Every finding on record at Beechwood Home for Incurables

Based on observations, policy review, staff interviews, and record review, the facility failed to ensure call lights were withing reach of the residents. This affected two (Resident #362 and #543) of the 70 residents who are able to utilize the call light system. The facility census was 73.Findings include:1. Medical record review for Resident #362 revealed an admission date of 09/15/06. Diagnoses included multiple sclerosis (MS), lack of coordination and epilepsy. Care plan intervention revealed Resident #362 was able to use call light system when placed in right hand. Velcro strap needs to be attached to call light is wrapped around right hand and resident brings call light up to his chin to activate.Observation and interview on 01/22/26 at 11:00 A.M. revealed Resident #362 sitting upright in his wheelchair in his room and his call light was lying on the floor next to him, and was out of his reach. Certified Nursing Aide (CNA) #219 verified the call light was out of reach for Resident #362. CNA #219 retrieved the call light and placed it under his right arm and in his right hand. There was no Velcro strap attached to the call light. Interview with Registered Nurse (RN) #241, the third floor unit manager, on 01/22/26 at 11:05 A.M. revealed Resident #362 has been equipped with a Velcro strap that attaches to the call light cord and goes over his right hand, so he can press the call button to his chin.Observation on 01/22/26 at 11:07 A.M. revealed Resident #362 made multiple attempts to press his call light utilizing his chin but the call light fell from his grasp onto the floor. There was no Velcro strap visible.Interview with RN #241 and Psychiatric Nurse Practitioner (PNP) #110 on 01/22/26 at 11:16 A.M. revealed PNP #110 verified the call light was out of reach when he arrived in Resident #362's room. RN #241 and PNP #110 verified there was no Velcro strap attached to the call light; they scanned the room for the strap and were unable to locate. RN #241 made a telephone call while in Resident #362's room requesting the therapy department to come with a Velcro strap for the call light. 2. Medical record review for Resident #543 revealed an admission date of 10/24/24. Diagnoses included amyotrophic lateral sclerosis (ALS), respiratory failure with hypercapnia, and Parkinson's disease. Observation and interview on 01/22/26 at 9:25 A.M. revealed Resident #543 was in his bed with his call light sitting on the bedside nightstand, out of his reach. Licensed Practical Nurse (LPN) #200 verified the call light was out of reach for Resident #543. LPN #200 picked up the call light and placed it across the Resident #543's stomach.Interview with the Director of Nursing (DON) and Administrator on 01/22/26 at 1:15 P.M. verified when residents were brought back to their rooms, following resident care and assistance with activities of daily living (ADLs), the expectation was for the residents to be provided with a call light using the tools they require according to the individual care plans.Review of the facility's Nurse Call System Policy, last reviewed on 08/14/20, revealed the facility will provide a means for residents to make staff aware of care needs at all times, including utilizing different devices wherein the need for modification has been determined necessary.This was an incidental finding discovered during the complaint survey.

Based on staff interview, record review, review of the facilities Self-Reported Incident (SRI) and investigation, and policy review, the facility failed to report to law enforcement an allegation of staff-to-resident physical abuse. This affected one (Resident #70) of one resident reviewed for abuse. The facility census was 73. Findings include: Review of Resident #70's medical record revealed Resident #70 admitted to the facility on [DATE]. Resident #70 had a medical history which included pseudobulbar effect and post-traumatic stress disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #70 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #70 was dependent on staff assistance for toileting hygiene. Review of the care plan initiated 11/28/23 revealed Resident #70 had impaired communication, including impaired speech, and communicated by typing on their cell phone. Interventions included directing staff to allow the resident time to respond/text and do not rush, observe for nonverbal communication, and keep call light in reach. The care plan also included a focus area initiated 11/28/23 which indicated Resident #70 had an alteration in elimination. Interventions included directing staff to assist with toileting transfers and provide dignity and privacy when giving incontinence care. Review of the facility's SRI dated 03/27/25, revealed an allegation of physical abuse that occurred on 03/26/25 at 1:40 P.M. The SRI indicated the alleged perpetrator was a Certified Nursing Assistant (CNA). Resident #70 alleged CNA #14 was rough when providing care to the resident. The SRI included resident statements, staff statements, and a statement from the alleged perpetrator (CNA #14). The SRI revealed no evidence the facility reported the allegation of abuse to law enforcement. The facility unsubstantiated the allegation of staff-to-resident physical abuse. The facility's investigation documentation included a typed statement, dated 003/27/25 and signed by the Administrator, that indicated Resident #70 stated CNA #14 had strong-armed the resident and the resident received a small bruise to the inner part of their eye near the bridge of their nose. The Administrator's statement indicated the contents of video surveillance of the resident's room on the date of the alleged incident showed CNA #14 providing incontinence care to Resident #70, who had been incontinent of bowel. While CNA #14 had the resident rolled to the side and was cleaning the resident, Resident #70 was pushing back against the CNA. The CNA was holding Resident #70 to the side with one arm while cleaning with her other hand. Due to the angle of the video, the Administrator was unable to clearly see the resident's face and could not ascertain whether there was a bruise or reddened area to the same area of the resident's face where the bruise was subsequently identified. The facility's investigation documentation also contained a print-out of screenshots of a text conversation between the Director of Nursing (DON) and CNA #14. CNA #14 indicated in her text messages to the DON that she had provided incontinence care to Resident #70 and the resident got upset during the care and wanted their phone but CNA #14 was in the midst of cleaning the resident and was unable to hand the phone to Resident #70. CNA #14 denied being rough with Resident #70 and indicated the resident turned back over while CNA #14 was attempting to clean the resident, then Resident #70 started yelling for CNA #14 to get out of the room. CNA #14 indicated she complied with Resident #70's request and went to the nurse to report what had happened. During an interview on 05/22/25 at 12:38 P.M., the Administrator confirmed the abuse allegation made by Resident #70 was not reported to law enforcement. The Administrator stated they would have reported the allegation if there was reasonable evidence or information that could prove an abuse incident happened. Review of the facility's undated policy titled Abuse Policy revealed all reports of suspected crime and/or alleged sexual abuse must be immediately reported to local law enforcement to be investigated.

Based on staff interview and record review, the facility failed to ensure the level one Preadmission Screening and Resident Review (PASARR) accurately reflected a resident's existing mental illness at the time of admission. This affected one (Resident #69) of two residents reviewed for PASARR . Findings include: Review of Resident #69's medical record revealed Resident #69 admitted to the facility on [DATE]. Diagnoses included dementia, post-traumatic stress disorder (PTSD), and epilepsy. Review of the PASARR Identification Screen dated 02/09/23 revealed Resident #69 did not have any of the diagnoses or disorders listed on the form. Mood disorder, panic or other severe anxiety disorder, and another mental disorder that may lead to a chronic disability were included in the list of diagnoses; however, none of the diagnoses were selected as applicable to Resident #69. Review of Resident #69's five-day Minimum Data Set (MDS) assessment dated [DATE] revealed PTSD was selected as an active diagnosis under psychiatric/mood disorder. During an interview on 05/22/25 at 10:30 A.M., the Director of Social Services (DSS) #500 stated the facility did not have a policy for PASARRs. During an interview on 05/22/25 at 1:00 P.M., the Director of Nursing (DON) verified Resident #69's PASARR level one dated 02/09/23 should have been marked with a mood disorder and stated her expectation going forward was that the PASARR would be reviewed upon admission, and corrections would be made based on the resident's diagnoses and medical records. During an interview on 05/22/25 at 1:04 P.M., the Administrator stated going forward they would review the PASARR upon admission, make corrections based on the resident's diagnoses and medication records, and ensure the PASARR was correct.

Based on staff interview, record review, and facility policy review, the facility failed to ensure a resident was free from significant medication errors, when the facility failed to follow a physician's order to hold a blood pressure medication when the systolic blood pressure (SBP), the top number in a blood pressure (BP)) reading was above 120. This affected one (Resident #7) of six residents reviewed for unnecessary medications. The facility census was 73. Findings include: Review of Resident #7's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included cerebral palsy, hyperlipidemia, and acute kidney failure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Review of the care plan revealed a focus area revised on 03/23/20, which indicated Resident #7 had an alteration in cardiac status. Interventions included directing staff to provide medications and labs as ordered and to obtain vital signs as ordered. Review of Resident #7's Order Summary Report, with active orders as of 05/22/25 revealed an order dated 02/18/25, for Midodrine HCL (hydrochloride) (treats low blood pressure) oral tablet 10 milligrams (mg), one tablet by mouth three times a day for hypotension (low blood pressure), with instructions to hold for systolic blood pressure greater than 120. Review of the Medication Administration Record (MAR) from 05/01/25 to 05/21/25, revealed staff administered the Midodrine HCL oral tablet 10 mg to Resident #7 when the resident's SBP was greater than 120 on 05/03/25 at 2:00 P.M. (SBP was 127), 05/04/25 at 2:00 P.M. (SBP was 146), 05/05/25 at 2:00 P.M. (SBP was 125), 05/07/25 at 2:00 P.M. (SBP was 133), 05/08/25 at 2:00 P.M. (SBP was 136), 05/12/25 at 2:00 P.M. (SBP was 125), 05/13/25 at 2:00 P.M. (SBP was 129), 05/14/25 at 8:30 A.M. (SBP was 141) and 2:00 P.M. (SBP was 127), 05/18/25 at 2:00 P.M. (SBP was 150), 05/19/25 at 2:00 P.M. (SBP was 142), and 05/21/25 at 2:00 P.M. (SBP was 131). During an interview on 05/22/25 at 9:40 A.M., Licensed Practical Nurse (LPN) #1 stated blood pressure parameters were located in the physician's order on the MAR. She stated if Resident #7's SBP was higher than 120 and the medication was not held, it would be considered a medication error. LPN #1 stated when the nurses documented a held medication, it would auto populate in the progress notes. She said if no number was entered on the MAR for the reason a medication was held, and no progress note indicated the medication was held, then the checkmark on the MAR meant the medication was given. LPN #1 confirmed multiple doses of medication that were outside of the parameters of the order, were documented as given with her initials and a checkmark. LPN #1 stated if she did not document the medication was held, then it was probably given, but she could not say for sure. During an interview on 05/22/25 at 10:37 AM, Registered Nurse (RN) #3 stated if a medication was ordered to be held for a SBP over 120 and was not, it would be a medication error. RN #3 stated if there was not a numeric reason a medication was held or a progress note for the reason a medication was held, then a checkmark in the box on the MAR meant a medication was given. RN #3 reviewed Resident #7's Midodrine order and agreed there were multiple times the medication was recorded as given when it should not have been, based on the blood pressure recorded. She stated for the days where the medication was coded as held and there was no progress note, that it was held, but the checkmark meant they gave the medication when they should not have and that it was a medication error. During an interview on 05/22/25 at 10:49 A.M., RN #4 stated parameters for a medication should be in the order and should show up on the MAR. She stated if a medication was given outside of those parameters, it would be a medication error. During an interview on 05/22/25 at 12:11 P.M., the Director of Nursing (DON) confirmed there were multiple times where there was no documentation in the progress notes or on the MAR that the medications were held when the SBP was over 120 for Resident #7. She stated her expectation was for the nurses to take vital signs prior to administering the medications, and if the value was outside of the parameters, the nurse should hold the medication, document it was held, and the reason it was held. The DON stated that if there was a checkmark in the box on the MAR, no numeric value to indicate it was held, and no progress note for the reason it was held, it would be considered a medication error. During an interview on 05/22/25 at 12:41 P.M., the Administrator stated she deferred to nursing for the clinical portion, but she would expect the nurses to follow the physician's order and hold the medications when they needed to be held. Review of the facility policy titled Medication Administration dated 11/01/24 revealed nurses will administer medications safely and effectively following the five rights of medication administration. Nurses will follow physician/physician extender orders regarding medication administration. Vital signs and other measurements will be checked prior to administering medications with parameters as indicated/ordered. The facility policy titled Medication Regimen - Unnecessary Medications dated 11/01/24 revealed each resident's drug regimen will be free of unnecessary drugs.

Based on record review, observation, staff interview, and facility policy review, the facility failed to maintain appropriate infection control practices during Resident #42's wound care. This affected one (#42) of two residents observed for wound care. Findings include: Review of Resident #42's medical record revealed the resident admitted to the facility on [DATE]. Diagnoses included ataxia, pneumonia, and acute embolism and thrombosis of deep veins of lower extremity. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 had intact cognition. Resident #42 had one unstageable pressure ulcer (slough and/or eschar: known but not stageable due to coverage of wound bed by slough and/or eschar) and received pressure ulcer care. Review of the care plan dated 03/04/25 revealed Resident #42 had a pressure area to their sacrum. Interventions included for staff to provide treatment per physician orders. Review of Resident #42's active physician orders dated 5/21/25 revealed there were treatment orders to clean the sacrum area with soap and water, tap dry, and apply a treatment to the wound and apply an abdominal (ABD) pad. During an observation of wound care for Resident #42 on 05/21/25 at 1:37 P.M., Licensed Practical Nurse (LPN) #1 donned a gown and gloves. LPN #1 did not perform hand hygiene prior to placing the gloves on. With gloved hands, she reached for Resident #42's electronic bed control and raised the bed prior to starting the wound treatment. With the same gloves on, LPN #1 pulled the bedside table to within reach, turned and assisted Resident #42 to roll to their left side, and loosened the incontinence brief and pulled it to the side to gain access to the wound. Without changing gloves, LPN #1 cleaned the wound with four-by-four gauze pads and soap and water then rinsed the wound with four-by-four gauze pads and normal saline. Without changing gloves, LPN #1 grabbed two dry four-by-four gauze pads and patted the wound bed dry. Without changing gloves or performing hand hygiene, LPN #1 grabbed a tube of lidocaine gel, squirted a dime-size amount on her gloved right index finger and applied the gel over the wound bed. Again without changing gloves or performing hand hygiene, LPN #1 grabbed a 30 cubic centimeter medication cup with skin barrier cream in it and squirted a small amount of Silvadene cream into the cup, then mixed the two creams together with a tongue blade. LPN #1 then used the tongue blade to apply the mixture over the wound bed. Without changing gloves or performing hand hygiene, LPN #1 grabbed an ABD pad, placed it over the wound, and then closed Resident #42's brief. LPN #1 then threw away the used supplies and doffed her gloves and gown. LPN #1 did not perform hand hygiene after removing her gloves and gown. At no time prior to donning gloves and gown for Resident #42's wound care, during the wound care, or immediately after she took off her gloves following Resident #42's wound care did LPN #1 perform hand hygiene. During an interview on 05/21/25 at 1:51 P.M., LPN #1 verified she did not perform prior to donning her gown and gloves, did not change gloves and perform hand hygiene in between the dirty and clean part of wound care, and did not perform hand hygiene when she completed wound care for Resident #42 and removed her gown and gloves. LPN #1 stated she should have completed the hand hygiene prior to placing the gown and gloves on, changed her gloves in between dirty and clean part of wound care, and after wound care and removing gown and gloves. During an interview on 05/22/25 at 9:42 A.M., LPN #2 stated a nurse should wash their hands before and after a wound treatment and in between wounds, should a resident have more than one wound. She stated if a nurse donned a gown and gloves at the beginning of a wound treatment and did not change gloves or wash their hands throughout the entire process, this would be a breach of infection control. During an interview on 05/22/25 at 10:00 A.M., Registered Nurse (RN) #3, who was a Nursing Supervisor, stated a nurse should put on gloves going into the room, change gloves in between dirty and clean processes of wound care, and sanitize their hands in between glove changes. She stated if a nurse put on gloves at the beginning of a wound treatment and did not change them or wash their hands throughout the process, it would be considered a breach in infection control practice. RN #3 could not remember when her last in-service on infection control or wound care was. During an interview on 05/22/25 at 12:11 P.M., the Director of Nursing (DON) stated her expectation was for the nurse to wash their hands prior to putting on gloves and to remove their gloves after removing the soiled dressing and sanitize their hands. The DON stated the nurse should then re-glove, clean the wound, and remove their gloves again and sanitize their hands. Per the DON, the nurse would then re-glove and perform the treatment for the wound and then remove their gloves when finished with the treatment and wash their hands. The DON stated the nurses should be changing gloves between dirty and clean processes of the treatment. During an interview on 05/22/25 at 12:41 P.M., the Administrator stated her expectation was for the nurses to change gloves when they were supposed to for infection control practices during wound care. Review of the facility policy titled Dressing Change revised 11/01/22 revealed staff were to follow the procedure: 1. Perform hand hygiene 2. Put on clean gloves. 3. Remove the old dressing and dispose of it. 4. Clean the wound per physician order 5. Perform hand hygiene 6. Put on clean gloves 7. Apply treatment per physician order, if applicable. 8. Apply the new dressing and secure it in place. 9. Remove gloves and perform hand hygiene.

Based on medical record review, staff interview, and facility policy review, the facility failed to discuss and notify the resident's family of changes in his care/treatment. This affected one (Resident #22) of three residents reviewed for notification of change. The census was 74. Findings include: Resident #22 was admitted to the facility on [DATE]. His diagnoses were Parkinsonism, dementia, change in skin texture, erythema, mixed incontinence, abnormal posture, dry eye syndrome, cognitive communication deficit, dysarthria and anarthria, repeated falls, lack of coordination, major depressive disorder, preglaucoma, muscle weakness, anxiety disorder, hyperlipidemia, hypertension, adjustment disorder, vitamin D deficiency, spondylosis, arthropathy, osteoporosis, dysphonia, hypothyroidism, hypothyroidism, and neuromuscular dysfunction of bladder. Review of his minimum data set (MDS) assessment, dated 08/01/24, revealed he had a severe cognitive impairment. Review of Resident #22's progress notes, dated 09/12/24, revealed a note that stated the following, Resident no longer attempts to get out of his w/c (wheelchair) independently. It was IDT (interdisciplinary team) decision to discontinue the seat belt. Review of Resident #22's progress notes and medical records found no evidence to support the family was contacted, consulted, or notified about the discontinuation for Resident #22's seat belt as a fall intervention. Interview with Director of Nursing (DON) and Administrator on 11/15/24 at 2:30 P.M. and 5:36 P.M. confirmed there was no evidence to support Resident #22's family was notified or consulted about the removal of the seat belt. DON confirmed it is typical for the facility staff to speak with various members of a resident's IDT, which includes the physician, facility staff, and resident/representative prior to removing a fall intervention, and the resident/representative should be notified at the time it's removed as well. Review of facility Change in Health Status policy, dated 07/01/23, revealed resident will be routinely monitored by all associates to determine the need for additional health services monitoring of chronic, unstable, or acute changes in condition. Upon the identification of a change in condition in a resident, non-nurse associates will notify the nurse. Upon the identification of a change in condition in a resident the nurse will observe the resident's status, and document findings in the resident's electronic medical record. The nurse will inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident's representative regarding the following: an accident involving the resident which results in injury and has the potential for requiring physician intervention or a significant change in resident's physical, mental, or psychosocial status such as a deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical complications. The notification shall include a description of the circumstances and cause, if known, of the illness, injury, or death. A notation of change in health status and any intervention taken shall be documented in the medical record. This deficiency represents non-compliance investigated under Complaint Number OH00158993.

Based on observations, review of a therapeutic spreadsheet, record review, review of the facility's policy, and staff interviews, the facility failed to serve the correct portion sizes for a pureed diet. This affected eight residents (#13, #19, #31, #40, #48, #52, #53, and #57) residing in the facility whom receive puree diets. The facility census was 71. Findings include: Review of the facility's therapeutic spreadsheet revealed the pureed diet consisted of pork loin three ounce measuring scoop, grilled buttered asparagus four ounce measuring scoop, roasted sweet potatoes four ounce measuring scoop, and hot spiced apples four ounce measuring cup. Observation on 04/27/22 at 11:58 A.M. of tray line service revealed Cook #160 partially filled a four-ounce scoop of puree food items including sweet potato, asparagus, and pork and placed them on a plate to be served to Resident #57. Review of the diet ticket revealed Resident #57 was to receive a pureed diet. Interview on 04/27/22 at 11:59 A.M. with Cook #160 verified he was giving a partial measuring scoop of pureed food to the residents who had pureed meal. Subsequent observation on 04/27/22 at 12:00 P.M. of tray line service revealed Dietician #170 was educating Cook #160 to fill up the scoop when serving pureed diets instead of providing pureed diets a partial scoop. Interview on 04/27/22 at 12:01 P.M. with Dietician #170 verified Cook #160 was not filling the scoop serving up for pureed diets. Review of the facility's list of pureed diets revealed Residents #13, #19, #31, #40, #48, #52, #53, and #57 were on a pureed diet. Review of facility's policy titled Forefront Standard Serving Portions Policy, issued on 05/01/19, revealed pureed vegetables were to be served in a number eight scoop that was equivalent to four ounces.

Based on resident and staff interview, review of the facility's policy, and record review, the facility failed to ensure residents received timely dental services. This affected two (#22 and #33) of two residents reviewed for dental services. The facility census was 71. Findings include: 1. Review of Resident #33's medical record revealed the resident was admitted on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #33 was cognitively intact, had no behaviors, did not refuse care, and did not wander. Review of the progress note dated 02/06/22 revealed Resident #33 lost a filling to his right lower molar during lunch. The supervisor was notified and the dentist was to be called the following Monday. Review of the medical record reviewed no documentation related to dental appointments for Resident #33 on or after 02/06/22. There was no evidence Resident #33 was seen by a dentist on or after 02/06/22. Interview on 04/26/22 at 9:30 A.M. with Resident #33 stated he didn't like to go but needed to see the dentist related to a filling that had fallen out. Resident #33 stated the area was not painful, but there was a sharp edge to the tooth that he avoided when chewing. Interview on 04/27/22 at 10:26 A.M. with Licensed Practical Nurse (LPN) #13 stated Resident #33 had a filling fall out a couple months ago, was seen by a dentist in the facility, but could not be treated in house. Resident #33 had an appointment scheduled with a dentist in the community. On the day of the appointment, date not specified, Resident #33 got up and ready for the appointment, but LPN #13 was not sure if the appointment was canceled by the dental office or transport. LPN #13 was not sure if the appointment was ever rescheduled. Interview on 04/27/22 at 10:57 A.M. with Registered Nurse (RN) #105 stated she was unaware of any dental concerns, and had not scheduled any dental appointments for Resident #33 since she assumed the role of scheduler on 02/14/22. Resident #33 was not on the list to be seen by Care 360 and did not receive dental services on 04/22/22. Care 360 was scheduled to return on 06/02/22. Subsequent interview on 04/28/22 at 8:47 A.M. with LPN #13 clarified she told the unit manager (Registered Nurse #45) that Resident #33 needed a dental appointment. On the day of the appointment, unspecified, Resident #13 was out of bed, dressed and waiting in the lobby for transportation when LPN #13 began her shift. LPN #13 stated after she started her medication pass, she saw Resident #33 returning to the floor. LPN #13 questioned Resident #33 about his dental appointment and he indicated either the appointment or the transportation had been canceled. 2. Review of Resident #22's medical record revealed Resident #22 admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 was cognitively intact and Resident #22 had obvious or likely cavity or broken teeth. Review of the dental care plan, last revised on 07/12/21, revealed Resident #22 had an alteration in dentition. Interventions included dental exams routinely and as needed by the dentist. Review of Resident #22's dental summary report dated 09/01/21 revealed an oral surgeon referral was made to extract all remaining teeth. Further review of the summary report revealed the resident, and the facility were advised the resident needed to be seen by an oral surgeon for extractions. Review of the dental oral surgery referral dated 09/01/21 revealed Resident #22's dentist completed referral form for Resident #22 to have all remaining teeth extracted. Further review of the oral surgery referral revealed the referral was not sent to the oral surgeon until 04/28/22. Review of Resident #22's medical record from 09/01/22 to 04/27/22 revealed no documentation that an appointment was made for Resident #22 to see the oral surgeon. There was also no documentation that Resident #22 was seen by an oral surgeon. Interview with Resident #22 on 04/25/22 at 8:30 P.M. revealed Resident #22 had not seen the dentist and all of her teeth were falling out. Interview with the Administrator on 04/28/22 at 9:38 A.M. verified Resident #22 was not seen by the oral surgeon and the oral surgeon referral was not sent until 04/28/22. Review of the facility's dental services policy dated 11/15/15 revealed the facility will promptly refer residents with lost or damaged dentures to a dentist.

Based on medical record review, observation, staff interview, resident interview, and review of facility policy, the facility failed to assess, and monitor a resident's restraint. This affected one resident (#39) of one reviewed for restraints. The facility census was 78. Findings include: Review of the medical record revealed Resident #39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #39's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately cognitively impaired with no behaviors noted. Review of Section P-Physical Restraints revealed no physical restraints were used during the look back period for the resident. Review of Resident #39's physician orders revealed the resident did not have an order for [REDACTED]. Observation and interview on 03/18/19 4:28 P.M., with Resident #39 revealed the resident was in her wheelchair with a seatbelt fastened over her lap. Resident #39 stated she was unsure why she had a seatbelt and she was unable to unfasten it due to not having full function and strength of her hands. Interview on 03/21/19 at 11:28 A.M., with Licensed Practical Nurse (LPN) #12 revealed she was the nurse caring for Resident #39. LPN #12 revealed the resident had a seatbelt on her wheelchair and to the best of her knowledge she wore it whenever she was in the chair. LPN #12 revealed the resident was able to unbuckle the seatbelt when needed, however she never did. Observation and interview on 03/21/19 at 12:42 P.M., with State tested Nursing Assistant (STNA) #56 revealed Resident #39 was observed in the dining room after eating her lunch, in her wheelchair, her seatbelt attached. STNA #56 verified the resident's seatbelt was attached. Resident #39 was asked to unbuckle the seatbelt and she was not able to do so. Resident #39 revealed she did not like wearing the seatbelt. Interview on 03/21/19 at 1:26 P.M., with LPN #12 verified Resident #39's nursing progress notes and physician orders revealed the seatbelt was to be discontinued on 03/11/19. Interview on 03/21/19 at 2:47 P.M., with Occupational Therapy Program Director (OTPD) #299 revealed she put the order in to discontinue Resident #39's seatbelt. OTPD #299 revealed the resident was being evaluated last week for new cushions for her custom wheelchair and it was noted the seatbelt was no longer necessary. OTPD further revealed she was unable to find where the resident had ever been assessed for the seatbelt use and/or safety. OTPD #299 stated she also reviewed the resident orders, including her discontinued orders, and was unable to find any order related to the use of the seatbelt. Review of the facility policy titled, Physical Restraints dated 01/03/06, revealed residents will be free from physical restraints that are not required to treat the resident's medical symptoms. When a restraint is used, an assessment shall identify the medical symptom that warrants it's use, risk and benefits of usage will be discussed with the resident and/or their representative, physician's order including type/medical reason/duration will be documented, care plan will be developed, and periodical assessments will be completed to reassess for continued use.

Based on medical record review, staff interview, resident interview, review of the facility Self Reported Incident(SRI), and review of facility policy, the facility failed to implement their abuse policy when an allegation of staff to resident verbal abuse was alleged. This affected one resident (#45) of one reviewed for abuse. The facility census was 78. Findings include: Review of the medical record revealed Resident #45 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact with no noted behaviors. Review of the SRI revealed investigation statements were collected from State tested Nursing Assistant (STNA) #100, Registered Nurse (RN) #101, and Resident #45, regarding the allegation of abuse made by Resident #45's wife. The SRI revealed no evidence the facility had conducted interviews of other staff and residents that STNA #100 had come into contact with that day. Review of the SRI statement from RN #101 revealed she was the nurse providing care for the resident the day of the alleged incident, and Resident #45 only told her STNA #100 wasn't nice to him and didn't make his bed correctly. Review of the SRI statement from the Director of Nursing (DON) revealed Resident #45 had reported STNA #100 was verbally abusive when she asked him, can't you stand? The resident further revealed when he asked the STNA to take him to the dining room, the STNA revealed she had seen him in the halls in the wheelchair and asked him if he was able to do it by himself. Review of STNA #100's statement revealed she was rushing to pull Resident #45's pants up in the morning of 03/18/19 because he was shaky and unsteady on his feet. STNA #100 noted Resident #45 requested assistance to the dining room and she asked him if he was pulling her leg because she had witnessed the resident be independently mobile in his wheelchair. The STNA told the resident she would assist him to the dining room after providing care for another resident. Interview on 03/18/19 at 2:36 P.M., with Resident #45 revealed during his morning care a STNA was providing care to him and the STNA started accusing him of not trying to assist her. He felt the STNA did not treat him in a dignified manor. Resident #45 was unable to identify the STNA by name, however he stated he did inform his nurse of the situation that morning after the incident. Interview on 03/20/19 at 12:36 P.M., with the Administrator and DON revealed they submitted a SRI related to the alleged verbal abuse between STNA #100 and Resident #45. The Administrator stated Resident #45's wife had notified the facility on 03/18/19 around 4:00 P.M., that she felt the resident had been verbally abused by the STNA, when she was rushing the resident though personal care. The resident had asked the STNA to assist him down to the dining room, and the STNA told him she had seen him take himself to lunch before and she did not assist him. The Administrator revealed the facility reviewed the allegation, filed an SRI, and concluded the incident was unsubstantiated. The Administrator verified the investigation consisted of interviews with Resident #45 and STNA #100. The Administrator confirmed no other interviews with staff or other residents were completed. Review of the facility policy, Abuse Reporting and Investigation review dated 11/12/18 revealed the facility will report and thoroughly investigate any allegation of abuse.

Based on medical record review, staff interview, resident interview, review of the facility Self Reported Incident(SRI), and review of facility policy, the facility failed to thoroughly investigate an allegation of staff to resident verbal abuse. This affected one resident (#45) of one reviewed for abuse. The facility census was 78. Findings include: Review of the medical record revealed Resident #45 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact with no noted behaviors. Review of the SRI revealed investigation statements were collected from State tested Nursing Assistant (STNA) #100, Registered Nurse (RN) #101, and Resident #45, regarding the allegation of abuse made by Resident #45's wife. The SRI revealed no evidence the facility had conducted interviews of other staff and residents that STNA #100 had come into contact with that day. Review of the SRI statement from RN #101 revealed she was the nurse providing care for the resident the day of the alleged incident, and Resident #45 only told her STNA #100 wasn't nice to him and didn't make his bed correctly. Review of the SRI statement from the Director of Nursing (DON) revealed Resident #45 had reported STNA #100 was verbally abusive when she asked him, can't you stand? The resident further revealed when he asked the STNA to take him to the dining room, the STNA revealed she had seen him in the halls in the wheelchair and asked him if he was able to do it by himself. Review of STNA #100's statement revealed she was rushing to pull Resident #45's pants up in the morning of 03/18/19 because he was shaky and unsteady on his feet. STNA #100 noted Resident #45 requested assistance to the dining room and she asked him if he was pulling her leg because she had witnessed the resident be independently mobile in his wheelchair. The STNA told the resident she would assist him to the dining room after providing care for another resident. Interview on 03/18/19 at 2:36 P.M., with Resident #45 revealed during his morning care a STNA was providing care to him and the STNA started accusing him of not trying to assist her. He felt the STNA did not treat him in a dignified manor. Resident #45 was unable to identify the STNA by name, however he stated he did inform his nurse of the situation that morning after the incident. Interview on 03/20/19 at 12:36 P.M., with the Administrator and DON revealed they submitted a SRI related to the alleged verbal abuse between STNA #100 and Resident #45. The Administrator stated Resident #45's wife had notified the facility on 03/18/19 around 4:00 P.M., that she felt the resident had been verbally abused by the STNA, when she was rushing the resident though personal care. The resident had asked the STNA to assist him down to the dining room, and the STNA told him she had seen him take himself to lunch before and she did not assist him. The Administrator revealed the facility reviewed the allegation, filed an SRI, and concluded the incident was unsubstantiated. The Administrator verified the investigation consisted of interviews with Resident #45 and STNA #100. The Administrator confirmed no other interviews with staff or other residents were completed. Review of the facility policy, Abuse Reporting and Investigation review dated 11/12/18 revealed the facility will report and thoroughly investigate any allegation of abuse.

Based on closed medical record review and staff interview, the facility failed to complete a recapitulation/discharge summary for a resident discharged from the facility. This affected one resident (#79) of one reviewed for discharge. The facility census was 78. Findings include: Review of the closed medical record revealed Resident #79 was admitted to the facility on [DATE], discharged on [DATE] to another facility. [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #79 was cognitively intact with no noted behaviors. Review of Section Q- Participation in Assessment and Goal Setting revealed the resident expected to remain in the facility with no active discharge planning occurring, and no interest in talking to someone about the possibility of leaving the facility. Review of the progress note dated 02/14/19 revealed Resident #79 was discharged to another facility and left the facility with their guardian. The note revealed the resident left with medication and an order summary. There was no evidence of a discharge summary for Resident #79. Interview on 03/21/19 at 4:17 P.M., with Social Worker (SW) #111 revealed she was the discharge planner for Resident #79. SW #111 stated Resident #79's discharge request was abrupt, and that the resident had only lived in the facility for a couple weeks. SW #111 stated the resident's discharge was initiated by his mother and she took control of everything. SW #111 stated she faxed over the information the mother had requested, and a couple days later he discharged . SW #111 stated she provided the items the facility requested, however she did not complete a recapitulation of stay.

Based on medical record review, observations, review of manufacturer recommendations, staff interview, and facility policy review, the facility failed to ensure their medication administration error rate was five percent (%) or lower. There were 32 opportunities observed with two errors. This resulted in a medication administration error rate of 6.25%. This affected two residents (#3 and #8) of six observed during medication administration. The facility census was 78. Finding include: 1. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #3's physician orders [REDACTED]. Observation on 03/20/19 at 11:15 A.M., revealed Licensed Practical Nurse (LPN) #9 administered Resident #3's medications through her [DEVICE]. LPN #9 flushed the [DEVICE] with 10 milliliters (ml) of water and administered the three medications through the [DEVICE]. She flushed the [DEVICE] with 10 ml of water between each medication administration. LPN #9 then administered a final flush of 25 ml of water. Interview on 03/20/19 at 12:00 P.M., with LPN #9 revealed she flushed Resident #3's [DEVICE] with 10 to 30 ml of water before and after medication administration. On 03/20/19 at 5:00 P.M., interview with the Director of Nursing (DON) verified the facility policy instructed the nurses to administer 30 ml of a water flush before and after medication administration. Review of the facility's policy for Administration of Medications via Feeding Tubes with a revision date of 09/08/17 revealed the nurse was to flush [DEVICE]s with 30 ml of water to rinse the feeding tube before and after giving medications. 2. Medical record review revealed Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #8's physician orders [REDACTED]. On 03/21/19 at 8:30 A.M., LPN #12 administered two puffs of the inhaler medication to Resident #8. LPN #12 did not offer or instruct Resident #8 to rinse and spit after inhaling the medication. Interview with LPN #12 verified she had forgotten to offer or instruct the resident to rinse and spit after inhaling the medication. Review of the [MEDICATION NAME] manufacturer recommendations revealed the resident should rinse their mouth with water after each dose (two) puffs. This will help to lessen the chance of getting a yeast infection (thrush) in the mouth and throat. A review of the facility's policy for Administration of Metered-Dose Inhalers (undated) revealed the resident should rinse their mouth and spit out the rinse water.

Based on medical record review, observation, food test tray, staff interview, resident interview, and review of facility policy, the facility failed to serve meals at appetizing temperatures. This affected two residents (#53 and #66) of 24 residents reviewed for food temperatures. The facility census was 78. Findings include: 1. Review of the medical record revealed Resident #53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment 02/06/19 revealed the resident was cognitively intact. Interview conducted on 03/18/19 at 3:08 P.M., Resident #53 revealed the food comes to the unit at 5:00 P.M., and the residents do not receive it until 5:30 P.M. Resident #53 stated she had voiced her concerns to the food committee, and said she was entitled to warm food. 2. Review of the medical record revealed Resident #66 was admitted the the facility on 06/14/17 with [DIAGNOSES REDACTED]. Review of the resident's MDS assessment dated [DATE] revealed her cognition was intact. Interview on 03/19/19 at 9:32 A.M., with Resident #66 revealed her food was sometimes cold when she received it. A meal test tray was completed on 03/21/19 11:49 A.M., with the Dietary Manager (DM) #27. The food was plated and taken to the third floor at 11:54 A.M., after all residents were served. The test tray was removed from the transportation cart at approximately 12:23 P.M. Temperatures were completed with DM #27. The potatoes were 119 degrees Fahrenheit (F), the BBQ ribs were 120 degrees (F), the cabbage was 127 degrees (F), and the pea soup was 116 degrees (F). Food was then tasted for temperature with verification by DM #27. The food was no longer hot, and at luke warm temperature. DM #27 revealed the plate warmer had been broken and plates were being heated in the oven prior to the food being plated. Review of the facility policy, Food Preparation and Consistencies dated 09/10/15 revealed foods are maintained at proper temperature both during preparation and at serving time.

Based on review of a Self-Reported Incident, review of facility policy, record review, review of a video, and resident and staff interviews, the facility failed to ensure three residents (#9, #35 and #56) medications were free from misappropriation by staff. This affected three Residents (#9, #35 and #56) of three sampled residents for misappropriation of medications. Findings include: 1. Record review revealed Resident #9 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #9 had physician orders [REDACTED].) by mouth four times a day. A review of Resident #9's Controlled Drug Record revealed, on 04/08/18, he received 0.5 mg. but it was not signed out. Also, on 04/08/18 there was a date without a signature or time that indicated the Resident had received the [MEDICATION NAME]. On another Controlled Drug Record sheet the count was supposed to be 30 tablets of [MEDICATION NAME]. However, upon reconciliation there were 29 tablets. One tablet of [MEDICATION NAME] 0.5 mg. was unaccounted for. Review of the packing slip from the Pharmacy, dated 04/10/18, documented the facility had replaced two tablets of [MEDICATION NAME] at their own expense. Review of nursing notes, dated 04/11/18 at 2:05 P.M., revealed, on 04/08/18, a call was placed to the Attending Physician. The resident reported he did not get his evening medications and received a new order to administer his evening medications at that time. Further review of nursing notes, dated 04/11/18 at 2:33 P.M., revealed, on 04/08/18, the resident was administered Tylenol 1000 milligrams (mg), Klonopin (anxiety) 0.5 mg, [MEDICATION NAME] (for malignant neoplasm of prostate) 0.4 mg, [MEDICATION NAME] (for unspecified myalgia and myositis) 300 mg., [MEDICATION NAME] (for [MEDICAL CONDITION] disorder) two mg., [MEDICATION NAME] ([MEDICAL CONDITION]) 150 mg., Trazadone ([MEDICAL CONDITION]) 50 mg. and [MEDICATION NAME] (sleeping aid) 30 mg. at 2:15 A.M. per one time physician order. Medications were taken without difficulty. On 04/18/18 at 4:15 P.M., an interview with Resident #9 said he was not receiving his eye drops, his digestive medications or his psychiatric pills. 2. Record review revealed Resident #35 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of physician orders [REDACTED]. Review of Resident #35's Controlled Drug Record documented one mg. of [MEDICATION NAME] was signed out but the resident stated she had not received it. Review of the packing slip from the pharmacy, dated 04/10/18, documented the facility had replaced one tablet of [MEDICATION NAME] at their own expense. Review of nursing notes, dated 04/11/18 at 1:59 P.M., documented a note for 04/08/18. A call was placed to the physician at 2:00 A.M. and notified him the resident did not receive her evening medications. A new order to given to administer evening medications at that time. The writer followed up with resident at approximately 3:00 A.M., and noted the resident was resting in bed with no complaints. Further review of the nursing notes, dated 04/11/18 at 2:29 P.M., documented a note for 04/08/18. Resident was administered [MEDICATION NAME] (insulin) 40 units, [MEDICATION NAME] (anxiety) 20 mg., Klonopin (anxiety) one mg, [MEDICATION NAME] (for leg pain), [MEDICATION NAME] (major [MEDICAL CONDITION] without psychotic features) 450 mg., [MEDICATION NAME] (depressive and [MEDICAL CONDITION] disorders), [MEDICATION NAME] V (antibiotic), Potassium (supplement) 500 mg. and [MEDICATION NAME] ([MEDICAL CONDITION] disorder) 100 mg. per one time physician order [REDACTED]. Medications were noted to be taken without difficulty. On 04/18/18 at 4:35 P.M., interview with Resident #35 stated she had received her medications in accordance with physician orders. 3. Record review revealed Resident #56 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #56's physician orders [REDACTED]. of [MEDICATION NAME] by mouth twice daily for anxiety. Review of the Controlled Drug Record revealed, on 04/08/18, Resident #56 had received one tablet of [MEDICATION NAME] on 04/08/18 but it was not signed out or timed. The Controlled Drug Record revealed, on 04/08/18, there was one tablet of [MEDICATION NAME] unaccounted for. Review of the packing slip from the pharmacy, dated 04/10/18, documented the facility had replaced one tablet of [MEDICATION NAME] at their own expense. On 04/18/18 at 4:40 P.M., interview with Resident #56 said she was receiving medications in accordance with physician order A review of the facility's Self Reported Incident (SRI) Control Number 4 revealed the date of discovery was 04/08/18 and the category was misappropriation. The alleged/suspected perpetrator (Registered Nurse #30) was facility staff or other care provider. The initial source of allegation/suspicion was staff. There were two involved Residents (#9 and #35). The facility conclusion/disposition was substantiated. The Narrative Summary of the Incident documented at approximately 11:30 P.M. on 04/07/18, Registered Nurse (RN) Supervisor #31 contacted the Director of Nursing (DON) via telephone. She stated the third floor RN #30 was acting confused, unsteady on her feet and could not locate her medication cart keys. The DON instructed the RN Supervisor #31 to collect the backup keys and count down the cart with the RN. The RN Supervisor #31 collected the keys and returned to the cart to find RN #30 was nowhere to be found. Security found RN #30 in the men's restroom on a different floor huddled over a trash can and very disoriented. The local Police Department were notified and arrived on the scene along with the squad. The DON arrived at the building and inventoried the medication cart with the RN Supervisor and found that two different narcotics (a total of four pills) were missing. RN Supervisor #31 filed a theft report with the police and the third floor RN #30 was transported to the hospital for evaluation and drug test. The third floor RN #30 was immediately suspended pending investigation. The DON and RN Supervisor #31 assessed each resident on the unit and verified that Resident #9 and Resident #35 did not receive their scheduled narcotic dose during the evening med pass. The DON contacted the Medical Director and obtained approval to administer the medications off-schedule for the Residents. The Medical Director reported to the facility on [DATE] to perform rounds with the residents on the third floor and no adverse reactions were observed. On 04/09/18, the Administrator and DON reviewed video footage from 9:00 P.M. to midnight on 04/07/18 and observed the third floor RN #30 appearing to self-administer resident medications on four different occasions between 9:39 P.M. and 11:31 P.M. The third floor RN #30 employment was terminated immediately following the review of the video footage. The suspected diversion on behalf on the third floor RN #30 had been reported to the State Board of Pharmacy and the State Board of Nursing. All four missing narcotic doses were replaced on 04/10/18 at the facility's expense. On 04/18/18 at 11:09 A.M. an interview with the Administrator and the DON verified the SRI investigation and results. The Administrator stated two residents did not receive any of their evening medications scheduled to be given around 8:30 P.M. to 9:00 P.M. The Administrator said he watched the video and said around 9:00 P.M. she was becoming unsteady on her feet and appeared to be under the influence of something Between 9:30 and 11:00 it appeared she put something from the med cart and tilted her head back to swallow. Per the video, it appeared RN #30 pulled the narcotics from the narcotic drawer to the regular medications in the cart and swallowed something. Initially the squad arrived and said they were not going to take someone to the hospital to have a drug screen. Then the DON called them for a second time and stated the nurse was impaired. On the second run, the squad took her to the hospital for assessment and drug testing. From the narcotic count and the video showed the medications did not reach the resident which was misappropriation. On 04/08/18 at 12:00 A.M. RN #30 left the shift without a narcotic count. On 04/08/18 at 3:30 A.M. the DON and LPN #21 did a medication cart audit and found four missing medications. On 04/18/18 at 11:40 A.M. the video was reviewed with the Administrator and the Director of Nursing (DON). The facility developed a timeline of the video as follows and was signed and dated 04/09/18 by the Administrator and DON.: A review of video footage review of diversion incident on 04/07/18 was conducted. On 04/09/18 the Administrator and DON reviewed security camera footage from the night of 04/07/18 from 9:00 P.M. through 12:00 A.M. The following timeline represents our observation where it appears RN #30 placed a pill (or pills) from the medication cart into her mouth followed by a drink of water from her mug to aide in swallowing: · 9:39 P.M. - RN #30 pulls her hand from drawer and places it to her mouth then tilts head back in swallowing fashion followed by a drink of water. · 9:44 P.M. - RN #30 brings medication cup to her mouth and tilts head back in swallowing fashion followed by a drink of water. · 10:41 P.M. - RN #30 brings medication cup to her mouth and tilts head back in swallowing fashion followed by a drink of water. · 11:30 P.M. - RN #30 pulls her hand from drawer and places it to her mouth then tilts head back in swallowing fashion followed by a drink of water. · 11:31 P.M. - RN #30 dumps contents of what appears to be a medication box into her hand and places items into her right jacket pocket. We observed RN #30 very unsteady on her feet throughout the footage often swaying sideways or backwards and almost falling to the ground on a couple of occasions. The unsteadiness became more prominent as time passed consistent with the presumed self-administration of non-prescribed medications. On 04/18/18 at 2:03 P.M., an interview was conducted with LPN #21. LPN #21 said she was coming on duty for the 11:00 P.M. to 7:00 A.M. When she arrived, she never saw RN #30 but the Supervisor was speaking with another nurse (LPN #20) asking her to help RN #30. LPN #20 said let me count with LPN #21 then she would help RN #30. LPN #20 and LPN #21 found missing narcotics, narcotics that were not signed out and narcotics unaccounted for. There were unsigned medications on the Medication Administration Record [REDACTED]. Resident #9 and Resident #35 said they had not received their evening medications. Resident #56 said she did not get her medications and was crying. This Resident had a visitor who said she had been there and had not seen a nurse give medications to the Resident. A State tested Nurse Aide said Resident #9 stated he did not get his medications and it was signed off. Resident #9 said he knew he did not receive medications and she relayed this to Supervisor #31. Both of these residents had their medications signed off. Resident #9 had missing narcotics and she did not want to sign with the missing medications. The physician gave the okay to give these two residents their medications. On 04/18 at 2:51 P.M., an interview was conducted with LPN #20. LPN #20 said she was working with RN #30 on 04/07/18. The nurse said at approximately 11:00 P.M., she received a call from Supervisor #31 who asked if she could assist on the third unit as the nurse was behind in her medication pass. LPN #20 gave report to LPN #21 and went to the third unit. As she was approaching the unit, she and Supervisor #31 walked around to the unit. LPN #20 looked at the screen and noted there were spaces in the password and the caps lock was lit up. RN #30 did not appear to hear her and she squinted into the computer. RN #30 gait and balance was off. Several times she visibly corrected her alignment and appeared to fall and almost fell . Supervisor #31 phone was ringing from a resident who did not receive his medications. LPN #20 said she would bring them to him. She went through the medications and saw an order for [REDACTED].#30 asked if anyone picked them up. Supervisor #31 contacted the Director of Nursing (DON) and was given directions to obtain the extra set of keys from the emergency box and to ensure the keys worked. At that time, she tested the keys and closed the cart. LPN #20 returned and RN #30 was not on the unit. She went to Supervisor #31 and said she could not find RN #30 and she was not sure where she was. Supervisor #31 attempted to notify security. LPN #21 came and both proceeded to do a narcotic count. Several pills were missing and Supervisor #31 was notified. LPN #20 remembered the [MEDICATION NAME] of Resident #9 was missing and could not remember the other missing pills. She said RN #30 was found in the men's bathroom and Supervisor #31 went to her. On 04/18/18 at 3:27 P.M. a telephone interview was conducted with RN Supervisor #31. Supervisor #31 said she made rounds around 9:00 P.M. and RN #30 seemed fine. When she went back for a final round RN #30 did not appear to be dealing with a full deck as she appeared impaired. Supervisor #31 tried to help her log onto the system but RN #30 was unable. The narcotic drawer was locked and RN #30 could not find the keys. LPN #20 and herself assessed RN #30 and she agreed she was impaired. She contacted the Director of Nursing (DON) by phone and this was at change of shift. The keys were taken out of the emergency box. When RN #30 was at the hospital, the keys were found in her back pocket and returned to the facility. Supervisor #31 said RN #30 was not capable of passing medications. The night shift nurse counted with LPN #20 and determined there were missing medications. LPN #20 and LPN #21 said there were issues with [MEDICATION NAME] and [MEDICATION NAME]. Review of the facility's policy for Abuse Reporting and Investigation, which was last revised on 10/20/16, revealed the policy documented it was the policy of the facility that allegations of abuse be reported and thoroughly investigated, in accordance with all state and federal regulations. This deficiency substantiated Complaint Number OH 339.

Based on review of a Self Reported Incident, review of facility policy, record review, review of a video, and resident and staff interviews, the facility failed to implement their abuse policy when residents had their medications diverted by staff. This affected three Residents (#9, #35 and #56) of three sampled residents for misappropriation of medications. Findings include: 1. Record review revealed Resident #9 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #9 had physician orders [REDACTED].) by mouth four times a day. A review of Resident #9's Controlled Drug Record revealed, on 04/08/18, he received 0.5 mg. but it was not signed out. Also, on 04/08/18 there was a date without a signature or time that indicated the Resident had received the [MEDICATION NAME]. On another Controlled Drug Record sheet the count was supposed to be 30 tablets of [MEDICATION NAME]. However, upon reconciliation there were 29 tablets. One tablet of [MEDICATION NAME] 0.5 mg. was unaccounted for. Review of the packing slip from the Pharmacy, dated 04/10/18, documented the facility had replaced two tablets of [MEDICATION NAME] at their own expense. Review of nursing notes, dated 04/11/18 at 2:05 P.M., revealed, on 04/08/18, a call was placed to the Attending Physician. The resident reported he did not get his evening medications and received a new order to administer his evening medications at that time. Further review of nursing notes, dated 04/11/18 at 2:33 P.M., revealed, on 04/08/18, the resident was administered Tylenol 1000 milligrams (mg), Klonopin (anxiety) 0.5 mg, [MEDICATION NAME] (for malignant neoplasm of prostate) 0.4 mg, [MEDICATION NAME] (for unspecified myalgia and myositis) 300 mg., [MEDICATION NAME] (for [MEDICAL CONDITION] disorder) two mg., [MEDICATION NAME] ([MEDICAL CONDITION]) 150 mg., Trazadone ([MEDICAL CONDITION]) 50 mg. and [MEDICATION NAME] (sleeping aid) 30 mg. at 2:15 A.M. per one time physician order. Medications were taken without difficulty. On 04/18/18 at 4:15 P.M., an interview with Resident #9 said he was not receiving his eye drops, his digestive medications or his psychiatric pills. 2. Record review revealed Resident #35 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of physician orders [REDACTED]. Review of Resident #35's Controlled Drug Record documented one mg. of [MEDICATION NAME] was signed out but the resident stated she had not received it. Review of the packing slip from the pharmacy, dated 04/10/18, documented the facility had replaced one tablet of [MEDICATION NAME] at their own expense. Review of nursing notes, dated 04/11/18 at 1:59 P.M., documented a note for 04/08/18. A call was placed to the physician at 2:00 A.M. and notified him the resident did not receive her evening medications. A new order to given to administer evening medications at that time. The writer followed up with resident at approximately 3:00 A.M., and noted the resident was resting in bed with no complaints. Further review of the nursing notes, dated 04/11/18 at 2:29 P.M., documented a note for 04/08/18. Resident was administered [MEDICATION NAME] (insulin) 40 units, [MEDICATION NAME] (anxiety) 20 mg., Klonopin (anxiety) one mg, [MEDICATION NAME] (for leg pain), [MEDICATION NAME] (major [MEDICAL CONDITION] without psychotic features) 450 mg., [MEDICATION NAME] (depressive and [MEDICAL CONDITION] disorders), [MEDICATION NAME] V (antibiotic), Potassium (supplement) 500 mg. and [MEDICATION NAME] ([MEDICAL CONDITION] disorder) 100 mg. per one time physician order [REDACTED]. Medications were noted to be taken without difficulty. On 04/18/18 at 4:35 P.M., interview with Resident #35 stated she had received her medications in accordance with physician orders. 3. Record review revealed Resident #56 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #56's physician orders [REDACTED]. of [MEDICATION NAME] by mouth twice daily for anxiety. Review of the Controlled Drug Record revealed, on 04/08/18, Resident #56 had received one tablet of [MEDICATION NAME] on 04/08/18 but it was not signed out or timed. The Controlled Drug Record revealed, on 04/08/18, there was one tablet of [MEDICATION NAME] unaccounted for. Review of the packing slip from the pharmacy, dated 04/10/18, documented the facility had replaced one tablet of [MEDICATION NAME] at their own expense. On 04/18/18 at 4:40 P.M., interview with Resident #56 said she was receiving medications in accordance with physician order A review of the facility's Self Reported Incident (SRI) Control Number 4 revealed the date of discovery was 04/08/18 and the category was misappropriation. The alleged/suspected perpetrator (Registered Nurse #30) was facility staff or other care provider. The initial source of allegation/suspicion was staff. There were two involved Residents (#9 and #35). The facility conclusion/disposition was substantiated. The Narrative Summary of the Incident documented at approximately 11:30 P.M. on 04/07/18, Registered Nurse (RN) Supervisor #31 contacted the Director of Nursing (DON) via telephone. She stated the third floor RN #30 was acting confused, unsteady on her feet and could not locate her medication cart keys. The DON instructed the RN Supervisor #31 to collect the backup keys and count down the cart with the RN. The RN Supervisor #31 collected the keys and returned to the cart to find RN #30 was nowhere to be found. Security found RN #30 in the men's restroom on a different floor huddled over a trash can and very disoriented. The local Police Department were notified and arrived on the scene along with the squad. The DON arrived at the building and inventoried the medication cart with the RN Supervisor and found that two different narcotics (a total of four pills) were missing. RN Supervisor #31 filed a theft report with the police and the third floor RN #30 was transported to the hospital for evaluation and drug test. The third floor RN #30 was immediately suspended pending investigation. The DON and RN Supervisor #31 assessed each resident on the unit and verified that Resident #9 and Resident #35 did not receive their scheduled narcotic dose during the evening med pass. The DON contacted the Medical Director and obtained approval to administer the medications off-schedule for the Residents. The Medical Director reported to the facility on [DATE] to perform rounds with the residents on the third floor and no adverse reactions were observed. On 04/09/18, the Administrator and DON reviewed video footage from 9:00 P.M. to midnight on 04/07/18 and observed the third floor RN #30 appearing to self-administer resident medications on four different occasions between 9:39 P.M. and 11:31 P.M. The third floor RN #30 employment was terminated immediately following the review of the video footage. The suspected diversion on behalf on the third floor RN #30 had been reported to the State Board of Pharmacy and the State Board of Nursing. All four missing narcotic doses were replaced on 04/10/18 at the facility's expense. On 04/18/18 at 11:09 A.M. an interview with the Administrator and the DON verified the SRI investigation and results. The Administrator stated two residents did not receive any of their evening medications scheduled to be given around 8:30 P.M. to 9:00 P.M. The Administrator said he watched the video and said around 9:00 P.M. she was becoming unsteady on her feet and appeared to be under the influence of something Between 9:30 and 11:00 it appeared she put something from the med cart and tilted her head back to swallow. Per the video, it appeared RN #30 pulled the narcotics from the narcotic drawer to the regular medications in the cart and swallowed something. Initially the squad arrived and said they were not going to take someone to the hospital to have a drug screen. Then the DON called them for a second time and stated the nurse was impaired. On the second run, the squad took her to the hospital for assessment and drug testing. From the narcotic count and the video showed the medications did not reach the resident which was misappropriation. On 04/08/18 at 12:00 A.M. RN #30 left the shift without a narcotic count. On 04/08/18 at 3:30 A.M. the DON and LPN #21 did a medication cart audit and found four missing medications. On 04/18/18 at 11:40 A.M. the video was reviewed with the Administrator and the Director of Nursing (DON). The facility developed a timeline of the video as follows and was signed and dated 04/09/18 by the Administrator and DON.: A review of video footage review of diversion incident on 04/07/18 was conducted. On 04/09/18 the Administrator and DON reviewed security camera footage from the night of 04/07/18 from 9:00 P.M. through 12:00 A.M. The following timeline represents our observation where it appears RN #30 placed a pill (or pills) from the medication cart into her mouth followed by a drink of water from her mug to aide in swallowing: · 9:39 P.M. - RN #30 pulls her hand from drawer and places it to her mouth then tilts head back in swallowing fashion followed by a drink of water. · 9:44 P.M. - RN #30 brings medication cup to her mouth and tilts head back in swallowing fashion followed by a drink of water. · 10:41 P.M. - RN #30 brings medication cup to her mouth and tilts head back in swallowing fashion followed by a drink of water. · 11:30 P.M. - RN #30 pulls her hand from drawer and places it to her mouth then tilts head back in swallowing fashion followed by a drink of water. · 11:31 P.M. - RN #30 dumps contents of what appears to be a medication box into her hand and places items into her right jacket pocket. We observed RN #30 very unsteady on her feet throughout the footage often swaying sideways or backwards and almost falling to the ground on a couple of occasions. The unsteadiness became more prominent as time passed consistent with the presumed self-administration of non-prescribed medications. On 04/18/18 at 2:03 P.M., an interview was conducted with LPN #21. LPN #21 said she was coming on duty for the 11:00 P.M. to 7:00 A.M. When she arrived, she never saw RN #30 but the Supervisor was speaking with another nurse (LPN #20) asking her to help RN #30. LPN #20 said let me count with LPN #21 then she would help RN #30. LPN #20 and LPN #21 found missing narcotics, narcotics that were not signed out and narcotics unaccounted for. There were unsigned medications on the Medication Administration Record [REDACTED]. Resident #9 and Resident #35 said they had not received their evening medications. Resident #56 said she did not get her medications and was crying. This Resident had a visitor who said she had been there and had not seen a nurse give medications to the Resident. A State tested Nurse Aide said Resident #9 stated he did not get his medications and it was signed off. Resident #9 said he knew he did not receive medications and she relayed this to Supervisor #31. Both of these residents had their medications signed off. Resident #9 had missing narcotics and she did not want to sign with the missing medications. The physician gave the okay to give these two residents their medications. On 04/18 at 2:51 P.M., an interview was conducted with LPN #20. LPN #20 said she was working with RN #30 on 04/07/18. The nurse said at approximately 11:00 P.M., she received a call from Supervisor #31 who asked if she could assist on the third unit as the nurse was behind in her medication pass. LPN #20 gave report to LPN #21 and went to the third unit. As she was approaching the unit, she and Supervisor #31 walked around to the unit. LPN #20 looked at the screen and noted there were spaces in the password and the caps lock was lit up. RN #30 did not appear to hear her and she squinted into the computer. RN #30 gait and balance was off. Several times she visibly corrected her alignment and appeared to fall and almost fell . Supervisor #31 phone was ringing from a resident who did not receive his medications. LPN #20 said she would bring them to him. She went through the medications and saw an order for [REDACTED].#30 asked if anyone picked them up. Supervisor #31 contacted the Director of Nursing (DON) and was given directions to obtain the extra set of keys from the emergency box and to ensure the keys worked. At that time, she tested the keys and closed the cart. LPN #20 returned and RN #30 was not on the unit. She went to Supervisor #31 and said she could not find RN #30 and she was not sure where she was. Supervisor #31 attempted to notify security. LPN #21 came and both proceeded to do a narcotic count. Several pills were missing and Supervisor #31 was notified. LPN #20 remembered the [MEDICATION NAME] of Resident #9 was missing and could not remember the other missing pills. She said RN #30 was found in the men's bathroom and Supervisor #31 went to her. On 04/18/18 at 3:27 P.M. a telephone interview was conducted with RN Supervisor #31. Supervisor #31 said she made rounds around 9:00 P.M. and RN #30 seemed fine. When she went back for a final round RN #30 did not appear to be dealing with a full deck as she appeared impaired. Supervisor #31 tried to help her log onto the system but RN #30 was unable. The narcotic drawer was locked and RN #30 could not find the keys. LPN #20 and herself assessed RN #30 and she agreed she was impaired. She contacted the Director of Nursing (DON) by phone and this was at change of shift. The keys were taken out of the emergency box. When RN #30 was at the hospital, the keys were found in her back pocket and returned to the facility. Supervisor #31 said RN #30 was not capable of passing medications. The night shift nurse counted with LPN #20 and determined there were missing medications. LPN #20 and LPN #21 said there were issues with [MEDICATION NAME] and [MEDICATION NAME]. Review of the facility's policy for Abuse Reporting and Investigation, which was last revised on 10/20/16, revealed the policy documented it was the policy of the facility that allegations of abuse be reported and thoroughly investigated, in accordance with all state and federal regulations. This deficiency substantiated Complaint Number OH 339.

Based on observations and staff interviews, the facility failed to ensure staff provided a dignified dining experience while feeding Residents during meals. This affected four (#4, #18, #52, and #70) of ten residents who required assistance eating in the second floor dining room. The facility census was 80. Findings include Initial dining observation on 01/29/18 from 12:15 P.M. to 12:35 P.M. revealed State tested Nursing Assistants (STNA's) #50, #52, Registered Nurse (RN) #83, Director of Activities (DOA) #61, and the Director of Nursing (DON) were all standing while feeding Residents in the second floor dining room. Observation on 01/31/18 at 5:03 P.M. of the second floor dining room revealed Licensed Practical Nurse (LPN) #75 was standing over and feeding Resident #20 whom was seated in a wheelchair and totally dependent upon staff for eating. STNA #115 was standing over and feeding Resident #4 whom was seated in a wheelchair and totally dependent upon staff for eating. Adjustable stools were being utilized by other staff members and there weren't any available seats remaining in the dining room for LPN #75 and STNA #115 to utilize. At 5:09 P.M., Dietician #84 provided a folding chair to LPN #75 and STNA #115 whom both then sat and continued feeding Residents #4 and #20. At 5:16 P.M., LPN #70 was standing and feeding Resident #18 and STNA #122 was standing and feeding Resident #52. Both residents were seated in wheelchairs and totally dependent upon staff for eating. Interview on 02/01/18 at 11:58 A.M. with the Administrator reported staff should be seated and engaging in conversation with the residents while assisting them to eat. Interview on 02/01/18 at 3:51 P.M. with Dietician #84 reported there were numerous staff whom provided assistance to several residents in the second floor dining room and staff didn't always ensure there were enough seats available prior to starting to feed. Dietician #84 reported upon observing staff standing and feeding residents during dinner on 01/31/18, she went to another lounge on the floor and obtained chairs as the expectation was for staff to be seated and at eye level with the resident while providing assistance with eating.

Based on observation, staff interview, and review of facility policy, the facility failed to ensure residents received feeding assistance in a sanitary manner. This affected one (Resident #17) of 13 residents receiving meals in the third floor dining room. The facility census was 80. Findings include: Review of Resident #17's medical record revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #17's care plan dated 11/16/17 documented the resident had impaired movement in both shoulders and contractures in both hands. Interventions included the resident was to be fed by staff in the third floor dining room. Observations on 01/20/18 between 11:52 A.M. and 12:34 P.M., revealed State tested Nursing Assistant (STNA) #89 was wearing gloves and seated at table with Resident #17 and Resident #54. At 12:22 P.M., STNA #89 was observed to use gloved hands to grab the table edge to pull self closer to Resident #17, and then fed Resident #17 a portion of a sandwich using the gloved hands. At 12:23 P.M., STNA #89 was observed tapping and rubbing Resident #54's left arm with the gloved hands in an attempt to arouse the drowsy resident. At 12:26 P.M., STNA #89 was observed using the gloved left hand to place a portion of sweet potato onto a spoon and fed it to Resident #17. At 12:31 P.M., STNA #89 was observed to yawn onto the left gloved hand, then picked up a portion of a sandwich and fed it to Resident #17 with the gloved hands. Interview on 01/29/18 at 12:34 P.M. with STNA #89 verified gloves were worn while feeding residents to avoid touching food with bare hands. STNA #89 confirmed touching the table, touching Resident #54's arm several times, and yawning onto gloved hands during the process of feeding Resident #17. Interview on 01/31/18 at 2:31 P.M. with Registered Nurse (RN) #93 revealed staff were taught in orientation to wear gloves if there was a need to touch a resident's food, but it was not acceptable for staff to touch the table or other potentially contaminated items while feeding residents from gloved hands. Review of facility policy titled, Bare Hand Contact with Food and Use of Plastic Gloves with review date 04/11/17 documented, Single-use gloves will be worn when handling food directly with hands to assure that bacteria are not transferred from the food handlers' hands to the food product being served. Bare hand contact with food is prohibited. The policy further indicated, While using gloved hands to feed residents finger foods, staff may not touch a non-food item such as the table, resident's clothes, hair, condiment bottles, etc.

Based on observations, staff interviews, and review of facility policy, the facility failed to dispose of soiled equipment in a sanitary manner. This had the potential to effect 38 residents residing on the Third Floor. The facility census was 76. Findings include: Observation on 11/29/16 at 10:09 A.M. revealed State tested Nursing Assistant (STNA) #47 walking in the hall on the Third Floor Unit. STNA #47 was carrying incontinent pads and wipes, which appeared to be soiled with stool, and dropped a soiled wipe on the floor. STNA #47 picked up the soiled wipe and walked away, however she did not wipe the stool off the floor. Interview on 11/29/16 at 10:17 A.M. with STNA #47 verified she did drop an incontinence wipe that was soiled with stool onto the floor while transporting it to the soiled utility room unbagged. STNA #47 reported she was not aware of the procedure for transporting soiled incontinent products from resident's rooms to the soiled utility. Review of the facility policy titled Linen Handling Policy, dated 11/30/15, revealed soiled linen shall be placed in a plastic bag in the soiled linen cart or placed in a plastic bag and discarded in the linen chute. Interview on 11/30/16 at 4:58 P.M., the Administrator verified per the facility policy for disposal of soiled linens and incontinence products, items must be bagged while transporting from resident rooms to the soiled utility room.

Based on record review and staff interview, the facility failed to develop a plan of care or the attendance at a community workshop for one (#32) of one resident reviewed for preadmission screening and resident review (PASRR). The facility census was 76. Findings include: Review of Resident #32 ' s record revealed she was admitted to the facility in 2003. [DIAGNOSES REDACTED]. unspecified Intellectual disability, polyarthropathy, [MEDICAL CONDITIONS], congenital musculoskeletal deformity of spine, [MEDICAL CONDITION], scoliosis, profound hearing loss, decubitus, and microcephalus. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderate impaired cognition, impaired decision making, required extensive assistance from staff for bed mobility, transfers, locomotion, dressing, and personal hygiene. The resident required supervision for eating and was totally dependent on staff for toilet use and bathing. Review of Resident ##32 ' s preadmission assessment screening and resident review (PASRR) screen completed by the Area Agency on Aging, dated 03/03/03, indicated the resident approved for admission with level II services. Review of the resident ' s admission assessment dated [DATE] noted the resident had been living at home with family prior to admission and was attending the local disability workshop. The assessment indicated the resident would probably change workshops after admission. Review of the current plan of care revealed no care plan was developed to address the resident ' s attendance at a workshop. Interview on 11/30/16 at 10:28 A.M. Social Worker #111 verified there was no care plan to coordinate the care between the facility and the workshop Resident #32 attended.