Every finding on record at Amherst Meadows Skilled Nursing and Rehab

Based on record review, interview and policy review the facility failed to assess and implement treatment for pressure ulcers for Resident #11. This affected one resident (Resident #11) of three residents reviewed for wound care. The facility census was 81.Findings include: Review of the medical record revealed Resident #11 was admitted on [DATE] with diagnosis including diabetes, congestive heart failure, coronary artery disease and an unstageable sacral pressure area. Resident #11 was admitted to the hospital on [DATE] and returned to the facility on [DATE].Review of Resident #11's minimum data set admission assessment dated [DATE] revealed Resident #11 was moderately cognitively impaired and required maximum assistance for all activities of daily living except for eating.Review of Resident #11's care plan revealed impaired skin integrity and required assistance with bed mobilityReview of a progress note dated 09/10/25, authored by licensed practical nurse (LPN) #666, revealed Resident #11 returned from a hospital stay. Further the note stated that a skin assessment was completed by the wound care nurse #563 . The only skin impairment noted was the pre-existing sacral wound.Review of a progress noted dated 09/10/25, authored by the wound care nurse #563, revealed documentation an unstageable pressure area to Resident #11's sacrum. No other areas were noted. This note was struck out by wound nurse #563 as an error on 09/17/25.Review of a late entry progress note dated for 09/10/25 but entered on 09/17/25 and authored by wound nurse #563, revealed documentation of an unstageable pressure area on Resident #11's right heel. Further review revealed wound nurse #563 notified the family, physician, and obtained new orders on 09/10/25.Review of the physician ' s orders revealed a treatment order for a pressure area on Resident #11's right heel was entered on 09/17/25. The order stated to cleanse the right heel with normal saline, apply skin prep, then cover with an abdominal pad, wrap with Kerlix two times a week and as needed. There was no documentation of a treatment order for Resident #11's right heel prior to this date.Review of the September treatment administration record (TAR) for Resident #11 revealed an order for a treatment to Resident #11's right heel was initiated on 09/17/25 and documented as being completed on assigned days.An interview with LPN #666 on 09/24/25 at 5:00 P.M. revealed she did the readmission assessment for Resident #11. Wound nurse #563 told LPN #666 she had completed the skin assessment and there were no new skin issues, only the pressure ulcer on Resident #11's sacrum that he originally admitted with. LPN #666 stated she specifically documented who did the wound assessment because she was documenting another nurse ' s assessment.An interview on 09/25/25 at 10:45 A.M. with wound care nurse #563 revealed upon admission, the floor nurse does a skin evaluation as part of the admission assessment. The next day the wound nurse does a second skin assessment as a double check. The wound nurse back dates her second assessment back to the date of admission because she was trained that way. Further interview revealed the unstageable pressure area to Resident #11's right heel was present upon their return from the hospital. Wound nurse #563 was aware of the pressure area but waited until the Nurse Practitioner. from an outside company came in to assess Resident #11 to get wound orders. Wound Nurse #563 was unable to explain why she documented she had obtained new orders on 09/10/25.An interview on 09/25/25 at 11:00 A.M. with the Director of Nursing (DON) revealed the skin was assessed at the time of admission or return from the hospital. The expectation was that notifications are completed, and orders are obtained at time of discovery of any abnormal findings. The DON also stated documentation was not to be back dated.Review of facility policy titled Pressure Ulcers/Skin Breakdown-Clinical Protocol dated 09/21 revealed the nurse would examine the skin of a new admission for alterations in skin and that they would document and report the findings to the physician.This deficiency substantiates allegations contained in Complaint Number 2617894.

Based on observation, staff interviews, and facility policy review, the facility failed to ensure food was stored in a sanitary manner, dented cans were removed from stock, and dietary staff wore facial hair coverings during food service. This had the potential to affect 78 residents who the facility identified as receiving meals from the kitchen. The facility census was 80. Findings Include: 1. Observation during the initial tour of the kitchen on 03/31/25 at 8:30 A.M. revealed two dented cans of diced potatoes and two dented cans of whole potatoes in the dry storage area can-rack used for stock. An interview on 03/31/25 at 8:45 A.M. with Dietary [NAME] #240 confirmed there were a total of four dented cans in the storage can-rack for use. Dietary [NAME] #240 stated the dented cans should have been removed from circulation stock and returned to the food vendor. 2. Observation during the initial kitchen tour on 03/31/25 at 8:35 A.M. revealed in the walk-in cooler there was the lunch preparation cart with seven uncovered small bowls of pureed peaches sitting on a tray on a middle shelf, with a tray of other deserts on the shelf above the uncovered bowls. An interview on 03/31/25 at 8:45 A.M. with Dietary [NAME] #240 confirmed there were seven uncovered bowls of pureed peaches sitting on the lunch preparation cart in the walk-in cooler. Dietary [NAME] #240 stated the prepared food should have been covered and dated prior to being placed in the cooler for use. Review of the facility's undated policy titled Food Storage revealed for safety, foods should be labeled, covered, and dated when stored. 3. Observation on 04/02/25 at 11:50 A.M. during the lunch meal service tray line revealed Dietary Aide #271 was placing food items, drinks and utensils on the food trays. Dietary Aide #271 did not have any type of covering over his facial hair and beard. An interview on 04/02/25 at 11:55 A.M. with Dietary Manager #390 confirmed Dietary Aide #271 did not have his facial hair and beard covered during food service and tray line for the lunch meal. Dietary Manager #390 stated hair and facial hair should be covered during any food preparation and service.

Based on medical record review, observation, staff interviews, and facility policy review, the facility failed to ensure resident dignity was maintained when personal care was administered for a resident while in the dining room and when a urinary catheter drainage bag was not covered. This affected two residents (Resident #10 and #133) out of two residents reviewed for dignity. The facility census was 80. Findings Include: 1. Review of the medical record for Resident #10 revealed admitted on 06/22/22 with diagnoses including, but not limited to, Alzheimer's Disease, major depression, cerebral palsy, anxiety and muscle weakness. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 had a Brief Interview Mental Status (BIMS) score of 08 indicating impaired cognition. The assessment stated Resident #10 had impairment on one side and required moderate assistance from staff for eating and personal hygiene, and that the resident utilized a wheel chair for mobility. Review of Resident #10's care plan for Activities of Daily Living (ADL) self care performance deficit dated 03/27/23 revealed Resident #10 required staff assistance with self-care tasks and required assistance from one person for eating meals. Resident #10 was to sit at the assistance table in the dining room. An observation on 03/31/25 at 11:33 A.M. revealed Resident #10 was sitting at the dining room table with three fell ow residents when he started wiping his nose with his hands, and Certified Nursing Assistance (CNA) #317 went to assist Resident #10 with wiping his nose. CNA #317 took Resident #10's clothing protector from the table and wiped Resident #10's nose two times, then placed the clothing protector on Resident #10 neck and upper chest to cover Resident #10's clothing. An interview on 03/31/25 at 11:45 A.M. with CNA #317 confirmed CNA #317 had assisted Resident #10 with wiping his nose with the clothing protector and then placing the clothing protector on Resident #10. CNA #317 confirmed there were three other residents sitting at the table with Resident #10. Review of the facility's undated policy titled Dignity revealed each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. 35765 2. Review of Resident #133's medical record revealed an admitted [DATE] with diagnoses including encephalopathy, respiratory failure, cardiomyopathy, retention of urine, hypertension, seizures, anxiety disorder, and depression. Review of the physician's orders revealed Resident #133 had an order for an indwelling Foley catheter dated 03/27/25. Observations on 03/31/25 at 10:30 A.M. and 11:35 A.M. revealed Resident #133 was up in her wheelchair in her room. The urinary catheter collection bag, which was full of urine, was hanging on the side of her wheelchair, not covered with a dignity cover, and the bag was in view from the hallway. On 03/31/25 at 11:35 A.M. an interview with Registered Nurse #281 verified Resident #133's urinary catheter collection bag should have been covered with a dignity cover. Review of the facility's undated policy titled Dignity revealed each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem.

Based on record review, staff interview, review of the infection control log, and review of facility policy, the facility failed to implement their antibiotic stewardship program to promote the appropriate use of antibiotics. This affected two (Resident #7 and #44) out of five residents reviewed for antibiotic use. The facility census was 80. Findings include: 1. Review of the medical record revealed Resident #7 was admitted on [DATE] with diagnoses that included obstruction of bile duct, atrial fibrillation, acute respiratory failure, duodenal ulcer, celiac disease, major depressive disorder, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was cognitively intact. Review of the nursing note dated 04/01/25 at 5:06 P.M. revealed Resident #7 had complaints of urinary symptoms. The physician was notified and new orders were received for a urinalysis with culture. Review of the nursing note dated 04/02/25 at 6:05 A.M. revealed Resident #7's urine sample was sent to the laboratory and Resident #7 was ordered Rocephin (antibiotic). The nursing note at 10:04 A.M. revealed Resident #7 was started on Rocephin for signs and symptoms of a urinary tract infection (UTI) and the urine results were pending. Interview on 04/03/25 at 11:49 A.M. with the Director of Nursing (DON) verified Resident #7 was ordered Rocephin before the results of Resident #7's urinalysis or culture and sensitivity were received. The DON verified the antibiotic was ordered without meeting the proper criteria. Review of the facility policy titled Antibiotic Stewardship revealed the facility was to follow the McGeers criteria (a set of clinical and microbial criteria used to identify and define infections and to help determine when antibiotics are likely needed and when they may be unnecessary, to reduce antibiotic overuse) for infection surveillance. 2. Review of the medical record revealed Resident #44 was admitted on [DATE] with diagnoses that included chronic respiratory failure, type two diabetes, chronic kidney disease, and dementia. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #44 was cognitively impaired. Review of the nursing noted dated 02/06/25 at 12:59 P.M. revealed Resident #44 denied pain when urinating, burning, or abdomen discomfort. No foul odor was noted to Resident #44's urine. Review of the nursing note dated 02/06/25 at 2:56 P.M. revealed Resident #44 was unable to urinate in a urinal. The family refused to allow intermittent cauterization to obtain a urine sample. Resident #44 had increased anxiousness and racing thoughts. The note stated that hospice staff would speak with the physician to see if an antibiotic could be ordered. Review of the nursing note dated 02/06/25 at 4:31 P.M. revealed Resident #44 received the initial dose of Cipro (antibiotic) for a urine infection. Review of the February 2025 infection control log revealed Resident #44 had a urinary tract infection (UTI) with a 02/06/25 date of onset. It noted that the resident was experiencing confusion and that laboratory results were not applicable, indicating they were potentially not obtained. The log also noted a section which stated Indicate per McGeers' whether infection criteria were met [with] lab, culture, etc. and the response was No. The log further noted that Resident #44 was ordered Cipro 250 milligrams twice daily for seven days. Interview on 04/03/25 at 12:32 P.M. with the Director of Nursing (DON) verified Resident #44 was ordered Cipro without a urine sample being obtained. The DON verified the antibiotic was ordered without meeting the proper criteria. Review of the facility policy titled Antibiotic Stewardship revealed the facility was to follow the McGeers criteria (a set of clinical and microbial criteria used to identify and define infections and to help determine when antibiotics are likely needed and when they may be unnecessary, to reduce antibiotic overuse) for infection surveillance.

Based on observation, closed medical record review and interview the facility failed to prevent the development of an unstageable pressure ulcer to Resident #1's left lower leg. Actual harm occurred on 07/05/22 when Resident #1, who was cognitively impaired and dependent on staff for activity of daily living care, was discharged home and found to have an unstageable pressure ulcer to the left lower leg from a leg immobilizer. The facility failed to provide written evidence routine skin monitoring/skin checks had been completed for the resident related to the use of the immobilizer during her stay in the facility to prevent and/or timely identify the area. This affected one resident (#1) of three residents reviewed for pressure ulcers. Findings include: Review of the closed medical record for Resident #1 revealed the resident was admitted to the facility on [DATE] and discharged home with family on 07/05/22. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the hospital discharge orders, dated 06/06/22 revealed the resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The order indicated the immobilizer was to be worn at all times, but did not specify it could not be removed for bathing activities or skin assessment/monitoring. Review of the nursing progress note, dated 06/06/22 at 12:34 P.M. revealed Resident #1 arrived (to the facility) from hospital. The resident had a surgical dressing to left femur with an immobilizer in place. The note indicated the resident required a mechanical (Hoyer) lift for transfers. Review of the skin integrity care plan, dated 06/07/22 revealed Resident #1 had the potential for impaired skin integrity and pressure ulcer development related to immobility, incontinence and use of a blood thinner. Interventions included to monitor/document/report as needed any changes in skin status. Review of the Braden Scale for Predicting Pressure Sore Risk assessment, dated 06/09/22 revealed Resident #1 was a moderate risk for developing a pressure ulcer. Review of the Minimum Data Set (MDS) 3.0 admission assessment, dated 06/13/22 revealed Resident #1 was cognitively impaired and required extensive assistance from staff for personal hygiene, dressing and bed mobility. The assessment revealed the resident had no pressure ulcers but was at risk of developing pressure ulcers. Review of a restorative progress note, dated 06/14/22 revealed the resident admitted with orders for therapy. Left knee immobilizer maintained at all times due to left femur fracture. Transfers via mechanical lift to standard wheelchair. Review of an orthopedic (ortho) progress note, dated 06/14/22 revealed patient [Resident #1] presents to office for post operation evaluation of left lower extremity status post [MEDICAL RECORD OR PHYSICIAN ORDER] . The note revealed to continue daily skin checks on all incisions and remain non-weight bearing with knee immobilizer. Review of a skin/wound note, dated 06/14/22 revealed Resident #1 returned from ortho appointment with orders to remove staples from left upper thigh. Seven staples removed per order. Area remained well approximated but was reinforced with steri-strips as ordered. Surgical site on knee and thigh were resolved. The note revealed to continue with compression wrap and knee immobilizer. Resident to remain non-weight bearing on left lower extremity. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a social service progress note, dated 06/22/22 revealed Resident #1's cognitive score reflected the resident had mild to moderately impaired cognition. Review of the most recent bathing sheet, dated 07/01/22 revealed Resident #1 received a bed bath. Documentation on the bathing sheet revealed no new areas and the resident's skin was intact. However, there was no evidence the skin under the left leg immobilizer was assessed/inspected at that time. Record review revealed four skilled nursing note assessments, dated 07/03/22 and 07/05/22. None of the notes contained evidence the resident's skin under the left leg immobilizer was assessed. Review of the July 2022 Treatment Administration Record (TAR) revealed Resident #1 had a weekly head to skin assessment completed on 07/05/22 during the 7:00 P.M. to 7:00 A.M. shift. The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a social service progress note, dated 07/07/22 revealed Licensed Social Worker (LSW) #4 received a call from Resident #1's family member at approximately 12:30 P.M. on this date. The family member explained Resident #1 had a wound above her ankle, below her knee on the left lateral side. LSW #4 checked with the wound nurse and Resident #1's nurse who denied knowledge of a wound present on 07/05/22 when the resident had been discharged . The family member insisted she saw the wound on Tuesday [07/05/22] evening but indicated she had not called on that day. The note revealed Home Health Care was set up for therapy to start tomorrow and LSW #4 would call to give them a heads up concerning the family member's concerns about a new wound so they could take a look to see if a wound had started since time of discharge. Review of the home health care skilled nursing note, dated 07/08/22 and authored by Home Healthcare Registered Nurse (HHCRN) #14, revealed Patient [Resident #1] wears immobilizer to left at all times except for hygiene and skin checks until seen by Physician #7. Patient needs moderate to maximum assist with activities of daily living. Patient has an unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) pressure ulcer to left outer ankle measuring 1.5 centimeters in diameter, with 90% yellow/tan eschar, which was pulling away from wound edges with edges pink and intact. Small amount of tannish drainage without odor. Nurse cleaned wound with saline and four by four gauze, patted dry, applied skin prep to peri wound area, then covered with thin Duoderm with foam backing, cut to size. ACE rewrapped to LLE and reminded patient and family member left leg immobilizer and ACE wrap to remain intact until after appointment on Tuesday with Physician #7. The note revealed immobilizer and ACE could be removed daily for hygiene and skin checks. Review of the home health care skilled nursing note, dated 07/12/22 revealed caregiver (Resident #1's family member) completed wound care with nurse obtaining assessment and measurements. The pressure ulcer wound bed was covered with thick non-adherent yellow slough, measured 2.0 centimeters (cm) in length by 2.4 cm width with and undetermined depth and had a small amount of thick yellow drainage. The surrounding tissue measured three cm by three cm and was non-blanchable, with the wound edges non-adherent and no odor. The physician was notified with orders received for a change in wound care orders. A new order was obtained for Santyl (a prescription medication used to help the healing of skin ulcers) with treatment orders, effective 07/13/22 to apply Santyl ointment (nickel thick) to wound bed, cover with normal saline moistened gauze and wrap with Kerlix, secure with tape daily. Caregiver to complete daily if nurse unavailable. Review of Orthopedic Physician #7's progress note, dated 07/12/22 revealed small round wound on lower lateral leg most likely from pressure from brace. The note indicated the physician advised the wound appeared to be a pressure sore that could have happened from not taking the brace off. On 07/18/22 at 9:55 A.M. telephone interview with Resident #1's family member revealed after transporting Resident #1 home on 07/05/22, she removed the resident's brace and wrap and found a significant wound to the resident's left leg above her ankle. The resident's family member indicated she had taken a picture of the sore that day and was concerned how bad it looked. The family member described the wound as being round and yellow in color. The family member revealed the sore looked similar when the home health nurse came on 07/08/22. On 07/18/22 following the telephone interview, the family member provided the picture of the pressure ulcer she had taken. The picture, taken on 07/05/22 showed the resident's left leg including her calf, ankle and heel. There was a round, yellow wound present on the left lateral ankle/calf consistent with the appearance of an unstageable pressure ulcer. On 07/18/22 at 11:05 A.M. interview with Registered Nurse (RN) #2 revealed Resident #1 was pleasantly confused, alert only to herself and was a poor historian. RN #2 revealed Resident #1 wore a left knee immobilizer during her stay which extended from below her left hip to two inches above her left ankle. On 07/18/22 at 1:15 P.M. interview with Licensed Social Worked (LSW) #4 revealed Resident #1's daughter-in-law called her on Thursday 07/07/22 with concerns related to a wound on the resident's left lower extremity. LSW #4 stated she notified the home healthcare company of the wound when the home healthcare company went to assess the resident the following day [07/08/22]. On 07/18/22 at 1:45 P.M. interview with Wound Nurse (WN) #1 revealed the facility had no knowledge of Resident #1 having a pressure ulcer to the left lower extremity when she was discharged from the facility. WN #1 revealed Resident #1 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 07/18/22 at 2:30 P.M. interview with Orthopedic Physician Assistant (OPA) #6 revealed it was the expectation for the facility to have opened the knee immobilizer to complete daily skin checks for Resident #1 during the resident's stay in the facility. On 07/18/22 at 2:45 P.M. interview with the Administrator, the Director of Nursing and WN #1 revealed although the resident was admitted with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The administrative staff indicated there wasn't a specific physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 07/18/22 at 4:55 P.M. interview with the Administrator verified there weren't any bathing/shower skin sheets for Resident #1 from 07/02/22 to 07/05/22 (discharge). On 07/19/22 at 8:15 A.M. interview with Licensed Practical Nurse (LPN) #8 revealed she had provided care to Resident #1 during the resident's stay in the facility. The LPN denied completing a skin assessment or observing the resident's skin underneath the knee immobilizer when she was assigned to care for the resident On 07/19/22 at 9:35 A.M. interview with LPN #9 revealed Resident #1 had a knee immobilizer extending from above her knee to near the ankle. LPN #9 indicated she believed the knee immobilizer was not removed to check the resident's skin. The LPN revealed Resident #1 was alert yet confused and needed staff assistance with activities of daily living. On 07/19/22 at 1:00 P.M. interview with Home Healthcare Registered Nurse (HHCRN) #14 revealed Resident #1's left lower extremity pressure ulcer was caused by rubbing/pressure from the leg immobilizer. HHCRN #14 indicated her assessment was that the ulcer was not new and had been there for awhile. This deficiency substantiates Complaint Number OH 094.

Based on observation, medical record review, facility investigation, wound assessments, physician notes, review of the facility neglect policy and procedures, and interviews with facility staff, the facility failed to prevent an incident of neglect involving Resident #50. This resulted in Immediate Jeopardy with actual physical harm on 06/22/22 at approximately 1:30 P.M. when Resident #50, who was dependent on staff for mobility, was left sitting outside in the courtyard unattended with temperatures reaching 94 degrees Fahrenheit on 06/02/22 from 1:30 P.M. until 3:00 P.M. Licensed Practical Nurse (LPN) #144 found Resident #50 sitting outside in the heat, slumped over, eyes fixed, drooling, and not responding to verbal or touch stimuli at 3:00 P.M. on 06/22/22. Once the resident was brought inside, Resident #50 required intravenous hydration, pain medication, and presented with blisters to her right and left feet, thigh, and left shoulder. This affected one resident (Resident #50) of three residents reviewed for neglect. The facility census was 79. On 07/08/22 at 3:24 P.M., the Administrator and the Director of Nursing (DON) were notified Immediate Jeopardy began on 06/22/22 at approximately 1:30 P.M. when Resident #50 was left unattended outside for an hour and a half with temperatures reaching 94 degrees Fahrenheit, resulting in the resident losing consciousness, becoming dehydrated, developing blisters, and developing pain described at a ten out of ten. The Immediate Jeopardy was removed on 06/23/22 when the facility implemented the following corrective actions: · On 06/22/2022 at 3:20 P.M. Resident #50 was assessed by LPN #221, once brought inside. · On 06/22/2022 at 3:25 P.M. LPN #144 notified Resident #50's son of resident over heating while outside. · On 06/22/22 at 3:30 P.M. LPN #144 completed a skin assessment on Resident #50. · On 06/22/2022 the Regional Nurse Consultant #222, in conjunction with the Administrator, developed a Facility Courtyard - Residents policy and procedure. · On 06/23/22 Administrator completed education on the abuse policy to all staff which included information of neglect, identification, reporting and investigation. · On 06/23/22 Director of Nursing (DON) and/or designee, began auditing residents in the courtyard twice a week for four weeks to ensure the Facility Courtyard- Residents policy is being followed. · On 06/23/2022 Administrator completed a training with all staff on the new Facility Courtyard - Resident policy. · On 06/23/22 Administrator completed 1:1 education with staff members involved in incident. · On 06/23/2022 at 12:39 A.M. LPN #112 called the Physician #300 and obtained orders for pain medication, intravenous (IV) hydration, and wound treatments for the development of blisters to Resident #50. · On 06/23/2022 at 1:44 A.M. Stark Summit arrived and placed an IV to back of Resident #50's right hand for the resident to receive IV hydration. · On 06/23/2022 at 7:53 A.M. a new skin assessment was completed by LPN #144 which noted blisters on Resident #50's left dorsal foot, right dorsal foot, a cluster of blisters on the residents left upper thigh, and right upper arm/shoulder. Physician #300 was notified and new orders were received for treatment to the resident's wounds. · On 06/23/22 at 9:00 A.M. Administrator reviewed staffing schedules and collected statements. · On 06/23/22 at 1:25 P.M. Resident #50's blood work was obtained. · On 06/23/22 at 2:30 P.M. Licensed Social Worker (LSW) #168 completed a Brief Interview for Mental Status (BIMS) assessment on the Resident. · On 06/23/22 at 3:00 P.M. Administrator placed doorbells outside of courtyards. · On 06/23/22 at 3:00 P.M. the maintenance team reviewed outdoor areas for safety. · On 06/23/22 at 3:00 P.M. the maintenance team initiated daily doorbell checks. · On 06/23/22 at 3:15 P.M. the activities department handed out extreme weather/temperature education to all residents · On 06/23/22 at 3:15 P.M. Administrator added a courtyard log to the nurse's station. · On 06/23/22 at 3:30 P.M. Activities Director #209 met with Resident to develop a one-on-one care plan for outdoor visits. · On 06/23/22 at 4:00 P.M. the therapy department offered Resident #50 occupational therapy for manipulation of wheelchair safety/mobility. · On 06/23/22 at 5:00 P.M. Administrator spoke with resident regarding incident. The resident's Power of Attorney (POA) was updated on interventions. · On 06/23/22 at 10:00 P.M. Resident #50 was assessed in person by Physician #300. · On 6/24/22 Director of Nursing (DON) initiated a head-to-toe skin assessment on all residents that were out in the courtyard on 06/22/2022. Resident #52 was identified to be the only resident outside on 06/22/22. · On 06/24/22 at 12:05 P.M. wound care and facility wound nurse reviewed Resident #50's wounds. · On 06/28/22 the Interdisciplinary team met to review the specialized Quality Assurance and Performance Improvement (QAPI) plan. · On 07/08/22 at 10:00 A.M. Administrator updated the courtyard policy to specify frequency in courtyard checks when a resident is outside unsupervised. · On 07/08/22 at 10:30 A.M. LSW #168 offered counseling services to Resident #50. · On 07/08/22 at 11:30 A.M. Administrator reported the incident as a self-reported incident to state agency. · On 07/08/22 at 1:30 P.M. the facility ordered an umbrella for the courtyard to offer residents shade. · On 07/08/22 Administrator was educated by the Chief Executive Officer on Abuse identification and reporting. · On 07/08/22 Administrator and or designee initiated education on the updated courtyard policy. Although the Immediate Jeopardy was removed on 06/23/22 the deficiency remained at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of Resident #50's medical record revealed an admitted on 11/20/19 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #50's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 03/31/22, revealed the resident had a mild cognitive impairment. The assessment identified Resident #50 used a wheelchair and required extensive physical assistant with the help of one person for bed mobility, transferring, locomotion on and off the unit, dressing, personal hygiene, and toilet use. Review of Resident #50's Care Plan, dated 06/06/22, revealed the resident had an activities of daily living (ADL) self-care performance deficit related to impaired balance, limited mobility, history of a [CONDITION(S)], and weakness. Interventions included providing the resident extensive assist of one to two staff to turn and reposition in bed, providing extensive assist of one to two staff to dress, and providing her assistance of one staff with or without assistive device for all transfers. Review of the facility provided investigation, dated 06/22/22, revealed Resident #50 was out in the sun on 06/22/22 from 1:00 P.M. until 3:00 P.M. Resident #50 presented with blisters after the incident. Continued review of the witness statements revealed Resident # 50 was last checked on around 1:20 P.M. Review of LPN #144 witness statement involving the incident on 06/22/22 with Resident #50 revealed on 06/22/22 at approximately 3:00 P.M. she discovered Resident #50 sitting outside on the patio. The resident was slumped over to her left side, eyes fixed, drooling, and not responding to verbal or touch stimuli. With additional staff assistance the resident was brought inside, her clothing was removed, cold towels were placed on the resident's body and after a few minutes the resident began responding to staff. Review of Registered Nurse (RN) #218's witness statement revealed Resident #50 asked her to go outside on 06/22/22. She stated she asked another staff to take the resident outside. She stated this was sometime after lunch. She continued that after the resident was let outside, she became preoccupied with her duties. She found out about the resident's condition at approximately 3:00 P.M. Review of STNA #107's witness statement revealed she assisted Resident #50 outside to the patio on 06/22/22 at approximately 1:15 P.M. Review of the facility history of Self-Reported Incidents (SRI) revealed the facility did not report the incident of Resident #50 being left outside unattended in extreme heat on 06/22/22 as an allegation of neglect. Review of the National Weather Service website revealed that the temperature reached a high of 94 degrees Fahrenheit on 06/22/22. Continued review of the heat index for 06/22/22 revealed individuals should take extreme caution when temperatures are between 90-105 degrees. Possible heat disorders in individuals included sunstroke, muscle cramps, and heat exhaustion with prolonged exposure and/or physical activity. Review of Resident #50's nursing notes dated 06/23/22 at 12:39 A.M. revealed during nighttime medication pass Resident #50 complained of a blister on her inner left thigh, and upon observation several fluid filled blisters were noted. The resident complained of pain at a 10 out of 10, and as needed Tylenol was administered with no effect. The physician was notified, and orders were received for [MEDICATION(S)] 50 mg every six hours as needed and normal saline 100 ml (milliliters)/hour for one litter, then 75 ml/hour for one litter to be administered intravenously. Additional orders were given to apply [MEDICATION(S)] to affected areas and pad and protect. A complete blood count (CBC) and comprehensive metabolic panel (CMP) lab was to be done in the morning. Review of Resident #50's Physicians progress note, dated 06/23/22 revealed Resident #50 was outside yesterday for a long time. The resident had developed a blister to her right shoulder, left medial thigh, and bilateral feet, with pain. Multiple blisters were due to heat/pressure, use [MEDICATION(S)] cream, IV fluids, check labs, and increase fluids. Review of the Resident #50's facility Physician orders, dated 06/23/22, revealed orders for [MEDICATION(S)] (narcotic pain medication) 50 milligrams (mg) every six hours as needed for pain, Saline Solution 0.9 % with directions to use 100 ml/hour intravenously for one, litter one time for dehydration, Saline Solution 0.9 %Use 75 ml/hour intravenously for one litter for dehydration, and [MEDICATION(S)] Cream 1 percent with directions to apply to bilateral lover extremities and bilateral upper extremities topically two times a day for skin care, and to pad and protect the areas. Review of Resident #50's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #50's facility provided wound worksheet revealed on 06/23/22 Resident #50 presented with a 15 centimeter (cm) long by 7.5 cm wide blister to her left dorsal foot, 4 cm long by 5.5 cm wide blister to her right dorsal foot, 8 cm long by 13.5 cm wide blister to her left upper thigh. A 15 cm long by 11.5 cm wide by 0.1 cm deep blister was present to the resident's right upper arm/shoulder. Review of the 06/24/22 Wound Care Wound Evaluation documentation completed by Wound Physician #400 revealed Resident #50 presented with several concerning areas related to a heat rash. She was noted to have a 4.9 cm by 6.1 cm intact blister, and the wound bed involved the skin and subcutaneous tissue. On the resident's left dorsal foot was a 14.4 cm by 7.5 cm intact blister, and the wound bed was composed of skin and subcutaneous tissue. The resident had a 7.9 cm by 10.3 cm intact blister to the left inner thigh, and the wound bed involved the skin and subcutaneous tissue. The resident had a 15.8 cm by 9.2 cm with undetermined depth wound with partially intact fluid filled blister to the resident's right upper arm. Orders included to cover the areas with [MEDICATION(S)] and cover with an abdominal pad. Observation of Resident #50 on 07/07/22 at 9:40 A.M. revealed she was sitting in a chair in her room. She had bandages to the top of both feet, her left inner thigh, and her right upper shoulder. Interview on 07/07/22 at 9:40 AM. With Resident #50 revealed on 06/22/22 she asked a staff member if she could sit outside after lunch around 12:30 P.M. One of the facility state tested nursing assistants (STNA) wheeled her outside, and placed her in the courtyard alone. She stated she was fully clothed in a sweatshirt, sweatpants, socks, and a sun hat. The resident stated the facility did not offer her water or sunblock upon taking her outside. She stated it was a very hot day and after a little while she wanted to come back in. The resident stated she started to yell for help when she felt herself overheating. She continued to yell and scream for help and attempted to wheel herself to the doors so she could bang on them to get the attention of a staff member. She stated that she was too weak to make it to the doors and eventually passed out from the heat. She continued that when she woke up, she was inside of the facility and a nurse was putting ice on her back. She stated she developed blisters on several parts of her body and was in extreme pain. She stated if she did not have a sunhat, she would have been burnt all over her body. Observation on 07/07/22 at 10:25 A.M. of the facility courtyard, where Resident #50 was placed on 06/22/22, revealed a code was needed to enter and exit the area. Continued observation revealed the area did not have a shaded area to sit under. Interview on 07/07/22 at 9:38 A.M. with LPN #144 revealed on 06/22/22 at approximately 3:00 P.M. she found Resident #50 unresponsive, slumped over and drooling outside in her wheelchair. She stated she brought the resident inside and began using ice and water to cool her down. She stated that after a couple minutes she began to respond again. She stated it was a very hot day, and she was wearing a sweat shirt, sweat pants, and socks. She stated the resident required IV hydration, and developed large blisters to her bilateral feet, shoulder, and thigh. She stated Resident #50 was currently receiving wound treatments and pain medications due to the incident. Interview on 07/07/22 at 12:40 P.M. with STNA # 107 revealed on 06/22/22 RN #218 asked her to take Resident #50 to sit outside in the courtyard around 1:00 P.M. She stated the Resident was fully dressed and had a can of soda. She stated she did not offer water or sunblock prior to taking her outside, and it was very hot that day. STNA #107 continued with she was not assigned to Resident #50 and did not let Resident #50's assigned staff know that she had assisted her outside. She also stated she did not check on the resident once she took her outside, and when she left at 2:00 P.M. that day she did not inform the on-coming staff that Resident #50 was left outside unattended. Interview on 07/07/22 at 12:35 P.M. with RN #218 revealed on 06/22/22 she asked another staff to take Resident #50 outside to the courtyard. She revealed she got very busy that day and forgot the resident was outside. She stated that she should have been checked on every 15 to 30 minutes while she was outside but confirmed she did not complete any checks on the resident. Interview on 07/07/22 at 1:09 P.M. with Physician #300 revealed she was made aware of the incident involving Resident #50. She revealed she ordered lab work, IV hydration for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . She confirmed the resident had developed large blisters covering her feet, shoulder, and thigh. Physician #300 revealed in her opinion the resident should have not been allowed outside with the temperature above 85 degrees due to safety. She stated with her condition and age it would not be safe, and indicated the incident was neglectful. Physician #300 revealed there was a potential for heat stroke, burning, and blistering due to the heat. Interview on 07/07/22 at 11:40 A.M. with Wound Physician #400 revealed Certified Nurse Practitioner (CNP) #450 assessed Resident #50's wounds shortly after the incident on 06/22/22. At that time CNP #450 called Wound Physician #400 for a consult. Physician #400 stated he believed Resident #50 developed a bad heat rash that caused blistering due to prolonged heat and sun exposure. He revealed this type of rash can develop in the elderly within 15 to 20 minutes of prolonged heat exposure. Interview on 07/07/22 at 10:05 A.M. with the facility's Administrator revealed on 06/22/22 Resident #50 requested to go outside to the courtyard. She stated that RN #218 asked STNA #107 to take the resident outside to the courtyard. She indicated STNA #107 wheeled her outside, gave her a can of soda, and left her unattended outside. The Administrator confirmed a code that only the staff knew had to be used to get in and out of the courtyard. The Administrator stated this took place around 1:00 P.M. She indicated the resident was fully dressed in a sweatshirt, sweatpants, socks, and a sun hat and the weather was probably in the 80's at this time. Around 1:30 P.M. the activities director went outside and talked to the resident, but did not offer her any type of beverage or water at that time. The resident remained outside alone until 3:00 P.M. when LPN #144 noted that Resident #50 was slumped over outside and it appeared she had passed out. The resident was then brought inside where the staff applied ice water to the resident to cool her down. The Administrator indicated later the same night the resident presented with complaints of blisters to her right thigh and had several blisters with pain rated 10 on a scale of 1-10. The physician was notified, and the resident received new orders for IV fluids, [MEDICATION(S)], wound treatments to affected areas, and lab work to be done in the morning. The facility also consulted with a wound physician who determined the wounds were related to a heat rash. The Administrator stated it would have been her expectation the facility staff would have checked on the resident at least every 15 to 20 minutes while she was outside. She confirmed the resident was not checked on every 15 to 20 minutes resulting in the resident suffering dehydration, pain, and needing treatments for her wounds. The Administrator confirmed she did not report the incident as neglect to the State Agency as she did not feel like there was an intent to harm the resident. Review of the facility policy titled, Abuse Prohibition, dated 11/2016, revealed the facility management prohibits neglect and determined that the definition of neglect is the unintentional failure of the facility, its employees or service providers who provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. All allegations of neglect were to be reported immediately to the Administrator and the State agency. This deficiency substantiates Complaint Number OH 864.

Based on observation, medical record review, facility investigation review, wound assessments, physician notes, review of the facility neglect policy and procedures, and interviews with facility staff, the facility failed to report an incident of neglect involving Resident #50. This affected one resident (Resident #50) of three residents reviewed for neglect. The facility census was 79. Findings include: Review of Resident #50's medical record revealed an admitted on 11/20/19 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #50's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 03/31/22, revealed the resident had a mild cognitive impairment. The assessment identified Resident #50 used a wheelchair and required extensive physical assistant with the help of one person for bed mobility, transferring, locomotion on and off the unit, dressing, personal hygiene, and toilet use. Review of Resident #50's Care Plan, dated 06/06/22, revealed the resident had an activities of daily living (ADL) self-care performance deficit related to impaired balance, limited mobility, history of a [CONDITION(S)], and weakness. Interventions included providing the resident extensive assist of one to two staff to turn and reposition in bed, providing extensive assist of one to two staff to dress, and providing her assistance of one staff with or without assistive device for all transfers. Review of the facility provided investigation, dated 06/22/22, revealed Resident #50 was out in the sun on 06/22/22 from 1:00 P.M. until 3:00 P.M. Resident #50 presented with blisters after the incident. Continued review of the witness statements revealed Resident # 50 was last checked on around 1:20 P.M. Review of LPN #144 witness statement involving the incident on 06/22/22 with Resident #50 revealed on 06/22/22 at approximately 3:00 P.M. she discovered Resident #50 sitting outside on the patio. The resident was slumped over to her left side, eyes fixed, drooling, and not responding to verbal or touch stimuli. With additional staff assistance the resident was brought inside, her clothing was removed, cold towels were placed on the resident's body and after a few minutes the resident began responding to staff. Review of Registered Nurse (RN) #218's witness statement revealed Resident #50 asked her to go outside on 06/22/22. She stated she asked another staff to take the resident outside. She stated this was sometime after lunch. She continued that after the resident was let outside, she became preoccupied with her duties. She found out about the resident's condition at approximately 3:00 P.M. Review of STNA #107's witness statement revealed she assisted Resident #50 outside to the patio on 06/22/22 at approximately 1:15 P.M. Review of the facility history of Self-Reported Incidents (SRI) revealed the facility did not report the incident of Resident #50 being left outside unattended in extreme heat on 06/22/22 as an allegation of neglect. Review of the National Weather Service website revealed that the temperature reached a high of 94 degrees Fahrenheit on 06/22/22. Continued review of the heat index for 06/22/22 revealed individuals should take extreme caution when temperatures are between 90-105 degrees. Possible heat disorders in individuals included sunstroke, muscle cramps, and heat exhaustion with prolonged exposure and/or physical activity. Review of Resident #50's nursing notes dated 06/23/22 at 12:39 A.M. revealed during nighttime medication pass Resident #50 complained of a blister on her inner left thigh, and upon observation several fluid filled blisters were noted. The resident complained of pain at a 10 out of 10, and as needed Tylenol was administered with no effect. The physician was notified, and orders were received for [MEDICATION(S)] 50 mg every six hours as needed and normal saline 100 ml (milliliters)/hour for one litter, then 75 ml/hour for one litter to be administered intravenously. Additional orders were given to apply [MEDICATION(S)] to affected areas and pad and protect. A complete blood count (CBC) and comprehensive metabolic panel (CMP) lab was to be done in the morning. Review of Resident #50's Physicians progress note, dated 06/23/22 revealed Resident #50 was outside yesterday for a long time. The resident had developed a blister to her right shoulder, left medial thigh, and bilateral feet, with pain. Multiple blisters were due to heat/pressure, use [MEDICATION(S)] cream, IV fluids, check labs, and increase fluids. Review of the Resident #50's facility Physician orders, dated 06/23/22, revealed orders for [MEDICATION(S)] (narcotic pain medication) 50 milligrams (mg) every six hours as needed for pain, Saline Solution 0.9 % with directions to use 100 ml/hour intravenously for one, litter one time for dehydration, Saline Solution 0.9 %Use 75 ml/hour intravenously for one litter for dehydration, and [MEDICATION(S)] Cream 1 percent with directions to apply to bilateral lover extremities and bilateral upper extremities topically two times a day for skin care, and to pad and protect the areas. Review of Resident #50's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #50's facility provided wound worksheet revealed on 06/23/22 Resident #50 presented with a 15 centimeter (cm) long by 7.5 cm wide blister to her left dorsal foot, 4 cm long by 5.5 cm wide blister to her right dorsal foot, 8 cm long by 13.5 cm wide blister to her left upper thigh. A 15 cm long by 11.5 cm wide by 0.1 cm deep blister was present to the resident's right upper arm/shoulder. Review of the 06/24/22 Wound Care Wound Evaluation documentation completed by Wound Physician #400 revealed Resident #50 presented with several concerning areas related to a heat rash. She was noted to have a 4.9 cm by 6.1 cm intact blister, and the wound bed involved the skin and subcutaneous tissue. On the resident's left dorsal foot was a 14.4 cm by 7.5 cm intact blister, and the wound bed was composed of skin and subcutaneous tissue. The resident had a 7.9 cm by 10.3 cm intact blister to the left inner thigh, and the wound bed involved the skin and subcutaneous tissue. The resident had a 15.8 cm by 9.2 cm with undetermined depth wound with partially intact fluid filled blister to the resident's right upper arm. Orders included to cover the areas with [MEDICATION(S)] and cover with an abdominal pad. Observation of Resident #50 on 07/07/22 at 9:40 A.M. revealed she was sitting in a chair in her room. She had bandages to the top of both feet, her left inner thigh, and her right upper shoulder. Interview on 07/07/22 at 9:40 AM. With Resident #50 revealed on 06/22/22 she asked a staff member if she could sit outside after lunch around 12:30 P.M. One of the facility state tested nursing assistants (STNA) wheeled her outside, and placed her in the courtyard alone. She stated she was fully clothed in a sweatshirt, sweatpants, socks, and a sun hat. The resident stated the facility did not offer her water or sunblock upon taking her outside. She stated it was a very hot day and after a little while she wanted to come back in. The resident stated she started to yell for help when she felt herself overheating. She continued to yell and scream for help and attempted to wheel herself to the doors so she could bang on them to get the attention of a staff member. She stated that she was too weak to make it to the doors and eventually passed out from the heat. She continued that when she woke up, she was inside of the facility and a nurse was putting ice on her back. She stated she developed blisters on several parts of her body and was in extreme pain. She stated if she did not have a sunhat, she would have been burnt all over her body. Observation on 07/07/22 at 10:25 A.M. of the facility courtyard, where Resident #50 was placed on 06/22/22, revealed a code was needed to enter and exit the area. Continued observation revealed the area did not have a shaded area to sit under. Interview on 07/07/22 at 9:38 A.M. with LPN #144 revealed on 06/22/22 at approximately 3:00 P.M. she found Resident #50 unresponsive, slumped over and drooling outside in her wheelchair. She stated she brought the resident inside and began using ice and water to cool her down. She stated that after a couple minutes she began to respond again. She stated it was a very hot day, and she was wearing a sweat shirt, sweat pants, and socks. She stated the resident required IV hydration, and developed large blisters to her bilateral feet, shoulder, and thigh. She stated Resident #50 was currently receiving wound treatments and pain medications due to the incident. Interview on 07/07/22 at 12:40 P.M. with STNA # 107 revealed on 06/22/22 RN #218 asked her to take Resident #50 to sit outside in the courtyard around 1:00 P.M. She stated the Resident was fully dressed and had a can of soda. She stated she did not offer water or sunblock prior to taking her outside, and it was very hot that day. STNA #107 continued with she was not assigned to Resident #50 and did not let Resident #50's assigned staff know that she had assisted her outside. She also stated she did not check on the resident once she took her outside, and when she left at 2:00 P.M. that day she did not inform the on-coming staff that Resident #50 was left outside unattended. Interview on 07/07/22 at 12:35 P.M. with RN #218 revealed on 06/22/22 she asked another staff to take Resident #50 outside to the courtyard. She revealed she got very busy that day and forgot the resident was outside. She stated that she should have been checked on every 15 to 30 minutes while she was outside but confirmed she did not complete any checks on the resident. Interview on 07/07/22 at 1:09 P.M. with Physician #300 revealed she was made aware of the incident involving Resident #50. She revealed she ordered lab work, IV hydration for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . She confirmed the resident had developed large blisters covering her feet, shoulder, and thigh. Physician #300 revealed in her opinion the resident should have not been allowed outside with the temperature above 85 degrees due to safety. She stated with her condition and age it would not be safe, and indicated the incident was neglectful. Physician #300 revealed there was a potential for heat stroke, burning, and blistering due to the heat. Interview on 07/07/22 at 11:40 A.M. with Wound Physician #400 revealed Certified Nurse Practitioner (CNP) #450 assessed Resident #50's wounds shortly after the incident on 06/22/22. At that time CNP #450 called Wound Physician #400 for a consult. Physician #400 stated he believed Resident #50 developed a bad heat rash that caused blistering due to prolonged heat and sun exposure. He revealed this type of rash can develop in the elderly within 15 to 20 minutes of prolonged heat exposure. Interview on 07/07/22 at 10:05 A.M. with the facility's Administrator revealed on 06/22/22 Resident #50 requested to go outside to the courtyard. She stated that RN #218 asked STNA #107 to take the resident outside to the courtyard. She indicated STNA #107 wheeled her outside, gave her a can of soda, and left her unattended outside. The Administrator confirmed a code that only the staff knew had to be used to get in and out of the courtyard. The Administrator stated this took place around 1:00 P.M. She indicated the resident was fully dressed in a sweatshirt, sweatpants, socks, and a sun hat and the weather was probably in the 80's at this time. Around 1:30 P.M. the activities director went outside and talked to the resident, but did not offer her any type of beverage or water at that time. The resident remained outside alone until 3:00 P.M. when LPN #144 noted that Resident #50 was slumped over outside and it appeared she had passed out. The resident was then brought inside where the staff applied ice water to the resident to cool her down. The Administrator indicated later the same night the resident presented with complaints of blisters to her right thigh and had several blisters with pain rated 10 on a scale of 1-10. The physician was notified, and the resident received new orders for IV fluids, [MEDICATION(S)], wound treatments to affected areas, and lab work to be done in the morning. The facility also consulted with a wound physician who determined the wounds were related to a heat rash. The Administrator stated it would have been her expectation the facility staff would have checked on the resident at least every 15 to 20 minutes while she was outside. She confirmed the resident was not checked on every 15 to 20 minutes resulting in the resident suffering dehydration, pain, and needing treatments for her wounds. The Administrator confirmed she did not report the incident as neglect to the State Agency as she did not feel like there was an intent to harm the resident. Review of the facility policy titled, Abuse Prohibition, dated 11/2016, revealed the facility management prohibits neglect and determined that the definition of neglect is the unintentional failure of the facility, its employees or service providers who provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. All allegations of neglect were to be reported immediately to the Administrator and the State agency. This deficiency substantiates Complaint Number OH 864.

Based on record review, staff interview and facility policy and procedure review, the facility failed to refund the resident or resident representative all refunds due within 30 days of discharge. This affected two residents (#84 and #86) of three residents reviewed for resident fund disbursement. Findings include: 1. Review of the medical record revealed Resident #84 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed the resident passed away on [DATE]. Review of the significant change Minimum Data Set (MDS) 3.0 assessment, dated [DATE] revealed Resident #84 had severely impaired cognition, had a prognosis of less than six months and received Hospice services. Review of the Refund Check Request Form, dated [DATE] revealed Resident #84 received Hospice and was a private pay resident and the family was requesting a refund as the family was trying to close the resident's estate. Resident #84 expired, private and hospice private overpayment was due to the resident's estate. There was a difference of a small therapy balance which corporate billing staff were trying to appeal. The amount owed to the family was $5397.77. The amount of the insurance bill was $194.35. Review of the check number revealed a check for $5395.77 was issued to the responsible party for Resident #84 on [DATE] from the facility. The check cleared the bank on [DATE]. On [DATE] at 9:11 A.M. interview with Family Member #210 revealed she received the refund from the facility in the middle of February 2022 but could not recall the exact date. Family Member #210 revealed the facility had been holding the funds due an outstanding insurance invoice. She stated the facility still owed her $200.00 but they stated they were keeping that to cover the cost of the outstanding insurance invoice. On [DATE] at 12:10 P.M. interview with Business Office Manger (BOM) #211 revealed the facility had been transferred to new owners on [DATE] and she does not have access to the resident accounts (from the previous owners) anymore. However, it was the policy of the old company to hold funds if there were any outstanding insurance bills. She stated they sent a payment to the family of Resident #84 in [DATE], but they kept $100 for an insurance bill that was not paid yet. On [DATE] at 1:50 P.M. interview with BOM #211 verified the money owed to Resident #84 had not been disbursed within 30 days of the resident passing away as required. 2. Review of the medical record revealed Resident #86 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident passed away on [DATE]. Review of the MDS 3.0 assessment, dated [DATE] revealed Resident #86 had moderately impaired cognition and did not have Hospice. Review of the account statement, dated [DATE] revealed Resident #86 had an amount for $2466.01 owed to him as of this date. On [DATE] at 12:10 P.M. interview with BOM #211 revealed the facility had been transferred to new owners on [DATE] and she does not have access to the accounts to the resident accounts (from the previous owners) anymore. However, it was the policy of the old company to hold funds if there were any outstanding insurance bills. She stated Resident #86 had an outstanding insurance invoice, so his funds were being held due the that invoice. On [DATE] at 1:50 P.M. interview with BOM #211 verified a final accounting of Resident #86's funds had not been completed within 30 days of the resident passing away and no funds had been disbursed within 30 days. The resident still had a personal funds account with the facility as of [DATE]. Review of the undated facility policy titled, RFMS Policy-Resident Fund Management, revealed the facility must maintain accurate, organized records for all resident fund activities, All records were to be maintained according to the facility and State regulations. Trust accounts for discharged or expired residents must be closed within 30 days of the discharged dated. Funds were to be disbursed according to State regulations. This deficiency substantiates Complaint Number OH 995.

Based on record review and interview the facility failed to prevent staff misappropriation of resident narcotic medications. This affected two (Resident #22 and #52) of three residents reviewed for misappropriation of medications. Findings include: 1. Review of the medical record revealed Resident #22 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #22 was alert, oriented with intact cognition and received opioid medication five days in the assessment period. Review of the February 2021 physician's orders revealed Resident #22 had an order dated 01/25/21 for one table of 5/325 milligrams (mg) oxycodone-acetaminophen (narcotic pain medication) every six hours prn, which means as needed for pain. Review of the AlixaRx (a medication dispensing system) Control PRN Dispense by Shift document dated 02/24/21 from 7:00 A.M. to 5:00 P.M. revealed Licensed Practical Nurse (LPN) #300 removed one tablet of oxycodone/acetaminophen 5/325 mg at 8:59 A.M. and one tablet of oxycodone/acetaminophen 5/325 mg at 3:43 P.M. for Resident #22. Review of the employee time sheet revealed LPN #300 worked on 02/24/21 from 8:00 A.M. to 4:15 P.M. Review of the February 2021 Medication Administration Record (MAR) revealed Resident #22 had not been administered pain medication by LPN #300 on 02/24/21. Review of the undated facility's Diversion Investigation revealed LPN #300 denied drug diversion. There were no discrepancies involving LPN #300 prior to February 2021. The investigation indicated there were no medication errors identified, no negative outcomes involving a resident and all mediation were credited back to the resident's account via the pharmacy. On 02/24/21, LPN #300 was assigned to work 8:00 A.M. to 4:30 P.M. At approximately 7:30 P.M. the nurse on the 100 Hall reviewed the narcotic dispense report and noticed three doses of as needed narcotics had been dispensed to LPN #300 for two separate residents [later identified as Resident #22 and #51]. The 100 Hall nurse reported this information to the Director of Nursing (DON). This resulted in an investigation being initiated and conducted, including nurse and resident interview statements obtained. The Administrator, Human Resources and the Medical Director were notified. The two residents in the report were alert and oriented and both reported they had not requested as needed pain medication, nor did they receive any pain medication the previous shift. The DON checked the MARs for Resident #22 and #51 and they stated they had not received the controlled medication as listed on the narcotic dispensary report. The pain medication was not documented on the MARs by LPN #300 as administered. A limited accountability audit (the audit would only go back 90 days) was conducted for LPN #300's dispensing occurrences of controlled substances from 12/01/20 to 02/24/21 and the substance audit included all controlled medications from the AlixaRx machine. This pharmacy report identified 280 medications dispensed by LPN #300 just for February, 2021. The summary results of the audits included, but may not be limited to, controlled substances which were dispensed without further documentation on the MAR to substantiate the administration of the drug to the resident, residents denied administration of controlled substances, and controlled substances were signed out without accountability of wasting them. Additionally, during the audit period, LPN #300 was the only nurse to dispense this narcotic pain reliever (oxycodone/acetaminophen) for Resident #22 and #51 on each of the 280 occasions. Of the 280 medications dispensed by LPN #300, none were documented as administered on the MARS. On 02/24/21, LPN #300 worked in the restorative department and was not assigned to a resident unit but dispensed three oxycodone tablets from the AlixaRx machine. When LPN #300 was questioned by the Administrator and the DON, LPN #300 denied diverting the medications for herself or anyone else. LPN #300 admitted she dispensed the medications but said she administered the medication but forgot to document the administration on the MAR. The resident denied receiving the mediation as referenced by LPN #300. In addition, LPN #300 provided evidence of having her own prescriptions for oxycodone for pain management. Thus, her drug test was positive. LPN #300 was suspended on 02/24/21 pending investigation. As a result of the investigation, LPN #300's employment was terminated on 03/01/21. Review of the unsigned, undated handwritten witness statement by Resident #22 revealed he had not asked for any pain medications on the day in question. Interview on 04/02/21 at 9:15 A.M. with the DON revealed nurses go into the AlixaRx and choose what medication they need, put in a password and fingerprint and then the medication would be dispensed, and a report generated. The nurse had to then have another nurse sign off to verify the medication was pulled, and she would get the report. The DON said the other nurse does not have to be in the room when the medication was dispensed so there was a possibility the nurse could pull a medication and put it in their pocket and throw the dispense report away. She verified there was a video of LPN #300 going into the AlixaRx dispensing room on 02/24/21 at the times the medications were dispensed to her. It was unclear if LPN put the narcotics in her pocket but she then shortly left the premises without administering any medication to any residents. The DON said the video had been turned over to the Ohio Attorney General's Office, so they did not have it available for surveyor review. Interview on 04/02/21 at 3:00 P.M. with the DON verified they had not completed and submitted a facility Self-Reported Incident (SRI) to the State Agency as required for misappropriation. The DON said the former Administrator stated it was not needed because there was no misappropriation since the residents were reimbursed the money from the medication. Review of the facility policy, Abuse Prohibition, dated 11/17, revealed the health care center's management prohibits neglect, mental or physical abuse, including misappropriation of resident's property and/or funds. This policy indicated the health care center management would conduct a prompt investigation of any allegation received of suspected abuse, neglect, or misappropriation of property and or funds. If warranted the health care center's management would provide notification to the proper authorities and when required, the release of information to those agencies. Misappropriation was defined as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. 2. Review of the medical record revealed Resident #51 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the February 2021 physician's orders revealed Resident #51 had an order dated 02/23/21 for one tablet of 3/325 mg of oxycodone-acetaminophen (narcotic pain reliever) every four hours as needed for pain. Review of the February 2021 MAR revealed Resident #51 was not administered any narcotic pain medication by LPN #300 on 02/24/21. Review of the AlixaRx Control PRN Dispense by Shift sheet dated 02/24/21 from 7:00 A.M. to 5:00 P.M. revealed LPN #300 removed one tablet of oxycodone/acetaminophen 5/325 mg at 3:45 P.M. for Resident #51. Review of the employee time sheet revealed LPN #300 worked on 02/24/21 from 8:00 A.M. to 4:15 P.M. Review of the admission Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #51 was alert, oriented, had intact cognition and received opioid medication seven days in the assessment period. Review of the undated facility's Diversion Investigation revealed LPN #300 denied drug diversion. There were no discrepancies involving LPN #300 prior to February 2021. The investigation indicated there were no medication errors identified, no negative outcomes involving a resident and all mediation were credited back to the resident's account via the pharmacy. On 02/24/21, LPN #300 was assigned to work 8:00 A.M. to 4:30 P.M. At approximately 7:30 P.M. the nurse on the 100 Hall reviewed the narcotic dispense report and noticed three doses of as needed narcotics had been dispensed to LPN #300 for two separate residents [later identified as Resident #22 and #51]. The 100 Hall nurse reported this information to the Director of Nursing (DON). This resulted in an investigation being initiated and conducted, including nurse and resident interview statements obtained. The Administrator, Human Resources and the Medical Director were notified. The two residents in the report were alert and oriented and both reported they had not requested as needed pain medication, nor did they receive any pain medication the previous shift. The DON checked the MARs for Resident #22 and #51 and they stated they had not received the controlled medication as listed on the narcotic dispensary report. The pain medication was not documented on the MARs by LPN #300 as administered. A limited accountability audit (the audit would only go back 90 days) was conducted for LPN #300's dispensing occurrences of controlled substances from 12/01/20 to 02/24/21 and the substance audit included all controlled medications from the AlixaRx machine. This pharmacy report identified 280 medications dispensed by LPN #300 just for February, 2021. The summary results of the audits included, but may not be limited to, controlled substances which were dispensed without further documentation on the MAR to substantiate the administration of the drug to the resident, residents denied administration of controlled substances, and controlled substances were signed out without accountability of wasting them. Additionally, during the audit period, LPN #300 was the only nurse to dispense this narcotic pain reliever (oxycodone/acetaminophen) for Resident #22 and #51 on each of the 280 occasions. Of the 280 medications dispensed by LPN #300, none were documented as administered on the MARS. On 02/24/21, LPN #300 worked in the restorative department and was not assigned to a resident unit but dispensed three oxycodone tablets from the AlixaRx machine. When LPN #300 was questioned by the Administrator and the DON, LPN #300 denied diverting the medications for herself or anyone else. LPN #300 admitted she dispensed the medications but said she administered the medication but forgot to document the administration on the MAR. The resident denied receiving the mediation as referenced by LPN #300. In addition, LPN #300 provided evidence of having her own prescriptions for oxycodone for pain management. Thus, her drug test was positive. LPN #300 was suspended on 02/24/21 pending investigation. As a result of the investigation, LPN #300's employment was terminated on 03/01/21. Review of the unsigned, undated handwritten witness statement by Resident #51 dated revealed she had needed pain medication for a headache and asked the male nurse but that was the only person. Interview on 04/02/21 at 9:15 A.M. with the DON revealed nurses go into the AlixaRx and choose what medication they need, put in a password and fingerprint and then the medication would be dispensed, and a report generated. The nurse had to then have another nurse sign off to verify the medication was pulled, and she would get the report. The DON said the other nurse does not have to be in the room when the medication was dispensed so there was a possibility the nurse could pull a medication and put it in their pocket and throw the dispense report away. She verified there was a video of LPN #300 going into the AlixaRx dispensing room on 02/24/21 at the times the medications were dispensed to her. It was unclear if LPN put the narcotics in her pocket but she then shortly left the premises without administering any medication to any residents. The DON said the video had been turned over to the Ohio Attorney General's Office, so they did not have it available for surveyor review. Interview on 04/02/21 at 3:00 P.M. with the DON verified they had not completed and submitted a facility Self-Reported Incident (SRI) to the State Agency as required for misappropriation. The DON said the former Administrator stated it was not needed because there was no misappropriation since the residents were reimbursed the money from the medication. Review of the facility policy, Abuse Prohibition, dated 11/17, revealed the health care center's management prohibits neglect, mental or physical abuse, including misappropriation of resident's property and/or funds. This policy indicated the health care center management would conduct a prompt investigation of any allegation received of suspected abuse, neglect, or misappropriation of property and or funds. If warranted the health care center's management would provide notification to the proper authorities and when required, the release of information to those agencies. Misappropriation was defined as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. This deficiency substantiates Complaint Number OH 189.

Based on record review and interview the facility failed to effectively and immediately implement their abuse policy and procedure following an allegation of staff misappropriation of medications to ensure the allegation was immediately reported to the state agency involving Resident #22 and #51. This affected two of three residents reviewed for misappropriation of medications. Findings include: 1. Review of the medical record revealed Resident #22 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #22 was alert, oriented with intact cognition and received opioid medication five days in the assessment period. Review of the February 2021 physician's orders revealed Resident #22 had an order dated 01/25/21 for one table of 5/325 milligrams (mg) oxycodone-acetaminophen (narcotic pain medication) every six hours prn, which means as needed for pain. Review of the AlixaRx (a medication dispensing system) Control PRN Dispense by Shift document dated 02/24/21 from 7:00 A.M. to 5:00 P.M. revealed Licensed Practical Nurse (LPN) #300 removed one tablet of oxycodone/acetaminophen 5/325 mg at 8:59 A.M. and one tablet of oxycodone/acetaminophen 5/325 mg at 3:43 P.M. for Resident #22. Review of the employee time sheet revealed LPN #300 worked on 02/24/21 from 8:00 A.M. to 4:15 P.M. Review of the February 2021 Medication Administration Record (MAR) revealed Resident #22 had not been administered pain medication by LPN #300 on 02/24/21. Review of the undated facility's Diversion Investigation revealed LPN #300 denied drug diversion. There were no discrepancies involving LPN #300 prior to February 2021. The investigation indicated there were no medication errors identified, no negative outcomes involving a resident and all mediation were credited back to the resident's account via the pharmacy. On 02/24/21, LPN #300 was assigned to work 8:00 A.M. to 4:30 P.M. At approximately 7:30 P.M. the nurse on the 100 Hall reviewed the narcotic dispense report and noticed three doses of as needed narcotics had been dispensed to LPN #300 for two separate residents [later identified as Resident #22 and #51]. The 100 Hall nurse reported this information to the Director of Nursing (DON). This resulted in an investigation being initiated and conducted, including nurse and resident interview statements obtained. The Administrator, Human Resources and the Medical Director were notified. The two residents in the report were alert and oriented and both reported they had not requested as needed pain medication, nor did they receive any pain medication the previous shift. The DON checked the MARs for Resident #22 and #51 and they stated they had not received the controlled medication as listed on the narcotic dispensary report. The pain medication was not documented on the MARs by LPN #300 as administered. A limited accountability audit (the audit would only go back 90 days) was conducted for LPN #300's dispensing occurrences of controlled substances from 12/01/20 to 02/24/21 and the substance audit included all controlled medications from the AlixaRx machine. This pharmacy report identified 280 medications dispensed by LPN #300 just for February, 2021. The summary results of the audits included, but may not be limited to, controlled substances which were dispensed without further documentation on the MAR to substantiate the administration of the drug to the resident, residents denied administration of controlled substances, and controlled substances were signed out without accountability of wasting them. Additionally, during the audit period, LPN #300 was the only nurse to dispense this narcotic pain reliever (oxycodone/acetaminophen) for Resident #22 and #51 on each of the 280 occasions. Of the 280 medications dispensed by LPN #300, none were documented as administered on the MARS. On 02/24/21, LPN #300 worked in the restorative department and was not assigned to a resident unit but dispensed three oxycodone tablets from the AlixaRx machine. When LPN #300 was questioned by the Administrator and the DON, LPN #300 denied diverting the medications for herself or anyone else. LPN #300 admitted she dispensed the medications but said she administered the medication but forgot to document the administration on the MAR. The resident denied receiving the mediation as referenced by LPN #300. In addition, LPN #300 provided evidence of having her own prescriptions for oxycodone for pain management. Thus, her drug test was positive. LPN #300 was suspended on 02/24/21 pending investigation. As a result of the investigation, LPN #300's employment was terminated on 03/01/21. Review of the unsigned, undated handwritten witness statement by Resident #22 revealed he had not asked for any pain medications on the day in question. Interview on 04/02/21 at 9:15 A.M. with the DON revealed nurses go into the AlixaRx and choose what medication they need, put in a password and fingerprint and then the medication would be dispensed, and a report generated. The nurse had to then have another nurse sign off to verify the medication was pulled, and she would get the report. The DON said the other nurse does not have to be in the room when the medication was dispensed so there was a possibility the nurse could pull a medication and put it in their pocket and throw the dispense report away. She verified there was a video of LPN #300 going into the AlixaRx dispensing room on 02/24/21 at the times the medications were dispensed to her. It was unclear if LPN put the narcotics in her pocket but she then shortly left the premises without administering any medication to any residents. The DON said the video had been turned over to the Ohio Attorney General's Office, so they did not have it available for surveyor review. Interview on 04/02/21 at 3:00 P.M. with the DON verified they had not completed and submitted a facility Self-Reported Incident (SRI) to the State Agency as required for misappropriation. The DON said the former Administrator stated it was not needed because there was no misappropriation since the residents were reimbursed the money from the medication. Review of the facility policy, Abuse Prohibition, dated 11/17, revealed the health care center's management prohibits neglect, mental or physical abuse, including misappropriation of resident's property and/or funds. This policy indicated the health care center management would conduct a prompt investigation of any allegation received of suspected abuse, neglect, or misappropriation of property and or funds. If warranted the health care center's management would provide notification to the proper authorities and when required, the release of information to those agencies. Misappropriation was defined as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. 2. Review of the medical record revealed Resident #51 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the February 2021 physician's orders revealed Resident #51 had an order dated 02/23/21 for one tablet of 3/325 mg of oxycodone-acetaminophen (narcotic pain reliever) every four hours as needed for pain. Review of the February 2021 MAR revealed Resident #51 was not administered any narcotic pain medication by LPN #300 on 02/24/21. Review of the AlixaRx Control PRN Dispense by Shift sheet dated 02/24/21 from 7:00 A.M. to 5:00 P.M. revealed LPN #300 removed one tablet of oxycodone/acetaminophen 5/325 mg at 3:45 P.M. for Resident #51. Review of the employee time sheet revealed LPN #300 worked on 02/24/21 from 8:00 A.M. to 4:15 P.M. Review of the admission Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #51 was alert, oriented, had intact cognition and received opioid medication seven days in the assessment period. Review of the undated facility's Diversion Investigation revealed LPN #300 denied drug diversion. There were no discrepancies involving LPN #300 prior to February 2021. The investigation indicated there were no medication errors identified, no negative outcomes involving a resident and all mediation were credited back to the resident's account via the pharmacy. On 02/24/21, LPN #300 was assigned to work 8:00 A.M. to 4:30 P.M. At approximately 7:30 P.M. the nurse on the 100 Hall reviewed the narcotic dispense report and noticed three doses of as needed narcotics had been dispensed to LPN #300 for two separate residents [later identified as Resident #22 and #51]. The 100 Hall nurse reported this information to the Director of Nursing (DON). This resulted in an investigation being initiated and conducted, including nurse and resident interview statements obtained. The Administrator, Human Resources and the Medical Director were notified. The two residents in the report were alert and oriented and both reported they had not requested as needed pain medication, nor did they receive any pain medication the previous shift. The DON checked the MARs for Resident #22 and #51 and they stated they had not received the controlled medication as listed on the narcotic dispensary report. The pain medication was not documented on the MARs by LPN #300 as administered. A limited accountability audit (the audit would only go back 90 days) was conducted for LPN #300's dispensing occurrences of controlled substances from 12/01/20 to 02/24/21 and the substance audit included all controlled medications from the AlixaRx machine. This pharmacy report identified 280 medications dispensed by LPN #300 just for February, 2021. The summary results of the audits included, but may not be limited to, controlled substances which were dispensed without further documentation on the MAR to substantiate the administration of the drug to the resident, residents denied administration of controlled substances, and controlled substances were signed out without accountability of wasting them. Additionally, during the audit period, LPN #300 was the only nurse to dispense this narcotic pain reliever (oxycodone/acetaminophen) for Resident #22 and #51 on each of the 280 occasions. Of the 280 medications dispensed by LPN #300, none were documented as administered on the MARS. On 02/24/21, LPN #300 worked in the restorative department and was not assigned to a resident unit but dispensed three oxycodone tablets from the AlixaRx machine. When LPN #300 was questioned by the Administrator and the DON, LPN #300 denied diverting the medications for herself or anyone else. LPN #300 admitted she dispensed the medications but said she administered the medication but forgot to document the administration on the MAR. The resident denied receiving the mediation as referenced by LPN #300. In addition, LPN #300 provided evidence of having her own prescriptions for oxycodone for pain management. Thus, her drug test was positive. LPN #300 was suspended on 02/24/21 pending investigation. As a result of the investigation, LPN #300's employment was terminated on 03/01/21. Review of the unsigned, undated handwritten witness statement by Resident #51 dated revealed she had needed pain medication for a headache and asked the male nurse but that was the only person. Interview on 04/02/21 at 9:15 A.M. with the DON revealed nurses go into the AlixaRx and choose what medication they need, put in a password and fingerprint and then the medication would be dispensed, and a report generated. The nurse had to then have another nurse sign off to verify the medication was pulled, and she would get the report. The DON said the other nurse does not have to be in the room when the medication was dispensed so there was a possibility the nurse could pull a medication and put it in their pocket and throw the dispense report away. She verified there was a video of LPN #300 going into the AlixaRx dispensing room on 02/24/21 at the times the medications were dispensed to her. It was unclear if LPN put the narcotics in her pocket but she then shortly left the premises without administering any medication to any residents. The DON said the video had been turned over to the Ohio Attorney General's Office, so they did not have it available for surveyor review. Interview on 04/02/21 at 3:00 P.M. with the DON verified they had not completed and submitted a facility Self-Reported Incident (SRI) to the State Agency as required for misappropriation. The DON said the former Administrator stated it was not needed because there was no misappropriation since the residents were reimbursed the money from the medication. Review of the facility policy, Abuse Prohibition, dated 11/17, revealed the health care center's management prohibits neglect, mental or physical abuse, including misappropriation of resident's property and/or funds. This policy indicated the health care center management would conduct a prompt investigation of any allegation received of suspected abuse, neglect, or misappropriation of property and or funds. If warranted the health care center's management would provide notification to the proper authorities and when required, the release of information to those agencies. Misappropriation was defined as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent.

Based on record review and interview the facility failed to ensure allegations of misappropriation of narcotics for Resident #22 and Resident #51 were reported immediately, but no later than two hours after the allegation was made and with results reported within five working days to the State Agency as required. This affected two of three residents reviewed for misappropriation of medications. Findings include: 1. Review of the medical record revealed Resident #22 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #22 was alert, oriented with intact cognition and received opioid medication five days in the assessment period. Review of the February 2021 physician's orders revealed Resident #22 had an order dated 01/25/21 for one table of 5/325 milligrams (mg) oxycodone-acetaminophen (narcotic pain medication) every six hours prn, which means as needed for pain. Review of the AlixaRx (a medication dispensing system) Control PRN Dispense by Shift document dated 02/24/21 from 7:00 A.M. to 5:00 P.M. revealed Licensed Practical Nurse (LPN) #300 removed one tablet of oxycodone/acetaminophen 5/325 mg at 8:59 A.M. and one tablet of oxycodone/acetaminophen 5/325 mg at 3:43 P.M. for Resident #22. Review of the employee time sheet revealed LPN #300 worked on 02/24/21 from 8:00 A.M. to 4:15 P.M. Review of the February 2021 Medication Administration Record (MAR) revealed Resident #22 had not been administered pain medication by LPN #300 on 02/24/21. Review of the undated facility's Diversion Investigation revealed LPN #300 denied drug diversion. There were no discrepancies involving LPN #300 prior to February 2021. The investigation indicated there were no medication errors identified, no negative outcomes involving a resident and all mediation were credited back to the resident's account via the pharmacy. On 02/24/21, LPN #300 was assigned to work 8:00 A.M. to 4:30 P.M. At approximately 7:30 P.M. the nurse on the 100 Hall reviewed the narcotic dispense report and noticed three doses of as needed narcotics had been dispensed to LPN #300 for two separate residents [later identified as Resident #22 and #51]. The 100 Hall nurse reported this information to the Director of Nursing (DON). This resulted in an investigation being initiated and conducted, including nurse and resident interview statements obtained. The Administrator, Human Resources and the Medical Director were notified. The two residents in the report were alert and oriented and both reported they had not requested as needed pain medication, nor did they receive any pain medication the previous shift. The DON checked the MARs for Resident #22 and #51 and they stated they had not received the controlled medication as listed on the narcotic dispensary report. The pain medication was not documented on the MARs by LPN #300 as administered. A limited accountability audit (the audit would only go back 90 days) was conducted for LPN #300's dispensing occurrences of controlled substances from 12/01/20 to 02/24/21 and the substance audit included all controlled medications from the AlixaRx machine. This pharmacy report identified 280 medications dispensed by LPN #300 just for February, 2021. The summary results of the audits included, but may not be limited to, controlled substances which were dispensed without further documentation on the MAR to substantiate the administration of the drug to the resident, residents denied administration of controlled substances, and controlled substances were signed out without accountability of wasting them. Additionally, during the audit period, LPN #300 was the only nurse to dispense this narcotic pain reliever (oxycodone/acetaminophen) for Resident #22 and #51 on each of the 280 occasions. Of the 280 medications dispensed by LPN #300, none were documented as administered on the MARS. On 02/24/21, LPN #300 worked in the restorative department and was not assigned to a resident unit but dispensed three oxycodone tablets from the AlixaRx machine. When LPN #300 was questioned by the Administrator and the DON, LPN #300 denied diverting the medications for herself or anyone else. LPN #300 admitted she dispensed the medications but said she administered the medication but forgot to document the administration on the MAR. The resident denied receiving the mediation as referenced by LPN #300. In addition, LPN #300 provided evidence of having her own prescriptions for oxycodone for pain management. Thus, her drug test was positive. LPN #300 was suspended on 02/24/21 pending investigation. As a result of the investigation, LPN #300's employment was terminated on 03/01/21. Review of the unsigned, undated handwritten witness statement by Resident #22 revealed he had not asked for any pain medications on the day in question. Interview on 04/02/21 at 9:15 A.M. with the DON revealed nurses go into the AlixaRx and choose what medication they need, put in a password and fingerprint and then the medication would be dispensed, and a report generated. The nurse had to then have another nurse sign off to verify the medication was pulled, and she would get the report. The DON said the other nurse does not have to be in the room when the medication was dispensed so there was a possibility the nurse could pull a medication and put it in their pocket and throw the dispense report away. She verified there was a video of LPN #300 going into the AlixaRx dispensing room on 02/24/21 at the times the medications were dispensed to her. It was unclear if LPN put the narcotics in her pocket but she then shortly left the premises without administering any medication to any residents. The DON said the video had been turned over to the Ohio Attorney General's Office, so they did not have it available for surveyor review. Interview on 04/02/21 at 3:00 P.M. with the DON verified they had not completed and submitted a facility Self-Reported Incident (SRI) to the State Agency as required for misappropriation. The DON said the former Administrator stated it was not needed because there was no misappropriation since the residents were reimbursed the money from the medication. Review of the facility policy, Abuse Prohibition, dated 11/17, revealed the health care center's management prohibits neglect, mental or physical abuse, including misappropriation of resident's property and/or funds. This policy indicated the health care center management would conduct a prompt investigation of any allegation received of suspected abuse, neglect, or misappropriation of property and or funds. This policy indicated all allegations would be reported immediately to the Administrator/Designee and to other agencies including the state survey agency. If warranted the health care center's management would provide notification to the proper authorities and when required, release of information to those agencies. Misappropriation was defined as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. 2. Review of the medical record revealed Resident #51 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the February 2021 physician's orders revealed Resident #51 had an order dated 02/23/21 for one tablet of 3/325 mg of oxycodone-acetaminophen (narcotic pain reliever) every four hours as needed for pain. Review of the February 2021 MAR revealed Resident #51 was not administered any narcotic pain medication by LPN #300 on 02/24/21. Review of the AlixaRx Control PRN Dispense by Shift sheet dated 02/24/21 from 7:00 A.M. to 5:00 P.M. revealed LPN #300 removed one tablet of oxycodone/acetaminophen 5/325 mg at 3:45 P.M. for Resident #51. Review of the employee time sheet revealed LPN #300 worked on 02/24/21 from 8:00 A.M. to 4:15 P.M. Review of the admission Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #51 was alert, oriented, had intact cognition and received opioid medication seven days in the assessment period. Review of the undated facility's Diversion Investigation revealed LPN #300 denied drug diversion. There were no discrepancies involving LPN #300 prior to February 2021. The investigation indicated there were no medication errors identified, no negative outcomes involving a resident and all mediation were credited back to the resident's account via the pharmacy. On 02/24/21, LPN #300 was assigned to work 8:00 A.M. to 4:30 P.M. At approximately 7:30 P.M. the nurse on the 100 Hall reviewed the narcotic dispense report and noticed three doses of as needed narcotics had been dispensed to LPN #300 for two separate residents [later identified as Resident #22 and #51]. The 100 Hall nurse reported this information to the Director of Nursing (DON). This resulted in an investigation being initiated and conducted, including nurse and resident interview statements obtained. The Administrator, Human Resources and the Medical Director were notified. The two residents in the report were alert and oriented and both reported they had not requested as needed pain medication, nor did they receive any pain medication the previous shift. The DON checked the MARs for Resident #22 and #51 and they stated they had not received the controlled medication as listed on the narcotic dispensary report. The pain medication was not documented on the MARs by LPN #300 as administered. A limited accountability audit (the audit would only go back 90 days) was conducted for LPN #300's dispensing occurrences of controlled substances from 12/01/20 to 02/24/21 and the substance audit included all controlled medications from the AlixaRx machine. This pharmacy report identified 280 medications dispensed by LPN #300 just for February, 2021. The summary results of the audits included, but may not be limited to, controlled substances which were dispensed without further documentation on the MAR to substantiate the administration of the drug to the resident, residents denied administration of controlled substances, and controlled substances were signed out without accountability of wasting them. Additionally, during the audit period, LPN #300 was the only nurse to dispense this narcotic pain reliever (oxycodone/acetaminophen) for Resident #22 and #51 on each of the 280 occasions. Of the 280 medications dispensed by LPN #300, none were documented as administered on the MARS. On 02/24/21, LPN #300 worked in the restorative department and was not assigned to a resident unit but dispensed three oxycodone tablets from the AlixaRx machine. When LPN #300 was questioned by the Administrator and the DON, LPN #300 denied diverting the medications for herself or anyone else. LPN #300 admitted she dispensed the medications but said she administered the medication but forgot to document the administration on the MAR. The resident denied receiving the mediation as referenced by LPN #300. In addition, LPN #300 provided evidence of having her own prescriptions for oxycodone for pain management. Thus, her drug test was positive. LPN #300 was suspended on 02/24/21 pending investigation. As a result of the investigation, LPN #300's employment was terminated on 03/01/21. Review of the unsigned, undated handwritten witness statement by Resident #51 dated revealed she had needed pain medication for a headache and asked the male nurse but that was the only person. Interview on 04/02/21 at 9:15 A.M. with the DON revealed nurses go into the AlixaRx and choose what medication they need, put in a password and fingerprint and then the medication would be dispensed, and a report generated. The nurse had to then have another nurse sign off to verify the medication was pulled, and she would get the report. The DON said the other nurse does not have to be in the room when the medication was dispensed so there was a possibility the nurse could pull a medication and put it in their pocket and throw the dispense report away. She verified there was a video of LPN #300 going into the AlixaRx dispensing room on 02/24/21 at the times the medications were dispensed to her. It was unclear if LPN put the narcotics in her pocket but she then shortly left the premises without administering any medication to any residents. The DON said the video had been turned over to the Ohio Attorney General's Office, so they did not have it available for surveyor review. Interview on 04/02/21 at 3:00 P.M. with the DON verified they had not completed and submitted a facility Self-Reported Incident (SRI) to the State Agency as required for misappropriation. The DON said the former Administrator stated it was not needed because there was no misappropriation since the residents were reimbursed the money from the medication. Review of the facility policy, Abuse Prohibition, dated 11/17, revealed the health care center's management prohibits neglect, mental or physical abuse, including misappropriation of resident's property and/or funds. This policy indicated the health care center management would conduct a prompt investigation of any allegation received of suspected abuse, neglect, or misappropriation of property and or funds. This policy indicated all allegations would be reported immediately to the Administrator/Designee and to other agencies including the state survey agency. If warranted the health care center's management would provide notification to the proper authorities and when required, release of information to those agencies. Misappropriation was defined as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent.

Based on interview and record review, the facility failed to ensure one of three staff (State tested Nurse Aide (STNA) 20) reviewed for COVID testing, was tested twice a week per the county positivity rate. This failure had the potential to increase the risk of spreading COVID-19 in the facility and had the potential to affect any residents or staff of the facility who had not either been fully vaccinated for COVID-19 or had not recently tested positive for COVID-19. Findings include: Review the Centers for Medicare and Medicaid Services (CMS) website titled COVID-19 Nursing Home Data, revealed the following county positivity rate and color for the week ending February 24, ,2021. The county positivity rate was 15.5%-Red, which indicated staff were to be tested twice a week. Continued review revealed for the week ending of March 2, 2021, the county positivity rate was 15.1%-Red, which indicated staff were to be tested twice per week. Further review revealed for the week ending of March 9, 2021, the county positivity rate was 14.4%-Red, which indicated staff were to be tested twice per week. Review of the QSO-20-38-NH Memo dated 08/26/20 revealed, .483.80(h) COVID-19 Testing. The LTC facility must test residents and facility staff, including individuals providing services under arrangement and volunteers, for COVID-19. At a minimum, for all residents and facility staff, including individuals providing services under arrangement .the LTC must: (1) Conduct testing based on parameters set forth by the Secretary, including but not limited to: testing frequency .(5) Have procedures for addressing residents and staff, including individuals providing services under arrangement and volunteers, who refuse testing or are unable to be tested . Facility staff includes employees, consultants, contractors, volunteers, and caregivers who provide care and services to residents on behalf of the facility .We note that the facility may have a provision under its arrangement with a vendor or volunteer that requires them to be tested from another source (e.g., their employer or on their own). However, the facility is still required to obtain documentation that the required testing was completed during the timeframe that corresponds to the facility's testing frequency . Routine Testing of Staff. Routine testing should be based on the extent of [MEDICAL CONDITION] in the community; therefore, facilities should use their county positivity rate in the prior week as the trigger for staff testing frequency . https://data.cms.gov/stories/s/COVID-19-Nursing-Home-Data/bkwz-xpvg .County Positivity Rate in the past week > (greater than) 10%. Minimum testing frequency twice a week . Review of the facility's policy titled, RESIDENT AND STAFF COVID-19 TESTING, revised 02/18/21 revealed, . To enhance efforts to keep COVID-19 from entering and spreading through nursing homes, facilities are required to test residents and staff, including individuals providing services under arrangement .for COVID-19 based on parameters and a frequency set forth by the HHS Secretary . On August 25, 2020, CMS published an interim final rule with comment period (IFC). This rule establishes Long-Term Care (LTC) Facility Testing Requirements for Staff and Residents .1. At a minimum, for all residents and facility staff, including individuals providing services under arrangement .the LTC facility will: a. Conduct testing based on parameters set forth by the Secretary, including but not limited to . i. Testing frequency . iv. The criteria for conducting testing of asymptomatic individuals specified in this paragraph, such as the positivity rate of COVID-19 in a county . 3. For each instance of testing: i. Document that testing was completed and the results of each staff test .PROCEDURE: 1. Staff testing will be conducted per the guidelines of CMS and/or ODH . For staff routine testing, document; The facility's county positivity rate both CMS data and ODH data a. The corresponding testing frequency indicated and; b. The date each positivity rate was collected and; c. The date(s) that testing was performed for all staff and d. The results of each test . Review of State tested Nurse Aide (STNA) 20's COVID-19 test results for the prior three weeks revealed: for the week of 02/21/21 the STNA was tested on [DATE]; for the week of 02/28/21 the STNA was tested on [DATE]. The facility did not provide any documented evidence of any other test results for the three weeks which indicated STNA20 was only tested on e time per week and not twice each week per the regulatory requirements based on the county positivity rate. Interview on 03/10/21 at 3:14 PM with STNA20 revealed she had worked consistently at the facility for the last three weeks. The Director of Nursing (DON) confirmed the dates STNA20 worked in the facility: 02/23/21, 02/24/21, 02/26/21, 03/01/21, 03/02/21, 03/04/21 and 03/05/21. STNA20 confirmed during the interview on 03/10/21 at 3:14 PM that she was COVID-19 tested on e time each week. STNA20 stated she was not aware she needed to be tested twice a week. Interview on 03/11/21 at 2:48 PM with the Medical Director revealed it was his expectation that facility staff would follow the mandated testing guidelines. Interview on 03/11/21 at 2:52 PM with the Administrator revealed it was her expectation that the agency staff would have been tested twice a week. Interview on 03/11/21 at 3:20 PM with the DON revealed it was her expectation all facility staff would be tested twice a week per the testing mandate. Interview on 03/11/21 at 3:04 PM with the Infection Preventionist (IP) revealed she was not aware STNA20 was not being tested twice a week. The IP stated it was her expectation staff are tested twice a week to be in compliance with the mandatory testing.

Based on observation, interview, and record review, the facility failed to have an effective Infection Prevention and Control Program (IPCP) to prevent the potential transmission of COVID-19 within the facility for one (R7) of seven sampled residents. The facility staff shared the same PPE gown for R7 who was on transmission-based precautions (TBP) due to quarantine for possible COVID-19. Findings include: Review of the facility's policy titled, Facility Isolation Zones and Use of PPE; COVID-19, revised 02/18/21 revealed, .14-day quarantine zone. Asymptomatic. Includes [MEDICAL TREATMENT] patients, new admissions/readmits. Any new admission or resident transferred out of the facility for [MEDICAL TREATMENT], or any other immune suppressing therapy will be placed in the 14-day quarantine unit until the treatments have been completed . PPE: N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and resident-specific gown. Usage of gowns in the blue and yellow zone are required to be resident specific d/t the risk of cross contamination. Review of the facility's policy titled, COVID-19 DONNING AND DOFFING, revised 12/14/20, revealed .2. BLUE: 14-day quarantine zone. Asymptomatic .DON/DOFF: PPE may be donned and doffed in resident room or designated donning and doffing area. Usage of gowns in the blue zone are required to be resident specific d/t the risk of cross contamination. CDC does not recommend the use of more than one isolation gown at a time by HCP when providing care to patients with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection. Staff should not enter another resident's room without changing PPE in the blue unit. Any PPE that becomes soiled or defective, it should be disposed of and replaced immediately. 3. YELLOW: suspected/symptomatic and/or pending PCR test results. DON/DOFF: PPE may be donned and doffed in designated areas separating clean and dirty. Usage of gowns in the yellow zone are required to be resident specific d/t the risk of cross contamination. CDC does not recommend the use of more than one isolation gown at a time by HCP when providing care to patients with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection. Staff should not enter another resident's room without changing PPE in the yellow unit . Review of R7's undated Admission Record, located in R7's electronic medical record (EMR) under the profile tab, revealed R7 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of R7's Order Summary Report, located in R7's EMR under the orders tab, revealed R7 was ordered 14 day (sic) isolation every shift for admission requirement for 14 days . Observation on 03/10/21 at 12:45 PM revealed State tested Nurse Aide (STNA) 20 in R7's room assisting R7 with her meal. STNA20 wore a mask, face shield and gloves but was not wearing a gown. Continued observation revealed Licensed Physical Therapy Assistant (LPTA) 5 also in the resident's room assisting with meal set up for the resident. The LPTA5 doffed her PPE gown and hung the gown up on R7's door, doffed and disposed of her gloves, used ABHR and exited the room. Further observation revealed STNA20 then retrieved the PPE gown from the door that LPTA5 used and donned the gown. Outside of R7's door was a PPE bin and signage on the double fire doors on the unit which indicated that the rooms were blue (isolation) rooms. During an interview on 03/10/21 at 12:47 PM, the LPTA 5 confirmed STNA20 donned the same PPE gown she had just doffed prior to exiting R7's room. The LPTA5 stated it was the facility's procedure that multiple staff use the same gown per each resident. Interview on 03/10/21 at 12:56 PM with Registered Nurse (RN) 8 revealed it was the facility's procedure that multiple staff were to use the same PPE gown. RN8 stated each resident room had a gown. Interview on 03/10/21 at 1:00 PM with STNA20 revealed there was only one gown available for R7's room and when she entered R7's room, LPTA5 was finishing up in the room but was still wearing the room's PPE gown. STNA20 stated she delivered R7's lunch meal and assisted R7 with her meal without a gown; however, as soon as the gown was doffed by LPTA5, she retrieved the gown and donned the gown. STNA 20 also stated it was her understanding all staff were to use the same gown available for each room. Interview on 03/10/21 at 1:12 PM with Licensed Practical Nurse (LPN) 13 revealed each isolation room should have a couple gowns on the door. LPN13 stated the gowns where resident specific meaning multiple staff could use the same gown as long as it was for that specific resident. Interview on 03/10/21 at 1:18 PM with the Director of Nursing (DON) revealed it was her expectation that each shift, each staff person obtains a new gown for each resident room. The DON stated each staff person would use their gown the whole shift for each resident room. Continued interview with the DON revealed PPE gowns should not be shared by staff. Interview on 03/10/21 at 1:23 PM with the Administrator revealed it was her expectation that gown would have been employee specific as well as resident specific. The Administrator stated staff should not have been sharing PPE gowns due to possible cross contamination. Interview on 03/11/21 at 2:48 PM with the Medical Director revealed it was his expectation that staff would follow the policy and staff would have their own gown. Interview on 03/11/21 at 3:04 PM with the Infection Preventionist revealed it was her expectation that each staff person would have had their own PPE gown and gowns would not have been shared due to infection control purposes of preventing cross contamination.

Based on observation, interview, review of staff in-services, and nursing home guidance from the Centers for Disease Control and Prevention (CDC), the facility failed to ensure staff donned appropriate personal protective equipment, and followed facility policy for storing N95 respirator masks to prevent and/or contain COVID-19. This affected 11 (Resident #4, Resident #8, Resident #14, Resident #20, Resident #25, Resident #27, Resident #28, Resident #34, Resident #40, Resident #48, and Resident #49) of 30 facility residents who resided on the 100 hall. Findings include: On 06/09/20 at 9:10 A.M. an observation of State tested Nursing Assistant (STNA) #1 removing the trash bag from the waste receptacle in the room of a resident, who was on droplet isolation precautions for COVID-19, indicated she was not wearing a N95 respirator mask while performing her job duties. STNA #1 was wearing a yellow gown with a hole in the waist band tied behind her back and a face shield. STNA #1 entered the resident's room and removed the trash bag from the waste receptacle from the room. STNA #1 proceeded to obtain a clean trash bag to place in the waste receptacle. STNA #1 entered the resident's room and shook the clean trash bag to open the bag and then placed the trash bag inside the waste receptacle. An interview with STNA #1 upon exiting the room indicated she was aware she was supposed to wear a N95 mask while performing her job duties. STNA #1 indicated she was provided an N95 mask by the facility and was presently carrying the N95 mask in her pocket. STNA #1 then reached in her pocket and donned the mask. When asked if she had been trained on the appropriate use of the N95 mask and other personal protective equipment she responded she had been in-serviced. STNA #1 then indicated the facility had caused the COVID-19 infections within the facility due to transferring the residents from one unit to another in the facility. STNA #1 stated the COVID-19 infection was not spread by the staff. STNA #1 did not believe the N95 mask protected her from contracting COVID-19 and indicated the mask did not fit her appropriately. STNA #1 demonstrated there was a gap between the mask and her face which left her exposed and at risk for contracting COVID-19. STNA #1 stated the Director of Nursing (DON) was aware of her feelings about wearing the personal protective equipment. STNA #1 stated the facility had provided her with three N95 masks and three separate paper bags to place each used N95 mask at the end of her shift. The N95 mask could be re-used after three days. STNA #1 indicated she felt the practice was disgusting and was not happy about wearing the personal protective equipment in the facility. On 06/09/20 at 9:20 A.M. an interview with the DON indicated all staff were provided an in-service and trained on the proper use of personal protective equipment. The DON indicated STNA #1 was verbally counseled and instructed to wear the personal protective equipment the facility provided while performing her job duties. The DON also indicated STNA #1 was informed the failure to wear the appropriate personal protective equipment would result in termination from the facility. A follow-up interview with the DON on 06/09/20 at 11:30 A.M. indicated STNA #1 was trained on wearing the appropriate personal protective equipment while performing her assigned duties. The DON indicated STNA #1 was assigned to care for the residents who had a positive [DIAGNOSES REDACTED]. Review of CDC Recommended Guidance for Extended Use and Limited Reuse of N95 Filtering Facepiece Respirators in Healthcare Settings revealed Hang used respirators in a designated storage area or keep them in a clean, breathable container such as a paper bag between uses. To minimize potential cross-contamination, store respirators so that they do not touch each other and the person using the respirator is clearly identified. Storage containers should be disposed of or cleaned regularly. Clean hands with soap and water or an alcohol-based hand sanitizer before and after touching or adjusting the respirator (if necessary for comfort or to maintain fit). Avoid touching the inside of the respirator. If inadvertent contact is made with the inside of the respirator, discard the respirator and perform hand hygiene as described above. Use a pair of clean (non-sterile) gloves when donning a used N95 respirator and performing a user seal check. Discard gloves after the N95 respirator is donned and any adjustments are made to ensure the respirator is sitting comfortably on your face with a good seal. A review of the facility policy and procedure titled Progressive Quality Care Policy: COVID 19 [MEDICAL CONDITION] indicated under item (iii) Environmental controls, such as implementation of short-term isolation with staff use of N95 Respirator masks, will be employed in caring for residents suspected or confirmed active COVID-19. The resident will be instructed and assisted to don a regular surgical mask in situations where they are likely to come in contact with other persons, such as during transport. A review of the facility staff in-service provided to the employees on 03/20/20 indicated STNA #1 was provided the training on wearing the N95 respirator mask and other personal protective equipment while caring for residents with the COVID-19 [MEDICAL CONDITION] infection. Review of the facility census revealed Resident #4, Resident #8, Resident #14, Resident #20, Resident #25, Resident #27, Resident #28, Resident #34, Resident #40, Resident #48, and Resident #49 resided on the 100 hall which was a dedicated unit for COVID-19 positive residents.

Based on observation and staff interview the facility failed to pass ice water in a sanitary manner on the 300 Hall. This had the potential to affect 19 residents ( #14, #59, #28, #39, #30, #62, #49, #79, #65, #10, #51, #46, #79, #6, #69, #36, #93, #16, and #38) residing on the 300 Hall. Facility census was 83. Findings include: Observation on 09/23/19 at 11:06 [NAME]M. revealed State tested Nursing Assistant (STNA) #709 passing ice water down the 300 Hall. Glasses of ice water were pre-poured on top of a two tiered cart which was uncovered. The uncovered glasses were left unattended in the hall as STNA #709 entered resident rooms to deliver the ice water. An interview on 09/23/19 at 11:15 [NAME]M. with STNA #709 indicated they always passed ice water this way but she would ask about the proper way to pass ice water. At 11:30 [NAME]M. STNA #709 stated she was suppose to use the metal ice cart with a lid to pass ice one room at a time but she was in a hurry and did not do it the proper way.

Based on review of infection control logs, interviews, and policy review, the facility failed to notify the appropriate government agencies upon an outbreak of influenza in (MONTH) 2019 for ten confirmed cases of influenza (Residents #5, #12, #27, #32, #45, #73, #77, #81, #82, and #83) and fourteen suspected cases of influenza (Residents #33, #35, #42, #44, #48, #56, #57, #70, #76, #79, #84, #85, #86, and #87). The current facility census was 83 residents. Findings include: Review of the facility monthly infection control logs on 09/25/19 at 3:00 P.M. with Registered Nurse (RN) #814 and Licensed Practical Nurse (LPN) #823 revealed from 03/24/19through 04/11/19, the facility had 24 residents who presented with signs and symptoms of influenza which included chills, loss of appetite, and fever. Nasal swab tests were conducted on the 24 residents with ten returning positive (Residents #5, #12, #27,#32, #45, #73, #77, #81, #82, and #83) and fourteen returning negative (Residents #33, #35, #42, #44, #48, #56, #57, #70, #76, #79, #84, #85, #86, and #87). All residents who were tested for influenza were given [MEDICATION NAME] doses of [MEDICATION NAME] (a medicine totreat influenza). RN #814 and LPN #823 were unable to state whether or not the appropriate government agencies were notified at the time of the influenza outbreak. Interview with the Director of Nursing (DON) on 09/26/19 at 1:20 P.M. verified the facility did not contact the local or state health department of the influenza outbreak.The DON stated she had telephoned the local health department to verify they had not been notified of the outbreak. Review of the Centers for Disease Control and Prevention Guidance for Influenza Outbreak Management in Long-Term Care and Post-Acute Care Facilities dated 02/12/19 revealed The local public health and state health departments should be notified of every suspected or confirmed influenza outbreak in a long-term care facility, especially if a resident develops influenza while on or after receiving [MEDICAL CONDITION]. The guidance indicated a confirmed or suspected outbreak included two or more ill residents. Review of the facility's policy titled Outbreak of Communicable Diseases, revised (MONTH) 2014, revealed an outbreak of influenza was defined as anything exceeding the endemicrate, or a single case if unusual for the facility. The policy indicated the Administrator would be responsible for telephoning a report to the health department and forwarding Communicable Disease Report Cards as required. Review of the facility's policy titled Infection Prevention and Control Committee, revised (MONTH) (YEAR), indicated the duties of the committee was to notify government agenciesof reportable contagious or infectious disease. Review of facility's policy titled Infection Prevention and Control Program, revised (MONTH) (YEAR), revealed outbreak management was a process which consisted of determiningthe presence of an outbreak and reporting the information to the appropriate public health authorities.

Based on observations, review of the medical record, review of restorative notes and staff interview the facility failed to provide restorative programs as ordered for Residents #40 and #46. This affected two residents (Resident #40 and #46) of three reviewed of mobility and range of motion. Findings include: 1. Review of the medical record revealed Resident #40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the plan of care dated 07/18/19 revealed Resident #40 had a non-weight bearing status and had generalized weakness. The resident was at risk for decline in strength and function. Interventions included passive range of motion (PROM) to her upper and lower extremities six to seven days a week for a total of 15 minutes per day. Review of the quarterly Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #40 had severely impaired cognition, required extensive assistance of two staff members for bed mobility, toilet use and total assistance of two staff members for transferring. Review of the (MONTH) 2019 physician's orders [REDACTED]. Review of the (MONTH) 2019 restorative nursing program documentation revealed Resident # 40 received restorative nursing on 07/18/19, 07/24/19, 07/25/19, 07/28/19, 07/29/19, and 07/30/19. Review of the (MONTH) 2019 restorative nursing program documentation revealed Resident # 40 received restorative nursing on 08/02/19, 08/05/19, 08/07/19, 08/08/19, 08/12/19, 08/14/19, 08/15/19, 08/16/19, 08/17/19, 08/18/19, 08/20/19, 08/22/19, 08/24/19, 08/29/19, 08/30/19, and 08/31/19. Review of the (MONTH) 2019 restorative nursing program documentation revealed Resident # 40 received restorative nursing on 09/01/19, 09/02/19, 09/06/19, 09/09/19, 09/12/19, 09/13/19, 09/15/19, 09/16/19, 09/19/19, and 09/22/19. 2. Review of the medical record revealed Resident #46 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the significant change Minimum Data Set assessment dated [DATE] revealed Resident #46 had severely impaired cognition, required total assistance of two staff members for bed mobility, transfer, and toilet use. The resident had upper and lower extremity impairment to both sides. Review of the (MONTH) 2019 physician's orders [REDACTED]. Review of the plan of care dated 07/30/18 revealed Resident #49 had impaired physical mobility due to decline in ROM and stiffness related to [MEDICAL CONDITION]. The interventions included PROM to all extremities six to seven days a week for a total of 15 minutes per day. Review of the (MONTH) 2019 restorative nursing documentation revealed Resident #46 received restorative nursing on 07/04/19, 07/05/19, 07/08/19, 07/17/19, 07/18/19, and 07/23/19. Review of the (MONTH) 2019 restorative nursing documentation revealed Resident #46 received restorative nursing on 8/04/19, 08/06/19, 08/15/19, 08/21/19, 08/24/19, and 08/31/19. Review of the (MONTH) 2019 restorative nursing documentation revealed Resident #46 received restorative nursing on 09/01/19, 09/04/19, 09/06/19, 09/14/19, 09/15/19, and 09/17/19. Observation on 09/25/19 from 9:40 [NAME]M. to 10:12 [NAME]M. revealed State tested Nursing Assistant (STNA) #718 performing PROM to Resident #46. STNA #718 preformed two sets of PROM to the resident's elbow, knees and his hips. An interview 09/25/19 at 11:55 [NAME]M with Licensed Practical Nurse #815 verified the nursing assistant only provided PROM to the elbows, knees and hips of Resident #46. LPN #815 stated he was very rigid and verified there was no documentation indicating he was unable to perform the PROM exercises. LPN #815 verified Residents #40 and #46 had not been receiving PROM six to seven days a week as ordered and care planned. LPN #815 stated she had hired two new restorative aides but one did not show up this week. She also indicated the restorative aides did get pulled to the skilled unit quite a bit to work but the other STNAs were aware they were to pick up the restorative programs in their absence. An interview on 09/26/19 at 11:24 [NAME]M. with restorative STNA #718 indicated she worked four-10 hour days and was pulled to the floor to work quite a bit and was unable to complete the restorative programs; however, she indicated the STNAs were aware they were to pick up the restorative programs when she was not doing them.

Based on record review and interview, the facility failed to ensure timely significant change Preadmission Screening/ Resident Review (PAS/RR) assessments were completed and submitted for four (Resident #54, Resident #269, Resident #270, and Resident #271) of four residents reviewed for significant change PAS/RR screening. Findings include: 1. Medical record review revealed Resident #54 was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #54's record revealed an admission to an inpatient geriatric psychiatric unit on [DATE]. Resident #54's record did not include a significant change in condition secondary to admission to psychiatric unit PAS/RR screen. After request, the facility provided an expired time limit for hospital exemption PAS/RR screen for Resident #54 dated [DATE]. Interview with Admissions Director (AD) #255 on [DATE] at 2:54 P.M. revealed AD #255 did not know the procedure for having to submit a significant change of condition PAS/RR screen when a resident was admitted to an inpatient psychiatric unit. AD #255 verified not submitting the significant change PAS/RR screen for Resident #54. 2. Medical record review revealed Resident #269 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #269 was admitted to an inpatient geriatric psychiatric unit on [DATE]. Resident #269's medical record did not include a significant change of condition PAS/RR screen. 3. Medical record review revealed Resident #270 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #270 was admitted to an inpatient geriatric psychiatric unit on [DATE]. Resident #270's medical record did not include a significant change of condition PAS/RR screen. 4. Medical record review revealed Resident #271 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #271 was admitted to an inpatient geriatric psychiatric unit on [DATE]. Resident #271's medical record did not inlcude a significant change of condition PAS/RR screen. Interview with the director of nursing (DON) on [DATE] at 2:52 P.M. revealed the facility did not have a PAS/RR policy but followed the required guidelines. On [DATE] at 10:15 A.M. the DON stated only Resident #269 returned to the facility and confirmed significant change of condition PAS/RR screens were not completed on Resident #269, Resident #270, and Resident #271. At 10:30 A.M. on [DATE], the Administrator also verified significant change of condition PAS/RR Screens were not completed for Resident #269, Resident #270, and Resident #271.

Based on record review and interview, the facility failed to ensure timely significant change Preadmission Screening/ Resident Review (PAS/RR) assessments were completed and submitted for four (Resident #54, Resident #269, Resident #270, and Resident #271) of four residents reviewed for significant change PAS/RR screening. Findings include: 1. Medical record review revealed Resident #54 was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #54 was admitted to an inpatient geriatric psychiatric unit on [DATE]. Resident #54's record did not include a significant change in condition secondary to admission to psychiatric unit PAS/RR screen. After request, the facility provided an expired time limit for hospital exemption PAS/RR screen for Resident #54 dated [DATE]. Interview with Admissions Director (AD) #255 on [DATE] at 2:54 P.M. revealed AD #255 did not know the procedure for having to submit a significant change of condition PAS/RR screen when a resident was admitted to an inpatient psychiatric unit. AD #255 verified not submitting the significant change PAS/RR screen for Resident #54. 2. Medical record review revealed Resident #269 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #269 was admitted to an inpatient geriatric psychiatric unit on [DATE]. Resident #269's medical record did not include a significant change of condition PAS/RR screen. 3. Medical record review revealed Resident #270 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #270 was admitted to an inpatient geriatric psychiatric unit on [DATE]. Resident #270's medical record did not include a significant change of condition PAS/RR screen. 4. Medical record review revealed Resident #271 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #271 was admitted to an inpatient geriatric psychiatric unit on [DATE]. Resident #271's medical record did not include a significant change of condition PAS/RR screen. Interview with the director of nursing (DON) on [DATE] at 2:52 P.M. revealed the facility did not have a PAS/RR policy but followed the required guidelines. On [DATE] at 10:15 A.M. the DON stated only Resident #269 returned to the facility and confirmed significant change of condition PAS/RR screens were not completed on Resident #269, Resident #270, and Resident #271. At 10:30 A.M. on [DATE], the Administrator also verified significant change of condition PAS/RR Screens were not completed for Resident #269, Resident #270, and Resident #271.

Based on record review and interview, the facility failed to ensure timely Preadmission Screening/ Resident Review (PAS/RR) assessments were completed at the time of the 30 day Hospital Exemption for one (Resident #54) of three residents (Resident #54, Resident #21, and Resident #65) reviewed for PAS/RR screening. Findings include: Medical record review revealed Resident #54 was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #54 was admitted with a Hospital Exemption from Preadmission Screening Notification screen (Job and Family Services Form (JFS) ) dated [DATE]. This screen was completed by the discharging hospital and indicated Resident #54 required fewer than 30 days of nursing facility services. The JFS form indicated the facility accepted responsibility for requesting a resident review (if required) prior to the 30th day following admission from the hospital. Resident #54's record did not include a resident review secondary to Resident #54 requiring longer than a 30 day length of stay. On [DATE] at 9:10 A.M. the facility provided an expired time limit for hospital exemption PAS/RR screen dated [DATE]. On [DATE] at 8:45 A.M. the Administrator provided an expired time limit for hospital exemption PAS/RR screen dated [DATE], however this screen was dated 40 days past the original date of admission. Interview with the Director of Nursing on [DATE] at 2:52 P.M. revealed the facility did not have a PAS/RR policy but followed the required guidelines. Interview with the Admissions Director (AD) #255 on [DATE] at 2:54 P.M. revealed the majority of the facility residents were admitted with the Hospital Exemption forms. AD #255 further stated during the first 30 days a PAS/RR screen was completed and stapled to the Hospital Exemption form and placed in the resident's business office folder. AD #255 verified not completing an initial screen upon Resident #54's expiration of her 30 day Hospital Exemption screen.

Based on staff interview and record review, the facility failed to ensure that residents received showers at a reasonable time and had shower schedules that promoted their quality of life. Three residents , (Residents #8, #54, #42), who were not capable of refusing or voicing complaints, were awakened from sleep during the night, gotten out of bed, showered and put back in bed. This resulted in Actual Harm for Resident #54 who would cry when awakened for a shower, for Resident #42 who was non-verbal but would tense up at shower time, and for Resident #8 who would cry, become combative, and fight staff when being undressed and during the shower. This affected three of seven residents reviewed in regard to third shift showers. Findings include: 1. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was assessed on the Minimum Data Set (MDS) 3.0 assessment dated [DATE] as being totally dependent for bed mobility, transfers all activities of daily living (ADLs) and bathing. Review of the facility shower schedule revealed Resident #8 was scheduled to get a shower on the night shift (10:45 P.M. to 6:45 A.M.) on Wednesday and Saturday. 2. Review of the medical record revealed Resident #54 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was assessed on the MDS 3.0 assessment dated [DATE] as being totally dependent for transfers and bathing, and required extensive assistance for ADLs. Review of the shower schedule revealed Resident #54 was scheduled for a shower on the night shift on Monday and Thursday. 3. Review of the medical record revealed Resident #42 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was assessed on the MDS 3.0 assessment dated [DATE] as being totally dependent with bathing, toileting, transfers, bed mobility, eating and ADLs. Review of the facility shower schedule revealed the resident was scheduled to get a shower on the night shift on Tuesday and Friday. In an interview on 01/20/15 at 4:30 A.M., Registered Nurse (RN) #4 stated that showers were done on the night shift. If a resident didn ' t want to get the shower they didn ' t have to. If a resident had dementia and was non-verbal they would not be capable of indicating that. RN #4 stated that residents on the short term rehab unit did not get their showers on the night shift because they did not want to get up for a shower. RN #4 stated that the residents who received showers on the night shift resided on the long term care unit. In an interview on 01/20/15 at 5:04 A.M., State tested Nurse Aide (STNA) #1 stated that the night shift STNAs clocked in for work at 10:45 P.M. Showers were started at that time. Residents were awakened from a sound sleep for their shower. STNA #1 stated that Resident #54 would cry when she was awakened for a shower. STNA #1 stated Resident #54 was confused but able to understand that it was time for a shower. STNA #1 stated Resident #42 was non-verbal but would tense up when it was shower time. In an interview on 01/20/15 at 5:12 A.M., STNA #15 stated that scheduled third shift showers were done at the beginning of the shift, and were usually done by 12:00 A.M. STNA #15 stated that residents were usually sound asleep at the beginning of the shift. Staff would wake them from a sound sleep, undress them, give them a shower, redress them and put them back in bed. STNA #15 stated that Resident #8 would grab and hold the covers to herself and try to grab the shower hose. STNA #15 felt Resident #8 wanted to stay asleep in bed. In an interview on 01/20/15 at 5:20 A.M. STNA # 14 stated the routine was that third shift showers were done at the beginning of the shift. Most of the residents were sound asleep. Staff would awaken them and ask if they wanted a shower. If the resident was not capable of responding, staff was told to get them up and give them a shower. In an interview on 01/20/15 at 5:30 A.M. STNA # 5 stated that residents were awakened from sleep for a shower at the beginning of the night shift. The residents were usually not capable of saying they didn ' t want to get a shower at that time. STNA #5 stated that Resident #8 would cry, hold the covers, fight when being undressed and during the shower. This resident was not normally combative. STNA #5 would tell the charge nurse or supervisor about this and was told to give the shower anyway. In an interview on 01/20/15 at 10:25 A.M. STNA #9 stated that when he/she worked night shift showers were given at 10:45 P.M. at the beginning of the shift. In an interview on 01/20/15 at 10:30 A.M. STNA # 10 stated that showers on the third shift were given at the beginning of the shift and the residents were awakened from sleep for the shower. The residents who were scheduled for the night shifts were usually non-verbal and not capable of complaining about the shower or refusing the shower. In a meeting on 01/20/15 at 12:56 P.M. the facility administrator and director of nursing both stated that staff was not told to give a shower to anyone who did not want one on third shift. Both stated that staff was not told to wake up a sleeping resident to give them a shower. Both verified that residents were scheduled for night shift showers. Both verified the shower logs indicated the residents received the scheduled showers. This deficiency substantiates Complaint Number OH 404.

Based on record review and interview the facility failed to ensure a mechanical lift transfer was performed in a safe manner for Resident #29. This resulted in harm when Resident #29 fell , fracturing her arm and suffering a brain hemorrhage. This affected one resident (Resident #29) of four residents reviewed for falls and had the potential to affect 19 residents who were transferred by mechanical lift. Findings include: Review of Resident #29's medical record revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. A progress noted dated 07/28/14 at 7:12 A.M. revealed the nurse was called to the resident's room. The resident was lying flat on the floor with a mechanical lift (Hoyer lift) above her. The note revealed the two State tested nursing assistants (STNA's) that were present indicated they were transferring Resident #29 from her bed into a wheelchair using the mechanical lift. The straps to the lift pad slipped off the lift bars and the resident fell . The nurse assessed the resident to have a hematoma to the back of her head near the neck, as well as a four inch hematoma at the base of her neck. Resident #29 was transferred to the hospital and admitted . A progress note dated 07/31/14 at 1:10 A.M., indicated the resident returned to the nursing home with [DIAGNOSES REDACTED]. Review of the facility's investigation did not indicate what caused the lift pad to slip off the Hoyer lift. On 09/02/14 at 9:47 P.M., the director of nursing (DON) indicated the hospital was unable to determine the age of Resident #29's C1 fracture. She agreed the fall from the Hoyer lift caused the fracture to Resident #29's right humerus and the subdural hemorrhage. The DON indicated the facility's investigation revealed the incorrect colored loop from the Hoyer lift pad was placed on the lower Hoyer lift hook prior to transfer. This caused the lift pad to slip off and resulted in the resident's fall and subsequent injury. This deficiency substantiates Complaint Number OH 092.