Every finding on record at Arbors at Minerva

Based on record review, interview and review of facility policy, the facility failed to ensure residents were administered medications according to ordered parameters. This affected four (Residents #4, #17, #84 and #96) of four reviewed for medication administration. The facility census was 70.Findings include:1. Review of orders for Resident #4 revealed on 03/20/26 he was prescribed Midodrine 5 milligrams (mg) by mouth three times daily for hypotension (low blood pressure). The order required a blood pressure be taken prior to administration of the medication. If the systolic blood pressure was greater than 140, the medication was to be held.Review of the medication administration record (MAR) for Resident #4 revealed on 07/08/26 and 07/10/26, the morning dose of Midodrine was administered with no recorded blood pressure. This was confirmed by the Director of Nursing (DON) on 07/15/26 at 11:30 A.M.2. Review of orders for Resident #17 revealed on 12/09/23 he was prescribed Digoxin 125 micrograms(mcg) by mouth every morning for atrial fibrillation. The medication was to be held for a heart rate less than 60 and notify the physician. Review of the MAR for Resident #17 revealed on 07/06/26, 07/13/26, and 07/14/26 the resident was administered Digoxin with no heart rate recorded. This was confirmed by the DON on 07/15/26 at 11:30 A.M.3. Review of orders for Resident #84 revealed on 07/10/26 he was prescribed Metoprolol succinate extended release 100 mg by mouth twice daily for atrial fibrillation. The order required the medication be held if the resident's heart rate was less than 60.Review of the MAR for Resident #84 revealed on 07/14/26, the resident was administered Metoprolol Succinate with no heart rate recorded. This was confirmed by the DON on 07/15/26 at 11:30 A.M.4. Review of orders for Resident #96 revealed on 04/17/26, the resident was ordered Midodrine 2.5mg by mouth three times daily for hypotension. The medication was to be held if the systolic blood pressure was greater than 120. Review of the MAR for Resident #96 revealed on 04/18/26 the resident was administered the night dose of midodrine with a systolic blood pressure of 128. On 04/19/26 the morning dose was administered with a systolic blood pressure of 132, and the night dose on 04/21/26 was administered with a systolic blood pressure of 126. This was confirmed by the DON on 07/15/26 at 11:30 A.M. On 07/15/26 at 2:13 P.M., an interview with Registered Nurse (RN) #202 revealed if she had a resident on Midodrine, she would expect to see parameters for administration. Generally, a blood pressure was required, and if the medication did not meet the parameters, the medication would be held and the physician notified.On 07/16/26 at 8:30 A.M. an interview with the DON confirmed the medications for Residents #4, #17, #84, and #96 were given when the parameters were out of range and should have been held. In the case of the medications for Resident #4 and Resident #17, the nurse (LPN #271) had documented NA (not applicable) in place of the vital signs for the resident and had administered the medication.Interview with LPN #271 on 07/16/26 at 9:00 A.M. revealed when she administered medications to residents with parameters she would take their blood pressures. She did confirm for Residents #4 and #17, she failed to document blood pressures or pulse. In fact, she documented NA or not applicable and did not document the vital signs in the medical record. She reported she realized this was incorrect and appeared she administered the medication without checking vital signs to be certain they were within the ordered parameters for the medication.Review of a facility policy titled Medication Administration, revised 01/17/26, revealed medications were administered by staff legally authorized to do so. Medications were to be administered as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.Compliance, according to the policy, included obtaining and recording vital signs, when applicable or per physician order. When applicable, medications were to be held for those vital signs outside the physician's prescribed parameters. This deficiency represents non-compliance investigated under Complaint Number 3035383.

Based on record review facility education review, and interview, the facility failed to develop and implement a comprehensive person-centered care plan for each resident to meet specific medical needs. This affected one (Resident 96) resident of three reviewed for care plans. The facility census was 70.Findings include:Review of the medical record for Resident #96 revealed an admission date of 04/17/26. Diagnoses included other chest pain, atherosclerotic heart disease, malignant neoplasm of supraglottis, chronic obstructive pulmonary disease, type two diabetes mellitus with hyperosmolarity without nonketotic hyperglycemia, history of irradiation, malignant neoplasm of anterior surface of the epiglottis, tracheostomy status, gastrostomy status, muscle weakness, malignant neoplasm of the larynx, constipation, anxiety, and depression.Review of facility education Record of Inservice dated 04/17/26 revealed education for [NAME] Tube Care. The education was presented by Licensed Practical Nurse (LPN) #216. Information included what a [NAME] tube was (a flexible silicone tube designed to maintain the stoma right after the laryngectomy surgery). The stoma should be cleaned before the straps were changed. If crusted areas, use a water-soluble lubricant around the stoma to moisten the crusting. Never pick or remove dried crusting without moistening it with lubricant. Use normal saline if crusted areas were inside the stoma to moisten it. The residents should cough to expel the dried, crusted plugs. To prevent infection, remove and clean the [NAME] tube regularly, as ordered. Usually done two or three times daily. Do not use hydrogen peroxide, rubbing alcohol or any chemicals to clean the tube. To remove, pull steadily up and outward. If the resident started to cough, the stoma should be covered. Scrub the tube with a clean gauze pad under running water. If it was heavily soiled, use hot water and mild soap. Rinse thoroughly with distilled water. Use lubricating jelly on the tube for easier placement into the stoma. The education indicated the provider should be notified if: The [NAME] tube could not be removed. Do not force it. If the nurse was unable to reinsert the [NAME] tube after removing it to clean it. If a resident was having breathing problems, call 911 immediately, or if there were signs of infection near the site, which could include swelling at the stoma site, red, painful or bleeding stoma; foul smelling or bloody mucus; fever over 100; increased amount of mucus.Review of the care plan initiated on 04/17/26 for Resident #96 failed to have interventions in place for risk for respiratory complications related to [NAME] tube. The care plan failed to address the resident needs for care and management of a [NAME] tube. The care plan had no interventions regarding suctioning, skin care ([NAME] tube collar), stoma care for the [NAME] tube or how to maintain the patency of the [NAME] tube. The care plan indicated the resident had a tracheostomy and the spouse would care for the tube and suctioning. Review of an admission Minimum Data Set (MDS) version 3.0 assessment dated [DATE] for Resident #96 revealed a Brief Interview for Mental Status (BIMS) score of 14/15. A score of 14 indicated the resident was cognitively intact. He used a wheelchair for mobility. He required partial to moderate assistance with all activities of daily living.Review of the physician's orders dated 04/22/26 for Resident #96 revealed an order for oxygen to be administered via the [NAME] tube. Further orders indicated the resident would require [NAME] tube care daily and as needed, with assessment of the stoma site and under the tube collar.On 07/15/26 at 3:06 P.M., an interview with Resident #96's significant other revealed she had many concerns regarding his care when he was a resident at the facility. She believed staff did not know how to take care of him, or anyone who may have a [NAME] tube. She did not feel his pulse ox (measure of oxygen using a pulse oximeter) was accurate because he was a neck breather, and he would be short of breath, but the staff would tell her he was fine, not to worry. She felt staff had no idea how to suction him or maintain his airway, and no one seemed to have a plan. She had to tell them what to do and when to do it, and the staff would just ignore her.On 07/15/26 a 2:30 P.M., an interview with the DON confirmed the care plan for Resident #96 did not include interventions to maintain his [NAME] tube. It also confirmed the education would have provided a guide when creating the care plan but was not on there. She confirmed the interventions on the care plan which indicated the resident had a tracheostomy tube were incorrect. She also confirmed the facility had no policy or procedure for the care of a [NAME] tube.This deficiency represents non-compliance investigated under Complaint Number 3035283.

Based on record review, interview and review of facility policy, the facility failed to implement interventions to prevent and/or treat constipation for one resident (Resident #96) of three residents reviewed for constipation. The facility census was 70.Findings include:Review of the medical record for Resident #96 revealed an admission date of 04/17/26. Diagnoses included other chest pain, atherosclerotic heart disease, malignant neoplasm of supraglottis, chronic obstructive pulmonary disease, type two diabetes mellitus with hyperosmolarity without nonketotic hyperglycemia; history of irradiation; malignant neoplasm of anterior surface of the epiglottis; tracheostomy status; gastrostomy status; muscle weakness; malignant neoplasm of the larynx; constipation; anxiety, and depression.Review of a care plan for Resident #96 revealed a focus of care for potential for incontinence, implemented 04/17/26. Interventions included observing for no bowel movement for three days.Review of an order dated 04/17/26 for Resident #96 revealed staff was to monitor/document/report to the physician any side effects of pain medication. The order included observing for constipation. Review of medication orders for Resident #96 revealed a 04/17/26 order for Lactulose (laxative) 10 grams per 15 milliliters, give 30 milliliters (ml) by mouth daily for constipation. There were also orders for Senna (laxative) 8.6 milligrams (mg) give two tablets by mouth every 12 hours as needed for constipation (ordered 04/17/26), Milk of Magnesia (laxative) give 30ml by mouth every 72 hours as needed for constipation if no bowel movement for three days (04/17/26), Dulcolax suppository (laxative) one suppository rectally every 24 hours as needed for constipation if no result from Milk of Magnesia (04/17/26) and Fleet enema insert one rectally every 24 hours as needed for no result from Dulcolax for constipation (04/17/26).Review of progress notes for Resident #96 revealed an admission note written by Licensed Practical Nurse (LPN) #208, dated 04/17/26 at 1:36 P.M. The note revealed the resident's last bowel movement was noted to have been of 04/16/26. This note was confirmed by the DON on 07/16/26 at 12:10 P.M.Review of a Minimum Data Set (MDS) version 3.0 assessment dated [DATE] for Resident #96 revealed a Brief Interview for Mental Status (BIMS) score of 14/15 scale. A score of 14 indicated the resident was cognitively intact. He used a wheelchair for mobility. He required partial to moderate assistance with all activities of daily living.Review of the medical record for Resident #96 revealed a task for bowel elimination. The task documentation revealed the resident had no bowel movement on 04/17/26, 04/18/26, 04/19/26, 04/20/26, and 04/21/26.Review of the medication administration record (MAR) for Resident #96 for the month of April 2026 revealed he was never administered as needed Senna, Dulcolax suppository, or Milk of Magnesia. He was given a Fleet enema on 04/22/26. This was confirmed by the Director of Nursing (DON) on 07/16/26 at 3:00 P.M.On 07/16/26 at 12:10 P.M. an interview with the DON confirmed the admission note written LPN #208 Resident #96's his last BM was known to have been on 04/16/26. Further, she confirmed the facility did not have a policy or procedure regarding constipation.On 07/16/26 at 2:41 P.M., an interview with LPN #216 revealed according to bowel protocol, after three days nursing would offer Milk of Magnesia, then if that was ineffective, they would move to the next thing. Then we would try a suppository, and then if that was ineffective, we would go to a fleet enema. The LPN reported the clinical dashboard in Point Click Care (the facility electronic medical record) would indicate who had not had a bowel movement in three days so nursing would initiate bowel protocol. If the resident had a Senna order that would be given first. On 07/16/26 at 3:00 P.M. an interview with the DON confirmed Resident #96 was not given as needed medications when he had not had a bowel movement in three days. No interventions were provided until the resident had not had a bowel movement on 04/22/26, and he should have had interventions beginning on 04/19/26.This deficiency represents non-compliance investigated under Complaint Number 3035283.

Based on record review, observation, policy review, and interview, the facility failed to follow physician orders to maintain the patency of Resident #20's feeding tube. This affected one of one resident (Resident #20) reviewed for medication administration via feeding tube. The facility census was 70.Findings include:Review of the medical record for Resident #20 revealed an admission date of 05/23/25. Diagnoses included muscle weakness, need for assistance with personal care, nontraumatic intracerebral hemorrhage in hemisphere subcortical, constipation, cerebrovascular disease, nutritional deficiency, and pneumonia. Review of a care plan for Resident #20 revealed she was at risk for nutrition/hydration due to enteral feeling. This was initiated on 03/12/26. Interventions included administering enteral nutrition per orders, flushing feeding tube per orders, providing supplements, vitamin/mineral supplements as ordered. Also, staff was to obtain her weight, and evaluate and report any significant weight changes to the physician per policy. Review of a care plan for Resident #20 revealed impaired gastrointestinal status related to feeding tube, constipation, malabsorption, nutrition deficiency and intra-abdominal mass. This was initiated 03/12/25 and revised 05/29/26. Interventions included medications as ordered (01/20/25), notifying the physician of any signs of dehydration (01/20/25), flushing feeding tube per orders (01/20/25), observing and reporting any abdominal pain, distension, tenderness at tube site, nausea or vomiting, and checking tube for tube placement and residual as indicated.Review of orders for Resident #20 revealed an order, dated 05/20/26, for flushing instructions. The nurse was to flush the feeding tube with 50 milliliters (ml) of water before and after every medication administration and feeding.On 07/14/26 at 5:30 P.M., an observation of Registered Nurse (RN) #235 administering medications via the feeding tube to Resident #20 revealed the RN flushed the tube with 30 ml of water before and after medication administration.On 07/14/26 at 5:55 P.M., an interview with RN #235 confirmed she administered the incorrect amount of water to Resident #20 before and after her medication administration. She should have used 50ml of water both before and after. Review of a facility policy titled Feeding Tubes, revised 10/25/24, revealed tube feeding would only be used as necessary to address malnutrition and dehydration, or when the resident's clinical condition deems the intervention was medically necessary to maintain acceptable parameters of nutrition and hydration. Feeding tubes would be maintained according to current clinical standards of practice with interventions to prevent complications to the extent possible. Feeding tubes would be utilized according to physician orders. The plan of care would reflect the use of a feeding tube and potential complications.This deficiency represents non-compliance investigated under Complaint Number 3035283.

Based on record review and interview, the facility failed to maintain accurate medical records on each resident. This affected one (Resident #96) of eight reviewed for accuracy of medical records. The facility census was 70.Findings include:Review of the medical record for Resident #96 revealed an admission date of 04/17/26. Diagnoses included other chest pain, atherosclerotic heart disease, malignant neoplasm of supraglottis, chronic obstructive pulmonary disease, type two diabetes mellitus with hyperosmolarity without nonketotic hyperglycemia, history of irradiation, malignant neoplasm of anterior surface of the epiglottis, tracheostomy status, gastrostomy status, muscle weakness, malignant neoplasm of the larynx, constipation, anxiety, and depression.Review of a care plan initiated 04/17/26 revealed Resident #96 was at risk for impaired communication related to tracheostomy. The care plan also indicated a risk of nutritional deficit related to tube feeding and tracheostomy, and he required Enhanced Barrier Precautions (EBP) for tracheostomy.Review of an admission note for Resident #96, dated 04/17/26 (incorrectly) indicated the resident had a tracheostomy. Review of an admission Minimum Data Set (MDS) version 3.0 assessment dated [DATE] for Resident #96 revealed a Brief Interview for Mental Status (BIMS) score of 14/15 scale. A score of 14 indicated the resident was cognitively intact. He used a wheelchair for mobility. He required partial to moderate assistance with all activities of daily living.Review of orders dated 04/22/26 for Resident #96 revealed orders for [NAME] (laryngectomy) tube care. The order was for [NAME] tube (a flexible silicone tube designed to maintain the stoma right after the laryngectomy surgery) care daily and as needed. Assess stoma site and under tube collar. Review of the history and physical for Resident #96 dated 04/22/26 indicated the resident was admitted following a lengthy hospital stay in which he had completed a course of radiation post laryngectomy. The note also (incorrectly) indicated the resident had a tracheostomy.An interview with the Director of Nursing (DON) on 07/16/26 at 2:00 P.M. revealed Resident #96 did not have a tracheostomy. Resident #96 had a laryngectomy and had a [NAME] tube in place during his stay at the facility. She confirmed the records indicating the resident had a tracheostomy were incorrect.This deficiency represents non-compliance investigated under Complaint Number 3035283.

Based on record review, observation, facility policy review, and interview, the facility failed to ensure care was provided to a resident with a feeding tube in a manner to prevent the development and transmission of communicable diseases and infections. This affected one (Resident #20) of three residents reviewed for Enhanced Barrier Precautions (EBP). The facility census was 70.Findings include:Review of the medical record for Resident #20 revealed an admission date of 05/23/26. Diagnoses included muscle weakness, need for assistance with personal care, nontraumatic intracerebral hemorrhage in hemisphere subcortical, constipation, cerebrovascular disease, nutritional deficiency, and pneumonia. Review of a care plan for Resident #20 initiated 01/17/25 and revised 05/28/26 revealed the resident required EBP because she had a percutaneous endoscopic gastrostomy tube (PEG) tube and a history of multi-drug-resistant organism infection (MDRO). Interventions included using gown and gloves when providing direct care to the resident, including incontinence care, feeding tubes, and personal hygiene. On 07/14/26 at 4:54 P.M. an observation of Resident #20's room revealed a sign indicating EBP for the resident. The sign indicated gloves and gown should be worn for personal care, which included wound care and care of feeding tubes. On 07/14/26 at 5:30 P.M., an observation of Registered Nurse (RN) #235 administering medications and flushing Resident #20's feeding tube was made. The RN failed to don a gown while providing care for the resident. This was confirmed by RN #235 following the observation. On 07/14/26 at 5:55 P.M., an interview with RN #235 confirmed she did not wear any Personal Protective Equipment (PPE) for this procedure and should have worn PPE appropriate for EBP.Review of a facility policy titled Enhanced Barrier Precautions, revised 03/26/24, revealed the facility implemented EBP for prevention of transmission of MDRO. EBP was an infection control intervention which employed targeted gown and glove use during high contact resident care activities. This included residents with indwelling medical devices such as feeding tubes. Gown and gloves would be readily available near or outside of the resident's room and worn only during the high contact activities. This policy was provided by the Director of Nursing (DON) on 07/15/26 at 9:00 A.M.This deficiency represents non-compliance investigated under Complaint Number 3035283.

Based on record review, observations and interviews, the facility failed to ensure transmission-based precautions were followed for Resident #2 and failed to ensure infection control practices were followed during catheter care for Resident #2 and #76. This affected one resident (Residents #2) out of five residents reviewed for transmission-based precautions and two (Residents #2 and #76) out of two residents reviewed for urinary catheters. The facility census was 74.Findings include: 1. Review of the medical record for Resident #14 revealed an admission date of 01/16/26 with diagnoses including sepsis, the presence of right artificial hip joint, need for assistance with personal care. Review of the Discharge summary dated [DATE] from the hospital for Resident #14 revealed she had diagnoses of sepsis and acute on chronic right hip periprosthetic methicillin-resistant staphylococcus aureus (MRSA) wound infection status post revision of total hip arthroplasty and debridement. Review of the care plan dated 01/16/26 for Resident #14 revealed she had an infection as evidenced by right hip revision with sepsis. Interventions included contact isolation precautions (gown and gloves). Review of the physician's orders for January and February 2026 for Resident #14 revealed she had a dressing ordered to her right hip daily. There were no orders noted for contact isolation. Review of the nursing progress notes for Resident #14 revealed on 01/16/26 at 10:30 P.M. she was admitted status post right hip debridement and there was skin impairment noted with a surgical incision to the right hip. On 01/17/26 at 8:53 A.M. nursing staff stated interoperative wound cultures from the hospital were positive for MRSA. She was to receive intravenous antibiotics until 02/17/26. On 01/26/26 at 10:53 A.M., nursing staff noted Resident #14's right hip wound was assessed and noted to have moderate drainage that was consistent with prior assessments. Review of the physician's progress note dated 01/21/26 by Medical Director (MD) #872 for Resident #14 revealed she was on prolonged intravenous antibiotic therapy through 02/17/26 for MRSA infection. Observation on 02/09/26 at 7:35 P.M. revealed Resident #14 did not have contact isolation signage on the door. Interview on 02/09/26 at 8:09 P.M. with Licensed Practical Nurse (LPN) #842 verified Resident #14 should have been on contact isolation because she was positive for MRSA. Interview on 02/10/26 at 1:50 P.M. with the Director of Nursing (DON) verified there were no contact isolation orders from 01/16/26 through 02/09/26. Review of the facility policy titled, Transmission-Based (Isolation) Precautions, dated 10/24/22, revealed contact precautions were intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment. 2. Review of Resident #2's medical record revealed the resident was admitted on [DATE] with diagnoses including end stage renal disease with dialysis, obstructive and reflux uropathy and chronic gout. Review of Resident #2's care plans revealed an intervention dated 04/05/24 to use gown and gloves when providing direct care. Face protection may be needed if performing activity with risk of splash or spray. Review of Resident #2's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #2's physician orders revealed an order dated 09/21/25 to use enhanced barriers while performing high-contact activity with the resident related to the catheter and dialysis; and an order dated 10/14/25 to change the suprapubic catheter every four weeks. Observation on 02/10/26 at 1:31 P.M. with Certified Nursing Assistant (CNA) #843 and CNA #839 revealed the staff members used a Hoyer mechanical lift to move the resident from the resident's wheelchair to the bed. CNA #843 and CNA #839 were observed to cleanse the suprapubic catheter with a washrag and soapy water. The staff members then cleaned the suprapubic catheter with clean water and dried the suprapubic with a clean towel. Both CNA #843 and CNA #839 were observed to implement latex gloves but not an isolation gown when providing suprapubic catheter care to the resident. Signage on the resident's door revealed the resident was placed in enhanced barrier precautions (EBP). Interview on 02/10/26 at 1:53 P.M. with CNA #843 and CNA #839 confirmed they did not implement isolation gowns during Resident #2's suprapubic catheter care as required. Review of the EBP policy revised 03/26/24 revealed it was the policy of the facility to implement EBP for the prevention of transmission of multidrug-resistant organisms. Even if a resident was not known to be infected or colonized with a multidrug-resistant organism, an order for EBP will be obtained for residents with wounds, indwelling medical devices such as central lines, urinary catheters, tracheostomy and ventilator tubes. Implementation of EBP may include but was not limited to gowns and gloves. 3.Review of the medical record for Resident #76 revealed an admission date of 06/12/25 with diagnoses that included malnutrition, chronic obstructive pulmonary disease (lung disease), obstructive uropathy (a blockage in the urinary system that can impede the ability to urinate), and heart failure. Review of the Minimum Data Set 3.0 (MDS) quarterly assessment dated [DATE] revealed Resident #76 was cognitively impaired, did not reject care, required maximal assistance for toileting hygiene, and had an indwelling urinary catheter (a tube inserted into the bladder to drain urine). Review of the physician orders revealed an order dated 06/26/25 for catheter care every shift. An observation on 02/12/26 at 9:17 A.M. of catheter care with CNA #868 revealed the following: located directly on the bedside table without a barrier was a resident cup, a television remote, a basin of water, a towel, a tube of barrier cream, skin cleanser, and what appeared to be two quarter sized areas of food residue; CNA #868 performed catheter; after catheter care was performed CNA # 868 performed perineal care of the external genitalia and after utilizing the skin cleanser placed it back down on the bedside table; CNA #868 then assisted Resident #76 to turn on their side and utilized the skin cleanser to clean the buttocks area and then placed the skin cleanser back down on the bedside table; CNA #868 then used the towel that was directly on the bedside table to dry Resident #76; CNA #868 then picked up the tube of barrier cream and applied it to the buttocks of Resident #76 and then placed the tube back on the bedside table; once care was completed the bed was moved into a low height and the urinary catheter bag was noted to be touching the floor; and after the soiled linens were gathered and CNA #868 washed their hands they left the room. An interview on 02/12/26 at 9:27 A.M. with CNA #868 revealed a barrier was not used because the bedside table was cleaned prior to the procedure. When CNA #868 was asked what disinfectant was used, they noted the standard blue cleanser with a spray top was the product used. When CNA #868 was asked to show which disinfectant was used on the bedside table, they produced a bottle of perineal skin cleanser. Perineal skin cleanser did not have disinfectant properties. At the time of the interview CNA #868 verified the above findings including the urinary catheter bag on the floor. Review of the facility policy titled Catheter Care Procedure-Urinary, dated 12/28/23 revealed catheter care would be provided to reduce bladder or kidney infections, and catheter care would be provided in accordance with current clinical standards.

Based on record review, emergency medical services (EMS) run report review, death certificate review, policy review, and interview, the facility failed to adequately monitor and provide timely and necessary care and treatment following a change in condition for Resident #1. This affected one (Resident#1) of three reviewed for change in condition. Actual Harm occurred on [DATE] at 1:48 A.M. when Resident #1 (who had previously been medicated for nausea/vomiting on [DATE] at 3:56 P.M. and 10:38 P.M.) vomited brown-colored emesis and had a decline in her baseline vital signs. The resident's blood pressure was ,d+[DATE] millimeters of Mercury (mm/Hg) (normal blood pressure is ,d+[DATE] mm/Hg), heart rate was 120 beats per minute (normal is ,d+[DATE]), temperature was 99.4 Fahrenheit (F), and oxygen saturation was 90% on room air (normal is 92% or higher on room air). Resident #1 complained of aching all over and was given Tylenol (analgesic and fever reducer) 325 milligrams (mg) two tablets. On [DATE] at 4:49 A.M. Resident #1 required cardiopulmonary resuscitation (CPR) following cardiac arrest. Licensed Practical Nurse (LPN) #200 went into the resident's room to reassess the effectiveness of the Tylenol administered earlier at 1:48 A.M., when Resident #1 complained that she did not feel right and was observed to have short, rapid respirations and was pale, cold and moist. The resident's blood pressure was unable to be read, oxygen saturation was 76% on room air, and temperature was 96.9 F. The physician was notified, and an order was given to send the resident to the emergency room (ER). Prior to the arrival of Emergency Medical Service (EMS) personnel, Resident #1's condition further declined, and CPR was initiated by nursing staff. Resident #1 required tracheal intubation (a flexible tube is inserted to maintain an open airway) and CPR was unsuccessfully administered for approximately 27 minutes in the facility. The resident was pronounced dead on [DATE] at 5:16 A.M. when the heart monitor revealed asystole (no pulse or electrical activity of the heart) following cardiac arrest. Findings include: Review of the medical record revealed Resident #1 was admitted to the facility on [DATE]. Diagnoses included paraplegia, morbid obesity, obstructive hydrocephalus, presence of cerebrospinal fluid drainage device, major depressive disorder, and abnormal posture. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had intact cognition. The resident required physical assistance with activities of daily living. Review of the nursing progress note dated [DATE] at 11:30 A.M. revealed the resident received Zofran 4 mg (ordered [DATE]) by mouth for nausea and vomiting. The administration was listed as effective. Review of the nursing progress note dated [DATE] at 8:55 A.M. revealed Resident #1 had frequent episodes of emesis for the last three days and was unable to keep medications, fluids, and food down. The physician was notified. Review of the nursing progress note dated [DATE] at 3:34 P.M. revealed a physician order was given for promethazine 12.5 mg intramuscularly (IM) injection to be given every six hours as needed for nausea and vomiting. Review of the Medication Administration Record, dated [DATE], revealed Resident #1 was administered promethazine 12.5 mg IM on [DATE] at 3:56 P.M. and 10:38 P.M. The medication administration was noted to be effective. Review of the nursing progress note dated [DATE] at 1:48 A.M. (authored by LPN #200) revealed brown colored emesis, varying from thick to watery. Vital signs: blood pressure ,d+[DATE], pulse 120, respirations 20, and oxygen saturation 90% on room air. Physician notified. (Subsequent interview with physician revealed he was not notified as documented in the progress note). Review of the nursing progress note dated [DATE] at 1:54 A.M. (authored by LPN #200) revealed acetaminophen 325 mg, two tablets, were given for pain. Review of the nursing progress note dated [DATE] at 5:15 A.M. (authored by LPN #200) revealed this nurse went into the resident's room to re-assess after Tylenol was given at 1:45 A.M. The resident stated she was not feeling right. This nurse observed the resident to have short, rapid respirations, her skin was cold and moist, pale in color. This nurse attempted to obtain another full set of vital signs; blood pressure was unable to be read, oxygen saturation was 76% on room air, and temperature was 96.2. Oxygen was applied via nasal cannula and the physician was notified. An order was given to send the resident to the ER. EMS was notified of the emergency need of transport. Second nurse arrived to assist this nurse (LPN #200), and the Director of Nursing (DON) was notified of the resident's rapid change in condition. This nurse grabbed the crash cart and automated external defibrillator (AED) from the wall. At 4:49 A.M. CPR was initiated by this nurse and second nurse. EMS arrive at 4:51 A.M. and stated they were unaware of need for an emergency and had to go back out to the ambulance to retrieve equipment. CPR was continued by nursing staff. Resident #1 was intubated. After 20 minutes, an emergency medical technician (EMT) told the nursing staff to stop CPR and called an ER doctor to get the time of death. The physician, DON, and power-of-attorney were notified. Review of the EMS Run Report revealed on [DATE] at 4:32 A.M. a call was received from the nursing facility for a low pulse oximetry and general illness. EMS arrived at the nursing facility at 4:51 A.M. Upon arrival, nursing staff informed EMS they were concerned Resident #1 was going to code. EMS personnel continued to the resident's room and observed nursing staff doing manual compressions to the resident who was in bed. Staff had their own AED applied and it was informed that compressions needed to be pushed harder. Paramedic #448 took over the compressions. Paramedic #448 noticed the resident's skin was cold on her upper extremities and chest. Staff reported the resident was talking before EMS arrived and coded one minute prior to EMS arrival. AED was advising no shock advised and the EMS cardiac monitor was showing asystole. The estimated time of cardiac arrest was 4:50 A.M. as witnessed by facility staff. CPR was discontinued at 5:16 A.M. EMS alerted hospital physician per protocol for the time of death. Review of Resident #1's Certificate of Death revealed the date of death was [DATE] at 5:16 A.M. The resident was [AGE] years old. The immediate cause of death was listed as sepsis syndrome with an approximate onset of 12 hours prior to death. The secondary cause of death was due to pyelonephritis, and the third cause of death was due to gastroenteritis. The Certificate of Death indicated no autopsy. Interview on at [DATE] at 1:51 P.M. with LPN #200 revealed on [DATE], Resident #1 had complained of not feeling well and had vomited brown emesis. LPN #200 stated she administered Tylenol at this time. LPN#200 stated she went back to re-assess Resident #1 and the resident complained that she didn't feel well. LPN #200 stated she was unable to obtain a blood pressure reading and the resident's oxygen saturation was low, so she notified the physician, who ordered the resident to be sent to the ER. LPN #200 stated the resident continued to decline and coded about one minute prior to the arrival of EMS. LPN #200 stated she and LPN #290 began CPR while awaiting the arrival of EMS. Interview on at [DATE] at 2:35 P.M. with DON stated she had noticed during her investigation that almost three hours elapsed between LPN #200 giving Resident #1 Tylenol and reassessing the resident. The DON confirmed she would have expected LPN #200 to have re-assessed the resident sooner. Interview on [DATE] at 3:53 P.M. with CNA #30 revealed she was assigned to provide care to Resident #1 on [DATE]. CNA #30 stated Resident #1 complained of not feeling well and of aching all over. CNA #30 stated she reported this to the nurse and the nurse medicated the resident. CNA #30 stated she did not check back on the resident because she had to leave her shift at 2:30 A.M. due to an elevated body temperature and her assignment was given to CNA #40. Interview on [DATE] at 4:07 P.M. with CNA #40 revealed she was assigned to care for Resident #1 after CNA #30 left early and did not recall checking on the resident until after 4:00 A.M. CNA #40 stated Resident #1's call light went off and LPN #200 told her not to bother with it because she was going in to check on her. CNA #40 stated she went into Resident #1's room to assist LPN #200 and the corner of Resident #1's lips were blue, and the resident stated she didn't feel good. CNA #40 stated after another nurse came into the room, she left. CNA #40 stated she later went back into the room and the nurses were doing CPR on the resident. Interview on [DATE] at 4:32 P.M. with Physician #400 revealed he had not been notified on [DATE] around 2:00 A.M. concerning Resident #1. Physician #400 stated Resident #1's vomiting and abnormal vitals were concerning and indicated the patient was on the edge, and he would have hoped the nursing staff would have called him. Physician #400 stated there should have been action beyond administering Tylenol. Physician #400 stated his expectation would have been for staff to check on the resident after the vomiting incident before the time that they did. Review of the facility policy titled, Notification of Changes, dated [DATE], revealed the purpose of the policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies the resident's representative when there is a change requiring notification. Circumstances requiring notification include significant change in the resident's physical, mental, or psychological condition such as deterioration in health, mental, or psychological status. This may include life threatening conditions or clinical complications. This deficiency represents non-compliance investigated under Complaint Number OH00161084.

Based on record review, policy review, and interview, the facility failed to ensure physician notification occurred with a change in resident condition . This affected one (Resident#1) of three reviewed for change in condition. Findings include: Review of the medical record revealed Resident #1 was admitted to the facility on [DATE]. Diagnoses included paraplegia, morbid obesity, obstructive hydrocephalus, presence of cerebrospinal fluid drainage device, major depressive disorder, and abnormal posture. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had intact cognition. The resident required physical assistance with activities of daily living. Review of the nursing progress note dated [DATE] at 11:30 A.M. revealed the resident received Zofran 4 mg (ordered [DATE]) by mouth for nausea and vomiting. The administration was listed as effective. Review of the nursing progress note dated [DATE] at 8:55 A.M. revealed Resident #1 had frequent episodes of emesis for the last three days and was unable to keep medications, fluids, and food down. The physician was notified. Review of the nursing progress note dated [DATE] at 3:34 P.M. revealed a physician order was given for promethazine 12.5 mg intramuscularly (IM) injection to be given every six hours as needed for nausea and vomiting. Review of the Medication Administration Record, dated [DATE], revealed Resident #1 was administered promethazine 12.5 mg IM on [DATE] at 3:56 P.M. and 10:38 P.M. The medication administration was noted to be effective. Review of the nursing progress note dated [DATE] at 1:48 A.M. (authored by LPN #200) revealed brown colored emesis, varying from thick to watery. Vital signs: blood pressure ,d+[DATE], pulse 120, respirations 20, and oxygen saturation 90% on room air. Physician notified. (There was no information documented in regards to how the physician was notified or what information was provided to the physician during the notification). Review of the nursing progress note dated [DATE] at 1:54 A.M. (authored by LPN #200) revealed acetaminophen 325 mg, two tablets, were given for pain. Review of the nursing progress note dated [DATE] at 5:15 A.M. (authored by LPN #200) revealed this nurse went into resident's room to re-assess after Tylenol was given at 1:45 A.M. The resident stated she was not feeling right. This nurse observed the resident to have short, rapid respirations, her skin was cold and moist, pale in color. This nurse attempted to obtain another full set of vital signs; blood pressure was unable to be read, oxygen saturation was 76% on room air, and temperature was 96.2. Oxygen was applied via nasal cannula and the physician was notified. An order was given to send the resident to the ER. EMS was notified of the emergency need of transport. Second nurse arrived to assist this nurse (LPN #200), and the Director of Nursing (DON) was notified of the resident's rapid change in condition. This nurse grabbed the crash cart and automated external defibrillator (AED) from the wall. At 4:49 A.M. CPR was initiated by this nurse and second nurse. EMS arrive at 4:51 A.M. and stated they were unaware of need for an emergency and had to go back out to the ambulance to retrieve equipment. CPR was continued by nursing staff. Resident #1 was intubated. After 20 minutes, an emergency medical technician (EMT) told the nursing staff to stop CPR and called an ER doctor to get the time of death. The physician, DON, and power-of-attorney were notified. Interview on at [DATE] at 1:51 P.M. with LPN #200 revealed on [DATE], Resident #1 had complained of not feeling well and had vomited brown emesis. LPN #200 stated she administered Tylenol at this time. LPN#200 stated she went back to re-assess Resident #1 and the resident complained that she didn't feel well. LPN #200 stated she was unable to obtain a blood pressure reading and the resident's oxygen saturation was low, so she notified the physician, who ordered the resident to be sent to the ER. LPN #200 stated the resident continued to decline and coded about one minute prior to the arrival of EMS. LPN #200 stated she and LPN #290 began CPR while awaiting the arrival of EMS. Interview on [DATE] at 4:32 P.M. with Physician #400 revealed he had not been notified on [DATE] around 2:00 A.M. concerning Resident #1. Physician #400 stated Resident #1's vomiting and abnormal vitals were concerning and indicated the resident was on the edge, and he would have hoped the nursing staff would have called him. Physician #400 stated there should have been action beyond administering Tylenol. Review of the facility policy titled, Notification of Changes, dated [DATE], revealed the purpose of the policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies the resident's representative when there is a change requiring notification. Circumstances requiring notification include significant change in the resident's physical, mental, or psychological condition such as deterioration in health, mental, or psychological status. This may include life threatening conditions or clinical complications. This deficiency represents non-compliance investigated under Complaint Number OH00161084.

Based on employee file review, staff interview and review of facility policy, the facility failed to ensure State tested Nursing Assistants (STNAs) had evaluations completed as required. This had the potential to affect all 69 residents residing in the facility. Findings Include: Review of the employee file for State tested Nursing Assistant (STNA) #274 revealed a hire date of 06/14/23. No annual performance evaluation was found. Review of the employee file for STNA #219 revealed a hire date of 08/17/22. No annual performance evaluation was found. Review of the employee file for STNA #501 revealed a hire date of 02/2024. A 90-day performance evaluation was not found. Interview on 08/22/24 at 12:30 P.M. the facility Administrator verified the evaluations for STNAs #274, STNA #219, and STNA #501 were not completed. Review of the facility policy Performance Appraisals dated 01/01/22 revealed it is the facility policy to evaluate performance of employees at least annually.

Based on record review, policy and interview, the facility failed to ensure Enhanced Barrier Precautions were in place, indwelling catheters were not dragging on the floor, handwashing met professional standards and tuberculin testing of staff was conducted on hire and annually. This affected Resident's #35 and #51 and had the potential to affect all the residents in the facility. The census was 69. Findings include: 1. Review of Resident #51's medical record revealed an admitted [DATE] with diagnoses including type 2 diabetes, generalized anxiety, cognitive communication disorder, depression, need for assistance with personal care, metabolic encephalopathy, gastroesophageal reflux disease without esophagitis, bipolar disorder, peripheral vascular disease, nicotine dependence, difficulty walking, muscle weakness, fractured femur, obstructive and reflux uropathy, anemia, hypertension, acquired absence of left great toe, acute respiratory failure, anemia, acute embolism and thrombosis of unspecified vein, Parkinson's disease, chronic obstructive pulmonary disease, severe sepsis with septic shock and ventilator associated pneumonia. Review of the 06/17/24 quarterly Minimum Data Set Assessment (MDS) included the resident was moderately impaired for daily decision making, behaviors not present, no upper or lower extremity impairment, uses a walker and wheelchair, substantiation/maximal assistance for personal hygiene, toileting, rolling, and sitting to standing, always incontinent of bowel and has an indwelling catheter. Observation 08/19/24 at 10:28 A.M. revealed the resident had a urinary drainage bag hanging under his wheelchair. He was in a wheelchair in the hall waiting to smoke. The urine drainage bag was not covered and exposed yellow urine in the bag and tubing. [NAME] urine was visible in the bag and tubing. Observation on 08/20/24 at 11:57 A.M. revealed the resident was in the dining room. His indwelling urinary catheter bag was now a privacy bag colored blue. The catheter bag was hanging under the seat of the wheelchair. The bag was resting on the floor. Observation on 08/20/24 at 12:21 P.M. the resident went to his room with the catheter bag dragging on the floor hooked under the wheelchair. Observation on 08/20/24 at 2:02 P.M. the resident was sitting in the dining room at an activity. The indwelling catheter bag was resting on the floor. Interview 08/20/24 at 2:04 P.M. with the Administrator verified the indwelling catheter bag was not positioned to remain off the floor and was resting on the floor. 2. Review of Resident #35's medical record revealed an admitted [DATE] with diagnoses including dysphagia, palliative care, Parkinson's disease, vascular dementia, psychotic disturbance, mood disturbance and anxiety, depression, gastroesophageal reflux disease, weakness, chronic obstructive pulmonary disease, transient cerebral ischemic attack, and hypertension. A resident plan of care for at Risk for Impaired Skin Integrity related to decline in mobility, and end of life/hospice care was initiated 06/24/24. The goal was resident will have intact skin to the extent allowed by the resident's age, mobility status, continence status, nutritional status, medication and/or treatment compliance, medical condition and/or comorbidities, and compliance with wound prevention recommendations. Interventions included a 06/24/24 intervention to apply protective barrier cream after incontinence episode. A 06/27/24, wound evaluation documented a Kennedy terminal ulcer (dark sores that develop rapidly in the final stages of life), Stage 1 (the mildest and affects the upper layer of your skin. In this stage, the wound has not yet opened) measuring 5.39 centimeters (cm) length x 5.02 cm width. There was not an order for Enhanced Barrier Precautions. A 08/01/24 physician order included Sacrum- cleanse with generic wound cleanse, pat dry, apply medihoney and calcium alginate, cover with silicone foam dressing (4x 4) daily and as needed. Observation of dressing change 08/21/24 at 12:42 P.M. with Licensed Practical Nurses #246 and #237 revealed the sacrum had several open areas. The LPN's wore gloves. There was no other personal protective equipment (PPE) used. Review of the facility's Enhanced Barrier Precautions revised 03/26/24 included even if the resident is not known to be infected or colonized with Multi Drug Resistant Organism (MDRO), an order for enhanced barrier precautions will be obtained for residents with any of the following: Wounds (chronic wounds such as pressure injuries, diabetic foot ulcers, unhealed surgical wounds and chronic venous stasis ulcers. Note:wounds generally include chronic wounds, not shorter-lasting wounds such as skin breaks or skin tears coverers with an adhesive bandage (e.g. Band-Aid) or similar dressing. Interview 08/21/24 at 01:00 P.M. with LPN's #246 and #237 verified the resident was in hospice care, bedridden, with an open wound terminal ulcer , on a pureed diet with weight loss. Neither nurse knew why the resident was not in enhanced barrier precautions. Interview 08/21/24 at 01:16 P.M. with the Director of Nursing verified the resident should of been on EBP with an open wound. 3. Review of Resident #35's medical record revealed an admitted [DATE] with diagnoses including dysphagia, palliative care, Parkinson's disease, vascular dementia, psychotic disturbance, mood disturbance and anxiety, depression, gastroesophageal reflux disease, weakness, chronic obstructive pulmonary disease, transient cerebral ischemic attack, and hypertension. A 08/15/24, wound evaluation documented a Kennedy terminal ulcer (dark sores that develop rapidly in the final stages of life), Unstageable (slough and/or eschar) measuring 1.38 centimeters (cm) length x 0.84 cm width and 0.3 cm depth. The 08/15/24 Wound Evaluation photo revealed the wound was open. Observation of the sacrum dressing change 08/21/24 at 12:42 P.M. with Licensed Practical Nurses #246 and #237 revealed the sacrum had several open areas. Both washed their hands and gloved. The resident was turned onto his right side for the dressing change. He had a small bowel movement contained between his gluteal folds. LPN #237 performed the dressing change. After cleansing the wound calcium alginate, medihoney and a foam dressing was applied all with technique meeting professional standards,. LPN #237 then cleansed the bowel movement. She wore the gloves she had changed into prior to applying the clean foam dressing. Perifresh was applied to a cloth and she wiped from back to front to remove the bowel movement, taking care not to touch the new dressing. There was deep red skin between the gluteal folds. She wiped with different parts of the cloth six times to remove the bowel movement until the cloth came out clean when wiped. With the same gloves on both LPN's turned the resident to his left side, pulled the soiled brief through and placed a new brief. LPN #246 threw the brief in the trash. Without removing their gloves they had on while cleaning the bowel movement LPN #237 who cleansed the bowel movement grabbed the pillow on each side of his face and pulled it down further to his shoulders. Her left hand was on the pillow near his mouth. She put a brown printed pillow between his knees and a pillow under his heels. She placed a pillow under his right arm. He stayed positioned to his left. She used the remote control on the bed to adjust the height of the bed. Then touched his overbed table moving it with her gloved hand, handed the resident his call light with his right hand, pulled a blue banket up to his chin along with LPN #246's help. Neither nurse had removed their gloves used for cleaning the bowel movement until after they made him comfortable in bed. Interview 08/21/24 at 01:00 P.M. with LPN's #246 and #237 verified between they did not remove their gloves after cleaning a bowel movement and touched the resident's pillows, bedding, call light, bed control and overbed table. 42015 4. Review of the facility's Annual tuberculosis (TB) Risk Assessment for 2024 revealed health care workers (HCW) will receive a baseline skin testing performed with two-step Tuberculin Skin Test. The assessment stated HCW are tested for TB at hire and annually. Review of the facility's policy, Employee Health Records dated 12/13/23 revealed, a health record for each employee should be maintain (with) a document (of a) TB screening record including the evidence of the most recent TB test as well as sign and symptom risk assessment screening. Review of the employee files revealed State tested Nursing Assistant (STNA) #219 was hired on 08/17/22 but did not receive annual TB test or screening. Review of the employee files revealed STNA #501 was hired on 07/16/24 but did not receive an initial TB two step test. Review of the employee files revealed STNA #504 was hired on 07/16/24 but did not receive an initial TB two step test. Review of the employee files revealed Licensed Practical Nurse (LPN) #265 was hired on 10/01/22 but did not receive annual TB test or screening. Review of the employee files revealed STNA #274 was hired on 06/14/23 but did not receive an annual TB test or screening. Review of the employee files revealed Director if Nursing was hired on 06/25/24 but did not receive an initial TB two step test. Review of the employee files revealed Registered Nurse #207 was hired 06/21/23 but did not receive an annual TB test or screening. Interview on 08/22/24 at 1:10 P.M. the facility Administer confirmed she was unable to find the above employees initial and annual TB test and screenings.

Based on observation, record review, and interview, the facility failed to maintain accurate medical records. This affected five (Resident's #4, #35, #37, #42, and #49) of 19 records reviewed. The census was 69. Findings include: 1. Review of Resident #35's medical record revealed an admitted [DATE] with diagnoses including dysphagia, palliative care, Parkinson's disease, vascular dementia, psychotic disturbance, mood disturbance and anxiety, depression, gastroesophageal reflux disease, weakness, chronic obstructive pulmonary disease, transient cerebral ischemic attack, and hypertension. Interview 08/19/24 at 01:59 P.M. with the resident's wife included her husband does not get out of bed. He doesn't watch television and isn't interested in a whole lot. Activities does not come in and interact with him. Review of the monthly calendar for August 2024 revealed the resident had on the television/movie in room, radio, reminisce, conversation, sermon on in room on television on Sundays. There were up to five refusals a day marked on the activity sheet, 50 refusals in the first 19 days of the month. Interview 08/20/24 at 2:43 P.M. with Activities Aide #267 revealed she does not ask Resident #35 if he wants to come to activities because he stays in bed. She stated she was new in the last few months. She indicated she was taught if a resident did not come to an activity to mark them as refused even if she did not ask them if they wanted to attend. Interview 08/20/24 02:47 P.M. with Activity Director #200 verified refused should not be marked on activity sheets if the resident was not asked or did not refuse to to attend an activity. Activity #200 verified it would be misleading to say a resident had refused to attend an activity when they had not been asked if they want to attend. 2. Review of Resident #42's medical record revealed an admitted [DATE] and re-admitted [DATE] with diagnoses including traumatic subarachnoid hemorrhage with loss of consciousness greater than 24 hours, severe protein calorie malnutrition, hyperosmolality and hypernatremia, contracture of muscle right forearm, left forearm, chronic respiratory failure with hypoxemia, gastrostomy, tracheostomy, seizures, dysphagia, cognitive communication disorder, wedge compression fracture of fourth lumbar vertebra, hypertension, esophageal reflux disease, post traumatic hydrocephalus, persistent vegetative state, and metabolic encephalopathy. The resident had a sign on his wall to please have the resident up in the chair and taken to all in-house activities every day, No exceptions. Resident is to be up, dressed, and taken to the day room during the day to allow interaction with staff and residents. Observation 08/19/24 at 10:00 A.M. of Resident #42 was lying in bed. His eyes were open but made no eye contact. He was dressed in a t shirt, sweat pants and socks. On 08/19/24 at 04:33 P.M., 08/20/24 at 9:30 A.M., 12:25 P.M., 1:59 P.M., 5:58 P.M. and 08/27/24 at 9:50 A.M. 08/22/24 at 9:01 A.M the resident was either in bed or in a wheelchair his room. The radio was on during observations. There were no observations of the resident out of his room, with the television on or engaged with activity staff. Review of the monthly activity log revealed in August two to four refusals a day for activities, 54 refusals marked in the first 20 days of the month. The resident had movie/TV in room, radio on and visitors as the only activities marked for the month. Interview 08/20/24 at 2:43 P.M. with Activities Aide #267 revealed she does not ask Resident #42 if he wants to come to activities. She said she only ask the residents who usually come to activities. She stated she was new in the last few months. She indicated she was taught if a patient did not come to an activity to mark them as refused even if she did not ask them if they wanted to attend. Interview 08/20/24 at 02:49 P.M. with Activities Director #200 revealed refused should not be marked on activity sheets if the resident was not asked or did not refuse to attend an activity. 3. Review of Resident #37 revealed a 09/23/23 admission with diagnoses including acute and chronic respiratory failure with hypoxia, COPD, congestive heart failure, osteoarthritis, type 2 diabetes, muscle weakness, morbid severe obesity, depression, asthma, hypertension, hypolipidemia, hypothyroidism, edema, insomnia, obstructive sleep apnea, and transient ischemic attack. Review of cut letters revealed the resident received Medicare Part A skilled services from 02/06/24 till 04/05/24. A facility initiated cut when days were not exhausted was signed 04/03/24 by the resident. A 10055 and 10123 were provided. The 10055 was marked the resident wanted to appeal. There was no evidence of the appeal being made. Interview 08/21/24 at 11:10 A.M. with Business Office Manager (BOM) #229 revealed she was with the resident when she signed the cut letter and she did not ask for an appeal. BOM #229 said she did not realize the resident filled in the square Option 1 indicating she wanted an appeal. Option 1: I want the care listed above. I want Medicare to be billed for an official decision on payment, which will be sent to me on a Medicare Summary Notice (MSN). I understand if Medicare doesn't pay I'm responsible for paying, but I can appeal to Medicare by following the directions on MSN. BOM #229 did not file an appeal because the resident did not say she wanted one and must of marked that she did by mistake and she did not notice what was marked. Interview 08/21/24 at 11:19 A.M. with Resident #37 revealed she did not remember if she asked for an appeal or not. She was not upset about how services ended. 42015 4. Review of the medical record for Resident #49 revealed an admitted for 10/18/22. Diagnoses included unspecified dementia, mood disturbance, and chronic atrial fibrillation. Review of Resident #49's Quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had a severe cognitive impairment. Review of Resident #49's Physician orders dated physician order dated 08/08/24, revealed Resident to be up in wheelchair for meals. Resident to be in dining room for meals. Observations of Resident #49 on 08/19/24 at 12:34 P.M., 08/20/24 at 9:56 A.M., 08/20/24 at 12:35 PM , and 08/21/24 at 11:01 A.M. revealed the resident was eating his in breakfast and lunch meals while in his bed. Review of Resident #49's medication administration record from 08/19.24 through 08/21/24 reveled the facility nurses were initialing that the resident was up in his chair at mealtimes. Interview on 08/21/24 at 9:31 A.M. with STNA #502 revealed the resident frequently refused to get out of bed but is offered to get up at each meal. Interview on 08/21/24 at 11:49 A.M. Interview with Registered Nurse (RN) #503 reported she has been documenting that Resident #49 is getting up for meals when he is actually refusing. She stated she thought that she was supposed to documented he was up for meals as long as the staff offered to get him up even if he refused. Interview on 08/21/24 at 12:38 P.M. the facility's Director of Nursing verified the facility's nurses are incorrectly documenting that Resident #49 is getting up out of bed for meals when he is refusing to do so. 44808 5. Review of the medical record for Resident #42 revealed an admitted [DATE] with diagnoses including traumatic brain injury, severe protein-calorie malnutrition, gastrostomy status, dysphagia, persistent vegetative state, aphasia, and tracheostomy status. Review of the physician's orders for June 2024 identified orders for Nutren 2.0 at 50 milliliters (ml) per hour for 24 hours and may substitute Jevity 1.5 if Nutren unavailable (ordered 05/23/24). The order did not specify an administration rate for the substitution of Jevity 1.5. Review of the Medication Administration Record (MAR) for June 2024 revealed there was documentation of Resident #42's enteral nutrition being held at any point from 06/01/24 to 06/30/24 and it was documented that Resident #42 received 400 ml of Nutren 2.0 on each of three shifts every day, which indicated Resident #42 received the full ordered amount of 1200 ml per day every day. There were no variances in the amount of formula infused and every shift was documented as exactly 400 ml infused. Enteral feeding residuals were documented ranging from 0 ml to 60 ml and there was no documentation on the MAR of any residual greater than 60 ml. Review of the progress note dated 06/17/24 at 5:27 A.M. revealed Resident #42 had emesis, the physician was notified and stated to check residuals and report any further episodes of emesis, Resident #42 had further emesis and residuals greater than 100 ml during morning medication pass, and the tube feed was turned off. Further review of the progress notes dated 06/17/24 through 07/09/24 revealed there were no additional nurses notes indicating the tube feed was turned off or held, there was no note indicating how long the tube feed was turned off on 06/17/24 or when it was turned back on, and there were no notes indicating Jevity 1.5 had to be used due to unavailability of Nutren 2.0. Review of the nutrition progress note dated 07/09/24 at 10:50 A.M. revealed Resident #42 had a 6.5% weight loss from 06/09/24 to 07/04/24. The note indicated Resident #42 had a period of intolerance as evidenced by emesis and Jevity 1.5 had to be used for a period of time as Nutren 2.0 was unavailable. The note did not specify a timeframe for the intolerance or use of Jevity 1.5, and the note did not specify an administration rate for Jevity 1.5. RD #278 recommended continuing the tube feeding as ordered and starting weekly weights. On 08/21/24 at 5:37 P.M., an interview with the Director of Nursing (DON) confirmed the MAR for June 2024 indicated Resident #42 received the same amount of formula on every shift, there was no indication on the MAR for when Jevity 1.5 had to be used, there was no specification in the order for an administration rate if Jevity 1.5 had to be substituted for Nutren 2.0, and the nurses note on 06/17/24 indicated Resident #42's tube feed had to be turned off. On 08/22/24 at 8:41 A.M., an interview with the DON stated RD #278 should have specified an administration rate for the use of Jevity 1.5. She also confirmed that although there was a nurses note indicating the tube feed was held, the documentation on the MAR indicated the full amount of formula was provided and there was no indication on the MAR that the tube feeding was held at any point. The DON further stated that the nurse on duty that day verified to the DON that she did not document when the tube feed was held or how long it was held. 28701 6. Review of Resident #4's medical record revealed an admitted [DATE] with diagnoses that included end staff renal disease with hemodialysis, atrial fibrillation and diabetes mellitus. Further review of the medical record revealed Resident #4 currently received hemodialysis three times weekly. Review of a quarterly nutritional assessment completed on 07/19/24 indicated the facility dietician (RD #278) communicated with Resident #4's hemodialysis dietician who recommended to continue a regular diet, oral nutritional supplements and to add protein. Further review of the nutritional assessment indicated a recommendation to add 30 milliliters (ml) of liquid protein daily to provide an additional 100 kilocalories and 15 grams of protein. Further review of the medical record for Resident #4 found no evidence of any type of liquid protein supplement ordered or provided. A dietary progress note from 08/20/24 completed by RD #278 indicated a regular diet and four ounces of oral nutritional supplement three times daily. No evidence of any type of liquid protein supplement was noted. On 08/21/24 at 10:30 A.M. interview with the Director of Nursing indicated a she had communicated with RD #278 who indicated the recommendation of adding a liquid protein supplement was a documentation error as he and the dialysis RD had discussed the resident's current diet, oral nutritional supplement and weights and determined a liquid protein supplement was not indicated at this time.

Based on observation and interview the facility failed to maintain a clean environment. This affected residents but had the potential to affect all residents residing in the facility. The census was 69. Findings include: On 08/22/24 fro 9:00 A.M. through 9:20 A.M. the following observations were made: 1. Torn wallpaper border was noted between resident rooms, above the medical and storage room on the 100 hall; 300 hall resident rooms as well as above the 300 hall shower room and nurses' station; and 400 hall resident rooms. 2. Black marks from adhesive tape where noted on the ceiling near Resident #20's room and the ceiling above the medical and storage rooms on 100/200 halls. 3. Repaired drywall with unfinished/untextured drywall compound was observed outside the women's bathroom in the front lobby, inside and outside the private dining room, at the 300/400 nurses' station and fire doors, 100/200 hall nurses' station and fire doors. 4. Scraped and damaged drywall from resident beds was noted in the following resident rooms: Resident #7, Resident #20, Resident #33, Resident #42, Resident #62 and Resident #20. On 08/22/24 at 9:20 A.M. interview with the Administrator and Maintenance Director verified the observations.

Based on observation, interview, medical record review, and policy review the facility to maintain privacy during Resident 7's wound care and failed provide a covering to prevent Resident #51's urine from being visible related to his catheter. This affected two residents (#7 and #51) of two residents reviewed for dignity. The facility census was 69. Findings include: 1. Review of the medical record for Resident #7 revealed an admitted [DATE]. Diagnoses included spina bifida, paraplegia, and stage three pressure ulcers to the resident's right and left ischial tuberosity. Review of Resident #7's Quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact and had two stage three pressure areas. Observation on 08/21/24 at 1:06 P.M. through 1:20 P.M. revealed Licensed Practical Nurse (LPN) #216 and State tested Nursing Assistant (STNA) #502 entered Resident #7's room to complete wound care. LPN #216 left the resident's door open and pulled the treatment cart up to the resident's door. She opened the resident's curtain and began to complete wound care while STNA #502 assisted with positioning. The resident was positioned on her left side, exposing the resident's buttocks, abdomen, perineal area, and pressure wounds, during the treatment. The resident could be seen, from the hallway by other residents visitors and staff. Interview on 08/21/24 at 1:35 P.M. with LPN #216 verified she did not provide privacy by shutting Resident #7's door or closing her curtain during wound care. She also confirmed the resident could be visualized from the hallway while she was providing Resident #7's wound care. Review of the facility policy, Clean Dressing Change dated 12/28/23 revealed the first step for compliance was to explain the procedure to the resident and screen for privacy. 26706 2. Review of Resident #51's medical record revealed an admitted [DATE] with diagnoses including type II diabetes, generalized anxiety, cognitive communication disorder, need for assistance with personal care, muscle weakness, obstructive and reflux uropathy. Review of the quarterly MDS assessment dated [DATE] revealed the resident was moderately impaired for daily decision making, no upper or lower extremity impairment, used a walker and wheelchair for mobility, substantiation/maximal assistance for personal hygiene, toileting, rolling, and sitting to standing and was always incontinent of bowel and has an indwelling catheter. Observation on 08/19/24 at 10:28 A.M. revealed the resident was seated in his wheelchair, waiting to go out to smoke. A urinary catheter drainage bag was observed, uncovered, hanging under the resident's wheelchair, exposing yellow urine in the drainage bag and tubing. On 08/19/24 at 12:22 P.M. the resident was observed in the dining room, eating lunch, with the exposed catheter bag under his wheelchair. He had yellow urine in the bag. On 08/19/24 at 1:35 P.M. the resident was observed outside smoking with other residents. The urine drainage bag was hanging from underneath his wheelchair, and yellow urine was observed in the drainage bag. Interview on 08/19/24 at 4:51 P.M. with the Director of Nursing and Administrator verified the resident's catheter bag was not covered and was exposing his urine. Review of the facility's Catheter Care Procedure Urinary policy revised 12/28/23 included provide catheter care in accordance with current clinical standards. Privacy bags are used to cover catheter drainage bags while in use.

Based on observation, medical record review, policy review and staff interview the facility failed to ensure the use of a geri chair was appropriate and not considered a restraint. This affected one (Resident #58) of one residents reviewed for restraints. The facility census was 69. Findings include: Observation of Resident #58 throughout the annual survey from 08/19/24 to 08/22/24 revealed the resident seated in a reclined geri chair (comfortable and supportive wheeled seating solution beyond typical wheelchairs and recliners). Review of Resident #58's medical record revealed an admitted [DATE] with diagnosis that included cerebrovascular accident with hemiplegia, prostate cancer and vascular dementia. Review of Resident #58's Minimum Data Set (MDS) 3.0 quarterly assessment with a reference date of 07/24/24 indicated the resident had a severely impaired cognition level and indicated no restraint use in place for the resident. Review of the resident assessments found no evidence of any type of assessment for the use of the geri chair to determine if the resident was able to release the chair from the reclining position independently. Additional review of the medical record revealed physician's orders from 02/21/24 to 05/06/24 for the use of a broda chair (wheeled, reclined and padded wheelchair). A safety device assessment for the use of the broda chair was completed on 05/02/24 which indicated the device was utilized for end of life care and comfort care. Review of Resident #58's care plans revealed no evidence of any use of a geri chair. On 08/21/24 at 10:30 A.M. interview with the Director of Nursing verified there was no order or assessment prior to the use of the geri chair for Resident #58. Review of the facility policy titled Use of Assistive Devices with a revision date of 10/26/23 indicated use of assistance devices will be based on the resident's comprehensive assessment. The policy did not indicate a physician's order was required for use.

Based on observation, record review, and interview, the facility failed to provide comprehensive, resident centered activities for dependent residents. This affected two (Resident's #35 and #42) of three residents reviewed for activities. The census was 69. Findings include: 1. Review of Resident #35's medical record revealed an admitted [DATE] with diagnoses including palliative care, Parkinson's disease, vascular dementia, psychotic disturbance, mood disturbance and anxiety, depression, and weakness. Review of an Activities Evaluation dated 06/24/24 revealed he finds strength in faith/religion, gardening/outdoors, movies/television, music/talk radio, pet visits, religious activities, and beauty and barber. Prefers activities in his room in the afternoon and evenings and 1:1 activities. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately impaired for daily decision making, no behaviors, has little interest or pleasure in doing things, feeling down, depressed or hopeless, and sometimes social isolation. It was very important to him to have snacks available between meals, chose a bedtime, have family involved, listen to music, somewhat important to be around pets, do favorite activities, participate in religious services, and go outside when the weather was good. His family provided the answers to the assessment. He had no upper or lower extremity impairment, partial moderate assist for eating, oral hygiene, substantial/maximum assistance for toileting, dressing, personal hygiene, and from rolling from left to right, sit to lying Review of an Activity plan of care dated 07/03/24 and revised 07/08/24 revealed Resident #35 was at risk for altered activity patterns/pursuits related to decline in health status. The resident will express satisfaction with the type of activities and level of activity involvement when asked, 1:1 visits from staff and volunteers as resident will allow, allow resident to make choices/decisions about their preferred activity pursuits, encourage to participate in leisure interests throughout the day, provide, when possible, based on interest (internet access, preferred radio programs, audio books, library books, word puzzles, magazines, etc.) for in-room use, provide resident with activity calendar, enjoys religious activities, and respect wishes to decline invitations into structured activity programs. Review of the State tested Nursing Assistant (STNA) task list in the electronic documentation system included one 1:1 activity for music on 07/22/24, and an activity refusal on 07/27/24 for planned activities. The music 1:1 was the only activity documented in the electronic record in the last 30 days. Observation 08/19/24 at 10:00 A.M. revealed the resident was on an alternating air mattress while he was in bed. Additional observations at 10:15 A.M., 12:56 P.M. and 4:30 P.M. revealed the resident remained in bed. Interview 08/19/24 at 1:59 P.M. with the resident's wife revealed her husband does not get out of bed. He doesn't watch television and isn't interested in a whole lot. Activities does not come in and interact with him. Observation 08/20/24 at 9:37 A.M., 12;03 P.M., 1:57 P.M., 2:09 P.M., and 5:57 P.M. the resident was in bed. His television was not on and a radio was not playing in the room. Interview on 08/21/24 at 9:54 A.M. with Resident #35 revealed no one has brought a pet in for him to see and he doesn't think anyone has read scripture to him. The resident stated it hurts to move. Observation 08/21/24 at 9:54 A.M. and 12:36 P.M. and 08/22/24 at 9:06 A.M. the resident was more awake and did not get out of bed. His television was not on. There was not a radio playing in the room. There were no observations of activities interacting with the resident. Review of the activity 1:1 binder revealed there was not a 1:1 sheet for Resident #35. Review of the monthly calendar for August 2024 revealed the resident had on the television/movie in room, radio, reminisce, conversation, sermon on in room on television on Sundays. There were up to five refusals a day marked on the activity sheet, 50 refusals in the first 19 days of the month. Interview 08/20/24 at 2:43 P.M. with Activities Aide #267 verified she does not ask Resident #35 if he wants to attend activities because he stays in bed. She stated she was new to her position in the last few months and said she was taught if a resident did not come to an activity, to mark them as refused even if she did not ask them if they wanted to attend. She said she did not have a 1:1 activity sheet for the resident but had cleaned his fingernails a few times when his wife asked her to. Interview on 08/20/24 at 2:47 P.M. with Activities Director #200 revealed she missed putting a 1:1 sheet in the binder for Resident #35. She verified the 1:1's were not completed per the plan of care for a hospice resident who was bed bound. Activity Director #200 further verified refused should not be marked on activity sheets if the resident was not asked or did not refuse to attend an activity. 2. Review of Resident #42's medical record revealed an initial admitted [DATE] and re-admitted [DATE] with diagnoses including traumatic subarachnoid hemorrhage contracture of muscle right forearm, left forearm, tracheostomy, seizures, dysphagia, cognitive communication disorder, and persistent vegetative state. Review of the activity plan of care dated 08/03/23 revealed the resident was at risk for altered activity patterns/pursuits related to being dependent on staff for meeting social needs. Resident is at risk for altered activity patterns/pursuits related to resident will accept and participate in 1:1 visits as evidenced by turning head, making eye contact one to two times a week from staff and volunteers. The resident's preferred activities are: offer aromatherapy, being read to, and music. Review of the Annual MDS dated [DATE] revealed the resident was severely impaired for daily decision making,, behaviors not present, little interest or pleasure in doing anything, feeling tired or having little energy, being short tempered and easily annoyed, rejection of care one to three days, it was somewhat important to take care of personal belongings, have animals around, keep up with the news, and to get fresh air when the weather is good. It was very important to chose between a tub bath, shower, bed bath or sponge bath, choose bedtime, have family involved, to listen to music, and do favorite activities. The resident had upper and lower extremity impairment on both sides, totally dependent for all care, always incontinent of bowel and bladder, received scheduled pain medication, tube feed (enteral nutrition), oxygen and tracheostomy. Review of the residents 1:1 activity sheet revealed 1:1 activities were not offered one to two times a week per the resident's plan of care. There was not a 1:1 activity between 06/03/24 and 06/16/23 (13 days) and between 07/25/24 and 08/09/24 (15 days). There was no aroma therapy, a preferred activity, since May 2024. Review of the monthly activity log for August 2024 revealed two to four refusals a day for activities, 54 refusals marked in the first 20 days of the month. The resident had movie/TV in his room, radio on and visitors as the only activities marked for the month. Observation of the resident on 08/19/24 at 10:00 A.M. revealed a sign on his wall that stated please have resident up in chair and taken to all in-house activities every day, No exceptions. Resident is to be up, dressed, and taken to the day room during the day to allow interaction with staff and residents. The resident was laying in bed, dressed in a t-shirt, sweatpants and socks. He was receiving oxygen per a tracheostomy mask, receiving enteral nutrition via a pump. The resident's eyes were open but made no eye contact when spoken to. The radio in his room was playing music. On 08/19/24 at 4:33 P.M., 08/20/24 at 9:30 A.M., 12:25 P.M., 1:59 P.M., 5:58 P.M. and 08/22/24 at 9:01 A.M the resident was observed either in his bed or in a wheelchair in his room. The radio was on during observations. There were no observations of the resident out of his room, with the television on or engaged with activity staff. Interview 08/20/24 at 2:43 P.M. with Activities Aide #267 revealed she does not ask Resident #42 if he wants to come to activities. She said she only asks the residents who usually come to activities. She stated she was new in the last few months and indicated she was taught if a resident did not come to an activity, to mark them as refused even if she did not ask them if they wanted to attend. She verified did not know he had a sign on his wall to attend all activities. Interview 08/20/24 at 02:49 P.M. with Activities Director #200 revealed she was short of staff so 1:1's were not completed one to two a week. Activity Director #200 further verified refused should not be marked on activity sheets if the resident was not asked or did not refuse to attend an activity. Interview 08/21/24 at 4:10 P.M. with the Director of Nursing DON revealed she called the resident's mother, who said the note on the wall to take to activities was an old note from when he first arrived at the facility and his mother does not expect him to be out at all activities. The DON verified the note should not be on the wall if it was outdated and it was not to be followed. Review of the facility's Activities policy revised 10/30/23 revealed activities will be designed with the intent to enhance the resident's sense of well-being , belonging, and usefulness, promote physical activity, cognition, emotional health, self esteem, dignity, pleasure, comfort, education, creativity, success and independence, reflect age and interest, cultural and religious interests.

Based on observation, record review, policy and interview, the facility failed to ensure preventative skin care was provided to residents with pressure ulcers. This affected one (Resident #35) of three residents reviewed for pressure ulcers. The census was 69. Findings include: Review of Resident #35's medical record revealed an admitted [DATE] with diagnoses including palliative care, Parkinson's disease, vascular dementia, psychotic disturbance, mood disturbance and anxiety, depression, weakness, chronic obstructive pulmonary disease, transient cerebral ischemic attack, and hypertension. Review of a Braden Scale for Predicting Pressure Sore Risk dated 06/23/24 revealed the resident had no sensory impairment, skin was occasionally moist, walks occasionally, very limited mobility, probably inadequate nutrition, potential problem with shear and friction, and was identified at risk for pressure ulcer development. Review of a resident plan of care for at Risk for Impaired Skin Integrity related to decline in mobility, and end of life/hospice care was initiated 06/24/24. The goal was the resident will have intact skin to the extent allowed by the resident's age, mobility status, continence status, nutritional status, medication and/or treatment compliance, medical condition and/or comorbidities, and compliance with wound prevention recommendations. Interventions included to apply protective barrier cream after each incontinence episode. Review of a wound evaluation dated 06/27/24 revealed the resident had a Kennedy terminal ulcer (dark sores that develop rapidly in the final stages of life), Stage 1 (the mildest and affects the upper layer of your skin. In this stage, the wound has not yet opened) measuring 5.39 centimeters (cm) length x 5.02 cm width. Review of the Admission Minimum Data Set assessment dated [DATE] revealed the resident was moderately impaired (cognition) for daily decision making, He had no upper or lower upper extremity impairment, partial moderate assist for eating, oral hygiene, substantial/maximum assistance for toileting, dressing, personal hygiene, rolling from left to right, sit to lying, and was frequently incontinent of urine and always incontinent of bowel. Review of physician orders dated 08/01/24 revealed to cleanse the sacrum with generic wound cleanser, pat dry, apply medihoney and calcium alginate, cover with silicone foam dressing (four by four) daily and as needed. Observation of a dressing change on 08/21/24 at 12:42 P.M. with Licensed Practical Nurses #246 and #237 revealed the sacrum had several open areas. The resident was turned onto his right side. He had a small bowel movement contained between his gluteal folds. LPN #237 performed the dressing change. The open areas left spots of blood on the resident's brief and the periwound area was deep red. After cleansing the wound, calcium alginate, medihoney and a foam dressing was applied. LPN #237 then cleansed the bowel movement. The resident had deep red skin between his gluteal folds. The LPN's cleaned the bowel movement, and placed a clean brief on the resident. The staff did not apply barrier cream to the red periwound or red gluteal folds areas. Barrier cream was observed on the resident's chest of drawers in his room. Interview 08/21/24 at 1:00 P.M. with LPN's #246 and #237 verified between the resident's gluteal folds his skin was deep red and the periwound exposed outside of the resident's newly placed sacral dressing was red. Both nurses verified the resident had barrier cream available that should have been applied per his plan of care. Review of the facility's Pressure Injury Prevention Guidelines policy revised 03/20/24 included to prevent the formation of avoidable pressure injuries and to promote healing of existing pressure injuries, it is the policy of the facility to implement evidence based interventions for residents who are assessed at risk or have a pressure injury present.

Based on medical record review, staff interview, and review of the facility policy, the facility failed to adequately monitor enteral nutrition administration for Resident #42 which resulted in a significant weight loss. In addition, the facility did not notify the physician or Registered Dietitian of the significant weight loss in a timely manner. This affected one resident (#42) of one identified by the facility as receiving enteral nutrition. The facility census was 69. Findings include: Review of the medical record for Resident #42 revealed an admitted [DATE] with diagnoses including traumatic brain injury, severe protein-calorie malnutrition, gastrostomy status, dysphagia, persistent vegetative state, aphasia, and tracheostomy status. Review of the physician's orders for June 2024 identified orders for Nutren 2.0 at 50 milliliters (ml) per hour for 24 hours and may substitute Jevity 1.5 if Nutren is unavailable (ordered 05/23/24). The order did not specify an administration rate for the substitution of Jevity 1.5. Review of the Medication Administration Record (MAR) for June 2024 revealed there was no documentation of Resident #42's enteral nutrition being held at any point from 06/01/24 to 06/30/24 and it was documented that Resident #42 received 400 ml of Nutren 2.0 on each of three shifts every day, which indicated Resident #42 received the full ordered amount of 1200 ml per day, every day. There were no variances in the amount of formula infused and every shift was documented as exactly 400 ml infused. Enteral feeding residuals were documented ranging from 0 ml to 60 ml and there was no documentation on the MAR of any residual greater than 60 ml. On 06/09/2024 Resident #42 weighed 161.2 pounds (lbs) and on 07/03/2024 Resident #42 weighed 150.7 lbs, which is a significant weight loss of 10.5 pounds (6.51%) in one month. On 07/04/24 Resident #42 weighed 150.7 pounds. There was no documentation in the medical record of the physician or Registered Dietitian (RD) #278 being notified of the weight loss. Review of the progress note dated 06/17/24 at 5:27 A.M. revealed Resident #42 had emesis, the physician was notified and stated to check residuals and report any further episodes of emesis, Resident #42 had further emesis and residuals greater than 100 ml during morning medication pass, and the tube feeding was turned off. Review of the progress note dated 06/17/24 at 4:29 P.M. revealed Resident #42 had no further emesis. Further review of the progress notes dated 06/17/24 through 07/09/24 revealed there were no additional nurses notes indicating the tube feeding was turned off or held, there was no note indicating how long the tube feeding was turned off on 06/17/24 or when it was turned back on, and there were no notes indicating Jevity 1.5 had to be used due to unavailability of Nutren 2.0. Review of the nutrition progress note dated 07/09/24 at 10:50 A.M. revealed Resident #42 had a 6.5% weight loss from 06/09/24 to 07/04/24. The note indicated Resident #42 had a period of intolerance as evidenced by emesis and Jevity 1.5 had to be used for a period of time as Nutren 2.0 was unavailable. The note did not specify a timeframe for the intolerance or use of Jevity 1.5, and the note did not specify an administration rate for Jevity 1.5. RD #278 recommended continuing the tube feeding as ordered and starting weekly weights. On 08/21/24 at 5:37 P.M., an interview with the Director of Nursing (DON) confirmed the MAR for June 2024 indicated Resident #42 received the same amount of formula on every shift, there was no indication on the MAR for when Jevity 1.5 had to be used, there was no specification in the order for an administration rate if Jevity 1.5 had to be substituted for Nutren 2.0, and the nurses note on 06/17/24 indicated Resident #42's tube feeding had to be turned off. She further stated that when the weight loss occurred, she told RD #278 that weight loss for a resident with tube feeding is the facility's fault. On 08/22/24 at 8:41 A.M., an interview with the DON stated RD #278 should have specified an administration rate for the use of Jevity 1.5. She also confirmed that although there was a nurses note indicating the tube feeding was held, the documentation on the MAR indicated the full amount of formula was provided and there was no indication on the MAR that the tube feeding was held at any point. The DON further stated that the nurse on duty that day verified to the DON that she did not document when the tube feeding was held or how long it was held. On 08/22/24 at 10:49 A.M., an interview with RD #278 stated Resident #42 was not tolerating his tube feed for a period of time and the tube feed had to be stopped for a period of time. He further stated the facility was short on Nutren 2.0 and Jevity 1.5 had to be used for a short period of time which could have contributed to the weight loss. RD #278 stated he did not know at what rate Jevity 1.5 was administered and he did not know how long Jevity 1.5 had to be used in place of Nutren 2.0. RD #278 said ideally, nursing should have contacted him when Jevity 1.5 had to be substituted so a rate adjustment could be made. He further stated when he reviewed the weight loss, he did not review the tube feed formula intake documentation on the MAR and he only used the information told to him by the nurses. RD #278 said he thought the main cause of the weight loss was inadequate nutrition provided via tube feed due to the tube feed being held and Jevity 1.5 being substituted for Nutren 2.0. On 08/22/24 at 12:22 P.M., an interview with the DON verified there was no documentation of the physician or RD #278 being notified of the weight loss on 07/03/24 (which was a Wednesday). The DON further stated that the interdisciplinary team (IDT) meets on Mondays and Tuesdays and the notification would not have occurred until the following Monday at the IDT meeting. Review of the facility's policy titled Feeding Tubes, revised 06/30/22, revealed feeding tubes would be used when medically necessary to maintain acceptable parameters of nutrition and hydration, the RD would estimate a resident's daily nutritional and hydration needs, staff would be directed on the types of enteral nutrition formulas available for use, the facility would collaborate with the RD to determine whether the tube feedings meet the resident's needs and when to adjust them accordingly, staff would ensure the administration of enteral nutrition was consistent with and followed the practitioner's orders, and the facility would notify and involve the physician or designated practitioner of any complications. Review of the facility's policy titled Weight Monitoring, revised 10/26/23, revealed the facility would ensure all residents maintained acceptable parameters of nutritional status, interventions would be identified and implemented with ongoing monitoring to maintain acceptable parameters of nutrition with intervention modifications made as appropriate, a significant change was defined as a 5% change in one month or a 7.5% change in three months or a 10% change in six months, the physician should be informed of a significant weight loss, meal consumption information should be recorded and may be referenced by the IDT as needed, the RD should be consulted to assist with interventions and actions should be recorded in the nutrition progress notes, and care instructions should be communicated to facility staff by the IDT.

Based on observation, record review and interview, the facility failed to label the contents in a tube feeding/enteral nutrition bag. This affected one (Resident #42) of one residents reviewed for tube feeding. The census was 69. Findings include: Review of Resident #42's medical record revealed an admitted [DATE] and readmitted [DATE] with diagnoses including traumatic subarachnoid hemorrhage, severe protein calorie malnutrition, gastrostomy, tracheostomy, seizures, dysphagia, cognitive communication disorder, and persistent vegetative state. Physician orders included a 05/23/24 order for Nutren 2.0 calorie at 50 millimeters (ml) an hour. Review of the 07/16/24 Annual Minimum Data Set (MDS) Assessment revealed the resident was severely impaired for daily decision making and the resident received tube feeding. Observation of Resident #42 on 08/19/24 at 10:00 A.M. revealed the resident had tube feeding infusing at 50 milliliters an hour through a gastrostomy tube. The bag of tube feeding was labeled with the resident's last name and dated 08/19/24. The label did not identify what was poured into the bag or at what time. Interview and observation on 08/19/24 at 4:33 P.M. with the Director of Nursing and Administrator verified the tube feeding was placed into a bag and the contents were not identified. It was undetermined what type of tube feeding was in the bag infusing. Review of the facility's Tube Feeding policy last updated 06/30/22 included ensuring the administration of enteral nutrition is consistent with and follows the practitioners orders.

Based on observation, record review, policy and interview, the facility failed to ensure oxygen tubing was dated when changed. This affected two (Resident's #32 and #35) of two residents reviewed for oxygen therapy. The census was 69. Findings include: 1. Review of Resident #35's medical record revealed admitted [DATE] with diagnoses including dysphagia, palliative care, Parkinson's disease, vascular dementia, psychotic disturbance, mood disturbance and anxiety, depression, chronic obstructive pulmonary disease, transient cerebral ischemic attack, and hypertension. Physician orders included an order dated 06/22/24 for oxygen tubing/filter to be changed every week. An order dated 07/29/24 to run the oxygen at 4.0 liters per minute continuous. Review of the Admission Minimum Data Set assessment dated [DATE] included the resident was moderately impaired for daily decision making and he received oxygen. Observation on 08/19/24 at 10:00 A.M. revealed the resident was in bed, His nasal cannula was on the floor, The oxygen condenser was set at 3.5 Liters Per Minute (LPM). The nasal cannula equipment was not dated but bag hanging on the oxygen condenser said 08/01/24, A nebulizer mask was on the bedside table not in the bag. The nebulizer mask had white spots inside the mask and the mask was dated 08/01/24. Review of the August treatment sheet revealed the oxygen tubing was signed off as being changed on 08/08/24, and 08/14/24 but the tubing was dated 08/01/24. Observation and interview on 08/19/24 at 4:32 P.M. with the Director of Nursing (DON) and the Administrator verified the nasal cannula attached to the oxygen condenser was not dated but the bag said 08/01/24. Further interview verified the nebulizer mask was soiled and not replaced as per policy. Interview 08/20/24 at 11:49 A.M. with the DON verified the treatment to change oxygen tubing weekly was signed off as completed weekly when it had not been changed. 2. Review of Resident #32's medical record revealed an admitted [DATE] with diagnoses including chronic obstructive pulmonary disease, cognitive communication deficit, muscle weakness, difficulty walking, anxiety disorder, need for assistance with personal care, and hypertension. A plan of care for pulmonary/respiratory status related to Chronic Obstructive Pulmonary Disease (COPD) initiated 01/31/24 included to administer oxygen as ordered. Physician orders included on 01/31/24 an order for oxygen tubing/filter change every week on Wednesday night shift. On 02/05/24 oxygen saturation every shift and as needed, and oxygen two to four liters per minute continuous via nasal cannula to keep oxygen saturation greater than 92 percent. The 08/06/24 Quarterly Minimum Data Set Assessment (MDS) revealed the resident was moderately impaired for daily decision making, and received oxygen. Observation 08/19/24 at 11:13 A.M. the resident was in physical therapy. He had oxygen being delivered via canister at three liters per minute (LPM). The nasal cannula tubing was dated 07/07/24. Review of the treatment sheets revealed the treatment to change the oxygen tubing weekly was signed off as completed 08/07/24 and 08/14/24. The tubing was signed of as being changed weekly when it was dated 07/07/24. Observation and interview 08/19/24 at 4:37 P.M. with the Director of Nursing (DON) and the Administrator verified the nasal cannula attached to the oxygen canister on his wheelchair was dated 07/07/24 and was not changed per orders Interview 08/20/24 at 11:49 A.M. with the DON verified the treatment to change oxygen tubing weekly was signed off as completed weekly when it had not been changed.

Based on facility Self-Reported Incident (SRI) review, medical record review, interview, and facility policy review, the facility failed to ensure residents were free from staff to resident verbal, physical, and sexual abuse. This affected two residents (#35 and #50) of three residents reviewed for abuse. Actual Psychosocial Harm occurred in August 2023 (exact date unknown) to Resident #35 when State tested Nurse Aide (STNA) #76 told him to scoot your fat a$$ back in the chair, move your fu### legs. Resident #35 was upset. Additionally, on another occasion, date unknown, STNA #76 flung Resident #35's legs into the bed. STNA #76 stretched his legs out and flung them in the bed. Resident #35 told STNA #76 it hurt when she did that. On 08/17/23 Resident #35 remained visibly upset raising his voice when he was describing the actions of STNA #76. Findings include: 1. Review of Resident #35's medical record revealed an admitted [DATE] with admission diagnoses that included impulse disorder, shizoaffective disorder, bipolar, anxiety disorder, chronic obstructive pulmonary disease, congestive heart failure, morbid obesity, mood affect disorder and hypertension. Further review of the medical record including the Minimum Data Set (MDS) 3.0 annual assessment with a reference date of 06/15/23 indicated Resident #35 was independent for daily decision making. The resident required extensive assist for bed mobility, transfers, personal hygiene and toileting. Review of the facility SRI #237972 with a created date of 08/10/23 revealed on 08/10/23 the Administrator was notified of an allegation of verbal abuse of Resident #35 by State tested Nurse Aide (STNA) #76. The accused staff member was interviewed and immediately placed on administrative leave. The allegation was substantiated and STNA #76 was terminated 08/15/23. Review of a 08/10/23 untimed statement from Resident #35 confirmed verbal abuse by STNA #76. He stated she told him to scoot your fat a$$ back in the chair, move your fu##### legs. He stated he got upset and cursed back at her. Review of staff statements included a 08/10/23 untimed statement by STNA #100 who witnessed STNA #76 verbally abuse Resident #35 in the shower room. STNA #76 was telling Resident #35 to scoot his fat a$$ back in the chair and to move his fu##### legs. STNA #76 totally was humiliating him (Resident #35). STNA #100 started to hear things from her (STNA #76) the beginning of August (2023) and was afraid of retaliation. Review of a 08/09/23 (came in on the 08/09/23 night shift) untimed statement by STNA #98 included she had witnessed STNA #76 being very condescending, making inappropriate comments and being aggressive with multiple residents including Resident #35. Per STNA #98, STNA #76 has made numerous comments in regards to her employment stating she can't be fired: she will use the race card and threatened to call the The National Advancement of Colored People (NWACP). Review of a 08/10/23 untimed STNA #99 statement revealed she was out in the hall on the 300 hall, by room [ROOM NUMBER], and overheard STNA #76 tell Resident #35 he was lazy and to do what she was asking him to do, by himself instead of begging her because he could. Review of an undated STNA #101 statement revealed she witnessed STNA #76 yell at Resident #35 after having to completely change him for a second time when he refused his shower. STNA #101 stated she reported it to a nurse who no longer works at the facility who said she would see what she could do. Review of a 08/10/23 untimed STNA #102 statement revealed she witnessed STNA #76 belittle Resident #35 on numerous occasions. Review of a 08/10/23 statement from Registered Nurse (RN) #97 included she asked Resident #35 about allegations of verbal abuse from STNA #76 and he confirmed verbal abuse and stated she said scoot your fat a$$ back in the chair, move your fu##### legs. Resident #35 stated he got upset when STNA #76 said that and cursed back at her. Interview on 08/17/23 at 3:09 P.M. with the Director of Nursing (DON) verified they walked STNA #76 out of the building on 08/10/23 and terminated her 08/15/23. STNA #76 would not give a statement. STNA #76 would not give the police a statement. During the course of the interviews, they identified several staff who had heard or seen something but had not reported it due to fear of retaliation. Staff also identified two other residents (#50 and #51) they saw or heard STNA #76 be inappropriate with so they were also added to the SRI and investigated. The DON verified those staff who heard or witnessed potential abuse and did not report it timely will receive discipline. Interview on 08/17/23 at 4:06 P.M. with Resident #35 revealed STNA #76 flung his legs into the bed. She stretched his legs out and flung them in the bed. Resident #35 told her it hurt. STNA #76 said you're not hurt. Resident #35 told her it hurt. Resident #35 said he gave a statement to the police. 2. Review of Resident #50's medical record revealed a 01/05/23 admission with diagnoses including quadriplegia, traumatic brain injury, major depressive disorder, anxiety disorder, and abnormal posture. Further review of the medical record including the Minimum Data Set (MDS) 3.0 annual assessment with a reference date of 07/27/23 indicated Resident #50 was independent for daily decision making. The resident required total assist of two for bed mobility, transfers, personal hygiene, toileting and extensive assist for eating. Resident #50 had upper and lower extremity functional limitation bilaterally. Review of the facility SRI #237972 with a created date of 08/10/23 revealed on 08/10/23 the Administrator was notified of an allegation of verbal abuse of residents by State tested Nurse Aide (STNA) #76. During the course of the investigation, Resident #50's name was given by staff with knowledge of inappropriate behaviors toward him by STNA #76. Behaviors of STNA #76 included flicking Resident #50's left nipple ring and penis, resulting in an allegation of sexual abuse. Resident #50 reported he was not affected by these acts and believed STNA #76 was just joking around. Review of a 08/10/23 untimed statement from Resident #50 included he answered yes when asked if anyone flipped his nipple ring. He said STNA #76 was joking with him. He denied she left a hoyer pad under him or cussed at him about changing his shirt. Review of staff statements included a 08/10/23 statement from STNA #100 as she witnessed STNA #76 cuss at Resident #50 about changing his shirt when he didn't want to. He swore at her so she got in his face. STNA #76 then hoyered him in bed and then left the pad under him and went to lunch. Another aide went in and finished providing care to Resident #50. STNA #100 started to hear things from STNA #76 last month/the beginning of month and was afraid of retaliation. There was a note at the bottom of the statement that stated STNA #100 was educated on the abuse policy at the bottom of the statement. Review of a 08/09/23 (night shift on 08/09/23) STNA #98's statement included she had witnessed STNA #76 being very condescending, making inappropriate comments and being aggressive with multiple residents including Resident #50. STNA #98 has made numerous comments in regards to her employment stating she can't be fired: she will use the race card and threatened to call the The National Advancement of Colored People (NWACP). Review of a 08/09/23 (night shift on 08/09/23) statement by Licensed Practical Nurse (LPN) #81 included STNA #76 had been verbally aggressive with the resident and was visually seen flicking Resident #50's nipple ring. LPN #81 and another nurse attempted to deescalate a situation with an aggressive resident and when STNA #76 came to the situation with an aggressive demeanor, the resident (#50) became more aggressive. Review of a 08/10/23 untimed statement from STNA #93 included STNA #76 would flick Resident #50's nipple ring when he would take a shower and would also do it in front of the 300/400 nurses station where the resident sits and would curse and scream at her and yell for someone to get her away from him. Review of an undated statement from STNA #94 included she heard STNA #76 swear at Resident #50. Two aides were putting the resident to bed and he swung at STNA #76. STNA #94 thought maybe he got hurt or was uncomfortable. STNA #76 grabbed Resident #50's right arm to stop him from hitting her and then stated something along the lines of you're not going to ever fu#### hit me again. STNA #94 reported she told a nurse, but doesn't know which one. STNA #94 couldn't remember the day it happened but thought it was a weekend. Review of a 08/10/23 untimed STNA #99 statement revealed she witnessed STNA #76 refusing to give care to Resident #50 because she wanted to eat. STNA #99 helped another aide use the mechanical lift to get Resident #50 into bed and left him there on the lift pad flat in his bed soiled without a call bell. Review of a 08/10/23 untimed statement by STNA #102 revealed she witnessed STNA #76 have an aggressive tone toward Resident #50 and inappropriate behavior including flicking Resident #50's nipple ring, on numerous occasions. Review of a 08/15/23 statement from Resident #50's sister included she asked him about the incident and he did tell her STNA #76 flicked his penis and nipple. Review of a statement revealed Registered Nurse (RN) #97 on 08/16/23 asked Resident #50 if STNA #76 flicked his bare penis or did he have a brief on. He stated it was his bare penis. Review of a 08/16/23 statement from the DON included Resident #50 refused to speak with the police and doesn't want to press charges. Interview on 08/17/23 at 3:09 P.M. with the DON included on 08/16/23 she spoke to Resident #50 because the police were at the facility to take a report. The resident did not want to talk about it and refused to give the police a statement and did not want to press charges. He did not want to get STNA #76 in trouble and said she was just joking but the facility substantiated sexual abuse based on witness statements. The DON further stated the third resident mentioned by name (Resident #51) did not have any concerns of abuse when she interviewed him. Interview on 08/17/23 at 4:10 P.M. with Resident #50 revealed he did not want to talk about STNA #76. He did not want her to get in trouble. Review of the facility's Abuse, Neglect, and Exploitation policy (revised 10/24/22) included verbal abuse means the use of oral, written, or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Sexual abuse is non-consensual sexual contact of any type with a resident. The facility will implement policies and procedures providing residents, representatives, and staff information on how and to whom they may report concerns, incidents, and grievances without the fear of retribution; and providing feedback regarding the concerns that have been expressed. Identification of abuse includes resident, staff or family report of abuse. Verbal abuse of resident overheard. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. The facility will have written procedures that include reporting of all alleged violations to the Administrator. This deficiency is cited as an incidental finding to Complaint Number OH00145527.

Based on record review and interview the facility failed to provide adequate assistance, including appropriate lower extremity support during transport of Resident #3 (with hemiparesis/hemiplegia to the right side) in a wheelchair. This affected one resident (Resident #3) of one resident reviewed for a fall with major injury. The facility census was 70. Actual Harm occurred to Resident #3 on 02/20/23 when staff failed to provide adequate lower extremity support to the resident during transport resulting in the resident's leg dragging on the floor and the resident falling from the wheelchair and suffering a right clavicle fracture and proximal humeral fracture. Findings include: Review of the medical record revealed Resident #3 was admitted on [DATE] with diagnoses that included hemiplegia and hemiparesis (weakness) affecting the right side, type 2 diabetes mellitus, chronic embolism and thrombosis, spinal stenosis, osteoporosis, long term use of anticoagulants, major depressive disorder, anxiety disorder, bipolar disorder, and schizophrenia. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #3 was cognitively intact and had no behaviors. The assessment revealed Resident #3 required extensive assistance of one staff for bed mobility and transfers. Review of the plan of care dated 12/14/22 revealed Resident #3 was at risk for falls related to weakness, history of cerebrovascular accident, and spinal stenosis. Interventions included to anticipate and meet Resident #3's needs based on nursing assessments and encourage rest periods as needed to avoid overtiring. A new intervention was added on 03/16/23 for bilateral foot rests to be on while Resident #3 was in wheelchair. Review of an initial fall assessment dated [DATE] at 3:15 P.M. revealed Resident #3 was being pushed by staff in wheelchair. Resident #3 had a small goose egg to right side of head and pain to right shoulder and right side of head. Review of Witnessed Fall documentation dated 02/20/23 (no time) revealed Resident #3 stated she could not keep her foot up all the way and it dropped down causing her to be thrown out of the wheelchair. A predisposing psychological factor of weakness and the resident was ambulating with assistance was marked on the form. State tested Nursing Assistant (STNA) #458's statement revealed she was pushing Resident #3 in the wheelchair and the resident's foot dragged on the floor and the resident fell forward. Review of a nurse's note dated 02/20/23 at 4:10 P.M. revealed the nurse was sitting at the nurse's station and heard a thud and an aide yell for help. Resident #3 was observed on the floor in the hallway lying on right side with her right arm underneath her and her head on the floor. The resident stated she hit her head and landed on her arm. Resident #3 stated she could not keep her foot up and when she dropped her foot down her shoe caught on the floor causing her to fall forward out of the wheelchair. Resident #3 complained of pain with range of motion and had a small goose egg to right side of the head. A nurse note dated 02/20/23 at 9:00 P.M. revealed Resident 3's sister was notified of the fall and increase in right shoulder pain. The resident's sister requested the resident be sent to the hospital for x-rays. Review of discharge instructions from the hospital dated 02/20/23 at 11:04 P.M. revealed Resident #3 had a clavicle injury and needed to follow up with orthopedic in three to five days. Information for fractured clavicle was also included in the discharge instructions. Review of x-ray results dated 02/20/23 at 11:42 P.M. revealed Resident #3 had a comminuted and angulated distal third right clavicle fracture without dislocation. The resident also had a remote proximal humeral fracture with questionable anterior subluxation versus positioning. An order dated 02/21/23 at 2:26 P.M. was received for Resident #3 to have bilateral foot rests on wheelchair during use. Review of a nurse note dated 02/21/23 at 2:45 A.M. revealed Resident #3 returned from the hospital without any new orders. The nurse called the hospital to get the results of the x-ray. The hospital reported Resident #3 had a right clavicle and right humerus fracture. Review of a nurse note dated 02/21/23 at 2:56 P.M. revealed Resident #3 returned from an orthopedic emergency department with new orders for non-weight bearing to right upper extremity and immobilizing splint to right arm. Resident #3 was evaluated by therapy and the resident was to remain one assist for ambulation and transfers. Bilateral leg rests were added to wheelchair for safety until Resident #3 could resume normal activity. Review of a nurse note dated 02/23/23 at 1:11 P.M. revealed Resident #3's sister reported the resident was depressed due to recent fall and requested possible consult with counselor. The nurse spoke with Resident #3 regarding sadness/depression. Resident #3 reported she was upset because she fell and she wanted to go home soon. Interview on 03/27/23 at 10:00 A.M. with Resident #3 revealed (on 02/20/23) she had a shower and staff were taking her back to her room in a wheelchair when she fell . Resident #3 stated she was holding her feet up and her foot fell down and caught the floor and she fell forward out of the wheelchair. Interview on 03/29/23 at 10:54 A.M. the Director of Nursing (DON) verified a staff member was pushing Resident #3 in her wheelchair when the resident fell forward out of the wheelchair. The DON verified there were no foot rests on the resident's wheelchair due to the resident frequently used her feet to propel herself. After the resident fell , an order was received for foot rests to be placed on wheelchair.

Based on observation, record review, policy and procedure review and interview the facility failed to implement individualized and effective fall risk safety interventions for Resident #3, who was cognitively impaired and at risk for falls to prevent falls including a fall with injury. Actual Harm occurred on 06/10/21 when Resident #3, who had a history of turning off her bed safety alarm, fell out of bed, when the alarm was off, resulting in a spiral fracture of the shaft of the right tibia and fibula requiring hospitalization . This affected one resident (#3) of three residents reviewed for falls. Findings include: Review of the medical record for Resident #3 revealed an admitted [DATE] with diagnoses including depression, intraocular lens, bilateral [CONDITION(S)], muscle weakness, difficulty walking, cognitive communication deficit, [CONDITION(S)], repeated falls, [CONDITION(S)] and [CONDITION(S)] following cerebral infarction of right dominant side 10/16/21, and displaced spiral fracture of shaft of right tibia and fibula with subsequent encounter for closed fracture with routine healing 06/12/21. Review of the plan of care, dated 12/26/18 revealed Resident #3 was at risk for falls related to gait and balance problems with generalized weakness and history of falls, surgery to remove hardware to left hip, and recent cerebral vascular accident (CVA) with [CONDITION(S)]. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 09/10/20 revealed the resident was severely impaired for daily decision making. Record review revealed the resident had a history of falls: On 09/29/20 at 11:45 P.M. the resident indicated she tried to get up too quickly and fell . The resident was found sitting on the floor beside her bed. The resident was assessed to have an open area to her forehead that did not require sutures. The resident was educated on the importance of utilizing call light for assistance with transfers. The resident was noted to be alert but forgetful. The resident was hospitalized from 10/13/20 to 10/19/20 related to a [CONDITION(S)] accident (CVA). On 10/26/20 the resident was observed on the floor in the bathroom by therapy. The resident stated she was trying to transfer herself to the toilet. There was a small abrasion noted to the resident's back and redness to forehead. The resident was educated by staff on the importance of using call light for assistance with transfers and a toileting program was implemented. On 11/05/20 a nursing progress note revealed the facility spoke with the physician regarding the resident's daughter requesting the use of bed/chair alarms to alert staff of unassisted rising. New orders were received for a bed and chair alarm. This was related to the resident's multiple attempts to self transfer as the resident had some independence prior to the CVA. The note revealed the resident had been educated multiple times on asking staff for assistance with transfers, but was unable to remember to do this at this time. On 03/01/21 at 6:53 A.M. a nursing progress note revealed the resident was found laying on the floor in her room by her wheelchair. The resident reported she attempted to get in her wheelchair from bed and slipped. The resident was educated on the importance of call light use. The note failed to contain any information related to a bed alarm at that time. On 03/30/21 at 7:18 A.M. a nursing progress note revealed the resident was observed laying on the floor on her left side. The resident reported she attempted to get into her wheelchair and slid from bed. The bed alarm was not working at time of incident. The batteries were replaced. An intervention to check safety alarm batteries every shift for placement and function was ordered. Review of the quarterly MDS 3.0 assessment, dated 04/01/21 revealed the resident was moderately impaired for daily decision making, required extensive assistance of one staff for bed mobility and transfers and did not walk. On 05/20/21 a nursing progress note revealed the resident was observed on the floor wrapped up in her blankets, laying on her right side with a large raised area on the right side of her forehead. Resident #3 revealed I rolled out of bed. The investigation included the personal alarm was in use but did not alarm. There was no explanation as to why the alarm did not ring. Following the incident, a bedside mat was ordered. The investigation indicated the resident was confused at times. Review of a 05/21/21 Fall Risk Evaluation revealed the resident was over the age 85, confined to a chair, not steady and only able to stabilize with physical assistance. On 05/21/20 a nursing progress note revealed Resident #3 reported she did like the alarm and tried to shut it off. The alarm was working properly at that time. The resident was re-educated on call light use and letting staff know of her needs. The resident was confused to person and place at that time. There was no evidence the resident was evaluated/assessed for alternate individualized and effective fall safety interventions at that time. On 06/03/21 at 11:57 P.M. a nursing progress note revealed Resident #3 turned off her personal alarm and transferred herself out of bed and into wheelchair. The resident wheeled herself up the hall looking for a little boy and was assured there was no little boy here. The resident then went back to her room. There was no evidence the resident was evaluated/assessed for alternate individualized and effective fall safety interventions at that time. On 06/04/21 at 6:27 A.M. a nursing progress note revealed the resident transferred herself from bed to wheelchair during the night and had turned off her alarm. The resident was up in a wheelchair until this morning. The resident had hid her personal alarm in a bag and transferred herself into bed. The note indicated counseling was ineffective. There was no evidence the resident was evaluated for any other fall safety interventions related to the identification she was turning off/removing the personal alarm at this time. On 06/10/21 at 2:25 A.M. a nursing progress note revealed during rounds staff found Resident #3 laying on her back on the floor with blankets partially on the padded mat and partially on the floor. The resident was assessed to have a raised bruise on the middle of her forehead just below the hairline, a large bruise from the ankle to the knee laterally on the right leg and a small bruise to the left knee. The resident complained of pain to her left shoulder. The note indicated the resident had turned off her bed alarm prior to the fall. The resident was reminded not to get out of bed without assistance and not to turn off bed alarm. On 06/10/21 at 7:00 A.M. Resident #3 was complaining of increased pain to the right leg, was having difficulty straightening the leg and had swelling just below the right knee. Radiology was ordered of the right knee/tibia/fibula. The x-rays revealed a fracture involving the proximal tibia and fibula with mild angulation and displacement. The resident was transferred to the hospital on 06/10/21 at 12:00 P.M. (over nine hours after the fall occurred). Resident #3 returned to the facility on [DATE]. A 06/16/21 fall follow up note included the resident had turned her safety alarm off. Resident #3 was confused at baseline and had a history of turning off or hiding the alarm box. Resident #3 had been educated multiple times to utilize call light for staff assistance and educated on not shutting off or hiding bed/chair alarms. On 06/21/21 at 4:01 P.M. Resident #3 was observed in bed. The left side of the bed was against the wall. To the right side of the bed a fall mat was in place on the floor. A pressure sensitive bed alarm was flashing green and was hanging on the side rail within reach of the resident. On 06/21/21 at 4:19 P.M. observation with the Director of Nursing (DON) revealed the resident was sitting on the side of her bed. The bed alarm was to her right hanging on the side rail and within the resident's reach. On 06/21/21 at 6:32 P.M. interview with the Director of Nursing verified Resident #3 was confused and interventions reminding the resident to use her call light on 09/29/20 an 03/01/21 were not effective to decrease fall risk. The DON verified the safety alarm was not functioning due to a dead battery at the time of the 03/30/21 fall. The DON verified the facility was aware the resident had a history of turning off her safety alarm and verified the alarm was not put out of reach of the resident and was turned off when the resident fell on [DATE] and on 06/10/21 when she fell out of bed and fractured her tibia and fibula. In addition, based on the identification of the resident turning off the alarm, there was no evidence the facility evaluated the resident for or implemented any other individualized and effective fall safety interventions to decrease the resident's risk of continued falls and/or sustaining an injury from a fall. The DON indicated she though if the alarm box was out of sight of the resident it was a restraint and did not think this would be allowed. Review of the facility 01/01/21 Fall Prevention Program included interventions would be monitored for effectiveness. This deficiency substantiates Complaint Number OH 301.

Based on observation, interview, record review and policy review, the facility failed to ensure appropriate interventions were implemented to prevent the development of an unstageable pressure ulcer. Actual Harm occurred when Resident #103 was not assisted with turning and repositioning in bed, and developed an unstageable pressure ulcer on the coccyx. This affected one (Resident #103) of two residents reviewed for pressure ulcers, of three residents with pressure ulcers in the facility. Findings include: Review of the medical record revealed Resident #103 was admitted to the facility on [DATE], from the hospital, following surgical repair for a [MEDICAL CONDITION] hip sustained during a fall on 04/27/15 that occurred at the resident's home. On 05/03/15 the resident was sent to the hospital and treated for [REDACTED]. Additional [DIAGNOSES REDACTED]. Review of Braden skin risk assessments completed on 04/30/15 and 05/05/15 indicated the resident was at risk for the development of a pressure ulcer. Admission skin assessments dated 04/30/15 and 05/05/15 revealed no pressure ulcers were present on the coccyx area or buttocks. Physician's orders from 05/05/15, when the resident was readmitted following treatment of [REDACTED]. Review of a care plan for skin integrity, initiated on 04/30/15 with the most recent update on 05/21/15, indicated the resident was at risk for the development of a pressure ulcer, had impaired mobility due to a left [MEDICAL CONDITION] and pain and medical [DIAGNOSES REDACTED]. Interventions included to use commercial moisture barrier, monitor meal intake, keep skin clean and dry, elevate head of bed no more than 30 degrees, and inspect skin for signs/symptoms of skin breakdown. Review of a care plan initiated on 04/30/15 and updated on 05/15/15 revealed Resident #103 was noncompliant with repositioning and with physician-ordered interventions for diabetes. Interventions included to educate the resident on possible negative outcomes, use verbal reminders, and encourage compliance. Nurses notes from admission on 04/30/15 through 05/27/15 described the resident as alert, weak and pleasant but made no mention of refusal of turning or repositioning. The care plan for skin integrity indicated the resident was not resistant to care. Review of a behavior tracking tool dated 04/30/15 to 05/26/15 revealed no instances of resistance to care. Social service assessment on 04/30/15 revealed the resident was alert and oriented with no mention of noncompliance with care. Medication/Treatment records for May 2015 revealed skin assessments were completed weekly on 05/05/15, 05/13/15 and 05/20/15. Skin assessment documentation dated 05/13/15 revealed Resident #103 had a pink, blancheable area on the coccyx. Review of therapy notes revealed Resident #103 was assessed by therapy on 05/01/15 and 05/06/15 to require maximum assistance with bed mobility (turning and repositioning in bed). On 05/12/15, the resident required moderate assistance with bed mobility. On 05/19/15, the resident required minimal assistance. On 05/26/15, the therapy assessment indicated the resident still required some hands on contact, but did the turning from side to side on his own. An assessment for cognitive function on 05/12/15 revealed the resident was cognitively intact. A skin grid initiated on 05/19/15 revealed the resident was identified with an unstageable pressure ulcer that measured 2.0 centimeters (cm) long by 2.0 cm wide on the coccyz. 100% of the wound bed was covered with yellow slough. Assessment on 05/25/15 revealed the wound remained the same. A progress note dated 05/19/15, authored by Registered Nurse (RN) #97, revealed Resident #103 had an unstageable pressure ulcer of the coccyx/sacrum and indicated the resident preferred to lay on his back. The pressure reduction mattress was changed to an air mattress. On 05/26/15 at 10:30 A.M., interview with Licensed Practical Nurse (LPN) #15 and RN #97 verified Resident #103 had an unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough, either yellow, tan, green or gray in color and/or eschar, either tan, brown or black in color) on the coccyx. They verified Resident #103 did not have any pressure ulcers on admission to the facility and the unstageable pressure ulcer on the coccyx was acquired in the facility. On 05/27/15 at 2:31 P.M., observation of wound care for the pressure ulcer on the coccyx on Resident #103 revealed that upon entering the room, Resident #103 was laying on his back in bed on an air mattress. The resident gave permission for wound care observation. LPN #18 was assisted by LPN #10. LPN #18 assembled normal saline for cleansing the wound, hydrogel (a moist dressing) and a padded dressing to cover and protect the wound, on a clean bedside stand. Both LPNs washed their hands. LPN #18 opened the dressings and gloved. The resident was assisted to his left side and the old dressing was removed. The old dressing had a small amount of tan colored drainage on it. The wound on the coccyx area was round, 2.0 cm in diameter and 100% of the wound base was covered with yellow slough. The edges were smooth and regular and skin around the wound was pink. LPN #18 cleansed the wound with saline, applied hydrogel and covered the area with the padded dressing. Interview with LPN #18 upon leaving the resident's room, revealed the resident was alert and oriented and able to make his needs known and turned himself side to side now. LPN #18 said that when first admitted to the facility, the resident was very sick and weak and sometimes out of it due to pneumonia and some issues with fluctuations in his blood sugar. On 05/27/15 at 5:37 P.M., the Director of Nursing (DON) and the Administrator verified Resident #103 was admitted to the facility with no pressure ulcer, developed an unstageable pressure ulcer of the coccyx on 05/19/15, and was not placed on a turning schedule until after he was seen by the wound specialist on 05/21/15. The DON explained the resident was not care planned for a turning schedule because he was noncompliant with care. The DON verified no evidence of documentation was found in the resident record to support a behavior of noncompliance with turning. On 05/27/15 at 5:45 P.M., interview with Physical Therapist (PT) #112 revealed maximum assistance meant the person assisting the resident with turning did 100% of the work, moderate assistance meant 50% of the work was done by the person assisting, and minimal assistance meant 25% of the work was still done by the person providing assistance. PT #112 had worked with Resident #103 since admission to the facility and verified the resident was not able to turn or reposition himself without help until 05/26/15. The DON was present during this interview. On 05/27/15 at 5:55 P.M., the DON explained the State tested Nurse Aides (STNAs) documented resident care in their electronic documentation system. Review of the STNA documentation revealed the nurse aides had signed off each shift that Resident #103 was turned and repositioned per the plan of care. The DON explained that the STNAs would turn the resident as directed by the resident's Care Delivery Guide which was kept in a binder on the unit. Review of Resident #103's Care Delivery Guide indicated there was no turn and repositioning provided to the resident. A second review of the resident's care plan for skin integrity reaffirmed there was no mention of providing turning and repositioning for the resident. The DON explained the STNAs automatically turned and repositioned all residents when they were in bed. Review of the facility policy and procedure relative to Pressure Ulcer Prevention/Treatment, revised April 2009, indicated if the resident was at risk for the development of a pressure ulcer, interventions to be used included frequent turning. On 05/27/15 at 6:01 P.M., interview with State-tested Nurse Aide (STNA) #47 revealed she knew which residents were on a turn schedule because they had a yellow dot posted next to their room number. Observation at that time of Resident #103's room number revealed no yellow dot. STNA #47 said she did not have to turn Resident #103 because he was alert and oriented. STNA #47 explained the nurse aides also used the Care Delivery Guide to find out who needed turned and showed this surveyor that Resident #103 was not on a turning schedule. STNA #47 explained she was familiar with Resident #103 and had taken care of him since his admission. STNA #47 did not recall the resident ever being on a turn and reposition schedule and as far as she knew, the resident was able to turn himself. STNA #47 explained she would document, turned and repositioned per plan of care each shift, because Resident #103 turned himself. STNA #47 did not recall having to turn the resident as he did it himself. On 05/27/15 at 6:10 P.M., Resident #103 was laying in bed on his back. Interview with the resident revealed he was able to turn himself onto his side, which he did since he now had a sore on his back. Resident #103 explained he could not remember a lot about when he first came in because he was pretty sick. The resident didn't remember if the nurse aides turned him on his side or not but did say he wasn't able to do it by himself back then. Resident #103 explained he received therapy and was now able to use the side rails to turn and reposition himself. On 05/27/15 at 6:25 P.M., the DON verified the STNAs documented the resident was turned per care plan. However, the resident's care plan and care guide both indicated the resident was not turned and repositioned by the nurse aides. On 05/28/15 at 10:59 A.M., interview with STNA#29 revealed she was assigned to and familiar with Resident #103. STNA #29 said Resident #103 was not on a turn and reposition schedule. She had taken care of him since admission and explained the resident did not need to be turned because he was alert and oriented. STNA #29 would document the resident was turned and positioned per plan of care, because he did it himself. LPN#18 was present during the interview with STNA #29 and added Resident #103 did not need to be on a turn schedule because he was young and was alert and oriented and could do it himself. LPN #18 explained that was why the resident wasn't placed on a turning schedule. When the resident was first admitted he was out of it because he was very sick, but since he was young and alert he didn't need to be turned. On 05/28/15 at 11:15 A.M., the Director of Nursing verified Resident #103 was admitted to the facility on [DATE] without any pressure ulcers, and on 05/19/15 had an unstageable pressure ulcer on the coccyx. The DON verified the facility policy and procedure for prevention of pressure ulcers was if the resident was assessed to be at risk for pressure ulcers, the resident would be care planned for frequent turning. There was no evidence of documentation found in the resident record that indicated the resident was to be turned frequently until 05/21/15, two days after the unstageable pressure ulcer was discovered.

Based on observation, interview and record review the facility failed to ensure all residents were free from sexual and/or verbal abuse. The facility failed to ensure Resident #2, #3 and #4 were free from unwanted sexual contact from Resident #1. The facility failed to ensure Resident #5 and Resident #7 were free from verbal abuse from staff. This affected five residents (Resident #2, #3, #4, #5 and #7) of nine residents reviewed for abuse, injury of unknown origin or misappropriation. Harm occurred to Resident #4 on 12/16/13 when State tested nursing assistant (STNA #26) found Resident #1 in Resident #4's room on his knees over his roommate's (Resident #4's) bed with Resident #4's brief off. Resident #4 was asked what happened and stated "I don't know the other guy did it". Review of a witness statement from STNA #26 revealed Resident #1 was on his knees over Resident #4's bed with his hands on Resident #4's genitals. The nurse was notified and Resident #1 was removed from the room. The facility failed to comprehensively assess Resident #4 following the incident to determine the extent of contact or injury if any from Resident #1. Findings include: 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) 3.0 dated 10/02/13 revealed the brief interview for mental status was a score of four out of 15, which indicated cognitive impairment. No behaviors were reflected in the MDS or plan of care (POC). Resident #1 needed set up to one person assistance with activities of daily living (ADL's). Review of the most recent social service progress note was dated 10/03/13 and revealed Resident #1 had no behaviors. Review of the nursing note dated 11/05/13 at 5:00 A.M., revealed Resident #1 was up tonight walking about, stopping and standing in front of open residents doors. Sometimes he looks and moves on, a few times he takes a step or two into the room before staff can stop him. Staff informed Resident #1 he could not go into other peoples rooms without being invited first. Resident #1 replied angrily "I'm just looking". Review of the nursing note dated 11/14/13 at 11:00 A.M., revealed Resident #1 was observed participating in inappropriate behavior in dining room during musical activities with a female resident (Resident #2 who was confused and had [DIAGNOSES REDACTED]. Review of nursing notes revealed there were no further notes documented until 11/16/13 at 1:00 P.M., when Resident #1 had been separated from Resident #2 several times "this shift" due to inappropriate touching and/or petting. Review of the nursing notes revealed the next note, dated 11/17/13 at 11:30 A.M.,when Resident #1 was visiting with Resident #2 at dining table. Resident #1 was placing his hand between Resident #2's legs and stroking Resident #2. This nurse asked Resident #2 to return to her table to eat lunch. At this time the nurse explained to Resident #1 that this behavior could not occur in the dining room or halls. Review of the nursing notes dated 11/17/13 at 1:20 P.M., revealed Resident #1 was sitting in the lobby area chair with Resident #2 in the wheelchair in front of Resident #1 holding her shirt up while Resident #1 fondled Resident #2's breasts. This nurse asked Resident #1 not to do this in a public area because it was not an acceptable behavior in public with visitors walking by. No changes to the resident's plan of care were made or initiated at this time. Review of the clinical nurse practitioner note dated 11/21/13 did not indicate any behaviors including sexually inappropriate behaviors for Resident #1. No changes to the resident's plan of care were made or initiated at this time. Review of the nursing notes dated 11/25/13 at 4:15 A.M., revealed Resident #1 was following a new female resident (Resident #3 who was confused with [DIAGNOSES REDACTED]. Staff separated the residents and instructed them it was not appropriate behavior in a public area. Resident #3 stated "she did not mind it". No changes to the resident's plan of care were made or initiated at this time. Review of the current physician orders [REDACTED]. Review of nursing notes dated 12/17/13 at 5:45 A.M., revealed Resident #1 was repeatedly entering his room and standing by his roommate' (Resident #4's) bed. Staff asked Resident #1 to leave his roommate alone because he was sleeping. Resident #1 stated he was just "looking" and this was his room and he could do anything he wanted. Resident #1 remained in his room sitting on his bed. Each time this occurred staff stood outside the door until Resident #1 left the room. Review of the nursing notes dated 12/17/13 at 10:00 A.M., revealed Resident #1's son was notified of the resident's actions the previous night. Review of the nursing notes dated 12/17/13 at 1:30 P.M., revealed this nurse spoke with Resident #1 about the events of last evening and Resident #1 had no recall of what happened and stated he stayed on his side of the room and was no where near Resident #4. Review of the mood and behavior care plan revealed there was no indication Resident #1 had any inappropriate sexual behaviors until 12/17/13 when the care plan was updated to indicated resident inappropriately touched Resident #4 in a sexual way. The intervention was frequent checks of Resident #1 to ensure he was not touching other residents inappropriately. Review of the nursing notes dated 12/17/13 at 6:30 P.M., revealed the nurse spoke with Resident #1's son about transferring the resident to an inpatient psychological hospital for evaluation and treatment. Review of the physicians telephone order dated 12/17/13 at 6:30 P.M., revealed send Resident #1 to the hospital for evaluation and treatment. Review of the resident transfer form for Resident #1 dated 12/17/13 revealed the resident was being sent to the hospital for inappropriate behavior and sexual action on other resident. No time was documented on the form. On 12/23/13 at 10:15 A.M., interview with State tested nursing assistant (STNA #29) revealed Resident #1 was confused and would usually be in the dining room. If involved in a sexual type behavior that was consensual with another resident they were asked not to do it in the public areas. On 12/23/13 at 10:45 A.M., interview with licensed practical nurse (LPN #30) revealed Resident #1 had been more quiet lately most likely due to the progression of his dementia. Resident #1 was usually in the dining room and if involved in a consensual sexual act with another residents we asked they don't do it in public. On 12/23/13 at 12:10 P.M., interview with the director of nursing (DON) indicated the inappropriate sexual contact between Resident #1, #2 and #3 was consensual and no family or responsible parties were notified despite all the residents having a [DIAGNOSES REDACTED]. The DON verified Resident #1 remained in the inpatient hospital at the time of the investigation. On 12/23/13 at 12:40 P.M., interview with the DON verified there was no documented evidence the relationships between Resident #1 and Residents #2 and #3 were consensual. However, the facility felt it was their right to have sexual relations just not in public areas per interviews conducted during the investigation. The DON verified there was no documented evidence the frequent checks were completed on Resident #1 on 12/16/13 at 9:45 P.M. when Resident #1 was found to be touching Resident #4's genitals. The DON indicated STNA #27 was disciplined for not documenting the checks on Resident #1. During the interview, the DON verified the first nursing note related to Resident #1's sexual behavior on the night of 12/16/13 was not until 12/17/13 at 5:45 A.M. when the nurse indicated Resident #1 continued to go in and out of his room this shift. The DON verified there was no documentation related to how the nurse observed Resident #1 or the resident's behaviors. The DON verified an incident had occurred on 12/16/13 9:45 P.M. when Resident #1 was found touching Resident #4's genitals. There was no documented evidence either Resident #1 or Resident #4 were assessed to attempt to determine the extent of the sexual abuse towards Resident #4. The DON verified there were no witness statements obtained from STNA #39 or RN #28 who were on duty at the time of the incident. On 12/23/13 at 4:25 P.M., interview with STNA #26 verified she observed Resident #1 on his knees over Resident #4's bed with Resident #4's brief off and Resident #1's hands on Resident #4's genitals. The STNA stated she left to get the nurse and had STNA #27 remain with Resident #1. Based on the information reviewed during the on-site investigation, the facility, who was aware of Resident #1's previous sexual behaviors with Resident #2 and #3, failed to implement adequate and necessary interventions to prevent an incident of sexual abuse from occurring involving Resident #4 on 12/16/13. The following information was obtained related to Resident #2: Review of Resident #2's face sheet revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2 had a power of attorney. Review of Resident #2's most recent social service progress note was dated 10/16/13 and indicated no evidence of sexual behavior. Review of Resident #2's nursing note dated 11/12/13 revealed the resident was going going in and out of other residents rooms turning off lights. Review of Resident #2's nursing note dated 11/17/13 revealed the resident returned from hospital from a fall fall resulting in a laceration to the nose. Review of Resident #2's nursing note dated 11/17/13 at 1:00 P.M., revealed Resident #2 was redirected after an observed situation which included fondling with Resident #1 in the common area. One to one was given explaining this behavior was inappropriate in front of other residents and family. Review of the initial psychologist note for Resident #2 dated 11/18/13 revealed resident had poor insight and was partially oriented. The psychologist had been asked to see the resident due to sexual behaviors. Review of Resident #2's nursing note dated 11/29/13 revealed the resident had to be removed from an activity in the dining area due to inappropriate sexual behavior with Resident #1. One to one with the resident was ineffective. Review of the current mood and behavior care plan updated through January 2014 revealed no evidence of sexually inappropriate behaviors. Review of Resident #2's physicians progress note dated 12/03/13 revealed the resident was confused but no inappropriate behaviors were noted. On 12/23/13 at 10:00 A.M., Resident #2 was observed sitting in the wheelchair outside of her room just looking down the hall holding a tissue. On 12/23/13 at 11:00 A.M., Resident #2 was observed sitting in the wheelchair outside of her room just looking down the hall holding a tissue. On 12/23/13 at 1:30 P.M., Resident #2 was observed sitting in the wheelchair outside of her room just looking down the hall holding a tissue. On 12/23/13 at 1:32 P.M., interview with Resident #2 revealed she could not recall any interactions with other residents. Resident #2 stated I am a widow and would not have anything to do with another man. Asked resident what she ate for lunch today and resident could not remember. Asked resident how long she had been at the facility and resident could not remember. Asked resident what she liked to do for entertainment and resident could not answer the question. On 12/23/13 at 2:15 P.M., 3:10 P.M., and 5:00 P.M., Resident #2 was observed sitting in the wheelchair outside of her room just looking down the hall holding a tissue. On 12/24/13 at 7:30 A.M., Resident #2 was observed in the dining room propelling around asking what day it was. On 12/24/13 at 12:20 P.M., Resident #2 was observed wheeling around the dining room asking what day it was and smiled at surveyor when asked if she ate lunch. On 12/23/13 at 12:10 P.M., interview with the DON indicated the inappropriate sexual contact between Resident #1 and #2 was consensual between the two residents. The DON verified both residents had a [DIAGNOSES REDACTED]. The DON verified neither of the resident's families or power or attorneys were informed of the sexual contact for either Resident #1 or Resident #2. The DON indicated Resident #2 was her own responsible party and had no family or responsible party. The following information was obtained related to Resident #3: Review of Resident #3's admission MDS dated [DATE] revealed a BIMS score of three out of 15, which indicated cognitive impairment. Resident #3 needed assistance of one person for ADL's. On 12/23/13 at 10:00 A.M., Resident #3 was observed sitting in a wheelchair with a lap buddy at the nurses station repeatedly asking to go home. On 12/23/13 at 1:20 P.M., interview with Resident #3 revealed she had no recall of any interaction with any male residents including Resident #1. Resident #3 was not reliable with answering questions and kept reverting back to when she was a care giver in the community. Resident #3 could not remember what she ate for lunch on this date. On 12/23/13 at 1:25 P.M., interview with Resident #3's son, who was her power of attorney (POA), verified either himself or his brother remained at facility as much as possible including staying the night because the resident was falling and wanting to go home. The POA stated no staff had informed him of Resident #1 inappropriately touching his mother. The POA verified the resident was very confused and was very focused on going home. On 12/23/13 at 12:10 P.M., interview with the DON verified there was no documented evidence of the inappropriate sexual contact between Resident #1 and #3 in Resident #3's medical record despite the nursing note in Resident #1's medical record dated 11/25/13 at 4:15 A.M., which revealed Resident #1 was following a new female resident (Resident #3 who was confused with [DIAGNOSES REDACTED]. Resident #3 stated "she did not mind it". The DON indicated this was consensual between Resident #1 and Resident #3 despite each resident having a [DIAGNOSES REDACTED].#1 or Resident #3's family or responsible parties were notified of the incident. The following information was obtained related to Resident #4: Review of the face sheet revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the readmission MDS dated [DATE] revealed a BIMS score of seven out of 15, which reflected cognitive impairment, no behaviors were noted and the resident was assessed to require one to two staff assistance for ADL's. Review of the interdisciplinary team review note dated 12/17/13 revealed due to Resident #4's roommate (Resident #1) touching Resident #4's genitals inappropriately last night Resident #4 would be moved to another room. On 12/23/13 at 10:25 A.M., Resident #4 was observed in the dining room watching television with other residents. Resident #4 was in a wheelchair with a mechanical lift pad under he, non skid socks and a bandage on the lower left leg. On 12/23/13 at 10:50 A.M., attempt to interview Resident #4 was unsuccessful. Resident #4 was not able to answer surveyors questions appropriately. On 12/23/13 at 12:10 P.M., interview with the Director of nursing (DON) revealed Resident #1 was placed on every 15 minute checks after the incident on 12/16/13 with Resident #4 but there was no documented evidence to support the 15 minute checks were ever completed. The DON verified the was no assessment completed on Resident #4 or Resident #1 after Resident #1 was observed touching Resident #4's genitals. On 12/24/13 at 10:05 A.M., during an interview with the DON, administrator and corporate nurse all concerns with the above residents were shared. This included the lack of family or responsible party involvement related to sexual activity with the residents especially since Resident #2, #3 and #4 could not provide consent. On 12/24/13 at 11:30 A.M., interview with social service designee (SSD) #25 revealed his role included discharge planning, monitoring mood and behavior care plans and level of care. SSD #25 verified if a resident to resident altercation including sexual behaviors occurred, the nurses took care of the situation and SSD #25 would update the resident's care plan. SSD #25 verified she attended IDT meetings, talked with the psychologist weekly and updated him with any changes in resident behaviors. SSD #25 verified the was no documented evidence Resident #1's inappropriate behaviors related to Residents #2 and #3 were discussed as a team or with the psychologist. SSD #25 verified when completing quarterly assessments she checked the care tracker computerized documentation for the last seven days of mood and behavior to identify any concerns with residents. SSD #25 verified she did not inform anyone when Resident #1 started inappropriately touching female residents because it was his right to do this, but just not in public areas. Explained to SSD #25 when one of the residents involved did not have the capacity to understand, such as demented residents, it was the facility's responsibility to involve the family, guardian or responsible part to ensure each resident was safe. 2. Review of Resident #5's face sheet revealed she was admitted to the facility with [DIAGNOSES REDACTED]. Review of self reported incident documentation, dated 07/31/13 revealed Resident #5 alleged STNA #31 verbally abused her by yelling at her and making her cry for urinating on the floor. Resident #5 reported the incident LPN #32 the morning after the incident occurred. Review of the witness statement (not dated or timed) by STNA #31 revealed Resident #5 urinated on the floor and STNA #31 asked her why she did it and Resident #5 replied "I didn't know". STNA #31 verified he left the room and went to provide care and change another resident into her night gown and then returned to Resident #5's room. STNA #31 verified he returned to Resident #5's room, changed her, cleaned up the urine and asked Resident #5 not to pee on the floor again. The statement was not signed by STNA #31. Below the statement the administrator wrote STNA #31 was coming to the facility to be interviewed on 08/01/13 at 10:00 A.M. Review of the witness statement from STNA #26 dated 07/30/13, no time, revealed STNA #26 heard STNA #31 complaining and cursing that Resident #5 had peed on the floor. STNA #26 verified STNA #31 seemed to be unusually irritated in general that night especially after leaving Resident #5's room at 8:00 P.M. Review of the witness statement from STNA #33 dated 07/30/13, not times, revealed STNA #31 answered Resident #5's light and when STNA #31 came out of Resident #5's room he said "she (f@#$%^ing) pissed all over the floor in her room". STNA #31 proceeded to provide care to another resident. STNA #33 indicated she thought he had cleaned up the mess in Resident #5's room but when STNA #31 came out of the shower room he grabbed towels and then went to clean up the mess (urine). STNA #31 asked me to help him with another resident and while we were in caring for the other resident STNA #31 said "I am still pissed off about Resident #5 and I reamed her ass and cursed her out. She knows better than that the bathroom is (f@#$%ing) three feet from her bed". STNA #33 indicated she told STNA #31 sometimes things like that happen and residents can't make it. STNA #33 stated when we exited the room she went and told LPN #32 immediately. Review of the witness statement dated 7/30/13, not timed from LPN #32, revealed Resident #5 was incontinent of urine on the floor of her room. STNA #31 was heard coming up the hall saying "she pissed on the floor and she knows better". LPN #32 stated she half way heard some of this but did not hear it all because of being with another resident. STNA #33 came to me and said STNA #31 was complaining to her about it. LPN #32 indicated she went and spoke to Resident #5. Resident #5 stated STNA #31 yelled at her and was mad because she peed on the floor. Resident #5 started to cry. LPN #32 verified she could not understand all of what Resident #5 was saying. LPN #32 stated she spoke to STNA #31 and he denied saying anything out of the line to Resident #5. On 12/23/13 at 4:23 P.M., interview with the DON and administrator, who completed the investigation because the DON was off, according to the DON. The administrator verified Resident #5 was very very hard to understand but could answer yes and no questions. Staff indicated to the administrator Resident #5 could write and the administrator requested Resident #5 write a statement throughout that day but Resident #5 never did. The administrator verified she did not get any other staff member to assist with obtaining a statement from Resident #5. The administrator indicated she asked Resident #5 if STNA #31 was mean to her and Resident #5 said yes. The administrator stated STNA #31's story kept changing. The administrator was not able to provide any documented evidence STNA #31 met with her on 08/01/13 at 10:00 A.M. as scheduled. The administrator verified an in-service was started on 07/30/13 related to abuse, neglect and resident rights and STNA #31 signed it on 08/02/13. The administrator verified STNA #31 was not sent home and continued to complete his shift on the date of the incident. The administrator verified according to the facility policy STNA #31 should have been sent home and suspended pending the investigation. On 12/23/3 at 4:25 P.M., interview with STNA #26 verified she was not in Resident #5's room with STNA #31 but was at nursing station when STNA #31 approached the nursing station cursing and yelling about Resident #5's incident. STNA #26 indicated she could not remember if other residents were in the area but believed some residents probably where because many liked to hang out around the nurse's station. Resident #5 hardly ever had accidents, she lets us know when she has to use the toilet and she needs supervision with toileting. Resident #5 wears a pull up in case of accidents. On 12/23/13 at 5:00 P.M., Resident #5 was observed in the dining room slowly drinking a beverage with a straw. The resident was observed to have food on her face and clothes. On 12/23/13 at 5:01 P.M., interview with Resident #5 revealed she was very difficult to understand with thick slurred speech. When asked about STNA #31 yelling at her resident seemed to get upset and starting to cry. The surveyor did not want to upset the resident further and did not ask anymore questions. On 12/23/13 at 5:05 P.M., interview with the administrator verified LPN #32 was the nurse who interviewed Resident #5 who was crying because STNA #31 was mad at her for peeing on the floor. The administrator verified "if the statement was directed at a resident the staff member should be suspended pending investigation" and the charge nurse must contact the administrative staff. The administrator verified STNA #31 was verbally abuse towards Resident #5 and was not sent home. The administrator stated "I think the nurse took into account Resident #5's typical behaviors which are you can't tell if she is laughing or crying". Also verified with the administrator STNA #31 let Resident #5 remain in soiled clothing while he went and showered another resident before returning to provide care to her. On 12/23/13 at 5:10 P.M. interview with LPN #32 (with the administrator present) verified STNA #33 came to her about STNA #31 yelling at Resident #5 and said "he told her about herself" saying she knows better she shouldn't be doing that. STNA #31 was cursing and upset about the situation. LPN #32 verified she went and talked to Resident #5 who stated STNA #31 yelled at her. LPN #32 verified she did not get anymore information from Resident #5. LPN #32 verified she went and talked to STNA #31 who denied anything happened or that he was upset and yelling at Resident #5. LPN #32 indicated she called an administrative staff person, but could not remember who and there was no documented evidence of such. LPN #32 verified she did not send STNA #31 home because the allegation was not witnessed. LPN #32 verified the facility policy was to send STNA #31 home pending investigation. On 12/24/13 at 8:00 A.M., Resident #5 was observed in the dining room eating breakfast with a divided plate feeding self very slow with food on face. On 12/24/13 at 12:15 P.M., Resident #5 was observed in the dining room eating breakfast with divided plate feeding self very slow with food on face. 3. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE] revealed a BIMS score of 15 out of 15, which reflected the resident's cognition was intact with no deficit. The resident was assessed to require one person physical assistance with ADL's. The current psychosocial well-being plan of care reflected a score between zero and four revealing no behaviors noted. A care plan was initiated for the resident being tired and needed encouragement for activity. Review of a self reported incident revealed Resident #7 reported to the day shift nurse (RN #35) that she was very upset about how the night shift nurse (LPN #34) treated her and told her she stunk. Review of the witness statement dated 10/11/13 from RN #35 revealed while passing medications on the morning of 10/10/13 STNA #36 informed me Resident #7 gave her a note to give to the administrator and wanted me to go talk to Resident #7. RN #35's statement also indicated, in report this morning (10/10/13) LPN #34 informed me she suggested to Resident #7 she should take a shower because she had a smell and that I would probably be hearing a complaint from Resident #7. RN #35 verified she talked with Resident #7 who said she was very unhappy with LPN #34 for telling her she stunk. Resident #7 stated she was going straight to the administrator. Resident #7 stated in the past when she had chest pains LPN #34 told her if she cried wolf too many times, one time we would not come running. RN #35 informed Resident #7 she would report her complaint and assured Resident #7 the nurses were here to take care of her needs. Review of the witness statement dated 10/10/13 at 5:00 A.M. from LPN #34 indicated she awoke Resident #7 to give medications. LPN #34 verified she noticed an offensive odor and sheepishly said "maybe you'd consider a shower?" Resident #7 replied "I had one yesterday afternoon. There's nothing wrong with me." LPN #34 replied "I am sorry maybe the linens need to be laundered" and LPN #34 left the room. Resident #7 yelled after LPN #34 stating "we will just see what the administrator has to say about this." LPN #34 verified this statement was made to prevent embarrassment when going out in public. LPN #34 tried to be polite without telling Resident #7 she smelled or stank. LPN #34 stated she never meant any harm. Review of the administrators short hand notes, not dated or signed, from an interview with Resident #7 revealed LPN #34 was supposed to apologize but never did about way she treated me before. I needed assistance going back to my room and LPN #34 told me "if you want to go back you take yourself". Another time LPN #34 was supposed to apologize to me when I needed help to the restroom. The light was on and LPN #34 stated "you do not need help, nothing is wrong with you. On 12/24/13 at 9:20 A.M., interview with Resident #7 revealed the resident was sitting on the edge of the bed with oxygen on and labored breathing. Resident #7 verified she was weak from pneumonia. Resident #7 verified she needed more assistance from staff at this time due to pneumonia. Resident #7 verified when she was first admitted LPN #34 was not nice to me and told me I did not need to be here. There was an STNA in the room but I haven't seen her in a long time. LPN #34 was suppose to apologize to me then but never did. Another time LPN #34 said if I keep complaining of chest pain and crying wolf one day no one will come check on me. Resident #7 verified she could usually get around herself either with a walker or wheelchair but when she was sick or feeling weak needed staff assistance. Resident #7 indicated when she was weak before she requested a bedside commode because she could not walk to the bathroom on her own but she was told the facility did not have any extra bedside commodes at that time. A few days later a received a bedside commode (observed siting in corner of room blocked by the wheelchair). LPN #34 was suppose to apologize three different times but never did until this last time in October 2013. When the DON came in to talk to me I told her how LPN #34 treated me and the DON said "I teach my staff to be stern". Record review revealed LPN #34 was to receive one on one counseling from the DON to review professional and courteous behavior when interacting with residents. Review of the one on one inservice/reeducation for LPN #34 dated 10/14/13 revealed to see the attached paper for some guidelines to deal with residents in a professional and courteous manner. LPN #34 indicated she was looking for free continuing education to complete the professional and courteous manners but had been unable to find any so would purchase some by the end of week and get the results to the DON. On 12/23/13 at 4:23 P.M., interview with the DON verified she teaches her staff to be stern. The DON verified no one on one had been completed as of yet for LPN #34 as planned above. The DON verified LPN #34 continued to provide care to Resident #7 without any discipline or interventions. The DON verified Resident #7 was alert and oriented and reliable. The DON verified Resident #7 use to work at the facility and would not make up stories. On 12/23/13 at 4:23 P.M., interview with the administrator verified no other staff were interviewed related to Resident #7's allegation of verbal abuse. This deficiency substantiates Self-Reported Incident Control Number OH 026.