Every finding on record at Briarwood Village

Based on review of resident council meeting minutes and staff interview, the facility failed to respond to resident concerns addressed in resident council meetings. This affected two residents (#242 and #249) of four residents reviewed for Resident Council. The facility census was 95.1.Review of the Resident Council Meeting Minutes (RCMM) dated 07/01/25 revealed concerns with the dietary department. Further review revealed there was no evidence of action taken to address residents' concerns. Interview on 09/15/25 at 12:12 P.M. with the Administrator verified she was unable to locate evidence of staff action taken in response to concerns brought up by residents during the August 2025 Resident Council Meeting (RCM). 2. Review of the RCMM for 08/05/25 revealed residents' voiced concerns of receiving their medications late on the weekends due to nurse helping the aides. Nurses were sitting medications at bed side and leaving. Also, residents voiced concerns of sheets not fitting bigger sized beds. 2. Review of 08/05/25 RCMM revealed on the weekends residents were getting their medications late due to nurses helping aides and nurses just sitting medications on bed side table and leaving. Sheets are not fitting the bigger size beds.Further review revealed there was no evidence of action taken to address residents' concerns. Review of the Resident Council Response Form revealed more blue sheets for larger beds were put on on 08/14/25. Interviews on 09/15/25 at 10:00 A.M. with Resident #242 and Resident #249 revealed both ladies attend resident council meetings on a regular basis and verbalized multiple items have been brought up each month with no action.Interview on 09/15/25 at 12:12 P.M. with the Administrator verified she was unable to locate evidence of staff action taken in response to concerns brought up by residents during the September 2025 RCM. This deficiency represents non-compliance investigated under Complaint Number 2595568.

Based on medical record review, resident interviews, and staff interviews, the facility failed to complete residents' showers as scheduled. This affected three residents (#249, #242, and #212) of three residents reviewed for showers. The census was 951.Review of the medical record for Resident #249 revealed an admission date of 03/06/23 with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD).Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #249 a Brief Interview for Mental Status (BIMS) score of eight, indicating impaired cognition. He required set-up or clean up assistance for Activities of Daily Living (ADLs).Review of Resident #249's shower sheets for the past 14 days revealed the following: 09/02/25 not applicable, 09/05/25 no shower given, 09/25/25 shower given, and 09/12/25 not applicable. Further review revealed Resident #249's scheduled shower days were Tuesdays and Fridays. Interview on 09/15/25 at 10:00 A.M. with Resident #249 revealed the resident needs help with her bathing and toileting. Resident #249 states she goes a long time without a shower because staff do not have enough time to help her.2. Review of the medical record for Resident #242 revealed an admission date of 12/26/23. Diagnoses included CPOS and respiratory failure with hypoxia. Review of the MDS assessment dated [DATE] revealed the resident had a BIMS score of 15, indicating intact cognition. The resident required moderate assistance with ADLs. Review of Resident #242's shower sheets for the past 14 days revealed the following: On 09/02/24, 09/09/25, and 09/12/25, the resident received a shower. On 09/05/25, the resident did not receive a shower. Resident #242's scheduled showers days were Tuesdays and Fridays. Interview on 09/15/25 at 10:00 A.M. with Resident #242 revealed the resident did not know when her shower days were and did not feel she was getting regular showers. Resident #242 voiced she did not feel she received an appropriate amount of showers.3. Review of the medical record for Resident #212 revealed an admission date of 08/16/25. Diagnoses included respiratory failure and hallucinations. Review of the MDS assessment dated [DATE] revealed a BIMS score of 13, indicating slight cognitive impairment. Resident #212 required moderate assistance with ADLs. Review of Resident #212's shower sheets for the past 14 days revealed the following: 09/04/25 the resident returned from the hospital, and 09/07/25 no shower given. Resident #212's scheduled shower days were Thursdays and Sundays. Interview on 09/15/25 at 10:44 A.M. with Resident #212's Family Member (FM) revealed family does not believe Resident #212 is receiving her showers. Observation at the time of the interview revealed Resident #212's hair appeared greasy. Interview on 09/15/25 at 3:20 P.M. with the Executive Director verified Residents #249, #242, and #212 were not receiving showers as scheduled.

Based on observation, medical review, staff interview, and review of a facility policy, the facility failed to follow infection control procedures for a resident positive with COVID-19. This affected one (Resident #249) of one resident reviewed for COVID-19 precautions. The facility census was 62.Review of the medical record for Resident #249 revealed an admission date of 03/06/23. The resident was admitted with diagnosis of COVID-19.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of eight, indicating moderately impaired cognition. This resident was assessed to require set or clean-up assistance for bathing, dressing, and toileting.Review of the progress note dated 09/09/25 revealed Resident #249 tested positive for COVID-19 and was placed in droplet isolation for ten days. Observation on 09/15/25 at 10:00 A.M. Resident #249 and Resident #242 were talking by Resident #242's doorway. Resident #242 was standing just outside of Resident #249's door talking with no mask on. This surveyor approached and introduced self and started a conversation. During conversation, the surveyor noticed personal protective equipment (PPE) in the hallway to the left of Resident #249's door along with dirty gowns in a laundry basket, dirty gowns on the floor, and leftover breakfast items (Styrofoam plate, plastic fork and spoon, Styrofoam bowl, and a regular coffee cup) on top of dirty laundry basket. No isolation signage was posted. Resident #242 stated Resident #249 was diagnosed with COVID-19 and is in isolation. Resident #249 states other residents are not allowed in her room or dining room but Resident #249 is allowed to stand at the doorway and visit her friends all she wants.Interview on 09/15/25 at 10:19 A.M. with Dietary Aide (DA) #515 verified Resident #249's door was open with Resident #242 standing outside her door, used breakfast items from Resident #249 were placed in the hallway on top of dirty linen container with used gown, and no isolation signs were in place.Interview on 09/15/25 at 10:25 A.M. with Register Nurse (RN) #40 revealed Resident #249 was diagnosed with COVID-19 and was placed on droplet isolation on 09/09/25. RN #40 confirmed no droplet isolation sign, dirty linen in hallway, Resident #249 door open and Resident #249 visits with friends at her doorway. RN #40 verbalized Resident #249 should be in her room with the door closed but no one follows the rules.Review of facility policy, dated 05/11/23, titled, PPE and Isolation Protocol, revealed the door is to remain closed, isolation signs placed entering and exiting room.Review of facility undated COVID-19 entry sign revealed staff is to wear N95 face mask, face shield, gown, and gloves at all times when entering.

Based on observation, medical record review, staff interview, review of facility investigation, physician interview, review of bed user service manual, and policy review, the facility failed to ensure Resident #01 was provided adequate supervision during the provision of activities of daily living. Resident #01 was cognitively impaired, and dependent on staff for transfer and bed mobility with bilateral lower extremity contractures. This resulted in Immediate Jeopardy, actual harm and death beginning on [DATE] at 10:11 A.M. when two Certified Nurse Aides (CNA) directed attention away from Resident #01, who was lying in bed on her left side with the bed elevated. Resident #01 rolled from the elevated bed and fell to the floor, sustaining a laceration to the scalp requiring six staples, acute odontoid process fracture (second cervical vertebra [C2] in the neck) and closed displaced fracture of first cervical vertebra (C1 in the neck). On [DATE] Resident #01 expired as a result of the injuries sustained at the time of the fall from bed. This affected one (Resident #01) of three residents reviewed for accidents and supervision. On [DATE] at 3:00 P.M., the Administrator, Director of Nursing (DON), Executive Director (ED) #34, and Clinical Corporate Support Registered Nurse (CCSRN) #55 were notified Immediate Jeopardy began on [DATE] at 10:11 A.M. when CNAs #61 and #89 directed attention away from Resident #01, allowing the resident to be unsupervised in an elevated bed. Resident #01 was dependent on staff to roll side to side in bed, and for bed mobility, and transfers. Resident #01 had bilateral lower extremity contractures, and her legs were fixed in the flexed position (pulled up toward the torso). CNA #61 left the left side of the bed to obtain a lift sling located approximately three feet from the foot of the bed and CNA #89 left the right side of the bedside and proceeded to the left side of the bed to remove a trash bag from a trash can, directing attention away from the resident. CNAs #61 and #89 heard a scream and turned around to see Resident #01 rolling off the bed. CNA #89 ran and attempted to catch Resident #01 however, CNA #89 was unable to reach Resident #01 before she hit the floor. Resident #01 was subsequently transported to the hospital and was treated for six staples to the laceration to the head and discovered with two cervical (neck) fractures which required surgical intervention. Resident #01 and responsible party declined further treatment, and Resident #01 returned to the facility for palliative care. Resident #01 expired on [DATE] due to her injuries. Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective action: On [DATE], at 10:40 A.M., Registered Nurse (RN) #83 assessed Resident #01 and contacted emergency medical services. Resident #01was transported to the hospital for evaluation. Resident #01 returned to the facility from the hospital on the same day ([DATE]) at 4:50 P.M. and the plan of care was revised to include floor mats to side of bed as the resident reported that she tried to get out of bed when she fell and hit the floor. On [DATE], Resident #01 expired in the facility. On [DATE], the DON began educating all nursing staff on the facility policies regarding fall prevention, including the Fall Reduction Policy, care of residents at bed side, completion of fall documentation and assessments post fall. All 46 licensed nurses and CNAs were educated by [DATE]. On [DATE], the SDC #95, Physical Therapy Assistant (PTA) #109 and CNA #106 completed competencies for all 46 licensed nurses and CNAs nursing staff regarding bed mobility, turning and repositioning and safely caring for residents in bed. On [DATE], the DON, Regional Nurse #103, Staff Development Coordinator (SDC) #95 and Case Manager #97 audited all residents who had falls within the past 30 days to ensure appropriate investigation and fall interventions in place in room and on care plan. On [DATE], SDC #95 and DON reeducated all 46 licensed nurses and CNAs to ensure adequate supervision in accordance with the resident's plan of care is provided during the provision of resident activities of daily living (ADL). Staff not educated by [DATE] will not be permitted to work until education completed. On [DATE], Regional Nurse #103, DON and Minimum Data Set (MDS) Nurse #114 completed care plan audits on all 43 residents who were totally staff dependent for all ADL care while in bed to ensure all fall risk assessments were up to date and to ensure care plans accurately reflect assessment and fall risk interventions. On [DATE], an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was conducted with Interdisciplinary Team (IDT) which included ED #34, Administrator, Human Resources Manager #115, MDS Nurse #114, Restorative Nurse #117, DON, and Medical Director #130 to discuss the incident and follow-up interventions in response to corrective actions that the facility needed to complete to keep their residents safe in the future. On [DATE], Regional Director of Operations #135 and Regional Nurse #103 educated ED #34, Administrator and DON on the need to ensure that investigations of falls are thorough. Beginning [DATE], the DON or designee will conduct daily observations of three residents receiving ADL care (e.g., bedside care, transfers, toileting, etc.) to ensure that supervision is being provided during the activity in accordance with the plan of care and resident needs. The audits will be completed daily for two weeks on varying shifts, and three days a week on varying shifts for four weeks. Although the Immediate Jeopardy was removed, the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in process of implementing their corrective action plan and monitoring to ensure on-going compliance.Findings include: Review of the medical record revealed Resident #01 was admitted to the facility on [DATE]. Diagnoses included cerebral ischemia, anxiety disorder, and cardiomegaly. Review of the nursing plan of care, dated [DATE], revealed Resident #01 was at risk for falls related to decreased mobility, use of psychoactive medications, and incontinence. Interventions included anticipating and meeting Resident #01's needs, Resident #01 needs a safe environment with bed in low position at night, and personal items in reach. Review of the physician orders, dated [DATE], revealed an order for the use of a mechanical lift (Hoyer) for all transfers and a low air loss mattress placed to bed. There was no documentation in the medical record that Resident #01 was assessed for proper use of the bed or mattress. Review of the fall risk assessment dated [DATE] revealed Resident #01 was at a fall risk. Review of the annual Minimum Data Set (MDS) assessment, dated [DATE], revealed Resident #01 was cognitively impaired and was dependent on staff for rolling side to side, bed mobility, and transfers. Resident #01 was always incontinent with bowel and bladder and did not have any falls during the review period. Resident #01 had lower leg contractures. Resident #01 was often non-compliant with care and frequently refused. Review of the progress note documented as a late entry on [DATE] at 10:11 A.M. revealed Licensed Practical Nurse (LPN) #69 heard CNA #61 yell out from Resident #01's room. Resident #01 was on the floor, on her left side beside her bed. Resident #01 was holding her head, and a pool of blood was on the floor. Resident #01 was moving around and was visibly upset about getting blood into her hair. LPN #69 looked at Resident #01's head and observed a laceration and called for Registered Nurse (RN) #83 to assess the resident. As RN #83 came into the room, LPN #69 contacted Physician Assistant (PA) #22 to obtain order to send the resident out to the emergency room (ER). LPN #69 called 911 and contacted the local hospital emergency room to provide report. LPN #69 met one squad member before returning to Resident #01's room. Upon her return to the room, Resident #01 was up in the wheelchair and the laceration had stopped bleeding. Resident #01 was taken to the local hospital for evaluation. This note was created as a late entry on [DATE] at 10:54 A.M. Review of the progress note dated [DATE] at 10:15 A.M., written by RN #83, revealed two CNAs (#61 and #89) had been assisting Resident #01 with incontinence care. Both CNAs had turned away from the bed to gather trash and the wheelchair when Resident #01 became upset and rolled herself from the bed, yelling as she fell. The two CNAs yelled for the nurse, who responded immediately, and then alerted RN #200. Resident #01 was contracted and transferred using a mechanical lift. Upon the nurse's arrival at the bedside, Resident #01 was lying on her left side with blood around her head. A laceration was noted to the left top side of head and a skin tear to the left elbow. Vital signs were stable, and Physician Assistant (PA) #22 was notified and ordered Resident #01 to be sent to the hospital for evaluation. Resident #01's daughter was also contacted. Review of the hospital note dated [DATE] at 10:59 A.M. revealed Resident #01 stated she was trying to get off the bed when she fell and hit the floor. Resident #01 reported hitting the top of her head without loss of consciousness. She complains of laceration and pain to the top of head and posterior neck. Assessment identified a four plus centimeter (cm) laceration that was subcutaneous on top of the head. Procedures included six staples placed to approximate the head wound edges. The computerized tomography (CT) results dated [DATE] revealed a closed displaced fracture of first cervical vertebra, closed odontoid fracture with type II morphology and posterior displacement. Follow-up recommendation was to assess cord compression. Physician consultation with Resident #01 and the responsible party requested no further treatment and hospice services would be obtained. Resident #01's responsible party refused higher level of care for evaluation for the cervical spine fractures. Resident #01 and responsible party understood the adverse outcomes including paralysis and cord injury. Resident #01 will be discharged back to the facility with hospice care. Resident #01 returned to the facility on [DATE] and was admitted under hospice care as discussed between the hospital physician and hospice physician due to cervical spine fractures. Resident #01 was non-compliant with wearing the c-collar. Resident #01's daughter took off the c-collar because the resident didn't want to wear it. Resident #01 expired in the facility on [DATE]. Review of incident report dated [DATE] noted Resident #01 rolled out of bed during check and change during agitated behavior towards staff. Review of the facility's investigation into the fall revealed Resident #01 was oriented to person, place and time. A note documented Resident #01 rolled out of bed during check and change and displayed agitated behavior towards staff. The facility identified the root cause was accidental and completed education on transferring. Review of CNA #89's written statement, dated [DATE], revealed CNA #61 and CNA #89 were changing Resident #01. After the resident was cleaned up and dressed, CNA #89 turned around to get the trash and CNA #61 went to get the wheelchair by the television (TV). CNAs #61 and #89 heard Resident #01 start to scream and turned around and she was rolling off the bed. CNA #89 ran and tried to catch her but did not make it in time to fully catch her before she hit the floor. CNAs #61 and #89 yelled for LPN #69 to come right away. Review of CNA #61's written statement, dated [DATE], revealed CNAs #61 and #89 were changing Resident #01 on her bed. When they were done changing the resident, Resident #01 was laying down. CNA #89 turned to take trash bag out of trash can and CNA #61 turned around to grab the wheelchair placed by the TV. CNAs #61 and #89 heard Resident #01 scream and turned around and Resident #01 was rolling off the bed. CNA #89 tried catching her but missed. LPN #69 immediately came to the room. The facility's investigation did not include an assessment of the bed and low air loss mattress, how Resident #01 was positioned in the bed, explain how Resident #01 could fall from her bed when she was dependent on staff rolling side to side and had bilateral leg contractures that were pulled up to the torso, did not identify CNAs #61 and #89 left Resident #01 unsupervised in a elevated bed, and did not identify Resident #01's root cause of the fall. The progress note dated [DATE] at 8:20 P.M. revealed Resident #01 was without vital signs. Review of the death certificate revealed the immediate cause of death was moderate to severe cervical canal stenosis with immediate cause of acute odontoid process fracture with comminuted first cervical body fracture. The approximate interval from onset and death was two days for the immediate causes of death. During an interview on [DATE] at 7:35 A.M., Maintenance Director #21 stated Resident #01 was on an air mattress owned by the facility. During an observation with Maintenance Director #21 at 10:10 A.M., the air mattress energized and operated (inflated) as designed with the firm setting. The air mattress edges (perimeters) compressed with little pressure or resistance. During an interview on [DATE] at 9:25 P.M., Director of Therapy (DT) #20 stated during a review of Resident #01's most recent occupational therapy (OT) Discharge summary dated [DATE], Resident #01 was assessed with bilateral lower extremity contractures and no lower extremity mobility. DT #20 stated Resident #01 was unable to position herself side to side due to contractures and legs being fixed in the flexed position (pulled up toward torso). Resident #01 was dependent on staff on mechanical lift transfers using two staff. DT #20 also confirmed Resident #01's bed and mattress were assessed by nursing to determine appropriated use. During an interview on [DATE] at 9:43 A.M., PA #22 stated Resident #01 required assistance with care. PA #22 stated Resident #01 was mostly seated in a wheelchair when observed. PA #22 stated she was informed resident fell and was bleeding. PA #22 placed an order to send Resident #01 to the ER. PA #22 reviewed hospital progress notes related to the incident and stated Resident #01 and her responsible party chose to go on hospice due to refusing further medical intervention for cervical fractures. Resident #01 was an unreliable historian with moderate cognitive impairment. PA #22 stated no further involvement or contact with Resident #01 occurred after the telephone order was given to have the resident sent to the ER on [DATE]. Further medical record review also confirmed the record lacked documentation by the primary physician following the [DATE] incident. During an interview on [DATE] at 11:01 A.M., CNA #45 stated on [DATE] at approximately 10:00 A.M. she was aware that CNA #61 and #89 were in Resident #01's room with the door closed. CNA #61 screamed from Resident #01's door for LPN #69. LPN #69 and RN #83 responded. CNA #45 entered the room and Resident #01 was observed with blood coming from the top of her forehead. No blood was observed on the dresser located next to the left side of the bed. Resident #01 was on left side of bed on the floor facing toward the room entry. Resident #01 was alert. With her head next to dresser within two inches. Resident #01's bed was elevated to approximately 36 inches. During an interview on [DATE] at 11:24 A.M. via telephone, CNA #61 stated on [DATE] Resident #01 needed changed. Resident #01 was on her bed and positioned on her left side. CNA #61 was standing on the left side of the bed with the bed elevated to approximately three feet from the floor. The bed was elevated to provide staff with sufficient access to Resident #01 which occurred during care. CNA #89 was standing on the right side of the bed. CNA #61 turned around to get the mechanical lift sling from the wheelchair which was located approximately one foot from the foot of the bed. At the same time CNA #89 left the right side of the bed and proceeded to the left side of the bed to obtain a trash can. CNA #61 confirmed CNAs #61 and #89 were not visualizing Resident #01 at that moment. Resident #01 screamed and proceeded to roll out of the left side of the bed onto floor. CNA #61 ran to the door of room and yelled for LPN #69 who was just outside door. CNA #61 verified Resident #01's bed was elevated at the time of the incident and both CNAs turned away from Resident #01 at the time of the incident. During an interview on [DATE] at 12:30 P.M., the DON confirmed the air mattress that was applied to Resident #01's bed provided little to no perimeter resistance when pressure was applied to the mattress edge. Additional interview verified no documentation contained in the medical record indicated Resident #01's air mattress or bed were assessed for appropriate use. During an interview on [DATE] at 1:05 P.M. via telephone, Hospice Physician #2 revealed the primary cause of Resident #01's death was due to cervical fractures sustained from the fall from bed on [DATE]. During an interview on [DATE] at 11:06 A.M. via telephone, CNA #89 confirmed Resident #01's bed was elevated approximately three feet when Resident #01 fell from the bed on [DATE]. CNA #89 walked around the foot of the bed to the left side of the bed and proceeded to access a trash can located at the left side of the bed. CNA #89 confirmed she took her visual focus away from Resident #01 while tending to the trash receptacle which left the resident unattended while in a elevated bed. CNA #89 responded to Resident #01 yelling out and observed the resident rolling from bed. CNA #89 lunged towards Resident #01. However, the resident proceeded to fall to the floor and sustained an injury to the head. CNA #89 confirmed she received training related to the transfer and use of mechanical lifts. However, no training included maintaining supervision to prevent accidents. Review of the policy titled Fall Reduction Policy, approved [DATE], revealed based on the outcome of fall assessments, a fall risk reduction plan will be incorporated into the resident's plan of care. The interdisciplinary team will review the residents' fall risk reduction plan at a quarterly minimum, during care conference and modify the plan as needed, based on the resident's functional status during the review period. Referrals will be made to other health professionals as needed. Follow-up investigations will be carried out to ascertain the cause of the incident to reduce the risk of further occurrences. Employee education will include body mechanics, transfer/ambulation techniques, transfer/ambulation equipment and assistive devices, maintenance of equipment and assistive devices. Review of the manual titled Joerns User-Service Manual dated 2023, documented important precautions included the following: Keep bed in lowest position except when providing care. Bed should be at lowest convenient height for entry or exit. Failure to do so could result in injury. Use of an improperly fitted mattress could result in injury or death. An optimal bed system assessment should be conducted on each resident by qualified clinician or medical provider to ensure maximum safety of the resident. This deficiency represents non-compliance investigated under Complaint Number 2565060.

Based on medical record review, staff interview, local health department staff interview, and review of facility policy, the facility failed to report norovirus cases and multiple resident's gastrointestinal (GI) symptoms (nausea/vomiting/diarrhea) to the local health department. This had the potential to affect all 92 residents of the facility. The census was 92. Findings include: 1. Review of Resident #4's medical record revealed an admitted [DATE]. Diagnoses listed included chronic kidney disease, obstructive sleep apnea, hypothyroidism, and morbid obesity. Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #4 was cognitively intact. Review of progress notes revealed Resident #4 was not feeling well and was sent to the emergency room (ER) for evaluation on 02/25/25. Resident #4 returned to the facility on [DATE]. Review of hospital documentation revealed Resident #4 tested positive for norovirus on 02/25/25. 2. Review of Resident #107's medical record revealed an admitted [DATE]. Diagnoses listed included chronic kidney disease, obstructive sleep apnea, hypothyroidism, and morbid obesity. Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #4 was cognitively intact. Review of progress notes revealed Resident #107 was sent to the ER for shortness of breath, abdominal pain, and difficulty urinating on 02/21/25. Resident #107 returned to the facility on [DATE]. Review of hospital documentation revealed Resident #4 tested positive for norovirus on 02/22/25. Review of facility timeline documentation revealed Resident #107 returned to the facility from the hospital on 02/23/25 and was positive for norovirus. Resident #4 was sent to the hospital on 02/25/25 and tested positive for norovirus on admission to the hospital. Between 02/23/25 and 03/05/25 16 residents (#30, #50, #61, #63, #64, #68, #83, #108, #77, #82, #84, #87, #97, #112, #120, and #121) throughout the facility experienced GI symptoms. Residents (#30, #68, #77, #84, #87) were tested and were negative for norovirus. The remaining residents with GI symptoms were put in contact isolation, but not tested . On 03/05/25 residents in the memory care unit started with GI symptoms and the entire unit was put on contact isolation. 16 residents (#13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, and #28) resided in the memory care unit. Interview with Licensed Practical Nurse (LPN) #50 on 04/03/25 at 10:44 A.M. revealed Resident #107 tested positive for norovirus when sent to the hospital. LPN #50 reported two staff members were tested at a local hospital and were positive for norovirus. All staff had been educated on how to prevent the spread of norovirus. LPN #50 stated the local health department had not been made aware of the norovirus cases. Interview with the Administrator on 04/03/25 at 1:50 P.M. confirmed two residents (#4 and #107) and two CNAs (#100 and #110) tested positive for norovirus at a local hospital. The Administrator confirmed multiple residents throughout the facility had GI symptoms. The Administrator confirmed the local health department was not called. Review of facility provided documentation revealed CNA #100 and CNA #110 were off work form 02/28/25 through 03/04/25. Test results for norovirus were not provided. Phone interview with Local Health Department Registered Nurse (LHDRN) #200 on 04/03/25 at 2:23 P.M. confirmed the local health department had not been contacted regarding residents and staff testing positive for norovirus and multiple residents with GI symptoms throughout the facility. Phone interview with LHDRN #210 on 04/07/25 at 10:53 A.M. confirmed the local health department had not been contacted regarding residents and staff testing positive for norovirus and multiple residents with GI symptoms throughout the facility. LHDRN #210 confirmed the facility should have called and reported. Interview with Regional Director of Clinical Services (RDCS) #150 on 04/07/25 at 8:50 A.M. confirmed norovirus cases and GI symptoms throughout the facility should have been reported to the local health department. Review of the facility policy titled, Reportable Diseases Ohio, dated revised April 2022 revealed it is the purpose of the facility to report diseases declared to be dangerous to the public health. It is the policy of the facility that all infectious, contagious or communicable diseases be reported in accordance with Ohio rules. The following diseases are classified as Class C and shall be reported by the facility to the local health department by the end of the next business day. This applies to an outbreak, unusual incidence, or epidemic of other infectious diseases from the following sources: (1) Community (2) Foodborne (3) Healthcare-associated (4) Institutional (5) Waterborne; and (6) Zoonotic; (7) If the outbreak, unusual incidence, or epidemic, including but not limited to, histoplasmosis, pediculosis, scabies, and staphylococcal infections, has an unexpected pattern of cases, suspected cases, deaths, or increase incidence of disease that is of a major public health This deficiency represent non-compliance investigated under Complaint Number OH00164181.

Based on medical record review, staff interview, review of facility policy, and review of the Ohio Department of Health (ODH) Application Gateway, the facility failed to report an incident of resident-to-resident physical abuse to the state agency. This affected one (#19) of three residents reviewed for abuse. The census was 92. Findings include: 1. Review of Resident #19's medical record revealed an admitted [DATE]. Diagnoses listed included Alzheimer's disease, psychotic disorder, hearing loss, and generalized anxiety disorder. Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #19 was rarely understood by staff. Review of progress notes revealed on 03/21/25 at 8:30 P.M. Resident #19 was walking with her walker and came to stop in front of of an empty recliner in the common area. A resident sitting in a nearby chair began yelling at Resident #19. A third resident came into the area and told Resident #19 to move. Resident #19 has confusion, and did not move. The resident sitting in the nearby chair began yelling more. The third resident then used her elbow and struck Resident #19 in the upper right arm, then immediately after doing so, placed both hands onto the resident's arm and pushed. Resident #19 stumbled but did not fall. The nurse was able to reach the residents before it escalated any further. The nurse removed Resident #19 from the area to ensure safety. No evidence of any injury was noted. 2. Review of Resident #23's medical record revealed an admitted [DATE]. Diagnoses listed included dementia, type II diabetes mellitus, atrial fibrillation, and major depressive disorder. Review of a annual MDS dated [DATE] revealed Resident #23 was severely cognitively impaired. Review of progress notes revealed on 03/21/25 at 8:30 P.M. a resident with a walker came to a stop in front of an empty recliner in the common area. A resident sitting in a nearby chair began yelling at the resident. Resident #23 came into the area and told the resident with the walker to move. The resident with the walker has confusion, and did not move. The resident sitting in the nearby chair began yelling more. Resident #23 then used her elbow and struck the resident with the walker in the upper right arm, then immediately after doing so, placed both hands onto the resident with the walker's arm and pushed. The resident with the walker stumbled but did not fall. The nurse was able to reach the residents before it escalated further. The nurse removed the resident with the walker from the area to ensure safety. No evidence of injury was noted on the resident with the walker. This nurse attempted to re-approach Resident #23 to see if they were ok, but the resident in the chair was still telling Resident #23 that she was in trouble, but should have been allowed to defend herself. All further attempts to provide care or follow up for Resident #23 resulted in agitation. The nurse monitored the situation until Resident #23 decided to go to into her room. The nurse asked Resident #23 if they needed assistance with getting ready for bed, and Resident #23 replied, no and don't touch me. Interview with the Administrator on 04/03/25 at 10:30 A.M. confirmed there was a physical altercation between Residents #19 and Resident #23 on 03/21/25. Resident #23 struck Resident #19 in the arm and pushed her. The Administrator confirmed the incident was not reported to ODH. Interview with Certified Nurse Aide (CNA) on 04/03/25 at 11:52 A.M. revealed Resident #19 obtained a bruise on her right upper arm when Resident #23 hit her on 03/12/25. CNA #180 did not witness the incident, but worked the morning after and was informed of what happened. Observation of of Resident #19's right upper arm with Registered Nurse (RN) #60 on 04/03/25 at 1:31 P.M. revealed a pale yellow bruise to the right upper arm. RN #60 stated it was the result of Resident #23 hitting Resident #19. Interview with Regional Director of Clinical Services (RDCS) #150 on 04/07/25 at 8:50 A.M. confirmed the physical altercation on 03/21/25 when Resident #23 struck Resident #19 should have been reported to ODH. RDCS #150 confirmed that Resident #23 striking Resident #19 met the definition of physical abuse per the facility's policy. Review of the ODH's Application Gateway website revealed the facility had not reported the resident-to-resident physical abuse between Resident #19 and Resident #23. Review of the facility policy titled, Abuse, Neglect, Injuries of Unknown Source, and/or Misappropriation of Resident Property Policy, dated 2016 revealed abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. The Administrator or his/her designee will notify ODH of all alleged violations involving abuse, neglect, exploitation, mistreatment of a resident, or misappropriation of resident property, and injuries of unknown source as soon as possible, but in no event later than twenty-four (24) hours from the time the incident/allegation was made known to the staff member. This deficiency represent non-compliance investigated under Complaint Number OH00164181.

Based on observation, staffing record review, and staff interviews, the facility failed to employ a Director of Nursing (DON) full time at the facility. This had the potential to affect all 86 residents. Findings include: Interview on 09/30/24 at 7:17 A.M. at the time of entrance with the Administrator revealed there was no DON employed at the facility. A second interview with the Administrator on 10/01/24 at 10:11 A.M. revealed the facility had not had a DON or acting DON since 09/18/24. Record review of the staffing sheets from 09/23/24 through 09/29/24 revealed no DON had been scheduled.

Based on employee file review and interview the facility failed to ensure State tested Nursing Assistant (STNAs) had 90 day evaluations and/or annual performance evaluations. This affected four of six employee files reviewed. This had the potential to affect all residents. The facility census was 99. Findings include: 1. Review of employee file for STNA #353 with hire date of 05/14/19 revealed no annual evaluation for July of 2023 or any for 2024. 2. Review of employee file for STNA #374 with hire date of 11/06/18 revealed no annual evaluation for 2020, 2021, and 2023. 3. Review of employee file for STNA #370 with hire date of 01/10/24 revealed no 90 day evaluation. 4. Review of employee file for STNA #331 with hire date of 10/05/23 revealed no 90 day evaluation. Interview on 08/08/24 at 11:04 A.M. with Human Resources (HR #508) verified the evaluations were not in the employee files for STNAs #353, #374, #370, and #331.

Based on employee file review, interview, and policy review, the facility failed to ensure State tested Nursing Assistants (STNAs) completed 12 hours of education. This affected two of three STNA files reviewed for annual training. This had the potential to affect all residents. The facility census was 99. Findings include: 1. Review of employee file for STNA #353 with hire date of 05/14/19 revealed no education training for 2023 or 2024. 2. Review of employee file for STNA #389 with hire date of 02/09/22 revealed no education training for 2023 or 2024. Interview on 08/08/24 at 11:02 A.M. with Executive Director (ED) verified the employees were not compliant with their education. ED stated the employees are scheduled to take courses. Review of policy titled, Inservice Education, dated 10/2003 revealed Nursing Assistants are required to have 12 hours of training per year calculated from their date of hire.

Based on record review, observation, resident interview, staff interview, and the review of the facility policy, the facility failed to develop and initiate a care plan in regards to a corrective device for a resident. This affected one resident (#195) of three residents reviewed for range of motion. The facility census was 99. Findings include: Record review for Resident #195 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #195 included post surgical care for digestive tract, overactive bladder, sciatica, and pulmonary hypertension. Further review of Resident #195's list of diagnoses revealed there were no diagnosis relating to a fracture of the leg noted in the medical records. Review of Resident #195's care plans dated 07/26/24 revealed no focus for the plan of care for a walking cast. Review of Resident #195's physician orders revealed no orders for a walking cast. Observation and interview on 08/05/24 at 11:22 A.M. with Resident #195 revealed the resident was alert and oriented. Resident #195 stated she was wearing the walking boot due to having a broken foot. Resident #195 stated she was not informed of any care plans regarding the walking cast and stated she did not know when the walking cast was to be removed. Resident #195 denied any issues with her skin on her right leg but stated she was unsure of the actual condition of the skin. Interview on 08/07/24 at 8:49 A.M. with Licensed Practical Nurse (LPN) #321 verified there was no care plan or physician orders relating to Resident #195's walking cast. Per LPN #321, the resident stated she had a broken foot. LPN #321 verified there was no diagnosis for the resident's right leg noted in the medical records. Interview on 08/07/24 at 9:46 A.M. Regional Clinical Services (RCS) #602 verified there were no orders, no care plans, and no diagnoses in regards to Resident #195's walking cast. Per RCS #602, the resident was admitted with the cast and there have been no skin assessments or care plans for the care of the resident's leg. Review of the facility policy titled, 'Comprehensive Care Plan', dated 11/2016, revealed the facility must develop a comprehensive care plan for all care to be provided for the health and well being of the residents.

Based on record review and interview, the facility failed to monitor bruises once observed. This affected one resident (#59) of one resident reviewed for bruising. The facility census was 99. Findings include: Review of medical record for Resident #59 revealed an admitted [DATE] with diagnoses including but not limited to Parkinson's disease, dementia, anxiety, pain in right hip, and syncope and collapse. Review of the Minimum Data Set (MDS) dated [DATE] revealed the resident had moderate cognitive impairment with no behaviors. Resident #59 required supervision/touching assistance for activities of daily living. Review of the care plan dated 07/10/24 revealed Resident #59 was at risk for bleeding/bruising related to platelet aggregated therapy. Interventions included medications as tolerated and monitor for signs and symptoms of bruising or bleeding every shift. Review of current physician orders for Resident #59 revealed clopidogrel (blood thinner) 75 milligrams (mg) daily and monitor for signs and symptoms of bruising/bleeding-anticoagulant therapy. Review of change in condition note dated 06/23/24 at 4:17 A.M. revealed State tested Nursing Assistant (STNA) informed this nurse that she found bruising while giving the resident a shower. Upon assessment, two bruises noted to left buttock measuring 12 centimeters (cm) by 6 cm and 9 cm by 6 cm next to each other. When the resident was asked what happened he stated, I was packing at the house and suddenly fell . Review of weekly skin and body review dated 06/26/24 revealed no new areas noted and subsequent weekly skin and body reviews through 08/08/24 revealed no new areas noted. No assessment noted with the description of bruises to determine age or when the bruises had healed. Interview on 08/08/24 at 10:23 A.M. with Regional Clinical Services (RCS) #602 verified they could not find any documentation regarding the nurses were monitoring the bruises to Resident #59's left buttock besides the normal physician order to monitor for signs and symptoms of bruising/bleeding-anticoagulant therapy. RCS #602 verified she could not locate any other documentation as to what the bruises looked like or when the bruises healed.

Based on observation, Medscape review, medical record review, interview, and policy review, the facility failed to ensure residents did not receive outdated insulin. This affected one (Resident #30) of two residents reviewed for insulin. The facility census was 99. Findings include: Review of the medical record for Resident #30 revealed an admitted [DATE] with diagnoses including but not limited to type two diabetes with diabetic neuropathy, type two diabetes with diabetic cataract, type two diabetes with hypoglycemia without coma, long-term (current) use of insulin, and dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. Resident #30 received insulin seven out of seven days during the look back period. Review of current physician orders revealed insulin aspart solution 100 unit/ml inject per sliding scale: if 150-200 give 2 units; 201-250 give 4 units; 251-300 give 6 units; 301-350 give 8 units; 351-400 give 10 units; and 401 and greater give 12 units and update the physician, subcutaneously before meals. Observation on 08/07/24 at 11:06 A.M. revealed Licensed Practical Nurse (LPN) #319 removed an insulin vial from the locked cupboard in the residents room. Insulin (Novolog) was dated 07/05/24. LPN #319 cleansed the port of the insulin vial with alcohol pad and drew up eight units of insulin into a syringe. LPN #319 administered insulin into the residents right lower abdomen. Interview on 08/07/24 at 11:10 A.M. with LPN #319 verified insulin (Novolog) was dated 07/05/24. LPN #319 believed the insulin was good for a month after opening. Verified today's date was 08/07/24. LPN #319 called someone to ask about the insulin who stated that the insulin was good for 31 days (vials) after opening. Interview on 08/07/24 at 12:39 P.M. with Director of Nursing (DON) verified Novolog was to be discarded 28 days after opening. Review of Medscape revealed Novolog to be stored at room temperature below 30 degrees for up to 28 days. Review of skills competency checklist for medication administration dated 04/2013 revealed multidose vials are good for 28 days.

Based on observation, medical record review, staff interview, and policy review, the facility failed to ensure medications were not left at the bedside. This affected one (Resident #26) of one residents observed. The facility census was 99. Findings include: Review of the medical record of Resident #26 revealed an admitted [DATE]. Diagnoses included congestive heart failure, rheumatoid arthritis, diabetes mellitus type II, anxiety disorder, depression, and cerebral ischemia. Review of the annual Minimum Data Set assessment dated [DATE] revealed Resident #26 was cognitively intact. Observation on 08/05/24 at 10:10 A.M. revealed a small plastic cup containing 18 pills/capsules sitting on the over bed table next to Resident #26. The medications included acetaminophen 325 milligrams (mg) 2 tablets, ascorbic acid 500 mg two tablets, cyanocobalamin 500 micrograms (mcg) tablet, isosorbide mononitrate extended release 30 mg capsule, multivitamin tablet, omeprazole 40 mg capsule, sitagliptin phosphate 50 mg tablet, spironolactone 25 mg tablet, zinc 50 mg tablet, carvedilol 12.5 mg tablet, ferrous sulfate 325 mg tablet, gabapentin 100 mg capsule, gabapentin 600 mg capsule, methocarbamol 500 mg tablet, sennosides 8.6 mg tablet, and oxycodone hydrochloride 7.5 mg tablet. Interview on 08/05/24 at 10:20 A.M. with Licensed Practical Nurse (LPN) #319 verified the medications left at the bedside. LPN #319 stated she had handed Resident #26 the cup of medications as she was ambulating back to her room from breakfast and did not ensure she had taken them. Review of the facility policy titled, Medication Storage in the Facility, dated 02/11/21 revealed medications are stored safely and securely.

Based on medical record review, interview, and policy review, the facility failed to notify a resident's representative of a resident's increased, severe pain. Additionally, the facility failed to honor the resident's representative request of being notified when as needed (PRN) pain medication was administered. This affected one (Resident #101) of three reviewed for notification. The facility census was 76. Findings include: Review of the medical record for Resident #101 revealed an admitted [DATE] and discharge date of [DATE] with diagnoses including but not limited to Alzheimer's, dementia with other behavioral disturbance, anxiety, major depressive disorder, pain in right hip, pain in unspecified knee, osteopenia, osteoporosis, disorder of bone, spondylosis, stiffness of unspecified shoulder, unspecified fracture of shaft of humerus unspecified arm, and unspecified psychosis not due to a substance or known physiological condition. Review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #101 revealed a Brief Interview for Mental Status (BIMS) score of two which indicated severe cognitive impairment. Resident #101 required extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. The resident received hospice services. Further review of physician orders for Resident #101 revealed an order for morphine sulfate (concentrate) solution 100 milligrams (mg) per five milliliters (ml) give five mg by mouth every hour as needed for mild pain or shortness of breath (SOB). 5 mg = 0.25 ml document pain level. Document non-pharmacological intervention used by yes/no answer. Give 10 mg = 0.5 ml every hour as needed for moderate pain/SOB document pain level. Document non-pharmacological interventions by yes/no answer. Give 20 mg = 1 ml every hour as needed for severe pain/SOB. Document pain level and non-pharmacological interventions by yes/no answer. Review of eMAR (electronic medication administration record) Medication Administration Note dated 11/17/22 at 9:23 P.M. for SR #101 revealed morphine sulfate (concentration) 100 mg/5 ml give 20 mg as needed for severe pain/SOB give 1 ml. was administered due to the resident complaining of right arm pain, constantly moaning and yelling out because of pain. Review of eMAR medication administration note dated 11/17/22 at 10:37 P.M. revealed morphine sulfate 20 mg- 1 ml given due to resident still moaning and yelling due to so much pain. Further review of Resident #101's medical record revealed no documentation Resident #101's representative was notified of the resident's pain to the right arm. Phone interview on 12/19/22 with Registered Nurse (RN) #666 at 1:11 P.M. reported on 11/17/22, Resident #101 was not acting like herself. The resident was yelling, and crying in her room regarding her right arm hurting. Resident #101 reported her, Arm was broken, it is cracked. RN #666 assessed the resident's arm and did not notice any injury at the time. Resident #101 was moaning, crying, and in so much pain. RN #666 administered pain medication per physician order. RN #666 stated that an hour later, Resident #101 was still yelling and miserable and the nurse checked on her again. Resident #101 was saying, It still hurts so bad, it didn't work. RN #666 administered pain medication per physician order. RN #666 verified she did not notify the resident's representative of the new onset of pain to the resident's right arm. Review of the eMAR for November 2022 revealed on 11/17/22 Resident #101 was administered 20 mg of morphine at 9:23 P.M. and 10:38 PM. Resident #101 received 10 mg of morphine on 11/18/22 at 11:53 A.M., and 11/19/22 at 11:23 A.M. On 11/19/22 at 8:41 A.M. Resident #101 was administered 5 mg of morphine. Further review of the medical record revealed no documentation supporting the resident's representative's wishes to be notified when PRN pain medication was administered to Resident #101. Additionally, there was no documentation the resident's representative was notified of PRN pain medication administered on 11/17/22, 11/18/22, and 11/19/22. Interview on 12/18/22 at 9:14 A.M. Resident #101's representative verified she wanted to be notified prior to adminstration of PRN medications and the facility was aware and did not notify her. Interview on 12/18/22 at 11:06 A.M. with Licensed Practical Nurse (LPN) #620 stated she worked with Resident #101 once or twice and knew the resident's representative wanted notified prior to administering as needed pain medication. Interview on 12/18/22 at 11:34 A.M. with RN #662 revealed it was a verbal request for Resident #101's representative to be notified prior to as needed medication administration. RN #622 verified she was told in report when Resident #101 was moved from Assisted Living to the nursing side. RN #622 verified there were no written instructions provided to notify the resident's representative of PRN pain medication administration. Phone interview on 12/19/22 at 8:45 A.M. with Hospice Staff #701 revealed Resident #101's representative wanted notified prior to administration of PRN morphine and hospice staff were aware of this. Interview on 12/19/22 at 1:11 P.M. with RN #666 verified there was no documentation contained in Resident #101's medical record to notify the resident's representative prior to administering PRN pain medication. Interview on 12/19/22 at 1:55 P.M. with LPN #580 verified there was no documentation contained in Resident #101's medical record to notify the resident's representative prior to administering morphine. Review of policy titled, Notification of Changes Policy, revised 11/2016 revealed the manor will inform the resident, the attending physician, and the resident's representative or interested family member of changes which affect the resident. The manor must inform the resident immediately, the attending physician, and the resident's representative or interested family member when there is an accident involving the resident, which may or may not result in injury, a significant change in the resident's physical, mental, or psychosocial status, a need to alter treatment, and a decision to transfer or discharge the resident from the manor. This deficiency represents non-compliance investigated under Complaint Number OH00137993.

Based on observation, staff interview, review of the kitchen daily cleaning schedule, and policy review, the facility failed ensure foods were labeled and dated, discard expired foods, and resident meals trays were covered during transport to resident rooms. In addition, the kitchen area and equipment was not maintained in a sanitary manner. This had the potential to affect all residents who resided in the facility and received food from the kitchens. The facility census was 73. Findings include: Observation on [DATE] at 9:20 A.M. of the facility kitchen and storage area revealed the following sanitation violations: 1. In the dry food storage one large bag of brown sugar next to a large plastic storage bin with brown sugar both open and undated. The large plastic storage container storing the brown sugar was sitting on a plastic food service tray with brown sugar laying on the surface. In the walk-in refrigerator, the following items were opened, unlabeled and undated, 1. Open package of cheddar cheese. 2. Open package of mozzarella cheese, 3. Open package of shredded lettuce, 4. Opened package of ham base. 5. Opened package of pepperoni. 6. Opened package of smoked ham. In the facility walk in freezer, the following items were opened, unlabeled and undated. Further observation revealed the food was not sealed properly. 1. Opened, undated and unsealed bag of broccoli. 2. Opened, undated and unsealed package of Garden burgers. 3. Opened, undated and unsealed package of cubed potatoes. Interview on [DATE] at 10:02 A.M. with Assistant Dietary Manager #246 verified the findings and the foods should have been labeled and dated with an open date. She verified perishable foods should have been discarded on the expiration date or 7 days after opening. 2. Observation on [DATE] at 10:22 A.M. of the facility main kitchen revealed six heated food storage carts being utilized for storage of warm food until transportation to individual serveries. All six food storage carts had multiple unidentified spills inside the units, on the doors and side of the carts and the wheel casters had accumulation of unknown brown, black colored substances. Observation on [DATE] at 10:25 A.M. of the facility main kitchen revealed a long stainless-steel worktable in the middle of the kitchen. The table had shelves under the top surface area. The shelves had multiple brown/black and yellow colored streaking on the legs, shelves and wheel castors. Observation on [DATE] at 10:30 A.M. of the facility main kitchen revealed cook units had unidentified gray/white dry flaky debris on top of the units. Further observation revealed unidentified streaking down the sides of both units and brown, black colored accumulation around inside shelves oven racks. Observation on [DATE] at 10:35 A.M. in the facility main kitchen revealed three black serving carts. The serving carts had three shelves. Observation on all three carts revealed multiple streaking of unidentified material on the handles, shelves and wheel castors. Review of the kitchen daily routine cleaning schedule posted for staff to initial revealed the last documentation was dated ,d+[DATE]. Interview on [DATE] at 10:45 A.M. verified the observations regarding the heated food storage units, shelves under stainless steel tables, cook units and serving carts were not kept in a sanitary manner. Further confirmed the daily cleaning schedule was not completed as it should have been. Interview on [DATE] at 12:40 P.M. with the Administrator and completed a tour of the dry storage area, and main kitchen cook areas and verified the daily cleaning schedule was not current and the last month the schedule was utilized was [DATE]. The Administrator further verified the kitchen areas were not maintained in a sanitary manner regarding the heated storage carts, ovens, and stainless-steel table shelves. Interview on [DATE] at 4:10 P.M. with the Director of Nursing (DON) verified the facility had no residents that did not receive food from the dietary department at the time of the survey. 3. Observation on [DATE] at 11:34 A.M. of Dietary cook #221 preparing meal tray to be transported from the unit serveries to residents eating in their room. Dietary Staff #270 transported a lunch tray for Resident #36 without appropriate coverings. Observation on [DATE] at 11:36 A.M. of Dietary Cook #221 prepare a meal tray to be transported form the unit serveries to residents eating in their room. Dietary Staff #270 transported a lunch tray for Resident #16 without appropriate coverings. Observation on [DATE] at 11:42 A.M. of Dietary Cook #221 prepare a meal tray to be transported form the unit serveries to residents eating in their room. Dietary Staff #270 transported a lunch tray for Resident #86 without appropriate coverings. Interview on [DATE] at 11:50 A.M. with Dietary Cook #221 stated the meal trays should be covered when they are transported to the resident's room. Dietary Cook #221 verified trays were not covered as they should have been. Review of facility policy titled Food Storage, dated [DATE] revealed the facility failed to implement the policy as written. Letter A of the policy states food storage areas will be clean at all times. Letter B of the policy states all packaged food, or food items will be dated, kept clean and dry and dry at all times. Review of facility policy titled Sanitation, dated [DATE] revealed the facility failed to implement the policy as written. Letter B of the policy states all utensils, counters, shelves and equipment will be kept clean and maintained in good repair.

Based on observation, staff interview, and policy review, the facility failed to ensure medications were stored at proper temperatures. This affected 15 residents (#11, #56, #14, #42, #14, #48, #34, #26, #15, #13, #61, #07, #06, #37 and #274) and had the potential to affect all 59 residents on the A, B, C, and D halls. The facility identified three resident medication refrigerators. The facility census was 73. Findings include: 1. Interview and observation on 10/19/22 at 1:20 P.M. with Registered Nurse (RN) #245 of the A, B, C, and D hall refrigerator revealed the third shift charge nurse was responsible to check the refrigerator temperatures and log them daily. The log sheet on the refrigerator had temperatures on 10/03/22, 10/05/22, 10/17/22, 10/18/22, and 10/19/22 and each were documented within the 35 to 46 degree Fahrenheit parameters. The temperature during the observation the temperature during observation was 50 degrees. This was verified at the time of finding. 2. Interview and observation on 10/19/22 at 1:28 P.M. with RN #245 of the refrigerator in the infection preventionist's office revealed the temperature was 44 degrees Fahrenheit. RN #245 verified there was no log for temperature checks and could not provide documentation. Interview on 10/19/22 at 4:38 P.M., with the Director of Nursing revealed individual medications and contingency medications were being disposed of by recommendation of the pharmacy due to the low temperatures in the refrigerators. Review of the policy titled Medication Storage in Facility, revised 02/11/22 revealed medications requiring refrigeration were to be kept in a refrigerator with a thermometer, with temperatures to be recorded daily.

Based on staff interview and review of personnel files, the facility failed to provide newly hired State tested Nurse Aides (STNA) with training on caring for residents with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] #27, #30, #48, #68, #277, #26, #60, #03, #07, #39, #69, #17, #56, #38, #12, #06, #19, #374, #62, #04, #28, #63, #70, #46, #08, #35, #37, #02, #29, #31, #15, #47, #36, #18, #67, #22, #124, #375, and #13) out of 44 residents diagnosed with dementia. The facility census was 73. Findings include: Review of the personnel file for STNA #231 revealed a hire date of 12/29/21. Further review revealed no documented training for residents with dementia. Review of the personnel file for STNA #236 revealed a hire date of 04/01/22. Further review revealed no documented training for residents with dementia. Interview on 10/20/22 at 1:31 P.M. with the Human Resources Director #248 verified the personnel files for STNA #231 and STNA #236 contained no verification they had received training on caring for residents with dementia. Interview on 10/20/22 at 3:15 P.M. with the Assistant Director of Nursing (ADON) #276 revealed she trained newly hired nurse aides and further revealed the training included no specific training on caring for residents with dementia.

Based on medical record review, observation, staff and resident interview, and policy review, the facility failed to ensure resident rooms remained clean. This affected two residents (#21 and #64) out of 73 residents' rooms observed. The facility census was 73. Findings include: 1. Review of the medical record of Resident #21 revealed an admitted [DATE] and a readmitted [DATE]. Diagnoses included [CONDITION(S)] following a cerebral infarction, [CONDITION(S)] and [CONDITION(S)] following cerebral infarction affecting left non-dominate side, [CONDITION(S)], benign neoplasm of peripheral nerves and autonomic nervous system, disorders of brain, and [CONDITION(S)] disease. Review of the annual minimum data assessment dated [DATE] revealed Resident #21 was cognitively intact and had 12 to 14 days of feeling down, depressed, or hopeless. She had trouble falling or staying asleep or sleeping too much two to six days, and felt tired or had little energy seven to 11 days. The total score was a six indicating a moderate potential for depression. The assessment indicated she required extensive assistance of two staff for bed mobility, dressing, toilet use and personal hygiene, and was totally dependent on two staff for transfers. The assessment indicated she had not received any therapy for the two week period. Interview on 10/17/22 1:42 P.M., with Resident #21 revealed the housekeepers had not cleaned the room. She said the toilet in the bathroom had been dirty for awhile now and the mirror had toothpaste spray on it for over a week. Observation on 10/17/22 1:58 P.M. of Resident #21's room revealed the floor to the left of the bed had a black, dried substance. The bathroom toilet had dried stool inside the toilet on the riser. The mirror had dried white blotches on the lower section. A pink bedpan was noted on the floor, under the counter, in a clear plastic bag. Observation on 10/18/22 1:21 P.M. of Resident #21's room revealed the dried black substances to the left of the bed remained on the floor, the dried stool remained in the toilet. The white blotches were still on the mirror. A pink bedpan was on the floor, under the counter, in a clear plastic bag and stool was visible on the pan. Interview on 10/18/22 at 1:39 P.M., with the Assistant Director of Nursing (ADON) #276 verified the above condition of Resident #21's room and bathroom. Review of the facility policy titled Housekeeping Services, dated 01/20 revealed in resident care areas, cleaning of non-carpeted floors and other horizontal surfaces will be done daily and more frequently if spillage or visible soiling occurs. Horizontal surfaces included toilet seats. 2. Review of medical record for Resident #64 revealed admitted [DATE]. Diagnoses included myotonic [CONDITION(S)], [CONDITION(S)] and muscle weakness. The annual Minimum Data Set (MDS) dated [DATE] revealed Resident #64 had intact cognition. The resident required extensive two person assistance for bed mobility, toilet use, one person assistance for eating and was totally dependent for transfers. Interview and observation on 10/17/22 at 10:35 A.M. with Resident #64 and a visitor revealed a medicine cup had been under the bed for several days. Observation revealed a medicine cup was on the floor about mid mattress and approximately two feet from the end of the bed. Observation on 10/18/22 at 1:41 P.M. revealed a medicine cup remained under the bed. Observation on 10/20/22 at 9:41 A.M. revealed a medicine cup remained under the bed. Interview on 10/20/22 at 9:49 A.M., with the Housekeeping Supervisor #344 revealed rooms were cleaned daily, which included sweeping the floors. The Housekeeping Supervisor #344 verified a medicine cup remained under Resident #64's bed.

Based on medical record review, observation, and staff and family interview, the facility failed to ensure a comprehensive skin assessment was completed on residents. This affected one resident (#46) out of 18 residents sampled. The facility census was 73. Findings include: Review of medical record for Resident #46 revealed admitted [DATE]. Diagnoses included dementia without behaviors, [CONDITION(S)], depression, and [CONDITION(S)]. The admission Minimum Data Set (MDS) dated [DATE] revealed he had intact cognition and required extensive two-person assistance for bed mobility, toilet use, one person for transfers and supervision for eating. No skin alterations documented. Review of the plan of care for potential/actual impairment to skin integrity related to fragile skin was created on 09/21/22. No other skin care plans were in place. Review of a progress note for Resident #46 dated 08/19/22 revealed a large brown protruding mole to the top of the scalp which measured two centimeters by two centimeters. Interview and observation on 10/17/22 at 1:13 P.M. with Resident #46's son revealed he had been a resident in the facility's assisted living area and had known skin cancer area to the top of his head. Resident #46's son believed the staff were putting something on it, and as far as he knew it had not continued since being moved to the skilled side and the son felt the area had doubled in the last four weeks. An area approximately 25 millimeters (mm) in diameter growth was protruding from the top of Resident #46's head. Review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 10/20/22 at 11:28 A.M., with the MDS Registered Nurse (RN) #230 revealed the initial skin assessment for Resident #46 provided no documentation on the admission assessment for any skin conditions, therefore it was not added to the care plan. RN #230 confirmed Resident #46 was an established resident of the facility Medical Director and she was unaware why there was no diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The skin area was present on Resident #46 during the initial admission MDS assessment.

Based on record review and staff interview, the facility failed to ensure an updated assessment was completed when residents had a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility census was 73. Findings include: 1. Review of the record for Resident #47 revealed she was admitted [DATE]. Diagnoses included [CONDITION(S)], chronic obstructive pulmonary disease, asthma, depression, [CONDITION(S)], [CONDITION(S)] heart disease, [CONDITION(S)], neuromuscular dysfunction, abdominal hernia, intervertebral disc degeneration of lumbar region, cerebral ischemia, acute kidney failure, [CONDITION(S)], dementia without behavioral disturbance, [CONDITION(S)], benign [CONDITION(S)] [CONDITION(S)], [CONDITION(S)] with hallucinations, [CONDITION(S)], [CONDITION(S)] and [CONDITION(S)]. Review of the Minimum Data Set, dated dated dated [DATE] revealed Resident #47 had moderate cognitive impairment and required supervision with eating. The resident required extensive assistance with dressing, toilet use, personal hygiene, bed mobility and transfers. Review of the Preadmission Screening and Resident Review (PASRR) for Resident #47 dated 05/10/22 revealed no diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with the Resident Services Coordinator (RSC) #306 on 10/20/22 at 10:27 A.M. verified she had not completed an updated assessment for Resident #47 when she received her new diagnoses on 06/02/22. Review of the policy titled Preadmission Screening, revised 03/17/15 revealed its purpose was to ensure that individuals with mental illness and intellectual disabilities received the care and services they needed in the most appropriate setting. The facility must not admit any residents with mental illness or intellectual disability unless those boards have determined they need the level of services provided by a nursing home and if the resident required any specialized services. 2. Review of the medical record of Resident #38 revealed an admitted [DATE]. Diagnoses included other speech disturbances, unspecified [CONDITION(S)], contusion of left knee sequela, unspecified constipation, other dysphagia, unspecified systolic (congestive) heart failure, [CONDITION(S)] [CONDITION(S)], non-ST elevation [CONDITION(S)], and rhabdomyolysis. Review of the PAS (Pre-Admission Screen) Review dated 04/11/13 revealed Resident #38 had no indications of serious mental illness nor a developmental disability. Review of the medical record revealed a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The record had no documentation of any additional PAS Reviews were completed. Interview on 10/20/22 at 1:35 P.M. with RSC #306 verified the lack of a second screening completed for Resident #38. 3. Medical record review for Resident # 17 revealed an admitted [DATE]. Diagnoses included dementia with behaviors, type two diabetes, anxiety disorder and mood affective disorder. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #17 revealed a severely impaired cognition. Resident #17 required extensive to total assistance for activities of daily living. Resident #17 was coded as having dementia with behaviors, and mood affective disorder. Review of the plan of care for Resident #17 dated 02/11/22 and revised on 7/21/22 revealed the resident had cognitive deficits and confusion. Resident #17 had diagnoses including [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Preadmission Screening and Resident Review (PASRR) Identification Screen dated 02/05/22 revealed Resident #17 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 10/20/22 at 2:15 P.M., with the RSC #306 verified the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on medical record review, review of facility self-reported incidents (SRI's), review of a facility investigation, observation, staff and family interview and review of an electronic mail (email) communication, the facility failed to ensure a resident received appropriate assistance during a transfer in accordance with the residents' care plan which indicated the resident required two-person extensive assist. This resulted in Actual Harm when State tested Nursing Assistant (STNA) #299 transferred Resident #53 with a one assist and the resident subsequently sustained a spiral tibia fracture of the right leg which required casting. This affected one (#53) of three residents reviewed for safe transfers. The facility census was 81. Findings include: Review of the medical record of Resident #53 revealed the resident was admitted to the facility on [DATE]. Diagnoses include unspecified dementia with behavioral disturbance, 09/21/21 unspecified fracture of lower end of right tibia, vitamin D deficiency, unspecified lack of coordination, [CONDITION(S)], and type 2 diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #53 was severely cognitively impaired and required extensive assistance of two staff for transfers and bed mobility. Review of the care plan revised on 01/20/21 revealed Resident #53 was at risk for falls related to decreased mobility, confusion and agitation and an intervention included to transfer with two assist. Review of the progress notes of Resident #53 revealed an entry on 09/21/21 at 8:18 A.M. documented by Case Manager #170 which revealed Nurse Practitioner (NP) #600 was notified of Resident #53 being in pain this morning during activities of daily living. Resident #53 was screaming in pain as pants and socks were being put on. Registered Nurse (RN) #200 was also notified, and the NP #600 assessed Resident #53. A progress note dated 09/21/21 at 8:32 A.M. documented by NP #600 revealed Resident #53 was alert and oriented to name only. Resident #53 was unable to verbally locate pain but during physical exam would state No lower until NP minimally manipulated her right foot and ankle. The assessment and plan, documented, revealed mild swelling and warmth noted to the right foot and ankle without associated bruising or [CONDITION(S)]. The acetaminophen was increased to 1,000 milligrams twice daily for seven days and an x-ray of the right ankle was ordered. Review of a progress note dated 09/21/21 at 8:32 P.M. revealed the physician was notified of the x-ray results which indicated a tibia fracture with orders received for an orthopedic consult as soon as possible. Review of an x-ray report dated 09/21/21 at 3:50 P.M. revealed Resident #53 had complaints of pain in the right ankle and joins of the right foot. The x-ray showed a distal tibial fracture of the right extremity with malalignment, soft tissue swelling and joint space narrowing. Review of an orthopedic progress note dated 09/22/21 revealed Resident #53 was seen for complaints of right lower leg pain. Resident #53 presents with her daughter, the daughter states the injury likely happened during a transfer on Monday night, 09/20/21. Resident #53's daughter states the resident is typically a two-person transfer but on that night the staff did a one person transfer at bedtime. Tuesday morning the resident was having concerns of right lower leg pain. Resident #53 was brought in for definitive management. Three view x-ray of he right ankle revealed a mildly displaced midshaft tibia fracture that spiral in nature with no other acute fractures or dislocations or malalignment. The plan is to have Resident #53 be non-weight bearing on the right lower extremity, place the resident into a short leg case today and have a follow up appointment for repeat imaging. Review of a orthopedic progress note dated 10/04/21 revealed Resident #53 will continue to be non-weight bearing on the right lower extremity, will get the resident set up for a long-leg cast today in the office and plan to follow up in four weeks for repeat imaging. Review of the SRI created on 09/21/21 at 12:01 P.M. completed by Administrator #98 revealed an allegation of injury of unknown origin involving Resident #53. The time of occurrence was documented as 8:00 A.M. The narrative summary of the incident and investigation revealed Resident #53 began screaming in pain as morning activities of daily living was being completed. NP #600 was in the facility and was notified and an x-ray was ordered. The results of the x-ray revealed an acute distal tibia fracture of the right extremity. The family, physician, Director of Nursing (DON) and Administrator #98 were notified. Review of the facility investigation revealed interviews conducted by the Administrator revealed a written statement dated 09/22/21. State tested Nursing Assistant (STNA) #299 stated she had asked the nurse (Registered Nurse (RN) #202) if it was fine to put Resident #53 to bed and she said it was okay. Resident #53 had been seated at the table asleep and lightly moaning. STNA #299 proceeded to put her to bed. As STNA #299 was transferring Resident #53 she grabbed her thigh area and screaming after STNA #299 got her laid down. Resident #53 went right back to sleep after she was undressed and in bed. A written statement dated 09/22/21 revealed RN #202 documented she was the nurse on Resident #53's hall on 09/20/21 from 3:00 P.M. to 11:00 P.M. Resident #53 was a two assist from bed to wheelchair for supper. Resident #53's daughter had visited, and Resident #53 appeared quiet and comfortable. STNA #299 asked RN #202 if it was okay to put Resident #53 to bed. RN #202 documented having asked STNA #299 if she was going to do her as a one assist, because most do her as a two assist. STNA #299 stated it was not necessary for her to have help. RN #202 documented accepting her response and went about her work. RN #202 denied hearing any screaming as she worked the same hallway where Resident #53 resided. An undated, written statement from Administrator #98 revealed she had met with Resident #53's daughter on 09/22/21 upon return form a follow-up x-ray. Daughter stated as she and her husband had been wheeling Resident #53 through the facility and outside the main entrance, they had to stop several times to reposition Resident #53's foot and leg because it had started to slip off the foot pedal. Administrator #98 documented Resident #53 had given no indications of pain during their visit. Further review of the facility investigation into Resident #53's injury of unknown origin revealed no additional residents had been interviewed or examined for any type of injury, upon discovery of the fracture sustained by Resident #53. An interview on 10/12/21 at 11:45 A.M. with Administrator #98 and Executive Director #99 revealed the investigation into Resident #53's right tibia fracture revealed the resident's daughter had reported Resident #53's feet slid off the footrests on 09/20/21 as Resident #53's daughter and son-in-law were pushing the wheelchair throughout the facility and even outside. Administrator #98 stated she had spoken with STNA #299 who had reported Resident #53 yelling out in pain immediately upon standing from the wheelchair. Administrator #98 reported DON and Case Manager were assisting Resident #53 to get out of bed on 09/21/21. Resident #53 would scream in pain if the right lower leg was manipulated. NP #600 was in the house and immediately assessed the leg and ordered an x-ray. The x-ray results revealed an acute fracture to the right tibia. Resident #53 went to a follow-up appointment with an orthopedic doctor on 09/22/21 and returned with a cast to the right lower leg. STNA #299 stated she had not used two staff to transfer Resident #53, as was care planned. Administrator stated RN #202 stated she had attempted to guide STNA #299 into using two staff for the transfer. Interview on 10/12/21 at 11:50 A.M. with Resident #53's daughter revealed on 09/20/21 she and her husband had been visiting with Resident #53 and pushed her throughout the facility and even outside for a short time. Resident #53's feet would occasionally begin to slide off the footrests and she and her husband would readjust but the resident's foot never slid totally off the footrests. Resident #53's daughter stated they had left the facility at 7:45 P.M. after adjusting Resident #53's feet on the footrests and positioned her in the dining area, right outside of her room. Resident #53 had never cried out in pain when her feet or legs were touched. Resident #53's daughter stated she had spoken with RN #202 on 09/22/21 who reported STNA #299 had asked if it was okay to assist Resident #53 to bed. RN #202 stated she had questioned STNA #299 about getting assistance as Resident #53 was a two person assist for transfers and STNA #299 replied she could do it herself, as she had in the past. Resident #53's daughter denied ever having said Resident #53's feet had ever slid off the footrests. Resident #53's daughter stated she would have immediately notified someone if that had been the case. During the interview Resident #53 was observed with a cast on the right lower extremity. Interview on 10/12/21 at 1:16 P.M. with STNA #299 revealed she had asked RN #202 if she could help Resident #53 to bed. STNA #299 denied hearing RN #202 state Resident #53 was a two assist with transfers. STNA #299 stated Resident #53 began screaming When I laid her down. When asked to clarify, exactly when Resident #53 began screaming, STNA #299 then said, As soon as I stood her up. STNA #299 denied having reported the indication of pain, screaming, to RN #202 stating I don't know her (Resident #53) well enough to know if that was her norm. STNA #299 stated she would ask the facility staff how individual residents are transferred if not sure. STNA #299 denied having checked the electronic record on Resident #53 to ensure transfer was done correctly as per care plan. Interview on 10/12/21 at 4:50 P.M. with RN #202 revealed STNA #299 had asked if it was okay to assist Resident #53 to bed. RN #202 stated she had looked around and did not see the other STNA near and asked STNA #299 if she knew Resident #53 was usually a two-person assist with transfers. STNA #299 stated I have done her by myself before, I can do it. RN #202 stated STNA #299 appeared so confident she said nothing more. RN #202 stated she was in the hallway near the birdcage as STNA #299 assisted Resident #53 into bed and had not heard any screams. RN #202 stated she had entered Resident #53's room at approximately 10:00 P.M. and had to wake her for her medications. RN #202 stated She did not appear to be in any pain. RN #202 stated when she raised the head of the bed Resident #53 said, in a calm voice, My foot hurts. RN #202 stated Resident #53's routine bedtime medications contained 500 milligrams of acetaminophen, which she administered at that time. RN #202 stated she adjusted Resident #53's feet and Resident #53 did not cry out in pain. When asked to clarify adjusted her feet RN #202 stated Well she has a foot cradle and I made sure the covers were straight. I never touched her feet. RN #202 denied STNA #299 having reported Resident #53 crying out in pain when assisted to bed. A second interview on 10/12/21 at 12:20 P.M. with Administrator #98 along with review of the staff interviews conducted on 09/22/21 revealed Administrator stated she had received verbal statements from RN #202 who stated she had been within hearing of Resident #53's room and had not heard any screams. A verbal statement from STNA #299 who stated the moment Resident #53 put weight on her leg, she screamed in pain. Interview on 10/13/21 at 2:01 P.M. with Administrator #98 and Executive Director #99 revealed STNA #299 had demonstrated the events of 09/20/21 to Administrator and Corporate Staff. STNA #299 demonstrated placing the wheelchair near the foot of the bed with the right side against the bed, facing the head of the bed. STNA #299 demonstrated putting her arms around Resident #53, in a bear hug, and assisted her to stand. STNA #53 then pivoted Resident #53 to the right and sat her on the edge of the bed and then laid her down. Administrator stated STNA #299 had verbally said Resident #53 had shuffled her feet a little during the pivot transfer. STNA #299 stated as soon as she stood Resident #53 up, Resident #53 screamed and grabbed her right thigh. Administrator stated STNA #299 used the bear hug and 90 degree stand and pivot transfer, appropriate with a one-person transfer. When this surveyor asked why, after Resident #53 screamed in pain, did STNA #299 continue with the improper transfer and why had she not reported the scream to the nurse. Administrator responded that STNA #299 felt it was okay to place Resident #53 in bed as she had already started the transfer. Administrator could not respond to the question as to why STNA #299 had not reported the scream as she had not questioned STNA #299 about that. Administrator #98 and Executive Director #99 had not felt it necessary to interview all residents and/or to complete a skin sweep on the residents in the hall after the discovery of the fracture. Review of an email communication from the Administrator on 10/14/21 at 10:25 A.M. revealed the facility did not have a safe transfer policy. This deficiency substantiates Complaint Number OH 203.

Based on review of medical records, review of the facility summary of investigation, staff and resident interviews, review of policies on mechanical soft and pureed diet textures, review of facility recipes, review of employee disciplinary action, review of in-service records, and surveyor observations, the facility failed to ensure residents on mechanically altered diets were provided food in the correct texture assessed to meet their individual needs. This resulted in Immediate Jeopardy for two (#1 and #3) of three residents reviewed for choking who experienced actual harm when they were served the incorrect texture of food items at their meal and subsequently choked requiring staff intervention to perform the [MEDICATION NAME] maneuver in an effort to remove the food bolus from the trachea where it was preventing air flow to and from the lungs. The facility identified four residents who had choked within the last four months. On 08/11/16 at 3:15 P.M., the Administrator was notified Immediate Jeopardy began on 08/08/16 at 4:55 P.M. when Resident #1 was given a meal tray with a whole hot dog, contrary to the resident's physician order for [REDACTED]. The Immediate Jeopardy continued on 08/11/16 at 11:50 A.M. when Resident #3, who had a physician order for [REDACTED]. Resident #3 subsequently was observed to choke and required the [MEDICATION NAME] maneuver to be performed by staff in an effort to clear the resident ' s airway. The Immediate Jeopardy was removed on 08/11/16 at 5:00 P.M. when the facility implemented the following corrective actions: · On 08/09/16, the Dietary Manager initiated in-service education to dietary staff related to the facility dietary policies regarding mechanical soft diet and pureed diet textures including what specific foods are allowed and a description of each modified texture for each type of food item. This in-service education was completed on 08/11/16 at 7:45 P.M. · On 08/11/16, the Regional Registered Dietitian completed a 100 percent audit of all resident records to compare physician orders to the dietary meal tickets. There were no discrepancies found. · On 08/11/16, the Administrator, the Assistant Administrator, the DON, the Regional Nurse, the Regional Manager, the Minimum Data Set Nurse, the Restorative Nurse, and the Dietary Manager began in-service education for all staff on checking meal tickets for accuracy of food items served during meal service. This in-service education was completed on 08/11/16 at 7:45 P.M. · On 08/11/16, the DON and the Dietary Manager completed one-on-one education for Licensed Practical Nurse (LPN) #7 and Dietary Staff #16 regarding dietary policies for following physician orders for specific diet textures. · On 08/11/16 at 12:00 P.M., one-on-one in-services were initiated by nurse management and dietary management to all nursing and dietary staff. These individual in-services were completed on 08/12/16 at 3:00 P.M. The in-services included training on specific diets, roles of individuals in the dietary department, following physician orders for specific diets, and who was allowed to be contacted regarding a potential change. · On 08/11/16 at 3:45 P.M., the management team provided additional in-service education to all staff related to any resident request for an alteration in diet orders, including consistency, which should be referred to the DON or Speech Therapist. · 08/11/16 at 5:00 P.M. the Administrator, Director of Nursing (DON), and Food Service Manager #10 initiated management supervision at each meal, three times daily, to monitor proper food diet/texture was being served by double checking each resident ' s meal tray with the meal ticket for accuracy prior to the meal being served to the resident. This new plan will continue as the facility ' s plan for service. · On 08/11/16 at 5:00 P.M., surveyor observation of all seven dining areas revealed management personnel were in place and meal tickets were being verified before residents were served. All residents were served the correct physician ordered diet. · On 08/11/16, the facility planned to begin random audits of at least three residents with swallowing deficits and/or mechanically altered diets to assure food items at meals were served per physician orders. These audits would be completed three times a week for four weeks through 09/16/16 and the results would be submitted to the facility Quality Assurance Performance Improvement committee. · On 08/11/16, the facility planned to begin random audits of at least five employees to assure the employees are knowledgeable about facility dietary policies. These audits will be conducted by the DON and the Dietary Manager three times a week for four weeks through 09/16/16 and the results would be submitted to the facility Quality Assurance Performance Improvement committee. · On 08/11/16, the medical records for Residents #2, #4 and #5 were reviewed for dysphagia, swallowing difficulties, and mechanically altered diet textures with no identified concerns noted. The medical record for Resident #7 was reviewed for choking, dysphagia, and a mechanically altered diet texture and revealed no identified concerns. · On 08/12/16 between 2:00 P.M. and 3:30 P.M., interviews with Dietary Staff #14, #16 and #40, State tested Nurse Aides (STNA) #11, #12, #13, #20, #21, #22, #24, #25, #26, #27, #29, #31, #32, #33 and #41, Registered Nurses (RN) #12, #15, #23, #30 and #34, LPNs #7, #19 and #29, and Staff Development Nurse #39 revealed all staff were able to describe the new meal service plan that had been implemented. All were able to verify they had been in-serviced regarding resident diets and food consistencies. Although the Immediate Jeopardy was removed, the facility remained out of compliance at severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy), as the facility is in the process of implementing their corrective actions and monitoring for effectiveness. Findings include: 1. Review of the medical record for Resident #1 revealed an admitted to the facility of 10/13/08. [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/20/16, revealed Resident #1 had no memory impairments. The resident was identified to have fluctuating periods of disorganized thinking and inattention. Resident #1 was independent with eating after set up help, received a mechanically altered diet, and had no signs or symptoms of swallowing issues noted within the seven day assessment reference period. Review of physician orders dated 09/23/15 revealed Resident #1 had a diet order for regular diet with a mechanical soft texture when wearing her dentures and to downgrade the diet texture to a pureed diet if not wearing her dentures. Review of Resident #1's plan of care initiated on 07/26/16 revealed the focus area for dietary indicated the resident had a history of [REDACTED]. Interventions included a mechanical soft diet texture if her dentures were in place, if the resident did not have her dentures in place, the diet was to be downgraded to a pureed diet texture, and for staff to monitor for signs of aspiration. Review of Speech Therapy (ST) notes dated 08/26/15 through 09/15/15 revealed the resident had been evaluated for difficulty swallowing and the resident had recalled choking on a hot dog on a previous occasion. The notes further revealed the resident had received new dentures. The notes revealed the resident denied chewing or swallowing difficulties at that time, the resident required safety reminders, and the resident frequently removed her dentures. Review of the nurse's notes dated 07/09/16 at 4:45 P.M. revealed Resident #1 was eating supper and choked on a piece of hot dog that was not cut up small enough. The resident was able to cough the food up on her own and no injuries were noted. Review of nurses' notes dated 08/08/16 at 4:55 P.M. revealed Resident #1 was eating the hot dog she had requested for supper and had a subsequent choking episode and received the [MEDICATION NAME] maneuver. The nurse's notes further revealed the resident did not have her bottom dentures in place and the hot dog had not been cut up before being served to the resident. The resident was assessed after the incident and no [MEDICATION NAME] effects were noted. Review of the undated Summary of Investigation regarding the incident on 08/08/16 when Resident #1 choked, documented a facility interview with STNA #11. She stated she was sitting near Resident #1 when the resident put her head down, and shook her head yes to indicate she was choking after being questioned by STNA #11. STNA #11 implemented the [MEDICATION NAME] maneuver while STNA #13 went to get the nurse. Resident #1 expelled a piece of hotdog during the [MEDICATION NAME] maneuver. STNA #13's statement revealed she had attempted to assist STNA #11 in standing Resident #1 up, however the resident was unable to stand. STNA #13 stated she went to get the nurse while STNA #11 initiated the [MEDICATION NAME] maneuver. RN #12's statement revealed he was not present in the dining room when the resident choked. STNA #13 summoned him to the dining room where upon arrival Resident #1 was expelling a piece of hotdog. The resident had no [MEDICATION NAME] effects related to the incident. The resident's physician and family were notified of the incident. During an interview on 08/08/16 at 1:13 P.M., Dietary Staff #14 stated she served a regular hot dog to Resident #1 on 08/08/16 without cutting it into small pieces. She stated she assumed the resident had her dentures in place but did not check. Dietary Staff #14 verified the resident was not to receive the hot dog without cutting it up. She further stated she was unaware of the resident's physician order to puree the food if the resident did not have her dentures in place. Interview on 08/11/16 at 1:35 P.M. with STNA #11 revealed she was in the dining room when she observed Resident #1 choke on 08/08/16 around 4:30 P.M. STNA #11 stated she was sitting at the same table as Resident #1 and when she looked over at the resident she observed her head to be drooping. The STNA stated she asked the resident twice if she was okay and the resident did not answer. She stated she then asked the resident if she was choking and the resident nodded her head yes but was unable to speak. She stated she performed the [MEDICATION NAME] maneuver on the resident and, when she rechecked the resident, there was slight discoloration of her lips and the resident still could not respond verbally to her. STNA #11 stated she performed the [MEDICATION NAME] maneuver again and the resident brought up pieces of a hot dog. STNA #11 stated she observed the resident's bottom dentures sitting on the resident's lap. STNA #11 stated STNA #13 was in the dining room with her at the time and went to get the nurse from the other dining room. Further interview with STNA #11 revealed she was trained on how to do the [MEDICATION NAME] maneuver. During an interview on 08/11/16 at 2:35 P.M., RN #12 revealed he was on duty when Resident #1 choked. He stated he was in another dining room and was informed by STNA #13 of a resident choking in the other dining room. He stated he immediately went to the dining room where Resident #1 was eating her meal. He stated the resident was in no distress when he arrived. STNA #11 had already performed the [MEDICATION NAME] maneuver and dislodged the hot dog. He stated he observed a whole hot dog in front of the resident with one bite missing. Resident #1's bottom dentures were sitting on the table by her plate when he arrived in the dining room. He stated he assessed the resident and noticed no lingering effects or signs of aspiration. He further stated he filled out an incident report and notified the physician and family. During an interview on 08/11/16 at 2:38 P.M., STNA #13 revealed she was in the dining room with STNA #11 on 08/08/16 when Resident #1 choked on a hot dog. STNA #13 stated she was at the table next to Resident #1 assisting other residents. STNA #13 stated she heard STNA #11 asking Resident #1 if she was okay and then if she was choking. She stated the resident did not verbally respond but nodded her head to indicate she was choking. She further stated the resident was unable to stand on her own so she helped STNA #11 stand the resident and then STNA #11 performed the [MEDICATION NAME] maneuver. STNA #13 stated she ran to get the nurse on duty in the other dining room. Upon returning to the dining room she noticed the resident had coughed up pieces of hot dog. During an interview on 08/11/16 at 3:00 P.M., Dietary Manager (DM) #10 verified Resident #1 received the wrong diet on 08/08/16. DM #10 verified the hot dog should have been cut up if the resident was wearing her dentures at the time the meal was served. DM #10 verified Resident #1's hot dog should have been pureed if she was not wearing her dentures at the time the meal was served. She provided a copy of the resident's meal ticket which revealed the resident was to be served a mechanical soft diet when dentures were in place and a pureed diet if there were no dentures in use. DM #10 stated the dietary staff takes each order from the resident just prior to serving the meal. The dietary staff should have observed whether the resident had her dentures in or not and then served the appropriate meal. She stated the dietary staff was responsible for obtaining the resident's meal request, preparing the food, and serving it to the residents. DM #10 stated each resident has a dietary meal ticket which was used by the dietary staff at each meal to identify the residents ' diets. Interview on 08/11/16 at 3:10 P.M. with the Registered Dietitian (RD) revealed she consulted at the facility at least monthly. During these visits she audited accuracy of dietary service and assured the correct diets were being served. She stated she worked closely with DM #10 on any problems encountered since the prior visit. Review of the last RD visit to the facility, dated 08/03/16, revealed the kitchen and each serving area were toured, findings were discussed, and plans of corrections, as well as menus, were being reviewed. Review of the disciplinary form titled Employee Conference, dated 08/09/16, revealed Dietary Staff #14 was educated by DM #10 regarding proper consistencies for a mechanical soft texture diet. Review of the facility policy titled Regular Mechanical Soft Diet, dated 02/2015, revealed the texture of meat on a mechanical soft diet was ground and moist, or naturally tender. The policy revealed foods which were difficult to chew were to be modified to ground consistency or shredded. Meats should be moistened with gravy, sauce or appropriate condiments to increase palatability and acceptance. The policy documented hot dogs were allowed if they were of ground texture. Review of the facility policy titled Regular Pureed Diet, dated 02/2015, revealed the texture of pureed foods should be smooth, thick, moist, hold shape, require little or no chewing, and be easy to swallow. It revealed it would include all foods on the regular diet. Review of the undated recipe for ground hot dogs and undated recipe for pureed hot dogs revealed the hot dog was to be ground to the desired consistency. 2. Review of the medical record for Resident #3 revealed the resident was originally admitted to the facility on [DATE] and re-admitted on [DATE]. [DIAGNOSES REDACTED]. Review of the comprehensive MDS assessment, dated 05/27/16, revealed Resident #3 had minimal cognitive deficits and required supervision for eating. The assessment identified the resident received a mechanically altered diet and had no issues with swallowing, chewing, or choking. Review of the physician order, dated 08/19/15, revealed Resident #3 had an order for [REDACTED]. Review of the plan of care for Resident #3, dated 06/06/16, revealed a focus area identifying the resident had a nutritional risk and a history of dysphagia. Interventions identified at the family's request revealed Resident #3 received a mechanical soft diet instead of a pureed diet. The family was provided education on the risk of the mechanical soft diet. Interventions also included a regular diet with ground meats, cream soups only and nectar think liquids, and observe for swallowing problems. Review of nurse's notes, dated 04/28/16, documented the resident had a coughing episode for five minutes during the lunch meal and coughed up chunks of mechanical soft Beef Manhattan. The note documented the resident was able to talk, had no signs of aspiration, and a care referral was sent to Speech Therapy. Review of a Care Referral sheet, dated 04/28/16, revealed Resident #3 had a coughing episode while eating mechanical soft Beef Manhattan and the resident had to cough up and expel the meat. The referral revealed the resident was screened by the Speech Therapist (ST) on 05/05/16 and found to have increased mastication and slight throat clearing at times. The resident refused therapy services at that time. Review of a modified [MEDICATION NAME] swallow test dated 12/11/15, revealed the resident had moderate to severe dysphagia and trace aspiration with a delayed swallow response. Review of an Interdisciplinary Team Meeting, dated 08/03/16, revealed the resident was on a regular ground meat diet with cream soups. Observation of Resident #3 on 08/11/16 at 11:50 A.M. revealed the resident was in the dining room eating chicken rice soup. The soup was observed with several crackers crushed on top of the soup and nickel sized chunks of chicken present. The soup appeared to be very dry in appearance. Resident #3 was observed to choke after a bite of the soup and the resident was unable to speak. ST #18 was seated at a table beside Resident #3 and called for the nurse. RN #15 approached the resident who was unable to respond and had a blue tint to her lips. RN #15 performed the [MEDICATION NAME] maneuver with three abdominal thrusts and the resident began breathing and swallowing. RN #15 assessed the resident, who stated she wanted to continue to eat, and the staff assisted her with alternate food. Review of Resident #3's nurse's notes, dated 08/11/16 at 11:50 A.M., documented the resident was seated at a table in the dining room eating when Speech Therapy signaled for RN #15 to assess the resident. The resident was observed choking on food, was not breathing or coughing, was flushed, tearful, gagging, and trying unsuccessfully to cough. RN #15 asked the resident if she could cough it out, no verbal response was obtained and RN #15 performed three abdominal thrusts and reassessed the resident at which time the resident was breathing, tearful, pink in color and coughing. No food objects were expelled or found by RN #15. The notes further revealed the nurse heard slight wheezing in the resident's lungs after the episode and the resident had an oxygen saturation level of 93 percent. The notes further documented the resident wanted to finish her meal with the food item of concern being removed and a substitute given. Review of nurse's notes dated 08/11/16 at 12:00 P.M. documented the resident had requested chicken rice soup for lunch. The note revealed the nurse had instructed the dietary staff to drain the liquid from the soup and add crackers for thickening purposes as the resident was to receive nectar thick liquids. Review of the meal ticket for Resident #3 revealed the resident was to have a regular diet with ground meat, nectar thick liquids and cream soups only. During an interview on 08/11/16 at 11:55 A.M., Dietary Staff #16 revealed Resident #3 was on a mechanical soft diet and thickened liquids. She stated she had received an approval to serve the chicken rice soup to the resident. She verified the broth was drained from the soup and crackers were added to provide the thickened liquid diet. She verified the resident was eating the soup when she choked. During interview on 08/11/16 at 12:00 P.M., RN #15 revealed Resident #3 began coughing and choking while eating her meal. RN #15 stated the resident was not breathing, she performed the [MEDICATION NAME] maneuver, and the resident started breathing. She further stated she did not observe any food expelled from the resident's mouth. RN #15 stated the resident wanted to continue eating and was provided a sloppy joe sandwich, cut into small pieces. RN #15 verified Resident #3 was eating the soup with the liquid drained from the soup and crackers added. She further stated the resident did have a history of choking. During an interview on 08/11/16 at 12:10 P.M., LPN #17 verified she gave permission to let Resident #3 have the chicken rice soup. She stated the resident had problems consuming thin liquids and was ordered creamed soups. LPN #17 stated the consistency of the soup with the chicken and rice would be thick enough for the resident to eat so she instructed Dietary Staff #16 to drain the liquid off the soup and add crackers to make it easier for the resident to eat. Interview on 08/11/16 at 12:30 P.M., DM #10 revealed she had been informed of the choking incident with Resident #3. She stated she did not feel the facility had served an inappropriate food because the resident's big problem was thin liquids and they drained off the thin liquids and added crackers. DM #10 revealed when the broth was drained from the soup it was more like an entree and the resident could have had the chicken and rice entree on a ground meat diet. She did verify the food item was served as a soup and it was not the same recipe as an entree nor had it been an approved substitute in the form it was changed to. She stated the facility used canned chicken that was shredded and was told the chicken had also been ground for the ground diets. DM #10 verified Resident #3 was to be served cream soups only per her physician order. During an interview on 08/11/16 at 12:50 P.M., ST #18 verified she witnessed the choking event with Resident #3 at the noon meal. She stated she was at the table beside the resident, noticed there was a problem with choking, and summoned the nurse. She stated she got up and went to the resident and observed the food items served. She stated as a speech therapist she did not feel the chicken rice soup was an appropriate diet even with the broth drained. She stated the chunks of chicken were too big for a ground texture diet and further stated some type of fluid was needed to assist with swallowing. She stated with the resident's history of choking it was unsafe to provide the meal which was served not according to the resident's current diet order as per the meal ticket. She stated the food looked very dry and had a lot of crackers on top. ST #18 further stated it may have been okay to add the crackers, but not after the broth had already been drained off because it made it too dry to swallow as the moisture was not present for mobility of food in the throat. During an interview on 08/11/16 at 1:45 P.M., Resident #3 stated the soup was too dry with all the crackers and she could not swallow it. She stated she needed some type of fluid to get it down. She further stated she was doing okay at the time of the interview. Review of an undated recipe for chicken rice soup revealed cooked chicken meat was to be used. Ground meat texture diets were to have the meat ground to the desired consistency. The soup should have bread crumbs, crackers or thickener added for thickened liquid diets and should be served at the prescribed thickened consistency. Review of facility policy titled Regular Mechanical Soft Diet, dated 02/2015, revealed the meat texture of a mechanical soft was ground and moist, or naturally tender. It revealed foods which were difficult to chew were to be modified to ground or shredded texture. It further revealed meats should be moistened with gravy, sauce or appropriate condiments to increase palatability and acceptance. This citation substantiates Complaint Number OH 086.

Based on record review and staff and physician interview, and review of a website reference, the facility failed to ensure one resident was free from a significant medication error. This resulted in actual harm when Resident #1 was hospitalized for [REDACTED]. This affected one (#1) of three sampled residents in a total facility census of 108. Findings include: Review of Resident #1's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of physician orders [REDACTED].M. and 6:00 P.M. [MEDICATION NAME] an extended release [MEDICATION NAME]. Review of the medication administration records (MAR's) revealed the resident received the [MEDICATION NAME] ordered until 09/01/12. Review of the controlled drug record (CDR) for the medication revealed the resident received a dose of the medication on 09/01/12 at 5:10 A.M. by the third shift (11 P.M. to 7:00 A.M.) licensed practical nurse (LPN). The nurse initialed the medication off on the MAR indicated [REDACTED].M. by first shift (7:00 A.M. to 3:00 P.M.) LPN #7, when she gave the resident her other morning medications. Further review of the CDR, revealed LPN #7 noticed the medication error when she signed out the narcotic on the controlled drug record. Review of nurses' notes revealed a late entry dated 09/01/12 that indicated at 10:00 A.M., the resident was resting in bed, was alert and continued to complain of back pain. The nurse documented the physician office was updated regarding the extra dose of [MEDICATION NAME] having been given. At 11:45 A.M., the resident was documented as being in the dining room area sitting in a recliner, crying and complaining of back pain. She was taken to her room at that time and a transcutaneous electrical nerve stimulation (TENS) unit was applied for pain relief. The resident had a blood pressure of 120/70 and a pulse rate of 68. At 12:00 P.M., the TENS unit was removed and the resident stated it had provided no relief. She requested a pain pill and Staff LPN #7 administered [MEDICATION NAME] 5-500 mg. tablet 1 per physician orders. At 1:30 P.M., the resident was put back to bed per her request. At 2:00 P.M., the notes documented the resident was resting quietly in bed. Further review of the notes revealed a late entry dated 09/01/12 at 6:00 P.M. by the third shift LPN. The note documented the resident was in her in her room, in bed resting with eyes closed and voiced no complaints. A late entry documented at 7:00 P.M., indicated the second shift LPN contacted the registered nurse (RN) charge nurse to inquire if the 6:00 P.M. dose of the [MEDICATION NAME] should be held due to the resident being sleepy. The notes documented the charge nurse stated the [MEDICATION NAME] should be held but other medications could be given per schedule. The nurses notes dated 09/01/12 at 7:30 P.M., indicated the RN charge nurse went to Resident #1's room upon being notified of the [MEDICATION NAME] mg. being administered to the resident that morning. The resident was assessed as being pale and was lying in bed with eyes closed. The resident took four deep breathes, then had 45 seconds of apnea. The resident opened her eyes with a glassy stare to verbal and tactile stimuli. The resident had a blood pressure of 83/51 (normal 120/80), pulse 60 (normal 60-100) and an oxygen saturation level of 80% (normal 92% or above) on room air. Oxygen was applied at 10 liters per mask and 911 was called for transport to the emergency room . The resident was transported to the hospital by emergency squad at 8:00 P.M. The physician on call for the resident's attending physician was notified of Resident #1's condition and transport to the hospital. Review of the hospital history and physical indicated the chief complaint was drowsiness with a diminished respiratory effort. The resident had periods of apnea with a respiratory rate down as low as 4 to 6 per minute. Resident #1 was found to have evidence of acute urinary tract infection [MEDICAL CONDITION] in addition to possible narcotic toxicity and was admitted to the hospital. The resident returned to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 was started back on the [MEDICATION NAME] mg. by mouth on 09/05/12 while in the hospital and this medication was resumed after readmission to the facility on [DATE]. An interview was conducted with LPN #7 on 10/15/12 at 12:00 P.M. The nurse stated she "misread" the MAR, not noticing the third shift nurse had initialed the MAR indicated [REDACTED]. LPN #7 stated she gave the resident all her morning medications, including the [MEDICATION NAME] realizing the error until she signed the controlled drug record. She further indicated that she faxed the physician office regarding the incident, but never heard back. When asked why all her nurses' notes regarding the incident had been written the next day and marked "late entry", she replied that she did not feel it was a significant error and the resident seemed her usual self. She also stated that was the reason she did not regularly monitor the resident and record vital signs. During telephone interview with Resident #1's attending physician on 10/15/12 at 3:15 P.M., he stated that when Resident #1 received the second dose of MS Contin, within three hours, he would have expected the nurse to call him to report this error. He did not have office hours on 09/01/12, as it was a Saturday and he did not see the fax until Tuesday, 09/04/12. He indicated this was a significant medication error and that vitals signs and respiratory rates should have been closely monitored and documented in the medical record. The resident had just been placed on this medication on 08/27/12 and close monitoring should have been a standard of practice. Review of the website www.drugs.com revealed respiratory depression, including fatal cases, may occur with the use of MS Contin, even when the drug has been used as recommended and not misused or abused. Proper dosing and titration are essential. Monitor for respiratory depression, especially during initiation of [MEDICATION NAME] following a dose increase. Acute overdosage with [MEDICATION NAME] is manifested by respiratory depression, somnolence progressing to stupor or coma, skeletal muscle flaccidity cold clammy skin, constricted pupils, and, in some cases, [MEDICAL CONDITIONS], [MEDICAL CONDITIONS], and death. Interview with the Administrator on 10/15/12 at 9:45 A.M., verified the above findings. "This deficiency substantiates Complaint Number OH 573."