Every finding on record at Andover Village Retirement Community

Based on observation, interviews, record review, and review of facility policy, the facility failed to implement care planned interventions to address dining needs for Resident #65. This affected one (Resident #65) resident of 20 residents reviewed for care plans. The facility census was 61.Findings include: Review of the medical record for Resident #65 revealed an admission date of 08/09/22 with diagnoses including dysphagia (difficulty swallowing), depression, anxiety disorder, restlessness and agitation, and dementia without behavioral disturbance. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #65 had moderate cognitive impairment, adequate hearing, and unclear speech. Resident #65 sometimes made herself understood, and she was sometimes able to understand others. There was no rejection of care and maximal assistance was needed by staff for eating. Review of the care plan, date initiated 08/17/22, revealed Resident #65 had a self-care deficit in eating related to cognitive deficits, impaired mobility, need for verbal and physical cues, required assistance with eating and weakness. Interventions included nursing rehab: dining program staff to feed resident all meals while in her room, 15 minutes, seven days a week; converse with Resident #65 during the meal to make mealtime more pleasant, alternate bites of food with fluids, allow the resident to choose the order of foods, when possible, give verbal and physical prompts and cues when necessary. Observation on 07/20/26 from 4:30 P.M. to 4:45 P.M. revealed Resident #65 was in the dining room with other residents for the dinner meal and Resident #65 was being provided with eating assistance by Certified Nursing Assistant (CNA) #507. CNA #507 was standing next to Resident #65, who was seated in a Broda chair. Resident #65 moaned and whimpered while CNA #65 stood over the resident and repeatedly placed spoons of food up to Resident #65's lips for five attempts as Resident #65 kept her lips tightly closed and continued to moan. Resident #65 was observed trying to push the food away while whimpering. During the interaction, CNA #507 stated to the resident You need to eat this, and after five attempts to get spoons of food into the residents mouth with no success, CNA #507 then forcefully set the spoon down onto the tray in front of the resident and in a frustrated tone stated to her coworkers and other residents in the dining room I don't know what to do! and does she always eat like this? CNA #507 did not explain to the resident what foods were being offered to her and did not try to make pleasant conversation with the resident who remained in the dining room throughout the observation. An interview on 07/20/26 at 4:50 P.M. with CNA #507 verified she stood while feeding Resident #65 and was unable to get Resident #65 to eat while in the dining room. CNA #507 stated she did not know if Resident #65 was care planned for any specific feeding interventions and did not know if she was prone to refusing meals or eating difficulty. CNA #507 stated Resident #65 kept letting food run down her mouth because she would not open her mouth. An interview on 07/21/26 at 4:20 P.M. with Licensed Practical Nurse (LPN) #532 revealed Resident #65 was usually pleasant, sometimes she would hold her mouth shut for food or medicine but if staff spoke pleasantly with her she would eat or take her medicine.An interview on 07/22/26 at 11:47 A.M. with Restorative Registered Nurse (RRN) #515 revealed Resident #65's baseline included dementia care requiring maximal assistance with feeding. RRN #515 stated Resident #65's care plan was initiated for a deficit in eating related to her cognitive deficit because the progression of dementia caused Resident #65 not to know how to feed herself. RRN #515 verified the care plan interventions were initiated to assist staff in how to be successful feeding Resident #65. RN #515 verified Resident #65 was to be fed in her room per the care planned interventions for a calm setting, staff were to provide pleasant conversation during the meal, explain what foods were being offered and provide verbal and physical cues and prompts during the meal. A follow-up interview on 07/23/26 at 8:37 A.M. with CNA #507 revealed she could not get Resident #65 to open her mouth while feeding her dinner on 07/20/26 so she wanted to stand by her face and put it in her mouth. CNA #507 stated she could not figure out how to get Resident #65 to eat, she was at a loss and stated she was unaware Resident #65 had a care plan to address eating due to her dementia. Review of facility policy titled Activities of Daily Living (ADLs), Supporting Revised March 2018, revealed appropriate care and services would be provided for residents who were unable to carry out ADLs in accordance with the plan of care.

Based on record review, interview and review of facility policy, the facility failed to obtain weekly weights for Resident #14 who was at nutritional risk for weight loss. This affected one (Resident #14) of five residents reviewed for nutrition. The facility identified 11 residents (Resident #14, #12, #18, #8, #30, #31, #72, #36, #71, #42, and #10) with physician orders for weekly weights. The facility census was 61.Findings include:Review of the medical record for Resident #14 revealed an admission date of 11/09/25 with diagnoses including malignant neoplasm of prostate, anorexia, mild protein calorie malnutrition, dysphagia ( difficulty swallowing) , and dementia without behavior disturbance.Review of the care plan, date initiated 11/13/25, revealed Resident #14 was at nutritional risk related to abnormal labs, polypharmacy, consumes less than seventy-five percent of meals, refusal to eat, loss of appetite, risk for skin impairment, Body Mass Index less than eighteen, diagnosis of dementia, dysphagia, respiratory failure, malignant neoplasm of prostate (cancer), and mild protein malnutrition. Interventions included Intake and Output as ordered, monitor weight weekly times four then monthly if stable, and notify the registered dietitian and physician of significant weight change of greater than or equal to five percent.Review of physician orders for Resident #14 revealed a weight order with a start date of 11/16/25 for weight every shift every seven days with a stop date of 06/15/26. Review of a physician order dated 06/12/26 revealed a weight order for weight every shift every seven days and there was no stop date.Review of the Treatment Administration Record (TAR) dated January 2026 revealed a treatment order start date 11/16/26 and discontinue date of 06/15/26 to obtain a weight every shift every seven days. There was no record of weight on 01/04/26. Review of the medical record weight summary section revealed no weight was documented on 01/04/26 for Resident #14.Review of TAR dated April 2026 revealed a treatment order start date of 11/16/26 and discontinue date of 06/15/26 to obtain a weight every shift every seven days. There was no record of weight on 04/12/26 and 04/25/26. Review of the medical record weight summary section revealed a weight was not documented on 04/12/26 and 04/25/26 for Resident #14.Review of the TAR dated May 2026 revealed a treatment order start date of 11/16/26 and discontinue date of 06/15/26 to weigh every shift every seven days. There was no weight documented on 05/10/26 and 05/24/26.Review of the medical record weight summary section revealed no weight was documented on 05/10/26 and 05/24/26 for Resident #14.Review of the TAR dated July 2026 revealed a treatment order dated 07/01/26 to obtain weekly weight today. There was no weight documented on 07/01/26.Review of the medical record weight summary section revealed no weight was documented for 07/01/26 for Resident #14. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #14 needed set up assistance to eat, needed supervision to roll in bed, maximum assistance to sit on the side of the bed and lie back in bed and to stand from sitting and maximal assistance was needed to transfer from bed to chair. No significant weight change was noted and Resident #14 received chemotherapy (treatment for cancer). An interview on 07/22/26 at 11:22 A.M. with Licensed Practical Nurse (LPN) #532 revealed if a physician ordered weight monitoring every shift every seven days the weight could be obtained any shift every seven days and the weight should be documented in the medical record under the weight summary section and on the TAR. LPN #532 verified Resident #14 was ordered weekly weights because the dietitian needed to monitor his weights. An interview on 07/23/26 at 8:59 A.M. with Restorative Registered Nurse (RRN) #515 revealed that the facility had a system to ensure weekly weights were completed and documented according to orders. Weekly weight orders appeared in the TAR to alert staff when due, and any refusals were to be documented in the medical record. RRN #515 stated weights were to be entered by the nurse into the medical record. RRN #515 stated the Registered Dietitian (RD) notified RRN #515 when residents should be added or removed from weekly weight monitoring. RRN #515 verified Resident #14 had physician orders dated 06/12/26 for a weekly weight with no stop date and verified the missing weights between 06/14/26 and 07/01/26. Phone interview on 07/23/26 at 9:58 A.M. with RD #509 revealed Resident #14 was at nutrition risk because he had a low body weight and food intake varied. Resident #14 was on weekly weights because he had an unplanned weight loss and those weights were needed to monitor him. An interview on 07/23/26 at 11:14 A.M. with the Assistant Director of Nursing ( ADON) #504 revealed Resident #14 needed weekly weights for a while but was stopped and restarted but was not sure why. ADON #504 verified Resident #14 had weekly weight orders dated 11/16/25 to 06/15/26 and also a weekly weight order dated 06/12/26 with no stop date. ADON #504 verified there were no weights recorded for Resident #14 on 01/04/26, 04/12/26, 04/25/26, 05/10/26, 05/24/26 and 07/01/26 and no refusals were documented. Review of the facility policy titled Weight Assessment and Intervention, dated 03/2022, revealed residents are weighed upon admission and at intervals determined by the interdisciplinary team. Weights are recorded in the medical record. Review of facility policy titled Charting and Documentation revised July 2017, revealed all services provided to the resident, progress toward the care plan goals, or any changes in the resident's condition would be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. The following information was to be documented in the resident medical record: treatments or services administered.

Based on observation, interviews, record review and review of facility policy, the facility failed to ensure medications were properly stored and secured. This affected two Residents (#4 and #59) out of 17 residents observed for medication storage. The facility had a total census of 61.Findings include:1.Review of the medical record for Resident #4 revealed an admission date of 10/18/22 with diagnoses including acute kidney failure, fracture of right fibula and right tibia, chronic respiratory failure, morbid obesity, dependence on supplemental oxygen, and pulmonary hypertension.Review of the admission collection assessment dated [DATE] revealed Resident #4 was not to self-administer medications. No other self-administration assessments were conducted.Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #4 had intact cognition. The functional assessment revealed the resident required moderate assistance for activities of daily living (ADL), hygiene, transfers, and mobility. Resident #4 was frequently incontinent of bowel and bladder and had no wounds.Observation on 07/20/26 at 9:00 A.M. revealed Resident #4 had a bottle of LubriFresh saline eye drops on her bedside table. Resident #4 also had a medicine cup containing two pills left on her bedside table.An interview with Resident #4 on 07/20/26 at 9:05 A.M. revealed the staff allowed her to have the eye drops at her bedside so she could use them as needed. She also stated she thought one of the pills was her calcium tablet and was unsure of the other. Resident #4 stated she liked to take the pills later.Review of provider orders dated July 2026 revealed no order for self-administration for any medications or orders to leave any medications at bedside for Resident #4.An interview with Licensed Practical Nurse (LPN) #541 on 07/20/26 at 2:26 P.M. verified the observation of eye drops and the pills on Resident #4's bedside table. LPN #541 stated she knew about the eye drops and confirmed the resident self-administered them; however, she stated she did not administer the two pills found in the medicine cup that morning. LPN #541 stated she gave the resident her pills in pudding that morning and stated she did not receive her calcium that morning. LPN #541 could not state how long the pills were left on the bedside or from what shift. LPN #541 also verified that there were no orders for self-administration in the electronic medical record and that the resident did not have a recent assessment of self-administration. LPN #541 removed the eye drops and placed them in the medication cart and disposed of the two pills in the medicine cup.2. Review of the medical record for Resident #59 revealed an admission date of 02/21/26 with diagnoses including pericardial effusion, hypothyroidism, chronic kidney disease, chronic obstructive pulmonary disease, and hypertension. Review of the admission assessment dated [DATE] revealed the resident was not to self-administer medications.Review of the MDS 3.0 assessment dated [DATE] revealed Resident #59 had severe cognitive impairment. A functional assessment revealed the resident required moderate assistance for ADLs, hygiene, toileting, transfers, and mobility. Resident #59 was frequently incontinent of bowel and bladder and had no wounds.Observation on 07/20/26 at 9:15 A.M. revealed Resident #59 had a large tube of Clotrimazole-Betamethasone 10.5 percent topical cream at bedside.An interview on 07/20/26 at 9:18 A.M. with Resident #59 revealed she was alert and able to participate in an interview. Resident #59 stated she had a vaginal infection and used the cream after each void. Resident #59 stated the staff let her keep the cream at bedside so she can apply it to herself. Review of provider orders dated July 2026 revealed no orders for self-administration for any medications or orders to leave any medications at bedside. Additionally, the Clotrimazole-Betamethasone external cream was ordered to be given every 12 hours only and not after each void. An interview with LPN #541 on 07/20/26 at 2:35 P.M. verified the Clotrimazole-Betamethasone 10.5 percent topical cream on Resident #4's bedside table. LPN #541 immediately removed the tube of Clotrimazole-Betamethasone and placed in the medication cart. LPN #541 also confirmed there were no orders for self-administration in the electronic medical record and that the resident was assessed to not self-administer medications. An interview with Administrator on 07/22/26 11:45 A.M. revealed no medications should be left at bedside.Review of facility policy titled, Administering Medications revised April 2019, revealed residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely.

Based on observation, interview, record review, and review of facility policy revealed the facility did not ensure pressure ulcer injuries were assessed and documented timely and accurately when identified. This affected one Resident (#64) out of three residents reviewed for pressure ulcers. This had the potential to affect seven Residents (#8, #9, #10 #14, #18, #29, and #43) the facility identified with pressure ulcers. The facility census was 63.Findings Include:Review of closed medical record for Resident #64 revealed an admission date of 07/10/25 and she was discharged home with home health on 08/19/25. She later readmitted back to the facility on [DATE] and then was sent to the hospital on [DATE]. Her diagnoses included fracture of right femur, malignant neoplasm of breast, malignant neoplasm of lung, malignant neoplasm of the bone, and hypertension. Review of July 2025 physician orders for Resident #64 revealed an order dated 07/25/25 to pad and protect the right heel with skin prep, and foam dressing three times a week and as needed. Review of care plan dated 07/10/25 revealed Resident #64 had impaired skin integrity and was at risk related to cancer, pain, impaired mobility and poor nutrition. The care plan revealed she refused to turn and reposition, wear her prevalon boots (boots with cushioned bottom that float the heels off the surface of the mattress), incontinence care, and showers. Interventions included two-hour time limit while in wheelchair, skin checks with showers and report abnormalities, low air loss mattress, encourage resident to elevate heels off surface of mattress and side to side turns. Review of nursing notes from 07/10/25 to 07/28/25 for Resident #64 revealed no documentation of her right heel having any skin impairment including on 07/25/25. Review of admission Minimum Data Set (MDS) dated [DATE] revealed Resident #64 had intact cognition and had impairment on one of her lower extremities. She was dependent of staff assistance with toileting, putting on footwear, and dressing. She required substantial to maximum assistance of staff with showers and transfers. She required partial to moderate assistance with rolling left and right. She was at risk for developing a pressure ulcer and had no unhealed pressure ulcers on admission. Observation of text message dated 07/25/25 at 5:43 A.M. sent from Licensed Practical Nurse (LPN) #616 to Resident #64's daughter revealed a picture of a heel that had a dark discolored circular area noted to the center of the heel. The text message revealed Resident #64's daughter asked who's heel that was and the message stated, mom's and that Certified Nursing Assistant (CNA) #602 had found it. Review of nursing note dated 07/28/25 at 8:54 A.M. and completed by LPN #616 revealed Resident #64's skin was checked prior to her leaving for the appointment and she did not have any new areas. Review of nursing note dated 07/28/25 at 10:50 A.M. and completed by LPN #616 revealed Resident #64 returned from the appointment and a skin check was completed. There was a new area to her right heel that was purple and non-blanching. Review of Wound Assessment- V1 dated 07/28/25 and completed by LPN/ Wound Nurse #612 revealed Resident #64 had a new pressure ulcer to her right heel that was identified as a community acquired pressure ulcer as it was present on return from her appointment. The pressure ulcer measured a length of 2 centimeters (cm), width of 2 cm and had no depth. The pressure ulcer was suspected to be a deep tissue injury and was described with 100 percent epithelial tissue. The assessment revealed the treatment was to clean the area with normal saline, apply skin prep and foam dressing three times a week. Interview on 09/30/25 at 8:00 A.M. with Resident #64's daughter revealed on 07/25/25 at 5:43 A.M. she received a text message as well as a picture from LPN #616 that Resident #64 had a pressure ulcer to her right heel. She revealed the area was dark purple in color. She revealed she used to work at the facility as a Registered Nurse (RN) and was upset as the facility did not document the pressure ulcer on 07/25/25 and they had falsified the documentation on 07/28/25 stating the pressure ulcer was found upon Resident #64's return from her appointment which was not accurate. Interview on 11/24/25 at 11:48 A.M. with LPN #616 revealed on 07/25/25 when she first came on duty CNA #602 had come up to her and reported she found an area to Resident #64's right heel. She revealed she assessed the area and took a picture of the heel. She described the heel as a small discolored dark area that appeared as a deep tissue injury. She verified she had sent a text message and the picture to Resident #64's daughter on 07/25/25 informing her of the new area and the area was found per CNA #602. She revealed she notified the Director of Nursing (DON) of the area as well as showed the DON the picture and she was told let's see if it resolves. She revealed the DON did not want anything charted regarding the pressure area. LPN #616 verified the DON did not come out and directly say not to document but that she knew what it meant by let's see if it resolves and she had known from the past the facility does not want any pressure ulcers identified as facility acquired. She revealed the DON had had given the directive when Resident #64 returned from her appointment on 07/28/25 to document the wound was found on her return from the appointment and identify it as community acquired. She verified she had falsified the documentation in Resident #64's chart as Resident #64 did have the area upon leaving for her appointment on 07/28/25 as it was the same area she had seen on 07/25/25 and she stated in the documentation the new area found on her return from the appointment per the DON's directive. Interview on 11/24/25 at 12:51 P.M. with CNA #602 revealed she had found a wound to Resident #64's right heel when she was putting on her nonskid socks. She revealed she could not remember the exact date when she found the area but that the area was dime size and dark purple in color. She revealed she reported it to the nurse but could not remember who she reported it to. Interview on 11/24/25 at 1:23 P.M. with the DON verified the text message from LPN #616 to Resident #64's daughter was dated 07/25/25 at 5:43 A.M. and included a picture of a heel that had a discolored area to the center of the heel. The DON described the area as approximately 2 cm by 2 cm purple discolored blister area. She verified the area appeared to be a deep tissue injury. She verified the text message included that CNA # 602 had found the area and there was not any documentation on the area in the nursing notes and/or a wound assessment completed on 07/25/25. She revealed a treatment order was obtained from Primary Care Physician (PCP) #900 on 07/25/25 to apply skin prep and pad and protect the area. She verified the area to Resident #64's heel was not documented until 7/28/25 as LPN #616 had documented prior to leaving for her appointment there was no skin impairments and upon return a discolored area was noted to her right heel. She revealed LPN/ Wound Nurse #612 had documented the wound was community acquired and verified this was inaccurate since the area was found per CNA #602 on 07/25/25. The DON stated she never told LPN # 616 not to document on 07/25/25 regarding the area and/ or never told her to document on 07/28/25 they had found the pressure injury upon her return from her appointment. She verified LPN # 616 should have documented in the nursing notes and completed a wound assessment on 07/25/25 of the wound to her right heel. Interview on 11/24/25 at 2:52 P.M. with LPN/ Wound Nurse # 612revealed on 07/25/25 she was working on the floor and LPN #616 had stated Resident #64 had an area to her right heel. She revealed LPN #616 had stated the area was red but blanchable and asked her to get an order from the physician for the area. She revealed she did not assess Resident #64's heel since LPN #616 had stated she did, but she did contacted PCP #900 for an order to apply skin prep and pad and protect the area with a foam dressing three times a week. She revealed she never told LPN #616 or heard the DON tell LPN #616 to not document on the area as well as not complete a wound assessment. LPN/ Wound Nurse #612 verified she had documented on 07/28/25 per the Wound Assessment that the wound was community acquired as she was going by the information LPN #616 had told her specifically that LPN #616 had checked her skin prior to leaving on the appointment and she did not have any new skin impairment. She revealed LPN #616 had stated on Resident #64's return from the appointment she had the area to her right heel. Review of facility policy labeled, Pressure Ulcer Risk and Skin Assessment dated 12/17/13 revealed it was the facility policy that all residents would receive routine assessments. The policy revealed if a CNA observes a skin alteration he/ she would inform the nurse and the identified skin change would be addressed by the nurse with an assessment, documentation in the nursing notes and physician/ family notification. This deficiency represents non-compliance investigated under Complaint Number 2619877, and 2603148.

Based on record review and facility staff interview the facility failed to ensure the medical record was accurate. This affected one, Resident #64, of three reviewed for wounds. The facility census was 63. Findings Include:Review of closed medical record for Resident #64 revealed an admission date of 07/10/25 and she was discharged home with home health on 08/19/25. She later readmitted back to the facility on [DATE] and then was sent to the hospital on [DATE]. Her diagnoses included fracture of right femur, malignant neoplasm of breast, malignant neoplasm of lung, malignant neoplasm of the bone, and hypertension. Review of admission Minimum Data Set (MDS) dated [DATE] revealed Resident #64 had intact cognition and had impairment on one of her lower extremities. She was dependent of staff assistance with toileting, putting on footwear, and dressing. She required substantial to maximum assistance of staff with showers and transfers. She required partial to moderate assistance with rolling left and right. She was at risk for developing a pressure ulcer and had no unhealed pressure ulcers on admission. Review of care plan dated 07/10/25 revealed Resident #64 had impaired skin integrity and was at risk related to cancer, pain, impaired mobility and poor nutrition. The care plan revealed she refused to turn and reposition, wear her prevalon boots (boots with cushioned bottom that float the heels off the surface of the mattress) Interventions included two-hour time limit while in wheelchair, skin checks with showers and report abnormalities, low air loss mattress, encourage resident to elevate heels off surface of mattress and side to side turns. Review of July 2025 physician orders for Resident #64 revealed an order dated 07/25/25 to pad and protect the right heel with skin prep, and foam dressing three times a week and as needed. Review of nursing notes from 07/10/25 to 07/28/25 for Resident #64 revealed no documentation of her right heel having any skin impairment including on 07/25/25. Observation of text message dated 07/25/25 at 5:43 A.M. sent from Licensed Practical Nurse (LPN) #616 to Resident #64's daughter revealed a picture of a heel that had a dark discolored circular area noted to the center of the heel. The text message revealed Resident #64's daughter asked who's heel that was and the message stated, mom's and that Certified Nursing Assistant (CNA) #602 had found it. Review of nursing note dated 07/28/25 at 8:54 A.M. and completed by LPN #616 revealed Resident #64's skin was checked prior to her leaving for the appointment and she did not have any new areas. Review of nursing note dated 07/28/25 at 10:50 A.M. and completed by LPN #616 revealed Resident #64 returned from the appointment and a skin check was completed. There was a new area to her right heel that was purple and non-blanching. Review of Wound Assessment- V1 dated 07/28/25 and completed by LPN/ Wound Nurse #612 revealed Resident #64 had a new pressure ulcer to her right heel that was identified as a community acquired pressure ulcer as it was present on return from her appointment. The pressure ulcer measured a length of 2 centimeters (cm), width of 2 cm and had no depth. The pressure ulcer was suspected to be a deep tissue injury and was described with 100 percent epithelial tissue. The assessment revealed the treatment was to clean the area with normal saline, apply skin prep and foam dressing three times a week. Interview on 09/30/25 at 8:00 A.M. with Resident #64's daughter revealed on 07/25/25 at 5:43 A.M. she received a text message as well as a picture from LPN #616 that Resident #64 had a pressure ulcer to her right heel. She revealed the area was dark purple in color. She revealed she used to work at the facility as a Registered Nurse (RN) and was upset as the facility did not document the pressure ulcer on 07/25/25 and they had falsified the documentation on 07/28/25 stating the pressure ulcer was found upon Resident #64's return from her appointment which was not accurate. Interview on 11/24/25 at 11:48 A.M. with LPN #616 revealed on 07/25/25 when she first came on duty CNA #602 had come up to her and reported she found an area to Resident #64's right heel. LPN #616 revealed she assessed the area and took a picture of the heel. She described the heel as a small discolored dark area that appeared as a deep tissue injury. She confirmed she had sent a text message and the picture to Resident #64's daughter on 07/25/25 informing her of the new area and the area was found per CNA #602. LPN #616 revealed she notified the Director of Nursing (DON) of the area as well and showed the DON the picture and she was told let's see if it resolves. LPN #616 stated the DON did not want anything charted regarding the pressure area, clarifying, the DON did not come out and directly say not to document the area, but that she knew what it meant when the DON stated let's see if it resolves. LPN #616 stated she had known from the past the facility does not want any pressure ulcers identified as facility acquired. She revealed the DON had had given the directive when Resident #64 returned from her appointment on 07/28/25 to document the wound was identified on her return from the appointment and to code it as community acquired. LPN #616 verified she had falsified the documentation in Resident #64's medical record when she documented the resident did not have the area to her heel when she left for her appointment stating it was the area she had noted on 07/25/25. LPN #616 stated she documented the area to the heel was identified when the resident returned from her appointment in the community per the DON's directive. Interview on 11/24/25 at 12:51 P.M. with CNA #602 revealed she had found a wound to Resident #64's right heel when she was putting on her nonskid socks. She revealed she could not remember the exact date when she found the area but that the area was dime size and dark purple in color. She revealed she reported it to the nurse but could not remember who she reported it to. Interview on 11/24/25 at 1:23 P.M. with the DON verified the text message from LPN #616 to Resident #64's daughter was dated 07/25/25 at 5:43 A.M. and included a picture of a heel that had a discolored area to the center of the heel. The DON described the area as approximately 2 cm by 2 cm purple discolored blister area. The DON verified the area appeared to be a deep tissue injury. She verified the text message included that CNA # 602 had found the area. The DON confirmed Resident #64's medical record did not include any documentation on the skin alteration in the nursing notes and/or a wound assessment completed on 07/25/25. The DON revealed a treatment order was obtained from Primary Care Physician (PCP) #900 on 07/25/25 to apply skin prep and pad and protect the area. The DON verified the area to Resident #64's heel was not documented until 7/28/25 as LPN #616 had documented prior to leaving for her appointment there was no skin impairments and upon return a discolored area was noted to her right heel. She revealed LPN/ Wound Nurse #612 had documented the wound was community acquired and verified this was inaccurate since the area was found per CNA #602 on 07/25/25. The DON stated she never told LPN # 616 not to document on 07/25/25 regarding the area and/ or never told her to document on 07/28/25 they had found the pressure injury upon her return from her appointment. She verified LPN # 616 should have documented in the nursing notes and completed a wound assessment on 07/25/25 of the wound to her right heel. Interview on 11/24/25 at 2:52 P.M. with LPN/ Wound Nurse # 612revealed on 07/25/25 she was working on the floor and LPN #616 had stated Resident #64 had an area to her right heel. She revealed LPN #616 had stated the area was red but blanchable and asked her to get an order from the physician for the area. She revealed she did not assess Resident #64's heel since LPN #616 had stated she did, but she did contacted PCP #900 for an order to apply skin prep and pad and protect the area with a foam dressing three times a week. She revealed she never told LPN #616 or heard the DON tell LPN #616 to not document on the area as well as not complete a wound assessment. LPN/ Wound Nurse #612 verified she had documented on 07/28/25 per the Wound Assessment that the wound was community acquired as she was going by the information LPN #616 had told her specifically that LPN #616 had checked her skin prior to leaving on the appointment and she did not have any new skin impairment. She revealed LPN #616 had stated on Resident #64's return from the appointment she had the area to her right heel. This deficiency represents non-compliance investigated under Complaint Number 2650968.

Based on interview, observation, record review, and review of facility policy, the facility failed to ensure proper infection control measures were maintained during tracheostomy (a surgical opening in the neck to provide direct airway into the windpipe) care. This affected one Resident (#53) out of one resident observed for tracheostomy care. This had the potential to affect 11 Resident (#2, #4, #9, #10, #21, #38, #43, #48, #53, #59, and #66) identified by the facility with tracheostomies. The facility census was 63. Findings included: Review of medical record for Resident #53 revealed an admission date of 12/12/22 with diagnoses to included chronic respiratory failure with hypoxia, cerebral infarction, and presence of tracheostomy. Review of care plan dated 12/13/22 revealed Resident #53 was at risk for respiratory distress due to respiratory failure, tracheostomy and oxygen. Interventions included administer oxygen as ordered, maintain tracheostomy as ordered, suction as ordered, and monitor for signs of respiratory distress. Review of quarterly minimum data set (MDS) dated [DATE] revealed Resident #53 was identified in a persistent vegetative state and had no discernable consciousness. He had a tracheostomy, used oxygen and needed suctioned. Review of November 2025 physician orders revealed Resident #53 had the following orders: change daily and as needed his disposable inner cannula (a sterile single-use tube that fits inside the tracheostomy tube's outer cannula to help prevent infection and keep the airway clear of mucus), and tracheostomy care every shift and as needed. Observation on 11/25/25 at 7:15 A.M. revealed Respiratory Therapist (RT) #600 applied a gown and walked into Resident #53's room. She proceeded to wash her hands, applied gloves and walked over to his bedside where the room was not well lit as she did not turn on the over- the- bed light. She removed Resident #53's split gauze dressing under his tracheostomy, and his inner cannula. She disposed of the gauze and inner cannula, removed her gloves and proceeded to wash her hands. RT #600 then applied sterile gloves from the tracheostomy kit and proceeded to take a gauze pad that was soaked in normal saline and wiped underneath his tracheostomy and stated, oh. RT #600 reached up with her right gloved hand and pulled the light switch cord. She stated she had thought the area was red and wanted to take a closer look but stated the site was not red. RT #600 proceeded to take another gauze dressing soaked with normal saline with the same right gloved hand and proceeded to clean above the tracheostomy. RT #600 used a single sweep on each side with the gauze. RT #600, then took a new disposable cannula from the container and inserted using her right-gloved hand. RT #600 proceeded to doff her gloves, gown and washed her hands. Interview on 11/25/25 at 7:25 A.M. with RT #600 verified she had applied sterile gloves and started cleaning his tracheostomy site but during the care she had reached up and pulled on the light cord above the bed to turn on the light with her right gloved hand. She verified she continued to wear the same gloves and proceeded to complete the tracheostomy care and replaced his disposable inner cannula without washing her hands and re-gloving after touching the light cord. She stated, I was not thinking and turned on the light and verified she contaminated her clean sterile gloves when she touched the light cord. Interview on 11/25/25 at 7:35 A.M. with Director of Nursing (DON) verified the RT and/ or nurse needed to maintain a sterile clean field and not cross contaminate her gloves during tracheostomy care and replacing the inner cannula. She revealed touching other items including pulling the light cord during the care would be an infection control issue. Review of facility policy labeled, Tracheostomy Care dated August 2013 revealed the purpose of the procedure was to guide tracheostomy care and the cleaning of. The general guidelines included aseptic technique must be used when tracheostomy tube changes (either reusable or disposable) were completed. The policy revealed gloves must be worn on both hands during any manipulation of the tracheostomy and sterile gloves must be used during aseptic procedures. The staff was to remove and dispose of the inner cannula and replace with another sterile inner cannula. In addition, the policy revealed for tracheostomy site and stoma care the staff was to apply clean gloves and clean with saline soaked gauze pads using a single sweep for each side, then rinse and dry in same manner. There was nothing in the policy regarding ensuring to maintain aseptic technique including not touching other items or surfaces during care including pulling the light cord. Review of facility competency test labeled, Trach Care Competency dated 04/18/25 and completed by RT #600 with the DON overseeing revealed the staff was to wash their hands, don gown, gloves and mask (if applicable). The staff was to remove and dispose of the trach dressing while observing the condition of the surrounding skin. The competency revealed the staff was to remove gloves, wash hands and don sterile gloves and proceed to clean the skin under the flange, pat area dry with sterile gauze and replace sterile trach dressing. The competency revealed the staff was to dispose of inner cannula and replace with another disposable sterile inner cannula. The policy revealed the staff was to remove their gloves and wash their hands. This deficiency represents non-compliance investigated under Complaint Number 2650968.

Based on observation, interview, record review, and review of facility policy the facility did not ensure range of motion (ROM) restorative nursing programs were completed for Residents #11 and #43 as ordered. This affected two residents (#11 and #43) of two residents reviewed for ROM. This had the potential to affect 48 residents (#1, #2, #3, #4, #5, #6, #7, #10, #11, #13, #15, #17, #19, #18, #20, #21, #22, #23, #24, #25, #26, #28, #29, #30, #31, #32, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43, #44, #45, #46, #47, #50, #52, #53, #54, #56, #58, #59, and #120) identified on a restorative ROM program. The facility census was 64. Findings included: 1. Review of the medical record for Resident #11 revealed an admitted [DATE] with diagnoses including muscle weakness, spastic hemiplegia affecting left nondominant side, multiple sclerosis, quadriplegic, and contractures to right and left hands. Review of the care plan dated 03/27/17 revealed Resident #11 had limited joint mobility per ROM assessment. Interventions included applying bilateral resting hand splints on each night during hours of sleep and as needed, report changes and abnormalities to nurse, and review progress quarterly and as needed. Review of the care plan dated 12/23/19 revealed Resident #11 refused a passive range of motion (PROM) restorative program. Interventions included accepting his right to refuse and show respect for his decision, explaining the importance of completing the program to prevent decline, re-approach in approximately 15 minutes to encourage compliance, and contact physician as needed. Review of the care plan dated 10/22/23 revealed Resident #11 had a self-care deficit as evidence by impaired mobility, impaired balance, and assistance needed with activities of daily living (ADL) tasks. Interventions included bilateral resting hand splints for contractual management and performing ROM exercises daily during ADL tasks. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 had intact cognition. He was totally dependent on staff for most all his ADL tasks including rolling left and right, personal hygiene, transfers, and bathing. He received one day in the last seven days during the assessment period of passive ROM (PROM) per restorative. Review of the Occupational Therapy Discharge Summary dated 05/20/24 and completed by Occupational Therapist (OT) #400 revealed Resident #11 was discontinued from therapy as he achieved his maximum potential. OT #400 referred Resident #11 to restorative to have a bilateral upper extremity PROM program implemented. Review of the restorative documentation from 06/02/24 to 07/01/24 for Resident #11 revealed he was to have a restorative PROM program to his bilateral lower extremities that included 15 repetitions of two sets for 15 minutes, six to seven times per day. The documentation revealed the program was completed and/ or refused 06/02/24, 06/04/24, 06/06/24, 06/08/24, 06/09/24, 06/14/24, 06/20/24, 06/22/22, 06/23/24, 06/25/24, and 06/27/24 (total 11 times). There was no other documented evidence that the program was completed and/ or that he refused per his medical record. Review of the Restorative Therapy Referral dated 06/06/24 revealed Resident #11 was to have an active/ passive ROM program to his bilateral upper extremities and neck that included joint compression to each upper extremity 20 times each, and a scooter board with hand strap across table that included 30 times horizontal adduction and abduction of each bilateral upper extremity. Review of the restorative documentation from 06/06/24 to 07/02/24 revealed Resident #11 had a restorative active/ passive ROM program to his bilateral upper extremities and neck that included joint compression to each extremity joint 20 times each movement. The program also included a scooter board with hand strap across table as able 30 times horizontal adduction and abduction to bilateral upper extremities for 15 minutes six to seven times a week. The documentation revealed the program was only completed on 07/02/24. Interview and observation on 07/01/14 at 9:42 A.M. with Resident #11 revealed he was supposed to get restorative several times a week, but stated he was lucky to get it once a week as the facility often had the restorative State tested Nursing Assistants (STNAs) work on the floor instead of completing the restorative programs. He revealed he was concerned his fingers were going to get more contracted without receiving restorative as recommended. Observation revealed he was unable to move his extremities independently as he was a quadriplegic. Interview on 07/03/24 at 8:34 A.M. with Restorative STNA #371 revealed there were a lot of residents on restorative programs and stated, I try to hit everyone up as much as I can, but I cannot get to everyone. She verified there were some days she was unable to complete Resident #11's restorative ROM program. Interview on 07/03/24 at 9:11 A.M. with Restorative Registered Nurse (RN) #314 verified Resident #11's restorative ROM programs were not completed as recommended per therapy to his upper and lower extremities per the documentation. She verified each program was to be completed six to seven days a week. Interview on 07/03/24 at 10:47 A.M. with Rehabilitation Director #401 revealed Resident #11 was discharged from OT on 05/20/24 as he reached his maximum potential. He revealed therapy referred Resident #11 to restorative to have a ROM program to his bilateral upper extremities and neck as well as to continue his already in place restorative ROM program to his bilateral lower extremities. He revealed the programs were to be completed six to seven days a week. 2. Review of the medical record revealed Resident #43's admitted was 03/10/23 with diagnoses including dislocation of internal left hip prosthesis, Alzheimer's disease, and heart failure. Review of the care plan dated 03/17/24 revealed Resident #43 had the potential/ actual limitations to his bilateral legs. Interventions included nursing restorative active ROM program to bilateral lower extremities six to seven days a week, restorative nurse to assess ROM quarterly and as needed, and report and pain and/ or discomfort to nurse or physician. Review of the quarterly MDS assessment dated [DATE] revealed Resident #43 had impaired cognition. He required staff supervision with transfers and ambulation. He required substantial to maximum staff assist with bathing. He received two days of a restorative ROM program during the seven-day assessment reference period. Review of the Physical Therapy Discharge Summary dated 05/20/24 and completed by Physical Therapist (PT) #402 revealed Resident #43 was discontinued from therapy as he met his maximum potential and was referred to restorative for ROM program to facilitate maintaining current level of performance and to prevent decline. Review of the Restorative Therapy Referral dated 05/20/24 revealed Resident #43 was to have active ROM to his bilateral lower extremities while seated that included 15 repetitions times two sets using one pound weight and green TheraBand (thick elastic band that provides a way to exercises and strengthen muscles) six to seven days a week. Review of the care plan dated 05/30/24 revealed Resident #43 refused his restorative active ROM and ambulation programs. Interventions included accepting his right to refuse, explaining potential of negative outcomes, re-approaching in approximately 15 minutes to encourage compliance, and contact physician as needed. Review of the restorative documentation dated from 06/04/24 to 07/01/24 revealed Resident #43 was to have active ROM to his bilateral lower extremities while seated using a one pound weight and green TheraBand 15 repetitions of two sets 15 minutes six to seven times per week. This was documented as completed and/ or the resident refused on: 06/04/24, 06/06/24, 06/07/24, 06/08/24, 06/09/24, 06/14/24, 06/20/24, 06/22/24, 06/23/24, 06/24/24, 06/25/24, 06/27/24, and 07/01/24 (total 13 times). Interview and observation on 07/01/24 at 9:40 A.M. revealed Resident #43 was lying in bed and was unable to provide any information regarding his ROM restorative program due to cognitive ability. Interview on 07/03/24 at 8:34 A.M. with Restorative STNA #371 revealed there were a lot of residents on restorative programs and stated, there are days I just do not get to him. She verified Resident #43 was not seen six to seven times a week as ordered. Interview on 07/03/24 at 9:11 A.M. with Restorative RN #314 verified Resident #43's restorative ROM program was not documented as completed as ordered. She verified he was to have restorative ROM six to seven days a week. Interview on 07/03/24 at 10:47 A.M. with Rehabilitation Director #401 revealed Resident #43 was discharged from PT on 05/20/24 as he reached his maximum potential. He revealed therapy referred Resident #43 to restorative to have a ROM program to his bilateral lower extremities and verified the program was to be completed six to seven days per week to maintain his current level and prevent decline. Review of the facility policy labeled; Restorative Nursing, dated March 2017, revealed restorative nursing programs would be provided for any resident who was identified as having a need for service. These services would include consistent and structured programs designed by the restorative nurse and carried out by staff as scheduled. The policy revealed documentation would include the date of service that was provided, the type of service, and total minutes provided. The documentation would be completed before the end of the staff member's shift. Review of the facility policy labeled; Resident Mobility and Range of Motion, dated July 2017, revealed residents would not experience an avoidable reduction in ROM. The policy revealed residents with limited range of motion would receive treatment and services to increase and/ or prevent a further decrease in ROM. The policy revealed the care plan would include specific interventions, exercises and therapies to maintain, prevent avoidable decline in and improve mobility and range in motion. The care plan would include the type, frequency, and duration of interventions, as well as measurable goals and objectives.

Based on observation, interview, record review, and facility policy review the facility failed to provide adequate tracheostomy care including timely respiratory evaluations as ordered for Resident #45. This affected one resident (#45) of four residents reviewed for tracheostomy care. The facility identified 11 residents (#15, #22, #38, #45, #47, #51, #54, #55, #57, #118 and #119) with tracheostomies. The facility census was 66. Findings include: Review of the medical record for Resident #45 revealed an admitted [DATE]. Diagnoses included chronic respiratory failure with hypoxia, diabetes mellitus type II, nontraumatic intracerebral hemorrhage, and tracheostomy status. Review of Resident #45's physician orders effective July 2024 revealed oxygen 21 to 50 percent to maintain oxygen saturation at 92 percent or greater every shift, change tracheostomy as needed, suction as needed, place a bag valve mask and oxygen emergency tank in room and check at the beginning of every shift, check breath sounds every shift and as needed, oxygen saturation every four hours and see respiratory flow record for documentation every shift, and evaluation by respiratory therapists per report of oxygen saturation by pulse oximetry and recommendations for pulmonary care as needed. Review of Resident #45's medication and treatment administration records from May to July 2024 revealed no documented evidence that tracheostomy related care was completed. Review of the Quarterly Minimum Data Set (MDS) assessment completed 06/14/24 indicated Resident #45 was in a persistent vegetative state with no discernible consciousness. Review of the care plan initiated 12/13/22 revealed Resident #45 was at risk for respiratory distress due to respiratory failure, tracheostomy, and oxygen. Interventions included administering oxygen as ordered, maintaining tracheostomy as ordered, and suctioning as ordered. Interview on 07/01/24 at 10:35 A.M. with Resident #45's mother complained of having an issue with the respiratory therapists (RT). They were required to enter Resident #45's room three times each twelve-hour shift to complete tracheostomy care and assess his needs, but the RTs were not checking on him. The mother asked RT to come into the room every two hours, especially because Resident #45 was unable to use a call light and there was no alarm for staff to identify respiratory distress or low oxygenation levels. The mother described having witnessed Resident #45 struggle with breathing via the in-room camera with inability to call staff for assistance and no alarms to alert staff, so the mother called staff on the telephone to request assistance for Resident #45. Due to this concern, the mother requested RT to check on Resident #45 every two hours, but they refused and maintain routine checks of three times each 12-hour shift. The mother indicated feeling no other choice but to drive one hour each way to the facility daily to sit with Resident #45 for 12 hours each day to complete more frequent checks since the RTs refused. The mother expressed feeling grateful she was a nurse and could advocate for him. She continued to state that now because of intervening, the RTs were just checking oxygenation without assessing him for needs, telling nurses not to bother providing tracheostomy care because the mother did it, or no longer coming into the room at times and just documenting the mother completed the care. The mother complained of feeling hopeless for a resolution because even after talking to the Administrator, Director of Nursing (DON) and Ombudsman, nothing had changed. She indicated feeling afraid and unsupported, so she was obligated to be with Resident #45 as much as possible to ensure he breathed without difficulty and received the necessary respiratory care. The mother continued stating she should not have to do it but believed there were no other options thinking the staff expected her to do the care, so she used the camera to watch when not in the facility. The mother requested the surveyor watch the RT on the next check and stated it would either not get done, or the RT would check the oxygenation level then leave without checking Resident #45 for respiratory care needs like suctioning or even speaking to the mother. The mother denied ever telling staff not to perform respiratory care or a desire to complete it in place of them but admitted requesting to assist the staff. The mother also denied documenting any respiratory care on the flow record or having access to or using a stethoscope to hear breath sounds to determine suctioning needs but described just listening for audible wheezing or congestion. The mother explained leaving the door closed when visiting to keep out the surrounding noise but stated it should not stop the staff from coming in and checking on Resident #45, indicating there were times the RT would only come in once during the shift while she was there and let the mother do the rest. The mother again stated she does the care because the staff did not, and expressed talking with the pulmonologist who refused to increase respiratory checks to every two hours but did not understand why especially when there were no safety interventions in place like a respiratory alarm to alert staff with respiratory distress or since Resident #45 was unable to request needs. Observation on 07/01/24 at 11:18 A.M. of Resident #45 with the mother present in the room revealed audible quiet crackling noises mixed with wheezing during respirations. Interview at the time of the observation with the mother indicated hearing congestion and wheezing and believed Resident #45 probably needed suctioned but was not confident the RT would assess him for it. Observation on 07/01/24 at 11:24 A.M. of Resident #45 with the mother present revealed RT #382 entered the room, placed a pulse oximeter onto Resident #45's left finger, then moved over to the respiratory log and wrote down some information. Once completed, RT #382 removed the oximeter and exited the room. RT #382 did not engage the resident, the mother or the surveyor, and did not perform an evaluation of Resident #45's respiratory status including breath sounds to identify needs for suctioning or provide any type of tracheostomy care. Interview on 07/01/24 at 11:26 A.M. with RT #382 reported respiratory therapy was available 24 hours daily, and each RT worked 12 hours shifts. Residents with tracheostomies or ventilators were monitored through evaluations completed at least every four hours or three times during each shift. RT #382 indicated residents were checked with each visit, and tracheostomy care was provided including suctioning if needed. RT #382 confirmed entering Resident #45's room to obtain a pulse oxygenation reading without performing a respiratory evaluation or related care during the routine every four-hour visit. RT #382 explained Resident #45's mother did the care, so it was not needed, but Resident #45 was the only one for whom care was skipped. RT #382 described only doing the care once in the morning then the mother completed it the rest of the 12-hour day shift, and it was because the mother was present, so RT #382 only documented oxygenation levels and oxygen settings. RT #382 further confirmed not engaging Resident #45 or the mother while in the room to question about whether the mother had completed any respiratory care to determine Resident #45's status or ask the mother if there were any needs or concerns and did not evaluate Resident #45's need for suctioning or tracheostomy care including listening to breath sounds. RT #382 complained Resident #45's mother did not speak to her but knew the mother suctioned Resident #45 every two hours whether it was needed or not, so RT #382 just lets her do the care. RT #382 admitted it was assumed the care was completed by the mother. RT #382 stated she had once talked to the mother and was mostly told nothing was needed so the mother was told to let RT know if care was needed, but RT #382 insisted the mother did not ask for any care. When questioned about routine monitoring of Resident #45 to ensure adequate breathing and oxygenation since Resident #45 was unable to call for assist and there were no alarms to alert staff of difficulties, RT #382 responded the staff did monitor Resident #45 but with the doors open to clearly see. RT #382 indicated the mother kept the door shut all the time, so the staff relied on the mother to report any concerns, and re-stated the mother did the care anyway. RT #382 complained that the mother took over the care and then turned her into the Ombudsman. RT #382 implied the mother changed everything on what was wanted, and so respiratory care including suctioning could not be tracked because the mother did all the care. Interview on 07/01/24 at 11:35 A.M. in Resident #45's room with the mother explained after RT #382 and the surveyor left, the mother completed suctioning because RT #382 did not evaluate him for respiratory care, so she had to do it. The mother also pointed out Resident #45's tracheostomy dressing was wet and needed changed. Observation at the time of the interview of Resident #45's tracheostomy dressing revealed the dressing was visibility wet. The mother stated she would have to change it too because it would not be done otherwise. Resident #45's mother denied staff had provided education regarding respiratory care, observation to ensure the mother's competency or monitor her completion of the care or discuss an arrangement for the mother's participation in the care. Interview on 07/01/24 at 11:38 A.M. with Licensed Practical Nurse (LPN) #333 reported Resident #45's mother was a nurse and over the top, having her own expectations but indicated Resident #45 was stable and had no medical issues. The mother was very involved and completed his care, but the staff also assisted with that care. LPN #333 stated the aides enter the room every two hours on the nose to provide turning, repositioning, and any personal care with the mother because there was a specific way she liked it not wanting it any other way. LPN #333 indicated nursing would provide suctioning if needed. The mother stays 12 hours daily, so staff ask if any care was needed. RT are in and out of rooms frequently and aides check frequently enough so alarms are not needed but confirmed RT was expected to provide care in conjunction with the mother because that was how she liked it, although staff was ultimately responsible to ensure respiratory care was completed appropriately as needed. Interview on 07/01/24 at 11:45 A.M. with DON and Administrator indicated Resident #45's mother was over the top and wanted things done her way which included tracheostomy care and suctioning completed every two hours even when it was not needed. They reported recently talking to the Ombudsman regarding concerns from the mother about RT and trying to appease the mother. Respiratory care and suctioning were every four hours but it did not satisfy the mother, despite the physician saying suctioning too frequently or more than needed would cause damage. They stated the mother wanted to do the care and the staff to do the care to assist her. The mother would inform staff when it was done or explain what still needed to be done. If staff did not go into the room at the two-hour mark, the mother would complete the care herself. Resident #45 was treated like everyone else. The staff completed care and drove the care so she needed to let us do the care and she could help. We talked to the mother and the Ombudsman about RT #382 because the mother complained about an issue with RT, but the mother told RT #382 not to do the care. The Administrator and DON verified they had not made any written agreements or understandings with the mother or directed the staff including RT on what actions to take if the mother refused to let staff provide the needed or ordered care, or how to approach the situation. The Administrator emphasized the staff provided respiratory care, but when informed of the surveyor observation when RT #382 did not complete a respiratory evaluation, confirmed it should have been provided. Interview on 07/02/24 at 7:48 A.M. with RT #383 reported only residents with ventilators had alarm systems to alert staff of any respiratory concerns. Most residents without ventilators were able to call for help or if not able, staff would let RT know if care was needed. RT #383 explained the standard of care was no less than once each shift for tracheostomy care and every four hours to complete pulse oximetry coupled with an assessment or evaluation to determine if any respiratory care needs were required like suctioning by using breath sounds or changing tracheostomy dressings if wet or soiled. Resident #45 had a flow record with variations to the flow record depending on resident needs, and it was completed only by RT or the nurse. Resident #45's mother was not expected to perform any assessments to determine care need or expected to complete the care or document any respiratory care provided but wanted to be involved in the care. RT #383 indicated if the mother completed respiratory related care like suctioning prior to the RT going into the room, the RT was required to go behind the mother and still check to ensure the care was completed correctly, and then perform any additional care needed as a result. RT would never expect the mother to complete any respiratory care in place of the RT's responsibility. Tracheostomy inner cannula changes and dressing changes were usually completed at the beginning of the 12-hour shift then evaluated during the following routine checks, and the dressing was changed if wet like a paper towel to prevent irritation even if there was no visible sputum. Additional evaluations completed at each four-hour visit included breath sounds to determine suctioning, pulse oxygenation levels, and water levels for humidification. RT #383 reported checking Resident #45 every two hours because the staff knew the mother desired it because Resident #45 cannot ask for any respiratory related care. Resident #45 did not necessarily need it so frequently, but it was not detrimental to just do it. The mother usually wanted RT to perform the care. RT #383 described knowing there was an issue between RT #382 and the mother and not being certain if RT #382 talked to the mother but would go into the room once and then not return to complete evaluations until the mother left. RT #383 verified completing evaluations on Resident #45 in the room and engaging the mother to make sure the mother was comfortable with the care and Resident #45's needs were met. RT #383 denied receiving any direction from administration on how to handle the issues between the mother and RT. Interview on 07/02/24 at 11:23 A.M. with MDS Coordinator #301 and MDS Coordinator #314 verified having no knowledge of Resident #45's mother providing tracheostomy related care, the physician being aware, or evidence of the mother demonstrating competent skills, or being educated of risks/effects to providing care more often than needed, and it was not included in the plan of care. Upon review of Resident #45's respiratory flow records from 06/30/24 to 07/01/24 showed multiple columns to reflect the dates and times of completed respiratory evaluations which included assessment and/or provision of the oxygen flow rate, respiratory rate, oxygenation levels, heart rate, breath sounds, suctioning amount including consistency and color, tracheostomy care, inner cannula change, collar change, equipment changes, and emergency equipment at the bedside. The flow records revealed Resident #45's mother completed suctioning in lieu of a RT on 06/01/24 at 8:30 A.M. and 11:30 A.M., 06/02/24 at 11:30 A.M and 6:55 P.M., 06/03/24 at 7:30 P.M., 06/04/24 at 8:00 P.M., 06/05/24 at 11:30 A.M., 06/06/24 at 7:00 A.M., 06/07/24 at 8:15 P.M., 06/08/24 at 7:54 P.M., 06/09/24 at 8:12 P.M., 06/10/24 at 6:50 P.M., 06/12/24 at 3:30 P.M. and 7:49 P.M., 06/13/24 at 8:00 P.M., 06/17/24 at 8:30 P.M., 06/18/24 at 7:50 P.M., 06/19/24 at 12:00 P.M. and 4:15 P.M., 06/21/24 at 8:00 P.M., 06/22/24 at 7:49 P.M., 06/23/24 at 8:05 P.M., 06/24/24 at 3:45 P.M., 06/25/24 at 11:30 A.M. and 3:15 P.M., 06/26/24 at 11:30 A.M., 3:30 P.M. and 8:00 P.M., 06/27/24 at 8:00 P.M., 06/29/24 at 3:30 P.M., 06/30/24 at 3:30 P.M., and 07/01/24 at 12:30 P.M. Resident #45's mother completed breath sounds in lieu of a RT on 06/05/24 at 3:30 P.M., 06/06/24 at 3:30 P.M., 06/07/24 at 1:20 P.M., and 06/10/24 at 11:30 A.M. and 3:30 P.M. Resident #45's mother completed tracheostomy care in lieu of a RT on 06/03/24 at 7:30 P.M., 06/04/24 at 8:00 P.M., 06/07/24 at 8:15 P.M., 06/08/24 at 7:54 P.M., 06/09/24 at 8:12 P.M., 06/12/24 at 7:49 P.M., 06/13/24 at 8:00 P.M., 06/17/24 at 8:30 P.M., 06/18/24 at 7:50 P.M., 06/21/24 at 8:00 P.M., 06/22/24 at 7:49 P.M., 06/23/24 at 8:05 P.M., 06/26/24 at 8:00 P.M., and 06/27/24 at 8:00 P.M. RT evaluations were not completed every four hours as ordered on 06/01/24 at 3:30 A.M. and not again until 8:30 A.M., and at 12:40 P.M. and not again until 7:20 P.M., on 06/02/24 at 7:00 A.M. and not again until 11:30 A.M. and not again until 7:55 P.M., on 06/03/24 at 3:30 A.M. and not again until 8:25 A.M., on 06/04/24 at 3:25 P.M. and not again until 8:00 P.M., on 06/05/24 at 7:00 A.M. and not again until 11:30 A.M., on 06/06/24 at 7:00 A.M. and not again until 11:30 A.M., on 06/07/24 at 7:00 A.M. and not again until 1:20 P.M. and not again until 8:15 P.M., on 06/09/24 at 3:15 P.M. and not again until 8:12 P.M., on 06/10/24 at 7:00 A.M. and not again until 11:30 A.M., on 06/10/24 at 6:50 P.M. and not again until 11:25 P.M., on 06/11/24 at 7:00 A.M. and not again until 11:30 A.M. and not again until 4:40 P.M., on 06/12/24 at 7:10 A.M. and not again until 11:35 A.M., on 06/13/24 at 3:15 P.M. and not again until 8:00 P.M., on 06/14/24 at 6:45 P.M. and not again until 11:35 P.M., on 06/15/24 at 6:55 P.M., and not again until 11:35 P.M., on 06/17/24 at 3:10 P.M. and not again until 8:30 P.M., on 06/21/24 at 5:10 A.M. and not again until 11:20 A.M., on 06/21/24 at 3:15 P.M. and not again until 8:00 P.M., on 06/23/24 at 3:20 P.M. and not again until 8:05 P.M., on 06/24/24 at 11:15 A.M. and not again until 3:45 P.M., on 06/26/24 at 3:30 P.M. and not again until 8:00 P.M., on 06/27/24 at 3:15 P.M. and not again until 8:00 P.M., on 06/29/24 at 6:30 A.M. and not again until 11:30 A.M., and on 07/01/24 at 7:00 A.M. and not again until 11:30 A.M. The daily inner cannula change with tracheostomy care was not completed on 06/12/24. Review of Resident #45's care plan updated on 07/03/24 after surveyor intervention revealed the mother was involved in all aspects of care, assisted with bathing, turning, suctioning, and caring for the tracheostomy. The mother was a nurse, competent in the skills and had given return demonstration. The mother preferred to do as much as possible for Resident #45 and was at the facility normally 12 hours daily. The mother had pillows marked for placement, diagrams on the wall, and often requested tasks to be completed more frequently than needed. Education regarding this related to suctioning and tracheostomy care was ineffective and at times provided care on her own and did not allow staff to do it. During night hours, the mother and boyfriend would often watch care through the in-room camera and speak out if they wanted something done differently. They would call and make aides wait for RT before turning and repositioning could be completed. The mother requested certain staff members and at times would demand assignments be changed to have those staff. The goal was for Resident #45's needs to be met by staff with assistance of the mother per her preference. Interventions included to continue to offer and provide care through the mother and boyfriend's visitation hours; continued education with the mother related to frequency of tasks needing to be completed; and education to the mother that all staff were trained to care for Resident #45 when she insisted assignments be changed. Review of progress notes and list of assessments from 06/01/23 to 07/03/24 revealed a note on 06/14/23 which indicated Resident #45's mother provided care when in the facility with assistance from staff as requested. On 07/29/23 the pulmonologist indicated Resident #45's mother and father were used to suctioning Resident #45 without any difficulty so this would continue the same. On 08/19/23 the pulmonologist indicated RT reported getting calls at night from the family using a video system in Resident #45's room to report suctioning was needed despite RT making rounds and determining there were not enough secretions to suction. This issue was discussed with RT who were directed that a normal amount of secretions was okay and sometimes frequent suctioning was of no benefit and may cause harm, irritation or blood-stained mucous with the mother being a nurse should understand it. The mother was directed to notify RT of concerns related to secretions. On 11/03/23 and 12/18/23, the primary care physician (PCP) indicated Resident #45's mother was very involved in his care and provided a lot of care herself. There was no evidence of education to the mother regarding standards of care, risk/effects of providing tracheostomy care too often, or staff observation to determine the mother's competency or to monitor what or how much respiratory care was provided. Interview on 07/03/24 at 12:10 P.M. with RT #383 indicated having once seen Resident #45's mother in process of changing a tracheostomy gauze dressing when Resident #45 was first admitted but had not observed her to determine any competency. RT #383 verified the above respiratory flow records findings and indicated the tracheostomy inner cannula needed changed daily to prevent infections, continuing that it was not a good standard of practice to go longer than once daily. RT #383 explained respiratory orders were written mostly on an as needed basis to allow for variances in care, but the standard of care should be met. Tracheostomy collars were changed on bath days or at least weekly or when needed if soiled. Resident #45's oxygenation checks were ordered for Resident #45 every four hours, but RT approached it to evaluate three times during each shift, so the respiratory log reflected that concept. Interview on 07/03/24 at 3:10 P.M. with DON and Administrator revealed additional oxygenation levels were recorded by various staff in the electronic medical record under vitals, however the results were not on the respiratory flow records as ordered with a RT evaluation. Review of emails between Ombudsman and Administrator from 06/04/24 to 07/02/24 revealed the Ombudsman requested Resident #45's physician orders and then the respiratory flow records because it was referenced in the physician order as the place where four-hour oxygenation levels were to be recorded. The Administrator also confirmed to Ombudsman the pulmonologist was the director or person who oversaw the respiratory department, gave orders and directed the care of residents who required respiratory services. Interview on 07/08/24 at 10:50 A.M. with DON, Administrator, and Assistant Director of Nursing (ADON) #304 confirmed there was no additional RT documentation to meet the four-hour requirement as ordered, and verified there was no evidence in the medical record of the mother performing return demonstration as documented in the updated care plan. They agreed the pulmonologist directed all respiratory related care and indicated the physician was aware of the mother providing care for Resident #45. However, there was no documented evidence that the pulmonologist approved of the mother's provided care to replace the ordered RT evaluation of every four-hour oxygenation level and needed respiratory care. Review of the facility policy, Tracheostomy Care, revised August 2013, tracheostomy care should be provided as often as needed, at least once daily for old, established tracheostomies, and each shift for residents with unhealed tracheostomies; remove supplemental oxygen mask from tracheostomy, inspect skin and stoma site for signs or symptoms of infection, leakage, subcutaneous crepitus or dislodged tube; assess resident for respiratory distress by measuring resident's oxygen saturation with pulse oximeter, listen to lung sounds with a stethoscope and observe for asymmetrical chest expansion.

Based on observation, interview, record review, and review of facility policy revealed the facility did not ensure Resident #13 was free of significant medication error. This affected one resident (#13) out of seven residents reviewed for medication administration. The facility census was 64. Findings include: Review of the medical record for Resident #13 revealed an admitted [DATE] with diagnoses including constipation, vitamin D deficiency, cardiac murmur, hypertension, and spinal stenosis. Review of the Admission Assessment/ Baseline Care Plan dated 06/03/22 and completed by Assistant Director of Nursing (ADON)/ Registered Nurse (RN) #304 revealed Resident #13 does not want to self-administer her medications. Review of the care plan dated 06/29/22 revealed Resident #13 refused care including medications at times. Interventions included accepting the resident's right to refuse, allowing resident choices as able, re-approaching in approximately 15 minutes to encourage compliance, and re-educating after each episode of care refusal. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 had intact cognition. Review of July 2024 Medication Administration Record (MAR) revealed RN #321 had documented she had administered Resident #13 the following medications that were scheduled on 07/01/14 at 8:00 A.M.: Amlodipine besylate 5 milligram (mg) give one tablet by mouth for hypertension, aspirin enteric coated delayed release 81 mg give two tablets by mouth for prevention of cardiac symptoms, calcium carbonate- vitamin D 600-400 mg/ unit one tablet by mouth as a supplement, Colace 100 mg give one capsule by mouth for constipation, glucosamine-chondroitin capsule give two capsules by mouth for osteoarthritis, vitamin C 500 mg tablet by mouth as a vitamin supplement, and ferrous sulfate 325 mg by mouth for anemia. Observation on 7/1/24 at 9:28 A.M. revealed there was a medication cup sitting on Resident #13's bedside table that contained nine tablets and/ or capsules: one red capsule, two white capsules, one green tablet, one dark green tablet, two yellow tablets, and two white tablets. Interview on 07/01/14 at 9:28 A.M. with Resident #13 revealed when the nurse had brought her morning medications, she did not feel like taking them until after she ate her breakfast. Resident #13 revealed she had forgotten then to take them as she did not realize the medications were still sitting on her table. Resident #13 revealed she should have taken her medication especially since her heart medication was one of the tablets. Interview on 07/01/24 at 9:31 A.M. with RN #321 verified she was the nurse that had given Resident #13 her medication this morning, 07/01/24. She verified she had left the medication cup with Resident #13 as Resident #13 had stated she was going to take the medications after breakfast. RN #321 verified she should not have left the medications on her table as she should have come back after she had eaten her breakfast to offer the medications again. RN #321 also verified she had documented that she had administered the medications on the MAR even though Resident #13 had not taken the medication. Review of the facility policy labeled, Medication Administration, dated 06/21/17, revealed medications would be administered in accordance with local, state and federal laws and consistent with accepted standards of practice. The policy revealed the nurse was to remain with the resident while the medication was swallowed and never leave a medication in a resident's room without orders to do so. The nurse was to document medication administration with initials on the MAR immediately after administering the medication to each resident. The policy revealed if a resident refused medications document on the MAR.

Based on interview, record review, review of the dialysis contact, and review of the facility policy on change in condition the facility failed to ensure Resident #65's emergency contact/ family was notified regarding his change in condition requiring cardiopulmonary resuscitation (CPR) and transport to the hospital. This affected one resident (#65) out of three residents reviewed for change in condition. The facility census was 64. Findings include: Review of the closed medical record for Resident #65 revealed an admitted [DATE]. The resident expired at the hospital on [DATE]. His diagnoses included acute respiratory failure with hypoxia, dependence on renal dialysis, ventilator dependent, diabetes, atrial flutter, tachycardia, biventricular heart failure, and tracheostomy. Review of the care plan dated [DATE] revealed Resident #65 had advanced directives to be a full code. Interventions included full code, adhere to his desired code status, and inform the resident and/or responsible party should the resident change his decision regarding his code status. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #65 had impaired cognition and was rarely and/or never understood. He required oxygen, suctioning, and dialysis. He also had a tracheostomy and ventilator. He required two person staff assist with bed mobility and was unable to transfer and/or ambulate. Review of the nursing note dated [DATE] at 8:10 A.M. and completed by the Director of Nursing revealed Resident #65 was unresponsive and without vitals while at dialysis. The note revealed CPR was initiated and the emergency rescue squad (EMS) was called. CPR continued with (Automated External Defibrillator) AED in place until the ambulance arrived and he was transported to the hospital. The note revealed dialysis was to make the family aware of the resident's transfer. Interview on [DATE] at 8:20 A.M. with Resident #65's sister revealed she was upset that the facility and/or dialysis had not contacted her that her brother had a change in condition while at dialysis requiring CPR and transfer to the hospital. She revealed she was not notified until later in the day by the coroner that Resident #65 had passed away. Interview on [DATE] at 8:14 A.M. with Licensed Practical Nurse (LPN) #600 revealed she was Resident #65's nurse on [DATE]. She revealed he had gone to dialysis which was next door, and she was contacted over a walkie-talkie that he had stopped breathing and had no vitals requiring CPR. She revealed dialysis had contacted EMS and transported him to the hospital. She verified she had not contacted Resident #65's emergency contact/family as she thought dialysis had. She revealed she did not realize the family was not notified until they had called her upset on [DATE] early afternoon and stated they had received a call from the coroner that he had passed away. Interview on [DATE] at 10:12 A.M. with the Director of Nursing revealed any time there was a change in status at dialysis including requiring CPR and/or sending a resident to the hospital, dialysis was to contact the family. She verified on [DATE] while Resident #65 was at dialysis he had a change in condition requiring CPR and was sent to the hospital where he was later pronounced dead. She verified the facility and/or dialysis had not contacted the family as Resident #65's sister was notified later in the day on [DATE] by the coroner of her brother's passing. Interview on [DATE] at 10:59 A.M. with LPN #605 revealed he worked at the facility on [DATE] and was assigned the respiratory therapy duties as he revealed if the facility did not have a respiratory therapist that they would assign a specific nurse just to do those duties. He revealed dialysis had called for respiratory assistance to come to the dialysis center on [DATE] at approximately 7:45 A.M. He revealed when he arrived at the dialysis center, Resident #65's skin color was not good, and he had no pulse. He revealed they initiated CPR and contacted EMS who transported him to the hospital. He verified he had not contacted Resident #65's family regarding the change in condition. Interview on [DATE] at 1:56 P.M. with Dialysis Regional Operations Manager #610 stated, the nursing home should have called the emergency contact/ family for Resident #65's change in condition but dialysis should have contacted the family as well. She revealed both dialysis and the facility missed it and verified neither contacted the family. She revealed she felt it was the primary residence which would have been the facility's responsibility to contact the family. She revealed she did not have anything specific in writing that included who should notify regarding a change in condition but revealed she recently had a meeting with the dialysis staff after the incident had occurred on [DATE] and educated the staff that they were to contact the family regardless, so the same situation did not occur again. Interview on [DATE] at 2:15 P.M. with the Administrator revealed per the dialysis contract dated [DATE] the dialysis center and the facility would develop a systematic approach to handling situations if a dialysis patient had a change in condition. She verified she did not have anything in writing that acknowledged the systemic approach of who would contact the family regarding the change in condition. Review of the Home Hemodialysis Coordination Agreement, dated [DATE], between the dialysis center and the facility revealed the dialysis center and the facility would develop a systematic approach to handling situations where a dialysis patient had a condition change and/or became ill during dialysis including knowing who would be contacted, who decided whether to stop dialysis, and who documented the situation. There were no specific approaches listed as to who was responsible for notifications to the family in regards to change in status. Review of the facility policy labeled, Change in Resident's Condition or Status, dated [DATE], revealed it was the policy of the facility to promptly notify the resident, his/her attending physician and representative of changes in the medical/mental condition and/or status. This deficiency represents non-compliance investigated under Master Complaint Number OH00143046.

Based on record review and interview the facility failed to ensure one resident (Resident #17) received restorative range of motion (ROM) and ambulation programs per the plan of care. This affected one (Resident #17) of two residents (Residents #1 and #17) reviewed for restorative nursing and had the potential to affect all 54 (Residents #1, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #20, #21, #22, #23, #25, #26, #28, #29, #30, #31, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43, #44, #45, #46, #47, #48, #49, #50, #52, #53, #57, #58, #60, #63, #64, #66, #319 and #320) residents with planned restorative nursing programs. The facility census was 65. Findings include: Review of the medical record for Resident #17 revealed an admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the comprehensive Minimum Data Set (MDS) dated [DATE] revealed Resident #17 had a Brief Interview for Mental Status (BIMS) score of three indicating severe cognitive impairment. He was independent in the areas of bed mobility and transferring and was unsteady with walking. He had no impairments to his upper and lower extremities. Restorative therapy was provided for passive ROM for four days during the review period and active ROM as provided for two days during the review period. He did not receive any training in walking or ambulation during the review period. Review of the current summary of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan dated 02/28/22 revealed a plan for decreased ambulation, decreased duration and unsteady gait to include a goal to maintain an ambulation distance of 50 feet for at least 15 minutes six to seven times per week, and to document the response, distance and tolerance. Review of the care plan dated 02/28/22 also revealed a plan to maintain Resident #17's ROM in his arms and legs by participating in ROM exercises for 15 minutes six to seven times per week. Review of the Physical Therapy (PT) discharge summary dated 03/03/22 revealed Resident #17 received physical therapy from 02/21/22 through 03/03/22 for strengthening, balance, bed mobility, transfers and ambulation. The summary further indicated Resident #17 walked 0 feet when he started PT on 02/21/22 and walked 50 feet upon discharge from PT services on 03/03/22. The discharge summary included a referral to restorative nursing for ambulation and active ROM to maintain the current level of functioning and prevent further decline. Review of the tasks from 04/12/22 to 05/11/22 documented by the State tested Nursing Aides (STNAs) revealed ROM exercises completed on 04/27/22 and documented as refused on 04/14/22, 04/17/22, 04/28/22 and 05/11/22. Walking exercises were documented for 15 minutes on 04/27/22 and marked as refused 04/14/22, 04/17/22, 04/28/22 and 05/11/22. For a total of 30 days reviewed restorative ROM and ambulation were both provided just one day and documented as refused four times. Interview on 05/11/22 at 1:08 P.M. with Registered Nurse (RN) #524 confirmed Resident #17 was ordered to receive restorative programs for active ROM and ambulation six to seven times a week to maintain current function and prevent decline. She verified she was not aware restorative ROM and ambulation were only provided to the resident on just one occasion from 04/12/22 to 05/11/22. Review of the policy labeled Restorative Nursing dated March 2017 revealed restorative nursing programs would be maintained until the goals were met or success was determined to no longer be attainable. Restorative programs would be provided for any resident identified as in need of the service. The procedure for implementing a restorative nursing program included daily documentation of the program.

Based on observation, record review, and interview, the facility failed to ensure Resident #1 was free from physical abuse. This affected one of three residents reviewed for abuse. Findings include: Review of the medical record for Resident #1 indicated an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the 12/04/18 psychiatrist progress notes indicated Resident #1 was pleasantly confused, his thoughts were poorly organized, his cognition was grossly impaired, and his insight and judgement were limited. Review of the 07/06/19 Minimum Data Set (MDS) 3.0 quarterly assessment indicated Resident #1 was severely cognitively impaired and needed extensive assistance of two staff for bed mobility. Review of the care plan, updated 09/12/19, indicated Resident #1 exhibited behaviors, at times could be combative with staff when upset when receiving care and a staff intervention was to provide a consistent relaxed/calm/quiet environment and approach him in a calm manner. Review of the 09/06/19 Self-Reported Incident to the State agency revealed Resident #1 reported State-tested Nurse Aide (STNA) #5 being rough and he had bruises on his arms. Review of the undated investigation summary statement, written by the Administrator, indicated based on the inconclusiveness of the video, the resident and staff interviews, as well as the skin assessment conducted, the facility was unable to determine if abuse occurred. Observation on 09/16/19 at 10:00 [NAME]M. of three video recordings revealed STNA #5 entered the room of resident #1 to provide care. She did not speak to the resident, voice her intent or explain what she was doing. The STNA was purposeful in her movements of arranging the resident's legs and body, and at times appeared forceful. The resident became combative with STNA #5. STNA #5 was seen slapping the forearm of Resident #1. Interview on 09/16/19 at 10:10 [NAME]M. with the Administrator and Director of Nursing verified STNA #5 was rough with Resident #1 and didn't use the best approach with Resident #1. The Administrator revealed the police department was sending the police report to the prosecutor to decide if STNA #5 would be charged with a crime. Observation on 09/16/19 at 11:00 [NAME]M. revealed Resident #1 was sitting in the hallway near the nurse's station in a geriatric wheelchair with his eyes closed. Interview at the time with Resident #1 revealed when the surveyor asked him if anyone had hurt him, Resident #1 muttered indiscernible words. Observation on 09/16/19 at 12:00 P.M. of Resident #1's room revealed there was a camera disguised as a flower decoration sitting on a dresser across from Resident #1's bed. Interview on 09/16/19 at 2:45 P.M. with Police Officer (PO) #6 revealed he had watched the three videos of Resident #1 and STNA #5 and observed STNA #5 slap Resident #1 and pull back Resident #1's thumb. PO #6 verified at no time during the videos did he observe STNA #5 speaking to Resident #1. PO #6 indicated the police report was given to the prosecutor to decide if criminal charges would be filed against STNA #5. Review of the Resident Abuse, Neglect, Exploitation and Injuries of Unknown Sources, revised 11/21/17, indicated physical abuse included hitting, slapping, pinching and kicking. This deficiency substantiates Complaint Number OH 879.

Based on observation, record review and interview the facility failed to follow pharmacy and manufacturer's instructions after the administration of an inhalation medication for Resident #9 to decrease the resident's risk of developing a fungal infection. This affected one resident (Resident #9) of five residents observed during medication administration. Findings include: On 04/03/19 at 8:20 A.M. Resident #9 was observed receiving medications from Licensed Practical Nurse (LPN) #902. LPN #902 administered medications to Resident #9, including one puff of a [MEDICATION NAME] inhaler (a [MEDICATION NAME][MEDICATION NAME] containing a corticosteriod). There was a label on the [MEDICATION NAME] dispenser with instructions to rinse the mouth after use. LPN #902 did not instruct or assist Resident #9 to rinse his mouth after the use of the [MEDICATION NAME] inhaler. On 04/03/19 at 9:45 A.M. LPN #902 verified the observation and the instructions on the [MEDICATION NAME] label. Review of the manufacturer's instructions for the use of the [MEDICATION NAME] inhaler indicated to rinse the mouth with water after use, without swallowing, to reduce the chance of getting thrush (a fungal infection).

Based on record review and interview the facility failed to ensure Resident #44's physician was notified timely of weight loss, failed to ensure timely assessments were completed and failed to ensure the timely implementation of interventions to address the resident's weight loss. This affected one resident (Resident #44) of four residents reviewed for nutrition. Findings include: Record review revealed Resident #44 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review revealed a plan of care, initiated 01/15/15 identified the potential for altered nutritional status related to obesity, [MEDICAL CONDITIONS] disorder and depression. The nutritional interventions included to assist resident at meals as necessary, encourage fluids, honor food preferences, monitor intake of meals and offer alternates. A nutritional intervention was added to the plan of care on 04/02/19 to give supplements as ordered. A physician order dated 11/09/17 revealed the resident was ordered a regular diet. A physician order dated 02/15/19 indicated the resident was ordered a Magic Cup (a nutritional supplement) three times a day with meals. Review of the current physician orders did not indicate that Resident #44 was on a planned weight loss program. The significant change Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact, had an unplanned significant weight loss and required staff assistance for bed mobility, dressing, toilet use and hygiene and set up for eating. Review of the Comprehensive Medical Nutrition Therapy assessment dated [DATE] completed by Registered Dietitian (RD) #900 revealed Resident #44 was eating 25-50% of meals, she had been refusing meals due to behaviors, she refused to talk to RD #900 about recent decreased meal intakes and RD #900 would send Magic Cup supplement with meals as a trial. Review of the resident's weights from 09/05/18 to 03/06/19 revealed the following: On 09/09/18 the resident weighed 242.0 pounds (#), on 10/09/18 - 239.6#, on 11/04/18 - 244.8#, on 12/01/18 - 238.0#, on 02/12/19 - 221.5#, on 03/05/19 - 214.0# and on 03/06/19 - 215.6# The above weights revealed a 26 pound (10.7%) weight loss in six months (from 09/09/18 to 03/06/19 ), 22 pound (9.2%) weight loss in three months (from 12/01/18 to 03/06/19) and six pound (2.7%) weight loss in one month (02/12/19 to 03/06/19). As of 04/04/19 a monthly weight had not been recorded yet in the medical record for the month of (MONTH) 2019. Review of the Medication Administration Records from 02/15/19 through 04/01/19 revealed poor to good acceptance of the Magic Cup supplement in (MONTH) 2019, 35 refusals in (MONTH) 2019 and seven refusals of nine administrations from 04/01/19 to 04/02/19. Review of the physician progress notes [REDACTED].M. authored by Physician #904 revealed the resident's weight was 214 pounds and there had been no recent weight loss. Physician #904 documented the resident was more depressed, deconditioned and he was recommending therapy. There was no evidence in the physician's note to indicate he had been notified of the significant weight loss for (MONTH) 2019. Review of the quarterly Nutrition Significant Weight Loss Assessment, dated 04/01/19 completed by RD #900 revealed Resident #44 was consuming 26-50% of meals, her weight on 03/05/19 was 214 pounds, and RD #900 was unable to talk to the resident due to behaviors. RD #900 noted the physician had been updated on resident's poor intake and weight loss over three months but did not identify the amount of weight loss, that it was a significant weight loss due to behaviors or that she had been refusing the Magic Cup supplements. No additional nutrition interventions were initiated by RD #44 for the significant weight loss at this time. Review of the dietary progress note dated 04/02/19 at 1:36 P.M. by RD #900 revealed the facility nurse informed her that Resident #44 no longer wanted her Magic Cup supplement. An interview was conducted on 04/01/19 at 9:18 A.M. with Resident #44 who revealed she had been losing weight due to not liking the food and supplement served to her. The resident indicated no one on the staff had visited her recently to discuss her food preferences. She reported she did not eat in the dining room for personal reasons and chose to eat her meals in her room. During the interview Resident #44 was polite, appropriate and engaged in reciprocal conversation. An interview was conducted on 04/01/19 at 9:41 A.M. with Licensed Practical Nurse (LPN) #902 who revealed Resident #44 had been more depressed over the last month and had been losing weight due to not eating well. LPN #902 revealed the resident no longer wanted the Magic Cup supplement because she did not like the taste of it and often refused it over the last several months. An interview was conducted on 04/03/19 at 4:01 P.M. with Dietary Manager (DM) #901 who revealed she had just started at the facility in (MONTH) 2019 and had not updated food preferences for Resident #44. DM# 901 revealed she had not discussed any supplement options with Resident #44 since the Magic Cup supplement that was ordered on [DATE] by RD #900. An interview was conducted on 04/03/19 at 6:01 P.M. with RD #900 who revealed she was not able to assess Resident #44's significant weight change for (MONTH) 2019, because she was covering three facilities and did not have the time to do it. RD #900 verified she was aware of the 26 pound weight loss from 09/09/18 to 03/06/19 and the 22 pound weight loss from 12/01/18 to 03/06/19 but was unable to assess the change until 04/01/19. RD #900 verified she put no new nutritional interventions in place for Resident #44 at that time because Resident #44 did not want to talk to her and she did not want to be too pushy with her to try new supplements due to her prior refusals to speak with RD #900. Review of the facility policy titled Weight Management Monitoring, dated 10/10/13 revealed identified significant, unplanned weight loss should be assessed by the dietitian and reported to the physician.

Based on interview and record review, the facility failed to ensure a treatment administration record accurately reflected dressing changes for a midline intravenous catheter. This affected one (Resident #90) of three residents (Residents #82, #89, and #90) reviewed for dressing orders. Findings include: Review of the closed record revealed Resident #90 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident had a physician order [REDACTED]. The physician order [REDACTED].#90 was discharged to the hospital on [DATE]. Review of the electronic treatment administration record (eTAR) for (MONTH) and (MONTH) (YEAR) indicated the order was transcribed as change midline and caps weekly and prn on day shift every Tuesday, start date (MONTH) 15, (YEAR). The eTAR was not signed to indicate the dressing was changed on 05/15/18, 05/29/18, 06/05/18 or 06/12/18. During an interview on 07/09/18 at 5:55 P.M., Registered Nurse Supervisor (RN Supervisor) #215 remembered Resident #90 had a midline to her right arm. She indicated the dressing should be changed once a week. RN Supervisor #215 agreed the documentation on the eTAR indicated the dressing was not changed for a three week period. She observed the dressing and knows the dressing was changed. RN Supervisor #215 indicated the eTAR did not accurately reflect the dressing changes.

Based on observation, interview, and review of the facility policy on glucometer maintenance, the facility failed to ensure a glucometer used on multiple residents was cleaned between uses. This affected one (Resident #30) of four residents (Residents #2, #7, #30, and #44) observed receiving blood sugar monitor. The facility identified six residents (Resident #2, #30, #41, #68, #86, and #87) residing on Cardinal Way who receive blood sugar monitoring. Findings include: On 07/09/18 at 11:06 A.M., Registered Nurse (RN) #204 checked Resident #2's blood sugar using a glucometer. After finding out his blood sugar, the nurse placed the glucometer on top of medication cart. RN #204 administered insulin, washed her hands, and signed the electronic Medication Administration Record [REDACTED]. She then moved the medication cart down the hallway. An observation on 07/09/18 at 11:14 A.M., revealed RN #204 using the same glucometer entered Resident #30's room and checked his blood sugar. After obtaining the blood sugar, the nurse placed the glucometer on top of the medication cart, then put it into the top drawer of the cart. She administered insulin, washed her hands, and signed the eMAR. The nurse did not clean the glucometer between residents or prior to placing it back into the top drawer of the medication cart. During an interview on 07/09/18 at 11:22 A.M., RN #204 agreed she used the same glucometer for both residents and did not clean the glucometer between residents or prior to putting it into the medication cart. The nurse indicated her wipes to clean it were not in the medication cart. Review of the facility's policy Glucometer Maintenance and Quality Control (revised 11/25/14) indicated glucometers used on multiple residents will be cleaned and disinfected with a solution that is listed as an EPA registered hospital disinfectant that contains a concentration of 1:10 bleach. Commercially prepared wipes may be used. Glucometers will be cleaned and disinfected before use and after each resident use.

Based on observation, record review, and interview the facility failed to ensure Resident #24, who required staff assistance for activities of daily living received adequate nail care. This affected one resident (Resident #24) of 18 residents reviewed for personal hygiene. Findings include: Record review revealed Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #24 was unable to participate in a mental status interview and was totally dependent on staff for bed mobility, transfers, dressing, toilet use and personal hygiene. A plan of care that was initiated on 09/23/09 identified Resident #24 was dependent on staff for all activities of daily living, had bilateral hand contractures and required hand splints to be put on at 10:00 A.M. each morning and removed at 4:00 P.M. each evening. A resident care card, updated 01/31/17 indicated Resident #24 was nonverbal and totally dependent for all hygiene needs. Resident #24 was to be bathed or showered twice a week. Observations were made on 03/12/18 at 8:25 P.M., 03/13/18 at 10:00 A.M., 03/13/18 at 4:11 P.M. and 03/14/18 at 9:25 A.M. of Resident #24. During the observation on 03/12/18 at 8:25 P.M. Resident #24 was observed lying on her back in bed with the fingernails of her right hand contracted against the palm of her right hand. The left hand was not visible underneath her blanket. During the remaining observations Resident #24 presented with hand splints on both hands which exposed ¼ inch to ½ inch long fingernails with old, red nail polish that had mostly worn off the nail. An interview was conducted on 03/14/18 at 9:25 A.M. with State tested nursing assistant (STNA) #13. STNA #13 revealed she was familiar with Resident #24's activity of daily living needs and Resident #24 was totally dependent on staff for hygiene which included trimming her nails. STNA #13 explained Resident #24 was unable to voice her needs to staff and nail trimming was part of the bathing and showering procedure for dependent residents. STNA #13 verified Resident #24 had not had her nails trimmed during baths or showers.

Based on observation, record review and interview the facility failed to ensure Resident #20, who was assessed to have limitations to range of motion was provided palm protectors as ordered. This affected one resident (Resident #20) of two residents reviewed for limitations in range of motion. Findings include: Record review revealed Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 assessment, dated 01/01/18 indicated the resident required extensive assistance of two staff for bed mobility and was dependent on staff for hygiene. She had limited range of motion to both arms and legs. She was identified as nonverbal. The resident had physician's orders [REDACTED]. On 03/13/18 at 12:24 P.M. Resident #20 was observed in bed. Her left hand was in a closed fist position. Her left hand did not have a palm protector in place. Her right hand was covered with a blanket and not visible. On 03/13/18 at 5:10 P.M. the resident was observed in bed. Her left hand was in a closed fist position with no palm protector in place. Licensed practical nurse (LPN) #11 uncovered the resident's right hand, which was observed in a closed fist position without a palm protector in place. LPN #11 verified the palm protectors were not in place. LPN #11 searched the resident's room and drawers and was unable to locate the palm protectors.

Based on observation and interview the facility failed to ensure open multi-dose insulin pens for Resident #71 were properly dated when opened. This affected one resident (Resident #71) of 20 residents in the facility prescribed insulin. Findings include: On 03/13/18 at 4:35 P.M. the medication cart was observed on the 500 unit with licensed practical nurse (LPN) #10. The medication cart contained one opened prefilled Humalog insulin (a fast-acting insulin) administration pen and one opened prefilled [MEDICATION NAME](long-acting insulin) administration pen for Resident #71. The open insulin pens were not dated when opened. The label on the Humalog insulin pen indicated to discard 28 days after opening. The label on the [MEDICATION NAME]pen indicated to discard 42 days after opening. There were no visible dates on the pens that indicated when the insulin pens were ordered or received from the pharmacy. The findings were verified with LPN #10 at the time of the observation. She indicated the pens were usually received from the pharmacy in a plastic bag that contained an additional label. She was unable to locate the plastic bags.

The following survey finding pertains to an incident of past noncompliance that was subsequently corrected prior to this survey. Based on record review and interview the facility failed to ensure medications were administered to residents in a manner to prevent accident hazards. This affected four residents (Residents #81, #43, #78 and #34) out of four residents reviewed for unsecured medications. Findings include: On 02/26/18 at 2:00 P.M. interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) #10 revealed after the breakfast meal on 12/27/17 the previous Administrator, Administrator #9, called ADON #10 to report the dietary supervisor had found pills on the meal trays which had come down to the kitchen from Resident #43 and Resident #81. ADON #10 said Dietary Supervisor #25 took the pills back to the nurses on the floor. The nurses were Licensed Practical Nurse (LPN) #26 and LPN #27. The nurses handed Resident #43 and Resident #81 their medications and walked out of the room, prior to the residents swallowing them. The residents put the medications on their meal trays and then forgot to take them. LPN #26 and LPN #27 gave the missed medications to Resident #43 and Resident #81 after verifying that they had not taken them. When Resident #43 and Resident #81 were interviewed by the DON they indicated that it was not a usual practice for the nurses to leave the medications at the bedside. LPN #26 and LPN #27 admitted they just left the medications at the bedside. The medications left at the bedside did not include any controlled medications. The DON said the incidents on 12/27/17 did not result in medication errors for the residents, so a medication error report was not made. Both nurses received education by the DON and written warnings on 12/27/17 for negligence and carelessness related to the medications being left at the bedside and not observing to ensure the residents ingested them. The DON said the incidents were isolated and they had no knowledge of any medications being left in rooms prior to the incidents on 12/27/18. Continued interview with ADON #10 and the DON on 02/26/18 at 2:00 P.M. revealed the DON said on 01/15/18 Administrator #9 called Corporate Regional Nurse (CRN) #28 on the phone to report that medications were left on the meal tray for Resident #78 and were whole, not crushed. The DON said Administrator #9 was not speaking to the DON or ADON during that period of time, so they were not told. CRN #28 came out and investigated the incident. The Medication and Treatment Errors and Omissions report dated 01/15/18 by CRN #28 indicated medications were found on the dinner meal tray that was returned to the kitchen for Resident #78. The dietary staff member gave the medications to the nurse. There were two pills identified as [MEDICATION NAME] (medication to lower phosphorous blood levels) and [MEDICATION NAME] (blood pressure medication) that were on the meal tray, but not in a medication cup. Review of the Medication Administration Record [REDACTED].M., [MEDICATION NAME] and [MEDICATION NAME] (blood pressure medication). The medications were signed as administered at 3:56 P.M. and 4:00 P.M. The dinner trays were delivered to the resident's unit at 4:45 P.M., after the medication administration. Resident #78 was interviewed by the DON on 01/17/18. The resident said he always receives his medications and they are always crushed and in pudding. He denied the nurses left medications on his table or in his room. Interviews were conducted with the nurses who administered medications to the resident that day. An interview with Registered Nurse (RN) #29 dated 01/18/18 indicated she always crushed the medications for Resident #78 and administered them by mouth or per his feeding tube if he was very sleepy. She has never given him medications whole or left them at the bedside. An interview with LPN #30 dated 01/18/18 indicated she crushed the medication for Resident #78 and put them in pudding. She said she has never given him medications whole or left them at the bedside. Continued interview with ADON #10 and DON on 02/26/18 at 2:00 P.M. revealed a quality assurance and performance improvement plan (QAPI) was completed. Education was provided to nurses on 01/15/18 that medications were not to be left at any patient's bedside unless a self-medication assessment had been completed and they have been deemed safe to take them independently. Medications that are turned in that as not taken will result in medication errors going forward. The DON said there was also an incident when a housekeeper found pills in the room of Resident #34, who has a history of hoarding pills. Resident #34 said he just does not want to take them, but instead of refusing them he would hoard them. The nurses were aware and it was care planned. The care plan for Resident #34 was reviewed and indicated he was non-compliant with liquid medications and hides medications in his room at times. Interventions included to accept his right to refusal, make three attempts to give a medication and notify the physician as needed. On 02/27/18 at 9:45 A.M. interview with the nurse educator, LPN #36, revealed Administrator #9 called her to the office in mid-January and handed her a medicine cup with two pills. LPN #36 identified the pills as Tums (an antacid) chewable tablets. Administrator #9 said she usually gave them to the coordinator, RN #37 , but she was not there. Administrator #9 told LPN #36 to take care of them. Administrator #9 told LPN #36 someone gave the pills to her. Administrator #9 did not say who gave them to her, where they were found or who they belonged to. LPN #36 said she discarded the Tums and told the DON. On 02/27/18 at 9:55 A.M. interview with Housekeeping and Laundry Supervisor #38 revealed Housekeeper #39 was deep cleaning the room of Resident #34 and found a few pills in his bed. The housekeeper brought them to her. She gave them to a nurse, but did not remember who the nurse was or the date it occurred. She said she also told Administrator #9. The monthly quality assurance (QA) committee meeting form dated 01/23/18 indicated the medical director was present. Medications left at the bedside were discussed with an indication that in-services were started and audits were on-going. The QAPI plan dated 01/15/18 indicated medications left at the bedside were identified with a root cause that nurses were not ensuring residents were taking medications and some residents were insisting on medications being left in their room. Actions included secure conversations sent on 01/15/18 to all nurses by the DON discussing medication administration and not leaving medications at the bedside, nurse education on 01/16/18 by the assessment coordinator, LPN #2, regarding not leaving medication at the bedside and ensuring residents are taking medications prior to leaving the resident during medication pass with a goal date of 01/26/18 and then random medication audits twice weekly by the DON. Medication audits were completed by the DON and ADON on 01/15/18, 01/17/18, 01/18/18, 01/19/18, 01/22/18, 01/23/18, 01/24/18, 01/25/18, 01/26/18, 01/29/18, 01/30/18, 01/31/18, 02/01/18, 02/02/18 and 02/05/18. No medications were left in the resident rooms or at the bedsides. The monthly QA committee meeting form dated 02/20/18 indicated the QAPI related to medications left at the bedside was completed 01/26/18 and discontinued. Random audits continued until 02/05/18. There were no further incidents of medications located in resident rooms or on resident meal trays since 01/15/18. Review of the facility's corrective action revealed the following actions were implemented and the deficiency corrected as of 02/05/18. Corrective action included: · The identified nurses involved received disciplinary action on 12/27/17 related to leaving medications at the bedside. · The incidents were investigated by management. · A Medication and Treatment Errors and Omissions report was completed 01/15/18. · Interviews of staff and residents involved were conducted. · All nurses were educated regarding medication administration and not leaving medications at the bedside. · The medical director was notified. · A QAPI was completed and discussed at the monthly QA meetings on 01/23/18 and 02/20/18. · Medication audits were completed by the DON between 01/15/18 and 02/05/18. This deficiency substantiates Complaint Number OH 237.

Based on review of resident medical records, facility investigation reports and interviews with staff, residents and family, the facility failed to protect Resident #10 and Resident #6 from sexual abuse. The facility failed to ensure staff reported the incidence of sexual abuse immediately to prevent further abuse. This resulted in Immediate Jeopardy for two residents (Residents #6 and #10) who were sexually abused by Respiratory Therapist (RT) #33. This affected two of 90 residents reviewed for abuse. The census was 90. The Administrator and Director of Nursing (DON) were notified on 05/06/14 at 3:50 P.M. that Immediate Jeopardy began on 04/21/14 at 12:00 A.M. when state tested nursing assistant (STNA ) #30 observed RT #33 standing in Resident #10's room with his hand on the resident's breast and, at the same time, adjusting his own pants. STNA # 30 did not report this occurrence until 04/22/14 at 8:20 A.M. after RT#33 worked his entire shift. RT #33 was suspended pending an investigation of potential sexual abuse. RT #33 was terminated by the facility on 04/23/14. Review of a staff statement dated 04/25/14 at 11:25 P.M. revealed after termination of the employment of RT #33, another facility resident indicated RT #33 and Resident #6 were sexually active since October 2013. Resident #6 verified that a sexual relationship was ongoing from October of 2013 until RT #33 was terminated from the facility on 04/23/14. Resident #6 thought the respiratory therapist was her "boyfriend." The Immediate Jeopardy was removed on 04/23/14 when RT #33 was terminated from the facility. This reduced the potential for imminent sexual abuse for all residents. Although the Immediate Jeopardy was removed, the facility remains out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) because the facility did not assess all potential victims, did not interview staff to determine if sexual activity could be suspected between RT #33 and any other residents and did not complete abuse training for all staff. Findings include: 1.Review of the medical record for Resident #10 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. The resident had a [MEDICAL CONDITION]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact and able to make her needs known. Review of a self-reported incident (SRI) dated 04/21/14 revealed on 04/21/14 at 8:20 A.M., STNA#30 wrote a statement that on 04/21/14, as she was doing 12:00 A.M. rounds, she went to the room of Resident #10. The resident's door was closed. The statement indicated that when she walked into the room, RT #33 was standing at the side of Resident #10's bed, with his hand on Resident #10's breast. The statement revealed RT #33 "took a step back when he saw me and adjusted his pants." STNA #30 wrote on her rounds paper and left the room. As STNA #30 was walking out, RT #33 asked Resident #10 if she was feeling better. At about 2:00 A.M., Resident #10 asked STNA #30 if she could get out of bed and if the STNA would get her up. Resident #10 stated she "didn't feel comfortable with men in her room." Interview with STNA #30 on 05/07/14 at 8:15 A.M. revealed she did not knock on Resident #10's door because she thought the resident was asleep. She stated she opened the door quietly and walked in the room. The curtain was half pulled. When STNA #30 walked around the curtain, the resident was in bed, awake, and RT #33 was standing with his hand on her breast and adjusting his pants. She stated RT #33 did not see or hear her until she came around the curtain. STNA #30 stated she was shocked by what she saw and she wasn't sure what to make of it. STNA #30 made a notation on a form hanging on the bathroom door and left the room. STNA #30 stated she heard RT #33 ask the resident if she felt better and later saw him leave the room. STNA #30 stated that at 2:00 A.M., Resident #10 rang the call light and asked if she could get up and who would help her. STNA #30 stated she would help her and Resident #10 stated that was good because she didn't feel comfortable with men in her room. STNA #30 stated Resident #10 never said anything about being uncomfortable with men in her room prior to that day. STNA #30 stated that she was "in shock" and didn't know what to think about the incident. She stated she mentioned the incident to two other staff members, STNA #36 and STNA #37, at some point during that early morning. STNA #30 finished her shift and went home. She stated that she came back to the facility on [DATE] at 8:00 A.M. and reported the incident to the DON. STNA #30 stated she knew she should have reported the incident right away, but that she was "in shock and didn't know what to do." A second interview with STNA #30 was conducted by phone on 05/12/14 at 9:10 A.M. STNA #30 verified she wrote her statement concerning the incident on 04/22/14 and had misdated the original statement by writing the date as "04/21/14." Interview with the DON and Administrator on 05/07/14 at 9:20 AM revealed the facility's investigations and statements were unclear regarding which staff members were aware of the suspected abuse and did not report it as required. Interview with the Administrator on 05/06/14 at 10:40 A.M. verified she reported the incident to the state agency on 04/22/14. The Administrator revealed she called RT #33 to come in on 04/22/14, had him write a statement and then suspended him. Review of RT #33's statement dated 04/22/14 at 11:20 A.M. revealed he was informed on 04/19/14 that Resident #10 needed her [MEDICAL CONDITION] changed. RT #33 went to Resident #10's room to check her. RT #33's statement indicated Resident #30 stated she didn't feel right, so he adjusted the air bottle attached to her [MEDICAL CONDITION]. The RT's statement indicated that he checked Resident #30 again on 04/21/14 at 12:00 A.M. His statement revealed he placed his hand at her "apicals to (check) tactile fremitise" (tactile fremitus). His statement indicated that process was used in place of a stethoscope to feel for anything abnormal. Per the statement, the resident had no complaints and RT #33 left the room at that time. RT #33 did not document in the resident's medical record concerning this assessment/check of the resident. The statement by RT #33 did not address him adjusting his pants. Review of the facility's investigation revealed Resident #10 was interviewed by the DON and Administrator on 04/22/14 at 10:00 A.M. A statement form completed by the administrator indicated Resident #10 reported her oxygen levels had been dropping so the staff asked RT #33 to check Resident #10. The statement indicated RT #33 made an adjustment to the resident's oxygen concentrator and the resident felt better. When asked if the RT touched her breast, the resident stated "no." Resident #10 stated she slept naked and the RT pulled up the sheet. When asked if RT #33 touched her breast or did anything inappropriate, the resident said "no." The investigation also revealed three other residents, Residents #1, #2 and #3, were interviewed as to whether RT #33, or any other staff member had touched them in an inappropriate manner. The three residents denied concern with this. A phone interview was conducted and documented on 04/22/14 at 1:43 P.M. by the DON. The interview was with the nurse coordinator, Registered Nurse (RN) #35. Review of this documented interview revealed Resident #10 asked when the "head of respiratory" was going to change her [MEDICAL CONDITION]. The resident was not having respiratory concerns and she only questioned about when the [MEDICAL CONDITION] would be changed. RN #35 told RT #33 that the resident wanted the director of therapy to change her [MEDICAL CONDITION] and did not want RT #33 to do it. Licensed practical nurse (LPN) #34, the nurse assigned to the unit where Resident #10 resided on 04/21/14, wrote a statement on 04/22/14 that indicated nothing was reported to her about inappropriate touching. Interview with the Administrator on 05/06/14 at 12:15 P.M. verified that the three additional residents interviewed during the investigation were alert and oriented residents on the respiratory/ventilator unit of the facility. Resident #10 did not reside on that unit. The Administrator verified the respiratory therapist routinely treated residents on the respiratory/ventilator unit, which included six other female residents. The Administrator stated she interviewed those residents because they were alert and oriented and could express their feelings or concerns. The Administrator verified the other residents on the unit were not interviewed. She also verified the respiratory therapist would also see residents with respiratory concerns on other units in the facility, but she could not identify which residents RT #33 may have treated beyond the ventilator unit. The Administrator verified Resident #10 was not questioned as to why she told RN #35 that she did not want RT #33 to change her [MEDICAL CONDITION] or why she told STNA #30 that she did not want male staff caring for her on 04/21/14 at 2:00 A.M. The Administrator also verified no other staff were interviewed concerning any observations of RT #33's behaviors or statements related to the incident. During interview with Resident #10 on 05/06/14 at 2:30 P.M., the resident denied concerns with care at the facility or with specific staff, but stated she was not always comfortable with care by male staff. An interview with the Administrator on 05/06/14 at 12:15 A.M. revealed the investigation was initiated due to suspected sexual abuse. The Administrator stated based on the interview with Resident #10, interviews with three other residents and the staff mentioned above; she decided that sexual abuse was unsubstantiated. The Administrator stated she terminated the employment of RT #33 on 04/23/14 based on a recurring concern that he provided care to a resident without documentation of his actions. Interview by phone with RN #35 on 05/12/14 at 5:10 P.M. verified she spoke with Resident #10 on 04/20/14 between 10:00 P.M. and 12:00 P.M. when she was in the resident's room to do a respiratory treatment. RN #35 stated Resident #10 asked when her [MEDICAL CONDITION] would be changed and stated she would prefer the respiratory therapy director (RT #45) change it instead of RT #33. RN #35 stated she was unsure why Resident #10 had that preference, but thought it was because RT #45 was more familiar with her [MEDICAL CONDITION]. 2. Review of the medical record for Resident #6 revealed an admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment dated [DATE] revealed Resident #6 was cognitively intact and able to make her needs known. Review of a self-reported incident (SRI) dated 04/28/14 revealed on 04/28/14 at 11:25 P.M. Resident #4 asked STNA #37 why RT #33 had been "fired." Review of a witness statement written by STNA #37 revealed he told Resident #4 that he was not sure and Resident #4 replied "It's probably because (Resident #6) was jerking him off in her room." Resident #4 stated Resident #6 told her about this. Review of the facility's investigation revealed Resident #4 was interviewed (undated/untimed statement) by the DON. The statement indicated Resident #6 told Resident #4 that she was in a "relationship" with RT #33 and that Resident #4 was aware of this "from the beginning." Resident #4 told the DON that she told Resident #6 the relationship was not a good idea. Resident #4 revealed she did not report it because she "promised" Resident #6 that she would not say anything. Review of a written interview conducted with Resident #6 on 04/28/14 at 11:20 p.m. by RN #35 revealed when asked about any inappropriate activities Resident #6 may have had with any respiratory therapist, Resident #6 answered "yes it did." The resident stated the activity included "mostly massaging" for both she and RT #33. Resident #6 stated to RN #35 that RT #33 would "pull his thing out." When questioned about intercourse, Resident #6 stated "he did it from behind, it hurt at first" and she was "not sure if it was her rectum or vagina." Resident #6 stated RT #33 would put his penis in her mouth when he massaged her, "like he was having sex with my mouth." The statement revealed Resident #6 said it was consensual, she didn't think anything was wrong with it and it would remain their "secret." Resident #6 stated this happened when she resided on the D wing and when she moved to her current room on the main hall, he didn't come to that room. Resident #6 stated that when RT #33 worked, he would come to her former room, "so it happened a lot, I also went to see him." Resident #6 stated that it "started after Christmas this past year and lasted until I moved." Review of a written interview conducted with Resident #6 on 04/29/14 at 9:50 A.M. by the DON revealed Resident #6 mentioned to RT #33 that she wanted a boyfriend and stated "I was joking when I said it." The resident stated RT #33 came into her room at a later time and asked what she liked in a boyfriend. Resident #6 revealed RT #33 began to rub her shoulders, "I liked it and then he rubbed my breast." The resident stated RT #33 "unzipped his pants, pulled it out and I rubbed him." When questioned how many times this happened, the resident could not give a number but estimated it started around October 2013. The resident stated that RT #33 would wait until other staff went on breaks and then go see her. Resident #6 stated "I thought he was my boyfriend, I thought he liked me." In this interview, the resident stated that when she moved rooms, she would meet RT #33 in the computer room, dining room and once in the respiratory office. Resident #6 stated that she had "sex with him" twice, as she "bent over for him." The interview indicated the resident stated "over and over again, 'I liked it and I wanted it.' " A statement written by LPN #39 on 4/29/14 at 9:50 A.M. indicated that once the resident moved to her new room "it was my idea to meet in the computer room, dining room and the last time, a couple of weeks ago, we were in the respiratory office." The resident stated repeatedly "I thought he was my boyfriend, I was stupid." Further review of the facility's investigation revealed five female residents (Resident #8, #9, #11, #13 and #14) and one male resident (Resident #7) were asked if they had experienced any type of inappropriate behavior from a staff member and each resident denied this. Interview with the Administrator on 05/06/14 at 12:15 P.M. revealed she interviewed five alert and oriented female residents. She verified that there was no particular reason for the choice of these residents to interview. The Administrator verified she did not attempt to determine which residents may have been directly cared for by RT #33. The Administrator further verified she did not interview other staff members who may have worked when RT #33 was in the building to determine if other residents may have been potentially sexually abused or in another type of relationship with RT #33. The Administrator stated, as she felt Resident #6 consented to the sexual relationship with RT #33, she did not conclude the actions of RT #33 were sexual abuse. She stated that RT #33 was terminated from employment prior to the discovery of the interactions with Resident #6 and she did not attempt to contact him to obtain a statement or ask if other residents may have been affected. The Administrator stated again that the termination of RT #33 was due to lack of documentation of care provided by RT #33 in the course of his duties. The conclusion of the facility's investigation indicated as the action of RT #33 was a "violation of professional conduct" on the part of RT #33, he would be reported to the Ohio Respiratory Care Board. The conclusion also indicated the facility contacted the local police department. Review of Resident #6's progress notes dated 04/27/14 at 3:19 P.M. (prior to the discovery of her relationship with RT #33) revealed Resident #6 visited with other residents and staff. A note on 04/30/13 at 1:27 P.M., (two days after discovery) revealed Resident #6 was very quiet on that day, talking with staff only. There were no other notes in Resident #6's medical record concerning the incident until 05/02/14 when a social work note at 11:03 P.M. revealed the resident was "feeling very ashamed." Resident #6 was encouraged to talk with staff as needed. The social worker (SW #1) also made sure the resident was on the list to be seen by the psychologist on 05/07/14. The note indicated Resident #6's counselor was notified of "abuse." A social service note dated 05/06/14 at 1:05 P.M. revealed Resident #6 requested to talk and was asked about "being quiet and sad looking last week." Resident #6 stated she was upset thinking that RT #33 was her "boyfriend and now she has no one." A nursing note dated 05/06/14 at 2:13 P.M. revealed Resident #6 was crying and sobbing and asking "Why did I do that?" Resident #6 requested a medication for her nerves and was medicated with [MEDICATION NAME], an anti-anxiety medication. During interview with Resident #6 on 05/07/14 at 2:20 P.M. she denied concerns with care or staff, but admitted to some concern with RT #33. The resident stated she thought RT #33 liked her, but she felt badly because "I am a Christian and I should not have done that." Resident #6 was slightly tearful and stated that she was upset before "because I miss my family," then stated "my sister never would have done what I did." An interview was requested by Resident #6 and the resident's family. Interview on 05/12/14 at 11:00 A.M. with Resident #6 and family members #1 and #2 revealed family member #1 was quite upset. Family member #1 stated she felt RT #33 took advantage of Resident #6 and she wasn't sure if the facility took the issue as seriously as they should have. During the interview, Resident #6 related the details of the interactions she had with RT #33. Resident #6 stated her interactions with RT#33 included "sex in my mouth" with his penis, and RT #33 would hold her head down as she completed this act. Resident #6 stated that sometimes she would feel like she couldn't breathe, but because RT#33 was holding her head down, she would "pretend to choke" to be able to put her head up and get a breath. Interview with Resident #4 on 05/12/14 at 4:30 P.M. verified Resident #6 told her about her relationship with RT #33 around October 2013. Resident #4 stated she promised not to tell anyone about the relationship. Resident #4 stated she heard that RT #33 no longer worked at the facility and that RT #33 was let go because of an interaction with a female resident. Resident #4 assumed the resident was Resident #6. Resident #4 stated that she felt badly about breaking her promise to Resident #6. Two attempts were made to interview STNA #37 were not successful, as he did not answer his phone and voice mail was not available. Review of the facility abuse policy (undated) revealed each resident has the right to be free from abuse and should not be subjected to abuse by anyone, including facility staff. The policy defined "sexual abuse" to include, but was not limited to, sexual harassment, sexual coercion or sexual assault. The policy indicated that it was the responsibility of every employee to report any incident or suspected incident of abuse, neglect or misappropriation. The Administrator was to be notified immediately of an incident of suspected or actual abuse. The policy indicated a confidential and thorough investigation of the incident would be conducted and the occurrence of other incidents would be prevented. The investigation would consist of interviewing the person reporting the incident, witness, involved residents, other residents that many have been in the area or have some knowledge of the situation and family members. All staff members who had contact with the resident within 24 hours of the alleged incident would be interviewed. The medical record and all circumstances surrounding the incident would be reviewed. Review of the "prevention" section of the policy revealed that staff were to be supervised to identify inappropriate behaviors. Assessments, care planning and monitoring of residents with needs and behaviors that might lead to conflict or neglect would be used for prevention of abuse. Review of the employee handbook revealed it was a "violation of this facility for any staff member to have a sexual relationship with a resident. The prohibition applies even though the parties may claim that it is a voluntary relationship which both has freely consented to. This is a serious matter and all staff members are expected to be in full compliance with this policy. There are no exceptions. Any individual that violates this policy will be terminated." Review of the Employee Code of Conduct revealed that a sexual relationship with a resident by a staff member was a "Class C offense," which automatically resulted in a 3 day suspension or termination of employment. This citation substantiates Complaint Numbers OH 569 and OH 560.

Based on record review, interview and observation, the facility failed to ensure appropriate interventions were initiated to prevent Resident #114 from developing a deep tissue injury on her left heel and failed to implement dietary interventions to assist with healing. This affected one of four residents reviewed for pressure ulcers. Findings include: Resident #114 was admitted to the facility on [DATE], and [DIAGNOSES REDACTED]. A care plan to address her risk of developing impaired skin integrity was initiated on 06/29/11. Interventions included avoiding skin friction/sheering, float/elevate heels, supportive devices to maintain position changes, turn and reposition in bed/chair every two hours, a therapeutic mattress and a gel or pressure reducing cushion in her wheelchair. The minimum data set assessment dated [DATE] revealed the resident was moderately impaired cognitively. This assessment indicated Resident #114 was at risk for the development of pressure ulcers and needed extensive assistance with two or more staff to move and reposition in bed. The February 2012 physician order [REDACTED]. The nurse's note on 12/19/11 at 1:32 P.M. indicated the physician and Resident #114's daughter were notified of the area on her right heel and the new orders in place. The pressure ulcer tracking for 12/19/11 indicated the right heel blister measured 4.5 centimeters (cm) long by 2.5 cm wide. As of 02/01/12, the pressure ulcer tracking indicated the area was 1.5 cm long by 1.5 cm wide. The dressing change was observed with Licensed Practical Nurse (LPN) #1 on 02/07/12 at 8:55 A.M. Resident #114 was in bed on her side and Prevalon boots, boots to relieve/reduce pressure on her feet, were on both feet. The dressing on Resident #114's right foot/heel was removed. The pressure ulcer was black and was not measured by the nurse. The skin was intact and the tissue around the black area was cracked and peeling. LPN #1 cleaned the area with normal saline, dried it and applied a thick pad and gauze wrap. The Prevalon boots were reapplied. After the treatment was completed, LPN #1 was interviewed and indicated they had been elevating Resident #114's heels off of the bed with a pillow prior to the development of her pressure ulcer. LPN #1 indicated that Resident #114 did not always leave the pillow in place and would kick or move it out of place herself. LPN #1 indicated the Pravalon boots were initiated last Friday, 02/03/12. Interview with State tested Nurse Aide (STNA) #2 on 02/07/12 at 9:20 A.M. verified that Resident #114 was cooperative some days with leaving the pillow under her feet to elevate her heels and some days she was not. STNA #2 stated the STNAs were to check each resident's skin with daily care and dressing. On 02/07/12 at 3:20 P.M., the director of nursing (DON) and assistant director of nursing (ADON) #5 were interviewed and the medical record for Resident #114 was reviewed. Staff members had stated that Resident #114 was not always compliant with having her feet/heels elevated, however no alternative interventions were attempted. The Pravalon boots were not initiated until the nurse practitioner examined Resident #114 on 02/03/12. The DON verified that the STNAs were to check and observe each resident's skin daily with personal care/dressing. Review of the dietary progress note dated 01/18/12 indicated Resident #114 had sustained a significant weight loss of 5% in one month, weekly weights would be requested and additional dietary interventions would be added as needed. There was no mention of Resident #114's development of a pressure ulcer. The next dietary progress note on 02/06/12 indicated Resident #114's weight was up five pounds but she still had experienced a gradual weight loss in the last one, three and six month intervals. This note indicated a three day calorie count was completed and revealed Resident #114 had an average daily intake of 1017 calories and 47 grams of protein. The registered dietician (RD) increased the healthshake from two a day to three a day. The RD did not document any information related to the pressure ulcer and did not implement any interventions to aid in healing and to address the resident's low protein consumption. An interview was conducted with RD #6, the RD who wrote the dietary progress notes, on 02/08/12 at 3:50 P.M. RD #6 verified she did not include the pressure ulcer in her dietary notes. RD #6 indicated Resident #114's estimated nutritional needs had not been calculated since the assessment completed on 03/15/11. The estimated calorie needs at that time were 1770 per day and her estimated protein needs were 85 grams per day. RD #6 verified Resident #114's current intakes were well below these estimated needs, from almost a year ago. This deficiency substantiates Complaint Number OH 056.

Based on interview and record review, the facility failed to ensure the appropriate number of staff assisted Resident #34 during a transfer which resulted in a fall and fractured right leg. The facility also failed to provide the physician-ordered 1:1 supervision to Resident #115 at the time of his fall. This affected two of five residents reviewed for falls. Findings include : 1. Resident #34 was admitted [DATE]. The resident's [DIAGNOSES REDACTED]. The minimum data set assessment dated [DATE] indicated the resident had no cognitive impairment and required the extensive assistance of two people for transfers and toilet use. The resident used a wheelchair for mobility. Review of the resident's care plans revealed a care plan for the resident's impaired ability to transfer initiated on 11/12/09. According to the intervention initiated on 02/23/10 and discontinued on 12/16/11 after the resident's fall, the resident transferred from the bed to the wheelchair and back to bed with a sliding board and the assistance of two. The resident also used a mechanical lift as needed. A fall progress note dated 12/09/11 at 11:30 A.M., revealed the nurse walked into the room and found Resident #34 on the floor. The state tested nurse aide (STNA) stated he/she was transferring the resident from the bed to the wheelchair; the resident slipped and the STNA lowered her to the floor. The resident complained of knee pain and stated she heard her knee crack. The resident was sent to the hospital. Review of hospital records dated 12/09/11 revealed the resident had sustained a fracture of the fibula (the outside bone in her lower leg). Resident #34 was interviewed on 02/09/12 at 2:30 P.M. The resident relayed the story that she fell and fractured her right leg on 12/09/11. The resident stated there was one STNA assisting her instead of two. The director of nursing (DON) was interviewed on 02/09/12 at 2:50 P.M. The DON verified there was one STNA instead of two transferring the resident when she fell . 2. Resident #115 was admitted to the facility on [DATE], and [DIAGNOSES REDACTED]. The nurse's notes dated 12/09/11 at 1:06 P.M., and dated 12/10/11 at 1:06 P.M., stated Resident #115 was alert to himself with confusion. Nurses notes dated 12/08/11 at 5:23 P.M. indicated Resident #115 was restless and a bed alarm was initiated to alert staff if he attempted to get out of bed. On 12/08/11 at 11:30 P.M., the nurse's notes stated they heard the ventilator alarming, entered Resident #115's room and saw him sliding off of the bed. The nurse indicated Resident #115 was repositioned and he was confused. No injuries were found and the new safety intervention was to place blue mats on the floor next to either side of the bed. Nurses notes dated 12/09/11 and 12/10/11 documented Resident #115 continued to be restless. On 12/10/11, a new physician order [REDACTED]. On 12/10/11 at 1:06 P.M., Resident #115 was observed to be anxious and he was trying to pull at his tracheostomy and trying to get out of bed. This nurse's note indicated Resident #115's safety was ensured with one on one supervision. On 12/13/11, a physician order [REDACTED]. The nurse's notes on 12/12/11 at 2:42 P.M., and on 12/13/11 at 9:21 A.M., indicated Resident #115 was restless and pulling at his tubing. On 12/14/11, the physician reordered one on one supervision. Nurses notes dated 12/15/11 at 5:55 A.M., indicated Resident #115 had been observed putting his legs over the side of the bed and rolled his feet and knees over until they were touching the floor mat. The nurse stated Resident #115 had been restless throughout the night and slept little. On 12/15/11 at 1:14 P.M., the nurse's note indicated the STNA left the room to get a bed pad and upon returning found Resident #115 on the floor mat next to the bed. There was no documentation in the medical record to indicate whether the bed alarm was in place as ordered and sounding. The facility did not provide the continuous one on one supervision resulting in Resident #115 falling out of bed on 12/15/11. The DON verified these findings on 02/07/12 at 3:25 P.M. This deficiency substantiates Complaint Number OH 056.

Based on observation, record review and interview, the facility failed to re-evaluate pressure relieving interventions to address head and neck positioning after Resident #59 developed a pressure ulcer on her ear and a pressure ulcer to the right chin/jaw. The facility also failed to provide treatment to pressure ulcers in a manner to prevent the spread of infection for Resident #59. This affected one of three residents reviewed for pressure ulcers, out of 16 residents identified in the facility with pressure ulcers. Findings include: 1. Resident #59 was admitted to the facility on [DATE]. She had current [DIAGNOSES REDACTED]. The admission skin risk assessment dated [DATE] indicated the resident was at moderate risk for skin breakdown. The resident was provided a pressure reducing mattress, heels were elevated at all times and turn and reposition every two hours and as needed. Wound documentation dated 05/06/11 indicated Resident #59 developed a 0.8 centimeter (cm) x 1.2 cm x < 0.1 cm pressure ulcer with red thin drainage to the right ear. A protective cream was ordered and to keep the head midline. A u-shaped neck pillow was implemented. The use of the u-shaped neck pillow continued. On 05/13/11 an order was obtained to keep a pad under the right side of the chin at all times and keep the ear off the pad. Resident #59 was observed on 05/15/11 at 2:00 P.M., in bed on her back with her head turned slightly to the right side. A neck pillow was in place with the open end in front. The pad was not in place. The resident was observed in bed on her back with a neck pillow in place and her head midline with her body on 05/17/11 at 8:15 A.M. The pad was not in place. On 05/17/11 at 8:15 A.M., dressing changes were observed with Registered Nurse (RN) #1. RN #1 stated she observed a new open area on the resident's right jaw/chin area. She stated she had not seen the area before and had not been provided any information from the previous shift about the new area. State tested Nurse Aide (STNA) #3, who was in the room, was also unaware of the area. RN #1 assessed the area on the right side of the face along the jaw line as a pressure ulcer that measured 0.4 cm x 1.2 cm x 0.1 cm. It was dark pink and moist, with defined edges. She cleaned the area, placed a dry dressing over it, and said she would notify the physician for a treatment order. She stated the resident had a history of [REDACTED]. She then changed the dressing to the resident's right ear. Interview with the unit Licensed Practical Nurse (LPN) #5 on 05/17/11 at 10:40 A.M., revealed she was unaware of the open area on the resident's right jaw. Interview with Respiratory Therapist (RT) #6 on 05/17/11 at 10:45 A.M., revealed he provided [MEDICAL CONDITION] care for the resident that morning at 6:00 A.M. and did not see the new area on the resident's right jaw. He stated the resident held her head to the right. Resident #59 was observed on 05/17/11 at 2:45 P.M., in bed on her back with her head slightly to the right with the neck pillow with the open end in front and pad in place. An interview was conducted with RN #1 on 05/18/11 at 9:50 A.M. She stated that even with the neck pillow in place, the resident was able to flex her neck to the right side and press her chin onto her chest. On 05/13/11 a pad was added to help position the resident's head. On 05/17/11 the resident developed a pressure ulcer to the right jaw. The jaw wound was not observed when the RT provided [MEDICAL CONDITION] care on 05/17/11 at 6:00 A.M. It was not observed by any staff prior to that time. RN #1 stated it was difficult to turn the resident on her left side, but verified that the resident had not been assessed for the use of other interventions to position the resident on her left side or prevent the resident from turning her head to the right side. She stated the resident had not been evaluated by therapy for any positioning devices. All findings were verified with RN #1 at the time of the interview.