Every finding on record at Atlantes the

Based on medical record review and facility staff interview, the facility failed to ensure a resident's advance directive status was consistent on all forms of the medical record. This affected one resident (#8) of 16 reviewed for advanced directives. The facility census was 27. Findings include: Medical record review revealed Resident # 8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. Review of the resident's 1/2019 physician's orders [REDACTED]. Further review of the hard chart revealed an Ohio Do Not Resuscitate (DNR) Identification form signed and dated 01/09/19 by the resident's physician. The form documented the resident's code status as Do Not Resuscitate Comfort Care (DNRCC). Interview on 01/22/19 at 5:35 P.M., with the Director of Nursing (DON) verified the physician's orders [REDACTED].

Based on record review, staff interview and policy review, the facility failed to implement a baseline care for residents at risk for falls. This affected two (Resident #1 and #2) of three residents reviewed for falls. The facility census was 17. Findings include: 1. Review of the medical record for Resident #1 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively impaired and required extensive assistance of two staff for bed mobility and transfers. Review of fall risk assessment for Resident #1 dated 09/06/18 revealed resident was at moderate risk for falls. Review of the baseline care plan for fall prevention for Resident #1 dated 09/06/18 revealed the resident was risk for falls related to impaired mobility, confusion, weakness, and incontinence. The care plan did not include a goal, nor did it include specific individualized interventions to prevent falls. Interview with the Director of Nursing (DON) on 12/16/18 at 10:40 A.M. confirmed Resident #1's baseline care plan did not include a goal, nor did it include specific individualized interventions to prevent falls. 2. Review of the medical record for Resident #2 revealed the resident was admitted [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS dated [DATE] revealed the resident was cognitively intact and required limited assistance of one staff for bed mobility and transfers. Review of the fall risk assessment dated [DATE] revealed the resident was at moderate risk for falls. Review of the baseline care plan for fall prevention dated 09/06/18 revealed the resident was risk for falls. The care plan did not include a goal, nor did it include specific individualized interventions to prevent falls. Interview with the Director of Nursing (DON) on 12/16/18 at 10:40 A.M. confirmed that Resident #2's baseline care plan did not include a goal, nor did it include specific individualized interventions to prevent falls. Review of policy titled Care Plans dated 09/2017 revealed care plans should include problems related to the provision of safety and that each care plan should include a goal with a target date and individualized specific interventions and approaches. Review of policy titled Fall Risk Assessment and Identification dated 05/15/17 revealed that if a resident's fall assessment indicates a risk of falls the nurse will immediately initiate an acute care plan for falls prevention. This was an incidental finding during the complaint investigation.

Based on record review and staff interview, the facility failed to ensure a registered nurse worked for at least eight consecutive hours daily seven days per week. This had the potential to affect all 17 residents residing in the facility. Findings include: Review of staffing schedules for 11/17/18 through 12/16/18 revealed a registered nurse (RN) was scheduled for twelve consecutive hours every day with the exception of 11/17/18 and 11/18/18. There was no RN scheduled on 11/17/18 and 11/18/18. Interview with Administrator on 12/16/18 at 10:20 AM. confirmed there was no RN scheduled on 11/17/18 and 11/18/18. This deficiency substantiates Complaint Number OH 624.

Based on record review and staff interview, the facility failed to timely complete resident assessments. This affected one (#2) of three residents sampled for resident assessments. The facility census was 26 residents. Findings include: Review of Resident #2's medical record revealed an admission date of [DATE] for therapy, with [DIAGNOSES REDACTED]. Review of the nurses notes dated 10/31/17 at 3:15 P.M., revealed Resident #2 was discharged home with family. Review of the assessments revealed an Entry assessment dated [DATE], an Admission Minimum Data Set (MDS) assessment dated [DATE], and a 14 day MDS assessment dated [DATE]. The record was silent for a completed Discharge MDS Assessment. Interview on 04/17/18 at 1:04 P.M., with Licensed Practical Nurse #30 confirmed the Discharge Assessment for Resident #2 was missed.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of self-reported incident, review of employee file, review of time cards, review of in-service records, review of facility investigation, review of witness statements, review of facility policy and staff interview, the facility failed to implement the facility poilcy on preventing verbal abuse of a resident by a staff member and a staff memeber immediately reporting an alleged incident. This affected one (#81) of seven residents reviewed facility self-reported incidents. The facility census was 26 residents. Findings include: Review of Resident #81's closed medical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. [MEDICAL CONDITION], major [MEDICAL CONDITION], systemic lupus, wedge compression fracture T11 and T12 vertebra with fusion, urinary tract infection, and displaced fracture of great toe with non-weight bearing on the right foot. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was cognitively intact with two person extensive assist for transfers and toileting, occasionally incontinent of urine. The resident was not ambulatory during the assessment period. The Nurses Notes revealed the resident had frequent complaints of pain. Resident #81 was discharged from the facility to home on 09/22/17. Review of the facility self reported incidents (SRI) with the Administrator revealed Resident #81 was verbally abused by State tested Nurse Aide (STNA) #80. The incident was witnessed by STNA # 51. STNA #51 failed to immediately report the incident to the charge nurse on duty. Review of the SRI dated 08/23/17 revealed on on 08/23/17 at approximately 4:00 A.M., STNA #80 and STNA #51 answered the call light for Resident #81. Upon entering the room STNA #80 made negative comments to Resident #81 about wetting herself and the need to use the bathroom instead of wetting herself as part of her therapy. The incident was witnessed by STNA #51. STNA #80 assisted with the care of residents until the end of the shift. At that time STNA #80 clocked out and was taken off the schedule. STNA #80 was terminated by the facility. Review of the Resident #81's witness statement dated 08/23/17 revealed it was early morning when the resident put on the call light for help going to the bathroom. The resident had already voided when the STNA answered the call light. STNA #80 told the resident you are wet again? You need to get up to the bathroom. STNA #80 told the resident there was a rash from wetting herself that could lead to skin breakdown . Resident #81 stated STNA #80 makes her uncomfortable when she is working with her and the resident hates to use the call light. Review of the facility time punches for STNA #80 revealed the STNA punched out at the end of the shift at 7:04 A.M. and did not return to the facility. Review of the employee file for STNA #80 revealed a date when hired of 04/05/17. STNA completed orientation that included an in-service on abuse prevention and what constitutes abuse in the facility. The employee file contained two previous warnings. A warning dated 08/07/17 was a final warning for procedure error for transfer a resident without a brace. STNA #80 refused to sign the warning. A warning dated 08/17/17 was a first warning for absences/tardiness. A 90 day evaluation dated 08/17/17 revealed STNA #80 needed improvement that included: 1. improve attendance, 2. build rapport with guests, 3. attend monthly employee in-services. STNA #80 was suspended pending an investigation and was terminated on 08/25/17. Interview on 04/20/18 at 3:30 P.M., with the Administrator verified the date the incident, the incident occurred, STNA #51 did not report the incdent immediately and the facility has implemented corrective action. The facility has implemented the following corrective action and was corrected by 08/29/17: · On 08/23/17, removal of STNA #81 form job duties. · On 08/23/17, conducted full investigation of alleged verbal abuse. · On 08/23/17, reported allegation to state agency. · On 08/25/17, terminated STNA #81 employment for verbal abuse. · On 08/28/17, all facility staff in-serviced upon abuse policy and procedures. · On 08/29/17, one on one in-servicing provided for STNA #51 for immediate reporting and written warning issued. · On 4/16-20/18, random interviews conducted with residents revealed no concerns with alleged abuse. · On 04/20/18, review of SRIs revealed no additional incidents occurring. Review of the facility policy titled Abuse, Neglect, Misappropriation Policy dated 04/2017 revealed verbal Abuse referred to any use of oral or gestured language that willfully included disparaging and derogatory term to the resident. The staff should report all incidents immediately to their direct supervisors or the Administrator.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of self-reported incident, review of employee file, review of time cards, review of in-service records, review of facility investigation, review of witness statements, review of facility policy and staff interview, the facility failed to prevent verbal abuse of a resident by a staff member. This affected one (#81) of seven residents reviewed facility self-reported incidents. The facility census was 26 residents. Findings include: Review of Resident #81's closed medical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. [MEDICAL CONDITION], major [MEDICAL CONDITION], systemic lupus, wedge compression fracture T11 and T12 vertebra with fusion, urinary tract infection, and displaced fracture of great toe with non-weight bearing on the right foot. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was cognitively intact with two person extensive assist for transfers and toileting, occasionally incontinent of urine. The resident was not ambulatory during the assessment period. The Nurses Notes revealed the resident had frequent complaints of pain. Resident #81 was discharged from the facility to home on 09/22/17. Review of the facility self reported incidents (SRI) with the Administrator revealed Resident #81 was verbally abused by State tested Nurse Aide (STNA) #80. The incident was witnessed by STNA # 51. STNA #51 failed to immediately report the incident to the charge nurse on duty. Review of the SRI dated 08/23/17 revealed on on 08/23/17 at approximately 4:00 A.M., STNA #80 and STNA #51 answered the call light for Resident #81. Upon entering the room STNA #80 made negative comments to Resident #81 about wetting herself and the need to use the bathroom instead of wetting herself as part of her therapy. The incident was witnessed by STNA #51. STNA #80 assisted with the care of residents until the end of the shift. At that time STNA #80 clocked out and was taken off the schedule. STNA #80 was terminated by the facility. Review of the Resident #81's witness statement dated 08/23/17 revealed it was early morning when the resident put on the call light for help going to the bathroom. The resident had already voided when the STNA answered the call light. STNA #80 told the resident you are wet again? You need to get up to the bathroom. STNA #80 told the resident there was a rash from wetting herself that could lead to skin breakdown . Resident #81 stated STNA #80 makes her uncomfortable when she is working with her and the resident hates to use the call light. Review of the facility time punches for STNA #80 revealed the STNA punched out at the end of the shift at 7:04 A.M. and did not return to the facility. Review of the employee file for STNA #80 revealed a date when hired of 04/05/17. STNA completed orientation that included an in-service on abuse prevention and what constitutes abuse in the facility. The employee file contained two previous warnings. A warning dated 08/07/17 was a final warning for procedure error for transfer a resident without a brace. STNA #80 refused to sign the warning. A warning dated 08/17/17 was a first warning for absences/tardiness. A 90 day evaluation dated 08/17/17 revealed STNA #80 needed improvement that included: 1. improve attendance, 2. build rapport with guests, 3. attend monthly employee in-services. STNA #80 was suspended pending an investigation and was terminated on 08/25/17. Interview on 04/20/18 at 3:30 P.M., with the Administrator verified the date the incident, the incident occurred, STNA #51 did not report the incdent immediately and the facility has implemented corrective action. The facility has implemented the following corrective action and was corrected by 08/29/17: · On 08/23/17, removal of STNA #81 form job duties. · On 08/23/17, conducted full investigation of alleged verbal abuse. · On 08/23/17, reported allegation to state agency. · On 08/25/17, terminated STNA #81 employment for verbal abuse. · On 08/28/17, all facility staff in-serviced upon abuse policy and procedures. · On 08/29/17, one on one in-servicing provided for STNA #51 for immediate reporting and written warning issued. · On 4/16-20/18, random interviews conducted with residents revealed no concerns with alleged abuse. · On 04/20/18, review of SRIs revealed no additional incidents occurring. Review of the facility policy titled Abuse, Neglect, Misappropriation Policy dated 04/2017 revealed verbal Abuse referred to any use of oral or gestured language that willfully included disparaging and derogatory term to the resident. The staff should report all incidents immediately to their direct supervisors or the Administrator.

Based on medical record review, observations, resident, family and staff interviews, the facility failed to utilize a therapy recommended slide board for transfers resulting in a fall for one resident. This affected one (#5) of three residents reviewed for falls in a facility census of 25. Findings include: Review of Resident #5's medical record revealed an admission date of [DATE] with a re-admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the admission minimum data set (MDS) assessment dated [DATE] revealed Resident #5 was cognitively intact for daily decision making. Resident #5 was assessed for requiring extensive assistance with all activities of daily living (ADL's) except for limited assistance with eating. Resident #5 utilized a wheelchair for mobility. Review of a fall risk assessments completed on 04/02/16 and 04/14/16 indicated Resident #5 was at moderate risk for falls and an assessment completed on 04/11/16 indicated a high risk for falls. Review of a nursing progress note dated 04/14/16 at 11:00 A.M. revealed therapy clarified and educated staff on proper transfers with slide board. Resident #5 was assessed and without injuries. The state tested nursing assistants (STNAs) were present to witness the incident. An additional progress note timed 11:21 A.M. revealed Resident #5 was noted on the floor and denied any discomfort. All parties were notified. Review of a physical therapy evaluation and plan of treatment dated 04/12/16 revealed Resident #5 was a maximum assist with a slide board for transfers. Review of STNA plan of care, undated, revealed Resident #5 was an extensive assist of two employees with a slide board for transfers. Interview on 04/24/16 at 2:53 P.M. with Resident #5 and her family both denied Resident #5 had any falls since admission to the facility. Resident #5 reported she utilized her call light when she wanted to get up, staff responded and would assist her as needed. Observation during the interview revealed the call light was within reach. Interview on 04/24/16 at 3:40 P.M. with STNA #25 reported she had been off work for a few days and upon return she consulted another STNA about the assistance Resident #5 required with transfers. The other STNA reported Resident #5 was a two person assist with a gait belt and proceeded to transfer Resident #5 with the use of a gait belt. Upon standing Resident #5, she was unable to support any of her weight and the other STNA let go and I lowered her to the floor but her legs went underneath her and she was uncomfortable. After the fall, the physical therapist came into the room and informed us Resident #5 was a two person transfer with the use of a slide board. STNA #25 reported she then observed the slide board on a shelf in the room. STNA #25 reported being informed about the assistance residents required by another STNA, the nurse, or refer to the residents plan of care. She reported she would have to look at Resident #5's plan of care to find out if a slide board for transfers was listed. Interview on 04/24/16 at 4:29 P.M. with licensed practical nurse (LPN) #75 and the director of nursing (DON) reported Resident #5 was classified as a two person assist with a slide board for transfers. On 04/14/16, two STNAs transferred Resident #5 without a slide board and the Resident was lowered to the floor. Resident #5 had been evaluated by therapy on 04/12/16 and a two person transfer with slide board was recommended and added to her plan of care. Resident #5 was not injured as a result of the fall. This deficiency substantiates Complaint Number OH 673.

Based on observation, staff interview and record review the facility failed to ensure dishes and utensils were cleaned under sanitary conditions as evidenced by the staff being unaware of the correct temperature the dishwasher machine should reach prior to doing dishes and the lack of documentation that the temperatures were checked at each meal. All residents currently residing in the facility were identified as eating food served from the kitchen. The census was 26. Findings include: On 09/02/14 at 10:10 A.M. an observation was made of Dietary/Housekeeping staff #1 running a load of plastic containers through the dishwasher. It was noted the wash temperature was 112 degrees and the rinse 124 degrees. Dietary/Housekeeping staff #1 proceeded to send the plastic containers through again. It was noted the wash temperature was 114 degrees and the rinse temperature was 124 degrees. She removed the containers and placed them on a wire shelf. When asked how hot the dishwasher was required to be, she stated she was unsure how hot the water should be. The employee continued to load the dish machine again and was stopped by the surveyor. Consulting Dietician #2 came in and was informed of the concern. She instructed Dietary/Housekeeping staff #1 to utilize the three sink unit with sanitizer for washing dishes until the staff was able to identify the manufacturers recommended temperature for the dishwasher wash cycle. She also asked the dietary staff where the containers were that had initially been washed by the dishwasher and instructed her to rewash them in the three compartment sink with sanitizer. On 09/02/14 at 10:20 A.M. the Dietary/Housekeeping staff #1 verified in the presence of the Consulting Dietician #2 that she was unaware of the wash and rinse temperatures required to safely use the dishwashing machine. The information was not posted, and the staff working at that time were not aware of the requirements. On 09/02/14 at 10:30 A.M. the temperatures were verified as being within the required limits, the wash temperature was 120 degrees and the rinse temperature was 126 with a chlorine parts per million (PPM) of 50 verified by a test strip. The facility then proceeded to use the machine again to wash dishes. A review of the dish machine temperature logs from the past three months revealed there were multiple missing entries. This included water temperatures not recorded as being checked on 07/30/14, 08/06/14, 08/13/14, 08/14/14, 08/22/14, 08/23/14, 08/24/14, 08/27/14 and 08/31/14. This was verified by Maintenance staff #3. The facility was using a Jackson Conserver XL dishwashing machine. The manufacture's recommendations reviewed were for the wash temperature to be 140 degrees with a minimum requirement of 120 degrees, the rinse temperature was recommended to be 140 degrees with a minimum requirement of 120 degrees also. All of the dietary staff were in-serviced immediately and a service technician for the dishwasher came out to the facility on [DATE]. The service report noted the machine was working, chemicals dispensing appropriately and the temperatures were good reading 125 degrees for the wash and rinse. There were no identified outbreaks of food borne illness identified by the facility. On 09/02/14 the Dietary Manager stated the Dietary/Housekeeping staff #1 only works in the kitchen one day each week. She also stated that she had been trained previously, but there was no written information to indicate how she was trained. She stated she was in serviced along with the rest of the dietary staff that day. Review of the facility's policy and procedure entitled "Dish Machine Temperature Log" copyright 2009 stated the staff will be trained to record dish machine temperatures for the wash and rinse cycles at each meal. It also stated the dining services manager would spot check the log to assure temperatures were appropriate and staff was actually monitoring dish machine temperatures.

Based on record review, observation, and staff interview, the facility failed to complete blood sugar checks for Resident #3 and failed to administer insulin in accordance with the physician's orders [REDACTED]. This involved 2 of 3 sampled residents with finger stick/insulin orders. The facility had a total of 8 residents with orders for finger stick blood sugars and insulin. Findings include: 1. Review of Resident #3's admission sheet revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's progress note dated 05/23/14 listed a problem of diabetes mellitus uncontrolled. The resident had a 05/23/14 physician's orders [REDACTED]. Review of her plan of care revealed the fingerstick blood sugar was listed as an intervention on the plan of care and referred to the Medication Administration Record [REDACTED] On 05/27/14 at 3:19 P.M. the MAR indicated [REDACTED]. Review of the MAR indicated [REDACTED]. RN #10 stated she gave the 3 units of [MEDICATION NAME] about 1:00 P.M.; however, she did do the accucheck one hour after the insulin was administered as ordered by the physician. LPN #12 also verified she had not completed the accucheck per the physician's orders [REDACTED]. 2. Review of Resident #17's admission sheet revealed she was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of her physician's orders [REDACTED].M., 12:00 P.M. and 5:00 P.M. According to the order insulin was to be administered as follows: 70-139 no insulin; 140-199 1 unit, 200 to 249 2 units, 250 to 299 3 units, 300 to 349 4 units 350 to 399 5 units-- over 399 6 units. Review of her plan of care revealed the fingerstick blood sugar was listed as an intervention on the plan of care and referred to the MAR. On 05/27/14 at 11:22 A.M., State tested Nursing Assistant (STNA) #14 was observed to obtain Resident #17's finger stick blood sugar level. The blood sugar level was 145. At 3:14 P.M. the MAR indicated [REDACTED].M. and the administration of the sliding scale insulin in accordance with the physician's orders [REDACTED]. and verified she had forgotten to obtain the accucheck reading and to administer the one unit of insulin in accordance with the physician's orders [REDACTED].M. RN #2 stated she called the physician and obtained another accucheck. She stated the accucheck was 198 so she gave Resident #17 one unit of insulin per the physician's orders [REDACTED]. This is an incidental deficiency found during the investigation of complaint OH 665.