revealed orders dated 11/17/22 for the resident to wear moon boots while in bed and an order to cleanse the left heel with normal saline (NS), pat dry, apply Calcium alginate and collagen and secure with an ABD pad once daily and as needed. Observation on 11/22/22 at 8:35 A.M. revealed Resident #76 was resting in bed and was not wearing moon boots. Interview on 11/22/22 at 8:35 A.M. with Resident #76 confirmed she had developed a pressure ulcer to her left heel a couple months ago and it was painful. Resident #76 further confirmed she had moon boots which she was supposed to wear when she was in bed, but she was not sure where the moon boots were. Resident #76 confirmed she was unable to don or doff the moon boots herself and she had not worn them the night before. Interview on 11/22/22 at 8:37 A.M. with STNA #300 confirmed Resident #76's moon boots were not on her feet. STNA #300 confirmed night shift must have not put them on. Interview on 11/22/22 at 9:35 A.M. with LPN #200 confirmed Resident #76's moon boots were available in her closet and should have been placed on her feet while resident was in bed. Observation of wound care for Resident #76 on 11/22/22 at 9:36 A.M. per LPN #200 revealed the resident had a dime-sized darkened area to her left heel. The upper portion of the wound was yellow in color. Interview on 11/22/22 at 9:36 A.M. with LPN #200 confirmed Resident #76 had a pressure ulcer to her left heel which was first identified as an unstageable deep tissue injury on 09/16/22. LPN #200 confirmed the wound physician now classified the wound as a Stage III pressure ulcer due to the presence of slough in the wound bed. LPN #200 further confirmed the facility had not conducted regular weekly skin assessments for Resident #76. Interview on 11/22/22 at 1:08 P.M. with the DON confirmed the facility staff first identified an area of impaired skin integrity to Resident #76's heel on 09/16/22. The DON confirmed the wound physician identified a DTI to the resident's right heel on 09/29/22. The DON further confirmed the most recent weekly skin assessment for Resident #76 was dated 07/07/22. The DON further confirmed the pressure ulcer to Resident #76's heel was avoidable. Review of the facility policy titled Skin Care Pressure Prevention dated 11/2018 revealed the facility would ensure resident skin was observed routinely and preventative care plans completed upon admission and developed and implemented for each resident based on resident's risk factors for the development of skin breakdown. Review of the facility policy titled Assessments undated revealed a skin assessment should be completed upon admission and skin inspections should be conducted weekly and recorded in the resident's record. Review of the NPUAP guidelines dated 2014 pages 70-71 at https://npiap.com/general/custom.asp?page=2014Guidelines revealed facilities should educate health professionals on how to undertake a comprehensive skin assessment that includes the techniques for identifying blanching response, localized heat, edema, and induration. Further review of the guidelines revealed ongoing assessment of the skin was necessary in order to detect early signs of pressure damage. Visual assessment for erythema (redness of the skin) was the first component of every skin inspection. Skin redness and tissue edema resulting from capillary occlusion was a response to pressure, especially over bony prominences. Staff should conduct a head-to-toe assessment with particular focus on skin overlying bony prominences including the sacrum, ischial tuberosities, greater trochanters and heels and each time the patient was repositioned was an opportunity to conduct a brief skin assessment. Review of the NPUAP guidelines dated 2014 page 115 revealed ideally, heels should be free of all pressure, a state sometimes called floating heels. Pressure can be relieved by elevating the lower leg and calf from the mattress by placing a pillow under the lower legs, or by using a heel suspension device that floats the heel. Consequently, the pressure will instead spread to the lower legs, and the heels will no longer be subjected to pressure. This deficiency represents non-compliance investigated under Complaint Number OH00136575.

SERIOUS (G) 📢 Someone Reported This

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

Actual Harm - a resident was hurt due to facility failures

Accident Prevention (Tag F0689)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of facility policy, the facility failed to conduct a thorough investigation to determine potential hazards and resident-specific interventions to reduce and/or eliminate falls and falls with injury. This resulted in Actual Harm when Resident #87 experienced a fall on 11/06/22 which was not investigated to implement effective interventions. Resident#87 sustained a right comminuted hip fracture from the fall. This affected one (#87) of three residents reviewed for falls. The census was 84. Finding include: Review of the medical record for Resident #87 revealed an admission date of 09/15/20 with a diagnosis of Alzheimer's disease. Review of the Minimum Data Set 3.0 (MDS) for Resident #87 dated 10/10/22 revealed the resident was cognitively impaired and required limited assistance of one staff with activities of daily living (ADLs). Review of the fall risk assessment for Resident #87 dated 06/01/22 revealed the resident was at high risk for falls. Review of the care plan for Resident #87 last updated 05/27/22 revealed the resident was at risk for falls related to memory impairment and schizophrenia. Interventions included the following: display a use call light sign in room, hipsters to be worn at all times when out of bed may remove for care, keep bed in lowest position except during care, keep call light within reach, non-skid strips to floor next to bed, offer to lay down after lunch, offer toileting every two hours, room modification, staff to anticipate resident's needs, therapy screen as needed, wheelchair removed from room. Review of the nurse progress note for Resident #87 dated 11/06/22 timed at 4:25 A.M. per an agency nurse revealed Resident #87 was found on the floor, had a fall and was complaining of pain to her right hip. The nurse administered Tylenol per order and gave witness statement forms to the two aides working on the unit. Review of witness statement per State Tested Nursing Assistant (STNA) #225 revealed she saw Resident #87 on the floor near her bed on 11/06/22 at approximately 4:15 A.M. Review of witness statement per STNA #380 dated 11/06/22 revealed the aide saw Resident #87 in her bed at 2:00 A.M. when the aide was performing rounds. Further review of the statement revealed at the time of the fall the aide walked by the resident's room, she saw the resident sitting on the floor with no bottoms on. The floor was a little wet and the resident was helped up off the floor, cleaned up, and helped back into bed. Review of the nurse progress note for Resident #87 dated 11/09/22 revealed the facility obtained a stat (immediate) x-ray of the right hip and it was positive for hip fracture. The resident was sent to the hospital via ambulance. Review of hospital notes for Resident #87 dated 11/09/22 revealed the resident presented in the emergency room on [DATE] after a fall on 11/06/22. The hospital obtained a computerized tomography (CT) scan which showed a comminuted fracture of the resident's right hip and pelvis attributed to the fall. Further review of the hospital notes revealed Resident #87 was not a surgical candidate due to advanced dementia. Interview on 11/22/22 at 1:08 P.M. with the Director of Nursing (DON) confirmed the facility had not completed an investigation of Resident #87's fall on 11/06/22 to determine the root cause of the fall and if care planned fall interventions were in place at the time of the fall nor had the facility reviewed the resident's care plan following the fall. The DON confirmed the facility medical director examined Resident #87 on 11/09/22 after the facility informed the physician of the resident's fall on 11/06/22. The DON stated Resident #87 complained of right hip pain, and the physician ordered a stat x-ray. The x-ray was positive for an acute fracture due to the fall on 11/06/22. The DON confirmed Resident #87 was transferred to the hospital per ambulance. Review of the facility policy titled Fall Policy dated October 2018 revealed an investigation will be completed after an incident where a resident investigation will be done on an incident where a resident, visitor, or staff member says a fall has occurred, a resident is observed on the floor, or a resident is lowered to the floor with or without an injury. Current interventions will be reviewed, and a new intervention implemented to reduce the risk of a fall. Relevant information will be documented regarding the fall, assessment, notifications and interventions. This deficiency represents non-compliance investigated under Complaint Number OH00137573 and OH00137574

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 F0557 (Tag F0557)

Could have caused harm · This affected 1 resident

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Based on record review and staff interview, the facility failed to ensure resident's food ordered from an outside vendor was delivered to the resident and failed to ensure resolution of the concern when it was identified. This affected one (#85) of three residents reviewed for resident rights. The census was 84. Findings include: Review of the medical record for Resident #85 revealed an admission date of 08/25/22 with a diagnosis of chronic obstructive pulmonary disease (COPD) and a discharge date of 09/08/22. Review of the Minimum Data Set (MDS) for Resident #85 dated 09/03/22 revealed resident was cognitively intact and was independent with activities of daily living (ADL's). Review of the nurse progress note for Resident #85 dated 08/29/22 revealed the Director of Nursing (DON) spoke with resident's representative regarding resident did not receive a meal they ordered for him from an outside vendor. Meal was given to the wrong resident. Review of note revealed DON was to follow up with the family on their concern. Review of the facility concern log dated August 2022 revealed there were no concerns noted for Resident #85 Interview on 11/22/22 at 1:08 P.M. with the DON confirmed she spoke with Resident #85's representative on 08/29/22 regarding their concern over resident not receiving the meal they had paid for and sent to the facility for resident. DON confirmed representative wanted to be reimbursed for the cost of the meal. DON confirmed she referred the issue to the Administrator at the time of the concern because it involved financial reimbursement and the DON had just started working at the facility. DON confirmed she did not think the issue had been resolved. Interview on 11/22/22 at 1:15 P.M. with the Administrator confirmed she had started with the facility in mid-September 2022 and she was unaware if the issue involving reimbursement for Resident #85's food had been resolved. This deficiency represents non-compliance investigated under Complaint Number OH00136587.

CONCERN (D) 📢 Someone Reported This

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

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

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

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Based on record review, staff interview, and review of facility policy, the facility failed to notify the resident representatives of transfer to the hospital and failed to notify resident representatives and physician of falls. This affected two (#86 and #87) of three residents reviewed for falls. The census was 84. Finding include: 1. Review of the medical record for Resident #86 revealed an admission date of 10/15/22 with a diagnosis of diabetes mellitus (DM) and a discharge date of 11/09/22. Review of face sheet for Resident #86 revealed resident's emergency contact and a local phone number are listed. Review of the Minimum Data Set (MDS) for Resident #86 dated 10/31/22 revealed resident was cognitively impaired and required extensive assistance of one staff with activities of daily living (ADL's). Review of the nurse progress notes for Resident #86 dated 10/15/22 and 10/20/22 revealed the resident expressed suicidal ideation and was sent to the hospital via emergency transport for an evaluation. The record did not include documentation of resident representative notification of the transfers. Interview on 11/22/22 at 1:08 P.M. with the Director of Nursing (DON) confirmed Resident #86's record did not include documentation of resident representative notification of the transfers on 10/15/22 and 10/20/22. Interview on 11/22/22 at 1:15 P.M. with the Administrator confirmed she added the emergency contact number for Resident #86's representative to the resident's electronic medical record on 11/03/22 because she spoke to the resident representative on this date. Administrator confirmed generally the facility should obtain resident representative/emergency contact information upon admission. 2. Review of the medical record for Resident #87 revealed an admission date of 09/15/20 with a diagnosis of Alzheimer's disease. Review of the MDS for Resident #87 dated 10/10/22 revealed resident was cognitively impaired and required limited assistance of one staff with ADL's. Review of the nurse progress note for Resident #87 dated 11/06/22 timed at 4:25 A.M. per an agency nurse revealed Resident #87 had a fall and was complaining of pain to her right hip. The note did not include documentation of resident's representative or resident's attending physician regarding the fall. Interview on 11/22/22 at 1:08 P.M. with the DON confirmed the facility had no documentation of resident representative or physician notification for Resident #87's fall on 11/06/22. Review of the facility policy titled Change in Condition and Physician Notification dated 09/2019 revealed the facility would ensure staff promptly identified, responded to, and notified resident's representative and attending physician of changes in condition. This deficiency represents non-compliance investigated under Complaint Number OH00137573.

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 F0624 (Tag F0624)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and policy review, the facility failed to ensure a safe and orderly discharge for residents. This affected one (#85) of three residents reviewed for discharge resident rights. The census was 84. Findings include: Review of the medical record for Resident #85 revealed an admission date of 08/25/22 with a diagnosis of chronic obstructive pulmonary disease (COPD) and a discharge date of 09/08/22. Review of the Minimum Data Set (MDS) for Resident #85 dated 09/03/22 revealed resident was cognitively intact and was independent with activities of daily living (ADL's). Review of hospital notes for Resident #85 prior to his admission to facility dated 08/19/22 revealed the resident had been admitted to the hospital due to shortness of breath (SOB) and was diagnosed with Coronavirus Disease 2019 (COVID-19) on 08/19/22. During Resident #85's hospital stay he received oxygen intermittently via nasal cannula (NC) when his oxygen saturation level was below 90 percent (%.) Review of the medical record for Resident #85 revealed it did not include a baseline care plan for resident. Review of the comprehensive care plan for Resident #85 revealed it included a nutritional risk care plan initiated 08/30/22. The comprehensive care plan did not address any other issues. Resident #85 did not have a discharge care plan. Review of the daily oxygen saturation levels for Resident #85 dated 08/25/22 through 09/08/22 revealed they were taken while resident was receiving oxygen via NC Review of the September 2022 monthly physician orders for Resident #85 revealed an order for resident which read, May discharge home with durable medical equipment (DME.) Review of discharge summary and plan of care for Resident #85 dated 09/08/22 revealed resident would discharge to home with medications and oxygen. Interview on 11/22/22 at 1:08 P.M. with the Director of Nursing (DON) confirmed the facility did not have oxygen orders for Resident #85 but resident did receive oxygen regularly via NC at two liters per minute (LPM) in order to maintain his oxygen saturation levels above 90 %. DON confirmed Resident #85 was sent home on [DATE] without oxygen. DON confirmed she took an oxygen concentrator and tubing and NC to resident's home on [DATE] and assisted him with administering oxygen at two LPM. Review of the facility policy titled Transfer and discharge date d 10/17/22 revealed orientation for transfer or discharge will be provided and documented to ensure safe and orderly transfer or discharge from the facility, in a form and manner that the resident can understand. Depending on the circumstances, this orientation may be provided by various members of the interdisciplinary team. This deficiency represents non-compliance investigated under Complaint Number OH00136587.

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 F0655 (Tag F0655)

Could have caused harm · This affected 1 resident

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Based on record review, staff interview and policy review, the facility failed to ensure a baseline care plan was developed for a newly admitted resident. This affected one (#85) of three residents reviewed for resident rights. The census was 84. Findings include: Review of the medical record for Resident #85 revealed an admission date of 08/25/22 with a diagnosis of chronic obstructive pulmonary disease (COPD) and a discharge date of 09/08/22. Review of the Minimum Data Set (MDS) for Resident #85 dated 09/03/22 revealed resident was cognitively intact and was independent with activities of daily living (ADL's.) Review of the medical record for Resident #85 revealed it did not include a baseline care plan for resident. Review of the comprehensive care plan for Resident #85 revealed it included a nutritional risk care plan initiated 08/30/22. The comprehensive care plan did not address any other issues. Interview on 11/22/22 at 1:08 P.M. with the Director of Nursing (DON) confirmed the facility had not developed a baseline care plan for Resident #85. DON further confirmed the comprehensive care plan for Resident #85 had been started on 08/30/22 but only included a nutritional risk care plan and did not address any other resident issues or concerns. DON confirmed the facility should develop and implement a baseline care plan for each resident within 48 hours of the resident's admission. Review of the facility policy titled Care Plans dated 12/2019 revealed the facility will develop and implement a baseline care plan for residents within 48 hours of admission. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

CONCERN (D) 📢 Someone Reported This

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

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

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and policy review, the facility failed to ensure oxygen was administered per physician orders. This affected one (#85) of three residents reviewed for oxygen therapy. The census was 84. Findings include: Review of the medical record for Resident #85 revealed an admission date of 08/25/22 with a diagnosis of chronic obstructive pulmonary disease (COPD) and a discharge date of 09/08/22. Review of the Minimum Data Set (MDS) for Resident #85 dated 09/03/22 revealed resident was cognitively intact and was independent with activities of daily living (ADL's). Review of hospital notes for Resident #85 prior to his admission to facility dated 08/19/22 revealed resident had been admitted to the hospital due to shortness of breath (SOB) and was diagnosed with Coronavirus Disease 2019 (COVID-19) on 08/19/22. During Resident #85's hospital stay he received oxygen intermittently via nasal cannula (NC) when his oxygen saturation level was below 90 percent (%.) Review of the medical record for Resident #85 revealed it did not include a baseline care plan for resident. Review of the comprehensive care plan for Resident #85 revealed it included a nutritional risk care plan initiated 08/30/22. The comprehensive care plan did not address any other issues. Resident #85 did not have a care plan regarding oxygen therapy. Review of the daily oxygen saturation levels for Resident #85 dated 08/25/22 through 09/08/22 revealed they were taken while resident was receiving oxygen via NC. Review of the August and September 2022 Medication Administration Records (MAR's) and Treatment Administration Record (TAR's) for Resident #85 revealed they did not include documentation of oxygen therapy for resident. Review of discharge summary and plan of care for Resident #85 dated 09/08/22 revealed resident would discharge to home with medications and oxygen. Interview on 11/22/22 at 1:08 P.M. with the Director of Nursing (DON) confirmed the facility did not have oxygen orders for Resident #85 but resident did receive oxygen regularly via NC at two liters per minute (LPM) in order to maintain his oxygen saturation levels above 90 %. DON confirmed Resident #85 was sent home on [DATE] without oxygen. DON confirmed she took an oxygen concentrator and tubing and NC to resident's home on [DATE] and assisted him with administering oxygen at two LPM. DON confirmed she did not have a physician's order indicating the appropriate LPM for the oxygen administration for Resident #85. Review of facility policy titled Oxygen Administration dated October 2010 revealed the facility would provide safe oxygen administration. The nurse should verify that there was a physician's order for oxygen prior to administration and the nurse should review the physician's orders and/or facility protocol for oxygen administration prior to providing oxygen. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

CONCERN (E) 📢 Someone Reported This

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

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

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Based on observation, staff interview, and review of the facility documents and policy, the facility failed to ensure resident medications were stored appropriately. This had the potential to affect 15 residents on [NAME] Hall (#70, #71, #72, #73, #74, #75, #76, #77, #78, #79, #80, #81, #82, #83, #84) and three residents on South Hall (#12, #13, #14). The census was 84. Findings include: Observation on 11/21/22 at 8:55 A.M. with Licensed Practical Nurse (LPN) #200 revealed the employee breakroom had approximately 45 lockers to be used by employees on a temporary basis for storing personal items during the shift. Most of the lockers were empty and unlocked or contained personal items such as hats or hand sanitizer and were unlocked. Two lockers had locks on them. Locker #32 was empty and unlocked and contained a bottle of hand sanitizer with Registered Nurse (RN) #135's name on it. Interview on 11/21/22 at 8:55 A.M. with LPN #200 confirmed staff could use the lockers for storing personal items while at work and employees could provide a lock if desired. LPN #200 confirmed the lockers were not to be used for medication storage. Interview on 11/21/22 at 9:12 A.M. with the Director of Nursing (DON) and the Administrator confirmed medications should not be prepared ahead of time for administration and medications should not be stored in the employee storage lockers. Administrator confirmed an employee notified management that Registered Nurse (RN) #135 had prepulled oral medications for residents on her assignment for the following shift and left the medications in her employee locker. Administrator confirmed the facility tried to contact RN #135 but was unable to reach her. Facility had Maintenance Director (MD) #350 remove locks from the lockers and found in locker #32, RN #135's locker numerous cups of pills and medications with resident names on them. They interviewed RN #135 on Sunday 11/20/22 and nurse confirmed she had prepulled resident medications. Administrator confirmed the nurse received disciplinary action because this practice was not permitted. The facility confirmed there were medications in RN #135's locker for 15 residents on [NAME] Hall (#70, #71, #72, #73, #74, #75, #76, #77, #78, #79, #80, #81, #82, #83, #84) and three residents on South Hall (#12, #13, #14). Interview on 11/21/22 at 2:34 P.M. with MD #350 confirmed he was asked to accompany LPN #280 into the employee break room on 11/18/22. MD #350 confirmed the Administrator told him they were supposed to check the lockers for possible resident medications and a nurse accompanied him in case there were any medications found which would need to be handled by a nurse. MD #350 confirmed they found multiple medications in locker #32 after he cut the lock off the locker. MD #350 confirmed LPN #350 took a photograph of the contents of the locker with her telephone and then took the medications to the DON. Interview on 11/21/22 at 2:58 P.M. with LPN #280 confirmed when MD #350 cut the lock off employee locker #32 she saw hand sanitizer with RN #135's name on it and four large Styrofoam cups each full of multiple smaller cups of medications with resident names written on them. LPN #280 confirmed the large cups had Sunday A.M., Sunday P.M., Monday A.M., and Monday P.M. written on them. Observation of photograph on 11/21/22 at 2:58 P.M. on LPN #280's phone revealed there was a bottle of hand sanitizer with RN #135's name on it and four Styrofoam cups which had Sunday A.M., Sunday P.M., Monday A.M., and Monday P.M. written on them. Interview on 11/21/22 at 5:48 P.M. with RN #135 confirmed when she worked on 11/17/22 she had pulled all oral medications excluding controlled substances and liquids for the residents on [NAME] Hall and three residents on South Hall (#12, #13, #14) for Sunday and Monday, 11/21/22 and 11/22/22. RN #135 confirmed she prepulled the medications and placed them on the locker to save time on her medication pass for the following week. RN #135 confirmed she had received a final written warning for this practice because medications were not allowed to be prepulled but should be administered immediately after removing from the medication cart. Review of facility disciplinary action form for RN #135 revealed it was signed by the Administrator and RN #135 and was dated 11/20/22. RN #135 received a final written warning for violating standards of nursing practice. Review of the facility policy titled Storage of Medications dated January 2018 revealed all medications provided by the pharmacy are to be stored in the container with the pharmacy label. Review of the facility policy titled Medication Administration dated January 2018 revealed medications are administered at the time they are prepared. Medications are not pre-poured either in advance of the med pass or for more than one resident at a time. This deficiency represents non-compliance investigated under Complaint Number OH00137063.

Aug 2022 6 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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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the Preadmission Screening and Resident Review, and staff interview, the facility failed to update a resident's Preadmission Screening and Resident Review (PASARR) when a new diagnosis of schizophrenia was added. This affected one resident (#28) out of three residents reviewed for PASARR. The facility census was 63. Review of Resident #28 medical record revealed he was admitted to the facility on [DATE]. Diagnoses included dizziness and giddiness, history of traumatic brain injury, vascular dementia with behavioral disturbance, type II diabetes, post traumatic stress disorder, depression, phobic anxiety disorder, acquired absence of right leg below knee, hypertension, and epilepsy. On 08/07/19 a new diagnosis of schizophrenia was added to his diagnosis. Review of the quarterly Minimal Data Set (MDS) dated [DATE] revealed Resident #28 was cognitively intact. His functional status was listed as limited to extensive one person assistance for all activities daily living. The MDS also revealed Resident #28 was continent of urine and bowel and had no skin issues. Review of the Preadmission Screening and Resident Review (PASARR) dated 09/26/17 revealed no schizophrenia diagnosis on the PASARR document. No updated PASARR was available. Interview with the Administrator on 08/25/22 at 1:00 P.M., verified the PASARR should have been updated when the new diagnosis was added.

CONCERN (D)

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

Deficiency F0645 (Tag F0645)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the Agency on Aging determinations, review of the hospital exemption form, and staff interview, the facility failed to complete the Preadmission Screening and Resident Review. This affected two residents (#19 and #42) out of three residents reviewed for Preadmission Screening and Resident Review. The census was 63. Findings include: 1. Medical Record Review for Resident #42 revealed admission date of admission date of 07/27/12. Diagnoses included cerebral infarction, hemiplegia and hemiparesis, aphasia, dysphagia, major depressive disorder, dementia, post polio syndrome, contracture, unspecified joint, psychosis not due to a substance or known physiological condition, and anxiety disorder. Review of the comprehensive Minimum Data Set (MDS) dated [DATE] revealed the resident had impaired cognition. Review of the Agency on Aging dated 11/08/12 revealed Pre-admission Screening (PAS) Determination was not applicable. Level of Care Determination effective date 09/08/12, Intermediate Level of Care. There was no Preadmission Screening and Resident Review noted in the medical record. Interview on 08/23/22 at 3:35 P.M., the Administrator stated she was unable to locate documentation for Resident #42's Preadmission Screening and Resident Review. 2. Medical Record Review for Resident #19 revealed admission date of 03/24/22. Diagnoses included anxiety disorder, paranoid schizophrenia, diabetes mellitus type II, and unspecified convulsions. Review of the quarterly MDS dated [DATE] revealed the resident had severely impaired cognition. Review of the hospital exemption for preadmission screening ([NAME]) dated 03/24/22 revealed Resident #19 required fewer than 30 days of nursing facility services, no later than the date of discharge. Interview on 08/23/22 at 3:35 P.M., the Administrator stated she was unable to locate documentation for Resident #19's Preadmission Screening and Resident Review.

CONCERN (D)

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, review of the facility incidents, and policy review, the facility failed to ensure a fall investigation was completed and root cause was identified post resident fall. This affected one resident (#15) out of 20 sampled residents. The facility census was 63. Review of the medical record for Resident #15 revealed an admission date of 11/03/21. Diagnosis included obstructive and reflux uropathy, pseudobulbar affect, personal history of Covid-19, dementia, and adult failure to thrive. Review of the quarterly minimum data set (MDS) assessment dated on 06/23/22 revealed Resident #15 had severe cognitive impairment. Resident #15 required total dependence for bed mobility, dressing, bathing, and personal hygiene. Resident was setup assistance for all meals. Resident #15 required extensive one-person assistance for toilet use, and transfers. The resident used a wheelchair for ambulation. Review of the plan of care dated on 07/11/22 revealed Resident #15 was at risk for falls related to decreased mobility, medications, and memory impairment. Interventions included gripper socks when up, keep the bed in the lowest position except for care, keep the call light within reach, and therapy screening as needed. Review of the medical record for Resident #15 revealed there was a neurological check dated 07/03/22 at 7:00 P.M. through 07/04/22 at 6:00 A.M. Review of the medical record for Resident #15 revealed there was no fall investigation or Interdisciplinary team (IDT) meeting for follow up on the unwitnessed fall on 07/03/22. Review of the facility incidents dated from 02/28/22 through 08/23/22 revealed Resident #15 had an unwitnessed fall on 07/03/22. Interview on 08/24/22 at 4:20 P.M., with the Director of Nursing (DON) revealed the only thing she had for the fall for Resident #15 on 07/03/22 was the neurological check flow sheet. There was no fall investigation or root cause to why the resident fell on [DATE]. Review of the policy titled Fall Policy, review date 10/2018 revealed an investigation would be done on any incident where a resident, visitor, or staff member says a fall had occurred on a resident that was observed on the floor or resident was lowered to the floor with or without any injuries.

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, staff interview, and policy review, the facility failed to ensure weights were monitored per recommendation. This affected one resident (#42) out of seven residents reviewed for nutrition. The census was 63. Findings include: Review of the medical record for Resident #42 revealed admission date of 07/27/12. Diagnoses included cerebral infarction, hemiplegia and hemiparesis, aphasia, dysphagia, major depressive disorder, dementia, post polio syndrome, contracture, unspecified joint, psychosis not due to a substance or known physiological condition, and anxiety disorder. Review of the comprehensive Minimum Data Set (MDS) dated [DATE] revealed Resident #42 had impaired cognition. The resident required total assistance of two persons for bed mobility and transfers. The resident had a functional limitation in Range of Motion (ROM) on one side of the upper extremity and impairment on both sides of the lower extremities. The resident required supervision with setup help only for eating. The resident had no swallowing disorders and required a mechanically altered diet. Review of the care plan dated 07/24/22 revealed Resident #42 was at risk for altered nutrition and hydration status related to sedentary, unconcerned with weight status, cognitive impairments, dislikes white milk, need for mechanically altered diet due to dysphagia, no significant weight changes noted, variable oral intakes, supplements in place. On 08/22/22 a significant weight loss times 90 days was identified. Interventions included supplement change received, variable oral intakes. Interventions included honor food preferences/requests as able. Keep fluids available and within reach. Monitor and record meal percentage and fluid ounces at each meal. Monitor nutritional status and notify physician/dietician as indicated. Obtain/monitor weights as ordered. Provide supplement as ordered. Review of the dietary note dated 8/9/2022 at 5:04 P.M. revealed Resident #42 with weight loss noted and a re-weigh was requested to verify the weight loss. Nursing was notified and made aware. Review of the dietary note dated 8/22/2022 at 4:11 P.M. revealed Resident #42 had a weight change nutrition review: August weight: 140 pounds with significant weight loss of 11.8 pounds (7.8 percent) over 90 days. Non-significant weight loss of 13 pounds (8.5 percent) over 13 days. Current body mass index (BMI) 27.3 indicated overweight for height. Re-weigh was previously requested to verify weight loss and not noted currently. Question accuracy of August weight as previous weights had been stable and current oral intakes/supplement acceptance would not support current weight loss. Will add to weekly weights for monitoring. Continue with the plan and monitor weights, intake percentages, supplement acceptance and any changes. Review of the documented weights revealed no additional weights after 08/09/22. Interview on 08/25/22 at 9:35 A.M., the Administrator verified weights had not been completed as recommended. The Administrator stated the dietician notified the Assistant Director of Nursing (ADON) or the Director of Nursing (DON) of recommendations. She stated Resident #42 would be put on a list for the day to be weighed. She stated the charge nurse would be responsible to verify weights were completed and documented. The Administrator stated the recommendations were also discussed during morning meetings. Review of facility policy titled Weighing and Measuring the Resident, revised date 03/2011, revealed the purpose of this procedure are to determine the resident's weight and height, to provide a baseline and an ongoing record of the resident's body weight as as indicator of the nutritional status and medical condition of the resident, and to provide a baseline height in order to determine the ideal weight of the resident.

CONCERN (D)

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

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff and resident interview, and policy review, the facility failed to comprehensively document care provided for residents. This affected two residents (#54 and #61) of 24 resident record reviews. The census was 63. Findings include: 1. Medical Record Review for Resident #54 revealed admission date of [DATE]. Diagnoses included neoplasm of uncertain behavior of spinal cord, pressure ulcer unspecified site, stage III, pressure ulcer of sacral region, unspecified stage, and severe protein calorie malnutrition. Review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #54 had intact cognition. The resident required extensive one person assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. The resident required supervision set up help only for eating. The resident had a pressure ulcer/injury. The resident had one stage three pressure ulcer and two stage four pressure ulcers, one upon admission/entry or reentry. The resident received hospice care. Review of the plan of care dated [DATE] revealed the resident had actual skin impairment. Interventions included follow facility protocols for wound care. Review of the Treatment Administration Record (TAR) for [DATE] revealed documentation for sacral wound care, ordered twice daily, revealed no documentation on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] for the day shift. Documentation for monitoring the left knee and the left second toe until healed every shift was not documented on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] for the day shift. Documentation for output every shift was not completed on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] for the day shift. Interview on [DATE] at 11:30 A.M., Resident #54 stated he received wound care as ordered, some of his wounds had healed, and the wound physician provided all of his wound treatments every Thursday morning. Interview on [DATE] at 12:15 P.M., the Administrator verified the absent documentation on the TAR. Review of facility policy titled Charting and Documentation, revised date 07/2017, revealed all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. 2. Review of Resident #61's medical record revealed she was admitted to the facility on [DATE] with a diagnosis of bipolar disorder major depressive disorder, encounter for orthopedic aftercare, displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing, vascular dementia with behavioral disturbance, type II diabetes, stage III kidney disease, and retention of urine. Resident #61 expired on [DATE] while at the facility. Review of the (MDS) assessment dated [DATE] revealed Resident #61 had severe cognitive impairment. Her functional status was listed as limited to one person assistance to totally dependent for all activities of daily living. The MDS also revealed Resident #61 was free of skin issues. Review of the care plan dated [DATE] revealed Resident #61 had a code status of full code. Review of the progress note dated [DATE] at 5:57 P.M. revealed Resident #61's family was called and explained her current condition. The family requested the resident be changed to Do Not Resuscitate Comfort Care (DNRCC) at this time and the physician was notified and made aware and the record updated. There was no other documentation about the change in resident condition. Review of the progress notes dated [DATE] at 9:30 P.M. revealed Resident #61 was found in her room without pulse, respirations, or a blood pressure at approximately 8:45 P.M. The absence of vitals was verified by two nurses. The Power of Attorney (POA) was notified at 9:00 P.M. and informed us to send the body to the local funeral home. The physician was notified at 9:07 P.M. and released the body to the funeral home. Interview with the Assistant Director of Nursing (ADON) #564 on [DATE] at 11:30 A.M., revealed she was unaware of the reason Resident #61 passed away or the details of her deterioration on [DATE]. The ADON confirmed the lack of documentation concerning the death of Resident #61 was inappropriate and unacceptable.

CONCERN (F)

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

Infection Control (Tag F0880)

Could have caused harm · This affected most or all residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and policy review, the facility failed to ensure personal protective equipment was worn in resident areas to prevent the potential spread of infection. In addition, the facility failed to ensure contaminated linens and trash were handled to prevent the potential spread of infection. This had the potential to affect all 63 residents at the facility. 1. Observation and interview on 08/22/22 at 8:52 A.M. State Tested Nurse Aide (STNA) #563 walked out of Resident #213 room. The STNA was wearing a N95 mask, eye protection, and an isolation gown. She walked down the walkway along the common area with no residents present and turned left out of view. The STNA returned within minutes carrying bath linens. The STNA #563 stated when she was given report at 6:00 A.M. she was told all residents on the corner were in isolation and believed she did not have to remove her gown if she was not entering another resident room or leave the isolated section of rooms. She then stated the Assistant Director of Nursing (ADON) #564 had just informed her that all the residents on that corner were no longer in quarantine/isolation. Observation of room [ROOM NUMBER] and #04 had personal protective equipment (PPE) carts with signage on the doors for droplet precautions. Rooms #05 and #07 had no signage and room [ROOM NUMBER] was open and appeared to be unoccupied. Interview on 08/24/22 at 4:45 P.M., with the ADON #564 said no gowns should be worn in the halls of the COVID unit. The ADON #564 stated the room was the quarantine area only. 2. Observation on 08/22/22 at 1:00 P.M. the Dietary Aid #529, who was also the Laundry Aid, was wearing a surgical mask on and was picking up dirty dishes from tables. There were three residents (#34, #57, and #47) in the dining room at this time who were not wearing any masks. Interview on 08/24/22 at 1:49 P.M., the Dietary Manager #567 stated the Dietary Aid #529 was educated about not wearing an N95 on around residents in the dining area on Monday 08/22/22 at 1:00 P.M. Dietary Manager #567 verified staff should wear an N95 mask around residents. 3. Observation and interview on 08/24/22 at 4:32 P.M. with STNA #651 who was carrying two bags around. One clear trash bag, and one light blue large trash bag. STNA #651 stated they were COVID-19 items and did not know where to dispose of them. Observation on 08/24/22 at 4:36 P.M. STNA #651 asked the nurse where to put the two bags that contained trash and dirty linen. The Registered Nurse (RN) #744 said to put the two bags back in the residents' room that he had taken it from. The RN #744 told STNA #651 to ask the aid on the next hall where to put the bags. STNA #651 put both clear trash bag and dirty linen bag back into room [ROOM NUMBER]. STNA #651 then went and asked STNA #823 where to put the bags and STNA #823 told STNA #651 to put both bags in the dirty linen room on the non-covid hall near the nurse's station. Observation on 08/24/22 at 4:38 P.M. STNA #651 went to the room [ROOM NUMBER] picked up the two bags and took the two bags to the dirty linen and trash room on the other hall. 4. Observation on 08/24/22 at 4:38 P.M. of the soiled linen and trash room near the nurse's station of the long term care hall, there was a soiled bath blanket and a soiled wash cloth laying on the floor not in a trash bag. Interview on 08/24/22 at 4:38 P.M., with STNA #823 verified the urine soiled bath blanket and wash cloth were laying on the floor and not in a receptacle or in a bag. Interview on 08/24/22 at 4:45 P.M., the ADON #564 said the the COVID-19 skilled unit had its own barrels to use for disposing of dirty linen or trash. ADON #564 said the STNA should not have brought the linen down to the other unit. Review of facility policy titled Coronavirus Prevention and Management that was revised on 08/08/2022, revealed when entering and exiting a COVID-19 positive unit, it was required to used Personal Protective Equipment that must be donned prior to entry of the unit and doffed prior to exiting the unit. Residents on isolation or quarantine will have droplet precautions, contact precautions, and how to don and doff Personal Protective Equipment (PPE). It is the policy of this facility to follow the frequently updated recommendations set forth by CMS, ODH, and CDC regarding the prevention and management of the COVID-19 virus.

Aug 2019 25 deficiencies

CONCERN (D)

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

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medial record review, observation and staff interview the facility failed to provide meals to all of the residents at a table at the same time. This affected one Resident (#24) of 17 residents observed eating in the dining area on the secured unit. The facility census was 67. Findings include: Review of Resident #24's medical record revealed the resident was admitted [DATE] with diagnoses including a left femur fracture and dementia. Review of the Minimum Data Set (MDS) dated [DATE] revealed the resident had severe cognitive deficit. The MDS also identified the resident required extensive one-person assistance for bed mobility, transfer, dressing, toileting and personal hygiene. The resident required only supervision for eating. Review of care plan dated 06/14/19 revealed the resident had a potential nutritional risk related to her femur fracture and dementia. Observation of dining on 08/25/19 from 11:50 A.M. to 12:25 P.M. revealed two State Tested Nursing Assistants (STNAs) #15 and #62 were assisting residents with lunch trays. There were five tables in the dining area and 17 residents eating in the dining area. Resident #24 was seated with three other residents at a table. Resident #24's husband was seated next to her. Resident #24's table was the second table to be served at approximately 12:02 P.M The other three residents sitting at Resident #24's table were served and all three began eating. Resident #24 had not yet received a lunch tray. STNAs #15 and #62 served all of the other residents in the dining area. STNA #62 sat at another dining table and began feeding a resident. Resident #24 had still not received her lunch tray. Resident #24's husband walked over to STNA #15 and requested the tray for his wife. STNA #15 walked over to the food cart and took out Resident #24's lunch tray and took it to Resident #24 at approximately 12:19 P.M. Interview on 08/25/19 at 12:40 P.M. with STNA #62 confirmed Resident #24 did not receive her tray timely and should have received her tray when the other three at her table were served. Interview on 08/25/19 at 1:00 P.M. with Dietary Manager (DM) #10 confirmed all residents sitting at a dining table should be served at the same time. The facility did not provide a policy related to dining.

CONCERN (D)

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

Deficiency F0569 (Tag F0569)

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, personal funds statement review, staff interview and review of facility policy the facility failed to provide a spend down letter to residents and/or the resident's representative when the resident's personal trust fund account was $200 less than Social Security Income (SSI) resource limit. This affected one Resident (#11) of five reviewed for personal funds accounts. The facility census was 67. Findings include: Review of the medical record revealed Resident #11 was admitted to the facility on [DATE]. Diagnoses included heart disease, tracheostomy, gastrostomy, atrial fibrillation, chronic respiratory failure, epilepsy, type two diabetes, and major depressive disorder. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed Resident #11 was severely cognitively impaired with delirium, inattention and altered level of consciousness noted. The MDS also revealed the resident was totally dependent with one person assistance for bed mobility, locomotion, dressing, eating, toileting, personal hygiene, and total dependent with two person assistance with transfer. Review of Resident #11's plan of care dated 06/19/19 revealed no concerns related to the personal fund's account. Review of Resident #11's personal funds quarterly statement dated 06/30/19 revealed balances from 04/03/19 thru 06/30/19 all exceeded the resource limit for personal trust fund accounts. The balance for 04/30/19 was $2,229.70. The balance for 05/31/19 was $2,624.05. The balance for 06/30/19 was $2,751.22. Interview on 08/26/19 at 11:30 A.M. with facility's Business Office Manager (BOM) #52 confirmed Resident #11's personal funds account exceeded the resource limit and confirmed a spend down letter should have been sent to Resident #11's representative. BOM #52 provided check number 309 dated 08/10/10, payable to Treasurer of Ohio in the amount of $900. BOM #52 stated the check was written to lower the balance in Resident #11's personal fund trust account. Review of the facility's undated policy titled, Resident Trust did not identify any reference to spend down letters or exceeding the resource limit for personal trust funds.

CONCERN (D)

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

Deficiency F0582 (Tag F0582)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility record review and staff interview, the facility failed to provide the required Beneficiary Protection Notifications (BPN) when Medicare Part A residents were discharged from services with skilled days remaining. This affected three Residents (#16, #323 and #324) of four residents reviewed for BPN during the annual survey. The facility census was 67. Findings include: 1. Review of the facility BPN and medical record review revealed Resident #16 was admitted to the facility on [DATE], and discharged from Medicare Part A Services on 03/22/19 with skilled days remaining. The resident remained in the facility. Further review of the BPN revealed Resident #16 was only provided the Notice of Medicare Non-Coverage (NOMNC) form and was not provided the required Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN). Interview conducted on 08/27/19 at 11:38 A.M., Social Services (SS) #75 stated he was only able to find verification Resident #16 was provided the NOMNC, and was unable to provide verification the SNFABN was provided as required. 2. Review of the facility completed BPN form revealed Resident #323 received Medicare Part A services and was discharged from services on 08/08/19 with skilled days remaining. Further review of the BPN record revealed the resident was not provided the required NOMNC form prior to discharge. Review of the medical record for Resident #323 revealed a Progress Note dated 08/09/19 from Social Services noting the resident would be discharging home per her preference and goal, and reviewed the residents planned discharge. 3. Review of the facility completed BPN form revealed Resident #324 received Medicare Part A services and was discharged from services on 07/11/19 with skilled days remaining. Further review of the BPN record revealed the resident was not provided the required NOMNC form prior to discharge. Review of the medical record for Resident #324 revealed a Progress Note dated 07/16/19 from Social Services noting the resident discharged home on [DATE] per her preferences, with planned discharge reviewed. Interview conducted on 08//27/19 at 11:13 A.M. SS #75 stated Residents (#323 and #324) did not receive the required NOMNC forms due to they choose the day they wanted to leave. SS #75 verified residents were both planned discharges and he was not aware the forms were still required for them.

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 medical record review, staff and resident interviews, review of concern forms, review of facility self-reported incidents (SRI), and review of facility policy, the facility failed to implement their abuse and misappropriation policy when they failed to report to the state agency. This affected one Resident (#10) of 24 residents reviewed. The facility census was 67. Findings include: Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including peripheral vascular disease, hypertension, orthostatic hypotension, type two diabetes, schizoaffective disorder, absence of left leg above the knee, falls, and chronic obstructive pulmonary disease. Review of the five day Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact with no behaviors. Review of the Resident/Family/Staff Concern form dated 05/17/19 revealed Resident #10 reported his laptop missing. Social Service (SS) #75 noted both resident rooms (previous and current) were searched, staff and residents were interviewed, and the computer was not found. Interview conducted on 08/26/19 at 9:03 A.M. and 08/28/19 at 8:10 A.M., Resident #10 stated his laptop computer had been missing for about three to four months. The resident stated they moved him from room [ROOM NUMBER] to another room and it had been missing every since. Resident #10 stated he talked to SS #75 about it, but it was never found. Resident #10 stated he paid $400 for his laptop and would have liked something to have been done about it. Interview conducted on 08/28/19 at 8:21 A.M., SS #75 stated it was brought to his attention that Resident #10's computer was missing when he changed rooms. SS #75 stated he talked to the staff housekeepers and they stated it was moved to his new room. SS #75 stated staff searched for it and it was not located. SS #75 stated he did not recall anyone following up on it, it being replaced, and/or the police being notified. Interview conducted on 08/28/19 at 8:26 A.M. and 11:38 A.M., the Administrator stated she was not working in the facility at the time the computer was missing, and she was never told about the situation. The Administrator verified no Self Reported Incident (SRI) was filed regarding the missing computer. The Administrator stated she did follow up with with Resident #10 who felt it was stolen and would like a police report filed. The Administrator verified an SRI should have been filed, and she would be doing that today along with notifying the police to file a report. The Administrator verified the situation should have been followed up on with a formal investigation prior to notification by the surveyor, and she was unaware if the former Administrator was aware of the situation. Review of the facility policy titled Abuse, Neglect, Exploitation, and Misappropriation of Residents Property dated 11/21/16 revealed abuse includes verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enabled through the technology. Misappropriation of resident property include deliberate misplacement, exploitation, or wrongful use of a residents property or money without their consent. The facility will supervise staff to identity inappropriate behaviors such as using derogatory language, rough handling, ignoring residents. All allegations would be reported to the Administrator and State Agency. If a crime is suspected, staff would also report to the local law enforcement. The investigation would be completed and reported to the state agency within five working days from the date discovered.

CONCERN (D)

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff and resident interviews, review of concern forms, review of facility self-reported incidents (SRI), and review of facility policy, the facility failed to ensure allegations of misappropriation of property were reported to the state agency. This affected one Resident (#10) of 24 residents reviewed. The facility census was 67. Findings include: Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including peripheral vascular disease, hypertension, orthostatic hypotension, type two diabetes, schizoaffective disorder, absence of left leg above the knee, falls, and chronic obstructive pulmonary disease. Review of the five day Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact with no behaviors. Review of the Resident/Family/Staff Concern form dated 05/17/19 revealed Resident #10 reported his laptop missing. Social Service (SS) #75 noted both resident rooms (previous and current) were searched, staff and residents were interviewed, and the computer was not found. Interview conducted on 08/26/19 at 9:03 A.M. and 08/28/19 at 8:10 A.M., Resident #10 stated his laptop computer had been missing for about three to four months. The resident stated they moved him from room [ROOM NUMBER] to another room and it had been missing every since. Resident #10 stated he talked to SS #75 about it, but it was never found. Resident #10 stated he paid $400 for his laptop and would have liked something to have been done about it. Interview conducted on 08/28/19 at 8:21 A.M., SS #75 stated it was brought to his attention that Resident #10's computer was missing when he changed rooms. SS #75 stated he talked to the staff housekeepers and they stated it was moved to his new room. SS #75 stated staff searched for it and it was not located. SS #75 stated he did not recall anyone following up on it, it being replaced, and/or the police being notified. Interview conducted on 08/28/19 at 8:26 A.M. and 11:38 A.M., the Administrator stated she was not working in the facility at the time the computer was missing, and she was never told about the situation. The Administrator verified no Self Reported Incident (SRI) was filed regarding the missing computer. The Administrator stated she did follow up with with Resident #10 who felt it was stolen and would like a police report filed. The Administrator verified an SRI should have been filed, and she would be doing that today along with notifying the police to file a report. The Administrator verified the situation should have been followed up on with a formal investigation prior to notification by the surveyor, and she was unaware if the former Administrator was aware of the situation. Review of the facility policy titled Abuse, Neglect, Exploitation, and Misappropriation of Residents Property dated 11/21/16 revealed abuse includes verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enabled through the technology. Misappropriation of resident property include deliberate misplacement, exploitation, or wrongful use of a residents property or money without their consent. The facility will supervise staff to identity inappropriate behaviors such as using derogatory language, rough handling, ignoring residents. All allegations would be reported to the Administrator and State Agency. If a crime is suspected, staff would also report to the local law enforcement. The investigation would be completed and reported to the state agency within five working days from the date discovered.

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 medical record review, staff and resident interviews, review of concern forms, review of facility self-reported incidents (SRI), and review of facility policy, the facility failed to thoroughly investigate allegations of misappropriation of property. This affected one Resident (#10) of 24 residents reviewed. The facility census was 67. Findings include: Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including peripheral vascular disease, hypertension, orthostatic hypotension, type two diabetes, schizoaffective disorder, absence of left leg above the knee, falls, and chronic obstructive pulmonary disease. Review of the five day Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact with no behaviors. Review of the Resident/Family/Staff Concern form dated 05/17/19 revealed Resident #10 reported his laptop missing. Social Service (SS) #75 noted both resident rooms (previous and current) were searched, staff and residents were interviewed, and the computer was not found. Interview conducted on 08/26/19 at 9:03 A.M. and 08/28/19 at 8:10 A.M., Resident #10 stated his laptop computer had been missing for about three to four months. The resident stated they moved him from room [ROOM NUMBER] to another room and it had been missing every since. Resident #10 stated he talked to SS #75 about it, but it was never found. Resident #10 stated he paid $400 for his laptop and would have liked something to have been done about it. Interview conducted on 08/28/19 at 8:21 A.M., SS #75 stated it was brought to his attention that Resident #10's computer was missing when he changed rooms. SS #75 stated he talked to the staff housekeepers and they stated it was moved to his new room. SS #75 stated staff searched for it and it was not located. SS #75 stated he did not recall anyone following up on it, it being replaced, and/or the police being notified. Interview conducted on 08/28/19 at 8:26 A.M. and 11:38 A.M., the Administrator stated she was not working in the facility at the time the computer was missing, and she was never told about the situation. The Administrator verified no Self Reported Incident (SRI) was filed regarding the missing computer. The Administrator stated she did follow up with with Resident #10 who felt it was stolen and would like a police report filed. The Administrator verified an SRI should have been filed, and she would be doing that today along with notifying the police to file a report. The Administrator verified the situation should have been followed up on with a formal investigation prior to notification by the surveyor, and she was unaware if the former Administrator was aware of the situation. Review of the facility policy titled Abuse, Neglect, Exploitation, and Misappropriation of Residents Property dated 11/21/16 revealed abuse includes verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enabled through the technology. Misappropriation of resident property include deliberate misplacement, exploitation, or wrongful use of a residents property or money without their consent. The facility will supervise staff to identity inappropriate behaviors such as using derogatory language, rough handling, ignoring residents. All allegations would be reported to the Administrator and State Agency. If a crime is suspected, staff would also report to the local law enforcement. The investigation would be completed and reported to the state agency within five working days from the date discovered.

CONCERN (D)

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

Transfer Notice (Tag F0623)

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 staff interview the facility failed to provide a notice of transfer/discharge to the resident's representative upon being transferred to the hospital. This affected two Residents (#10 and #48) of four reviewed for hospitalization. The facility census was 67. Findings include: 1. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including peripheral vascular disease, hypertension, orthostatic hypotension, type two diabetes, schizoaffective disorder, absence of left leg above the knee, falls, and chronic obstructive pulmonary disease. Review of the five day Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact with no behaviors. Review of Section E-Behaviors revealed no behaviors were noted. Review of Section G-Functional Status revealed the resident required extensive one-person assistance with bed mobility, toileting, personal hygiene, dressing, transfer, supervision with setup assistance with eating, limited one-person assistance with locomotion, walking did not occur. Review of Section K-Nutritional Status revealed the resident was noted with a weight loss however was noted on a prescribed weight-loss regimen and note on a therapeutic diet. Review of Section M-Skin Assessments revealed the resident had a stage four pressure area noted upon entry, a unstageable pressure area not noted on reentry, and a diabetic foot ulcer. Interventions included pressure reducing devices for her chair, bed, turning/repositioning program, pressure ulcer care, ointments/medication, and applications of dressings to feet. Further review of the medical record revealed Resident #10 was discharged from the facility to the hospital on [DATE], 04/16/19, 07/22/19 and 08/19/19 for greater the 24 hours. The medical record was silent of verification bed hold notices were provided to Resident #10 for transfer/discharges on 03/02/19 and on 04/16/19, and/or bed hold notification to Resident #10's representative for any of the four noted transfer/discharges. Interview conducted on 08/28/19 at 9:29 A.M., the Director of Nursing (DON) stated she just educated the nurses on transfer discharge forms. The DON stated she was new to the facility and there had been nothing sent to the family when residents were transferred/discharged , that she was aware of. 2. Review of Resident #48's medical record revealed being admitted on [DATE] with diagnoses including fracture of the left tibia, heart failure and altered mental status. Review of the MDS dated [DATE] revealed the resident had severe cognitive decline. The MDS additionally revealed the resident required total dependence for bed mobility, transfers, toileting, dressing and personal hygiene. Resident required only supervision for eating. The MDS revealed the resident received medications including anticoagulants, antipsychotics and antidepressants. Review of Resident #48's plan of care dated 07/19/19 revealed no interventions related to side effects of the anticoagulant including resident being at risk for bleeding. Review of Resident #48's progress note dated 07/24/19 revealed the resident was found lying on his stomach in the middle of the room approximately five feet from the bed. The resident complained of left knee and leg pain. Documentation revealed the physician and the power of attorney were notified of the fall. Documentation revealed the physician ordered the resident be evaluated at the hospital. Resident #48 was transferred to the hospital on [DATE] at 10:07 P.M. and returned to the facility on [DATE]. Further review of Resident #48's medical record revealed no documentation that the resident's representative received a transfer/discharge notice for the resident's hospitalization on 07/23/19. Interview on 08/27/19 at 2:15 P.M. with the Administrator provided documentation the resident received the transfer/discharge notice on 07/23/19, however the Administrator confirmed the facility had not provided a written notice of transfer/discharge to the Resident #48's representative.

CONCERN (D)

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

Deficiency F0625 (Tag F0625)

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 staff interview the facility failed to provide a bed hold notice to the resident's representative upon being transferred to the hospital. This affected two residents (#10 and #48) of four reviewed for hospitalization. The facility census was 67. Findings include: 1. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including peripheral vascular disease, hypertension, orthostatic hypotension, type two diabetes, schizoaffective disorder, absence of left leg above the knee, falls, and chronic obstructive pulmonary disease. Review of the five day Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact with no behaviors. Review of Section E-Behaviors revealed no behaviors were noted. Review of Section G-Functional Status revealed the resident required extensive one-person assistance with bed mobility, toileting, personal hygiene, dressing, transfer, supervision with setup assistance with eating, limited one-person assistance with locomotion, walking did not occur. Review of Section K-Nutritional Status revealed the resident was noted with a weight loss however was noted on a prescribed weight-loss regimen and note on a therapeutic diet. Review of Section M-Skin Assessments revealed the resident had a stage four pressure area noted upon entry, a unstageable pressure area not noted on reentry, and a diabetic foot ulcer. Interventions included pressure reducing devices for her chair, bed, turning/repositioning program, pressure ulcer care, ointments/medication, and applications of dressings to feet. Further review of the medical record revealed Resident #10 was discharged from the facility to the hospital on [DATE], 04/16/19, 07/22/19 and 08/19/19 for greater the 24 hours. The medical record was silent of verification bed hold notices were provided to Resident #10 for transfer/discharges on 03/02/19 and on 04/16/19, and/or bed hold notification to Resident #10's representative for any of the four noted transfer/discharges. Interview conducted on 08/26/19 at 9:11 A.M., Resident #10 stated he did not recall receiving a bed hold notice when sent out of the hospital. Interview conducted on 08/28/19 at 9:29 A.M., the Director of Nursing (DON) stated she just educated the nurses on bed hold notices. The DON stated she was new to the facility and there had been no bed hold notices sent to the family when residents were transferred/discharged , that she was aware of. 2. Review of Resident #48's medical record revealed being admitted on [DATE] with diagnoses including fracture of the left tibia, heart failure and altered mental status. Review of the MDS dated [DATE] revealed the resident had severe cognitive decline. The MDS additionally revealed the resident required total dependence for bed mobility, transfers, toileting, dressing and personal hygiene. Resident required only supervision for eating. The MDS revealed the resident received medications including anticoagulants, antipsychotics and antidepressants. Review of Resident #48's plan of care dated 07/19/19 revealed no interventions related to side effects of the anticoagulant including resident being at risk for bleeding. Review of Resident #48's progress note dated 07/24/19 revealed the resident was found lying on his stomach in the middle of the room approximately five feet from the bed. The resident complained of left knee and leg pain. Documentation revealed the physician and the power of attorney were notified of the fall. Documentation revealed the physician ordered the resident be evaluated at the hospital. Resident #48 was transferred to the hospital on [DATE] at 10:07 P.M. and returned to the facility on [DATE]. Further review of Resident #48's medical record revealed no documentation that the resident's representative received a bed hold notice for the resident's hospitalization on 07/23/19. Interview on 08/27/19 at 2:15 P.M. with the Administrator provided documentation the resident received the bed hold notice on 07/23/19, however the Administrator confirmed the facility had not provided a written bed hold notice to Resident #48's representative.

CONCERN (D)

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

Deficiency F0637 (Tag F0637)

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 staff interview the facility failed to complete a significant change Minimum Data Set as(MDS) with the required 14 days for residents with a significant change in status. This affected two Residents (#35 and #48) of 20 residents reviewed for MDS assessments during the investigation stage of the annual survey. The facility census was 67. Findings include: 1. Review of Resident #35's medical record revealed being originally admitted on [DATE] and readmitted on [DATE]. Medical diagnosis included cerebral infarction, need for assistance with personal care, hemiplegia and hemiparesis, malignant neoplasm of unspecified part of bronchus or lung, acute or chronic respiratory failure, muscle wasting or or atrophy, muscle weakness, cognitive communication deficit, dysphagia, hyperlipidemia, chronic kidney disease, anemia, arteriosclerotic heart disease, hypertension and peripheral vascular disease. Review of the quarterly MDS assessment dated [DATE] revealed Resident #35 was cognitively impaired. Continued review of Resident #35's medical record revealed a signed contract with the date of effective election into hospice services of 07/25/19. Interview on 08/27/19 at 6:15 P.M. with MDS Registered Nurse (RN) #7 verified the facility had not completed a significant change MDS assessment when Resident #35 was admitted into hospice services. 2. Review of Resident #48's medical record revealed being admitted on [DATE] with diagnoses including fracture of the left tibia, heart failure and altered mental status. Review of the MDS dated [DATE] revealed the resident had severe cognitive decline. MDS additionally revealed in section G on 05/18/19, Resident #48's bed mobility, transfer, toileting, and personal hygiene indicated resident required extensive assistance. Section G on the same date, identified the resident required total dependence for dressing and required only supervision for eating. On 07/16/19 Resident #48's MDS revealed a decline in four areas of function from the previous MDS. The MDS dated [DATE] revealed the resident now required total dependence for bed mobility, transfer, personal hygiene, toileting and dressing. Review of Resident #48's medical record revealed no significant change assessment was completed. Interview on 08/27/19 at 5:42 P.M. with MDS RN #7 confirmed a significant change MDS assessment should have been completed for Resident #48. MDS RN #7 stated a significant change assessment should be completed when a resident has two or more areas of decline in function.

CONCERN (D)

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

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the Minimum Data Set (MDS) assessment data, and staff and resident interviews, the facility failed to accurately code data on the resident MDS assessment. This affected one (Resident #26) of 24 residents reviewed during the investigation stage of the annual survey. The facility census was 67. Findings include: Review of the medical record revealed Resident #26 was admitted to the facility 06/27/18 with diagnoses including hemiplegia and hemiparesis following a cerebrovascular disease, type two diabetes, major depressive disorder, and gastro-esophageal reflux disease. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed Resident #26 was cognitively intact, with no behaviors noted. Review of Section G-Functional Status revealed the resident required total one-person dependence with bed mobility, extensive one-person assistance with transfers, toileting, extensive two-person assistance with personal hygiene, supervision and setup with locomotion, one person assistance with dressing, resident was independent with setup assistance for eating, walking did not occur. Review of Section L-Dental/Oral Status revealed the resident has no noted dental concerns, including no obvious or likely cavity or broken natural teeth, no inflamed gums, and/or no mouth or facial pain. Review of the Physician and Nursing Progress notes revealed on 02/22/19 the resident was referred to the dentist for lower molar pain. On 03/11/19 the resident was seen by dental services and referred to oral surgery. On 06/07/19 the resident was scheduled for extractions however missed her appointment. On 06/17/19 the resident was seen by the local dental agency, whom then again referred the resident for oral surgery. Review of Resident #26 Medication Administrator Record (MAR) dated 06/2019 reveled the resident was ordered and received Tylenol 500 milligram (mg) twice daily, for pain, and Oxycodone (pain medication) 5 mg tablet, every eight hours as needed for pain. The resident was documented as requesting/receiving the Oxycodone on 06/09/19, 06/10/19, 06/13/19, 06/14/19, 6/15/19, twice on 06/16/19, 06/20/19, 06/23/19, and 06/27/19. Observation and interview conducted on 08/25/19 at 11:42 A.M. and again on 08/27/19 at 11:53 A.M., Resident #26 stated she had been having mouth pain and issues since February. The resident was observed with swelling noted to both sides of her face and gums, and multiple broken and discolored/black teeth. The resident stated she was supposed to have her teeth pulled in June but there was in issue and she was taken to the wrong office. The resident stated since she missed her appointment the dental office would no longer see her. The resident said the facility had been working on getting her surgery somewhere else. Resident #26 stated she has had constant pain and off-and-on swelling in her face since February. The resident stated she get's Tylenol for pain and it helps most days, but she had to take her Oxycodone sometimes for relief. Interview conducted on 08/28/19 at 9:34 A.M., the Director of Nursing (DON) stated she was aware of all the issues with Resident #26's teeth for the last several months and she had an upcoming appointment to have her teeth pulled. The DON verified the MDS completed on 07/02/19 did not accurately assess the residents dental conditions. The DON stated the facility was without an MDS nurse for a while and the corporate team was completing them for the facility.

CONCERN (D)

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure residents had complete and accurate care plans. This affected one Resident (#48) of 20 residents care plans reviewed during the investigation phase of the annual survey. The facility census was 67. Findings include: Review of Resident #48's medical record revealed being admitted on [DATE] with diagnoses including fracture of the left tibia, heart failure and altered mental status. Review of the minimum data set (MDS) dated [DATE] revealed the resident had severe cognitive decline. The resident required total dependence for bed mobility, transfers, toileting, dressing and personal hygiene. The resident required only supervision for eating. The resident received medications including anticoagulants, antipsychotics and antidepressants. Review of Resident #48's physician order dated 05/24/19 revealed Eliquis (anticoagulant) five milligrams, give one tablet by mouth two times a day. Review of Resident #48's plan of care dated 07/19/19 revealed no interventions related to side effects or monitoring of the resident's anticoagulant. Review of Resident #48's medication administration record (MAR) for the month of 08/2019 confirmed the resident received the anticoagulant (Eliquis) as per physician order. Interview on 08/27/19 at 5:42 P.M. with MDS Registered Nurse (RN) #7 confirmed interventions related to the anticoagulant were not included in Resident #48's plan of care. RN #7 revealed the resident's plan of care should have included interventions related to the medication, Eliquis.

CONCERN (D)

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

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident and staff interview, and review of facility policy, the facility failed to complete and revise resident care plans. This affected four Residents (#26, #34, #35 and #57) of 24 reviewed during the investigation stage of the annual survey. The facility census was 67. Findings include: 1. Review of the medical record revealed Resident #26 was admitted to the facility 06/27/18 with diagnoses including hemiplegia and hemiparesis following a cerebrovascular disease, type two diabetes, major depressive disorder, and gastro-esophageal reflux disease. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed Resident #26 was cognitively intact, with no behaviors noted. Review of Section G-Functional Status revealed the resident required total one-person dependence with bed mobility, extensive one-person assistance with transfers, toileting, extensive two-person assistance with personal hygiene, supervision and setup with locomotion, one person assistance with dressing, resident was independent with setup assistance for eating, walking did not occur. Review of Section L-Dental/Oral Status revealed the resident has no noted dental concerns, including no obvious or likely cavity or broken natural teeth, no inflamed gums, and/or no mouth or facial pain. Review of Resident #26's Care Plans revealed the record was silent of a care plan related to the resident's mouth pain and/or swelling. Review of the Physician and Nursing Progress notes revealed on 02/22/19 the resident was referred to the dentist for lower molar pain. On 03/11/19 the resident was seen by dental services and referred to oral surgery. On 06/07/19 the resident was scheduled for extractions however missed her appointment. On 06/17/19 the resident was seen by the local dental agency, whom then again referred the resident for oral surgery. Review of Resident #26 Medication Administrator Record (MAR) dated 06/2019 reveled the resident was ordered and received Tylenol 500 milligram (mg) twice daily, for pain, and Oxycodone (pain medication) 5 mg tablet, every eight hours as needed for pain. The resident was documented as requesting/receiving the Oxycodone on 06/09/19, 06/10/19, 06/13/19, 06/14/19, 6/15/19, twice on 06/16/19, 06/20/19, 06/23/19, and 06/27/19. Observation and interview conducted on 08/25/19 at 11:42 A.M. and again on 08/27/19 at 11:53 A.M., Resident #26 stated she had been having mouth pain and issues since February. The resident was observed with swelling noted to both sides of her face and gums, and multiple broken and discolored/black teeth. The resident stated she was supposed to have her teeth pulled in June but there was in issue and she was taken to the wrong office. The resident stated since she missed her appointment the dental office would no longer see her, and the facility had been working on getting her surgery somewhere else. Resident #26 stated she has had constant pain and off-and-on swelling in her face since February. The resident stated she takes Tylenol for pain and it helps most days, but she had to take her Oxycodone sometimes for relief. Interview conducted on 08/28/19 at 9:34 A.M., the Director of Nursing (DON) stated she was aware of all the issues with Resident #26's teeth for the last several months and she had an upcoming appointment to have her teeth pulled. The DON verified the resident's care plans did not reflect her ongoing dental issues related to pain and/or swelling. The DON stated the facility was without an MDS nurse for a while and the corporate team was completing them for the facility. 2. Medical record review for Resident #34 revealed an admission date of 02/26/19. Medical diagnosis included sepsis, muscle weakness, dysphagia, cognitive communication deficit, paraplegia, acute and chronic respiratory failure with hypoxia, acute kidney failure, bacteremia and hypertension. Review of Resident #34's quarterly MDS assessment dated [DATE], revealed Resident #34's cognition was intact. Resident #34 was noted to require extensive assistance with his activities of daily living (ADL's), noted to have an indwelling catheter (internal device used for the removal of urine) and noted as always incontinent of bowel movements. Review of Resident #34's care plan, reviewed there were no care plans for an indwelling catheter or bowel incontinence. Interview on 08/28/19 at 2:12 P.M. with Registered Nurse (RN) #7 verified Resident #34's baseline care plan included the indwelling catheter and bowel incontinence but his comprehensive care plan had not been revised to include the indwelling catheter or bowel incontinence. 3. Medical record review for Resident #35 revealed an original admission date of 11/15/18 and a re-admission date of 12/28/18. Medical diagnosis included cerebral infarction, need for assistance with personal care, hemiplegia and hemiparesis, malignant neoplasm of unspecified part of bronchus or lung, acute or chronic respiratory failure, muscle wasting or atrophy, muscle weakness, cognitive communication deficit, dysphagia, hyperlipidemia, chronic kidney disease, anemia, hypertension, and peripheral vascular disease. Review of Resident #35's care plan with a revised date of 08/26/19 revealed a care plan for hospice services with no terminal diagnosis listed. Interview on 08/27/19 at 6:15 P.M. with RN #7 who verified she had looked everywhere and could not find the terminal diagnosis listed and could not find the resident's hospice binder. RN #7 verified the care plan should have listed the terminal diagnosis and it did not. 4. Review of the medical record revealed Resident #57 was admitted to the facility on [DATE] with diagnoses including dementia without behavioral disturbance, dysuria, falls, malignant neoplasm of the brain, cerebral infarction, hemiplegia and hemiparesis, encephalopathy, mood disorder, dysphagia, convulsions, major depressive disorder, muscle weakness, aphasia, gastrostomy, constipation, and anxiety disorder. Review of the Quarterly MDS dated [DATE] revealed Resident #57 was severely cognitively impaired with no noted behaviors. Review of Section G-Functional Status revealed the resident required total two-person assistance with bed mobility, transfer, total one-person assistance with locomotion, dressing, eating, toileting, personal hygiene, and walking did not occur. Review of section K-Swallowing/Nutritional Status revealed no swallowing disorder, and no noted significant weight loss/gain for the last six months, the resident was noted with a mechanically altered diet. Review of Resident #57's Care Plan on 08/25/19 revealed the resident had no noted care plan related to preferences of not being dressed and/or resistance to dressing. Further review of the care plans revealed the resident's ADL and activities care plans noted the resident enjoyed playing chess, will maintain or increase mobility, utilizes special utensils for meals, eats in the dining room with peers, and propels himself. Observation conducted 08/26/19 at 8:46 A.M., 4:16 P.M., 08/27/19 at 10:40 A.M., and 12:02 P.M., with Resident #57 revealed the resident was laying in bed, only noted in a depend with no clothes on, watching television. The resident was not appropriate for interview. Interview and observation conducted on 08/27/19 at 12:37 P.M., State Tested Nursing Assistant (STNA) #47 stated she worked with the resident often. STNA #47 stated the resident could tell you when he was thirsty, and when he was hungry by hand gestures. He could no longer feed himself, she had to spoon feed him his food and thickened liquids. STNA #47 stated the resident refused clothes and to be up to his wheelchair, every time staff attempted to put clothes on him or get him up, he fought and kicked. STNA #47 stated she was unsure of how long the resident had been refusing, however stated it had been a while now. Interview conducted on 08/27/19 at 2:36 P.M. with Activities Director (AD) #73 stated Resident #57 got irritated easily, and wasn't very responsive to her. AD #73 stated activities did at least three one-on-one visits a week, and will usually sit and chat and talk with him since he didn't like to get up. When Resident #57 was getting up, he would refuse activities and keep to himself. AD #73 stated the resident did love to play chess but he had declined so much that he couldn't play anymore. Interview conducted on 08/28/19 at 8:57 A.M. Licensed Practical Nurse (LPN) #18 stated Resident #57 had not been up to his wheelchair in a long time. LPN #18 stated the resident refuses clothes and to get up anymore, and she was unsure if it is noted in his care plan. Interview conducted on 08/28/19 at 9:45 A.M., the DON stated she was aware that Resident #57 wound not allow staff to put his clothes on, and no longer got out of bed. The DON reviewed Resident #57's care plans and verified they did not accurately reflect his status related to activities, refusals, and/or ADL's. Review of the facility policy titled, Care Plans, Comprehensive Person-Centered dated 12/2016 revealed resident care plans are initiated with objectives and time-tables to meet the resident's physical, psychosocial and functional needs, and assessments are to be on-going and revised as the information and/or resident conditions change.

CONCERN (D)

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

Deficiency F0658 (Tag F0658)

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, family and staff interview, review of After Visit Summary, review of Medication Error log and review of facility policy the facility failed provide medications with professional standard of quality when a nurse hid medications in food and left the food unattended. This affected two residents (#27 and #60) of 17 residents who received medications on the memory care unit. The facility census was 67. Findings include: 1. Review of Resident #60's medical record revealed the resident was admitted on [DATE] with diagnoses including dementia without behavioral disturbance, history of falling and malignant neoplasm of the large intestine. Review of Resident #60's Minimum Data Set (MDS) dated [DATE] revealed the resident had severe cognitive deficit. The resident required extensive one-person physical assistance for bed mobility, transfers, eating, dressing and toileting. The resident required total dependence for personal hygiene. Review of Resident #60's plan of care dated 03/25/19 revealed the resident had severe cognitive impairment, dementia and cognitive communication deficits. Review of Resident #60's progress notes dated 08/11/19 at 2:39 P.M. revealed Resident #60 was sitting at the dining room table with another female resident eating breakfast. The female resident (Resident #27) gave her oatmeal to Resident #60 which had Resident #27's medications in the oatmeal. Progress note revealed notification was made to the Director of Nursing (DON), physician, and family. Vital signs documented were blood pressure 121/62 (manual), pulse 65 beats per minute (BPM), oxygen saturation 97 percent, and respirations 18. Progress note identified Resident #60's wife requested for the resident go to the hospital for an evaluation. Progress note revealed Resident #60 was transported to the hospital via emergency medical service (EMS). Review of Resident #60's progress note dated 08/11/19 at 9:57 P.M. revealed the resident returned to the facility on stretcher and was transferred to bed. Vital signs were documented as temperature 98.4, pulse 62 BPM, respirations 16, blood pressure 98/47. Review of Resident #60's After Visit Summary dated 08/11/19 revealed the reason for Resident #60's visit was altered mental status and ingestion. Diagnoses for the visit revealed, accidental drug ingestion resulting in somnolence. 2. Review of Resident #27's medical record revealed the resident was admitted on [DATE] with diagnoses including dementia with behavioral disturbance, schizoaffective disorder and unspecified psychosis. Review of Resident #27's MDS dated [DATE] revealed severe cognitive decline. The resident required supervision for all activities of daily living. Review of physician order dated 02/03/18 indicated May crush and mix medications together unless contraindicated. Any drug which cannot be crushed, may be given whole in applesauce. Review of Resident #27's plan of care dated 04/11/19 revealed no interventions related to administering medications in food. Review of Resident #27's progress notes from 08/01/19 through 08/26/19 revealed multiple documented refusals to take her medication. Review of Resident #27's Medication Administration Record for 08/11/19 revealed the following medications were crushed and put in Resident #27's oatmeal: Aspirin 81 milligram (mg), Benztropine (anticholinergic) 0.5 mg., Metoprolol (blood pressure) 50 mg., Zoloft (antidepressant) 50 mg., clonazepam (antianxiety) 0.5 mg., Lasix (diuretic) 40 mg., methenamine (antibiotic) 1 gram, guaifenesin (mucous relief) 400 mg., potassium chloride (supplement) ER 20 mill-equivilents (meq) and Seroquel (antipsychotic) 50 mg. Interview on 08/25/19 at 10:25 A.M. with Resident #60's wife revealed coming to the facility daily to visit her husband who resided on the secured memory care unit at the facility. Resident #60's wife revealed being called at her home on [DATE] and being notified that her husband possibly consumed oatmeal that contained another resident's morning medications. Resident #60's wife revealed she came to the facility right away. Resident #60's wife stated her husband was difficult to arouse and she requested for him to be transferred to the hospital. Interview on 08/25/19 at 1:11 P.M. with Nurse #100 confirmed an incident occurred on 08/11/19. Resident #60 was of eating ate Resident #27's oatmeal which contained Resident #27's crushed morning medications. Nurse #100 stated on 08/11/19, she crushed Resident #27's medications and sprinkled them in Resident 27's oatmeal. Nurse #100 stated she gave Resident #27 a spoon full of the oatmeal with some of the medications and walked away leaving the remaining oatmeal (with the medications) unattended. Nurse #100 stated there were no staff who witnessed Resident #60 eating Resident #27's oatmeal. Resident #27 told an aide that Resident #60 was hungry and she (Resident #27) gave Resident #60 her oatmeal. Nurse #100 stated Resident #60 was noted to be lethargic later in the morning. Nurse #100 stated the resident did respond to tactile stimulation, however he was very lethargic. Nurse #100 stated the resident's blood pressure was only slightly elevated. Nurse #100 stated the wife was contacted and she came to the facility. Resident #60 was sent to the hospital for evaluation on 08/11/19 about 1:00 P.M. Nurse #100 confirmed she received education from the Director of Nursing (DON) concerning the incident. Interview with the DON on 08/26/19 at 1:30 P.M. revealed knowledge of the incident on 08/11/19. The DON stated there was no direct observation of Resident #60 eating the oatmeal containing Resident #27's medications. The DON stated Resident #27 told an aid that Resident #60 was hungry and she gave him her oatmeal. The DON stated Resident #60 was evaluated at the hospital and returned later that evening. The DON stated she provided education to Nurse #100. The DON denied providing education for other nurses. The DON denied having provided any monitoring of medication administration. Review of the facility's Medication Error log from last annual certification period revealed three medication errors on 06/19/19, 08/11/19 (Resident #27) and 08/13/19. Review of facility policy titled, Oral Medication Administration Policy and Procedure dated 08/01/19 revealed to crush medications if indicated by the prescriber's order. Crush tablet with appropriate device and mix crushed medication in small amount of appropriate substance. This deficiency substantiates Complaint Number OH00106716.

CONCERN (D)

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

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record, observation, and staff interview, the facility failed to provide mouth care for a dependent resident. This affected one Resident (#11) of one reviewed for activities of daily living (ADL's). The facility census was 67. Findings include: Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including heart disease, tracheostomy, gastrostomy, atrial fibrillation, chronic respiratory failure, epilepsy, type two diabetes, and major depressive disorder. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed Resident #11 was severely cognitively impaired with delirium inattention and altered level of consciousness noted. Review of Section E-Behaviors revealed the resident had rejection of care and physical behavioral symptoms directed towards others was noted one to three days during the lookback period. Review of Section G-Functional Assessment revealed the resident was totally dependent with one-person assistance with bed mobility, locomotion, dressing, eating, toileting, personal hygiene, total dependent with two-person assistance with transfer, and walking did not occur. Review of Section K- Swallowing/Nutrition Status revealed the resident had no noted swallowing disorder with no significant weight loss/gain in the last six months, was noted with a feeding tube that provided 51% or more of total calories during the seven days lookback. Review of Section L-Oral/Dental Status revealed dental issues noted. Review of Section O-Special Treatments revealed the resident did not receive oxygen and/or suctioning, however resident was noted with tracheostomy care. Review of Resident #11's ADL Care Sheets for nursing aide assignment revealed Resident #11's task noted mouth care was to be provided twice daily and as needed. Further review of the task sheet revealed the sheet was only signed off that mouth care was only provided four times in the prior five days. The resident should have had mouth care at least 10 times Observations conducted on 08/26/19 at 9:21 A.M. and again on 08/28/19 at 8:27 A.M. and 10:32 A.M. revealed Resident #11 was observed laying in bed, with a thick film noted in and around her mouth and a thick yellow sediment build-up noted on her teeth. Resident #11 was observed with tube feeding running and was inappropriate for interview. Observation and interview conducted on 08/28/19 at 10:32 A.M., Licensed Practical Nurse (LPN) #18 was observed providing stoma care for the resident. LPN #18 observed Resident #11's mouth and verified the thick substance on her mouth and teeth and stated she would have the aids provide her mouth care when they give her a shower. Interview conducted on 08/28/19 at 2:53 P.M. the Director of Nursing (DON) verified there was multiple areas of missing documentation on Resident #11's mouth care, and sign-off sheets were not documented for aides completing mouth care as ordered.

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 medical record review, observations and staff interview, the facility failed to ensure a resident was provided with activities per the plan of care. This affected one Resident (#17) of two reviewed for activities. The facility census was 67. Findings include: Medical record review for Resident #17 revealed an admission date of 02/28/15. Medical diagnoses included encounter for attention to gastrostomy, dysphasia oropharyngeal phase, feeding difficulties, dementia, hypotension, anemia, hyperlipidemia, Alzheimer's, chronic kidney disease, type two diabetes mellitus, anemia, adult failure to thrive, depression, and hypertension. Review of Resident #17's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed, the resident's cognition was severely impaired and the resident required extensive assistance with activities of daily living (ADL's). Review of Resident #17's care plan revealed Resident #17 would participate in activities of her choice two times per week to promote socialization and stimulation. Review of Resident #17's August 2019 activity log revealed nine active visits for the month. No other activities were noted. Observation on 08/27/19 at 12:08 P.M., revealed Resident #17 in her low position bed, no television, or music playing, in her room. Observation on 08/27/19 at 2:35 P.M. revealed Resident #17 in her low position bed, no television, or music playing, in her room. Observation on 08/27/19 at 5:39 P.M. revealed Resident #17 in her low position bed, no television, or music playing, in her room. Observation on 08/28/19 at 8:38 A.M. revealed Resident #17 in her low position bed, no television, or music playing, in her room. Observation on 08/28/19 at 12:14 P.M. revealed Resident #17 in her low position bed, no television, or music playing, in her room. Observation on 08/28/19 at 1:56 P.M. revealed Resident #17 in her low position bed, no television, or music playing, in her room. Interview on 08/28/19 at 2:27 P.M. with Registered Nurse (RN) #150 verified the resident was lying in bed and there there was no music or television on. The residents room was dark and the facility calendar was posted on the bathroom door where the resident couldn't see it. RN #150 verified the activity log for the resident for the month of August only a couple entries and Resident #17 had not been engaged in activities per her care plan. The resident had not been out in the common area to promote socialization and stimulation

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 observation, medical record review, family interview, staff interview and review of hospital records, the facility failed to provide timely care for one resident and failed to provide proper positioning for one resident. This affected Resident (#61) reviewed for delay of care and Resident (#40) reviewed for positioning. The facility census was 67. Findings include: 1. Review of the medical record revealed Resident #40 was admitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbance, myocardial infarction, heart disease, encephalopathy, stage four chronic kidney disease, and hallucinations. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was severely cognitively impaired with delirium inattention and disorganized thinking behaviors continuously present. Review of Section G-Functional Status revealed the resident required total one-person assistance with bed mobility, locomotion, total two-person assistance with transfer, and walking did not occur. The resident was noted as not steady, only able to stabilize with staff assistance for balance and walking. Observations conducted on 08/25/19 at 3:00 P.M., 08/28/19 at 7:20 A.M., 8:52 A.M. and again at 9:23 A.M., revealed Resident #40 was up in the common area, in her wheelchair, with her legs dangling above the floor. There were no foot rests noted on the wheelchair. Interview conducted on 08/28/19 at 8:52 A.M., Licensed Practical Nurse (LPN) #18 stated she had worked in the facility over a year, and had never witnessed Resident #40 self-ambulate in her wheelchair. LPN #18 verified Resident #40 was noted in the activities room with her wheel chair tilted back, and the resident's feet were noted to be dangling. LPN #18 stated she believed the resident had foot rest for her wheelchair, however stated she had never seen them put on. Interview conducted on 08/28/19 at 9:23 A.M. the Director of Nursing (DON) verified the resident tilted back in her wheelchair with her legs dangling and stated that it was not proper positioning. The DON indicated the resident should have leg rest on her chair. 2. Review of the closed medial record revealed Resident #61 was originally admitted on [DATE] with a re-admission date of 01/03/17. Medical diagnoses included muscle wasting and atrophy, sepsis, gout, type two diabetes mellitus, acute kidney failure, anxiety disorder, Parkinson's disease, atherosclerotic heart disease, hypertension and heart failure. Review of Resident #61's 90-day MDS assessment dated [DATE] revealed Resident #61's cognition was intact. Resident #61 was noted as supervision for bed mobility and transfers. Resident #61 was noted as independent with locomotion on and off the unit and noted as limited assistance for dressing, toileting and personal hygiene. Review of the progress note dated 08/19/19 at 7:43 P.M. revealed the daughter had approached the nurse at shift change inquiring about the call made to the physician by the day shift nurse in regards to lethargy and altered mental status. Vital signs were temperature 98.5 auxiliary, pulse 76, respirations 16 and blood pressure 125/59. Report called to hospital and squad was called. There was no entry in the medical record from the day shift nurse in regards to her call or her evaluation of the resident. Review of hospital record revealed the resident arrived at 7:50 P.M. and her vitals were temperature 98.0, pulse 78, respirations 16 and blood pressure 149/76. The residents final diagnosis was anemia and her hemoglobin had decreased from 11.2 to 7.9 within one week. Interview on 08/27/19 at 2:39 P.M. with the family member of Resident #61 stated the resident was moved to a different facility due to lack of care. She stated the resident was sent to the hospital on [DATE]. The family member indicated on 08/19/19 there was a facility staff nurse who stated she was stretched thin and she had couldn't complete the necessary paperwork to transfer the resident to the hospital. The nurse supposedly stated it was shift change and she (the nurse) needed to leave. The family member stated Resident #61 had been lethargic all day and was not waking up. Another family member who was visiting the resident notified her the resident was having issues. When she arrived at the facility the resident was lying in a low bed and she was hanging off of the bed with her arm on the floor. She stated the residents tongue was hanging out of her mouth. The family member stated she shook the resident, and yelled at her, but the resident would not respond. The family member stated she went to the nurses' station and informed the nurse that something was wrong with the resident. The family member stated the nurse informed her the resident's vital signs were fine. The family member stated she asked the nurse to call the physician and that it took 45 minutes for the nurse to call the physician. The family member stated she had to remind the nurse and the nurse stated she had forgotten. The family member stated she heard the phone conversation and the nurse informed the doctor the family member thought something was wrong with the resident. The family member stated Resident #61 was breathing, but it was shallow breathing. The family member stated the physician stated to send the resident out to the hospital. The family member stated the nurse was straightening up the nurses' station and not calling the squad. She said the nurse pointed to the nurse behind her and stated she would have to call the squad and complete the paperwork because it was shift change and she (the nurse) had to leave. The family member stated, at shift change, another nurse, whom she believed was an agency nurse, stated if the family could give her 10 minutes she would complete the paperwork and have Resident #61 sent out to the hospital. The family member indicated Resident #61 was admitted to the hospital, but had been released the morning of the interview (08/27/19). Interview on 08/27/19 at 4:40 P.M. with Licensed Practical Nurse (LPN) #19 stated Resident #61 had a twin sister who sat with the resident for hours on 08/19/19. LPN #19 stated she received report from LPN #27 who seemed flustered. LPN #19 stated LPN #27 had asked if she could call the physician and LPN #19 stated she wasn't sure what was wrong. LPN #19 asked the family member what was going on with Resident #61 and was informed the resident was not eating or drinking. LPN #19 assessed the resident, she attempted to lift the resident's arm which just flopped down to the bed, she attempted three times to get the resident to respond, and the resident was not responding to her. LPN #19 stated the day shift nurse (LPN #27) had stated they could send the resident out if they needed to. LPN #19 stated she was going to send out the resident because she didn't know her baseline. LPN #19 stated she obtained vitals, called nine-one-one (911) and talked to the family. LPN #19 stated LPN #27 had stated in front of the family that she had too many people to care for and she didn't have time. LPN #19 verified the nurses typically worked 12 hour shifts (6 to 6). Interview on 08/28/19 at 7:17 A.M. with LPN #27 stated Resident #61 was normally independent with propelling in her wheelchair and was alert and oriented as her baseline. LPN #27 stated on 08/19/19 the resident's sister stated the resident was very sleepy that day. The sister reported the morning nurse had checked the resident's blood sugar and it was 84 (normal blood sugar is 70-100). The nurse had asked the resident to eat and the resident smiled. LPN #27 stated she kept an eye on the resident throughout her shift and that the resident didn't eat very much. LPN #27 stated the resident's blood sugar reading in the afternoon was in the 140's and she was a little more alert. LPN #27 stated the family member wanted the resident sent out because she couldn't keep her eyes open, she couldn't hold onto things and the resident was very sleepy. LPN #27 stated Resident #61 was not vary far from her baseline and her vital signs were normal. LPN #27 stated she contacted the physician about an hour before the end of her shift. LPN #27 stated she informed the physician she thought the resident needed sent out as the resident was unusually sleepy, couldn't hold anything and earlier in the day the blood sugar reading was low. LPN #27 stated the physician said if she thought the resident was not her normal self to send her out. LPN #27 stated she was working the north hallway and the right hand side of the south hallway. She said she only had one STNA on the north hallway and one STNA for the south hallway. When asked by the surveyor if she was able to monitor Resident #61, LPN #27 stated she did the best she could. LPN #27 stated around 5:00 P.M. to 6:00 P.M. at the end of the shift she noticed the resident was different. LPN #27 denied making the statement she didn't have time to send the resident out or that he on-coming nurse could prepare the paperwork and call the squad. Interview on 08/28/19 at 10:05 A.M. with the Director of Nursing (DON) stated LPN #27 had been suspended, due toconcerns from the family, pending an investigation. The DON stated LPN #27 had previously been written up due to a performance issue. The DON stated she had given verbal education to LPN #27. The DON stated further education had been discussed for LPN #27.

CONCERN (D)

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

Deficiency F0685 (Tag F0685)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and resident and staff interview, the facility failed to ensure a resident was sent for an ophthalmology referral in a timely manner. This affected one Resident (#70) of one reviewed for vision. The facility census was 67. Findings include: Review of Resident #70's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dysarthria following unspecified cerebrovascular disease, mood disorder, generalized osteoarthritis, hypertension, peripheral autonomic neuropathy, anxiety, diaphragmatic hernia without obstruction or gangrene, psoriasis, benign prostatic hyperplasia without lower urinary tract symptoms, major depressive disorder, type 2 diabetes mellitus with hyperglycemia, kidney failure, anemia, and insomnia. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had moderately impaired cognition with no delusions, hallucinations or behaviors. Resident #70 required extensive assistance for activities of daily living (ADLs). Further review of the medical record revealed a referral dated 05/17/19 for the resident to visit with an ophthalmologist. There was no documentation the resident was scheduled to see an ophthalmologist. Interview on 08/25/19 at 10:25 A.M., Resident #70 reported he had eye glasses when he arrived at the facility. He further stated he needed eye glasses. Resident #70 was observed sitting in a hospital gown with television on and he was not wearing any eye glasses. Interview on 08/27/19 at 3:16 P.M., the Director of Nursing (DON) revealed she found a pair of eye glasses in the resident's room. The eye glasses had something dried up but smeared across both lenses. Interview on 08/27/19 at 3:30 P.M., Social Services (SS) #75 was unable to provide evidence the resident was scheduled to see an ophthalmologist as recommended or that the resident refused.

CONCERN (D)

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, resident and staff interview, and review of facility Smoking Policy, the facility failed to ensure a resident assessed to require supervision with smoking was not permitted to possess their own smoking materials. This affected one Resident (#26) of six observed for smoking. The facility census was 67. Findings include: Review of Resident #26's medical record revealed an admit date of 06/27/19 with diagnoses including hemiplegia, hemiparesis, cerebral infarction, encephalopathy, anemia, type 2 diabetes mellitus without complications, depression, insomnia, atrial fibrillation, cerebral atherosclerosis, gastro-esophageal reflux disease without esophagitis, vascular disease, anxiety, traumatic amputation of one unspecified lesser toe, subsequent encounter, hypertension, heart disease and aphasia. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had no cognitive impairment with no delusions, hallucinations or behaviors. Resident #26 required extensive assistance for most activities of daily living. Review of the smoking assessment dated [DATE] indicated Resident #26 was to be supervised while smoking. Observation on 08/25/19 at 12:48 P.M., revealed Resident #26 pulled out half of a cigarette that appeared had previously been smoked. Interview at the timeof the observtion State Tested Nursing Assistant (STNA) # 66 verified she did not give Resident #26 a cigarette. STNA #66 reported Resident #26 was on the supervised smoke list. Reviewe of facilitiy policy titled, Smoking Policy and Procedure, dated 04/05/19 indicated the facility staff will supervise all residents while smoking on the premise. All smoking materials will be kept in a secured area and distributed by facility staff for residents during designated smoking times.

CONCERN (D)

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

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure monthly Medication Regimen Reviews (MRR) were performed. This affected three Residents (#2, #41, and #67) of five residents reviewed for unnecessary medications. The facility census was 67. Findings include: 1. Medical record review for Resident #2 revealed an admission date of 11/30/15. Medical diagnoses included dementia without behavioral disturbance, encephalopathy, hypothyroidism, occlusion and stenosis of unspecified carotid artery, vitamin B deficiency, heart disease, hyperlipidemia, spinal stenosis, psychosis, depression. Review of Resident #2's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2's cognition was severely impaired. Resident #2 was noted as being totally dependent for Activities of Daily Living (ADLs) and was noted as always incontinent of both bladder and bowel. 2. Review of Resident #41's medical record revealed an admission date of 03/08/18. Diagnosis included difficulty in walking, atrial fibrillation, pneumonia, muscle weakness, cognitive communication deficit, Alzheimer's disease, dementia without behavioral, gastritis, overflow, vitamin d deficiency, chronic kidney, hypertensive chronic kidney disease with stage one through stage four chronic kidney, type two diabetes mellitus without complications, hypothyroidism, peptic ulcer site unspecified as acute or chronic without hemorrhage or perforation, major depressive, angina pectoris, hydronephrosis, anxiety, hypertension, chronic obstructive pulmonary disease, osteoarthritis, encephalopathy, obesity, gastro-esophageal reflux disease without esophagitis. Review of MDS assessment dated [DATE] indicated Resident #41 had severe cognitive impairment and required limited assist of one for bed mobility, transfers, toileting and personal hygiene and was independent for eating. Review of the MRR revealed 10/2018 ad 11/2018 MRR's were missing. 3. Medical record review for Resident #67 revealed an admission date of 06/26/09. Medical diagnoses included but not limited to, dementia with behavioral disturbance, abnormal weight loss, vitamin d deficiency, insomnia, Alzheimer's disease, other specified mental disorder, cerebral infarction, anemia, type two diabetes mellitus, anxiety, depression, peripheral vascular disease, and osteoporosis. Review of Resident #67's annual MDS assessment dated [DATE] revealed Resident #67's cognition was severely impaired. Resident #67 was noted to require limited assistance for bed mobility, walking in the room and corridor and locomotion on the unit. Resident #67 was noted as extensive assistance for transfers, toileting and hygiene and total dependence for dressing. Resident #67 was noted as always incontinent of both bladder and bowel. Interview on 08/28/19 at 11:14 A.M. with the Director of Nursing (DON) stated she could not locate the October 2018 and November 2018 monthly MRR sheets.

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 closed and open medical record review and staff interview, the facility failed to maintain residents medical records in a complete and accurate manor. This affected two Resident's #21 and #35) of six reviewed. The facility census was 67. Findings include: 1. Review of the closed medical record revealed Resident #21 was admitted to the facility [DATE]. The resident expired on [DATE]. Further review of the medical record revealed no documentation of the resident expiring and of the release of her body. Review of the last progress note dated [DATE] at 11:43 A.M. revealed hospice was with the resident full time. The resident was resting comfortably in her bed with no verbal vocalization, only moans and groans noted. The resident was able to take her medication orally. The daughter called to check on the resident and spoke with her briefly. Interview conducted on [DATE] at 8:55 A.M., Licensed Practical Nurse (LPN) #18 verified the medical record did not contain documentation of Resident #21's death. LPN #18 stated the resident was hospice, and they should have put in a nurse progress note when the resident expired. LPN #18 stated there was no where else in the medical record the information would be documented. Interview conducted on [DATE] at 9:42 A.M., the Director of Nursing (DON) stated Resident #21 was on hospice and she remembered she passed on a Friday. The DON stated the staff were supposed to call and notify her when a resident passed. The DON indicated staff did not notify her of the resident expiring and she did not learn of it until the following Monday when she returned to work. The DON verified there were no progress notes regarding Resident #21's death. The DON stated the resident prior to her death she was moved to a private room so hospice could be at her bedside. 2. Medical record review for Resident #35 revealed an original admission date of [DATE] and a readmission date of [DATE]. Medical diagnoses included but not limited to, cerebral infarction, need for assistance with personal care, hemiplegia and hemiparesis, malignant neoplasm of unspecified part of bronchus or lung, acute or chronic respiratory failure, muscle wasting or or atrophy, muscle weakness, cognitive communication deficit, dysphagia, hyperlipidemia, chronic kidney disease, anemia, arteriosclerotic heart disease, hypertension and peripheral vascular disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35 was cognitively impaired. Continued review of Resident #35's medical record revealed a signed contract for hospice services dated [DATE]. There was a physician order but it was not signed by the physician. There was nothing else in the record in regards to the resident being admitted to hospice. Review of a progress note dated [DATE] indicated Resident #35 had not urinated all shift and hospice was contacted. Interview on [DATE] at 10:01 A.M. with the DON revealed even though the resident was on hospice the nurse still should have assessed the resident and documented on the resident in regards to her not urinating. The DON verified the physician telephone order for admission to hospice was not signed and there was no other documentation in the record in regards to admission to hospice.

CONCERN (E)

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

Medication Errors (Tag F0758)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure, gradual dose reductions (GDR) were made and responded to and acted upon timely. This affected three Residents (#2, #41, and #67) of five reviewed for unnecessary medication use. The facility census was 67. Findings include: 1. Medical record review for Resident #2 revealed an admission date of 11/30/15. Medical diagnoses included dementia without behavioral disturbance, encephalopathy, hypothyroidism, occlusion and stenosis of unspecified carotid artery, vitamin B deficiency, heart disease, hyperlipidemia, spinal stenosis, psychosis, depression. Review of Resident #2's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the residents cognition was severely impaired. Resident #2 was noted as being totally dependent for activities of daily living (ADLs) and was noted as always being incontinent of both bladder and bowel. Further review of Resident #2's medical record revealed a pharmacy GDR request dated 04/24/19 which indicated the resident was on Buspar (depression) 5.0 milligrams (mg) by mouth twice daily, Remeron (appetite stimulant) 7.5 mg by mouth at bedtime, Seroquel (antipsychotics) 25 mg by mouth at bedtime. The pharmacist recommended reducing Seroquel to 12.5 mg by mouth at bedtime, continuing with Remeron and Buspar. The GDR form indicated the prescriber was to consider the GDR or document the need for the current dose. If no reduction was indicated, documentation was to be provided indicating the benefit versus the risk of the prescribed medication. Review of the 04/24/19 GDR revealed the physician did not select from any of the choices on the form. The physician selected the other box and wrote same reevaluate monthly dated 06/19/19. Interview on 08/28/19 at 10:17 A.M. with the Director of Nursing (DON) verified the physician did not address the GDR for this resident in an appropriate manner. He did not address it timely and he did not answer the GDR or document the need or contraindication to the GDR. The DON stated in the month she has been in the facility she had implemented her own practice of copying the GDR and sending the GDR to the physician and making sure they sign off on it. 2. Review of Resident #41's medical record revealed an admission date of 03/08/18. Diagnosis included difficulty in walking, atrial fibrillation, pneumonia, muscle weakness, cognitive communication deficit, Alzheimer's disease, dementia without behavioral, gastritis, overflow, vitamin d deficiency, chronic kidney, hypertensive chronic kidney disease, type 2 diabetes mellitus without complications, hypothyroidism, peptic ulcer site unspecified as acute or chronic without hemorrhage or perforation, major depressive, angina pectoris, hydronephrosis, anxiety, hypertension, chronic obstructive pulmonary disease, osteoarthritis, encephalopathy, obesity, gastro-esophageal reflux disease without esophagitis. Review of MDS assessment dated [DATE] indicated Resident #41 had severe cognitive impairment and required limited assist of one for bed mobility, transfers, toileting and personal hygiene and was independent for eating. Review of physician orders for 08/2019 revealed an antidepressants Cymbalta 60 mg) daily, Buspirone 10 mg three times a day and a mood stabilizer Depakote 125 mg twice daily. Review of the GDR recommendations of dosage reductions for Depakote, Cymbalta and Buspirone revealed GDR's were missing for 10/2018 ad 11/2018. Interview on 08/28/19 at 11:14 A.M., the DON stated she could not locate October 2018 and November 2018 GDR's. 3. Medical record review for Resident #67 revealed an admission date of 06/26/09. Medical diagnoses included dementia with behavioral disturbance, abnormal weight loss, vitamin d deficiency, insomnia, Alzheimer's disease, other specified mental disorder, cerebral infarction, anemia, type two diabetes mellitus, anxiety, depression, peripheral vascular disease, and osteoporosis. Review of Resident #67's annual MDS assessment dated [DATE] revealed Resident #67's cognition was severely impaired. Resident #67 was noted to require limited assistance for bed mobility, walking in the room and corridor and locomotion on the unit. Resident #67 was noted as extensive assistance for transfers, toileting and hygiene and total dependence for dressing. Resident #67 was noted as always incontinent of both bladder and bowel. Further review of Resident #67's medical record revealed a pharmacy GDR request dated 10/24/18 which indicated the resident was on Trazodone (insomnia) 25 mg by mouth at bedtime. The GDR form indicated the prescriber was to consider the GDR or document the need for the current dose. If no reduction was indicated, documentation was to be provided indicating the benefit versus the risk of the prescribed medication. Review of the 10/24/18 GDR revealed the physician did not select from any of the choices on the form. The physician selected the other box and wrote following dated 07/17/19. At the bottom of the page it had been handwritten by an unknown source MD aware 10/26. That was unable to be verified. Further review of Resident #67's medical record revealed a pharmacy GDR request dated 04/24/19 which indicated the resident was on Trazodone 25 mg by mouth at bedtime. The GDR form indicated the prescriber was to consider the GDR or document the need for the current dose. If no reduction was indicated, documentation was to be provided indicating the benefit versus the risk of the prescribed medication. Review of the 04/24/19 GDR revealed the physician did not select from any of the choices on the form. The physician selected the other box and wrote considering dated 06/19/19. Further review of Resident #67's medical record revealed a pharmacy GDR request dated 06/19/19 which indicated the resident was on Trazodone 25 mg by mouth at bedtime. The GDR form stated the prescriber was to consider the GDR or document the need for the current dose. If no reduction was indicated, documentation was to be provided indicating the benefit versus the risk of the prescribed medication. Review of the 06/19/19 GDR revealed the physician did not select from any of the choices on the form. The physician selected the other box and wrote I will evaluate at each visit as always dated 07/04/19. Interview on 08/28/19 at 10:17 A.M. with the DON verified the physician did not address the three GDRs for this resident in an appropriate manner. He did not address them timely and he did not answer the GDR or document the need or contraindication to the GDR. She stated in the month she had been in the facility she had implemented her own practice of copying the GDR and sending the GDR to the physician and making sure they sign off on it.

CONCERN (E)

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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Based on observation, staff interview and review of facility policy the facility failed to properly and safely store food items. This had the potential to affect all residents who consumed meals from the facility kitchen. The facility identified one resident (Resident #11) who did not consume food prepared by the kitchen staff. The facility census was 67. Findings include: Observation on 08/25/19 at 8:40 A.M. of the kitchen revealed an open-undated carton of potato salad, open-undated bags of shredded cheese, open-undated thickened juice, open-undated slices of pie and multiple miscellaneous leftovers without dates. There were also multiple open-undated cereals and pretzels in the dry storage area. The walk-in freezer had boxes of frozen meats sitting on the floor in the freezer that had not been placed on the shelves. Interview on 08/25/19 at 8:55 A.M. with Dietary [NAME] (DC) #35 confirmed the open and undated products in the walk-in cooler and in the dry storage. DC #35 also confirmed the boxes of frozen meat in the walk-in freezer that were sitting directly on the floor. Review of the facility's undated policy titled, Dietary Food Storage revealed food items should be dated when opened. The policy also revealed food items shall be stored at least six inches above the floor on shelves.

CONCERN (F)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected most or all residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview and review of medication storage policy, the facility failed to properly label drugs and biological's used in the facility and the facility failed to ensure medication carts were secure. This directly affected two Residents (#70 and #62) of two whose medication were observed opened and undated. This had the potential to affect all residents. The facility also failed to ensure medication carts on the memory impaired unit were locked. Facility census was 67. Findings include: 1. Review of the medical record for Resident #70, revealed an admission date of 08/31/12. Diagnoses included acute angle-closure glaucoma, mood disorder, hemiplegia and heart failure. Review of the most recent Minimum Data Set (MDS) 3.0 assessment, dated 08/01/19, revealed the resident had moderately impaired cognition. Resident #70 had no behaviors, did not reject care, and did not wander. Resident was dependent or required extensive assistance for activities of daily living (ADLs). Review of physician orders for Resident #70 dated 05/17/19 revealed Timolol Maleate solution 0.5 % instill one drop in both eyes two times daily for glaucoma. Physician orders dated 02/02/18 revealed Lumigan Solution 0.03 % instill one drop in both eyes at bedtime for acute angle-closure glaucoma. Observation of the South medication cart with the Director of Nursing (DON) on 08/28/19 at 9:06 A.M. revealed one opened and undated bottle Lumigan solution 0.03 % and one bottle of opened and undated bottle of Timolol Maleate solution 0.5 % for Resident #70. Interview with DON on 08/28/19 at 9:07 A.M. verified one opened and undated bottle Lumigan solution 0.03 percent and one bottle of opened and undated bottle of Timolol Maleate solution 0.5 percent for Resident #70. DON stated both bottles should have been dated when opened. 2. Review of the medical record for Resident #72, revealed an admission date of 07/25/19. Diagnoses included acute pulmonary insufficiency, atrial fibrillation, kidney disease and congestive heart failure. Review of the most recent MDS 3.0 assessment dated [DATE] revealed the resident was cognitively intact, had no behaviors, did not reject care, and did not wander. Resident was a one-person physical assist and required extensive assistance for ADLs. Review of physician orders dated 07/25/19 revealed Albuterol Sulfate HFA Aerosol Solution inhaler 90 mcg two puffs inhale orally every four hours as needed for wheezing. Observation of the Rehabilitation cart with Licensed Practical Nurse (LPN) #100 on 08/28/19 at 8:05 A.M. revealed one Albuterol Sulfate HFA Aerosol Solution 90 microgram (mcg) inhaler that was opened and undated for Resident #72 Interview with LPN #100 on 08/28/19 at 8:07 A.M. verified the Albuterol Sulfate Inhaler 90 mcg for Resident #72 was opened and undated. LPN #100 stated the inhaler should have been dated when opened. 3. Observation of the medication storage room refrigerator with LPN #18 on 08/28/19 at 8:20 A.M. revealed one vial of tuberculin PPD that was opened and undated. Another vial was opened and dated 07/17/19. Interview with LPN #18 verified one vial of tuberculin PPD was opened and undated and one vial was opened and dated 07/17/19. LPN #18 stated the one vial of PPD should have been dated when opened the other vial should have been discarded after 30 days. 4. Observation on 08/27/19 at 11:33 A.M. revealed LPN #100 walked away from her medication cart and left it unlocked. Interview on 08/27/19 at 11:35 A.M. with Registered Nurse (RN) #63 verified the medication cart was unlocked, LPN #100 was not present and the residents on the unit were cognitively impaired. Review of the facility policy titled Medication Storage Policy and Procedure dated 08/01/18 revealed medication carts, rooms, medication supplies are to be locked when not attended by persons with authorized access. Medications and biological's are stored safely, securely, and properly, following manufacturers recommendation or those of the supplier.

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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Based on observation, staff interview, and review of facility policy on cleaning glucometers and facility policy the facility failed to maintain an infection program. The facility failed to ensure a glucometer was cleaned between resident use. This directly affected three Residents (#15, #48 and #54) of three observed. The facility also failed to follow their Legionella plan. This had the the potential to affect all residents that resided in the facility. Facility census was 67. Findings include: 1. During observation on 08/28/19 at 8:25 A.M. revealed Licensed Practical Nurse (LPN) #5 completed a finger stick blood sugar (FSBG) on Resident #48 and returned the glucometer to the top of the medication cart. At 8:33 A.M., LPN #5 used the same glucometer and completed a FSBG on Resident #54. At 8:50 A.M., LPN #5 used the same glucometer and completed a FSBG on Resident #15. LPN #5 did not clean the glucometer in between residents use of the glucometer. Interview with LPN #5 on 08/28/18 at 8:55 A.M. verified she did not clean the glucometer between resident use when checked the residents FSBGs. LPN #5 stated she should have cleaned the glucometer with sani-wipes in between resident use. Review of undated policy revealed the glucometers were to be cleaned and disinfected between each resident use to maintain infection control. The facility was to use germicidal disposable wipes for cleaning and disinfecting glucometers after each use. 2. Review of the facility policy titled, Infection Control Water Systems dated July 2017 revealed unoccupied room that have been empty for more than ten days will have hot water run through the lines for five minute intervals. The program also indicated the eye wash stations will be checked periodically and water will run for a five minute period of time to ensure stagnant water lines are cleared. Interview on 08/27/19 at 4:54 P.M. with the Maintenance Director (MD) #30 confirmed daily water temperatures were obtained, however denied following the process of flushing water lines in vacant rooms and flushing eye wash stations.

CONCERN (F)

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

Antibiotic Stewardship (Tag F0881)

Could have caused harm · This affected most or all residents

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Based on review of the infection control book, staff interview and review of facility policy the facility failed to ensure they had an infection prevention and control program (IPCP) that included antibiotic use and a system to monitor antibiotic use. This had the potential to affect all the residents that resided in the facility. Facility census was 65. Findings include: Review of the infection control book with infection control designee/Assistant Director of Nursing (ADON) #63 on 08/28/19 at 3:25 P.M. revealed the infection control book only contained surveillance, tracking and resident information that include infections and possible communicable disease for July and August 2019. The infection control book contained no evidence that included antibiotic use nor a system to monitor antibiotic use prior to July 2019. Interview with ADON #63 at the time of the review verified the facility had no evidence of an IPCP that included antibiotic use and a system to monitor antibiotic use. ADON #63 also verified the facility only had surveillance, tracking and resident information that included infections and possible communicable diseases for the months of July and August 2019. ADON #63 stated she just started in July and could not find any records from the previous infection control designee. Review of 08/01/19 policy titled Infection Control / Infection Surveillance Policy and Procedure revealed the facility was to track infections and monitor trends and nosocomial infections.

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

• Licensed and certified facility. Meets minimum state requirements.

Concerns

• Multiple safety concerns identified: 4 harm violation(s), $64,816 in fines, Payment denial on record. Review inspection reports carefully.
• 62 deficiencies on record, including 4 serious (caused harm) violations. Ask about corrective actions taken.
• $64,816 in fines. Extremely high, among the most fined facilities in Ohio. Major compliance failures.
• Grade F (20/100). Below average facility with significant concerns.

Bottom line: Trust Score of 20/100 indicates significant concerns. Thoroughly evaluate alternatives.

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About This Facility

What is Alpine Nursing And Rehabilitation Center's CMS Rating?

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

How is Alpine Nursing And Rehabilitation Center Staffed?

CMS rates Alpine Nursing and Rehabilitation Center's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 48%, compared to the Ohio average of 46%.

What Have Inspectors Found at Alpine Nursing And Rehabilitation Center?

State health inspectors documented 62 deficiencies at Alpine Nursing and Rehabilitation Center during 2019 to 2025. These included: 4 that caused actual resident harm, 57 with potential for harm, and 1 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.

Who Owns and Operates Alpine Nursing And Rehabilitation Center?

Alpine Nursing and Rehabilitation Center is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 99 certified beds and approximately 67 residents (about 68% occupancy), it is a smaller facility located in XENIA, Ohio.

How Does Alpine Nursing And Rehabilitation Center Compare to Other Ohio Nursing Homes?

Compared to the 100 nursing homes in Ohio, Alpine Nursing and Rehabilitation Center's overall rating (2 stars) is below the state average of 3.2, staff turnover (48%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.

What Should Families Ask When Visiting Alpine Nursing And Rehabilitation Center?

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 Alpine Nursing And Rehabilitation Center Safe?

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

Do Nurses at Alpine Nursing And Rehabilitation Center Stick Around?

Alpine Nursing and Rehabilitation Center has a staff turnover rate of 48%, 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 Alpine Nursing And Rehabilitation Center Ever Fined?

Alpine Nursing and Rehabilitation Center has been fined $64,816 across 8 penalty actions. This is above the Ohio average of $33,727. Fines in this range indicate compliance issues significant enough for CMS to impose meaningful financial consequences. Common causes include delayed correction of deficiencies, repeat violations, or care failures affecting resident safety. Families should ask facility leadership what changes have been made since these penalties.

Is Alpine Nursing And Rehabilitation Center on Any Federal Watch List?

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

Facility Details

Beds: 99
Avg. Residents: 67
Occupancy: 68.5%
Ownership: For profit - Limited Liability company
Chain: Independent
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
2-Star Rating: +10
4 Actual Harm citations: -20
62 Deficiencies: -10
Fines ($64,816): -10
Final Score: 20/100

Nearby Alternatives

JAMESTOWN PLACE HEALTH AND REH... 5-star FRIENDS EXTENDED CARE CENTER 5-star TRINITY COMMUNITY AT FAIRBORN 4-star

View all in XENIA →

Check Bed Availability

Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 365601