Every finding on record at Altercare Newark North Inc.

Based on record review, family, resident, and staff interviews, observations, review of International Dysphagia Diet Standardization Initiative (IDDSI) resources, review of the Comparison Chart National Dysphagia Diet > IDDSI, review of American Diabetes Association and Academy and Nutrition and Dietetics guidance, and policy review, the facility failed to ensure a resident did not have a severe weight loss and failed to ensure the proper diet texture was provided. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, negative health outcomes, and/or death on 06/12/26 when Resident #50 was admitted to the facility and the facility placed the resident on a pureed diet. The facility did not timely identify and address Resident #50's severe, unplanned weight loss and failed to acknowledge or act on the resident's expressed preference and repeated requests for an upgraded diet texture. As a result, Resident #50 experienced poor oral intake, muscle wasting, decreased participation in therapy services, and severe unplanned weight loss. The resident reported distress regarding his appearance and stated that his skin was hanging from his body. This affected one (Resident #50) of four residents reviewed for nutrition and weight loss. The facility census was 71.On 08/19/26 at 11:11 A.M., the Administrator was notified Immediate Jeopardy began on 06/12/26 when Resident #50 admitted to the facility and changed his diet texture to a pureed diet. Despite ongoing concerns voiced by the resident and his wife-including repeated requests for a second opinion on the diet texture-no reassessment or modification occurred until 07/21/26, when his diet was changed to mechanical soft. During this period, the facility failed to establish effective processes to monitor dietary tolerance, evaluate nutritional risk, and escalate concerns to appropriate clinical staff. As a result, Resident #50 experienced poor oral intake, muscle wasting, decreased participation in therapy services, and severe weight loss. The resident reported distress regarding his appearance and stated that his skin was hanging from his body. Observations confirmed a narrowed facial appearance, visible hanging skin, generalized weakness, and clothing that appeared significantly oversized, indicating marked malnutrition. There was no registered dietitian (RD) involvement or intervention until 07/23/26, more than one month after admission and only after significant decline had occurred. Additionally, the physician was not notified of the resident's 14.3 percent severe unplanned weight loss in less than two months. The facility lacked effective communication, monitoring, interdisciplinary coordination, and escalation processes necessary to ensure the resident's nutritional status was assessed and addressed in a timely manner.The Immediate Jeopardy was removed on 08/20/26 when the facility implemented the following corrective actions:-On 08/14/26, Certified Nurse Practitioner (CNP) #120 assessed Resident #50 and gave a new order for Remeron seven point five milligrams (mg) at bedtime for weight loss. This order was entered in Resident #50's medical record.-On 08/19/26, all 70 current in-house residents were assessed by a licensed nurse and/or registered dietitian (RD) for significant weight loss. Any resident identified with new weight loss had findings reported to the physician for follow up. -On 08/19/26, the Director of Nursing (DON) completed education for all 18 licensed nurses on ensuring they are reviewing admitting orders clearly and calling the physician to clarify if they do not understand the orders. Upon hire, all new licensed nurses will be educated by the DON/designee on the above information as well as any agency nurses and any as needed (PRN) licensed nurse who is not actively working in the facility at this time will be educated by the DON via lecture or telephone on the above information prior to their next working shift.-On 08/19/26, RD #103 was educated by the Regional Nurse Consultant #160 on ensuring that residents that have been identified with significant weight loss will be assessed weekly with documentation in the medical record until the resident no longer has significant weight loss.-On 08/19/26, all 70 current in-house residents were assessed by a facility staff member to determine dietary preferences. If a resident is unable to state dietary preferences due to cognition, the resident representative was interviewed. If the resident's preference does not follow physician order, the governing body was notified for follow up. -On 08/19/26, the DON completed education for all 18 licensed nurses and 49 certified nursing assistants (CNAs) on the importance of following physician orders, honoring resident's preferences for diets, and responding to resident and family concerns. Upon hire, all new licensed nurses will be educated by the DON/designee on the above information as well as any agency nurses and any PRN licensed nurse who is not actively working in the facility at this time will be educated by the DON via lecture or telephone on the above information prior to their next working shift.-On 08/19/26 at 5:51 P.M., RD #103, the DON, and Assistant Director of Nursing (ADON) #13 were educated by the Regional Nurse Consultant #160 on when significant weight loss is identified for a resident that the physician must be notified immediately and documented in the medical record.-On 08/19/26 at 7:45 P.M., an Ad Hoc Quality Assurance (QA) meeting was completed with the Administrator, DON, Regional Nurse Consultant #160 via telephone call and Medical Director # 170 via telephone call in attendance related to event with discussion of plan including education, root cause, and audits. Medical Director #170 agreed with the plan at this time.-By 08/20/26, the DON completed education for all 18 licensed nurses on the facility's Resident Rights Policy with emphasis on if the resident's dietary preference does not follow the physician order that the physician is to be notified for follow up. If a resident rights conflict with the diet order persists, which places the resident at risk for serious injury, harm, impairment, or death, the Medical Director #170 and/or governing body representative will be notified for follow-up and resolution as indicated. Upon hire, all new licensed nurses will be educated by the DON/designee on the above information as well as any agency nurses and any PRN licensed nurse who is not actively working in the facility at this time will be educated by the DON via lecture or telephone on the above information prior to their next working shift.-On 08/20/26, all 70 current in-house residents had their medical record reviewed by the DON to ensure that they were on the proper diet. Any identified findings were reported to the physician upon discovery for follow-up.-On 08/20/26, the DON audited all 70 current in-house residents for current significant weight loss and nine residents were identified. The DON ensured the physician was notified of the nine residents who had significant weight loss. Any identified findings will be reported to the physician upon discovery for follow up.-Beginning 08/21/26, the DON or designee will audit five random residents to ensure no significant weight loss has been identified and if significant weight loss was identified that physician orders have been followed daily for seven days, then three times a week for three weeks and then PRN.-Beginning 08/21/26, the DON or designee will audit all current residents with identified significant weight loss daily times seven days, then three times a week, three times three weeks, and then PRN to ensure that the RD has completed an assessment weekly until the resident no longer has significant weight loss.-Beginning 08/21/26, the Administrator or designee will interview five random residents to ensure staff are honoring residents' preferences for diets and if resident's dietary preference does not follow the physician order that the governing body was notified for follow up. If there is a resident rights conflict with the diet order persists, which places the resident at risk for serious injury, harm, impairment, or death, Medical Director #170 and/or governing body representative was notified for follow-up and resolution as indicated daily for seven days, then three times a week times for three weeks, and then PRN. Any concerns identified with the audits would be forwarded to the Quality Assurance Performance Improvement (QAPI) committee weekly for four weeks and as needed for immediate follow-up. The Administrator will be responsible for ongoing complianceAlthough the Immediate Jeopardy was removed on 08/20/26, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: Review of the medical record for Resident #50 revealed an admission date of 06/12/26. Diagnoses included cerebral infarction, hemiplegia and hemiparesis, hypertension, chronic diastolic heart failure, dysphagia, oropharyngeal, cognitive communication deficit, dysphagia, anxiety disorder, type two diabetes mellitus, hyperlipidemia, and depression.Review of the discharge instructions from the outside inpatient rehabilitation hospital dated 06/12/26 revealed Speech Therapy (ST) discharge instructions were for Resident #50 to receive International Dysphagia Diet Standardization Initiative (IDDSI) diet of five and zero (5/0) which was equivalent to minced and moist solids with thin liquids. Swallowing strategies were to sit upright in bed when eating or drinking, small bites, and alternate food and liquids. The Dietary Instructions included fortified ice cream supplements three times a day. Resident #50 continues to require encouragement with meal intake and accepts the following foods well: mashed potatoes and gravy, eggs, oatmeal with brown sugar, cottage cheese, yogurt, any fruits, chicken noodle soup or tomato soup, pudding, ice cream, and green beans. Resident #50 enjoys fortified ice cream supplements very well. His weight history was the following: on 05/21/26 at 148 pounds, on 06/02/26 at 142.5 pounds, and on 06/06/26 at 143 pounds.Review of the admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #50 revealed he was moderately cognitively impaired. Resident #50 required supervision assistance with eating, had complaints of difficulty or pain with swallowing and was on a mechanically altered diet such as pureed. Resident #50 weighed 139 pounds.Review of the admission physician orders dated 06/12/26 revealed Resident #50's diet was limited concentrated sweets (LCS), pureed texture and thin liquids. There were no physician orders for a fortified ice cream supplement.Review of the progress note dated 06/14/26 revealed Resident #50 was not eating, and a house supplement was given.Review of the speech therapy (ST) evaluation by Speech Language Pathologist (SLP) #105 dated 06/14/26 revealed Resident #50's diet was recommended to be pureed with thin liquids which included to minimize the risk of weight loss.Review of the initial Medical Nutrition Therapy (MNT) note dated 06/17/26 revealed Resident #50 was at risk for altered nutrition related to diagnoses of cerebral infarction hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, chronic diastolic (congestive) heart failure, dysphagia, oropharyngeal phase, cognitive communication deficit, type two diabetes mellitus with diabetic neuropathy, and hyperlipidemia. Current body weight was 138.6 pounds and a body mass index (BMI) 23.8 kilograms per meter squared (within normal limits). Currently diet was LCS, pureed texture, and thin liquids. Intakes have been zero to 100 percent of meals. No new nutritional recommendations currently. The initial MNT note did not address the decision not to follow hospital's discharge instructions which included the diet texture and frozen nutritional treats and the resident's weight history and food preferences.Review of the nutrition care plan dated 06/17/26 revealed Resident #50 was at a nutritional risk. The care plan did not address Resident #50's dissatisfaction with pureed texture, ill-fitting dentures, and severe weight loss. Interventions included: supplements per physician order, offer menu alternatives as needed, honor food preferences as available and reasonable, monitor weekly weights times four then monthly if stable, notify registered dietician or physician if significant weight change is greater than five percent, review resident skin status, and provide diet per physician order.The behavioral symptoms care plan revealed the resident rejected care including meals and supplement. Interventions included to allow Resident #50 to make choices/decisions, and in capital letters Resident #50 has the right to refuse care and treatment. This was dated 06/22/26. The dental care plan dated 06/24/26 revealed it did not address Resident #50's loose fitting dentures.The ST progress notes by SLP #105 dated 06/20/26 revealed Resident #50 told the SLP he did not want that slop [pureed diet] and refused to eat in front of the SLP. SLP #105 ordered frozen nutritional supplements three times daily. On 06/20/26, there was a physician order for frozen nutritional supplement three times daily.On 06/22/26, first weekly weight was 133 pounds. This was a 4.8 pounds weight loss since admission; 3.6 percent weight loss.The ST progress notes by SLP #105 dated 06/24/26 revealed Resident #50 ate only one bite of every item on the plate. Resident #50 refused most foods as they were currently of pureed consistency. On 06/25/26, Resident #50 refused his pureed meal and told SLP #105 to leave. SLP #105 offered a frozen nutritional supplement as Resident #50 refused the entire meal. Resident #50 took the treat and demanded SLP #105 to leave. SLP #105 observed Resident #50 from a distance while he ate the frozen treat. The nursing progress note dated 06/30/26 revealed Resident #50 refused meals but did eat a bowl of fruit from home.On 07/01/26, Resident #50's weight was125.8 pounds and was the second weight obtained since admission. This was 12.8 pounds weight loss and 10.2 percent severe weight loss in less than three weeks at the facility.The ST progress notes by SLP #105 dated 07/03/26 revealed Resident #50 and family had continuing concerns about the resident's low oral intake and weight loss. The ST progress notes by SLP #105 dated 07/04/26 revealed concerns from the resident regarding decreased oral intake. SLP #105 stated the consequences if Resident #50 did not increase his overall oral intake and the option of hospice. The ST progress notes dated 07/05/26 revealed Resident #50 refused his lunch and only had the frozen fortified treat. SLP #105 stated Resident #50 was educated on the importance of making choices to meet his own needs. Resident #50 refused to answer questions from SLP #105.On 07/06/26, Resident #55's weight was 127 poundsReview of an email provided by the facility dated 07/06/26 revealed Registered Dietitian (RD) #103 ran the weight report and requested a reweigh on Resident #50. It noted Resident #50 had 8.4 percent severe weight loss in 20 days. There was no evidence in the medical record that a reweight was obtained and the next weight obtained was 07/20/26.The ST progress notes dated 07/07/26 revealed Resident #50 expressed he was not eating the yucky food, in reference to his pureed diet. The ST progress note dated 07/10/26 revealed Resident #50 stated he dd not know why he was on a pureed diet. Resident #50 educated on the right to refuse to eat but he needed nutrition for strengthening and to maintain his life.The nursing progress note dated 07/12/26 revealed Resident #50's family was feeding him non-pureed chunky noodle soup with large carrot and celery pieces and wide noodles.From 06/12/26 to 07/12/26, there was no interdisciplinary discussion including physician and MNT involvement regarding Resident #50's preference and refusal to eat pureed texture and severe 8.4 percent weight loss. There was no documentation by SLP #105 notifying RD and the physician for Resident #50's preference and refusal to eat pureed texture. There was no evidence Resident #50 and Resident #50's wife requesting for a second opinion of Resident #50's pureed texture until 07/13/26.The ST progress note dated 07/13/26 revealed the SLP changed to SLP #110. Resident #50 consumed 50 percent of mechanical meat without difficulty and wrote the physician order for mechanical meat, all other foods pureed.The ST progress notes by SLP #110 dated 07/15/26 revealed Resident #50 had a trial of mechanical meat and snack and was able to masticate both efficiently with moderate verbal cues and alternation of solids and liquids.The nursing progress note dated 07/16/26 revealed Resident #50 refused pureed food stating I am not eating that stuff [pureed texture]. Resident #50 refused substitution stating, I am not eating anything that looks like this [pureed texture].On 07/20/26, Resident #50 weighed 126 pounds, down another pound from 07/06/26.Review of Resident #50's meal intakes from 06/12/26 to 07/21/26, revealed Resident #50 received 182 meals. Resident #50 consumed one quarter of the meal 49 percent of the time and consumed a quarter to half of the meal 25 percent of the time. Review of the Modified Barium Swallow (MBS) study results dated 07/21/26 revealed recommendations for a mechanically soft diet with thin liquids. It was recommended for cueing strategies; allow extra time, and monitor patient for adequate nutrition and hydration.The physician orders dated 07/21/26 revealed Resident #50 had a new order for a mechanical soft texture diet.There was no MNT involvement from 06/17/26 to 07/23/26. Review of the MNT review note dated 07/24/26 revealed Resident #50 weighed 126.0 pounds Intakes have been variable between one to 100 percent of meals. Resident #50's weight seems to be going down and triggered for weight loss. The new intervention was for a house nutritional supplement twice a day and weekly weights. The MNT note did not address Resident #50's severe weight loss of 10 percent in one month. There was no documentation in the medical record the physician and family were notified of Resident #50's severe weight loss.Review of an email provided by the facility dated 07/24/26 revealed RD #103 requested to put Resident #50 back on weekly weights and noted Resident #50 seemed like he was slowly losing weight. On 07/2726, Resident #50 weighed 122 pounds; on 08/03/26,121.4 pounds; and 08/05/26, 118.8 pounds This was a 14.3 percent severe weight loss in less than two months.The ST progress notes by SLP #110 dated 07/28/26 revealed Resident #50 stated that he likes the upgraded diet and he was eating half of his meals now. Review of Certified Nurse Practitioner (CNP) note dated 08/03/26 revealed CNP #150 (who was filling in for CNP #120) was asked by the nurse see to Resident #50 for poor appetite and nausea. CNP #150 noted a decrease in Resident #50's appetite and stated to consider adding Remeron, which can increase appetite. CNP #150 also recommended adding Remeron on 08/09/26. There were no physician orders for Remeron on 08/03/26 or 08/09/26. CNP #120 ordered Remeron on 08/14/26.The MNT weight note dated 08/10/26 revealed Resident #50 weighed 118.8 pounds and triggered for significant weight loss in one month. Meal intakes varied from 25 to 75 percent and house nutritional supplement 25 to 50 percent acceptance. Resident #50 will eat the frozen nutritional treat over anything else. Will increase frozen nutritional treat from three times daily to four times daily, continuing the house nutritional supplements and adding to weekly weights.During an interview on 08/10/26 at 12:02 P.M., Resident #50 stated he had excessive weight loss since being at the facility. Resident #50 stated his skin was hanging off his body, and he did not want to lose any more weight. Resident #50 was not happy with the weight loss and reported he and his wife had complained to the facility multiple times about the weight loss and pureed diet. Observation at the time of the interview revealed the resident's face was narrow, and he lifted his arms up to show his skin hanging down. The resident appeared weak, thin, and malnourished. His clothes appeared to be too big for him. During an interview on 08/13/26 at 8:18 A.M., Certified Nursing Assistant (CNA) #46 revealed Resident #50 needed the head of the bed elevated with a tray set up for meals. CNA #46 stated Resident #50 had lost five pounds since being at the facility. CNA #46 stated Resident #50's intakes had increased since he had been on the mechanically soft diet. CNA #46 stated Resident #50 eats better on the mechanical soft diet than he did on the pureed diet. During an observation on 08/13/26 at 8:30 A.M., the head of Resident #50's bed was not elevated. The breakfast tray was in front of Resident #50 which was hard to reach, and there were no staff in room to encourage cueing. Licensed Practical Nurse (LPN) #21 verified the findings at the time of the observation. During an interview on 08/13/26 at 8:30 A.M., LPN #21 stated she admitted Resident #50 to the facility on [DATE] and had ordered the pureed diet based on the discharge instructions for minced and moist. LPN #21 stated she did not know what IDDSI 5/0 diet meant and stated she thought it meant something to do with his insulin. LPN #21 stated she did not monitor Resident #50's weights, but the Director of Nursing (DON) and dietician monitored them. LPN #21 stated she assumed Resident #50 was losing weight as he was getting supplements. LPN #21 stated she did not report any weight loss to the DON for Resident #50. LPN #21 stated if Resident #50 had lost weight, then it would hinder his rehabilitation and recovery.During an interview on 08/13/26 at 10:05 A.M. to 10:30 A.M., RD #103 revealed she was unaware of Resident #50 needing any assistance with meals. RD #103 stated Resident #50's biggest nutritional risk was his intakes which were fluctuating. RD #103 stated Resident #50 had triggered for a weight loss both months he had been at the facility. RD #103 stated the IDDSI 5/0 diet was equivalent to mechanical soft diet with thin liquids. RD #103 stated if the discharge instructions stated IDDSI 5/0 diet then a mechanical soft diet should have been ordered. RD #103 stated she did review Resident #50's discharge instructions but ST determines the texture of the diet, and she did not consult with ST for the diet. RD #103 stated Resident #50 did not like the pureed diet. During an interview on 08/13/26 at 10:55 A.M., SLP #105 stated she reviewed Resident #50's discharge instructions. SLP #105 stated if the diet was minced and moist she would recommend a pureed diet. SLP #105 stated minced is between mechanical soft diet and pureed. SLP #105 stated minced is not more aligned with mechanical soft in this facility. SLP #105 stated with IDDSI 5/0 diet she would look at the comparison chart on at her desk. SLP #105 stated she did not remember the first time Resident #50 stated he did not want the pureed diet.During an interview on 08/13/26 at 11:08 A.M., SLP #110 revealed a mechanical soft diet was meat finely chopped and vegetables softer, which helps with swallowing for people with no teeth or who don't like certain textures, and the kitchen uses gravy to moisten it. SLP #110 stated she was asked to evaluate Resident #50 by Director of Rehabilitation (DOR) #115 because Resident #50's wife was bringing in food and Resident #50 was refusing the pureed diet. SLP #110 stated the first day she met Resident #50 he stated, I am not eating any of that mush. SLP #110 stated she trialed Resident #50 on an oatmeal creme pie and he was able to do that. During an interview on 08/13/26 at 11:36 A.M., DOR #115 stated Resident #50 was motivated with therapy very early on, but after a couple of weeks started losing motivation. DOR #115 stated one of the biggest issues was Resident #50's diet. DOR #115 stated Resident #50's wife requested a change in SLP. DOR #115 stated Resident #50's wife said if Resident #50 did not get an upgraded diet, she was going to switch facilities and DOR #115 offered a second option and Resident #50's wife agreed. DOR #115 stated he talked to SLP #105 about Resident #50's diet because it was not the first time the pureed diet was brought up but stated SLP #105 thought it was the most appropriate diet for Resident #50 at the time. DOR #115 stated Resident #50 and his wife had spoken to DOR #115 every Friday since Resident #50's admission and Resident #50 had complained about his pureed diet from the first week. DOR #115 stated Resident #50's wife brought up Resident #50's weight loss and stated the weight loss was the biggest concern. DOR #115 stated he was excited for Resident #50 and his wife when Resident #50's diet was upgraded to mechanical soft.During an interview on 08/13/26 at 1:17 P.M., the Director of Nursing (DON) stated she had reviewed Resident #50's admission but did not review his diet orders. She verified Resident #50 was ordered ST in his referral to the facility. She did not know what an IDDSI 5/0 diet was and would need to look it up and did not look at the ST recommendations from the outside rehabilitation hospital for Resident #50. She did hear in passing that Resident #50 did not like pureed texture but was not sure of the exact date or if it was the first week. DOR #115 did not tell her about Resident #50's refusal of pureed until the first weeks of July 2026 in a utilization review meeting. DOR #115 told her Resident #50 did not like the pureed texture and was refusing the pureed diet. The DON stated she became aware of Resident #50's weight loss on 07/06/26 when she received an email from RD #103 requesting a re-weigh. She completed the re-weight and waited on the recommendations from RD #103 regarding Resident #50's weight loss. On 08/13/26, this was the first time she saw a comparison chart for diet but looking at it, she would have to say someone on an IDDSI 5/0 diet would be on mechanical soft with thin liquids. No CNAs or nurses had reported to her Resident #50 was refusing to eat. Only the RD looks at the meal intakes unless one of the CNAs or nurses reports something to her regarding the intakes. The DON stated a 20-pound weight loss in two months was a significant amount of weight loss. Resident #50 had some muscle wasting when she had last seen him.During an interview on 08/13/26 at 1:58 P.M., Resident #50 stated he was frustrated when he kept getting pureed and refused to eat it. Resident #50 stated he told the staff the first time he got the pureed diet he told the CNA he did not like it and was not going to eat it. Resident #50 stated he does not know why the staff took him off the diet he had in the hospital and stated he was eating better since the staff changed him to mechanical soft diet. Resident #50 stated he felt like his body image changed with the weight loss because his skin just hangs off him now. Resident #50 stated one of the nurses kept telling him she could see he was losing weight because of the changes in his face. Res0ident #50 stated it did not make him feel good when she said that to him. Resident #50 stated he could tell he was losing weight because his legs hurt. Resident #50 stated the staff would bring him a tray and ask if he was going to eat it and if he said I do not know then the staff would immediately take it out of the room. Resident #50 stated he stopped doing physical therapy (PT) and occupational therapy (OT) because he felt too weak and it was getting harder to do. Resident #50 stated he would be sore after therapy because of the weight loss. Resident #50 stated the staff tried to stand him up by the side of the bed and the staff must hold him because he was too weak to stand. Resident #50 stated he cannot sit up in bed by himself because he was too weak. Resident #50 stated he was eating with dentures at first and when it was pureed, I lost so much weight my dentures do not fit now. Resident #50 stated he was eating with dentures at the outside rehabilitation hospital.During an interview on 08/13/26 at 3:11 P.M., Certified Nurse Practitioner (CNP) #120 stated he did skim through Resident #50's discharge instructions from the outside rehabilitation hospital but did not specifically recall the diet order. He usually does not order the diet but signs off on the diet order; he relies on ST to recommend the resident's diet and just signs the order of what the ST recommends. CNP #120 stated he was aware Resident #50 was on a pureed diet and signed the order on it because he was relying on the ST recommendation to be accurate. When SLP #105 recommended the pureed diet for Resident #50, he was not aware it was a downgrade, but he would still go by her recommendation for diet because he trusted the interdisciplinary team. CNP #120 stated he was not aware that Resident #50 had a 14.3 percent weight loss since he had been in the facility. He had not seen the original weight of 138.6 pounds and stated the first weight he had was from 07/27/26 of 122.0 pounds CNP #120 stated the facility only notifies him if there is a significant decrease or gain in weight and they have not notified him of any significant weight loss for Resident #50. The facility did not notify him on 07/06/26 of a severe weight loss for Resident #50. CNP #120 stated it makes sense that Resident #50 does not want to do PT or OT because of the weakness. He did not ask Resident #50 about the weight loss because CNP #120 was not aware of the severe weight loss. CNP #120 stated he would give Resident #50 another three to four weeks from now and Resident #50 should start trending upward in weight given that it truly is a diet issue of not liking pureed or could be longer for weight gain if there are other issues. CNP #120 stated Resident #50's dentures not fitting properly will be an obstacle to re-gaining the weight. CNP #120 stated it sounded like Resident #50 had significantly declined in a month. During an interview on 08/19/26 at 2:40 P.M., Dietary Coordinator #53 stated on 08/18/26, she had met with Resident #50 and updated his food preferences. Dietary Coordinator #53 stated she added foods to all three of Resident #50's meals to include peanut butter and jelly sandwich, pudding and a sliced banana. Dietary Coordinator #53 stated Resident #50 gets a menu daily and usually chooses a grilled cheese sandwich and soup or peanut butter and jelly sandwich and soup. Dietary Coordinator #53 stated she had talked with the RD #103 on 08/19/26 to verify if the add on foods were acceptable. During an interview on 08/19/26 at 3:18 P.M., [NAME] President of Clinical Services (VPCS) #155 stated he directly supervises RD #103. His expectations for the skin and weight assessment team (SWAT) would consist of at the minimum nursing and a dietary member to meet weekly. VPCS #155 stated he would expect the SWAT team to take notes and use those notes from the SWAT meeting to document any interventions or changes recommended for the resident discussed in the resident's medical record. VPCS #155 stated he would expect the weekly weights to be followed and discussed in the SWAT meetings and for SWAT team members to make effective interventions. VPCS #155 stated the changes or recommendations are not always a supplement or medication and the nurses would have suggestions such as resident food preferences for specific residents. During an interview on 08/19/2026 at 3:29 P.M., RD #103 stated she did not remember reviewing Resident #50's weights in the discharge instructions. RD #103 stated the first four weekly weights were to get a baseline weight of the resident and doesn't worry about a weight loss trend because the initial four weekly weights were to establish the baseline weight. The hospital weights do not mean much because there could be several reasons to see a different weight change at the facility. RD #103 stated she does meet with the DON weekly to discuss residents, they do not take notes during the meeting on who they discuss, and she does email DON with resident concerns. RD #103 stated she does sign that she meets with the DON weekly but does not put in a note in the medical records for the residents discussed after the meeting. RD #103 stated she and the DON had d

Based on interview and medical record review, the facility failed to provide adequate monitoring of psychotropic medications for Residents #2, #3, #8, and #10. This affected four (Residents #2, #3, #8, and #10) of five residents reviewed for unnecessary medications. The facility census was 71. Findings include: 1. Review of Resident #2's medical record revealed the resident was admitted [DATE] and had diagnoses that included unspecified dementia, anxiety disorder, bipolar disorder, and depression. Review of Resident #2's Minimum Data Set (MDS) dated [DATE] revealed the resident had severe cognitive impairment. Review of Resident #2's physician orders revealed an order for sertraline (selective serotonin reuptake inhibitor - SSRI) 25 milligrams (mg) by mouth once a morning with a start date of 06/12/26. Review of the care plan dated 06/12/26 revealed Resident #2 used a psychotropic medication with an intervention to observe or report any side effects. Review of Resident #2's progress notes from 05/21/26 to 08/11/26 revealed no evidence of monitoring for side effects of sertraline. Review of Resident #2's Medication Administration Records (MARs) for May 2026, June 2026, July 2026, and August 2026 revealed no evidence of monitoring for side effects of sertraline. Interview on 08/11/26 at 3:44 P.M. with the Director of Nursing (DON) confirmed monitoring for side effects of psychotropics medications is not routinely documented in the medical record. 2. Review of Resident #8's medical record revealed the resident was admitted to the facility 06/26/26. Resident #8 had diagnoses that included unspecified dementia, anxiety disorder, Alzheimer's disease, and depression. Review of Resident #8's MDS dated [DATE] revealed the resident had severe cognitive impairment. Review of Resident #8's care plan dated 09/21/23 revealed the resident used psychotropic medications with an intervention to observe or report any side effects. Review of Resident #8's discontinued physician orders revealed an order for lorazepam (benzodiazepine) 0.5 mg by mouth every 4 hours as needed from 06/12/26 to 06/25/26. Review of Resident #8's MAR for June 2026 revealed the resident received lorazepam 0.5 mg by mouth on 06/19/26 at 1:58 P.M. for pain. Review of Resident #8's active physician orders revealed orders for lamotrigine (mood stabilizer) 150 milligrams (mg) by mouth once a day started 06/29/26; mirtazapine (antidepressant) 15 mg by mouth once a day started 06/29/26; sertraline (SSRI) 150 mg by mouth once a day started 06/29/26; cariprazine (antipsychotic) 3 mg by mouth once a day started 06/29/26; buspirone (antianxiety) 10 mg by mouth three times daily started 07/02/26; and lorazepam 0.5 mg by mouth every 6 hours as needed from 08/10/26 to 08/23/26. Review of Resident #8's progress notes from 05/01/26 to 08/11/26 revealed no evidence of monitoring for side effects of psychotropic medications. Review of Resident #8's MARs for June 2026, July 2026, and August 2026 revealed no evidence of monitoring for side effects of psychotropic medications. Interview on 08/11/26 at 3:44 P.M. with the Director of Nursing (DON) confirmed monitoring for side effects of psychotropics medications is not routinely documented in the medical record. Interview on 08/12/26 at 2:40 P.M. with the DON confirmed lorazepam should not be given for pain. 3. Review of the medical record for Resident #3 revealed an admission date of 12/04/25 with diagnoses of but not limited to acute and chronic respiratory failure with hypoxia, malignant neoplasm of upper lobe, right bronchus or lung, end stage renal disease, chronic viral hepatitis C, type two diabetes mellitus, anxiety disorder, chronic obstructive pulmonary disease, hypertension, depression, chronic diastolic heart failure, hyperglyceridemia, and anemia. Review of the MDS dated [DATE] for Resident #3 revealed the resident was cognitively intact. Resident #3 was receiving an anti-anxiety medication and an antidepressant medication. Review of the care plan dated 12/05/25 for Resident #3 revealed the resident received a psychotropic medication: anti-depressant with interventions to observe/report any effects such as hypotension, tachycardia, nauseas, hallucinations, dry mouth, constipation, blurred vision, sleep disturbances or dizziness, notify doctor as needed and antianxiety with interventions of observe/report any side effects such as: lethargy, posture changes, nausea, slurring, cognition changes, dizziness or unsteadiness to notify doctor as needed, administer medication per physician, and observe and report any adverse side effects. Review of psychiatric visit notes dated 02/06/26, 03/05/26, 04/09/26, and 06/11/26 revealed treatment recommendations to monitor effectiveness and side effects of medications. Review of an order dated 04/10/26 to 08/08/26 for Resident #3 revealed lorazepam 1 milligram (mg) at bedtime on Sunday, Tuesday, and Thursday, target behaviors noted as anxiousness. Review of an order dated 05/11/26 to 08/08/26 for Resident #3 revealed lorazepam 1 mg once a morning on Monday, Wednesday, and Friday, targeted behaviors noted as anxiousness. Review of Resident #3's progress notes dated 07/07/26 to 08/12/26 revealed no documentation showing staff were monitoring for adverse effects of psychotropic medications. Review of an order dated 08/09/26 revealed sertraline 50 mg once a day, no target behaviors noted on order. Review of the MAR and Treatment Administration Record (TAR) dated August 2026 revealed no behavior monitoring for antidepressant and antianxiety medications. Interview on 08/12/26 at 12:16 P.M. Licensed Practical Nurse (LPN) #73 stated there are special instructions on each medication order. LPN #73 was unable to name any adverse effects or specific behaviors for sertraline or lorazepam and stated the facility had not listed the adverse effects or behaviors which needed monitored. LPN #73 verified there are no adverse effects or behavioral monitoring on the MAR or TAR for Resident #3's lorazepam or sertraline. Interview on 08/12/26 at 2:48 P.M. Director of Nursing (DON) stated the nurses and aides look on the resident's profile or the care plan and know what behaviors they are monitoring for each resident. DON stated there is no documentation area for the nurses to document behaviors or adverse effects except by exception in the progress notes. DON verified the adverse effects were noted in Resident #3's care plan but there was no area to specifically document the adverse effects were monitored. 3. Review of Resident #10's medical record revealed an admission date of 07/05/26 with diagnoses that included but were not limited to cerebral infarction with hemiparesis and hemiplegia, anxiety disorder, insomnia and depression. Review of Resident #10's Minimum Data Set (MDS) dated [DATE] revealed the resident had moderate cognitive impairment. Further review revealed she received antianxiety and antidepressant medications during the lookback period of the assessment. Review of Resident #10's psychotropic drug use care plan dated 12/21/23 revealed the resident received antianxiety and antidepressant medications with an intervention to observe/report any side effects. Review of Resident #10's active physician orders revealed orders for alprazolam (used for anxiety) 0.25 mg by mouth three times a day started 02/06/26; Paxil (used for depression) 30 mg by mouth in the morning started 03/06/26, and for trazodone (used for insomnia) 50 mg by mouth at bedtime started 05/08/26. Review of Resident #10's progress notes dated 05/02/26 to 08/07/26 revealed no evidence of monitoring for side effects of alprazolam, paxil or trazodone. Review of Resident #10's MAR for July 2026 revealed no evidence of monitoring for side effects of alprazolam, Paxil, or trazodone. Interview on 08/11/26 at 3:44 P.M. with the DON confirmed monitoring for side effects of psychotropics medications was not routinely documented in the medical record. This deficiency represents non-compliance investigated under Complaint Number 3173858.

Based on record review and staff interview, the facility failed ensure there was accurate pharmaceutical records were maintained for narcotic pain medications administered to residents. This affected two (#30 and #36) of three residents reviewed for narcotic administration. The facility census was 71.Findings include:1. Review of the medical record for Resident #30 revealed an admission date of 04/29/26. Diagnoses included spondylosis with myelopathy, disease of spinal cord, and paraplegia.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #30 had intact cognition and received an opioid pain medication.Review of an physician order dated 05/01/26 for Resident #30 revealed Oxycodone schedule two (II) five milligrams (mg) every six hours as needed.Review of the August 2026 controlled drug receipt count record for Resident #30 revealed on 08/01/26 at 9:30 A.M., 08/10/26 at 10:00 P.M., 08/12/26 at 9:30 P.M., and 08/18/26 at 11:55 P.M., a five mg tablet had been signed out for Resident #30.Review of the medication administration record (MAR) for August 2026 revealed there was no documentation Resident #30 had received Oxycodone five mg on 08/01/26 at 9:30 A.M., 08/10/26 at 10:00 P.M., 08/12/26 at 9:30 P.M., and 08/18/26 at 11:55 P.M.Interview on 08/24/26 at 3:46 P.M. with Registered Nurse (RN) #13 verified the August 2026 controlled drug receipt count record for Resident #30 showed Oxycodone was signed out for Resident #30 on 08/01/26 at 9:30 A.M., 08/10/26 at 10:00 P.M., 08/12/26 at 9:30 P.M., and 08/18/26 at 11:55 P.M. and the MAR for Resident #30 had no documentation of administration to Resident #30 noted. RN #13 stated the August 2026 controlled drug receipt count record for Resident #30 was accurate or the facility would have flagged the Oxycodone for a re-count. RN #13 stated the nurses should not have any distractions and should sign out Oxycodone for Resident #30 on both the MAR and the controlled drug receipt count. Observation and interview on 08/24/26 at 4:03 P.M. revealed the Oxycodone card had nine oxycodone tablets in the prepackaged narcotic card and matched the August 2026 controlled drug receipt count record for Resident #30 which had nine tablets on the amount left. RN #13 and Director of Nursing (DON) both verified the Oxycodone prepackaged card and the August 2026 controlled drug receipt count record for Resident #30 matched at the time of the observation.2. Review of the medical record for Resident #36 revealed an admission date of 07/14/26. Diagnoses included Crohn's disease, osteoarthritis, Rhabdomyolysis, and metabolic encephalopathy. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 had moderate cognitive impairment and received an opioid.Review of the physician order dated 07/27/26 for Resident #36 revealed an order for Tramadol schedule four (IV) 50 milligrams (mg) every six hours as needed.Review of the August 2026 controlled drug receipt count record for Resident #36 revealed on 08/02/26 at 12:00 A.M., 08/09/26 at 7:00 P.M., 08/16/26 at 8:05 A.M., 08/20/26 at 8:20 P.M., 08/21/26 at 8:30 P.M., and 08/23/26 at 8:10 P.M., Tramadol 50 mg tablet had been signed out for Resident #36.Review of the medication administration record (MAR) for August 2026 revealed no documentation Resident #36 had received Tramadol 50 mg on 08/02/26 at 12:00 A.M., 08/09/26 at 7:00 P.M., 08/16/26 at 8:05 A.M., 08/20/26 at 8:20 P.M., 08/21/26 at 8:30 P.M., and 08/23/26 at 8:10 P.M. Interview on 08/24/26 at 3:29 P.M. with Registered Nurse (RN) #13 verified the August 2026 controlled drug receipt count record for Resident #36 showed Tramadol was signed out for Resident #36 on 08/02/26 at 12:00 A.M., 08/09/26 at 7:00 P.M., 08/16/26 at 8:05 A.M., 08/20/26 at 8:20 P.M., 08/21/26 at 8:30 P.M., and 08/23/26 at 8:10 P.M. and the MAR for Resident #36 had no documentation of administration to Resident #36 noted. Observation and interview on 08/24/26 at 4:05 P.M. revealed the Tramadol card had eight Tramadol tablets in the prepackaged narcotic card and matched the August 2026 controlled drug receipt count record for Resident #36 which had eight tablets on the amount left. RN #13 and Director of Nursing (DON) both verified the Tramadol prepackaged card and the August 2026 controlled drug receipt count record for Resident #30 matched at the time of the observation.Review of the facility's policy titled Medication Administration-General Guidelines dated 05/2020 revealed medications are administered as prescribed in accordance with good nursing principals and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's distribution system (procurement, storage, handling, and administration). The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions. The MAR is always employed during medication administration. Prior to administration of any medication, the medication and dosage schedule on the resident's MAR are compared with the medication label.Review of the facility's policy titled Preparation and General Guidelines IIA7: Controlled Medications dated 05/2020 revealed medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and record keeping in the facility, in accordance with federal and state laws and regulations.This deficiency represents non-compliance investigated under Complaint Number 3173858.

Based on observation, interview, and review of the State of Ohio Nurse Aide Training and Competency Evaluation Program Standards and Guidelines, the facility failed to provide complete perineal care per nursing standards of care for one resident. This affected one (Resident #17) of one resident reviewed for bladder and bowel incontinence. The facility census was 71 residents. Findings include:Review of Resident #17's medical record revealed the resident was admitted [DATE]. Resident #17's diagnoses included unspecified dementia, altered mental status, need for assistance with personal care, and other specified urinary incontinence. Review of Resident #17's Minimum Data Set (MDS) dated [DATE] revealed the resident had severe cognitive impairment and was always incontinent of bowel and bladder. Review of Resident #17's care plan revealed a care plan for urinary incontinence with a start date of 06/10/20 and an intervention to provide incontinent care as needed. Observation on 08/12/26 at 10:27 A.M. of perineal care for Resident #17 by Certified Nursing Assistant (CNA) #22 and CNA #19 revealed CNA #22 and CNA #19 performed hand hygiene, donned gloves, and provided privacy. CNA #19 obtained supplies. CNA #19 performed hand hygiene and donned new gloves. With Resident #17 lying supine in bed, CNA #19 cleaned Resident #17's anterior perineal area using a washcloth, soap, and water. CNA #19 used a clean area of the washcloth with each wipe. CNA #19 removed soiled gloves, performed hand hygiene, and donned new gloves. CNA #22 rinsed anterior perineal area using a washcloth and water. CNA #22 removed soiled gloves, performed hand hygiene, and donned new gloves. CNA #19 dried the anterior perineal area. Resident #17 rolled self to the left side. CNA #19 placed an incontinence brief without cleansing the posterior perineal and anal area. Resident #17 rolled to the right. CNA #22 and CNA #19 positioned and secured the incontinence brief.This deficiency represents non-compliance investigated under Complaint Number 3173858.Interview on 08/12/26 at 10:40 A.M. with CNA #22 and CNA #19 confirmed Resident #17's posterior perineal and anal area was not cleansed but should have been during perineal care. The CNAs stated this is normally done but they just did not do it this time. Review of the State of Ohio Nurse Aide Training and Competency Evaluation Program Standards and Guidelines revised 08/17/22 revealed, when performing perineal care, the nursing assistant should work from the cleanest to the dirtiest area (from the urethra to the anal area).

Based on record review, observations, and interviews, the facility failed to ensure a dependent resident was assisted with getting dressed. This affected one resident (#36) of four residents reviewed for activities of daily living. The facility census was 71. Findings include:Review of the medical record for Resident #36 revealed an admission date of 07/14/26 with diagnoses of but not limited to syncope and collapse, dehydration, gastro-esophageal reflux disease, dysphagia, and Crohn's disease, mixed incontinence, osteoarthritis, urinary tract infection, Rhabdomyolysis, metabolic encephalopathy, essential tremor, unspecified fall, chronic kidney disease stage three, major depressive disorder, and unsteadiness on feet. Review of the Minimum Data Set (MDS) dated [DATE] for Resident #36 revealed a Brief Interview for Mental Status (BIMS) score of 12 which indicated moderate cognitive impairment. Resident #36 required substantial assistance with all personal care and required supervision with eating and oral hygiene. Resident #36 had not rejected any care. Review of the care plan dated 07/27/26 for Resident #36 revealed the resident had impaired ability to perform or participate in daily functional abilities. Interventions included offer assistance with clothing choices daily and encourage the resident to dress daily and provide prompting/cueing/assistance as needed with upper and/or lower body dressing. Observation on 08/10/26 at 12:56 P.M. revealed Resident #36 lying in bed wearing a purple shirt which had dried liquid/food on the neckline. Interview on 08/10/26 at 12:56 P.M. Resident #36 stated she had been wearing the same shirt for a couple of days. Resident #36 stated she usually wears a nightgown to bed. Observation on 08/11/26 at 10:04 A.M. revealed Resident #36 wearing the same purple shirt which she was wearing on 08/10/26 with dried liquid/food on neckline. Interview on 08/11/26 at 10:06 A.M. Licensed Practical Nurse (LPN) #73 verified Resident #36 was wearing the purple shirt with dried liquid/food on the neckline. Interview on 08/11/26 at 10:13 A.M. Certified Nursing Assistant (CNA) #38 stated Resident #36 should have been changed into a hospital gown or pajamas for overnight. Interview on 08/11/26 at 10:22 A.M. CNA #37 stated Resident #36 was wearing a purple shirt from yesterday and they were going to change her after breakfast but had not made it in there yet. CNA # 37 stated Resident #36's brief had been changed this morning at 6:30 A.M. but Resident #36 did not get her clothes changed. CNA #37 stated Resident #36 was in the purple shirt when she came into the facility this morning. Review of the facility policy, Dressing and Undressing the Resident, dated 05/01/25 revealed it is the facility's policy to provide assistance with dressing and undressing while maintaining the residents highest level of function the residents condition will allow. Residents who may need some assistance with dressing and undressing include: a resident with limited mobility. Review of the facility job description for CNAs dated 12/01/12 revealed duties to be performed shall include but not be limited to the following: provides all basic care services as required by the resident and provides support in hygiene, grooming, toileting, mobility, and eating. This deficiency represents non-compliance investigated under Complaint Numbers 3173858 and 3070270.

Based on medical record review, interview, and facility policy review, the facility failed to follow correct orders for wound care for a resident with a pressure ulcer. This affected one resident (Resident #03) of three residents reviewed for wound care. The facility census was 64.Findings include:Review of the medical record for Resident #03 revealed an admission date of 12/17/25 with diagnoses of, but not limited to, type two diabetes, paroxysmal atrial fibrillation, and chronic kidney disease.Review of Resident #03's care plan dated 12/29/25 revealed the resident had a pressure injury noted to his right heel. Listed interventions noted to observe the wound for any redness, warmth, drainage, odor, and report to physician as needed, perform current treatment as ordered and see the treatment administration record (TAR) and observe the treatment for effectiveness. An additional care plan focus dated 12/31/25 revealed the resident had a pressure ulcer/injury and was at risk for skin breakdown related to impaired mobility, diabetes, history of cellulitis, incontinence, and history of impaired skin integrity. Listed interventions included a pressure re-distribution cushion to the wheelchair, assisting the resident as needed, and pressure re-distribution mattress to the bed. Review of Resident #03's wound care notes from January 2026 through April 2026 revealed the resident had a stage four (indicating a severe, full-thickness skin injury which involves exposed muscle, tendon, or bone) pressure ulcer on his right heel.Review of Resident #03's physician orders revealed an order dated 01/06/26 for the resident's right heel wound to be cleansed with normal saline or wound cleanser and then for fluffed Mesalt (a sodium chloride dressing used to stimulate the cleansing of discharging wounds) to be applied to the wound and covered with bordered gauze once daily and as needed. The order was discontinued 03/26/26.Review of the wound care note dated 03/19/26 revealed Resident #03 was seen by Wound NP #300 who referenced she would switch the resident's treatment. The new wound care orders for the right heel wound to include cleansing the wound with normal saline, applying a nickel thick layer of Santyl (an ointment used to aid in autolytic debridement of wounds to facilitate healing), followed by calcium alginate and covered with a silicone super absorbent dressing daily and as needed.Review of Resident #03's corresponding wound care orders revealed the order from Wound NP #300 for the right heel would to be cleansed with normal saline and dressed with Santyl, calcium alginate, and covered with a silicone dressing was not transcribed until 03/26/26, one week after the treatment order change was noted by Wound NP #300. Continued review of Resident #03's wound care notes revealed Resident #03 was seen by Wound NP on 04/09/26. The note referenced the ordered treatment no longer included the use of calcium alginate. Review of Resident #03's wound care orders revealed the order dated 03/26/26 for the right heel wound to be cleansed with normal saline and dressed with Santyl, calcium alginate, and covered with a silicone dressing remained active and current at the time of the survey.Interview on 04/16/26 at 2:21 P.M. with the Director of Nursing (DON) confirmed the facility did not timely implement the new orders from Wound NP #300's note dated 03/19/26 for Resident #03.Interview on 04/16/26 at 2:35 P.M. with the Assistant Director of Nursing (ADON) #230 confirmed the facility had continued to apply a dressing containing calcium alginate to Resident #03's right heel despite Wound NP #300 discontinuing it.Interview on 04/16/26 at 3:45 P.M. with Wound NP #300 revealed she was unaware the facility was not following the wound care orders put into place. Review of the undated policy Wound Care revealed it was the facility's policy to provide guidelines for the care of wounds to promote healing. The procedure included to verify there was a physician order put into place for the treatment/procedure.This deficiency represents non-compliance investigated under Complaint Number 2982525.

Based on medical record review, hospital record review, staff interview, and facility policy review, this facility failed to ensure medication was transcribed in a resident's medication administration record as ordered by the physician. This affected one (Resident #66) of the four residents reviewed for medication administration. The facility census was 63. Review of the medical record for Resident #66 revealed and admission date of 02/24/2025 and a discharge date of 02/27/2025. Diagnosis included influenza, chronic pain, acute and chronic respiratory failure with hypoxia, and heart failure.Review of Resident #66 hospital discharge records dated 02/24/2025 revealed all ordered medication was transcribed into this resident's medication administration record correctly other than the order for Ipratropium-Albuterol 0.5-2.5 milligrams (mg)/3 milliliter (ml). The order was to take 3 ml by nebulization (a method of delivering medication in a fine mist or aerosol directly into the lungs) every 6 hours scheduled. Per review of the medication administration record while at this facility, the order was transcribed to be taken every 6 hours as needed and not scheduled. Interview 07/30/25 at 11:52 A.M. with the Director of Nursing (DON) confirmed RESIDENT #66'Ss breathing treatment was not entered into the Electronic Medication Administration Record (EMAR) how it was ordered per the physician. The DON revealed the new admission check off list was completed two days after admission and the error was identified at that time. This was also when the resident addressed it with the DON and she fixed it but Resident #66 left Against Medical Advice (AMA). Review of the facility policy titled Medication Administration-General Guidelines. dated 05/2020 revealed Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. This deficiency represents non-compliance investigated under Complaint Number OH001357353.

Based on observation, interviews, and review of facility policy the facility failed to ensure the kitchen was maintained in a clean and sanitary manner. This had the potential to affect 68 residents of 68 who consumed food from the kitchen. The facility identified no residents who consumed nothing by mouth. The facility census was 68. Findings include: Observation on 02/03/25 from 8:00 A.M. to 8:18 A.M. and on 02/05/25 at 11:30 A.M. revealed the following concerns: a. Package of bacon in the refrigerator was open to air, unlabeled, and undated b. There was a silver cart with two surfaces holding meal trays that were covered in food splatter and food debris. The food splatter also covered the back of the cart. c. Observation of the kitchen revealed under the dishwasher revealed there were tiles missing, broken, and chipped. A large section of missing tiles had a buildup of dirt and dust. The outside of the oven hood and the wall above it revealed it was covered what appeared to be grease stains. The wall next to the oven had dark colored drip stains spanning over most of the wall. e. Observation of the window near the dishwasher area revealed the blinds were covered in dirt and food splatter and were broken in many places. f. Observation of the additional kitchen area revealed multiple places where the flooring was chipped and broken. g. Observation of the ceiling revealed there were food splatters and stains throughout the kitchen. The areas surrounding ceiling vents were covered in dust. Interview on 02/03/25 from 8:00 A.M. to 8:18 A.M. and on 02/05/25 at 11:30 A.M. with Dietary Coordinator #181 verified the observations. Observation on 02/03/25 from 8:00 A.M. to 8:18 A.M. revealed the dishwasher had been run twice and had not met the expected temperature of 180 degrees Fahrenheit. Dietary Coordinator #181 checked the sanitation level following this, and it was also insufficient. Interview on 02/03/25 from 8:00 A.M. to 8:18 A.M. with Dietary Coordinator #181 verified the dishwasher was not meeting the expected temperature of 180 degrees Fahrenheit. He reported they had added chemicals to counteract the temperature being low. Dietary Coordinator #181 verified the sanitation level was not appropriate to sanitize the dishes. Observation on 02/03/25 at 9:12 A.M. revealed the dishwasher was run twice and did not meet the temperature or sanitation requirement either time. Interview on 02/03/25 at 9:12 A.M. with the Dietary Coordinator #181 revealed he believed it had been fixed but verified it was still not running appropriately. Review of the facility policy 'Operation and Cleaning Procedures' dated January 2020, revealed all areas of the kitchen will be cleaned on a daily basis to insure proper sanitation in the operation.

Based on review of employee files, the facility tuberculosis risk assessment, and staff interview, the facility failed to ensure two new employees were tested for tuberculosis. This had the potential to affect all 68 residents. Facility census was 68. Findings include: The tuberculosis risk assessment revealed a baseline skin testing for tuberculosis was performed with two-step tuberculin skin test (TST) for healthcare workers. Healthcare workers were tested upon hire and with exposure. The infection test records would be maintained in the employees file. Review of employee files revealed Staff Coordinator #106 and Activities Coordinator #115 were hired on 08/05/24. Staff Coordinator #106 and Activities Coordinator #115 did not have the two-step TST performed. Interview on 02/06/25 at 12:37 P.M. Staff Coordinator #106 verified a two-step TST was not completed for Staff Coordinator #106 and Activities Coordinator #115.

Based on record review and interview the facility failed to monitor and document on Residents #14, #21, #37, and #53's nutrition status, to implement nutrition interventions as ordered for Resident #37, and to address significant weight changes for Resident's #14, #21, and #53. This affected four residents (#14, #21, #37, and #53) of five residents reviewed for nutrition. The facility census was 68. Findings include: 1. Review of Resident #53's medical record revealed an admitted [DATE] with diagnoses including metabolic encephalopathy, chronic kidney disease, osteoporosis, scoliosis, unspecified dementia, generalized anxiety disorder, type two diabetes mellitus, mood disorder, and depression. Review of Resident #53's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a severe cognitive impairment. Review of Resident #53's plan of care dated 04/04/24 revealed she was at risk for altered nutrition related to altered mental status, diabetes mellitus, hypertension, and osteoporosis. The last weight change mentioned was from June 2024. Interventions included supplements as ordered, offering menu alternatives as needed, monitoring weekly weights for four weeks and then monthly if stable, notifying dietitian and physician of significant weight changes, observing resident labs, reviewing resident skin status, and providing diet as ordered. Review of Resident #53's weight on 05/01/24 revealed a weight of 117 pounds (lbs). Review of Resident #53's progress notes dated 06/19/24 revealed the dietitian made a note on the resident. This was the last dietary note or assessment on Resident #53. Review of Resident #53's weight on 06/10/24 revealed a weight of 107.5 lbs. Review of Resident #53's weight on 07/01/24 revealed a weight of 115.5 lbs. Review of Resident #53's weight on 08/01/24 revealed a weight of 94 lbs. Which was a significant weight loss of 18.6% over one month and 19.6% over three months. Review of Resident #53's medical record from 08/01/24 to 08/31/24 revealed no indication Resident #53's significant weight loss was addressed, and no indications Resident #53 was reweighed. Review of Resident #53's physician order dated 08/19/24 revealed she was admitted to hospice. Review of Resident #53's medical record revealed a nutrition assessment was not completed to address Resident #53's significant change having entered hospice care. Review of Resident #53's weight on 09/01/24 revealed a weight of 93 lbs. This weight was a significant weight loss of 13.2% over three months. Review of Resident #53's medical record from 09/01/24 to 12/02/24 revealed no indication Resident #53's significant weight loss was addressed, and no indications Resident #53 was weighed again. Review of Resident #53's weight on 12/03/24 revealed a weight of 104.5 lbs. This weight was a significant weight gain of 12.3% over three months. Review of Resident #53's medical record from 12/03/24 to 02/03/25 revealed no indication Resident #53's significant weight gain was addressed, and no indications Resident #53 was reweighed. Review of Resident #53's meal intake documentation from 01/01/25 to 02/04/25 revealed there was no documentation of her intake on 01/02/25, 01/03/25, 01/06/25, 01/07/25, 01/08/25, 01/15/25, 01/16/25, 01/17/25, 01/20/25, 01/25/25, 01/27/25, 01/29/25, 01/30/25, 01/31/25, 02/02/25, and 02/03/25. Only one meal's intake was documented on 01/01/25, 01/04/25, 01/13/25, 01/21/25, 01/22/25, and 01/23/25. Only two meal's intake was documented on 01/09/25, 01/10/25, 01/12/25, 01/14/25, 01/24/25, and 02/01/25. Review of Resident #53's physician order dated 01/07/25 revealed an order for a mechanical soft diet. Interview on 02/05/25 at 11:52 A.M. with Regional Nurse Consultant #190 and Registered Dietitian #199 revealed residents were to be seen by the dietitian upon admission, annually, with significant weight changes, and significant changes. Registered Dietitian #199 generates a report through the electronic medical record once a month to identify significant weight changes. Reweighs were to be done on residents with significant weight changes within a week. They verified there were no notes to address Resident #53's significant weight changes or her significant change when she went on hospice. The resident was not weighed anymore due to hospice, she verified this was their policy and not a physician order. Interview on 02/06/25 at 7:49 A.M. with Regional Nurse Consultant #190 verified the inconsistent meal intake documentation for Resident #53. She verified she was unable to find evidence her significant weight changes were addressed. 2. Review of Resident #14's medical record revealed an admitted [DATE] with diagnoses including dementia, acute systolic heart failure, dysphagia, major depression, and osteoarthritis. Review of Resident #14's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she had severely impaired cognition. Review of Resident #14's care plan dated 09/07/23 revealed the resident was at risk for altered nutrition related to the need for long term and memory care and weight above the ideal body weight. Interventions included offering menu alternatives as needed, honoring food preferences as available, monitoring weekly weights for four weeks and then monthly, notify dietitian and physician of significant weight changes, observing resident labs as available, providing diet as ordered, monitoring weights, intake and labs, and monitoring need to adjust the diet and to further supplement. Review of Resident #14's weight on 02/01/24 revealed she weighed 199.2 lbs. Review of Resident #14's weight on 05/01/24 revealed she weighed 204.5 lbs. Review of Resident #14's weight on 08/01/24 revealed she weighed 177 lbs. This was a significant weight loss of 11.1% over six months and 12.4% over three months. Review of Resident #14's medical record from 08/01/24 to 09/02/24 revealed no evidence her significant weight change was addressed or that a reweigh was completed. Review of Resident #14's weight on 09/02/24 revealed she weighed 192 lbs. Which was a significant weight gain of 8.5% over one month. Review of Resident #14's annual nutrition progress note dated 09/03/24 revealed it did not address her previous month's weight loss or her supposed weight gain Her September weight was 192 lbs and the dietitian indicated her weight was stable. Interview on 02/05/25 at 11:52 A.M. with Regional Nurse Consultant #190 and Registered Dietitian #199 revealed residents were to be seen by the dietitian upon admission, annually, with significant weight changes, and significant changes. Registered Dietitian #199 generates a report through the electronic medical record once a month to identify significant weight changes. Reweighs were to be done on residents with significant weight changes within a week. They verified a reweigh should have been done following Resident #14's August 2024 significant weight changes, they additionally verified the dietitian had not monitored the residents nutrition status since September 2024. 37100 3. Resident #21 was admitted to the facility on [DATE]. His diagnoses were end stage renal disease, repeated falls, anemia, hypokalemia, muscle weakness, difficulty walking, type II diabetes, hyperlipidemia, obesity, obstructive sleep apnea, insomnia, anxiety disorder, benign prostatic hyperplasia, hypertension, venous insufficiency, acute respiratory failure, dysuria, chronic kidney disease. Review of his Minimum Data Set (MDS) assessment, dated 11/25/24, revealed he was cognitively intact. Review of Resident #21 weights, dated 11/18/24 to 01/07/25, revealed the following weights and significant changes: 11/18/24 the resident weighted 143 pounds (lbs), on 11/25/24 the resident weighed 199.8 lbs reflecting a 39% weight gain in a week. On 11/28/24 the resident 213 lbs reflecting a seven percent weight gain in three days. On 12/03/24 the resident weighted 201 lbs reflecting a six percent weight loss in five days, on 12/09/24 the resident weighed 178.2 lbs reflecting an 11% weight loss in six days and a 25% gain in twenty one days, and on 01/07/25 the resident weighed 188 lbs reflecting a six percent weight gain in a month and a 31% weight gain in 50 days. Review of Resident #21 progress and nutritional notes, dated 11/18/24 to 01/02/25, revealed only one nutritional note (dated 01/09/25) to reflect significant weight change and/or any interventions to be put in place. There was no hospitalization or health decline related to the significant weight change, but the significant weight changes should have been discussed and addressed timely. Review of Resident #21's current care plan related to nutritional status, revealed the only addressed weight change was on 01/09/25, when it was documented as being a significant weight gain over a one month period. In line with the nutritional progress note, dated 01/09/25, Resident #21 was starting to refuse dialysis (resident choice), and that could have been a contributing factor for his significant weight gain. But other than this one note, the other significant weight changes were not addressed. Interview with Registered Dietitian #199 and Regional Nurse Consultant #199 on 02/05/25 at 11:52 A.M. and 12:00 P.M. confirmed there was no documentation to support re-weights were requested when there was a significant weight change and there was no documentation to support there was discussion about possible interventions for all the significant weight changes. 34298 4. Review of the medical record revealed Resident #37 was admitted on [DATE] with diagnoses that included cerebral infarction, enterocolitis, dysphagia, and epilepsy. A care plan dated 04/05/23 revealed Resident #37 was at risk for altered nutrition. The care plan revealed if Resident #37 ate less than fifty-percent of a meal, a tube feed bolus was to be provided. A physician order dated 05/14/24 revealed Resident #37 was ordered one can (250 milliliters) of Isosource (nutritionally complete formula for dietary management of those undernourished or at risk for malnutrition) if Resident #37 consumed less than 50-percent of a meal provided. On 10/01/24, Resident #37 weighed 245 pounds (lbs). The quarterly MDS dated [DATE] revealed Resident #37 had severely impaired cognition and required partial to moderate assistance for eating. Review of the meal intake documentation from 11/01/24 through 12/04/24 revealed Resident #37 ate less than fifty-percent for 38 meals out of the 94 meals documented. Review of the medication administration record from 11/01/24 through 12/04/24 revealed Resident #37 was not administered Isosource as ordered for less than fifty-percent of meal consumption. On 11/04/24, Resident #37 weighed 244 lbs, on 12/04/24, Resident #37 weighed 228 lbs reflecting a seven percent weight loss in one month. Interview on 02/05/25 at 11:52 A.M. Registered Dietician (RD) #199 verified RD#199 did not write a dietary note for Resident #37 until 01/07/25. Interview on 02/05/25 at 3:39 P.M. Regional Nurse Consultant #190 verified Resident #37 had a weight loss of 16 lbs between 11/04/24 and 12/04/24. Regional Nurse Consultant #190 also verified Resident #37 was not administered Isosource as ordered when Resident #37 ate less than fifty-percent of their meal.

Based on medical record review, and interview the facility failed to notify the physician of significant weight changes for Residents #14, #21, and #53. This affected three residents (#14, #21, and #53) of five residents reviewed for nutrition. The facility census was 68. Findings include: 1. Review of Resident #53's medical record revealed an admitted [DATE] with diagnoses including metabolic encephalopathy, chronic kidney disease, osteoporosis, scoliosis, unspecified dementia, generalized anxiety disorder, type two diabetes mellitus, mood disorder, and depression. Review of Resident #53's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a severe cognitive impairment. Review of Resident #53's weight on 05/01/24 revealed a weight of 117 pounds (lbs). Review of Resident #53's weight on 06/10/24 revealed a weight of 107.5 lbs. Review of Resident #53's weight on 07/01/24 revealed a weight of 115.5 lbs. Review of Resident #53's weight on 08/01/24 revealed a weight of 94 lbs. Which was a significant weight loss of 18.6% over one month and 19.6% over three months. Review of Resident #53's medical record from 08/01/24 to 08/31/24 revealed no indication Resident #53's physician was notified of the significant weight change. Review of Resident #53's weight on 09/01/24 revealed a weight of 93 lbs. This weight was a significant weight loss of 13.2% over three months. Review of Resident #53's medical record from 09/01/24 to 12/02/24 revealed no indication Resident #53's physician was notified of the significant weight change. Review of Resident #53's weight on 12/03/24 revealed a weight of 104.5 lbs. This weight was a significant weight gain of 12.3% over three months. Review of Resident #53's medical record from 12/03/24 to 02/03/25 revealed no indication Resident #53's physician was notified of the significant weight change. Interview on 02/05/25 at 11:52 A.M. with Regional Nurse Consultant #190 and Registered Dietitian #199 revealed Registered Dietitian #199 generated a report through the electronic medical record once a month to identify significant weight changes. Registered Dietitian #199 revealed she notified nursing of significant weight changes and they were supposed to notify the physician. Interview on 02/06/25 at 7:49 A.M. with Regional Nurse Consultant #190 verified there was no evidence the physician had been notified of Resident #53's significant weight changes. 2. Review of Resident #14's medical record revealed an admitted [DATE] with diagnoses including dementia, acute systolic heart failure, dysphagia, major depression, and osteoarthritis. Review of Resident #14's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she had severely impaired cognition. Review of Resident #14's weight on 02/01/24 revealed she weighed 199.2 lbs. Review of Resident #14's weight on 05/01/24 revealed she weighed 204.5 lbs. Review of Resident #14's weight on 08/01/24 revealed she weighed 177 lbs. This was a significant weight loss of 11.1% over six months and 12.4% over three months. Review of Resident #14's medical record from 08/01/24 to 09/02/24 revealed no evidence the physician was notified of her significant weight change. Interview on 02/05/25 at 11:52 A.M. with Regional Nurse Consultant #190 and Registered Dietitian #199 revealed Registered Dietitian #199 generated a report through the electronic medical record once a month to identify significant weight changes. Registered Dietitian #199 revealed she notified nursing of significant weight changes and they were supposed to notify the physician. Interview on 02/06/25 at 7:49 A.M. with Regional Nurse Consultant #190 verified there was no evidence the physician had been notified of Resident #14's significant weight changes. 37100 3. Resident #21 was admitted to the facility on [DATE]. His diagnoses were end stage renal disease, repeated falls, anemia, hypokalemia, muscle weakness, difficulty walking, type II diabetes, hyperlipidemia, obesity, obstructive sleep apnea, insomnia, anxiety disorder, benign prostatic hyperplasia, hypertension, venous insufficiency, acute respiratory failure, dysuria, chronic kidney disease. Review of his Minimum Data Set (MDS) assessment, dated 11/25/24, revealed she was cognitively intact. Review of Resident #21 weights, dated 11/18/24 to 01/07/25, revealed the following weights and significant changes: 11/18/24 the resident weighted 143 pounds (lbs), on 11/25/24 the resident weighed 199.8 lbs reflecting a 39% weight gain in a week. On 11/28/24 the resident 213 lbs reflecting a seven percent weight gain in three days. On 12/03/24 the resident weighted 201 lbs reflecting a six percent weight loss in five days, on 12/09/24 the resident weighed 178.2 lbs reflecting an 11% weight loss in six days and a 25% gain in twenty one days, and on 01/07/25 the resident weighed 188 lbs reflecting a six percent weight gain in a month and a 31% weight gain in 50 days. Review of Resident #21 progress and nutritional notes, dated 11/18/24 to 02/01/25, revealed no documentation to support the physician was notified each time there was a significant change. Review of Resident #21 current care plan related to nutritional status, revealed one of the interventions included notifying the registered dietitian and physician if a significant weight change of greater than five percent. Interview with Registered Dietitian #199 and Regional Nurse Consultant #199 on 02/05/25 at 11:52 A.M. and 12:00 P.M. confirmed nursing staff is responsible for notifying the physician when the dietitian tells them there is a significant weight change. They confirmed there was no documentation to support the physician was notified of Resident #21 significant weight changes.

Based on medical record review and staff interview, the facility failed to ensure dependent residents were able to take baths/showers per preference and the facility did not develop a plan/mechanism to address constant bathing refusals. This affected one (Resident #19) of three residents reviewed for activities of daily living (ADLs). The census was 68. Findings Include: Resident #19 was admitted to the facility on [DATE]. Her diagnoses were syncope and collapse, adult failure to thrive, cardiac arrest, anxiety disorder, type II diabetes, drug induced subacute dyskinesia, muscle weakness, need for assistance with personal care, dysphagia, cognitive communication deficit, hypertension, atherosclerotic heart disease, chronic obstructive pulmonary disease (COPD), bipolar disorder, hypokalemia, osteoporosis, hemiplegia and hemiparesis, difficulty walking, congestive heart failure, repeated falls, dehydration, chronic respiratory failure, mood disorder, hyperlipidemia, cerebrovascular disease, epilepsy, suicidal ideations, and pancreatitis. Review of her minimum data set (MDS) assessment, dated 12/08/24, revealed she was cognitively intact. Review of section GG, revealed she needed substantial/maximal assistance for bathing. Review of Resident #19 shower logs, dated 10/15/24 to 02/04/25, revealed documented refusals for all showers/baths offered except for three that were accepted, which were on 10/15/24, 10/29/24, and 11/01/24. A total of 29 baths/showers were offered, and after her acceptance of two showers on 10/15/24 and 11/01/24 and bed bath on 10/29/24, she refused 23 baths/showers in a row that were offered. Also, review of her bath/shower logs, there was documentation that she requested to have a bath/shower the next day, after refusing baths/showers on 11/08/24 and 01/17/25. There was no documentation to support Resident #19 was offered a bath/shower the following day for either. Review of Resident #19 ADL care plan, dated 08/24/23, revealed she is non-adherent with care/services, which included refusing showers/bathing. The interventions for this care plan included: offer resident alternatives when refusals occur and encourage following current physicians orders. There was no documentation to support what alternatives were offered when Resident #19 refused bed baths/showers. Review of Resident #19 progress notes, dated 10/15/24 to 02/04/25, revealed no documentation to support the physician was notified to discuss the constant refusals of baths/showers. There was no documentation to support the physician was contacted to discuss options or if there were changes in her medical condition that would support her refusing baths/showers. Interview with Resident #19 on 02/03/25 at 11:25 A.M. confirmed she does not receive baths/showers as she desires. Interview with Licensed Practical Nurse (LPN) #137 on 02/06/25 at 8:55 A.M. revealed if a resident refuses baths/ADL care, she will be told by an aide, and then she will try another time to get the resident to comply. If the resident continues to refuse, she will document the refusal on the shower logs and try again the next time they are scheduled. She confirmed she does not report the refusals to the Director of Nursing (DON) or to the physician typically. Interview with DON on 02/06/25 at 9:02 A.M. confirmed if a resident refuses showers, the aides will tell the nurse, and the nurse will try again. If the resident continues to refuse, the nurse is to document on the shower sheet the refusal, and then try again at next scheduled time or when resident requests a bath/shower. She confirmed the constant refusals is typically not reported to the physician for review.

Based on medical record review, staff interview, and facility policy review, the facility failed to assess all residents after falls to determine if they remained in the safest environment as possible. This affected one (Resident #21) of five residents reviewed for accidents. The census was 68. Findings Include: Resident #21 was admitted to the facility on [DATE]. His diagnoses were end stage renal disease, repeated falls, anemia, hypokalemia, muscle weakness, difficulty walking, type II diabetes, hyperlipidemia, obesity, obstructive sleep apnea, insomnia, anxiety disorder, benign prostatic hyperplasia, hypertension, venous insufficiency, acute respiratory failure, dysuria, chronic kidney disease. Review of his Minimum Data Set (MDS) assessment, dated 11/25/24, revealed he was cognitively intact. Review of Resident #21 fall risk assessment, dated 11/18/24, revealed a score of one, which indicated he was not a fall risk. There were no other fall risk assessments completed after 11/18/24. Review of Resident #21 Event Reports, dated 11/19/24 to 01/23/25, revealed a total of four unwitnessed falls; which were on 11/19/24, 11/24/24, 01/15/25 and 01/23/25. Review of each of the fall reports revealed that Resident #21 was found on the floor of his room all four times and the falls were unwitnessed. There were no new fall risk assessments completed after any of the four falls to determine if Resident #21 was at risk for falls or to find underlying causes for his falls. Interview with Regional Nurse Consultant #190 on 02/06/25 at 10:37 A.M. confirmed there were no other fall risk assessments completed after his four falls from 11/19/24 to 01/23/25. Interview with Director of Nursing (DON) on 02/06/25 at 11:11 A.M. confirmed Resident #21 has fallen four times in the last two months. She stated the facility felt like first two falls were related to a new environment for him, so they were going to monitor him a little closer. Then, his two falls on 01/15/25 and 01/23/25, she felt it was related to his refusals to go to dialysis. When asked if she felt those were deemed to be changes in condition, she stated they were. When asked if a new fall risk assessment could have discovered that Resident #21 was a risk for falls (different than his existing fall risk assessment), she confirmed that also. Review of facility Fall Prevention policy, undated, revealed it is the facility policy to maintain the safety of all residents. The facility will assess the fall risk and communicate to the staff. The fall assessment will be completed upon admission, quarterly, with identified significant changes, and annually. The facility will develop a care plan, for the resident based on risk factors from the falls assessment. The facility will identify and communicate residents that are high risk on the resident activity of daily living (ADL) care plan.

Based on interview, and medical record review the facility failed to ensure proper justification for the use of psychotropic medications. This affected one person (#5) of five residents reviewed for unnecessary medications. The facility census was 68. Findings include: Review of the medical record for Resident #5 revealed an admitted [DATE] with diagnoses including rhabdomyolysis, fracture of nasal bones, paroxysmal atrial fibrillation, dysphagia, chronic diastolic heart failure, hemiplegia and hemiparesis affecting left non-dominant side, cerebral infarction, and unspecified dementia. Review of Resident #5's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she had severely impaired cognition. Review of Resident #5's plan of care dated 01/03/25 revealed they received psychotropic medications including antidepressants, antianxiety, and antipsychotic medications. Interventions included monitoring for side effects of antianxiety and antipsychotic medication, administering medication as ordered, encouraging any questions by resident, monitoring for target behaviors, offering non-pharmacological approaches prior to as needed medications, psychological and or psychiatric consult, and physician to review medications. Review of Resident #5's physician order dated 01/03/25 to 01/09/25 revealed an order for Seroquel (an antipsychotic medication) 25 milligrams (mg) once a day for dementia. Review of Resident #5's physician order dated 01/03/25 to 01/10/25 revealed an order for Seroquel 12.5 mg twice a day as needed. There was no diagnosis for the medication indicated. Review of Resident #5's physician order dated 01/10/25 to 01/31/25 revealed an order for Celexa (an antidepressant) 10 mg every day. There was no diagnosis indicated for the medication. Review of Resident #5's physician order dated 01/31/25 revealed an order for Celexa 10 mg every day. There was no diagnosis indicated for the medication, but the target behavior was refusal of care. Review of Resident #5's physician order dated 01/31/25 to 02/03/25 revealed an order for Haloperidol (Haldol) Lactate Solution (an antipsychotic) one mg every day as needed. There was no diagnosis indicated for the medication, but the target behavior was refusal of care. Review of the physician order dated 02/03/25 revealed an order for Seroquel 12.5 mg at bedtime. There was no diagnosis for the medication indicated. Interview on 02/07/25 at 8:59 A.M. with the Director of Nursing (DON) verified diagnoses had not been put in the orders for the antipsychotics and antidepressants ordered for Resident #5. At this time Resident #5 did not have an appropriate diagnosis for antipsychotics and verified dementia was not an appropriate diagnosis for the medications.

Based on observation, interviews, medical record review, and review of facility policy the facility failed to ensure Resident #223's medication was secured appropriately and not left in his room. This affected one resident (#223) of one resident reviewed for accident hazards. The facility census was 68. Findings include: Review of Resident #223's medical record revealed an admitted [DATE] with diagnoses including hallucinations, rhabdomyolysis, spinal stenosis, other epilepsy, alcohol abuse, and atherosclerotic heart disease. Review of Resident #223's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he had intact cognition. Review of Resident #223's physician orders revealed morning medications to be administered from 7:00 A.M. to 11:00 A.M. included acamprosate (psychotropic) delayed release 666 milligrams (mg), cholecalciferol (vitamin)2,000 units, culturelle (probiotic) one capsule, gabapentin (anticonvulsant) 300 mg, levetiracetam (anticonvulsant) 500 mg, multivitamin one tablet, magnesium chloride (supplement) 71.5 mg, thiamine (vitamin) HCl 100 mg, and topiramate (anticonvulsant) 50 mg, The medical record did not indicate the resident could self-administer medications Observation on 02/03/25 at 11:30 A.M. revealed Resident #223 was in bed, in front of him was a medication cup with nine pills in it. He took them out of the cup and laid them on the bedside table, there was no nurse in the room. Interview on 02/03/25 at 11:35 A.M. with Licensed Practical Nurse (LPN) #137 reported she thought he had taken his pills when she gave them to him. At 11:42 A.M. LPN# 137 reported she had gone back in to the room to watch him take the pills and verified they were his morning medications. Review of the policy 'Medication Administration- General Guidelines' dated May 2020, revealed the resident could only self-administer medications when indicated by the physician. Additionally, residents were to be observed after administration to ensure the dose was completely ingested. To detect refusals, the nurse should observe the patient taking and swallowing the medication.

Based on medical record review, observation, and interview the facility failed to ensure Resident #53 was given the diet texture as ordered. This affected one resident (#53) of five residents reviewed for nutrition. The facility census was 68. Findings include: Review of Resident #53's medical record revealed an admitted [DATE] with diagnoses including metabolic encephalopathy, chronic kidney disease, osteoporosis, scoliosis, unspecified dementia, generalized anxiety disorder, type two diabetes mellitus, mood disorder, and depression. Review of Resident #53's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a severe cognitive impairment. Review of Resident #53's progress note dated 01/07/25 revealed the resident had been noted to be pocketing food. hospice was notified and a new order was obtained to downgrade the resident's diet from regular texture to mechanical soft. Review of Resident #53's physician order dated 01/07/25 revealed the resident was to receive a mechanical soft diet. Observation on 02/05/25 of the breakfast meal at 8:18 A.M. revealed Resident #53 eating in her room. She had a sausage patty that had been cut up to be a little larger than quarters. Interview on 02/05/25 at 8:21 A.M. at 10:29 A.M. with Transitional Nurse Specialist #195 revealed she declined to verify. However, she reviewed the physician order that indicated the resident was on a mechanical soft diet and took the resident's diet order. Following this, she reported the kitchen had been updated with the correct diet order. Interview on 02/06/25 at 12:42 P.M. with Regional Nurse Consultant #190 revealed the nurse had never communicated the diet change to the kitchen.

Based on medical record review, staff interview, review of facility contracts, and review of the facility policy, the facility failed to obtain laboratory tests as ordered by the physician. This affected one (Resident #24) of three residents reviewed for laboratory services. The facility census was 66 residents. Findings include: Review of the medical record for Resident #24 revealed an admitted [DATE] with diagnoses including dementia, anxiety disorder, hypertension, hyperlipidemia, atherosclerosis of aorta, urinary tract infection, and mood disorder. Review of the Minimum Data Set (MDS) assessment for Resident #24 dated 10/28/24 revealed the resident had severe cognitive impairment. Review of the progress note for Resident #24 dated 12/09/24 revealed the resident had bilateral edema in her extremities. The nurse contacted the physician and obtained an order for the following stat (immediate) laboratory blood tests: complete blood count (CBC), complete metabolic panel (CMP). Review of the physician's orders for Resident #24 revealed an order dated 12/09/24 for a stat CBC and CMP. Review of the progress note for Resident #24 dated 12/11/24 revealed the lab did not draw the resident's blood. The note did not include documentation regarding why the blood braw was not completed. Review of the physician's orders for Resident #24 revealed an order dated 12/13/24 for a stat CBC and CMP. Review of the laboratory results for Resident #24 revealed a CBC and CMP was completed for the resident on 12/13/24. Review of the physician's orders for Resident #24 revealed an order dated 12/16/24 to obtain an additional CBC. Review of the laboratory results for Resident #24 dated 12/16/24 to 01/07/25 revealed they did not include the CBC which was ordered for the resident on 12/16/24. Interview on 01/07/25 at 11:15 A.M. with the Director of Nursing (DON) confirmed the facility had not ensured the laboratory tests for Resident #24 were completed as ordered. The DON confirmed the lab did not draw Resident #24's blood for the CBC and CMP ordered stat on 12/09/24 until 12/13/24. The DON further confirmed the facility had not arranged for the laboratory to complete the CBC ordered for Resident #24 on 12/16/24. Review of the contract between the facility and the laboratory dated 02/01/18 revealed the laboratory company provided stat service 24 hours per day, 365 days per year. Laboratory stat testing would be reported within five hours. Review of the facility policy titled Lab and Diagnostic Test Results-Clinical Protocol undated revealed the physician would identify and order diagnostic and lab testing based on diagnostic and monitoring needs. The staff should process test requisitions and arrange for the tests. The laboratory, diagnostic radiology provider, or other testing source would report test results to the facility. This deficiency represents noncompliance investigated under Complaint Number OH00161041.

Based on medical record review, facility Self-Reported Incident (SRI) review, video recording review, interviews, and facility policy review, this facility failed to ensure residents were not recorded without their consent or knowledge. This affected one (Resident #300) of the four residents reviewed for respect and dignity. The facility census was 66. Findings include: Review of the medical record for Resident #300 revealed an admitted [DATE] with a discharge date of [DATE]. Diagnoses included burns to the left and right foot, osteomyelitis of the vertebra, sacral, and sacrococcygeal region, and Parkinson's disease. Review of Resident #300's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating an intact cognition for daily decision-making abilities. Resident #300 was noted to experience delusions and rejection of care at times. Review of the facility Self-Reported Incident #252058 dated 09/19/2024 revealed that Stated tested Nursing Assistant (STNA) #20 alleges recording of Resident #300 in the facility's common area. Resident #300 was interviewed and states he didn't recall any said event occurring. Narrative Summary of Incident included: STNA #20 called the Director of Nursing (DON) and stated she was made aware of Resident #300 being recorded. STNA #20 states Resident #300 and the staff member involved was Agency STNA #79 who was not at the facility during the time of the allegations being reported. The staffing agency was immediately contacted to suspend Agency STNA #79 pending investigation. Resident #300 was interviewed and does not recall the event occurring. Resident #300 also confirms he has no issues or concerns with caregivers. Agency STNA #79 states she did record resident and her dancing in the common area but had no ill intent behind recording. She states they were laughing and having fun. Additional staff and residents were interviewed, and no direct witnesses identified. After investigation was completed, the facility determined this allegation of verbal abuse was unsubstantiated. As a result of this investigation, the facility completed the following: As a result of the investigation the facility cannot conclude that abuse occurred. Willful intent to harm could not be verified. While Agency aide acknowledges the allegation occurred, the intention was not to harm the resident. Further, the resident did not suffer any physical harm, pain, or mental anguish. The resident does not recall any incident occurring. Out of precaution, this agency aide was placed on a Do Not Returned list. Review of the facility's investigation revealed an facility completed interview with Agency STNA #79 dated 09/19/2024 at 3:50 P.M. revealed, STNA stated she did record Resident #300 and stated it was an innocent playful moment with no malicious or ill intent. They were dancing in the common area. Per Agency STNA #79, they were laughing and having fun. She did not mean any harm by it. She feels as if he is one of her favorite patients and she was just kidding around and having fun. Agency STNA #79 reiterated on numerous occasions she was by herself, no other staff members or residents were involved. Attempted to call Agency STNA #79 on 10/22/2024 at 2:06 P.M. and again at 3:50 P.M. Phone call went directly to voice mail. A voice message was left for a return phone call but none was received. Interview on 10/22/2024 at 2:48 P.M. with STNA #20 revealed she is friends with someone who is friends with Agency STNA #79 and claimed that her friend showed her the video of Agency STNA #79 and Resident #300 and asked her if this was her work. When she saw Resident #300, she knew right away it was recorded at her work and that was one of her residents. STNA #20 claimed as soon as she saw the video which was on 09/19/2024 she reported it to the DON and an investigation was started. Claimed she could not confirm when the video was recorded but per her knowledge the last time this STNA worked at this facility was around 09/12/2024. Interview on 10/22/2024 at 3:13 P.M. with The DON revealed she received a message from STNA #20 on 09/19/2024 asking her if she was aware of a video recording of Resident #300 that was uploaded to social media by Agency STNA #79. The DON claimed she was not aware of this and an investigation was started immediately. Claimed Agency STNA #79 was suspended from the facility pending investigation and the staffing agency was notified of the incident that occurred. After completing the investigating and interviewing the Agency STNA, the staffing agency was made aware that Agency STNA #79 did record Resident #300. The DON claimed she spoke with this resident on two different occasions to check on his mental and emotional status with no negative findings. Other staff were interviewed to see if something like this had occurred on different occasions with no findings. Staff were interviewed to see if they were aware of this incident with no findings. Agency STNA #79 has not returned and is not permitted to return to this facility. Review of the facility policy titled Videotaping, Photographing, and Other Imaging of Residents, No date noted revealed It is the facility's policy that residents will be protected from invasion of privacy that might occur from the use of resident photographs, videotapes, digital images, and other visual recordings during resident care or other facility activities without the written consent of the resident. This deficiency was an incidental finding identified during the investigation for Complaint Number OH00158324.

Based on medical record review and staff interview, the facility failed to ensure physicians orders were transcribed and blood sugars were obtained as ordered. This affected one (Resident #64) of five medical records reviewed. The census was 62. Findings included: Review of Resident #64's medical record revealed she was admitted to the facility on [DATE] at 2:45 P.M. with diagnoses that included fracture of the right lower leg with surgical repair. anemia, anxiety, laceration of liver, right talus fracture, and diabetes. Review of the hospital transfer order dated 07/05/24 revealed orders for finger stick blood sugars before meals and at bedtime. Review of the facility physicians orders, treatment and medication administration record revealed no documented evidence the orders were transcribed or finger stick blood sugars were obtained. On 08/06/24 at 2:54 P.M., interview with the Director of Nursing verified the order for the finger stick blood sugars sugars before meals and at bedtime was not carried over and or completed. This deficiency represents non-compliance investigated under Master Complaint Number OH00155842.

Based on review of the medical record and staff interview, the facility failed to provide treatment as ordered for Resident #62. This affected one resident (#62) out of three residents reviewed for wound care. The facility census was 60. Findings include: Review of the closed medical record revealed Resident #62, was admitted on [DATE] and discharged to the hospital on 05/06/24 with diagnoses including infection following a procedure, chronic respiratory failure, type II diabetes, cellulitis of left lower limb, and chronic kidney disease. Review of the after-visit summary revealed Resident #62 was at the hospital from 04/27/24 through 05/02/24 for a postoperative wound infection. The hospital discharge orders revealed Resident #62 was ordered a wound vacuum system to the left upper anterior thigh/groin to be changed every Monday and Thursday for two weeks. A contact layer such as an oil emulsion gauze was to be placed at the base of the wound followed by black foam. The wound vacuum was to be at 125 millimeters of mercury (mmHg) with continuous low suction. A progress note dated 05/06/24 at 12:00 P.M. authored by Social Worker #117 revealed a meeting was held with Resident #62 and a family member. A family member asked about the wound treatment to Resident #62's groin area. The floor nurse spoke with Resident #62's family. A progress note dated 05/06/24 at 9:11 P.M. authored by an agency nurse revealed Resident #62's family member insisted Resident #62 be sent to the hospital to have the wound to left groin evaluated. Resident #62's wound remained open to air without the wound vacuum placed. Resident #62 was transferred to the hospital. Interview on 06/06/24 at 12:38 P.M. Social Worker #117 revealed Resident #62 had a wound, and a wound vacuum had been ordered. Social Worker #117 was unsure about treatments being provided to Resident #62's wound. Interview on 06/06/24 at 12:44 P.M. with the Director of Nursing (DON) revealed a wound vacuum was ordered on 05/01/24 for Resident #62, but a new process for ordering the wound vacuum had been put in place. The wound vacuum did not arrive and was not available when Resident #62 was admitted on [DATE]. On 05/03/24 the company that supplied the wound vacuum was contacted. The company reported they did not receive the order on 05/01/24. The wound vacuum arrived sometime in the evening on 05/03/24. The DON stated the wound vacuum was scheduled on the treatment administration record (TAR) to be changed on day shift on Mondays, Wednesdays, and Fridays. On 05/03/24 the day shift nurse had marked the TAR that the wound vacuum was not available. The DON verified the wound vacuum was in Resident #62's room but was not applied on 05/03/24, 05/04/24, 05/05/24, or 05/06/24. DON stated an agency nurse that worked day shift on 05/06/24 (Monday) stated they had never applied a wound vacuum, so they did not put the wound vacuum on. DON stated the wound vacuum was not scheduled to be placed on 05/04/24 and 05/05/24 so no one put the wound vacuum in place (the wound vacuum was to be on daily and changed on Mondays, Wednesdays, and Fridays). The DON also verified there was no documentation of an order or treatment being put in place while the wound vacuum was not available. This deficiency represents non-compliance investigated under Complaint Number OH00153812.

Based on observations, review of the medical record, review of staff statements, facility investigation reports, facility policy and staff and resident interviews, the facility failed to provide adequate supervision to prevent elopement of one severely cognitively impaired resident (Resident #1). This resulted in Immediate Jeopardy when Resident #1 exited the facility without staff knowledge on 04/18/19 at approximately 8:30 P.M. The likelihood of serious harm or injury occurred when the severely cognitive impaired resident exited the facility without a destination after sunset and ambulated with rollator walker 0.3 mile away from the facility crossing a four-lane highway before being stopped by a concerned citizen. This affected one (Resident #1) of 36 residents the facility identified as at risk for elopement (Residents#12, #13, #2, #14, #15, #16, #17, #18, #19, #20, #21, #22, #1, #23, #7, #3, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #4, #35, #36, #37, #38, #39, #9, #8 and #10). The facility census was 71. On 04/23/19 at 11:26 A.M., the interim Licensed Nursing Home Administrator (LNHA) was notified that Immediate Jeopardy began on 04/18/19 at 8:30 P.M. when Resident #1, who had a [DIAGNOSES REDACTED]. Resident #1 was able to tell the concerned citizen his name but did not know where he lived. The Immediate Jeopardy was removed on 04/23/19 at approximately 12:00 P.M. when the facility implemented the following corrective actions: · On 04/18/19 at approximately 8:55 P.M., State tested Nursing Assistant (STNA) #104 and STNA #106 picked up Resident #1 from the parking lot of a car dealership and brought him back to the facility. Resident #1 was immediately assessed and placed on direct 1:1 supervision. There were no injuries found and a headcount was completed of all residents. All residents were present in the facility. · On 04/18/19 at approximately 9:00 P.M., the physician was notified, and a new order was received to place Resident #1 on the secured Memory Care unit. In addition, fifteen-minute checks were ordered for 24 hours to monitor Resident #1 for exit seeking behaviors. At approximately 9:02 P. M, Resident #1 was moved to the secured Memory Care unit and fifteen-minute checks initiated. · On 04/18/19 at approximately 9:10 P.M., all door alarms were checked and were functioning as designed. The magnetic locks and key pad exit devices were also working appropriately. · On 04/19/19 an investigation was completed by the Director of Nursing (DON). Statements were taken from staff and one resident witness (Resident #8) was interviewed. · On 04/19/19 Resident #1's care plan was reviewed and updated by the Minimum Data Set (MDS) 3.0 nurse and Memory Care unit coordinator to include elopement risk and placement on the secured Memory Care unit. · On 04/19/19 at 3:00 P.M., all current residents were reassessed for elopement risk by the Memory Care unit coordinator and the Assistant Director of Nursing (ADON). · On 04/23/19 at 12:00 P. M, all facility staff were in-serviced by the DON on facility policies regarding elopement and supervision of residents. · On 04/23/19 the Quality Assurance and Performance Improvement (QAPI) committee met to review and approve the action plan. · On 04/23/19 at 6:00 P.M., a new sign was posted on the entrance/exit door of the facility indicating SAFETY ALERT, Watch that residents don't follow you out this door. Please check with a staff member. Thank you · On 04/25/19 at 11:00 A.M., an elopement book was placed at the receptionist desk in addition to the two nurses' stations. This book included pictures of all residents at risk of elopement. · On 04/25/19 at 11:30 A.M., the front door code was changed by the maintenance director. The maintenance director will change the codes the first Tuesday of each month moving forward. · On 04/25/19 at 2:00 P.M., education was provided to all staff by the DON or designee on the door codes for exiting the facility. · On 04/26/19, letters were sent out in the mail to re-educate visitors. The letters highlighted the importance of ensuring that no resident was exiting behind them. In addition, this same education will be provided to oriented residents quarterly during resident council meetings. · On 04/26/19, the facility initiated audits for the placement of the elopement risk book at the receptionist desk weekly times four weeks then monthly time three months. Audits will be reviewed in QAPI. · Interviews on 04/29/19 from 10:47 A.M. to 12:10 P.M. with Registered Nurse (RN) #11, RN #119, Licensed Practical Nurses (LPN) #109, LPN #108, LPN #118, STNA #110, STNA #111, STNA #112, STNA #113, STNA #114, STNA #115, STNA #116, Maintenance Director #100, Cook #127, Dietary Manager #126, Dietary Aide #124, Housekeeper #125, Lead Receptionist #120, Laundry Aide #123, Social Service Coordinator #122, Activities Coordinator #121 and the Assistant Director of Nursing #107. Each staff member indicated they had been provided education within the past week regarding the security of the front door. They were each given a new code for the door and told that they should only give the code to alert and oriented residents, visitors and family members. If they were unfamiliar with a resident's cognitive status, they should check with another staff member about that resident's current status (preferably a nurse or the receptionist). Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action plan including conducting in services for as needed staff and monitoring to ensure on-going compliance. Findings include: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a comprehensive assessment dated [DATE] revealed Resident #1 had severe cognitive impairment. Review of Resident #1's care plan initiated 02/25/19 indicated Resident #1 had been assessed and observed and had impaired mobility, was at risk for falls, was a recent admit, needed to adjust to the facility, had poor safety awareness and was non-compliant with care. Interventions included educating the resident regarding limitations and safety concerns, encourage him to ask for assistance, observe resident for safety, identify for non-compliance with safety issues, observe resident for decline in interests, monitor physical tiredness, encourage resident to activities of interest, report any significant changes in mental status or behavior, try to anticipate needs, provide cueing and redirection and explain all procedures to resident. Review of Resident #1's clinical admission assessment completed on 02/26/19 indicated his short- and long-term memory was intact. He was alert and oriented to self, place and time. He was chairfast and his ability to walk was severely limited or non-existent. He could not bear his own weight and/or had to be assisted into a chair or wheelchair. He had a history of [REDACTED]. He was a low risk for elopement and wandering. Resident #1's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #1 had severe cognitive impairment and he required limited assistance of one staff person for walking in the corridor and supervision for walking in the room. A nursing progress note dated 04/18/19 at 8:50 P.M. and authored by the DON indicated Resident #1 had been noted outside of the facility. Resident #1 had been assisted back into the facility per the STNA. Resident #1 had been very cooperative and was moved to the Memory Care unit and placed on fifteen-minute checks for 24 hours. A skin sweep was completed with no areas noted. The Power of Attorney for Resident #1 was made aware of the incident and agreed with the move. The Nurse Practitioner was notified and gave the order to transfer Resident #1 to the secured Memory Care unit. Resident #1 was oriented to the Memory Care unit and introduced to the staff. There were no signs or symptoms of distress. Review of Registered Nurse #5's statement regarding Resident #1's elopement dated 04/18/19 revealed Resident #1 had been sitting on the couch in the lobby area near the front door at 8:40 P.M. watching a movie with another resident (Resident #8). The investigation indicated this was verified by statement made by STNA #104 on 04/18/19 (no time indicated). At 8:50 P.M. a lady phoned the facility about a resident being outside at a car dealership, (approximately 0.3 miles from the facility). She stated she had a gentleman with her at the car dealership who was identified as Resident #1. At 9:00 P.M. STNA #104 and STNA #106 drove to the car dealership and brought Resident #1 back to the facility. He was assessed, and a skin sweep revealed no open areas and it was determined there was no harm. Resident #1 was taken to the secured Memory Care unit and fifteen-minute checks were put into place for 24 hours. The physician and family were notified. All facility doors were checked, and a head count was completed with all residents being present in the facility. Review of STNA #104's written statement dated 04/18/19 indicated at 8:40 P.M. she saw Resident #1 in the common area watching a movie with Resident #8. She proceeded into another resident's room and she heard STNA #106 yelling that she needed help. STNA #104 ran to the common area and followed STNA #106 out the front door to her car. At 8:52 P.M. she asked STNA #106 what was going on. She stated she got a call and Resident #1 was at the car dealership. When they arrived at the car dealership Resident #1 seemed to be okay. He was calm, so they assisted him into STNA #106's car and came straight back to the facility and told the nurses. Review of STNA #106's written statement dated 04/18/19 revealed on 04/18/19 at 8:50 P.M. she answered the phone. A lady said she had a gentleman with her at the car dealership by the name of (Resident #1). STNA #106 indicated she went and got him with STNA #104. When they got to the car dealership Resident #1 was cooperative and calm. They assisted him into her vehicle and put the seat belt on him. They returned him to the facility. Review of LPN #109's statement dated 04/18/19 indicated as of 9:23 P.M. on Thursday, (MONTH) 18, her unit had 31 residents present and accounted for which was accurate with the census. All residents had been visualized and location verified for safety purposes with no residents unaccounted for at that time. Observation and interview with Resident #1 on 04/22/19 at 11:32 A.M. revealed he was neatly dressed and well groomed. The resident was seated in a chair in his room in the Memory Care unit. He could not recall going outside the facility. He stated, once you are in, you can't get out. Resident #1 was alert to his name but unaware of the time, day, date or situation. On 04/22/19 at 3:42 P.M. an interview with the citizen who found Resident #1 at the car dealership revealed she, her husband and two children were returning to their home and as they were driving they saw an older man pushing his walker across the highway. She stated luckily all the cars stopped to let him pass. As he walked into the car dealership parking lot she approached him. When asked, he told them his name and when asked where he lived, he pointed in the opposite direction of the facility. He did not have any identification or keys. He said he was tired and sat down on the seat of the walker. According to the woman, believing he might have lived at the nursing home, they phoned the facility at 8:38 P.M. The time was based on her cell phone record. She said the girls who came to get him told her they had just seen him a few minutes ago; however, the woman stated that was impossible as she had been with him at least thirty minutes prior to their arrival. An interview with RN #105 on 04/22/19 at 4:04 P.M. revealed she was at the facility the night Resident #1 eloped from the facility (04/18/19). She stated around 9:00 P.M. the facility received a phone call from a lady who had Resident #1 with her. Two STNAs went to pick him up and he was assessed when he returned. She stated he had some confusion and told her he had been in a parking lot. An interview with Resident #8 on 04/22/19 at 4:17 P.M. revealed she was watching a movie with a man and all the sudden the man who had a wheeled walker got up and left the facility with two other couples. She could not remember anything else. An interview with STNA #106 on 04/22/19 at 4:28 P.M. verified Resident #1 had left the facility without staff knowledge on 04/18/19. STNA #106 received a phone call from a woman at either 8:40 P.M. or 8:50 P.M. The woman said Resident #1 was with her in the parking lot of the car dealership. STNA #106 was not sure when she last saw Resident #1 because they did not document when they checked on residents. She believed it to be at 8:35 P.M. when he was in the lobby drinking coffee. Interview with the DON on 04/23/19 at 4:57 P.M. confirmed a comprehensive assessment dated [DATE] included a brief interview of mental status score of six indicating severe cognitive impairment and the clinical admission assessment dated [DATE] indicated Resident #1's short- and long-term memory was intact, and he was alert and oriented to self, place and time. The DON indicated Resident #1 had severe cognitive impairment upon admission and the clinical admission assessment dated [DATE] was inaccurate. An interview with STNA #104 on 04/22/19 at 4:58 P.M. verified Resident #1 had left the building on 04/18/19 without staff knowledge and had walked to the parking lot of a car dealership. STNA #104 was assigned to the care of Resident #1 on 04/18/19. She stated Resident #1 and Resident #8 were in the lobby that evening watching a movie. He was wearing sweat pants, a hoodie, ball cap and tennis shoes. She was told by STNA #106 that there was an emergency and she had to go with her. In the car she was told Resident #1 had left the building and walked all the way down to the car lot across the street. She stated they tried to check on residents every two to three hours. Observation on 04/22/19 at 6:39 P.M. revealed Resident #1 walking in the secured Memory Care unit. Resident #1 had a slow, steady gait. He shuffled his feet as he pushed the rollator walker in front of him and his left foot intermittently dragged across the floor. As Resident #1 was walking he looked down at his feet briefly then looked back up to his path of direction. He was slightly hunched over as he leaned into the walker while moving. On 04/23/19 at 12:25 P.M. an observation of the route Resident #1 traversed to get to the car dealership revealed there were no sidewalks. The car dealership was located 0.3 mile away from the facility and across a busy four-lane highway with a posted speed limit of 35 miles per hour. Review of information on weathernetwork.com revealed the temperature was 64 degrees Fahrenheit the night Resident #1 left the facility. Review of the facility's undated elopement and missing resident policy revealed an elopement assessment would be completed upon admission, quarterly and with a change in condition. Staff would promptly report any resident who tried to leave the premises or was suspected of being missing. If an employee discovered a resident to be missing they should determine if the resident was out on an authorized leave and if not authorized to leave, initiate a search. This deficiency substantiates Complaint Number OH 892.

The following survey finding pertains to an incident of past noncompliance that was subsequently corrected prior to this survey. Based on record review and staff interview the facility failed to timely obtain a physician ordered urine analysis (UA) lab study or implement timely treatment for [REDACTED]. Actual Harm occurred when a physician ordered urinalysis was not collected after being ordered on [DATE] because the facility did not have the necessary supplies to obtain the specimen. The resident was subsequently hosptalized on [DATE] and diagnosed with [REDACTED].#1) of three residents reviewed for urinary tract infections. Findings include: Review of Resident #1's closed medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review revealed Resident #1 was discharged to the hospital on [DATE] and did not return to the facility. Record review revealed a plan of care, dated 07/13/18 indicating Resident #1 was marked as not applicable for being at risk for complications related to infections. However, the plan of care included interventions to obtain labs and cultures as ordered by the physician or nurse practitioner. Record review revealed on 07/19/18 a physician order [REDACTED]. A second order was received on 07/24/18 for a UA C&S. The urine specimen was noted to have been obtained on 07/25/18. Review of the Medication Administration Record [REDACTED]. A review of the UA C&S test results, dated 07/25/18 revealed Resident #1 had a urinary tract infection [MEDICAL CONDITION] that was positive for Escherichia coli (E Coli), a bacteria commonly found in lower intestines. Sensitivity testing revealed the bacteria was resistant to the antibiotic [MEDICATION NAME] and susceptible to the antibiotic [MEDICATION NAME] ([MEDICATION NAME]). A review of the physician's orders [REDACTED]. Review of the nursing progress notes from 07/19/18 through 07/29/18 revealed no evidence the physician was notified of the 07/19/18 UA C&S not being completed. A review of the Minimum Data Set (MDS) 3.0 assessment, dated 07/25/18 revealed Resident #1 exhibited impaired cognition. The resident was also assessed to require extensive two-person staff assistance for transfers, total dependence on one staff for locomotion, and was assessed to be incontinent of bowel and bladder. Continued review of nursing progress notes revealed on 08/02/18 and 08/03/18 nursing staff documented a decline in Resident #1's condition. On 08/04/18 Resident #1 was transferred to the hospital for shallow breathing, irregular heart beat and minimal response to pain stimuli. A review of hospital documentation revealed Resident #1 was diagnosed with [REDACTED]. An interview on 10/10/18 at 4:05 P.M. with Physician #7 revealed he did not recall ever being notified by the facility staff that the UA C&S ordered for 07/19/18 was not obtained as ordered. An interview on 10/10/18 at 1:50 P.M. with the Director of Nursing revealed Resident #1's 07/19/18 UA C&S was not obtained due to the absence of laboratory urine collection cups. The DON also verified the lack of timely treatment for [REDACTED]. Review of the facility's corrective action revealed the following actions were implemented and the deficiency corrected as of 08/09/18: Following the incident, the medical director was notified. All residents' lab orders were reviewed on 08/08/18 to ensure they were scheduled. Labs identified that were not scheduled were corrected and drawn on 08/09/18. The physician was notified. Resident #1's family was notified of the incident. Audits were initiated to ensure labs were drawn, as follows: five residents to be audited two times a week for four weeks, then five residents weekly for four weeks, then five residents twice a month for a month, then once a month for one month. Education was completed on 08/08/18 with nursing staff regarding early signs of infection/sepsis, ordering lab supplies, and collecting UA as ordered. All residents were reviewed to identify signs and symptoms of infection, none were found. All residents with current infections were reviewed for appropriate antibiotics and improvement of signs and symptoms. An inventory of lab supplies was completed to ensure supplies were readily available when needed. Audits were initiated to ensure appropriate antibiotics were given and the resident had no signs and symptoms [MEDICAL CONDITION]. Audits as follows: residents with current infections will be audited weekly for four weeks, then twice a month for one month, then monthly for two months. Audits were also initiated to ensure supplies were in the facility when needed. Audits as follows: weekly for four weeks, then twice a month for one month, then monthly for two months. This deficiency substantiates Complaint Number OH 336.

Based on observation, closed record review, facility staff interview, and facility investigation review, the facility failed to ensure fall interventions were functioning for one resident (Resident #66) assessed to be at risk for falls. This resulted in actual harm when Resident #66 fell out of bed, the alarm did not sound, and Resident #66 layed on the floor in close proximity to baseboard heating unit causing first and second degree burns requiring emergency unit treatment. This affected one resident of three residents reviewed for falls. Findings include: Review of Resident #66's closed record revealed the resident was [AGE] years old and was admitted to the facility on [DATE] with medical [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 dated 01/07/17 revealed the resident had severe memory impairment and required extensive assist of two staff with care and a mechanical lift for transfers. Resident #66 was identified as a fall risk. Review of the fall risk care plan originally dated 05/10/16 revealed Resident #66 was at risk for falls related to dementia, poor communication, gait/balance problems, incontinence, fall history, dementia, psychosis, and the need for a mechanical lift for all transfers. A bed alarm to alert staff to unassisted bed transfers at all times was initiated on 06/01/15. A review of the March, 2017 treatment administration record (TAR) revealed an order to check the bed alarm placement and functioning every shift. A further review of the TAR revealed the bed alarm was documented as being checked on dayshift on 03/13/17 but no documentation the alarm was checked on the night shift. A review of the nurses' note dated 03/13/17 at 3:05 A.M. revealed the nurse Licensed Practical Nurse (LPN) #87 was called to Resident #66's room by State tested Nurse Aide (STNA) #68. The resident was on the floor next to the operational base board heating unit. LPN #87 and STNA #68 moved Resident #66 away from the base board heating unit and the resident was found to have a large red area on the left hip. LPN #87 and STNA #68 returned the resident to bed using the mechanical lift. There was no documentation the resident's alarm was sounding at the time of the fall. The physician was notified of the injury and prescribed silvadene cream. A nurses' note dated 03/13/17 at 9:55 A.M. revealed the resident's daughter wanted the resident sent out to the hospital for evaluation of burns. The resident was transported by ambulance to the local hospital at 7:50 A.M. A review of the Emergency Department Record (EDR) dated 03/13/17 revealed Resident #66 was brought by ambulance to the Emergency Department (ED) to be evaluated for burns on 03/13/17 at 8:40 A.M. The EDR further stated the resident was evaluated by the ED physician and was diagnosed with [REDACTED]. Skin is red and painful without blistering) and second degree (burns are more serious and involve the deeper layers of skin; red, painful and with blisters. Scarring may result from second degree burns) burns to the left hip area. The ED physician prescribed Silvadene cream to be put on the burns twice daily and Percocet (pain medication) to be given as needed for pain. A review of the wound progress record dated 03/13/17 at 2:50 P.M. revealed Certified Nurse Practitioner (CNP) #200 evaluated the resident's burns. The note further revealed five (5) separate areas of blisters. luster #1 measured 6.0 centimeters (cm) by 2.5 cm. Cluster #2 measured 3.0 cm by 1.5 cm. Cluster #3 measured 5.0 cm by 3.0 cm. Cluster #4 measured 4.5 cm by 3.5 cm. and cluster #5 measured 4.0 cm by 1.5 cm. A review of the facility investigation dated 03/14/17 revealed a written statement from the LPN #87 and STNA #68. Review of the written statement provided by LPN #87 (undated) revealed STNA #68 came and got her to go in to Resident #66's room. LPN #87 noticed a red mark on the resident's left hip along with multiple small blisters. LPN #87 immediately assessed the resident for any other injuries. LPN #87 then left the resident with STNA #68 to call the on-call supervisor who advised her to call the on-call physician (MD #200). MD #200 gave orders for ice to area, as needed Tylenol, x-ray of left hip and Silvadene cream. A review of the phone interview completed on 03/13/17 with STNA #68 revealed that when STNA #68 was passing Resident #66's room she noticed the resident on the floor. The interview further revealed the resident was close to the heater (base board heating unit) but not touching it. STNA #68 put a blanket between the heater and the resident. The statement further revealed that STNA #68 stated it was only 30 minutes at most since she last saw her (Resident #66). The statement did not identify the bed alarm was sounding. A phone interview on 03/21/17 at 11:52 A.M. with STNA #68 revealed that on 03/13/17 she was scheduled to work 3:00 P.M. to 11:00 P.M. and due to a call off she was mandated to work from 11:00 P.M. until 7:00 A.M. STNA #68 stated she had gone to warm up her lunch and decided to do a resident check around 1:30 A.M. when she found Resident #66 on the floor between the bed and the wall. STNA #68 stated she placed a blanket between the resident and the heater and went off the secure unit to find the nurse (LPN #87). STNA #68 returned to the unit with the nurse and after LPN #87 assessed the resident they put the resident back in bed with the mechanical (Hoyer) lift. STNA #68 stated the resident's left hip was red and there were blisters present. STNA #68 revealed that a bed alarm was in place but was not sounding when she entered Resident #66's room. STNA #68 was unsure why the alarm was not sounding. A phone interview on 03/21/17 at 12:08 P.M. with LPN #87 revealed that STNA #68 came to her and was frantic and said she needed to come see Resident #66. LPN #87 stated she entered Resident #66's room and she was on the floor near the heater and a blanket was between the heater and the resident. LPN #87 stated she assessed Resident #66 and found her left hip area was red and had some blisters on it. LPN #87 stated that she touched the heater and her fingertips got burnt. LPN #87 and STNA #68 placed Resident #66 back in bed. LPN #87 confirmed the bed alarm was on and in place but had not sounded when the resident fell out of bed. This deficiency substantiates Complaint Number OH 251.

Based on observation, record review and interview the facility failed to implement interventions to prevent falls for Resident #47, Resident #53 and Resident #84. Harm occurred for Resident #84 when she fell fracturing her wrist, which required surgical repair, as a result of a lack of individualized interventions. Harm occurred for Resident #47 when she fell , fracturing her hip, as a result of a lack of interventions and required surgical intervention. Harm occurred for Resident #53 when she fell , suffering multiple facial injuries, as a result of a lack of appropriately implemented interventions. This affected three residents (Resident #84, Resident #47 and Resident #53) of four residents reviewed for falls. The facility census was 77. Findings include: 1. Review of the medical record revealed Resident #84 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 02/19/14, revealed Resident #84 was severely cognitively impaired with fluctuating inattention and disorganized thinking. She required extensive assistance of two staff for bed mobility, transfers, walk in room and out of room, dressing, toilet use, and personal hygiene and was independent in eating. She had no impairment to either side and normally used a wheelchair or walker. Resident #84 had a fall in the month prior to admission and a fall in the two to six months prior to admission, and suffered a fracture related to a fall in the past 6 months. Review of the Admitting Resident Assessment, dated 02/07/14, revealed Resident #84 was admitted at 12:00 P.M. that day due to a left pelvis fracture and required a two person assist with transfers and ambulation, and was non-weight bearing on the left side. Review of the Fall Risk Assessment, dated 02/08/14, revealed Resident #84 was a high risk of falls. She was assessed as having intermittent confusion, one to two falls in the past three months, chair-bound, to have balance problems while standing and walking, decreased muscular coordination, and required use of an assistive device for mobility. She was also assessed as receiving medications and having [DIAGNOSES REDACTED]. Review of the fall care plan, dated 02/21/14, revealed Resident #84 was at risk for falls related to a previous history of falls and decreased mobility. Interventions included, but were not limited to, assess for additional fall risk factors, report incidence of falls to physician and family, toilet with assistance, check and change, provide a wheelchair, and remind the resident of safety awareness. No individualized interventions were noted on the care plan on admission until after her fall. Review of an acute visit nurse practitioner note, dated 02/24/14, revealed Resident #84 was experiencing an increase in delusions and confusion. The nurse practitioner wrote there was some concern with the change in confusion from baseline. The plan was to obtain an urinalysis and make a neurology referral. No documented evidence was in the clinical record of those recommendations being completed. Review of the nurse's notes, dated 02/26/14 at 3:15 P.M. revealed Resident #84 was found on the floor of her room in a seated position. She was found next to a recliner, which was noted to be in the reclined position with the footstool out. An abrasion to the left side of the forehead and swelling to the left wrist were noted. Ice was applied to the forehead and the nurse and aide assisted the resident up to the wheelchair and notified the physician. The resident was sent to the emergency room for evaluation. Review of the hospital documentation, dated 02/26/14 revealed Resident #84 was admitted for surgical repair of a left forearm fracture. An x-ray of the left arm revealed comminuted (bone splintered or crushed into numerous pieces) and angulated fractures of the distal radius and ulna (forearm). Review of the facility's Summary of Accident/Incident Investigation, dated 02/26/14, revealed Resident #84 fell from her recliner. The cause of the accident includes a description of when the resident was found after falling, but does not determine a cause of the fall. Interventions put into place at that time were to remove the recliner from the room and place a sensor alarm on the bed and bedside chair. On 03/21/15 at 1:26 P.M., an interview with Registered Nurse (RN) #100 revealed Resident #84 was on the rehab unit on admission on 02/07/14. She revealed Resident #84 fell from the recliner sideways, as she went over the side of the recliner and it was knocked over with her. She stated it appeared as if Resident #84 had been trying to reach for something on the bedside table, which was out of her reach from the chair. RN #100 confirmed Resident #84 had increased delusions and confusion noted two days prior to this fall and that the resident was a high fall risk. She revealed that when any resident is admitted , whether or not they are at a high or low fall risk, the facility puts the same interventions in place, until after a fall, when more individualized interventions are put into place. She confirmed Resident #84 fell without anything other than basic interventions in place to prevent falls, resulting in a fracture of her left wrist that required surgical repair. 2. A review of Resident #47's medical record revealed the resident was admitted to the facility on [DATE] with medical [DIAGNOSES REDACTED]. Review of the fall risk assessment completed on 05/30/14 revealed the resident scored a 14 which was considered high risk. Fall risk assessment completed on 12/02/14 revealed a score of 11 which was also considered high risk. A review of the resident's care plan, dated 05/30/14 revealed a general, non-individualized fall care plan that only included fall interventions such as assess resident for falls, remind resident to use call light and supervise resident while ambulating. The residents fall care plan was not updated until resident had a fall on 01/12/15. A review of the nurse's notes from 10/01/14 to 01/20/15 revealed the resident required supervision with use of a wheeled walker to aide in ambulation. A review of the MDS dated [DATE] revealed resident exhibited moderate cognitive impairment. The assessment revealed the resident required supervision from staff to complete all activities of daily living (ADL). A review of a summary of accident investigation form completed by the facility on 01/12/15 at an unknown time revealed the resident was found laying on left side in the doorway of the bathroom. The resident complained of left hip pain. Resident was then sent out to the emergency room (ER) for evaluation. The summary further revealed the corrective actions put in place to prevent re-occurrence was ring for assistance and remind resident to use walker when ambulating. The resident was admitted to the hospital on [DATE] with a left hip fracture that required surgery to repair. The resident was in the hospital from 01/12/15 until 01/21/15. Resident #47 returned to the facility on [DATE]. Review of the fall risk assessment, dated 01/21/15 revealed the resident was at high risk for falls with a fall risk score of 21. Record review revealed the resident's fall care plan was not updated after the resident returned to the facility with any new interventions. The interventions that remained in place were remind resident to ring for assistance and assess resident for fall risk. A review of the residents MDS dated [DATE] revealed the resident exhibited severe cognitive impairment and was dependent on staff for all ADL care. Review of the Summary of Accident investigation form dated 03/07/15 revealed resident was found on the floor in the hallway. Facility assessed resident to have no injury from the fall. The new fall intervention initiated was to place a sensor on the residents bed and chair. The facility was asked to provide documentation about the fall investigation for the fall on 01/12/15 and 03/07/15 to determine if any interventions in place at the time of fall. No documentation was provided by the facility. An interview on 03/21/2015 at 1:02 P.M. with Stated tested nursing assistant (STNA) #90 revealed Resident #47 was able to get to the bathroom with a walker prior to the fall and fracture on 01/12/15 and after returning from the hospital resident requires two staff assist with bathing, dressing, grooming, toileting and transfer. Review of the STNA flowsheet from October 2014 to current revealed Resident #47 required only supervision from staff to perform ADL's until the resident fell on [DATE] and was sent out to the hospital. After 01/21/15 resident has been totally dependent on staff for all ADL's. A review of the facilities fall policy revealed nursing staff is able to place fall interventions in place if a resident has a fall risk assessment above 10. 3. Resident #53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual MDS 3.0 assessment, dated 07/29/14 revealed this resident had short and long term memory problems, no recall ability and severely impaired decision making skills. The assessment revealed the resident required staff supervision with set up help for bed mobility, transfer, to walk in her room, to walk in the corridor, and and locomotion on the unit. The MDS stated the resident had fallen since the last MDS with no injury. Review of the fall risk assessment dated [DATE] revealed this resident was a high risk for falls. Resident #53's fall risk score was a 19, a score of 10 or more represented high risk. Review of summary of accident/incident investigations for Resident #53 revealed on 07/31/14 this resident was observed standing up from sitting a position on the couch, she began to walk, lost her balance and fell to the floor. The investigation recommended for Physical Therapy to screen for possible therapy evaluation. Review of the Physical Therapy screen dated 08/06/14 revealed the resident was not medically stable at the time and was not appropriate for therapy at that time. The resident would be reassessed when she was medically stable. Review of the rehabilitation initial certification and plan of care for Resident #53 dated 09/12/14 revealed this resident was evaluated on 08/15/14 and Physical Therapy was initiated. Resident #53 received Physical Therapy until 09/12/14 when this resident was discharged from therapy due to the resident's poor cognition as a barrier for therapy and the resident had difficulty following commands. Review of the discharge summary revealed the resident was discharged from Physical Therapy services with a restorative nursing program due to limited progress. The therapist documented the resident required minimum to maximum assist to remain standing, and she could ambulate 25 feet with hand held support with minimum to maximum assistance and had a very slow shuffling gait. Review of the restorative referral dated 09/09/14 revealed the resident required a restorative nursing program for transfers and walking. The resident required no devices, she could ambulate 100 feet with no assistance device, required hand held assistance and use of handrails to walk. Further review of the fall risk assessments completed from 10/23/14 through 02/19/15 revealed the resident was at high risk for falls with a score of 20. Review of Resident #53's plan of care, dated 10/30/14 for risk of fall and injury revealed the goal for this resident was to have no fall related injuries. The interventions listed on the plan of care included the following: Assess for and record any additional fall risk factors, report falls to the physician and family/responsible party, monitor for side affects of any drugs that can cause gait disturbance, orthostatic hypertension, weakness, sedation, fatigue, seizures, syncope, or vertigo. Additional interventions included sensor pad to bed and bed side chair, appropriate foot wear, Physical Therapy consulted if needed, to encourage rest periods, staff to assist resident in sitting in dining room chair, encourage resident to sit on dining room couch, a vision consult, and on 02/02/15 a sensor (pressure) alarm at all times. The plan of care did not address the resident requiring hand held assistance for walking and for staff to assist the resident with transfers. Review of the summary of accidents/incidents, dated 10/23/14 revealed Resident #53 dropped a baby doll and was attempting to pick it up when she lost her balance and fell . The facility attempted an intervention of providing a baby carrier to resident so resident can hold baby and not have to bend down to pick up baby when dropped. On 10/24/14 the resident was attempting to sit in a dining chair. The resident sat down to close to the edge of chair, the chair flipped and the resident landed on her bottom. The identified intervention was for staff to assist resident with sitting in dining chair. The report dated 10/29/14 revealed Resident #53 was attempting to sit down in chair, missed the chair and fell on her bottom. The intervention for this fall was to encourage the resident to sit on couch and staff were to guide resident towards couch when exhibiting signs of wanting to sit down. The report dated 11/28/14 revealed Resident #53 was observed getting up from dining couch, she took a couple steps, lost her balance, fell backwards and landed on her bottom. The only intervention was a vision consult per an Internet healthcare site. Review of the report dated 02/02/15 revealed Resident #53 stood up from a sitting position on the couch with a blanket in her hand and took a step, stepped on the blanket, slipped on the floor, landed on her left side. The report further revealed this resident had a laceration to the left eye area and a skin tear on her palm. The resident was sent to the emergency room . The intervention put into place was a sensor alarm. Review of Resident #53's nursing notes, dated 02/02/15 revealed the nurse witnessed the resident's fall from the dining room couch with a blanket. The note stated the resident had a skin tear to her left palm and a laceration to the left orbital bone. The resident's vital signs were obtained, however there was no mention of a physical assessment of this resident. The note then stated the resident was assisted to the couch by Licensed Practical Nurse (LPN) #26 and an unnamed STNA. The nurse practitioner was notified and ordered the resident sent to the local emergency room for a Computer Tomography (CT) scan. When the resident returned to the facility the laceration above the left eye was treated with Dermabond (a glue type agent used in the place of sutures). Review of the wound/skin care management documentation form revealed on 02/02/15 the laceration above Resident #53's left eye measured 1.8 centimeter (cm) in length by 0.3 cm in width. Left orbital bone laceration with no undermining and healthy skin surrounding the wound. The left palm skin tear measured 1.0 cm in length by 0.5 cm in width. Observation on 03/20/15 at 2:49 P.M. of the blanket Resident #53 slipped on revealed it was a crocheted afghan that had large holes in it where the stitching had come apart. Observation on 03/21/15 at 1:13 P.M. of Resident #53 revealed this resident was seated in a wheelchair, STNA # 74 applied gait belt around the resident's waist. STNA #79 was on the other side of the resident. It took this resident two attempts to stand with the two STNA's assisting her. STNA #74 placed her foot in front of Resident #53's foot to assist her to stand. The two STNA's assisted Resident #53 to ambulate by holding her hands and grasping the gait belt. This resident walked with her knees bent leaning forward and had a very slow shuffling gait. Interview on 03/18/15 at 3:55 P.M. of LPN #26 revealed she witnessed Resident #53's fall. This LPN stated Resident #53 was sitting on the couch and the LPN was at the medication cart in the hallway and the STNA was in the corner of the room with her back to Resident #53. Resident #53 had her blanket, she stood up, stepped on blanket and fell on her face. I got down on the floor with her and saw she had hit her head and there was blood so we called for transport. She was awake and her vital signs were ok. Interview of STNA #21 on 03/19/15 at 3:27 P.M. revealed the resident was walking a little safer before the fall than now. This staff stated before this last fall the resident only had an alarm when she was in bed or in the rocking chair in her room. This STNA stated she did not see the resident fall because she had her back to the resident. This STNA stated the resident now is a one to one staffing when she is walking. Interview of Registered Nurse (RN) #100 on 03/20/15 at 11:03 A.M. revealed Resident #53 had a history of [REDACTED]. This RN confirmed the resident had a physical therapy evaluation and the therapist states she needs hands on assistance This RN went on to say, she did not think Resident #53 needed that level of assistance before this last fall (on 02/02/15). RN #100 stated Resident #53 really needs to be on a one to one with staff, but she did not have the staff to sit with her. She stated she thought since we had the alarm in the bedside chair that would be used in the dining room too. Review of the facility Fall Prevention Protocol, dated 01/01/03, revealed a fall risk assessment was to be completed on all residents on admission and with status changes, and if identified as high risk, the nurse should implement any necessary interventions immediately. Any resident who falls will have an immediate intervention implemented.

Based on observation, staff interview, review of facility self-reported incidents (SRI), facility policy review, and record review the facility failed to ensure Resident #3 and Resident #61 remained free from abuse and mistreatment by staff. Harm occurred when facility staff willfully engaged in an action meant to humiliate Resident #3 and Resident #61 (intentionally taking a video of the residents, who were assessed to be cognitively impaired, singing and distributing the video via the social media Snapchat), resulting in intentional humiliation and psychological harm of residents. This affected two residents (Resident #3 and #61) of six residents reviewed for abuse. Findings include: Review of Resident #3's medical record revealed the resident was admitted to the facility on [DATE] with medical [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 01/19/15 revealed the resident had moderate cognitive impairment with inattention and altered level of consciousness continually present. The resident was assessed to require extensive assistance from two staff members with bed mobility and transferring. The resident also had impairment to the upper and lower extremity on one side of the body. Review of Resident #61's medical record revealed the resident was admitted to the facility on [DATE] with medical [DIAGNOSES REDACTED]. Review of MDS 3.0 assessment dated [DATE] revealed the resident was moderately cognitively impaired related to short and long term memory impairment. The resident also had fluctuating levels of in-attention altered level of consciousness. The resident was assessed to require extensive assistance from two staff members with bed mobility and transferring. Review of a SRI, dated 02/22/15, revealed the facility reported an incident involving Resident #3 and Resident #61. The SRI revealed the facility substantiated an allegation of neglect related to the incident reported. Additional information contained in the SRI revealed someone from the community called in to the facility after being disturbed by a posting on a social media site, Snapchat, of residents from the facility being coached to say "co-co" along with crude slogans across each resident as they were recorded and photographed saying "co-co". The summary of the incident revealed on 02/23/15 the administrator and the unit manager viewed the video which revealed "two residents were taped without consent and placed on a social website for twenty four hours singing inappropriate lyrics along with a banner across the female chest containing degrading words." A review of written statements provided from the facility investigation revealed a statement dated 02/21/15 at 7:00 P.M. from licensed practical nurse (LPN) #66. The LPN revealed he received a call from Witness #2 implicating State tested nursing assistant (STNA) #101 of recording a video with residents singing songs with inappropriate lyrics and inappropriate mocking title which was posted on Snapchat. The director of nursing (DON) was notified at that time. A review of the statement written on 02/22/15 by the administrator revealed STNA #101 was sent home on 02/22/15 at approximately 3:00 P.M. and was suspended pending investigation. A review of the statement written on 02/23/15 by the administrator revealed she viewed the video brought in by Witness #1 which contained Resident #3 and Resident #61 singing "I love co-co" with a crude slogan across Resident #61's chest that read "I got my ho-ho ' s trained". A review of the statement written on 02/23/15 by the DON revealed the DON was informed by LPN #66 on 02/21/15 at 9:30 P.M. after returning LPN #66's phone call. The DON was notified of a video posted on Snapchat which had residents that resided in the facility on it. The DON asked Witness #2 to bring the video in to the facility on Monday morning (02/23/15) and Witness #2 agreed. A review of a social service progress note found in the SRI investigation written on 02/23/15 revealed interviews were conducted with Resident #3 and Resident #61. Resident #3 did not remember singing a song and Resident #61 could not answer any questions. No interviews were found in the investigation from any other residents including Resident #3's roommate. On 03/17/15 at 5:01 P.M., after reviewing the SRI, an interview with the DON revealed she stated that Resident #3 and Resident #61 were videotaped saying "I love co-co". The DON denies any foul language or derogatory terms were used in video. The DON stated the only staff who viewed the video were her, the administrator and registered nurse (RN) #100. An interview on 03/19/15 at 4:14 P.M. with RN #100 confirmed she viewed the video. The RN stated Resident #3 and Resident #61 were saying "I love co-co" and a banner was across Resident #3's chest that said "OMG Ha Ha". RN #100 denied any foul language or derogatory language was used in the video. A telephone interview on 03/20/15 at 10:13 A.M. with Witness #1 revealed STNA #101 posted a video on Snapchat that Witness #1 recorded on another cell phone and then saved to the cell phone. The video contained a male and a female resident singing "I'm in love with the co-co". An interview on 03/20/15 at 10:15 A.M. with LPN #96 revealed he had viewed the video through a company email but did not confirm the email was sent to all staff. When asked what I'm in love with the co-co meant he said it was about cocaine. A telephone interview on 03/20/15 at 10:28 A.M. with Resident #61's son revealed the facility had notified him of the video on 02/22/15, and only told him the resident was recorded lying in bed repeating the statement I love co-co. During the interview, discussion of the mocking nature of the video, revealed he felt the resident would have been embarrassed because she had previously worked as a church secretary for thirty years. A phone interview on 03/20/15 at 10:32 A.M. with Resident #3's son revealed the facility had notified him of a video that was recorded in the dining room with several other residents. During the interview, discussion of the mocking nature of the video revealed he felt the resident would have been embarrassed. On 03/20/15 at 11:49 A.M. the video was viewed by four surveyors after it was emailed to the State agency team member by Witness #1. The video began by showing STNA #101 in her work uniform. The video then flashed to Resident #3, lying in bed with a hospital gown on, with his face turned toward the wall and stated "what". A female voice is heard saying, "say it so everyone can hear it ...I'm in love with the co-co". The resident was observed on the video repeating I'm in love with the co-co with his left hand cupped over his mouth, with a female voice heard laughing in the background. Across the resident's chest was a banner that stated "Hahahhahaha omg" with three laughing emoticons (a representation of a facial that is used in electronic communication to convey the intended tone). The video then flashed to Resident #61 lying in bed with a hospital gown on facing toward the wall saying "I'm in love with the co-co" three times. A banner across her chest stated "Got these hoes trained". An attempt was made to contact STNA #101 on 03/20/15 at 12:43 P.M. via telephone. However, the STNA #101 indicated she did not feel comfortable talking over the phone and refused to answer questions stating "I don't want to incriminate myself". STNA #101 did confirm she completed her shift on 02/21/15 and had worked overtime until 7:00 A.M. on 02/22/15. She further confirmed she was sent home in the afternoon at the beginning of her shift on 02/22/15 and that she had resigned from her position at the facility on 02/23/15. A review of STNA #101's time card from 02/21/15 revealed STNA #101 was on shift from 2:55 P.M. until 07:02 A.M. on 02/22/15. An interview on 03/20/15 at 2:56 P.M. with the DON revealed she thought the time card could be wrong and she wasn't sure if STNA #101 actually worked from 2:55 P.M. on 02/21/15 until 07:02 A.M. on 02/22/15. She further revealed she returned a message left by LPN #66 around 10:00 P.M. because she stated, "I have a life". The DON then stated she wasn't sure if STNA #101 was still on shift at the time she received the call, but the facility wouldn't have sent her home because they hadn't seen the video. The DON further confirmed the only reason STNA #101 was sent home on 02/22/15 prior to providing care to residents was because RN #54 voiced a concern about working with her in relation to the allegation of the video. An interview on 03/20/15 at 3:29 P.M. with LPN #66 confirmed he was the afternoon shift supervisor on 02/21/15 and received a call from Witness #2 stating STNA #101 posted a video on a social media site involving two elderly people and mentioned STNA #101 by name. LPN #66 further revealed he called the DON and left a message on her voicemail, and that STNA #101 was providing care to residents at that time and had volunteered to work an extra shift from 11:00 P.M. until 7:00 A.M. LPN #66 confirmed he did not send STNA #101 home after the allegation was called in by Witness #2 or after speaking with the DON. An interview on 03/21/15 at 4:02 P.M. with the DON and LPN #66 revealed LPN #66 was unsure of what to do regarding the alleged abuse and called the DON for further guidance. The DON revealed she did not send STNA #101 home on 02/21/15 because she didn't know the identity of the residents on the video and didn't feel it was abuse. The DON revealed she wanted to further investigate the situation prior to sending STNA #101 home. An interview on 03/21/15 at 4:20 P.M. with RN #54 revealed she was providing care to residents on 02/21/15 when LPN #66 received the phone call from Witness #2 reporting alleged abuse by STNA #101. She stated she told LPN #66 multiple times to walk STNA #101 out of the facility but LPN #66 stated he wanted to talk to the DON first. RN #54 stated LPN #66 told her that he talked to the DON and was told to leave STNA #101 on the clock and that the DON would investigate later. RN #54 voiced concern to the administrator about the safety of the residents in the facility on 02/22/15 after STNA #101 was clocked in and preparing to provide care for the residents. RN #54 stated she told the administrator the video contained residents being mocked and was concerned about resident's safety, and the administrator told her that she had not been notified of the content of the video. RN #54 further revealed the administrator was scheduled as the manager on duty that day and did not come in specifically to investigate the alleged abuse allegation. A review of the facility abuse policy, dated 12/12/02 and revised on 12/29/11, revealed the seven components to abuse prevention, detection and reporting. The seven components were screening, education, prevention, identification, investigation, protection and reporting. All employees were to be in-serviced annually on abuse. The facility policy on investigation revealed any suspected abuse must be reported to the supervisor and the residents must be safe guarded immediately. An immediate investigation should begin and be thoroughly investigated. Employees suspected of abuse are to be immediately placed on suspension until the investigation is complete. A Google search of the phrase I love co co revealed the first item on the search results is gangster rap video by O.T. Genasis titled I'm in the love with CoCo. The beginning of the video shows a handgun, a roll of one hundred dollar bills, a clear plastic bag containing white powder and a glass of brown liquid on a glass top table. As the video continued it showed black males smoking marijuana, shooting handguns at the screen and exchanging bricks of white powder. This deficiency substantiates Self-Reported Investigation Control Number OH 132.

Based on observation, staff interview and record review the facility failed to comprehensively assess and implement interventions and treatment for [REDACTED]. Harm occurred to Resident #47 when the facility failed to implement pressure relieving interventions to prevent the avoidable decline of a suspected deep tissue injury to an unstageable pressure ulcer. This affected one resident (Resident #47) of three residents who were reviewed for pressure ulcers. Findings Include: Review of the medical record revealed Resident #47 was re-admitted to the facility on [DATE], after having surgical repair of a left [MEDICAL CONDITION]. Additional [DIAGNOSES REDACTED].#47 had developed a suspected deep tissue injury. Review of the Skin Assessment (Braden Scale), dated 01/21/15 revealed Resident #47 was assessed as a low risk for skin breakdown. Review of the Nursing Admission Assessment, on re-admission, dated 01/21/15 revealed Resident #47 did not have any areas of skin breakdown. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 01/28/15 revealed Resident #47 was assessed as severely cognitively impaired. The resident was assessed to be totally dependent on two staff for bed mobility and transfers. Resident #47 was assessed as at risk for developing pressure ulcers, but no current pressure ulcer was coded as present. Resident #47 was coded as having a pressure reducing device for the bed. Review of the MDS assessment, dated 02/18/15 revealed Resident #47 was severely cognitively impaired and required total dependence of two staff for bed mobility and transfers. Resident #47 was assessed as at risk for developing pressure ulcers, but no current pressure ulcer was coded as present. Resident #47 was coded as having a pressure reducing device for the bed as the only pressure reducing intervention coded on the assessment. Review of the admission physician's orders [REDACTED]. There was no evidence of any pressure relieving devices that were ordered for Resident #47 upon admission. Review of the nurse's notes, dated 02/05/15 revealed Resident #47 had been seen by the podiatrist and a large fluid filled mushy blister was noted to the left heel. The physician and family were made aware. Review of the physician's orders [REDACTED]. Review of the Wound/Skin Care Management Documentation Form dated 02/13/15 and 02/20/15, revealed there was a blister that was identified on the left heel, that was not identified or staged as a pressure ulcer. The area measured four centimeters (cm) by 5.5 cm with no depth noted. There was no evidence the blister to the left heel noted by the podiatrist on 02/05/15 was placed on a Wound/Skin Care Management Documentation Form to monitor the area. Review of the Wound/Skin Care Management Documentation Form, dated 02/23/15 revealed there was a pressure ulcer to the left heel that was assessed as a suspected deep tissue injury (SDTI). The SDTI measured 3.5 cm by 3.5 cm with no depth noted. Review of the Wound/Skin Care Management Documentation Form dated 03/19/15 revealed there was a SDTI pressure ulcer to the left heel that measured 3.2 cm by 2.1 cm. Review of the Nurse Practioner note, dated 02/16/15 revealed Resident #47 was evaluated for a follow up visit for the blister on the left heel. The area to the left heel was documented as a partially intact clear fluid filled blister to the left heel. The plan was identified as heel boot was to be worn to the left heel unless working with therapy or walking. Review of the nurse practitioner note, dated 02/23/15 revealed the left heel was noted with stable eschar and the surrounding tissue was pink and blanchable. The area was assessed as a SDTI pressure ulcer to the left heel that was documented as stable. Review of the physician's orders [REDACTED]. The area was to be left open to air and the heels were to be floated. Review of the physician's orders [REDACTED]. Review of the physician's orders [REDACTED]. Review of the physician's orders [REDACTED]. Review of the physician's orders [REDACTED]. Wrap bilateral lower extremities with loose ace wraps from the toes to the knees. Remove the ace wraps daily to assess circulation. Review of the nurse practitioner note, dated 03/16/15 revealed assessment of left heel revealed the medial area (of the pressure ulcer) was found with loose dark brown eschar with scant sero-sanguineous drainage. Area assessed as a SDTI and the plan was to change the treatment to Santyl with [MEDICATION NAME] ointment, with an abdominal dressing, and ace wraps. Review of the treatment administration record (TAR) for the month of February 2015 revealed an order dated 02/13/15 to apply skin prep three times a day to the underside of the left heel, leave open to air, and float the heels. There was no evidence of any treatment or pressure relieving device ordered or applied from the time the podiatrist identified the pressure area to the left heel on 02/05/15 until 02/13/15. Review of the TAR for the month of February 2015 revealed there was an order for [REDACTED]. Review of the TAR for the month of February 2015 revealed there was an order for [REDACTED]. Observation on 03/17/15 at 4:51 P.M. revealed Resident #47 was observed with no boot noted to the left foot. Resident #47 was asked if staff had been putting a boot on her left foot and she stated no. On 03/17/15 at 5:05 P.M. interview of registered nurse (RN) #50 revealed Resident #47 had a boot in her room in a drawer. RN #50 then read the physician's orders [REDACTED].#47 was suppose to wear the boot while in the dining room. RN #50 read the physician's orders [REDACTED].#47 was to have the boot removed only for therapy or while ambulating. On 03/17/2015 5:08 P.M. RN #50 verified Resident #47 should have the boot on and put the boot on Resident #47's left foot. On 03/21/15 at 1:50 P.M. observation of the wound to the left heel was completed with the DON and the surveyor, revealed the pressure ulcer had a quarter sized black necrotic area to the left heel, with the remainder of the pressure ulcer covered with a thin layer of slough, with a pinpoint red open area to the center. The area measured at 3.2 cm by 2.1 cm when measured by the nurse practitioner on 03/19/15. Review of the facility undated Skin and Wound Care Guideline revealed a SDTI was described as a purple or maroon localized area of discolored skin or blood filled blister due to damage of underlying tissue that is painful, firm, mushy,boggy, warmer, or cooler as compared to adjacent tissue. An unstageable pressure ulcer was defined as a necrotic wound with full thickness tissue loss in which the base of the ulcer was covered by slough, (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed. Until enough slough and /or eschar was removed to expose the base of the wound, the true depth and therefore stage could not be determined. On 03/21/15 at 2:10 P.M. verified with the DON that Resident #47 had developed a SDTI to the left heel on 02/05/15 and there was no treatment or monitoring of the area until 02/13/15. The treatment ordered on [DATE] for heel boot/protector to be on unless ambulating or with therapy secondary to a blister to the left heel had not been added to the TAR to ensure the orders were completed until 02/19/15. Additionally, confirmed with the DON that the nurse practitioner assessed the wound to the left heel on 02/13/15 and documented the wound as a SDTI. The DON verified that observation of the wound with the surveyor on 03/21/15 at 1:50 P.M. the wound to the left heel had a black necrotic area to the center with slough over the remainder of the wound. The DON verified according to the facility Skin and Wound Care Guideline the pressure ulcer to the left heel would represent an unstageable pressure ulcer which would be a decline in the pressure ulcer from a SDTI to an unstageable pressure ulcer.

Based on observation, medical record review, resident interview, and staff interview, the facility failed to ensure appropriate care and services were provided for skin assessments and pain management. This affected two of three residents reviewed for skin conditions (Residents #8 and #15) and one of two residents reviewed for pain management (Resident #37). The facility identified 28 residents receiving pain management. Harm resulted to Resident #15 when the resident's left heel ulcer was inaccurately assessed. There was no change in treatment after it was determined to be a stasis ulcer, and the facility failed to implement interventions resulting in deterioration of the wound. Findings include: 1. Medical record review revealed Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the wound/skin care management documentation form revealed the following for Resident #15: a. On 01/14/11, the resident was admitted with an unstageable left heel pressure ulcer that measured 0.3 centimeters (cm) length (l) by 1.1 cm width (w) by 0.0 cm depth (d) with the wound bed covered by 100% eschar (black, hard tissue). b. On 06/20/11, the left heel was documented as an unstageable pressure ulcer that measured 0.5 cm (l) by 0.9 cm (w) by 0.2 cm (d) covered with 100% slough (non-viable tissue) with purulent (product of inflammation that contains pus) drainage. No documented change in treatment. c. On 06/27/11, the left heel was documented as an unstageable pressure ulcer that measured 1.5 cm (l) by 2.0 cm (w) by 0.3 cm (d) covered with 100% eschar. Documentation included a new treatment order; however, review of the physician orders [REDACTED]. Review of the ultrasound report dated 04/19/11 revealed Resident #15 had mild to moderate arterial insufficiency/ischemia of both lower extremities. There was occlusion of the left posterior tibial artery. Review of the podiatry examination progress note dated 05/13/11 revealed Resident #15 had no venous, arterial, neuropathic or pressure ulcers of the lower extremities and dorsalis pedis and post tibial pulses on the both extremities was non-palpable to trace. On 07/02/11 at 3:44 P.M., interview with the director of nursing stated the podiatrist assessment of Resident #15 was inaccurate due to ulcers present. Review of nurse care practitioner progress note dated 05/23/11 revealed Resident #15 had a vascular heel ulcer and debridement was performed. Review of the physician progress notes [REDACTED]. Hospice was appropriate but the daughter has declined. Review of the daily State-tested nurse aide (STNA) flow sheet dated June 2011 revealed no documentation of turning and repositioning 45 out of 90 opportunities. Review of the monthly physician orders [REDACTED]. Resident #15 was observed with heels pressed against the mattress on 06/29/11 at 2:55 P.M., on 06/30/11 at 9:10 A.M., with feet resting on the floor, and on 06/30/11 at 11:54 A.M., with heels pressed against the mattress. Review of the skin condition left heel plan of care dated 06/23/11 revealed an intervention included to prevent pressure to the left heel. Review of the at risk for pressure ulcers plan of care revised 06/23/11 revealed bilateral heels were to be floated (elevated) when in bed. On 06/30/11 at 11:54 A.M., observation with STNA #52 revealed Resident #15 was lying in bed on her back with both heels pressed against the mattress. STNA #52 verified the resident's heels were not floated off the mattress at the time of the observation. On 07/02/11 at 1:20 P.M., phone interview with Nurse Care Practitioner (NCP) #54 stated the documentation in the physician and NCP notes were inaccurate stating the documentation should have stated a stasis ulcer and not a pressure ulcer after April 2011. NCP #54 verified the medical record had no documented evidence of the resident/guardian deferring aggressive treatment of [REDACTED]. 2. Record review for Resident #8 revealed he was readmitted to the facility 05/16/11 with [DIAGNOSES REDACTED]. Resident #8 was interviewed on 06/28/11 at 3:05 P.M. The resident showed the surveyor a large, fading bruise on his lower back extending along his right side. He stated the bruise was likely from a fall. Review of the facility nursing progress notes from 06/08/11 to the current date of 06/30/11 revealed the resident sustained [REDACTED]. There was no documentation in the nursing progress notes of the large bruise on Resident #8's lower back/side. Review of facility falls investigations from the four falls the resident sustained [REDACTED]. On 06/30/11 at 5:00 P.M., interview with the Director of Nursing (DON) revealed staff conduct a weekly skin sweep on the residents and any changes or bruises are documented on the Wound/Skin Care Management Documentation Form. The DON verified on 06/20/11 and 06/29/11 wound sweeps were completed on Resident #8 and there was no evidence on the Wound/Skin forms that any bruising was present. The DON verified all areas of the resident's body were assessed. On 06/30/11 at 5:10 P.M., Unit Manager Licensed Practical Nurse (LPN) #35 and the surveyor observed the large bruise on Resident #8's lower back/side which was faded tan in the center with a light bluish outer ring. LPN #35 verified the bruise. Review of current physician orders [REDACTED]. Review of the plan of care for Resident #8 related to the use of the anti-coagulant medication and being at risk for bleeding (dated 05/19/11) revealed approaches incuded assess for any negative outcomes on anti-coagulant drug use and assess for signs and symptoms of bleeding. Review of Resident #8's plan of care for skin condition, dated 05/16/11 revealed approaches incuded assess for and record changes in skin status and complete the skin condition report at least weekly. 3. Review of the clinical record revealed Resident #37 was admitted on [DATE] with an open area to the coccyx and [DIAGNOSES REDACTED]. The pain assessment dated [DATE] revealed the resident denied pain. There was no further assessment and the rest of the assessment was blank. Review of the Mediation Administration Records revealed the resident received Tylenol 500 milligrams, one tablet for pain on 05/20/11 at 1:30 P.M., again on 05/23/11 at 4:00 P.M., on 06/04/11 at 7:00 P.M., and 06/30/11 at 12:30 A.M. There was no Plan of Care in the clinical record related to pain management, what type of pain the resident experienced or what relieved the pain. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 06/30/11 at 9:30 A.M., interview with Licensed Practical Nurse (LPN) #92 confirmed the above medication was given for pain and there was no documentation of a pain assessment with the reason for the medication or any interventions attempted prior to administration. On 06/28/11 at 6:27 P.M., interview with Resident #37 revealed he did have pain on occasion on his "tail end" that was kind of sore and stated he sometimes takes pain medication for the pain.

Based on observation, clinical record review, staff interview, and interview with the certified nurse practitioner, the facility failed to comprehensively and accurately assess, provide necessary treatment and care to promote healing of two Stage II pressure ulcers. This affected one of two residents reviewed for pressure ulcers (Resident #37). There were two residents identified by the facility as having pressure ulcers. There were 60 residents residing in the facility. Harm occurred to Resident #37 when the facility failed to assess a pressure ulcer and implement interventions for a resident with a pressure ulcer, and the resident developed two Stage II pressure ulcers to the buttocks. Findings include: Review of the clinical record for Resident #37 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. He was admitted with an open area to the coccyx measuring 2 centimeters (cm) length (l) x 2 cm width (w) x 0.1 cm depth (d) and was identified as an abrasion on the admission nurses notes. The record included an Initial Plan of Care (undated) and identified the resident to have impaired skin. Wound, incontinent, and immobile were circled on the plan of care. Pressure ulcer was not circled. The goal included the resident would have no preventable alterations in skin integrity during stay and would show improved skin condition in 14 days. There was no date as to when the 14 days began or when the Plan of Care was initiated. The Plan of Care interventions included pressure relief mattress, turn and reposition per self, chair pad, wound/skin treatment per order, and barrier cream. When the 14-day comprehensive assessment was completed and the Plan of Care was revised it did not include a Plan of Care for the open area to the coccyx. The Minimum Data Set (MDS) assessment, dated 05/07/11, revealed the wound was not classified as a pressure ulcer. The assessment identified the resident as needing extensive assistance of one with bed mobility, yet the Plan of Care directed the resident was to turn and reposition every two hours per self. Review of the Wound/Skin Care Management Documentation form revealed the resident was admitted with an area documented as Type 5 (Abrasion - a wound caused by rubbing or scraping the skin or mucous membrane. May be accompanied by localized [MEDICAL CONDITION], discoloration and/or tenderness. These areas are prone to develop into pressure ulcers). The measurement was 2 cm l x 2 cm w x 0.1 cm d, wound bed 95% granulation, 5% slough, moderate amount of exudate, yellow/brown, no odor, periwound [DIAGNOSES REDACTED], no pain, new order. The wound was measured on 05/02/11 as Type 5, 1.8 cm l x 1.7 cm w x 0.1 cm d, no undermining, 95% granulation, 5% slough, moderate amount exudate serosangionous, no odor, periwound nothing marked, no pain, no order change. On 05/09/11, Type 5, 0.9 l x 0.3 cm w x d none, undermining no, 100% granulation, scant exudate, serosanguineous, no odor, periwound healthy, no pain, no order change. The wound was not measured again until 05/23/11 as Type 5, shearing was written in the stage area, 1.3 cm l x 1 cm w x d none, undermining no, tunneling no, nothing written in the wound bed area, exudate none, odor no, periwound area healthy, no pain, no order change. The area was measured again on 05/30/11 same as 05/23/11. On 06/06/11, Type 5, stage shearing, 1.2 l x 0.7 cm w x 0.1 d, no undermining, no tunneling, wound bed was blank, exudate none, odor none, periwound healthy, pain none, no order change. There were no measurements until 06/20/11: Type 5, stage shearing, 1.5 L x 2.0 W x 0.1 D, no undermining, non tunneling, wound bed blank, exudate none, odor none, pain none, no order change. On 06/21/11 the wound had become two areas now called left and right buttocks. Left buttocks area Type 14 (Open lesion other than ulcers, rashes, cuts - any open lesion not previously classified e.g., fistule, laceration, cancerous lesion or lesion from syphilis) Stage - unstagable 0.6 l x 1 cm w x 0.2 cm d, no undermining, tunneling none, wound bed 95% granulation 5% slough, exudate none, no odor, periwound healthy, pain no, no order change. Right buttocks on 06/21/11 - Type 14, unstagable, 3 cm l x 2 cm w x 0.1 cm d, no undermining, no tunneling, wound bed 95% granulation 5% slough, exudate none, no odor, periwound healthy, pain none, no order change. On 06/25/11 left buttocks, Type 14, unstageable, 0.7 cm l x 2 cm w x 0.2 cm d, no undermining, tunneling none, wound bed 95% granulation and 5% slough, exudate none, odor none, periwound healthy, pain none, no order change. Right buttocks on 06/25/11 Type 14, unstageable, 3.1 cm l x 2 cm w x 0.2 cm d, no undermining, tunneling none, wound bed 95% granulation and 5% slough, exudate none, no odor, periwound healthy, pain none, no order change. Observation on 06/30/11 at 4:30 P.M. of the dressing change revealed on entrance to the room the nurse pulled back the sheet covering the resident. The resident was wearing a brief incontinent pad that was removed and was soaked with urine. There was an incontinent pad under the resident that was soaked with urine, and the fitted sheet was soaked with urine. The resident was rolled to the left and the fitted sheet and incontinent pad was rolled to the middle of the bed to change the bed. The mattress had urine puddled in the center of the mattress that was soaked up by the nurse with a towel. The resident had a shirt on and was wet to his mid back. The fitted sheet was wet from his mid back to his knees. There was no dressing on the open areas to the left and right buttocks. The dressing was not found in the bed. Licensed Practical Nurse (LPN) #61 stated the 7:00-3:00 shift did not report the dressing had fallen off. She stated she had changed it the night before. The right buttocks was measured by the nurse at the time of the dressing change to be 3.5 cm l x 3.5 cm w x 0.1 cm d. The surrounding skin was macerated in an area on the coccyx about the size of a fist. The left buttocks was measured at 0.5 l x 0.3 cm w x 0.1 cm d. The nursing assistant washed the resident, wiped down the mattress, linens were changed and the dressing was applied. The wound was not cleansed with normal saline prior to applying the Allevyn dressing. The resident had a physician's orders [REDACTED]. There was no order to clean the wound with anything prior to applying the dressing. On the June 2011 physician's orders [REDACTED]. The physician's progress notes dated 05/18/11 and 06/22/11 and had checked skin condition was stable with routine nursing care. The certified nurse practitioner progress notes were reviewed for 05/09/11 and 05/23/11 and there was no mention of skin breakdown or pressure ulcers. The pressure ulcer risk assessment was completed on 04/30/11 and the score was 10. A score of eight or greater indicated high risk for skin breakdown. On 07/02/11 at 1:30 P.M., interview with the Certified Nurse Practitioner (CNP) #10 via telephone revealed she had not assessed this wound. She stated she was unable to say if the wound was a pressure ulcer because she had not seen the area. When asked if the physician was aware of the area she stated if he had not documented in the progress notes regarding the wound he probably had not seen the wound. On 06/30/11 at 7:27 A.M., interview with Licensed Practical Nurse (LPN) #35 confirmed the Plan of Care revision for the pressure ulcer was not completed. On 06/30/11 at 8:10 A.M., interview with the Director of Nursing (DON) confirmed there was no change in treatment since admission to the area even though there was no evidence of healing and the wound had declined. She stated the type of ulcer at a 14 means it was an open lesion. The DON was unable to explain what an open lesion was to be classified as. She reported unstagable on the skin grids should have just been blank because it shouldn't be staged. The DON stated that shearing and/or abrasions were not considered pressure even though the back of the skin sheet indicated shearing was a pressure ulcer. She could not explain what type of lesion the resident had if it was not pressure. The DON was not familiar with the back of the form which included the definition of a pressure ulcer is a localized injury to the skin and or underlying tissue usually over a bony prominence as a result of pressure or pressure in combination with shear and/or friction.

Based on medical record review, resident interview, observation, and staff interview, the facility failed to provide incontinence care to a resident and restore as much normal bladder function as possible for a resident who was admitted to the facility continent of bladder. This affected one of two residents reviewed for urinary incontinence of 22 residents identified by the facility as incontinent of bladder (Resident #37). Harm occurred to Resident #37, who was admitted to the facility on [DATE] as continent. The resident was not provided care and services, and the resident become incontinent and developed skin maceration. Findings include: On 06/30/11 at 4:30 P.M., observation with the Licensed Practical Nurse (LPN) #61 of a dressing change for Resident #37 to two Stage II pressure ulcers to the left and right buttocks revealed the sheet was pulled back to expose the resident. The resident was wearing a brief that was soaked with urine. This was removed in order to change the dressing. The resident was rolled to his left side, his shirt was observed to be wet from his mid back and the sheet was wet down to his knees. A cloth incontinent pad that was under the resident and was soaked with urine and the fitted sheet was soaked with urine as well. The mattress had urine puddled under the sheet when the sheet was removed and had to be soaked up with towels by the nurse and wiped clean and dried. This was repeated on the other side of the bed after the resident was rolled to the right side by the nursing assistant. There was no dressing on the resident's Stage II open areas at the time of observation. LPN #61 stated it must have fallen off and stated she had just put it on last night and stated day shift must not have reported it had fallen off. The dressing was not in the brief or the bed. The resident's open area was in contact with the urine. The residents skin peri- wound appeared moist and appeared macerated in an area approximately the size of a fist. Review of the clinical record for Resident #37 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Initial Plan of Care (undated) for impaired skin revealed wound was circled (not pressure), incontinent, immobile was circled. The goal was to have no preventable alterations in skin integrity during stay and the resident would show improved skin condition in 14 days. Interventions included for pressure relief mattress, turn and reposition per self, chair pad, wound/skin treatment per order and barrier cream. A comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident required extensive assistance of one for bed mobility, extensive assistance of two for transfers, limited assistance of one for toilet use, and extensive assistance of one for personal hygiene. Always continent was marked on the assessment, and urinary toileting program was not attempted. A Seven Day Bladder Assessment was started on the admission date of [DATE] at 6:00 P.M. and continued until 05/06/11 at 12:00 P.M. The staff documented every hour whether the resident was continent or incontinent of bladder. The resident's assessment was marked as continent of bladder the majority of the seven days but was incontinent at times. Another record used to record bladder continence (Daily State-tested Nurse Aide Flow Sheet) was reviewed and the resident was recorded as incontinent every shift except one in May 2011 and every shift in June 2011 was marked as incontinent. Review of the Admitting Resident assessment dated [DATE] revealed the resident was marked as continent of bladder. Review of the Daily Skilled Nurses Notes revealed the following: -05/02/11 continent all three shifts -05/03/11 continent all three shifts -05/04/11 continent day shift and evening shift and incontinent on nights -05/05/11 continent day shift and evening shift, night shift was blank -05/06/11 continent all three shifts -05/07/11 continent days and nights and evenings was blank -05/08/11 continent evenings and nights and day shift was blank -05/09/11 incontinent all three shifts -05/10/11 incontinent and continent was marked on all three shifts -05/11/11 a summary marked bladder continence frequently incontinent (daily, but some control present) -05/11/11 incontinent and continent was marked on all three shifts -05/12/11 incontinent and continent was marked on all three shifts -05/13/11 incontinent all three shifts -05/14/11 continent and incontinent all three shifts -05/15/11 continent and incontinent all three shifts -05/16/11 incontinent all three shifts -05/17/11 continent and incontinent all three shifts -05/18/11 nothing marked -05/19/11 incontinent day shift and evening shift -05/20/11 through 05/28/11 all were marked incontinent -05/29/11 continent and incontinent all three shifts -05/30/11 nothing marked -06/20/11 Monthly summary - incontinent (multiple daily episodes). Incontinent at all times at present. -06/23/11 through 07/01/11 all marked incontinent. There was no Plan of Care for bladder incontinence. The resident was admitted continent of urine most of the time. The MDS assessment dated [DATE] indicated the resident was always continent. The current nurses' notes and Daily STNA Flow Records records show the resident was incontinent of urine all the time showing a decline in function from 04/30/11 to 06/30/11. On 07/01/11 at 7:45 A.M., interview with Registered Nurse (RN) #1 revealed if a resident was coded as continent on the MDS assessment, the resident should be continent at all times. She stated she used the nurses' notes to code this but then stated she had helped complete the MDS assessment. RN #1 stated a nurse told her he was continent and she did not use the Bowel and Bladder Seven-Day Assessment to complete the MDS assessment and should have. RN #1 stated the reference date for the MDS assessment was 05/07/11 and the look back period to code urinary incontinence was seven days. She stated by looking at the Bladder Seven-Day Assessment the MDS assessment was coded incorrectly. On 06/30/11 at 8:00 A.M., interview with Licensed Practical Nurse (LPN) #35 revealed the resident was not on a toileting plan. To put a resident on a toileting plan, the nurse would have to report the resident was becoming more incontinent and then she would put the resident on a toileting plan. On 07/01/11 at 8:30 A.M., interview with the Director of Nursing revealed there was no other bladder assessment completed for the resident except the Seven-Day Assessment. She confirmed there was no Plan of Care for bladder incontinence. She stated she didn't feel the resident had a decline in condition because she felt the Bladder Seven-Day Assessment was incorrect. She stated the resident had always been incontinent. She had no explanation as to why the Admission Assessment revealed the resident was continent of bladder, the Daily Skilled Nurses' notes had multiple dates and times it was documented the resident was continent of bladder, and there were monthly summaries completed with the resident marked as continent of bladder. She confirmed the MDS assessment was incorrect. She stated another corporate nurse asked the resident if he was continent and he stated yes. She stated that is how the MDS was coded and not by using the Seven-Day Assessment. She confirmed the resident was not on a toileting plan to restore bladder function. On 06/28/2011 06:21 P.M. and again on 07/01/11 at 10:00 A.M., interview with Resident #37 revealed he was unable to use the urinal himself and it took two people to get him up to the bathroom. He stated the previous night he was incontinent in the bed and a nursing assistant did not change his bed and he had to lie in the bed wet all night. He was unable to remember which staff he reported this to but did state he reported it to staff. This certification deficiency substantiated Complaint Number OH 914.