Every finding on record at Berkeley Square Retirement Cen

Based on document review, staff interview, and policy review, the facility failed to ensure food temperatures were documented at the tray line for each meal served from the kitchenettes in the [NAME] and [NAME] Dining Rooms. This had the potential to affect all residents in the facility. The facility census was 27. Findings include:1. Review of facility document titled Trayline Taste & Temperature Log with a revised date of September 2018 revealed that tray line food temperatures were not documented for meals served from the kitchenette in the [NAME] Dining Room for dinner on 03/30/26, dinner on 03/31/26, lunch and dinner on 04/01/26, lunch and dinner on 04/02/26, dinner on 04/07/26, lunch and dinner on 04/08/26, and lunch and dinner on 04/10/26.Interview on 04/13/26 at 9:38 A.M., with the Senior Director of Culinary Services (SDCS) #224 verified the tray line food temperatures were not documented on the Trayline Taste & Temperature Log for meals served from the kitchenette in the [NAME] Dining Room for dinner on 03/30/26, dinner on 03/31/26, lunch and dinner on 04/01/26, lunch and dinner on 04/02/26, dinner on 04/07/26, lunch and dinner on 04/08/26, and lunch and dinner on 04/10/26. 2. Review of facility document titled Trayline Taste & Temperature Log with a revised date of September 2018 revealed that tray line food temperatures were not documented for meals served from the kitchenette in the [NAME] Dining Room for dinner on 04/01/26, breakfast and lunch on 04/02/26, and lunch and dinner on 04/07/26.Interview on 04/13/26 at 9:46 A.M., with the SDCS #224 verified the tray line food temperatures were not documented on the Trayline Taste & Temperature Log for meals served from the kitchenette in the [NAME] Dining Room for dinner on 04/01/26, breakfast and lunch on 04/02/26, and lunch and dinner on 04/07/26.A follow-up interview on 04/15/26 at 3:02 P.M., with the SDCS #224 revealed the revised date for the currently used document titled Trayline Taste & Temperature Log was September 2018.Review of a policy titled Food and Nutrition with an approval date of 09/07/21 revealed, The facility must store, prepare, distribute, and serve food in accordance with professional standards for food service safety.

Based on record review, interviews, and policy review the facility failed to document completion of care conferences at the required intervals. This affected two residents (#04 and #15) of 12 residents reviewed for care conferences. The facility census was 27.Findings include:1. Review of the medical record of Resident #04 revealed an initial admission date of 10/14/16 and a re-admission date of 01/31/20. Diagnoses included Parkinson's disease with dyskinesia, cognitive communication deficit, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, transient cerebral ischemic attack, type II diabetes mellitus, and major depressive disorder.Review of the most recent significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact, did not reject care, and did not wander. The resident was dependent on assistance for all Activities of Daily Living (ADL). Review of Resident #04's medical record revealed an annual MDS assessment was completed on 01/23/25, quarterly MDS assessments were completed on 04/23/25 and 05/16/25, a significant change MDS assessment was completed on 07/16/25, a quarterly MDS assessment was completed on 10/16/25, and a significant change MDS assessment was completed on 01/28/26. Further review of Resident #04's record revealed documentation of care conferences on 04/21/25 and 01/02/26. No additional care conference documentation was available in Resident #04's record.Interview on 04/14/26 at 4:18 P.M. with Unit Care Coordinator (UCC) #155 revealed no additional care conference documentation was available for the last 12 months for Resident #04. UCC #155 confirmed the only care conference documentation for the last 12 months were care conference notes dated 04/21/25 and 01/02/26. UCC #155 reported care conferences should be conducted quarterly with residents and family when possible.2. Review of the medical record of Resident #15 revealed an initial admission date of 10/24/23 and a re-admission date of 12/17/25. Diagnoses included aphasia following unspecified cerebrovascular disease, cerebral infarction, type II diabetes mellitus, unsteadiness on feet, difficulty in walking, coagulation defect, depression, and muscle weakness.Review of the most recent quarterly MDS assessment dated [DATE] revealed the resident had moderate cognitive impairment, did not reject care, and did not wander. The resident was independent for eating, setup assistance for oral hygiene, supervision assistance for upper body dressing, personal hygiene, bed mobility, sit to stand, transfers, walking ten feet, moderate assistance for toileting, bathing, lower body dressing, and mobilizing a manual wheelchair 50 feet.Further record review for Resident #15 revealed a quarterly MDS assessment dated [DATE], an annual MDS assessment dated [DATE], quarterly MDS assessments dated 10/30/25 and 01/09/26 and a quarterly MDS assessment in progress dated 04/10/26. Further record review of Resident #15 revealed a care conference was offered to Resident #15's representative on 08/16/24. It was documented that Resident #15's representative declined to attend this care conference. There was no documentation concerning care conferences in Resident #15's record for the most recent 12 months.Interview on 04/14/26 at 4:18 P.M. with UCC #155 revealed no additional care conference documentation was available for Resident #15 other than the note offering a care conference to Resident #15's representative dated 08/16/24. UCC #155 reported care conferences should be conducted quarterly with residents and family when possible.Review of policy titled Care Conference with a most recent approval date of 06/23/25 revealed the purpose of a care conference was, To review resident's comprehensive plan of care with the resident and/or significant others' participation, when possible. Further review of this policy revealed, The facility will hold periodic care conferences and involve the resident, family, and interdisciplinary team and shall be part of the care planning process.

Based on medical record review, staff interview, and facility policy review, the facility failed to ensure residents received treatment in accordance with professional standards of practice when a resident was not reevaluated for hyperglycemia. This affected one (Resident #03) of five residents reviewed for unnecessary medicine. The facility census was 27.Findings Included:Medical record review revealed Resident #03 had an admission date of 01/05/26. Diagnoses included Alzheimer's, diabetes mellitus type II, and depression Review of the current physician orders for Resident #03 included Humalog (an insulin medication to lower blood sugar) subcutaneous solution pen-injector 100 unit/milliliter (u/ml) per a sliding scale before meals, Lantus (an insulin medication to lower blood sugar) subcutaneous solution pen-injector 25 units daily, and lisinopril (a medication to treat high blood pressure) 5 milligrams (mg) by mouth once daily.Review of the Minimum Data Set assessment completed on 02/04/26 revealed Resident #03 was dependent on staff for transfers from bed to chair, requires substantial/maximal assistance with toileting hygiene, requires supervision/touch assistance with eating, and requires assistance with bathing.Review of Resident #03's progress note created on 04/15/26 at 12:19 A.M. by Registered Nurse (RN) #100 revealed the on call provider was notified of Resident #03's blood glucose level of 532 milligrams per deciliter (mg/dL) and a new order to administer eight additional units of lispro (Humalog) and to recheck the blood glucose in 30 minutes. Review of the electronic medication administration record for Resident #03 revealed a blood sugar level of 532 mg/dL obtained on 4/14/26 at 9:00 P.M. An additional eight units of lispro given on 4/14/26 at 9:21 P.M.Interview with the Director of Nursing (DON) on 4/16/26 at 8:36 A.M. verified there was no evidence in Resident #03's chart the residents blood glucose was re-evaluated after administration of additional insulin. The DON verified per facility policy concerning abnormal blood glucose, the resident should have been re-evaluated.Review of facility policy titled Abnormal Blood Glucose Procedure revised 8/24/16 revealed that signs and symptoms of hyperglycemia will be reported to the attending physician and that the nursing process step of evaluating will be included in progress note documentation.

Based on medical record review, observation, review of the medication regimen review, staff interview, and policy review, the facility failed to ensure the pharmacy recommendations from the monthly drug regimen review by a licensed pharmacist were acted upon. This effected one (Resident #08) of five residents reviewed for medication regimen review. The facility census was 27.Findings Included:Review of the medical record for Resident #08 revealed an admission date of 11/24/25. Diagnoses included Parkinson's, dementia, hypothyroidism. Review of the current physician orders included levothyroxine sodium (a hormone medication to treat the thyroid) tablet 150 microgram (mcg) once a day, buspirone hydrochloride (an antianxiety medication) 50 milligram (mg) by mouth twice a day, and losartan potassium (a medication to treat high blood pressure) tablet 100 mg by mouth once a day.Review of the Minimum Data Set assessment completed on 03/02/26 revealed Resident #08 utilized a walker and wheelchair for mobility and required setup/cleanup assistance with meals.Review of the medication regimen review for Resident #08 dated 11/25/2025 revealed the following recommendation from the consultant pharmacist: Per manufacturer, levothyroxine should be administered consistently in the morning on an empty stomach, at least 30-60 minutes before food. Further review revealed no specific physician response to the consultant pharmacist recommendation.Review of Resident #08's medication administration record for April 2026 revealed levothyroxine was to be given at 9:00 A.M.Observation on 04/16/26 at 8:03 A.M. Resident #08 was eating breakfast in dinning area. Interview on 04/16/26 at 8:28 A.M., with Licensed Practical Nurse (LPN) #150 revealed she gave Resident #08 her levothyroxine 150 mcg to her while she was in the dining area eating breakfast.Interview on 04/16/26 at 8:48 A.M., with the Director of Nursing (DON) verified there was no evidence in Resident #08's medical record as to why or why not the consultant pharmacist recommendation from 11/25/25 was acted upon.Review of facility policy titled Drug Regimen Review dated 10/01/18 revealed a consulting pharmacist shall provide monthly reviews of medications of in-house residents upon admission and monthly and the reviews are sent to nursing and are addressed with the primary care provider or consulting specialist for review and follow-up.

Based on record review, staff interview, observation, and review of the facility policy, the facility failed to follow the physician's order to treat the resident's pressure wounds and failed to routinely assess the resident's pressure wounds. This affected one (Resident #11) of three residents reviewed for pressure wounds. The facility identified eight residents with pressure ulcers. The facility census was 29. Findings include: Review of the medical record revealed Resident #11 had an admitted [DATE]. Diagnoses included chronic systolic heart failure, vertebra osteomyelitis, and Parkinson's disease. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 was cognitively impaired. Review of the skin only evaluation dated 07/29/24 revealed Resident #11 had the following skin concerns: left heel, buttocks excoriation, right buttocks medial, back excoriation, right elbow skin tear not painful, right and left lower legs discoloration, and right shin tear. There were no measurements or description of the wounds. Review of the plan of care dated 07/29/24 revealed Resident #11 was at risk for potential for skin breakdown related to bowel incontinence, catheter tubing in use, decreased mobility, previous issues with Moisture Associated Skin Damage (MASD) on right inner buttocks, stage III pressure injury (Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed) to the left heel. Deep tissue injury (purple or maroon area of discolored intact skin due to damage or underlying soft tissue) to right buttocks, yeast under right and left arm. Many refusals of care and treatment to be completed. On 08/06/24, a wound consultant assessed Resident #11's wounds and included the following pressure areas: right buttock was a deep tissue injury (DTI) and showed deterioration. Left heel stage III smaller in size. Resident #11 was discharged to the hospital on 08/11/24 and returned to the facility on [DATE]. Review of the skin only evaluation dated 08/15/24 revealed Resident #11 had wounds which included the following: left heel (DTI), right heel (DTI), right buttock (marked as open lesion), and left buttock (marked as open lesion). There were no measurements or descriptions of the wounds. Resident #11 was discharged to the hospital on 08/18/24 and returned to the facility on [DATE]. Review of the skin only evaluation dated 08/27/24 revealed Resident #11 had wounds which included the following: back had excoriation, coccyx (open area), left heel (DTI), and right heel (redness). There were no measurements or descriptions of the wounds. Resident #11 was discharged to the hospital on 09/02/24 and returned to the facility on [DATE]. Review of the skin only evaluation dated 09/03/24 revealed Resident #11 had wounds which included coccyx (open area), left heel (DTI), right heel (redness), and back (excoriation). Review of the Resident #11's wound measurements dated 09/10/24 revealed the right lateral buttocks measured 2.5 centimeter (cm) in length by 2.5 cm in width by 0.1 cm in depth, right inner buttocks measured 3.5 cm by 2.5 cm by 0.1 cm, left lateral buttocks measured 1.0 cm by 1.0 cm by 0.1 cm, and the left inner buttocks measured 1.2 cm by 0.5 cm by 0.1 cm. Review of the physician order dated 09/12/24 revealed Resident #11 had an order to clean with normal saline then apply Remedy Calazime paste 0.4-20.5% to the two open areas on the left buttocks topically daily on day shift. Cover with Optifoam gentle dressing. The order dated 09/12/24 stated to cleanse the two open areas on the right buttocks with normal saline and apply Triad Hydrophillic Wound Dress External Paste. Cover with Optifoam gentle dressing. Interview on 09/12/24 at 3:00 P.M. with the Director of Nursing (DON) verified the facility should have had wound assessments upon admission, and readmission from the hospital for Resident #11 on 07/29/24, 08/15/24, and 08/27/24. The DON verified the facility only completed skin assessments with measurements and description of the wounds for Resident #11 on 09/03/24 and 09/10/24. Observation and interview on 09/16/24 at 2:00 P.M. revealed Licensed Practical Nurse (LPN) #345 and State tested Nurse Aid (STNA) #277 provided wound care to Resident #11. LPN #345 removed Resident #11's ABD dressing to the right and left buttocks and the treatment was Hydrofero Blue (antibacterial, non-cytotoxic wound care product) dressing under the ABD dressing. LPN #345 confirmed Hydrofero Blue was not ordered for Resident #11's right and left buttocks wound treatment. Review of the facility policy titled Skin: Prevention, Detection and Treatment of Pressure Ulcers dated 08/2024 revealed to prevent pressures sores was to have early detection of potential or actual pressure ulcer sites. Assessments of pressure ulcers included type of ulcer pressure or not, the ulcer stage, ulcer's characteristics, progress toward healing or complications, presence of infection, presence and treatment of pain, and presence and type of dressing and treatment. Review of the facility policy titled Wound Treatment Protocol dated 10/2023 revealed the policy was to establish immediate treatment of non-intact skin, protocols in treating different levels of wounds, and to enhance the healing process of non-intact skin. Continue to describe the wound thoroughly included: wound bed, drainage, peri wound in the skin assessment, and document the specific area being treated in the order set upon admission. This deficiency represents non-compliance investigated under Complaint Number OH00156890.

Based on observations, staff interviews, and policy review, the facility failed to store and serve food in a sanitary manner. This affected two residents (#17 and #24) who were observed in the dining room. This had the potential to affect all 28 residents who receive food from the kitchen. The facility census was 28. Findings include: 1. Observations on [DATE] at 12:27 P.M. revealed State tested Nurse Aide (STNA) #6 picked up one half of a ham salad sandwich in her bare hand and held it up to Resident #24's mouth. STNA #6 placed her bare hand inside an individual-sized bag of cheeses puffs and placed a chip in Resident #24's hand. Observation on [DATE] at 12:31 P.M. revealed Dietary Technician #51 delivered a hamburger on a plate to Resident #17 in the dining room. STNA #6 asked Resident #17 if she wanted mustard, took the top bun off the sandwich with her bare hand, squeezed mustard on top of the hamburger patty, replaced the bun, and patted the bun down with her bare hand. STNA #6 did not sanitize her hands before she continued providing feeding assistance to both Resident #24 and Resident #17. During an interview on [DATE] at 12:39 P.M., STNA #6 verified she had touched both Residents #24's and #17's food with her bare hands. STNA #6 stated she had thought if she used hand sanitizer, it was ok to touch food with her bare hands. 2. Observation made on [DATE] at 9:14 A.M. revealed the walk-in refrigerator located in the hallway contained multiple expired eight ounce (oz) cartons of milk including: one carton chocolate milk dated [DATE], one carton 2% white milk dated [DATE], one chocolate milk dated [DATE], six cartons 2% white milk dated [DATE], and 19 cartons 2% white milk dated [DATE]. Observation made on [DATE] at 9:23 A.M. revealed the reach-in refrigerator located in the kitchen contained multiple bins of expired left over foods including one half-pan labeled chicken and rice prepared on [DATE] with a discard date of [DATE], one gallon-sized re-sealable bag of cooked hamburgers labeled prepared on [DATE] with a discard date of [DATE], one labeled quarter pan of chili prepared on [DATE] with a discard date [DATE] and one labeled plastic container with two and half quarts of black olives opened on [DATE] with a discard date of [DATE]. During an interview on [DATE] at 9:29 A.M., Dietary Staff #55 verified the reach-in refrigerator contained multiple pans of leftover foods stored beyond their discard date. Dietary Staff #55 stated leftover foods were labeled with the date they were prepared and discarded with in three to seven days depending on the food item. During an interview on [DATE] at 9:43 A.M., Line Cook #5 verified the walk-in refrigerator located in the hallway contained 28 eight ounce cartons of expired milk. Review of the facility's policy titled Food Service and Nutrition, revised [DATE], revealed the facility stored, prepared, distributed, and served food under sanitary conditions and in a manner that protected against contamination and spoilage according to food service requirements of the Ohio Administrative Code.

Based on observation, staff interview and review of facility policy, the facility failed to ensure the ice maker was free of mold. This had the potential to affect all residents residing in facility with exception of one resident (#1) whom the facility identified as not receiving food from the kitchen. The facility census was 30. Findings include; During initial observation of the kitchen on 08/08/19 at 8:15 A.M., revealed the ice maker in the main kitchen had several black areas inside the ice maker compartment. Interview with General Manager of Culinary #198 on 08/08/19 at 8:22 A.M. verified the black areas inside the main kitchen's ice maker. General Manager of Culinary #198 stated the black areas inside the ice maker were mold. Review of the facility's list of residents who don't receive food from the kitchen revealed Resident #1 did not. Review of the facility policy titled Ice Machine Maintenance and Cleaning Policy, dated 10/02/18, revealed the facility was to establish a maintenance and cleaning schedule to be certain machines are functioning properly and are clean for infection control.

Based on record review, observation, staff interview, review of facility policy, and review of the online resource, the facility failed to discard outdated resident medications. This affected Resident #3 for eye drops and had the potential to affect six residents (#8, #17, #22 , #25, #28, #85 and #86) for antacid medication. The facility census was 30. Findings include: 1. Review of record for Resident #3 revealed an admission date of [DATE] and a [DIAGNOSES REDACTED]. Review of the physician orders, dated 05/03/18, revealed an order for [REDACTED]. Review of Medication Administration Record [REDACTED]. Observation and interview on 08/07/19 at 10:23 A.M. with Licensed Practical Nurse (LPN) #242 revealed an opened bottle of artificial tear solution labeled with Resident #3's name and dated 06/25/19. The LPN confirmed that the bottle of artificial tear solution was used for Resident #3 and had been dated 06/25/19 to indicate when it had been opened. Interview with the Director of Nursing (DON) on 08/07/19 at 4:15 P.M. confirmed the artificial tear solution did not contain manufacturer instructions regarding when the medication should be discarded once opened. Review of the International Pharmacopoeia, Seventh Edition, dated (YEAR), revealed multidose ophthalmic drop preparations may be used for up to four weeks after the container is initially opened. Review of facility policy titled Storage of Medications, dated 07/25/19, revealed all multidose vials of medications are to be dated and initialed by the nurse opening the vial and indicating the date of opening. 2. Observation on 08/07/19 at 10:07 A.M. of the rehabilitation unit medication cart with LPN #238 revealed the cart contained an opened house stock bottle of [MEDICATION NAME] liquid (over the counter indigestion medication) with a manufacturer's expiration date of 07/2019. Interview with LPN #238 on 08/07/19 at 10:07 A.M. confirmed the opened bottle of house stock [MEDICATION NAME] in the rehab cart was expired and should have been discarded. Interview with the DON on 08/08/19 at 10:45 A.M. confirmed that Resident's #8, #17, #22, #25, #28, #85, #86 had orders for [MEDICATION NAME] as needed for indigestion and that expired medications should be discarded. Review of facility policy undated titled Storage of Medications revealed medications should not be kept past their expiration date and should be destroyed.

Based on observation and interview, the facility failed to ensure injectable medications were dated as to when opened and were discarded in accordance to their expiration dates. This had the potential to affect all 31 residents. Findings include: During observation of the facility's medication room refrigerator on 07/19/18 at 10:00 A.M., the following was observed: a. A Humalog Insulin Pen belonging to Resident #14 was located on a shelf in the refrigerator. The expiration date of the Insulin Pen was 06/13/18. b. A vial of Kenlog-40 (a steroid) was located on a shelf in the refrigerator. The medication expiration date was 03/18/18. c. Two opened vials of [MEDICATION NAME] Purified Protein were in the refrigerator and not dated as to when they were first opened and used. d. A vial of [MEDICAL CONDITION] in the refrigerator had an expiration date of 05/09/18. At the time of the observation the Director of Nursing verified the above items and subsequently discarded the medications.

Based on observation, staff interview and policy review, the facility failed to provide a clean and sanitary area within the kitchen. The facility identified all residents consume food from the kitchen. The facility census was 31. Findings include: 1. During the initial tour of the kitchen on 05/22/17 at 9:13 A.M., standing water was observed with food particles, corn, peas, and dirt floating on the floor beneath the water purification system and behind in the steamers. Standing water was also observed with floating debris and food particles was also observed on the floor beneath the boiling water pot container and tilt skillet. Dirt debris and a chicken nugget was also observed on the floor right of the tilt skillet on the floor lying in water. The wall behind the tilt skillet and boiler pot was observed to have food debris splattered over the wall spanning at a height of approximately five feet to the floor. Dried food particles were observed on the splatter guard of the large mixer which was not in use and had a clean bowel beneath. The splatter guard fencing had dried substance resembling dried batter hanging from the fencing and spotted on the fencing in several areas. During an interview with the general manager (GM) #900 on 05/22/17 at 9:20 A.M., confirmed the existence of dried food on the splatter guard and fencing. He also confirmed the standing water with dirt debris and food floating on the floor in the described areas. 2. During dining observations on 05/22/16 at 11:52 A.M. dining staff (DS) #200 was observed preparing ground cooked pork in a nutri-bullet container with separate blade attachment, washed the container and blade in soap and water, rinsed; reused to prepare liquefied peach yogurt, washed and rinsed and then used again to prepare liquefied cooked chicken; washed and rinsed and reused to prepare ground cooked pork. DS #200 did not sanitize the container or blade before reusing during any of the food preparation. During an interview with DS #200 on 05/22/16 at 12:20 P.M., she confirmed she did not sanitize the container and blade between uses and stated they do not have a sanitizer sink in the dining preparation area. She stated she sanitizes at the end to the meal periods by using the dishwasher. Review of policy dated 03/2010 titled Sanitation and Infection Control- Cleanliness and Sanitation- SS-1013 revealed the mixing bowl, blades, and surfaces of machine should be smooth to the touch, free of dirt, food, and grease build up. Floors should be free of debris, dirt, grease, and spills; corners and edges should be free of debris, grease, and dirt build up. Floor drains, grates, etc. should be free of dirt and grease build up. Walls should be clean, free of dirt, stains, grease, food, etc., smooth to the touch; free of dirt and grease build up at corner and floor junctions.

Based on record review, resident and staff interview and review of policy, the facility failed to resident's were provided a choice regarding bathing/showering. This affected three (#4, #34 and #40) out of three residents reviewed for choices. The facility census was 31. Findings include: 1. Medical recrod review revealed Resident #4 was admitted on [DATE]. His comprehensive assessment dated [DATE] revealed he was rarely or never understood. He was an extensive assistance for bed mobility, transfer and toliet use, supervision for locoomtion on and off the unit, and eating. He was a limited assistance for personal hygiene. Bathing he was phycial help in part with one person assistance. He was occassionally incontinent of bladder, and always continent for bowel. Medical [DIAGNOSES REDACTED]. Review of physician orders [REDACTED].#4 revealed to shower two times a week and as needed. Review of scedule for bathing for Resident #4 revealed he was sceduled on Wednesdays and Saturdays. Review of bathing sheets from 02/23/17 through 05/23/17 revealed Resident #4 had a shower on 03/11/17, on 03/18/17, on 03/22/17, on 03/30/17, on 04/10/17, on 04/17/17 and on 05/17/17. There were no other documented showers in the medical record for Resident #4. Interview with Resident #4 on 05/22/17 at 11:04 A.M. revealed he didn't appreciate not getting a shower everyday or twice a week. Resident #4 stated he did say something to the facility, but nothing was done about it. Interview with the Director of Nursing (DON) on 05/25/17 at 11:30 A.M. verified on ocassion between 02/23/17 through 05/23/17, Resident #4 did not get get two showers a week. 2. Medical record review for Resident #34 revealed she was admitted on [DATE] and currently resides in the facility. Her comprehensive assessment dated [DATE] revealed she was moderately cognitively impaired. She was an extensive assistance for actvities of daily living excpet for eating which was supervision. Her medical diagnoisis included heart failue, diabetes, Non Alzheimer's and Dementia. Review of physician orders [REDACTED].#34 revealed to Bath/Shower twice a week and as needed. Review of bathing schedule for Resdient #34 revealed Tuesdays and Fridays. Review of bathing for Resident #34 revealed from 02/23/17 through 05/23/17 the resident had a shower on 02/25/17, on 03/04/17, on 03/11/17, on 03/18/17, on 03/25/17, on 04/01/17, on 04/01/17, on 04/12/17, on 04/12/17, on 04/19/17, on 05/16/17. There were no other documented showers in the medical record for Resident #34. Interview with Resident #34 on 05/23/17 at 10:25 A.M. revealed when she first came to the facility she was getting her showers twice a week, but it seems like she is not getting as many. Interview with the Director of Nursing (DON) on 05/25/17 at 11:30 A.M. verified on ocassion between 02/23/17 through 05/23/17, Resident #34 did not get get two showers a week. 3. Medical record review for Resident #40 revealed she was admitted on [DATE] and currently resides at the facility. Her comprehensive assessment dated [DATE] revealed she was severely cognitively impaired. She was always ocntinent for bowel and bladder. Medical [DIAGNOSES REDACTED]. Review of physician orders [REDACTED].#40 revealed to Bath/Shower twice a week and as needed. Review of shower scedule for Resident #40 revealed she was scheduled on Tuesdays and Fridays. Review of bathing for Resident #40 from 02/23/17 through 05/23/17 revealed she was bathed on 03/08/17, on 03/18/17, on 03/22/17, on 03/30/17, on 04/10/17, on 04/17/17 and on 05/17/17. There were no other documented showers in the medical record for Resident #40. Interview with the Director of Nursing (DON) on 05/25/17 at 11:30 A.M. verified on ocassion between 02/23/17 through 05/23/17, Resident #4 did not get get two showers a week. Review of Bathing Policy dated 09/06/16 revealed the resident will have at least two scheduled showers/baths in a seven day period to ensure minimal hygiene was performed.

Based on observation, staff interview, and policy review, the facility failed to separate clean and soiled items in the laundry facilities to maintain infection control prevention. This affected all residents in the facility except three residents the director of nursing (DON) identified as having family wash their personal items (#76, #92 and #53). Facility census was 31. Findings include: During tour of the laundry facilities on 05/25/17 at 1:28 P.M., the laundry staff (LS) #300 was observed wearing gloves while sorting through soiled laundry on top of the dryers. She was not wearing any clothing protector. During the interview, LS #300 revealed she did not wear a gown or clothing protector while sorting soiled laundry. She also revealed that linens and isolation garments are laundered by a contracted entity outside of the facility. She explained if a resident's clothing is soiled with feces or blood that it is cleaned in the utility sink in the laundry room before laundering. The utility sink is located approximately three feet across from the dryers, clean clothing racks and mobile clothing cart used to disperse clean clothing to the residents. LS #300 recognized the areas by the dryers to be the clean area of the laundry facility and that the washers were considered the soiled area of the laundry facilities. The washers were located along the right wall entering the facility and were residential size laundry machines. A nook to the left of the washing machines contained the dryers, clean clothing racks, and counter with the utility sink. During the interview, LS #300 confirmed she had soiled clothing in three piles on top of the dryer that she was sorting. She admitted she had soiled clothing in the clean area. She also confirmed when dirty items are cleaned in the utility sink that it could be splashed on clean items hanging on the clean racks. The fixed clothing rack contained LS #300's personal jacket and two bras which were hanging to dry. Adjacent to the dryers was the portable clothing rack which contained seven blouses, five slacks, and various undergarments. LS #300 confirmed these items were clean and within the vicinity of the soiled items on the dryer. The portable clothing rack was open and did not have a cover. LS #300 confirmed when she disperses the clothing to the residents in the facility, the clean items hanging on the racks are not covered. Review of the facility policy titled, Laundry Room Protocol dated 09/01/16 revealed the purpose: to prevent the spread of infection policy. The policy further documented the washer area is considered contaminated and the dryer area is considered clean. Contaminated items must not be in proximity with clean items at any time. The sink is considered contaminated, therefore clean items must not be in proximity to the contaminated area. Laundry staff will wear personal protective equipment when handling contaminated items and clean items being delivered to resident rooms are to be covered from the laundry area to the resident's room for dispersal.

Based on medical record review, review of a facility investigation, review of self- reported incidents (SRI's), resident, staff and family interviews and review of a facility policy review, the facility failed to implement their abuse policy regarding reporting an alleged violation of abuse to the State Survey Agency. This affected one resident (#53) out of 27 residents interviewed during stage one of the annual survey. The facility identified one SRI in the past year. The facility census was 31. Findings include: Record review for Resident #53 revealed Resident #53 was admitted on [DATE] with [DIAGNOSES REDACTED]. The minimum data set 3.0 ((MDS) dated [DATE] did not identify delusions, hallucinations, physical behaviors, or other vocal or verbal calling out. The pain assessment identified the resident received routine and as needed (PRN) pain medication and nonpharmacological interventions for pain relief. The resident's mood was identified as little interest or pleasure in doing things, feeling down, depressed or hopeless, having little energy, feeling bad about herself or that she was a failure or have let herself or family down, trouble concentrating, moving or speaking slowly, thoughts that she would be better off dead or of hurting self in some way. The MDS dated [DATE] identified the resident to have a brief interview of mental status (BIMS) score of 14 out of 15. The functional status revealed Resident #53 needed extensive assist of two persons for bed mobility and transfers. The MDS did not identify Resident #53 as exhibiting abnormal behaviors. Resident #53's care plan dated 04/21/17 revealed problems identified were impaired mobility, self-care deficit and pain, alteration in comfort related to adverse effects of pain mediation, limited mobility, and [MEDICAL CONDITION]; risk for altered mood of anxiousness and sadness, adjustment issues to coping [MEDICAL CONDITION] limited physical abilities. During an interview on 05/22/17 at 11:08 A.M., Resident #53 alleged an incident of abuse. During the interview, Resident #53 described the event occurring approximately tree months ago and stated she reported this to her daughter. She stated her daughter notified the Director of Nursing (DON). She stated the State tested Nursing Assistant (STNA) was putting her to bed, grabbed her arm and was in extreme pain. She stated she told her to let go and the aide did not let go. The resident stated she could not remember if the DON or another nurse came to talk to her. Resident #53 was told the STNA would not be taking care of her any more. An interview with Resident #53's daughter on 05/22/17 at 3:36 P.M. revealed Resident #53 told her daughter of the incident and stated that the resident had told a nurse but could not remember who. The daughter confirmed she also told a nurse but could not remember which nurse. The daughter also confirmed she told the DON. She confirmed the incident occurred several months ago but could not recall the exact date. During an interview on 05/23/17 at 1:56 P.M. with the DON and Administrator, they stated their policy for abuse was for staff to report any allegations of abuse to the DON, Administrator, immediately remove the staff from the schedule and patient contact. The facility is to report to the state any allegations of abuse within 24 hours and follow up with results of an investigation. They further stated it is everyone's obligation to report anything they see or hear. The Administrator confirmed the facility had no SRI of abuse since December 2016. When asked if they recalled an incident involving a resident and an STNA grabbing a resident's arm, the DON stated she did remembered the incident. She stated the aide involved was STNA #500 and could not remember the exact date. The DON stated she investigated staff, STNA #500, the resident, and spoke with Resident #53's daughter. She stated the daughter had called her and informed her of the incident. During an interview with STNA #500, she stated after they finished with Resident #53's care they went to the nurse manager's office, (RN) #700 for her to check on Resident #53 because of her complaints of pain during care. STNA #500 further stated the DON reviewed with her how to care for Resident #53. She stated she stopped caring for resident #53 until recently when Resident #53 kept asking if she was going to help her. She confirmed she never completed a written statement of the incident. Interview with RN #700 on 05/23/17 at 4:15 P.M. revealed knowledge of facility policy for any allegation of abuse was to remove the employee from the situation and notify the administrator, no matter what type of allegation is made ., assess (the resident) depending on the type of abuse. She further confirmed documentation of the incident needed completed and then a report needed submitted in 24 hours. She further stated statements should be taken from any one that had knowledge of the incident. Staff member is on leave pending an investigation. RN #700 stated STNA #500 came to her that evening stating Resident #53 did not want STNA #500 as her aide. She questioned the resident if STNA #500 was rough with her or if she hurt her and she told her no and apologized for crying and being upset. RN #700 stated she didn't notify anyone because she didn't say she was hurt and denied that STNA #500 hurt her so I didn't report it. RN#700 was unaware of how DON became aware of the situation. Review of a handwritten investigation by the DON dated 01/09/17 was presented to survey team on 05/23/17 at 3:56 P.M. It revealed Resident #53's daughter contacted the DON regarding Resident #53's complaint of right shoulder pain following care by an STNA over the weekend. It read the daughter stated the resident told her the aide was turning her in bed and held her arm while doing so which caused arm/shoulder to hurt and asked if DON would speak to resident. The statement revealed the DON interviewed Resident #53 on 01/09/17 and wrote the resident stated the aide rolled her in bed and was rough. The DON asked the resident what rough was and the resident stated the aide was rushing and pushed on her arm during turning. Resident #53 identified STNA #500 as the aide, and stated she was a good aide and didn't want to get her in trouble. The DON asked the resident if she thought the aide meant to hurt her and stated, No. The DON interviewed STNA #500 on 01/10/17 who stated she had turned the resident and that the resident had reported her arm hurting and she told the nurse. The DON wrote that she followed up with the daughter and informed her that the aide would not be taking care of resident any longer. The Aide was also educated and instructed to slow down with care. The note also read that she interviewed the manager RN #700 who stated she also spoke with the resident after the incident that day and asked the resident if the aide was rough with her or hurt her and stated the resident said STNA #500 was just too fast. Review of Resident #53's day and night nursing assessment flow sheet dated 01/07/17-01/08/17 revealed documentation that the resident was pleasant and cooperative, no tearfulness documented. Review of the 24-hour report, used as a shift to shift report of residents' status, dated 01/07/17 from 7:00 A.M. to 7:00 P.M., 01/07/17 to 01/08/17 from 7:00 P.M. to 7:00 A.M., 01/08/17 from 7:00 A.M. to 7:00 P.M., (a report from 01/08/17 to 01/09/17 from 7:00 P.M. to 7:00 A.M. was not located by the DON), 01/09/17 from 7:00 A.M. to 7:00 P.M. were reviewed and there was no mention of any incident occurring, Resident #53 having discomfort, tearfulness or issues with Resident #53 except for the presence of a coccyx wound dressing. During an interview with the DON on 05/25/17 at 10:00 A.M., she confirmed there was no documentation in the electronic charting or in Resident #53's paper chart regarding the abuse allegation that could verify the abuse policy was followed in identifying abuse, notifying the proper personnel immediately, and that they had not reported the allegation to the Ohio Department of Health as a self-reported incident. Review of facility policy titled, Abuse, Neglect, Exploitation, Misappropriation, and Injuries of Unknown Source dated 11/28/16 reads all employees who know or suspect that a resident or client has been abused or neglected, or that a resident's property has been misappropriated, must report that knowledge or suspicion to their supervisor. The supervisor must immediately notify the Administrator, Director of Nursing or Executive Director of all allegations of abuse. In the health services or assisted living areas, the administrator or director of nursing must login and access the Enhanced Information Dissemination and Collection (EIDC) portal for the Ohio Department of Health and submit an online submission of a self-reported incident form to report any allegation of abuse, neglect exploitation, misappropriation or injury of unknown source has occurred to the Ohio Department of Health, Provider and Consumer Services Unit, immediately. Immediately reporting means as soon as possible, but not later than two hours if the events that cause the suspicion result in serious bodily injury, or not later than twenty-four hours if the events that cause the suspicion do not result in serious bodily injury after the alleged incident is discovered. After a thorough investigation is done, the Final Report of the self- reported Incident must be completed online. The final report must be completed within five working days of the incident, and if the alleged violation is verified, appropriate corrective action must be taken. Report only those incidents that meet one or more of the following criteria: there is a specific written or verbal allegation asserting that resident abuse, neglect, exploitation or misappropriation of resident property occurred. All allegations must be reported, even those unsubstantiated by our own investigation. Charting the following in the medical record: description of any bruises, skin tear, etc.; description of any incident that was observed; chart subjective resident statements and chart notifications to legal guardian or concerned family member and the resident's physician.

Based on medical record review, review of a facility investigation, review of self- reported incidents (SRI's), resident, staff and family interviews and review of a facility policy review, the facility failed to ensure an alleged violation of abuse to the State Survey Agency. This affected one resident (#53) out of 27 residents interviewed during stage one of the annual survey. The facility identified one SRI in the past year. The facility census was 31. Findings include: Record review for Resident #53 revealed Resident #53 was admitted on [DATE] with [DIAGNOSES REDACTED]. The minimum data set 3.0 ((MDS) dated [DATE] did not identify delusions, hallucinations, physical behaviors, or other vocal or verbal calling out. The pain assessment identified the resident received routine and as needed (PRN) pain medication and nonpharmacological interventions for pain relief. The resident's mood was identified as little interest or pleasure in doing things, feeling down, depressed or hopeless, having little energy, feeling bad about herself or that she was a failure or have let herself or family down, trouble concentrating, moving or speaking slowly, thoughts that she would be better off dead or of hurting self in some way. The MDS dated [DATE] identified the resident to have a brief interview of mental status (BIMS) score of 14 out of 15. The functional status revealed Resident #53 needed extensive assist of two persons for bed mobility and transfers. The MDS did not identify Resident #53 as exhibiting abnormal behaviors. Resident #53's care plan dated 04/21/17 revealed problems identified were impaired mobility, self-care deficit and pain, alteration in comfort related to adverse effects of pain mediation, limited mobility, and [MEDICAL CONDITION]; risk for altered mood of anxiousness and sadness, adjustment issues to coping [MEDICAL CONDITION] limited physical abilities. During an interview on 05/22/17 at 11:08 A.M., Resident #53 alleged an incident of abuse. During the interview, Resident #53 described the event occurring approximately tree months ago and stated she reported this to her daughter. She stated her daughter notified the Director of Nursing (DON). She stated the State tested Nursing Assistant (STNA) was putting her to bed, grabbed her arm and was in extreme pain. She stated she told her to let go and the aide did not let go. The resident stated she could not remember if the DON or another nurse came to talk to her. Resident #53 was told the STNA would not be taking care of her any more. An interview with Resident #53's daughter on 05/22/17 at 3:36 P.M. revealed Resident #53 told her daughter of the incident and stated that the resident had told a nurse but could not remember who. The daughter confirmed she also told a nurse but could not remember which nurse. The daughter also confirmed she told the DON. She confirmed the incident occurred several months ago but could not recall the exact date. During an interview on 05/23/17 at 1:56 P.M. with the DON and Administrator, they stated their policy for abuse was for staff to report any allegations of abuse to the DON, Administrator, immediately remove the staff from the schedule and patient contact. The facility is to report to the state any allegations of abuse within 24 hours and follow up with results of an investigation. They further stated it is everyone's obligation to report anything they see or hear. The Administrator confirmed the facility had no SRI of abuse since December 2016. When asked if they recalled an incident involving a resident and an STNA grabbing a resident's arm, the DON stated she did remembered the incident. She stated the aide involved was STNA #500 and could not remember the exact date. The DON stated she investigated staff, STNA #500, the resident, and spoke with Resident #53's daughter. She stated the daughter had called her and informed her of the incident. During an interview with STNA #500, she stated after they finished with Resident #53's care they went to the nurse manager's office, (RN) #700 for her to check on Resident #53 because of her complaints of pain during care. STNA #500 further stated the DON reviewed with her how to care for Resident #53. She stated she stopped caring for resident #53 until recently when Resident #53 kept asking if she was going to help her. She confirmed she never completed a written statement of the incident. Interview with RN #700 on 05/23/17 at 4:15 P.M. revealed knowledge of facility policy for any allegation of abuse was to remove the employee from the situation and notify the administrator, no matter what type of allegation is made ., assess (the resident) depending on the type of abuse. She further confirmed documentation of the incident needed completed and then a report needed submitted in 24 hours. She further stated statements should be taken from any one that had knowledge of the incident. Staff member is on leave pending an investigation. RN #700 stated STNA #500 came to her that evening stating Resident #53 did not want STNA #500 as her aide. She questioned the resident if STNA #500 was rough with her or if she hurt her and she told her no and apologized for crying and being upset. RN #700 stated she didn't notify anyone because she didn't say she was hurt and denied that STNA #500 hurt her so I didn't report it. RN#700 was unaware of how DON became aware of the situation. Review of a handwritten investigation by the DON dated 01/09/17 was presented to survey team on 05/23/17 at 3:56 P.M. It revealed Resident #53's daughter contacted the DON regarding Resident #53's complaint of right shoulder pain following care by an STNA over the weekend. It read the daughter stated the resident told her the aide was turning her in bed and held her arm while doing so which caused arm/shoulder to hurt and asked if DON would speak to resident. The statement revealed the DON interviewed Resident #53 on 01/09/17 and wrote the resident stated the aide rolled her in bed and was rough. The DON asked the resident what rough was and the resident stated the aide was rushing and pushed on her arm during turning. Resident #53 identified STNA #500 as the aide, and stated she was a good aide and didn't want to get her in trouble. The DON asked the resident if she thought the aide meant to hurt her and stated, No. The DON interviewed STNA #500 on 01/10/17 who stated she had turned the resident and that the resident had reported her arm hurting and she told the nurse. The DON wrote that she followed up with the daughter and informed her that the aide would not be taking care of resident any longer. The Aide was also educated and instructed to slow down with care. The note also read that she interviewed the manager RN #700 who stated she also spoke with the resident after the incident that day and asked the resident if the aide was rough with her or hurt her and stated the resident said STNA #500 was just too fast. Review of Resident #53's day and night nursing assessment flow sheet dated 01/07/17-01/08/17 revealed documentation that the resident was pleasant and cooperative, no tearfulness documented. Review of the 24-hour report, used as a shift to shift report of residents' status, dated 01/07/17 from 7:00 A.M. to 7:00 P.M., 01/07/17 to 01/08/17 from 7:00 P.M. to 7:00 A.M., 01/08/17 from 7:00 A.M. to 7:00 P.M., (a report from 01/08/17 to 01/09/17 from 7:00 P.M. to 7:00 A.M. was not located by the DON), 01/09/17 from 7:00 A.M. to 7:00 P.M. were reviewed and there was no mention of any incident occurring, Resident #53 having discomfort, tearfulness or issues with Resident #53 except for the presence of a coccyx wound dressing. During an interview with the DON on 05/25/17 at 10:00 A.M., she confirmed there was no documentation in the electronic charting or in Resident #53's paper chart regarding the abuse allegation that could verify the abuse policy was followed in identifying abuse, notifying the proper personnel immediately, and that they had not reported the allegation to the Ohio Department of Health as a self-reported incident. Review of facility policy titled, Abuse, Neglect, Exploitation, Misappropriation, and Injuries of Unknown Source dated 11/28/16 reads all employees who know or suspect that a resident or client has been abused or neglected, or that a resident's property has been misappropriated, must report that knowledge or suspicion to their supervisor. The supervisor must immediately notify the Administrator, Director of Nursing or Executive Director of all allegations of abuse. In the health services or assisted living areas, the administrator or director of nursing must login and access the Enhanced Information Dissemination and Collection (EIDC) portal for the Ohio Department of Health and submit an online submission of a self-reported incident form to report any allegation of abuse, neglect exploitation, misappropriation or injury of unknown source has occurred to the Ohio Department of Health, Provider and Consumer Services Unit, immediately. Immediately reporting means as soon as possible, but not later than two hours if the events that cause the suspicion result in serious bodily injury, or not later than twenty-four hours if the events that cause the suspicion do not result in serious bodily injury after the alleged incident is discovered. After a thorough investigation is done, the Final Report of the self- reported Incident must be completed online. The final report must be completed within five working days of the incident, and if the alleged violation is verified, appropriate corrective action must be taken. Report only those incidents that meet one or more of the following criteria: there is a specific written or verbal allegation asserting that resident abuse, neglect, exploitation or misappropriation of resident property occurred. All allegations must be reported, even those unsubstantiated by our own investigation. Charting the following in the medical record: description of any bruises, skin tear, etc.; description of any incident that was observed; chart subjective resident statements and chart notifications to legal guardian or concerned family member and the resident's physician.

Based on observation and staff interview, the facility failed to ensure nurse staffing information was posted. This had the potential to affect all 31 residents in the facility. Findings include: Observation conducted on 05/22/17 at 9:00 A.M. revealed the nurse staffing information was posted with the date of 05/19/17. Interview on 05/22/17 at 1:30 P.M. with Director of Nursing (DON) verified the nurse staffing information was out of date and an updated one should be posted everyday.

Based on observations, staff interviews, medical record review, review of medication administration policy, and drug manufacturer package inserts, the facility failed to maintain a medication error rate at five percent or below. Resulting in five medication errors out of thirty one opportunities. For an error rate of 16.12 % . This affected two (#20 and #160) of eight residents reviewed for medication administration. The facility census was 45. Findings include: 1. Observations made on 03/16/16 at 8:05 A.M. revealed Licensed Practical Nurse (LPN) #35 prepared [MEDICATION NAME] 5 milligrams (mg), losartan potassium 100 mg, and [MEDICATION NAME] extended release 60 mg for oral administration to Resident #160. LPN #35 placed the medications in a cup, took the cup into Resident #160's room, placed the medication cup on the bedside table next to Resident #160, and exited the room. Resident #160 did not take the medication in the presence of the nurse. Interview on 03/16/16 at 8:09 A.M. with LPN #35 upon exiting Resident #160's room reported the medication was left at the bedside for Resident #160 to take later as she was alert and oriented and would take the medication. LPN #35 reported she would return to Resident #160's room later to ensure the medication was taken. Review of undated policy titled Medication Administration revealed the nurse should always remain with the resident to observe that the medication was swallowed. 2. Observations made on 03/16/16 at 9:48 A.M. revealed LPN #42 administered [MEDICATION NAME] solution 0.2-0.5% eye drops one drop each eye for [MEDICAL CONDITION] to R #20 then proceeded to give dorzolamide HCL solution 2% one drop in each eye for [MEDICAL CONDITION] to Resident #20 at 9:50 A.M. Two minutes lapsed between eye drops. Interview on 03/16/16 at 2:13 P.M. with LPN #42, verified the eye drops were to be administered five minutes apart. LPN #42 reported she didn't actually time the exact minutes between the eye drops but estimated the time. Review of the undated manufacturer's drug packaged inserts for [MEDICATION NAME] solution and dorzolamide HCL revealed if more than one topical ophthalmic (eye) drug is being used, the drugs should be administered at least five minutes apart. .

Based on observation, staff interviews and policy review, the facility failed to provide sanitary food storage and sanitation of the pots and pans resulting in the potential for food contamination. The finding affected 42 of the 43 residents eating meals provided by the facility. Findings include: Observations during initial tour of the kitchen on 03/04/11 at 10:20 A.M. revealed two cases of milk stored on the floor in the walk-in refrigerator. Observation of the walk-in freezer revealed one case of bagels, two cases of pastries and one case of rolls stored on the floor. Observation of the dry storage area revealed four cases of food plus three cases of canned soft drinks sitting on the floor. Interview with Diet Technician #20 on 03/04/11 at 10:30 A.M. verified the cases of milk, food, and soft drinks on the floor of the walk-in refrigerator, freezer and dry storage areas noted above. Review of the policy titled "Food Storage", not dated, revealed food containers were stored at least six inches off the floor. Observations on 03/04/11 at 5:10 P.M. revealed the pot and pan sink was set up with a sanitizing solution in the third sink; however, there was no evidence of a test kit in the area. Review of the "Sanitizer Test Record" revealed a log for the sanitizer test results was recorded for breakfast, lunch and dinner. The log for March 2011 had eight meals that were blank with nothing recorded and three meals where 100 parts per million was recorded. Review of the February 2011 log revealed 16 meals that were blank and two meals where 100 parts per million was recorded. At the bottom of the "Sanitizer Test Record" there was a statement to maintain the sanitizer solution levels at 200 parts per million and to notify the Dining Services Director #1 if the sanitizer solution was above or below 200 parts per million. Interview with Diet Technician #20 on 03/04/11 at 5:10 P.M. verified the blank information eight meals in March and 16 meals in February on the "Sanitizer Test Record" documents. She also verified the recordings of 100 parts per million for three meals in March and two meals in February 2011. Interview with the Food Service Director #1 on 03/06/11 at 1:00 P.M. revealed he was informed by the staff in mid February of the low sanitizer levels and the chemical representative did correct the sanitizer problem. He also called the chemical representative on the morning of 03/04/11 and he was able to correct the problem at that time. Review of the policy titled Colonial Policy and Procedure for Monitoring Sanitizer Solution", dated 10/05/05, revealed the sanitizer level of the sink was tested at each meal and recorded on the Sanitizer Test Record. The level should be maintained at 200 parts per million.

Based on clinical record review and staff interview, the facility failed to provide care plans related to psychoactive medications that addressed the specific behaviors displayed by six (#1, #4, #6, #41, #7 and #16) of eleven sampled residents. In addition, the care plans did not provide individualized interventions related to the use of the psychoactive medications. The census was 43 at the time of the survey. Findings include: 1. Review of the medical record for Resident #1 stated an admitted 01//15/11, from the Admission Record. Review of the [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment, dated 01/21/11, assessed the resident to be cognitively intact, no mood or behaviors indicated, and assessed to receive an antidepressant and an hypnotic. Review of the physician's orders [REDACTED]. The interventions included to inform the responsible party of the benefits and risks and possible side effects of each psychoactive medication, administer the medication as per the physician's orders [REDACTED]. The care plan did not have individualized interventions. On 03/06/11 at 1:00 P.M. the Director of Nursing (DON) was interviewed. She affirmed there were specific for problems for the resident noted on the Care Plan for Psychoactive medications, and the interventions were not individualized for the resident. 2. Review of the medical record for Resident #6 stated an admitted 01//04/11, from the Admission Record. Review of the [DIAGNOSES REDACTED]. assessment period. She was assessed to receive an anti-anxiety medication. Review of the physician's orders [REDACTED]. Review of the Care Plan for Psychoactive medications stated the problem as psychoactive medications and was not specific for the problem. The interventions included to inform the responsible party of the benefits and risks and possible side effects of each psychoactive medication, administer the medication as per the physician's orders [REDACTED]. The care plan did not have individualized interventions. On 03/06/11 at 1:00 P.M. DON was interviewed. She affirmed there were specific for problems for the resident noted on the Care Plan for Psychoactive medications, and the interventions were not individualized for the resident. 3. Review of the medical record for Resident #7 stated an admission date of [DATE], from the Admission Record. Review of the [DIAGNOSES REDACTED]. The MDS assessment, dated 02/23/11, assessed the resident to be cognitively intact. He was assessed to have pain frequently at a level 6 on a pain scale of zero to 10, with ten being the worst pain. Review of the physician's orders [REDACTED]. The interventions included to inform the responsible party of the benefits and risks and possible side effects of each psychoactive medication, administer the medication as per the physician's orders [REDACTED]. The care plan did not have individualized interventions. On 03/06/11 at 1:00 P.M. the DON was interviewed. She affirmed there were specific for problems for the resident noted on the Care Plan for Psychoactive medications, and the interventions were not individualized for the resident. 4. Review of the medical record for Resident #41 stated an admission date of [DATE], from the Admission Record. Review of the [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment, dated 01/21/11, assessed the resident to be severely impaired for cognition, in mood area he had trouble with sleeping, poor appetite, trouble concentrating, stated life was not worth living, wishes for death,and was short tempered and easily annoyed. Behaviors indicated he rejected care up to three times a week. He was assessed to receive an anti-psychotic, and anti-anxiety an antidepressant, and an hypnotic. Review of the physician's orders [REDACTED]. Review of the Care Plan for Psychoactive medications stated the problem as psychoactive medications and was not specific for the problem. The interventions included to inform the responsible party of the benefits and risks and possible side effects of each psychoactive medication, administer the medication as per the physician's orders [REDACTED]. The care plan did not have individualized interventions. On 03/06/11 at 1:00 P.M. the DON was interviewed. She affirmed there were specific for problems for the resident noted on the Care Plan for Psychoactive medications, and the interventions were not individualized for the resident. 5. Review of the medical record for Resident #4 stated an admission date of [DATE], from the Admission Record. Review of the [DIAGNOSES REDACTED]. She was assessed to receive an hypnotic. Review of the physician's orders [REDACTED]. The interventions included to inform the responsible party of the benefits and risks and possible side effects of each psychoactive medication, administer the medication as per the physician's orders [REDACTED]. The care plan did not have individualized interventions. On 03/06/11 at 1:00 P.M. the DON was interviewed. She affirmed there were specific for problems for the resident noted on the Care Plan for Psychoactive medications, and the interventions were not individualized for the resident. 6. Review of the clinical record for Resident #16 revealed he was admitted to the facility on [DATE] and was [AGE] years old. His [DIAGNOSES REDACTED]. The resident had a physician's orders [REDACTED]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the care plan, dated 02/24/11, for psychoactive medications revealed under the problem area it stated "[MEDICATION NAME]" and no additional information to describe the behaviors the resident displayed to justify the reason was receiving the psychoactive medication. There was no evidence the interventions were individualized for Resident #16's behaviors. Interview with the DON on 03/06/11 at 1:00 P.M. verified Resident #16's care plan was not specific in addressing the behaviors the resident displayed related to the use of the psychoactive medication. She verified the interventions were not individualized for Resident #16.

Based on observations, staff interview, and review of the facility policy the facility failed to ensure the signs indicating that residents had oxygen and no smoking was permitted. This affected four residents (#8 #27, #39, and #40) of the nine residents the facility identified as utilizing oxygen concentrators in their rooms. The facility census was 43. Findings included: Observations were made on 03/04/11 at 11:45 P.M. with the Maintenance Man #33. The observations revealed oxygen concentrators in rooms of Residents # 8, #27, and #39. Resident #39 had a roommate #40. There were no signs near the doors indicating the oxygen concentrators were in use in the rooms and no smoking was permitted. On 03/04/11 at 11:45 A.M. Maintenance Man #33 was interviewed. He verified residents #8, #27, #39 and #40 had oxygen concentrators in use in their rooms and did not have a no smoking sign near the doors. The policy for "Oxygen Notification", dated 03/11, was reviewed. The policy stated notice of oxygen in a room was posted on the room door.

Based on clinical record review, staff interview, and review of the facility policy for pain management and psychoactive medications, the facility failed to implement non pharmacological interventions and failed to complete pain assessments prior to the administration of pain medication, and failed to ensure justification for the administration of psychoactive medications. This affected five residents (#1, #6, #7, #16 and #41) of 11 sampled . The facility census was 43. Findings include: 1. Review of the medical record for Resident #1 stated an admitted 01//15/11, from the Admission Record. Review of the Diagnosis List, and physicians' orders, included diagnoses of ankle injury, [MEDICAL CONDITION], and arthritis. The Minimum Data Set (MDS) assessment, dated 01/21/11, assessed the resident to be cognitively intact, no mood or behaviors indicated, and assessed to receive an antidepressant and an hypnotic. She was assessed to have pain frequently at a level 7 on a pain scale of zero to 10, with ten being the worst pain. Review of the Physician's Ordered dated 03/11, included an order for [REDACTED]. Review of the Care Plan for Altered Mood State included interventions to attempt to identify situational cause for the mood indicator and help correct if possible, eating meals in the common area or dining room with others, encourage expression of emotions, encourage out of bed and activities daily. Review of the Care Plan for Pain included to observe for effectiveness of interventions and record, assess for the cause of the pain and try to eliminate it if possible, reposition for comfort, and monitor for the effectiveness of the medication. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. In 02/11 the resident received 3 doses of the pain medication. Between 03/01/11 and 03/05/11 the resident received seven doses of the pain medication. Review of the reverse side of the MAR for 01/11, 02/11, and 03/11 revealed the nurses documented the time the pain medication was administered, the reason, the effectiveness and time effectiveness was noted. There was no documentation of the residents pain level, and any non-pharmacological interventions attempted prior to the administration of the pain medication. Review of the medical record revealed it was silent for a [DIAGNOSES REDACTED]. Review of the medical record revealed the resident was not consistently assessed prior to the administration of pain medication, non-pharmacological interventions were consistently documented prior to the administration of the pain medication. On 03/06/11 at 8:00 A.M. the Director of Nursing (DON) was interviewed. She affirmed there was no [DIAGNOSES REDACTED]. She affirmed there was no pain flow record for the pain medication monitoring. The facility utilized a Nursing Assessment Flow Sheet which was completed every shift for the skilled residents and weekly for the non-skilled residents. She affirmed the nurses did not document every time a pain medication was administered. She stated it was her expectation the nurses attempted a non-pharmacological intervention prior to the administration of a pain medication. The DON stated it was not her expectation the nurses documented the assessment and the attempts of a non-pharmacological interventions. 2. Review of the medical record for Resident #6 stated an admitted 01//04/11, from the Admission Record. Review of the Diagnosis List, and physicians' orders, included diagnoses of anxiety, [MEDICAL CONDITION], and arthritis. The MDS assessment, dated 01/11/11, assessed the resident to be cognitively intact, the mood assessment area indicated, she had little pleasure or interest in doing things had a poor appetite, nearly everyday, of the 14 days of the assessment period, had little energy, was tired several days during the assessment period, and felt bad about herself, seven to 11 days of the 14 days of the assessment period. She was assessed to receive an anti-anxiety medication. She was assessed to have pain frequently at a level 3 on a pain scale of zero to 10, with ten being the worst pain. Review of the Physician's Ordered dated 03/11, included an order for [REDACTED]. The Pain Assessment, dated 01/04/11, assessed the resident to have pain at a level three on a zero to 10 scale. The relieving factors included rest. Review of the Care Plan for Psychoactive Medications, included interventions to monitor for adverse affects, evaluate the necessarily of the medication upon initiation. Review of the Care Plan for Pain included to observe for effectiveness of interventions and record, assess for the cause of the pain and try to eliminate it if possible, reposition for comfort, and monitor for the effectiveness of the medication. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Between 03/01/11 and 03/05/11 the resident received nine doses of the pain medication. Review of the reverse side of the MAR for 01/11, 02/11, and 03/11 revealed the nurses documented the time the pain medication was administered, the reason, the effectiveness and time effectiveness was noted, and on four entries the pain level. There was not consistent documentation of the residents pain level, and any non-pharmacological interventions attempted prior to the administration of the pain medication. Review of the medical record revealed it was silent for a the monitoring of the [MEDICATION NAME] (anti-anxiety medication) for the month of 02/11. Review of the medical record revealed the resident was not consistently assessed prior to the administration of pain medication, non-pharmacological interventions were consistently documented prior to the administration of the pain medication. On 03/06/11 at 8:00 A.M. the DON was interviewed. She stated there was no monitoring for the routine antidepressant medication. She affirmed there was no pain flow record for the pain medication monitoring. The facility utilized a Nursing Assessment Flow Sheet which was completed every shift for the skilled residents and weekly for the non-skilled residents. She affirmed the nurses did not document every time a pain medication was administered. She stated it was her expectation the nurses attempted a non-pharmacological intervention prior to the administration of a pain medication. 3. Review of the medical record for Resident #7 stated an admission date of [DATE], from the Admission Record. Review of the Diagnosis List, and Physician's orders, included diagnoses of right [MEDICAL CONDITION], and [MEDICAL CONDITION]. The Minimum Data Set (MDS) assessment, dated 02/23/11, assessed the resident to be cognitively intact. He was assessed to have pain frequently at a level 6 on a pain scale of zero to 10, with ten being the worst pain. Review of the Physician's Ordered dated 03/11, included an order for [REDACTED]. The Pain Assessment, dated 02/25/11, assessed the resident to have pain at a level five on a zero to 10 scale. Review of the Care Plan for Pain included to observe for effectiveness of interventions and record, assess for the cause of the pain and try to eliminate it if possible, reposition for comfort, and monitor for the effectiveness of the medication. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Between 03/01/11 and 03/05/11 the resident received 12 doses of the pain medication. Review of the reverse side of the MAR for 02/11, and 03/11 revealed the nurses documented the time the pain medication was administered, the reason, the effectiveness, inconsistently the pain level, and time effectiveness was noted. There was no documentation of any non-pharmacological interventions were attempted prior to the administration of the pain medication. Review of the medical record revealed the resident was not consistently assessed prior to the administration of pain medication, non-pharmacological interventions were consistently documented prior to the administration of the pain medication. On 03/06/11 at 8:00 A.M. the DON was interviewed. She affirmed there was no pain flow record for the pain medication monitoring. The facility utilized a Nursing Assessment Flow Sheet which was completed every shift for the skilled residents and weekly for the non-skilled residents. She affirmed the nurses did not document every time a pain medication was administered. She stated it was her expectation the nurses attempted a non-pharmacological intervention prior to the administration of a pain medication. 4. Review of the medical record for Resident #41 stated an admission date of [DATE], from the Admission Record. Review of the Diagnosis List, and physician's orders, included diagnoses of manic [MEDICAL CONDITION], anxiety, [MEDICAL CONDITION], and [MEDICAL CONDITION]. The MDS assessment, dated 01/21/11, assessed the resident to be severely impaired for cognition, in mood area he had trouble with sleeping, poor appetite, trouble concentrating, stated life was not worth living, wishes for death,and was short tempered and easily annoyed. Behaviors indicated he rejected care up to three times a week. He was assessed to receive an anti-psychotic, and anti-anxiety an antidepressant, and an hypnotic. Review of the Physician's Ordered dated 03/11, included an order for [REDACTED]. Review of the Care Plan for Altered Thought Process, [MEDICAL CONDITION], Psychoactive medications included interventions provide simple clear explanations of all care, approach calmly, establish a consistent daily routine, avoid radical change, attempt to identify cause for the sleeplessness and help to eliminate or reduce as possible, encourage calm environment, offer back rubs, turning /reposition snacks, fluids, assist with toileting, reduce environmental stimuli, record the number of episodes , interventions used the effectiveness of the interventions, and prescience of adverse effects of medications on the behavior flow record. Administer the medications as ordered by the physician Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the Behavior / Intervention Monthly Flow Record The record was inconsistent for non-pharmacological intervention, and behaviors that warranted the use for the psychoactive medications. On 03/06/11 at 8:00 A.M. the DON was interviewed. She stated there was no monitoring for the routine psychoactive medications. for the months of 01/11, 02/11, and 03/11 and for the month of 01/11 the monitoring was inconsistent of the as needed psychoactive medications. 5. Review of the clinical record for Resident #16 revealed he was admitted to the facility on [DATE]. His diagnoses included dementia, chest pain, hypertension, [MEDICAL CONDITION] with a history of [MEDICAL CONDITION] and anxiety. The resident had a physician's order for a narcotic medication (Vicoden) at 5/500 milligrams every six hours as needed from admission. On 03/04/11, the physician's order for this narcotic was changed to a scheduled dose at 5/500 milligrams every six hours. Review of the documentation records for the narcotic pain medication revealed no evidence of the pain level or non pharmacological interventions attempted prior to administering the narcotic pain medication ten times in February and ten times in March 2011. Interview with Licensed Practical Nurse #100 on 03/05/11 at 3:30 P.M. verified Resident #16's documentation records for the narcotic pain medication revealed no evidence of the pain level or non pharmacological interventions attempted prior to administering the narcotic pain medication ten times in February and ten times in March 2011. Review of the policy titled "Psychoactive Medication Policy", dated 03/11, revealed all residents who receive a psychoactive medication must have a [DIAGNOSES REDACTED]. Patients who receive as needed medications for depression, anti-anxiety, anti-psychotic, and hypnotic medications were assessed for cause of behavior and non- pharmacological interventions were attempted prior to administering the medication. Review of the policy titled "Pain Management Policy", dated 06/09, revealed a pain scale from zero to ten was used to assess the intensity of pain and included the corresponding facial expressions. Residents were offered non-pharmacological interventions such as position change, temperature adjustment, or a back rub prior to the administration of the narcotic.