Every finding on record at Chapel Hill Community

Based on record review and interview, the facility failed to ensure Resident #9 was assessed following a reported incident in which the resident acquired bruising on her forehead. This finding affected one (Resident #9) of three residents reviewed for quality of care. Findings include: Review of Resident #9's progress note dated 04/10/25 at 3:00 P.M. revealed the resident stated yesterday morning while she was sitting on the commode, she leaned forward and bumped her forehead on the handrail which caused a small faint bruise. She stated she did not tell staff this occurred yesterday. Resident #9 denied complaints of pain/dizziness/or blurred vision. The daughter was present at the time of the conversation and the physician was notified. Review of Resident #9's progress note dated 04/11/25 at 9:23 A.M. revealed the interdisciplinary team (IDT) reviewed the incident of 04/10/25. The resident stated that yesterday morning while sitting on the commode, she leaned forward and bumped her forehead on the hand rail which caused a small faint bruise to the middle of the forehead. She denied complaints of pain/discomfort/dizziness. The power-of-attorney (POA) and physician were notified. Review of Resident #9's medical record did not reveal evidence the resident's skin was assessed following the incident in which the resident acquired a bruise on her forehead. Interview on 04/24/25 at 9:41 A.M. with the Director of Nursing (DON) revealed Registered Nurse (RN) #222 talked to resident who stated she bumped head on grab bar in bathroom. DON confirmed RN #22 did not complete a full assessment of Resident #9's skin on 04/10/25 following the reported incident in which the resident acquired a bruise to the resident's forehead. Review of the Accident/Incident policy and procedure revised 01/10/14 revealed the nurse would document the incident in the narrative nurse notes section of the resident's medical record and include the first aide, vital signs, and results of the physical assessment (i.e. bruises, scratches, edema, bleeding, redness, pain etc.). This deficiency represent non-compliance investigated under Complaint Number OH00165090.

Based on record review, policy review, and interview, the facility failed to ensure there was consistent communication between the facility and the dialysis center regarding Resident #48's health information and hemodialysis treatments. This affected one resident (Resident #48) out of one resident reviewed for dialysis. The facility census was 75. Findings include: Review of the medical record for Resident #48 revealed an admitted [DATE] with diagnosis including but not limited to paraplegia, end stage renal disease, acute kidney failure, and type 1 diabetes mellitus with hypoglycemia. Review of the physician's orders for April 2025 revealed orders for hemodialysis two times a week on Monday and Friday at the outside dialysis facility, send dialysis book with resident, obtain vital signs/assessment and post dialysis vital signs/assessment upon return, check vital sign pre and post dialysis (also check dialysis site) two times a day every Monday and Friday. Review of the dialysis communication binder for Resident #48 revealed only five (5) hemodialysis communication forms for January 2025 to April 2025, some were not completed accurately or at all. The first pre-dialysis communication form in the binder had no name or date, but had vital signs filled in the form. There was no signature of nurse who completed the pre-dialysis form. The post-dialysis form was completed by the dialysis unit with nurse signature and date of 01/10/25. There were no other forms located in the dialysis binder for Resident #48 for February 2025. The next communication form in the binder was dated 03/12/25 which included Resident #48's name date, and vital signs. There was no nurse signature of completion. The post-dialysis form was completed by the dialysis unit. The next communication form in the binder was dated 03/19/25 which included Resident #48's name and date. Nothing was completed on the pre-dialysis form and the post dialysis form was left blank. The next communication form in the binder was dated 03/26/25 which included Resident #48's name and date. Nothing was completed on the pre-dialysis form but it included the nurses' signature and date. The post dialysis form was left blank. The next communication form in the binder was dated 04/11/25 with the completed pre-dialysis information by the facility and post dialysis information by outside facility. Interview on 04/22/25 at 3:16 P.M. with Director of Nursing (DON) confirmed the dialysis communication forms were not being completed accurately or at all. DON confirmed the facility did not have all the dialysis communication forms for Resident #48 for all dialysis days. DON reported he just started the dialysis communication binder this year due to issues prior to getting notes for the dialysis facility. DON confirmed no other dialysis forms other than what is in the dialysis binder, to include only five (5) forms. DON reported there were no other dialysis communication forms available. Interview on 04/23/25 at 8:12 A.M. with Dialysis Registered Nurse (RN) 300 confirmed the outside dialysis facility didn't always receive the communication binder with forms completed. Review of facility policy, Outpatient Dialysis Services/Peritoneal Dialysis, revised 03/2022, revealed the facility provides in-house peritoneal dialysis and facilitates outpatient dialysis services to assure uninterrupted provision of care across the continuum.

Based on record review and interview, the facility failed to ensure non-pharmacological interventions were attempted prior to administering Resident #13's as needed anti-anxiety medication. This finding affected one (Resident #13) of five residents reviewed for unnecessary medications. Findings include: Review of Resident #13's medical record revealed the resident was admitted on [DATE] with diagnoses including vascular dementia, cognitive communication deficit and anxiety disorder. Review of Resident #13's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment. Review of Resident #13's care plans did not reveal interventions including attempting non-pharmacological interventions prior to administering the resident's anti-anxiety medication. Review of Resident #13's physician orders revealed an order dated 03/07/25 to document nonpharmaceutical and pharmaceutical interventions in the nurses notes along with the effectiveness every shift for behavior monitoring; an order dated 03/21/25 (discontinued 04/21/25) for Lorazepam (anti-anxiety) 0.5 mg (milligrams) administer one tablet by mouth every eight hours as needed for anxiety/agitation; and an order dated 04/21/25 for Lorazepam 0.5 mg give one tablet by mouth every eight hours as needed for anxiety/agitation for six months. Review of Resident #13's medication administration records (MARS) from 04/01/25 to 04/22/25 revealed the Lorazepam anti-anxiety medication was administered on 04/01/25 at 2:08 P.M.; 04/03/25 at 9:24 P.M.; 04/04/25 at 8:44 P.M.; 04/05/25 at 12:15 P.M.; 04/06/25 at 12:01 P.M.; 04/06/25 at 8:52 P.M.; 04/09/25 at 9:35 A.M.; 04/11/24 at 10:57 A.M.; 04/12/25 at 9:57 P.M.; 04/13/25 at 10:10 P.M.; 04/16/25 at 8:44 A.M.; 04/18/25 at 6:36 P.M.; 04/20/25 at 11:21 A.M.; and 04/20/25 at 9:06 P.M. Review of Resident #13's progress notes from 04/01/25 to 04/22/25 revealed no evidence non-pharmacological interventions were attempted prior to administering the as needed anti-anxiety medication. Interview on 04/22/25 at 1:44 P.M. with the Director of Nursing (DON) confirmed Resident #13's medical record did not have evidence non-pharmacological interventions were attempted prior to administering as needed anti-anxiety medications. Interview on 04/23/25 at 8:38 A.M. with Registered Nurse (RN) MDS #188 confirmed Resident #13's care plans were not complete and accurate and did not include an intervention for staff to attempt non-pharmacological interventions prior to administering the resident's anti-anxiety medication. Review of the Antipsychotic/Psychotropic Drugs policy revised 01/31/23 revealed antipsychotic and psychotropic drug therapy shall be used only when it was necessary to treat a specific condition. Gradual dose reductions and behavioral interventions, unless contraindicated, would be used to reduce or discontinue the use of antipsychotic and psychotropic drugs.

Based on record review, observation, staff interview and facility policy review the facility failed to implement enhanced barrier precautions during Resident #38's wound care. This deficient practice affected one resident (Resident #38) out of three residents reviewed for transmission based precautions. The facility census was 75. Findings Include: Review of Resident #38's medical record revealed admitted [DATE] with diagnoses including but not limited to fracture of right shoulder, dislocation of right shoulder, dementia, and depression. Review of Resident #38's admission Minimum Data Set (MDS) dated [DATE] revealed Resident #38 required assistance from staff to complete activities of daily living (ADL) tasks and required a sling to be worn on the right arm/shoulder related to a fractured right shoulder. Resident #38 had impaired cognition with a Brief Interview Mental Status (BIMS) score of five out of a possible 15. Review of Resident #38's physician orders dated 04/01/25 to 04/23/25 revealed an order dated 04/08/25 to cleanse spine with normal saline and pat dry. Apply Medihoney and cover with clean dry dressing. Change daily and as needed (PRN) if soiled, an order dated 04/08/25 to follow [NAME] Wound Care, and an order dated 04/21/25 for Resident #38 to be on enhanced barrier precautions (EBP) every shift for wound. Review of Resident #38's Treatment Administration Record (TAR) dated 04/08/25 to 04/22/25 revealed the order dated 04/08/25 to cleanse spine with normal saline and pat dry. Apply Medihoney and cover with clean dry dressing. Change daily and as needed (PRN) if soiled, was marked as completed daily. Review of Resident #38's at risk for skin alteration care plan dated 04/14/25 revealed Resident #38 had a pressure area Stage III to mid back with interventions including pressure reducing mattress and treatment as ordered, and enhanced barrier precautions (EBP) care plan related to chronic wounds (pressure ulcers) dated 04/22/25 with interventions including high contact resident care activities requiring EBP: performing wound care. Review of Resident #38's full skin assessment dated [DATE] revealed the initial wound assessment for pressure area to mid back measuring 5.8 centimeters (cm) by 1.0 cm by 0.1 cm with light drainage noted. Observation on 04/22/25 at 1:58 P.M. revealed Licensed Practical Nurse (LPN) #145 and LPN #190 completing wound dressing change for Resident #38. LPN #145 and LPN #190 entered Resident #38's room, washed their hands and donned gloves. Both LPN #145 and LPN #190 did not follow EBP protocol and don Personal Protective Equipment (PPE) prior to entering Resident #38's room. Further observation of Resident #38's room revealed there was no PPE cart available, there was no notification sign to reflect Resident #38 having EBPs, and there were no soiled linen bins for the used PPE to be placed after use. An interview on 04/22/25 at 2:15 P.M. with LPN #145 confirmed Resident #38 was ordered to have EBPs in place due to the wound located on the back and there was not a notification sign on the door, there was no PPE available outside the door for staff use, and there were no soiled linen bins in the room for soiled linen to be placed. Review of the facility's policy titled Isolation Precautions dated 03/2025 revealed Enhanced Barrier Protection (EBP) are used in conjunction with standard precautions and expand the use of personal protective equipment (PPE) to donning gown and gloves during high contact care activities. EBPs are indicated for residents with wounds, infection and/or indwelling medical devices.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on a facility self-reported incident (SRI) review, medical record review, policy review and staff interview the facility failed to ensure resident narcotic medication was not misappropriated by a staff member. This affected two (Resident #23 and #73) of two residents reviewed for misappropriation of resident property. The facility census was 72. Findings include: Review of Resident #73's closed medical record revealed an admitted [DATE] with diagnoses that included spinal stenosis, dorsalgia, chronic obstructive pulmonary disease and congestive heart failure. The resident was prescribed the use of oxycodone 5 mg every eight hours as needed for pain relief. Review of Resident #23's medical record revealed an admitted [DATE] with diagnoses that included end stage renal disease with hemodialysis and congestive heart failure. The resident was prescribed the use of primidone 50 mg three times daily for tremors. Review of the facility SRI #245842 revealed on 03/31/24 Registered Nurse (RN) #119 removed Resident #73's oxycodone (narcotic opioid analgesic) medication blister card from the medication cart after the resident had discharged home. Upon inspection of the medication blister card, she observed possible tampering of the medication card and medication. The facility administrator was notified immediately, who notified the facility pharmacist. The medication blister card was locked in the RN #119's secured lock box in her office for pharmacist review. On 04/01/24 the pharmacist verified that six oxycodone five milligram (mg) pills for Resident #73 were replaced with primidone (for control of tremors) 50 mg pills from Resident #23. Local police, the State Survey Agency, Pharmacy Board and Board of Nursing were notified at this time. Facility investigation identified Licensed Practical Nurse (LPN) #121 as staff member responsible for diversion of the narcotic medications (the LPN had been documenting an increase in resident narcotic use). LPN #121 was terminated. Review of RN #119 witness statement dated 03/31/24 verified discovery of diversion of six oxycodone 5 mg tablets for Resident #73 with six primidone 50 mg tablets from Resident #23. Review of the pharmacist statement dated 04/01/24 verified diversion of six oxycodone 5 mg tablets for Resident #73 with six primidone 50 mg tablets from Resident #23. On 05/21/24 at 2:25 P.M. interview with the Director of Nursing verified six oxycodone 5 mg tablets for Resident #73 were misappropriated by LPN #121 and replaced with six primidone 50 mg tablets from Resident #23 as indicated in the SRI. On 05/21/24 at 2:50 P.M. interview with RN #119 verified she identified a tampered medication blister card for Resident #73's oxycodone and reported the concern to the administrator immediately. Review of the facility policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property with a revision date of 10/20/22 indicated residents have the right to be free from abuse, neglect, exploitation and misappropriation of resident property. As a result of the incident, the facility took the following actions to correct the deficient practice on 04/01/24: On 03/31/24 when the discrepancy of the narcotic medication card was identified, the incident was reviewed, the residents were interviewed to make sure their pain was managed by the DON and ADON. LPN #121 was removed from the schedule and subsequently terminated. LPN #121 was determined, through facility investigation, to have misappropriated the residents' medications. Nursing staff were re-educated by the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 03/31/24 on the following procedures: narcotic counting, pain assessment and pain interventions. Facility wide audit of narcotic books and narcotic counting by DON and ADON on 03/31/24. Facility wide education for resident abuse including misappropriation of resident property by Administrator on 03/31/24. The pharmacist observed the medication blister card and determined six oxycodone were removed and replaced with six primidone on 04/01/24. The Board of Pharmacy was notified, the Board of Nursing was notified, the State Survey Agency was notified, a police report was made, nurses on that medication cart were sent to be drug tested on [DATE]. Starting on 03/31/24 monitoring and audits of all narcotic books will be conducted at a minimum of three to five times per week and a minimum of three to five staff members will be interviewed and observed on narcotic counting, pain interventions and pain assessment procedures and interventions for pain management by the DON and ADON. Results will be reviewed at Quality Assurance and Performance Improvement meetings for further intervention.

Based on observations, interviews, facility food temperature logs review, and facility policy, the facility failed to ensure food items were served at palatable temperature which had the potential to affect all 67 residents who received food from the kitchen. The facility identified Resident #67 as receiving nothing by mouth. The facility census was 68. Findings include: Interview on 06/05/23 at 10:34 A.M. revealed Resident #61 felt the food was cold sometimes. Observation was conducted on 06/05/23 from 5:00 P.M. to 5:40 P.M. of dietary staff plating the lunch meal from a steam table in the second-floor unit dining room. As the tray line neared an end, the surveyor requested a test tray be prepared and placed on the second-floor room tray food cart. Observation was made as the test tray was prepared, placed on the cart at 5:31 P.M., transported, and arrived at 5:32 P.M. to second floor room location where those room trays were going to be passed. The test tray remained on the cart in view of the surveyor, until all other trays were distributed to residents. The test tray was removed from the cart at 5:36 P.M. by Dietary Director (DD) #701 who confirmed with a facility thermometer the turkey was 120 degrees Fahrenheit (F), mashed potatoes were 120 degrees F, the beets were 119 degrees F, the milk was 46.9 degrees F, and the coffee was 153 degrees F. Immediately following confirmation of the test tray temperatures, the surveyor taste-tested the turkey, mashed potatoes, and beets. All items were found to have appropriate texture and flavor but were not at a palatable temperature since all items did not taste hot and were barely warm. At the time of observation, DD #701 confirmed the food items could be warmer, the facility used to have plate warmers in the past, and she had never done a test tray to ensure food was being served at an appropriate temperature. Interview on 06/06/23 at 9:36 A.M. with Social Services #704 revealed the food could be better and the biggest complaint from residents was the food was cold. Interview on 06/06/23 at 10:05 A.M. with Licensed Practical Nurse #315 revealed the food was cold especially at dinner and some items, like fish, don't appear to be cooked thoroughly. Interview on 06/06/23 at 1:40 P.M. revealed Residents #57 and #58 felt the food was cold when they received their room trays. Interview on 06/06/23 at 2:45 P.M. revealed STNA #647 had heard lots of food complaints from residents, which were mostly directed at the dinner meal with items being cold and not being cooked correctly. Review of the facility concern log from 03/20/23 to 05/31/23 revealed on 04/12/33 Residents #57 and #58 felt food was often served cold in their rooms and were told to go to the unit dining room for warmer food. Review of May 2023 food temperature logs in the main kitchen revealed dinner food temperatures had only been recorded nine out of 31 dinners served to the residents. Review of May 2023 food temperature logs in the ground floor servery revealed dinner food temperatures had only been recorded seven out of 31 days. Review of May 2023 food temperature logs in the second floor servery revealed dinner food temperatures had only been recorded 11 out of 31 days. Interview on 06/06/23 at 11:31 A.M. with the Director of Dietary #701 confirmed the food temperature logs for meal items served out of the main kitchen and in the servery on the ground floor and second floor had many days where the dinner meal items were not recorded. Since the meal item temperatures had not been recorded for those meals, she could not ensure those items were properly cooked. Director of Dietary #701 stated it was her job to ensure temperatures of meal items were being recorded but she had fallen behind on checking them. Review of facility policy Food and Drink, revised 12/17/18, revealed food and drink would be palatable, attractive, and at a safe and appetizing temperature. The temperatures of the food items would be taken and properly recorded for each meal. Hot food items would be greater than 135 degrees Fahrenheit (F) when leaving the hot holding serving system. Cold food temperatures would leave the serving area at or below 41 degrees F. This deficiency represents non-compliance investigated under Complaint Number OH00143294.

Based on observation, record review and interview, the facility did not ensure food was stored, prepared and served under sanitary conditions. This had the potential to affect 67 residents who received food from the kitchen. The facility identified one resident (#67) as receiving nothing by mouth. The facility census was 68. Findings include: 1. Observation of the facility kitchen on 06/05/23 from 2:25 P.M. to 3:20 P.M. with the Director of Dietary (DD) #701 revealed the following concerns verified at the time of observation by DD# 701: The microwave in the kitchen area had an accumulation of spattered debris on the walls, inside of the door, and the inside top of unit; In the walk-in cooler, there was one five-pound container of sour cream with an open date of 5/18/23 and best if used by date of 5/29/23. One 30-pound bucket of sliced strawberries in syrup which was one fourth full, had a layer of white mold growing in it; In the dry storage area, the three, plastic bulk containers of oats, flour, and sugar had an accumulation of debris on the lids and bases of the units; In the room containing the dishwasher, both the floor and the top of the dishwasher had an accumulation of dirt and debris; The bottom shelf of the steam table closest to the wall had an accumulation of red rust-colored dry particles next to the meal sheet pans which were being stored on that shelf; The four black serving carts revealed an accumulation of dirt and debris on the shelves and base of the units; The floor of the kitchen had an accumulation of dirt and debris around most of the perimeter of the floor. Review of the undated facility policy Food Storage revealed food would be stored in an area that was clean. Review of undated facility policy 'Food Safety and Sanitation revealed the dry storage areas would be clean, leftovers would be used within three days, perishable foods with expiration dates would be used or discarded prior to the use by date on the package, when a food package was opened the food item would be marked to indicate the open date, which would be used to determine when to discard the food. 2. Observation was conducted on 06/05/23 from 2:25 P.M. to 3:20 P.M. with Dietary Employee (DE) #418 as DE #418 demonstrated cleaning of the food processor parts that would be used in making pureed food items for the residents on pureed diets. DE #418 dipped the parts directly into the sanitizing solution in the sanitizing compartment of the three compartment sink skipping over the wash and rinse steps in that process. DE #418 did not test the level of sanitizer before dipping the parts into it nor was there a log of sanitizing solution levels in the three compartment sink area. Interview on 06/06/23 at 11:31 A.M. with DD #701 confirmed there was no log of recorded sanitizer solution levels since she didn't know she had to keep one and without the log DD #701 said she could not ensure proper sanitizing levels were being met. Review of manufacturer instructions for Array Concentrated Ultimate Quaternary Sanitizer revealed to be effectively sanitized, items had to be immersed for at least 60 seconds in a sanitizing solution of the product, which measured with 200 parts per million with test papers. 3. Observation on 06/05/23 from 4:40 P.M. to 5:40 P.M. of the dinner service in the second floor servery with DD #701 revealed while taking the food temperatures of the items in the steam table, DE #419 had taken the cover off of the thermometer and placed the thermometer probe in the turkey, then in the beets, then in the mashed potatoes and then in the gravy. After taking the temperature of the gravy, DE #419 was observed taking an alcohol swab and wiping the gravy residue off the thermometer probe. DE #419 then took the temperature of the ground turkey and then the grilled cheese. DE #419 was observed wiping the thermometer probe with an alcohol swab prior to putting the thermometer away. Interview at the time of observation with DE #419 revealed he only wiped the thermometer probe with an alcohol swab prior to putting it away unless he needed to clean some residue off the probe. Interview with DD #701 during the observation revealed the thermometer probe should have been wiped with an alcohol between different items to prevent cross contamination. According to Servsafe Manager. 7th ed., National Restaurant Association Education Foundation, 2018, thermometers must be sanitized before and after using to prevent cross contamination (page 4.9). This deficiency was a result of incidental findings investigated under Complaint Number OH00143294.

Based on record review, observation and interview, the facility failed to ensure Residents # 6, #35, #42, and #45 were fed in a respectful and dignified manner. This affected four (#6, #35, #42, and #45) out of six residents reviewed for dining services. The facility census was 68. 1. Record review for Resident # 6 revealed an admitted [DATE]. Diagnoses included dementia, muscle weakness, need for assistance with personal care, cognitive communication deficit, anxiety disorder, schizophrenia, and age-related physical debility. Review of physician orders for Resident #6 revealed an order dated 03/09/23 for a no added salt, regular texture, regular/thin liquids diet. Review of 06/09/23 annual Minimum Data Set (MDS) 3.0 assessment revealed Resident #6 was severely impaired cognitively and required extensive assist of one for eating. Observation on 06/05/23 at 12:57 P.M. of the memory care unit dining room revealed Licensed Practical Nurse (LPN) #315 was feeding Resident #6 standing up with an empty chair observed next to Resident #6. Interview on 06/05/23 at 1:14 P.M. with LPN #315 confirmed she stood to feed Resident #6 and stated sometimes she stood and other times she sat to feed residents. 2.Review of medical record for Resident #35 revealed an admitted [DATE]. Diagnoses included Alzheimer's disease, dementia, dysphagia (difficulty swallowing), severe protein calorie malnutrition, other lack of coordination, glaucoma (group of eye diseases that cause vision loss), and macular degeneration (eye disorders that cause blurred or reduced central vision). Review of the 03/19/23 quarterly MDS 3.0 assessment revealed Resident #35 had severe cognition impairment and required extensive assist of one person for eating. Review of physician orders for Resident #35 revealed an order dated 04/06/22 for a regular, mechanical soft, regular/thin consistency diet. Review of 06/29/21 care plan revealed Resident #35 had an activity of daily living (ADL) self-care performance deficit related to impaired mobility and cognitive impairment. Interventions included staff were to encourage Resident #35 to participate to the fullest possibility with each interaction. Observation on 06/05/23 at 4:40 P.M. revealed State tested Nursing Assistant (STNA) # 639 was standing up and feeding Resident #35 in the unit dining room. Interview on 06/05/23 at 5:00 P.M. with STNA #639 confirmed she fed Resident #35 while standing up and stated normally Resident #35 only needed some assistance with a couple bites but today needed more assistance. 3. Review of medical record for Resident #42 revealed an admitted [DATE]. Diagnoses included dementia, psychosis (mental disorder characterized by a disconnection from reality), weakness, age related physical debility, abnormal weight loss, and glaucoma (group of eye diseases that cause vision loss). Review of 04/17/23 annual MDS 3.0 assessment revealed Resident #42 had severe cognition deficit and required supervision with set up for eating. Review of physician orders for Resident #42 revealed an order dated 06/29/22 for a regular diet, regular texture, and regular/thin consistency diet. Review of care plan dated 06/29/22 revealed Resident #42 had a self-care performance deficit related to debility. Interventions included encourage participation to the fullest extent possible with each interaction. Observation of the memory care unit dining room on 06/05/23 at 1:04 P.M. revealed STNA #618 was feeding Resident #42 while standing up. Interview on 06/05/23 at 1:18 P.M. revealed STNA #618 confirmed she had stood while feeding Resident #42 and stated it all depended on if there was an empty chair if she stood or sat to feed residents. 4. Review of medical record for Resident #45 revealed an admitted [DATE]. Medical diagnoses included: heart failure, muscle weakness, unspecified dementia, cognitive communication deficit, dysphagia, altered mental status, and other lack of coordination. Review of Resident #45's physician order dated 09/08/22 revealed an order dated 09/08/22 for a regular diet, mechanical soft texture, 1800 milliliter fluid restriction. Review of quarterly MDS 3.0 assessment dated [DATE] revealed Resident #45 was severely impaired cognitively and required extensive assist of one for eating. Observation on 06/05/23 at 12:21 P.M. revealed STNA #648 was observed feeding Resident #45 in the unit dining room standing up while a stool on wheels was beside her. Interview on 06/05/23 at 12:33 P.M. with STNA #648 confirmed she had stood while feeding Resident #45 and stated at her prior place of employment she was not allowed to sit but instead had to crouch. Interview with the Director of Nursing on 06/05/23 at 5:45 P.M. confirmed staff should be sitting while feeding residents and he was going to in-service staff and order more stools. Review of facility policy Residents Rights, revised 10/14/19, revealed residents had the right to be treated with respect and dignity. This deficiency represents non-compliance investigated under Complaint Number OH00143294.

Based on review of the facility job description, personnel record review, and staff interview, the facility failed to ensure a qualified person was designated to serve as the director of food and nutrition services. This had the potential to affect all 68 residents residing in the facility. Findings Include: Review of the undated facility job description for Director of Dining Services revealed the Director of Dining Services was responsible for controlling and supervision the dining services to ensure the provision of quality of food service and nutritional care. Essential functions included ensuring cleanliness and sanitary work habits of dietary personnel, inspecting the entire department regularly to ensure safe, sanitary, and orderly conditions were maintained, and maintaining required records and reports. Requirements included: a bachelor's degree was preferred, two to three years of supervisory experience in hospital or long term care facility department was desirable, and applicant must have either a degree in dietetics or related area from a university/college approved by Commission on Dietetic Registration preferred, Dietetic Technician Registered certification desirable, possess a certified dietary manager certification, or has a similar national certification for food service management and safety from a national certifying body, and must obtain and maintain mandatory state/federal requirements and certifications for practice. Review of the personal file for Director of Dietary (DD) #701 revealed the DD #701 was not a certified dietary manager or certified food service manager. DD #701 did not hold an associate's or higher degree in food service management or in hospitality. DD #701 did not have two or more years of experience in the position of director of food and nutrition services in a nursing facility setting. DD #701 had completed a course of study in food safety on [DATE], however, the certification expired on [DATE]. DD #701 was noted to have over [AGE] years of experience as a cook in a nursing home or independent living kitchens. Review of the list of staff for the facility revealed the facility employed a part time registered dietician who worked at the facility two days a week. Interview on [DATE] at 10:30 A.M. with the Administrator verified the lack of necessary qualifications for DD #701 to serve as the Director of Dining Services, and the RD only worked at the facility two days a week This deficiency resulted from incidental findings during the investigation of Complaint Number OH00143294.

Based on record review, observation and interview, the facility failed to ensure adaptive eating equipment was provided at meals for Resident #21 and Resident #33. This affected two residents (#21 and #33) of six residents reviewed for dining services. The facility census was 68. Findings include: 1.Review of medical record for Resident #21 revealed an admitted [DATE]. Diagnoses included abnormal posture, anxiety disorder, bipolar disorder, cognitive communication deficit, dysphagia, unspecified dementia major depressive disorder, and Parkinson's disease. Review of the 04/05/23 annual Minimum Data Set (MDS) 3.0 assessment revealed Resident #21 had severe cognitive deficit, required supervision with one-person physical assist for eating, had no swallowing concerns, and was on a mechanically altered diet. Review of Resident #21's physician order dated 07/12/22 revealed an order for regular diet, mechanical soft texture, no bread or rice, pureed meat with divided plate and weighed silverware. Review of 07/07/22 care plan revealed Resident #21 had an activity of daily living deficit related to progressive diagnoses with an intervention of staff supervision with meals. Review of 07/11/22 care plan revealed Resident #21 had an increased risk of alteration in nutrition related to Parkinson's disease, needed a mechanically altered diet due to dysphagia, and sometimes refused adaptive utensils and requested regular utensils. Interventions included adaptive equipment per occupational therapy and may offer regular utensils upon resident request. Review of occupational therapy note dated 10/30/22 revealed resident #21 displayed 75 percent spillage while using regular utensils and improved ability and coordination while using adaptive utensils. Review of occupational therapy note dated 11/07/22 revealed resident #21 did not have correct adaptive equipment during breakfast and the occupational therapy assistant educated staff for the need for the adaptive equipment. Kitchen staff stated, I couldn't find it. Review of occupational therapy note dated 11/10/22 revealed resident #21 did not have proper adaptive equipment and displayed increased spillage and difficulty bringing spoon to mouth with regular utensils. Observation on 06/05/23 from 11:59 A.M. to 1:20 P.M. revealed Resident #21 was sitting at a table in the unit dining room. Resident #21 had a divided plate and regular silverware. While self feeding, Resident #21's hands shook and had difficulty getting the puree spaghetti on the regular spoon and then getting the spoon with the puree spaghetti into Resident #21's mouth. Interview at the time of observation revealed Licensed Practical Nurse #315 confirmed Resident #21 had not received weighted silverware as ordered for lunch. Observation on 06/06/23 from 8:56 A.M. to 9:30 A.M. revealed Resident #21 was sitting at a table in the unit dining room and had a divided plate with eggs and oatmeal and regular silverware. The table area around the divided plate was observed to have spilled oatmeal and egg and particles of egg were observed on Resident #21's left hand. State tested Nursing Assistant (STNA) #648 confirmed there were no adaptive utensils and stated she was not sure if Resident #21 was to receive adaptive equipment. STNA #648 added there was no adaptive silverware available today. 2. Review of Resident #33 medical record revealed an admitted [DATE]. Diagnoses included encephalopathy, sever protein calorie malnutrition, dysphagia, dementia, cognitive communication deficit, Alzheimer's disease, anxiety disorder, and depression. Review of physician orders revealed Resident #33 had an order dated 04/25/23 for regular diet, pureed texture, and thin liquids. Review of 05/09/23 quarterly Minimum Data Set (MDS) revealed Resident #33 had severe cognitive impairment, required total dependence of one person assist for eating, had no swallowing concerns or significant weight changes and was on a mechanically altered diet. Review of dietary note dated 05/15/23 revealed the family of Resident #33 had requested a small rubber spoon be used to feed her mother and no knife be offered at meals, and the facility would honor the request. Review of 03/28/23 care plan revealed Resident #33 had an activity of daily living deficit related to muscle weakness and age-related debility. Interventions included staff would provide total assistance with eating. Review of 03/30/23 care plan revealed Resident #33 was at increased risk for alteration in nutrition related to diagnoses of dementia, severe protein calorie malnutrition, and dysphagia, on a mechanical altered diet, and required increased nutrition for wound healing. Interventions included provide and serve diet as ordered, and facility would provide small rubber spoon with meals and no knife per daughter request. Review of dinner dietary tray card, dated 06/03/23, revealed Resident #33 was on a blended diet and was not to receive a knife and wanted a small rubber spoon. Interview on 06/05/23 at 3:21 P.M. with Dietitian #428 revealed Resident #33 was to receive small spoons at meals at the request of family and when the adaptive equipment was a family request, it was put on the tray card and in the care plan but was not put in as an order. Observations conducted on 06/05/23 from 4:40 P.M. to 5:40 P.M. revealed Resident #33 was sitting at a table in the unit dining room. Sitting in front of Resident #33 was a napkin with a regular fork, knife and regular spoon on top of it. STNA #616 took a large spoonful of mashed potatoes and tried to feed Resident #33 and Resident #33 would not open mouth wide enough for the spoonful of mashed potatoes. STNA #33 then took half of the mashed potatoes off of the spoon and was then able to get the mashed potatoes into Resident #33's mouth. Interview at the time of observation with STNA #616 revealed she did not think Resident #33 received any adaptive equipment since Resident #33 had been receiving regular silverware. Licensed Practical Nurse #329 was observed to take over feeding Resident #33 and used a fork to feed Resident #33. Observed in the utensils tray sitting on a cart in the unit dining room was two small pink spoons. Review of the undated facility policy Adaptive (Assistive) Eating Devices revealed the facility would provide special eating equipment and utensils as appropriate. This deficiency represents non-compliance investigated under Complaint Number OH00143294.

Based on observation, facility policy and procedure review and interview the facility failed to ensure staff washed their hands during the passing of the meal trays, failed to ensure the cleanliness of kitchen areas and timely and proper disposal of outdated/expired foods and failed to ensure dish machine temperatures were monitored to prevent contamination and/or food borne illness. This had the potential to affect 71 of 71 residents who received meal trays from the kitchen. The facility census was 72. Findings include: 1. On [DATE] at 8:32 A.M. observation during the initial kitchen tour revealed the following: a. The walk-in refrigerator had an unidentified spill which was white in color was noted under the right-side shelving unit that extended half of the length of the refrigerator and had also leaked into the refrigerator walkway. A saturated white towel was on the floor of the walkway. Observation while inside the walk-in freezer revealed two packages of undated frozen cinnamon rolls noted by themselves on the shelf. Observation of the reach in refrigerator revealed a plastic container with cut pears with a packaged use by date of [DATE], an open five-pound container of cottage cheese dated with a use by date of [DATE], and an open 64-ounce container of deli style tuna salad with a use by date of [DATE]. All items were confirmed at the time of the observation by Dietary #80. b. On [DATE] at 8:45 A.M. observation in the dish room revealed the gages for the dish machine were not working. Interview at the time of the observation with Dietary #37 revealed a service company had been out [DATE] to service the dish machine and replaced the booster. The dish machine booster read 184 degrees Fahrenheit. Dietary #37 confirmed the dish machine gages were not functioning and were on order for replacement. On [DATE] at 9:54 A.M. interview with Cook #31 revealed the dish machine booster was set to 185 degrees Fahrenheit and temperatures had not been recorded on a log sheet since the replacement of the booster on [DATE]. c. On [DATE] at 11:25 A.M. observation in the kitchen revealed ten packages of 12 count hot dog buns were observed with a use by date of [DATE], two 12 count packages of hot dog buns were observed with the use by date of [DATE], and one package of 12 count hot dog buns was observed with a use by date of [DATE]. Interview at the time of the observation with Dietary Manager #20 confirmed the expired items as well as confirmation he was unable to provide a temperature log for the dish machine since the repairs were done on [DATE]. Review of undated facility policy titled Labeling and Dating revealed all foods that had been opened must have the date of opening, the produce name if need be and a use by date. All foods that had been opened must have the date of opening. Most perishable foods were labeled for seven days. Review of 2005 facility policy titled Food Storage revealed all refrigerator units were always kept clean and in good working condition. Food should be covered, labeled and dated. Review of ,d+[DATE] facility policy titled Dish Machine Temperature Log revealed the dishwashing staff would monitor and record dish machine temperatures to assure proper sanitizing of dishes. Staff would be trained to record dish machine temperatures for the wash and rinse cycles at each meal. 2. On [DATE] at 12:16 P.M. observation of the lunch meal on the Memory Care unit revealed State tested Nursing Assistant (STNA) #78 wore gloves while she was passing out meal trays without changing her gloves or washing her hands in between residents. During the observation, STNA #78 went into Resident #1's touched her blanket and table and then went into Resident #60's room with her meal tray and placed it on her tray table wearing the same gloves. The STNA Then went into Resident #6's room and placed the meal on the resident's bedside table, opened her silverware, cut up her pork, picked up her fork and gave the resident a bite of food. The STNA exited the room and then wearing the same gloves, took a meal tray into Resident #18's room, moved the resident's bedside table over to the bed and opened the utensils, set up the tray (opened apple sauce) and gave the resident a bite of applesauce all without changing her gloves or washing her hands. On [DATE] at 12:25 P.M. interview with STNA #78 verified she had not changed her gloves or washed her hands as she was passing out the meal trays as noted above. The STNA indicated she was concerned about the food getting cold so she did not stop to wash her hands or change her gloves. On [DATE] at 10:45 A.M. interview with the Director of Nursing revealed staff should not be wearing gloves to pass the meal trays unless they were cutting up a resident's food. He stated the staff needed to perform hand hygiene (hand washing) between residents. This deficiency represents non-compliance investigated under Complaint Number OH 226.

Based on observation, record review, facility policy and procedure review and interview the facility failed to develop and implement a comprehensive and individualized activity program to meet the total care needs of all residents. This affected five residents (#28, #51, #56, #57 and #171) of nine residents reviewed for activities. Findings include: 1. Review of the medical record revealed Resident #28 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the activity assessment, dated 05/09/22 revealed Resident #28 enjoyed exercise, music, talking, and social gatherings. The resident had been admitted to the facility for long-term care placement. The assessment noted the resident enjoyed conversations with others and her sister-in-law often took her out of the facility. Review of the plan of care revealed Resident #28 did not have an activities plan of care. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/29/22 revealed Resident #28 had severely impaired cognition. The assessment revealed the resident required extensive assistance from staff for bed mobility, dressing, eating, toilet use and personal hygiene. Review of the August 2022 activity attendance records revealed Resident #28 had attended two activities, on 08/01/22 at 2:59 P.M. and 08/24/22 at 2:59 P.M. with no refusals documented for the whole month. Review of the September 2022 activity attendance records revealed Resident #28 had attended six activities, on 09/13/22 at 2:59 P.M., 09/14/22 at 2:59 P.M., on 09/15/22 at 2:59 P.M., on 09/18/22 at 2:59 P.M. and 09/28/22 at 2:59 P.M. with one refusal documented for the whole month. Review of the October 2022 activity attendance record revealed Resident #28 had not attended any activities with no refusals documented for the whole month. On 11/01/22 at 2:25 P.M., 11/02/22 at 9:40 A.M., 11:45 A.M., 12:12 P.M., and 3:26 P.M. and 11/03/22 at 9:40 A.M. and 1:44 P.M. revealed Resident #28 was observed in her room with no music playing, no television on and no activities being attempted with her. On 11/01/22 at 2:45 P.M. interview with Activity Director (AD) #124 revealed there were three activity personnel. They worked 8:00 A.M. to 4:00 P.M. or 9:00 A.M. to 5:00 P.M. She stated they rotated every week who conducted activities in the Memory Care Unit. She stated there were no times on the memory care activity calendars for activities because they were self-guided activities or the nursing staff provided the activities. She stated she just took coloring pages down to the unit for the residents to do. She placed them in the common area. She verified there was no Halloween craft on 10/31/22 because they had a Halloween party on the Long-Term Care (non memory care) side. She also verified there was no Let's Move on 11/01/22 in the morning because there was only one activity staff working and he had to be on the nursing home (non secured side) for exercise. On 11/02/22 at 11:00 A.M. interview with State tested Nursing Assistant (STNA) #54 revealed nursing assistant staff did not have time to do activities for residents on the memory care unit. She indicated they just give the resident(s) coloring paged to color and turn music on. On 11/02/22 at 11:05 A.M. interview with STNA #78 revealed the nursing assistant try to do activities with the resident(s) when they had time but it was really hard when there was only one nursing assistant; it was hard to do. On 11/02/22 at 2:10 P.M. interview with Social Service Designee (SSD) #24 verified Resident #28 did not have a activities plan of care completed. She stated she and AD #124 had just gone through and completed activity care plans because they were not up to date. On 11/02/22 at 3:00 P.M. interview with AD #124 revealed when they record attendance they write on a blank piece of paper and then transfer it onto the resident's attendance log in the electronic medical record in point click care. She verified there was only a few activities documented for Resident #28 from August 2022 and September 2022 and none during October 2022. On 11/07/22 at 10:00 A.M. interview with the Administrator revealed activity staff were asking residents to attend activities, however they were not capturing who they asked and who refused. He stated the activity staff had been in-serviced on documentation. Review of the facility policy titled, Activity/Community Life Programs, dated 12/18/18 revealed an ongoing program of activities was designed to meet the needs of each resident. The resident had a right to participate and attend activities. Activity programs consisted of individual, small/large group and indoor and outdoor activities and outing which are designed to meet the needs and interests of each resident. 2. Review of the medical record revealed Resident #56 was admitted t o the facility on 11/30/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the plan of care, dated 04/22/19 revealed Resident #56 had little or no activity involvement related to his preference not to participate. Interventions included the resident was on Hospice care and all staff were to assist with channel preferences while in the room, offer to call his family on hi tablet, assistance to do activities, invite family members to activities, and remind him he may leave an activity at any time. Review of the Activity Assessment, dated 05/25/22 revealed Resident #56 enjoyed music, trivia, puzzles, religious events, television and movies. Review of the modification to the quarterly MDS 3.0 assessment, dated 08/22/22 revealed Resident #56 had severely impaired cognition. Review of the August 2022 activity attendance record revealed Resident #56 had attended no activities with no refusals documented for the whole month. Review of the September 2022 activity attendance record revealed Resident #56 had attended one activity on 09/18/22 at 2:59 P.M. with no refusals documented for the whole month. Review of the October 2022 activity attendance record revealed Resident #56 had attended no activities with no refusals documented for the whole month. On 11/01/22 at 2:23 P.M. and 4:23 P.M., 11/02/22 at 9:30 A.M., 11:02 A.M., 1:30 P.M. and 3:33 P.M. and 11/03/22 at 9:45 A.M. Resident #56 was observed in his room in bed with no music playing, no television on and no activities being attempted with him. On 11/01/22 at 2:45 P.M. interview with Activity Director (AD) #124 revealed there were three activity personnel. They worked 8:00 A.M. to 4:00 P.M. or 9:00 A.M. to 5:00 P.M. She stated they rotated every week who conducted activities in the Memory Care Unit. She stated there were no times on the memory care activity calendars for activities because they were self-guided activities or the nursing staff provided the activities. She stated she just took coloring pages down to the unit for the residents to do. She placed them in the common area. She verified there was no Halloween craft on 10/31/22 because they had a Halloween party on the Long-Term Care (non memory care) side. She also verified there was no Let's Move on 11/01/22 in the morning because there was only one activity staff working and he had to be on the nursing home (non secured side) for exercise. On 11/02/22 at 11:00 A.M. interview with State tested Nursing Assistant (STNA) #54 revealed nursing assistant staff did not have time to do activities for residents on the memory care unit. She indicated they just give the resident(s) coloring paged to color and turn music on. On 11/02/22 at 11:05 A.M. interview with STNA #78 revealed the nursing assistant try to do activities with the resident(s) when they had time but it was really hard when there was only one nursing assistant; it was hard to do. On 11/02/22 at 3:00 P.M. interview with AD #124 revealed when they record attendance they write on a blank piece of paper and then transfer it onto the resident's attendance log in the electronic medical record in point click care. She verified there was only a few activities documented for Resident #56 as noted above. On 11/07/22 at 10:00 A.M. interview with the Administrator revealed activity staff were asking residents to attend activities, however they were not capturing who they asked and who refused. He stated the activity staff had been in-serviced on documentation. Review of the facility policy titled, Activity/Community Life Programs, dated 12/18/18 revealed an ongoing program of activities was designed to meet the needs of each resident. The resident had a right to participate and attend activities. Activity programs consisted of individual, small/large group and indoor and outdoor activities and outing which are designed to meet the needs and interests of each resident. 3. Review of the medical record revealed Resident #57 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the plan of care revealed Resident #57 did not have an activity plan of care. Review of the Activity Assessment, dated 06/14/22 revealed Resident #57 enjoyed reading, gardening/plants, music, cards, religious events, conversing, crafts, television and movies. Review of the August 2022 activity attendance records revealed Resident #57 had attended two activities, on 08/07/22 at 2:59 P.M. and on 08/25/22 at 2:59 P.M. with no refusals documented. Review of the September 2022 activity attendance record revealed Resident #57 had attended three activities, on 09/12/22 at 2:59 P.M., 09/13/22 at 2:59 P.M. and on 09/19/22 at 2:59 P.M. with one refusal for the whole month. Review of the October 2022 activity attendance record revealed Resident #57 had attended one activity, on 09/14/22 at 2:59 P. M with four refusals documented for the whole month. Review of the quarterly MDS 3.0 assessment, dated 10/02/22 revealed Resident #57 had moderately impaired cognition. On 11/01/22 at 4:21 P.M., 11/02/22 at 9:20 A.M., 12:10 P.M., and 11/03/22 at 9:35 A.M. and 1:33 P.M. Resident #57 was observed sitting in her room with no music playing, no television on and no activities being provided for her. On 11/01/22 at 2:45 P.M. interview with Activity Director (AD) #124 revealed there were three activity personnel. They worked 8:00 A.M. to 4:00 P.M. or 9:00 A.M. to 5:00 P.M. She stated they rotated every week who conducted activities in the Memory Care Unit. She stated there were no times on the memory care activity calendars for activities because they were self-guided activities or the nursing staff provided the activities. She stated she just took coloring pages down to the unit for the residents to do. She placed them in the common area. She verified there was no Halloween craft on 10/31/22 because they had a Halloween party on the Long-Term Care (non memory care) side. She also verified there was no Let's Move on 11/01/22 in the morning because there was only one activity staff working and he had to be on the nursing home (non secured side) for exercise. On 11/02/22 at 11:00 A.M. interview with State tested Nursing Assistant (STNA) #54 revealed nursing assistant staff did not have time to do activities for residents on the memory care unit. She indicated they just give the resident(s) coloring paged to color and turn music on. On 11/02/22 at 11:05 A.M. interview with STNA #78 revealed the nursing assistant try to do activities with the resident(s) when they had time but it was really hard when there was only one nursing assistant; it was hard to do. On 11/02/22 at 2:10 P.M. interview with Social Service Designee (SSD) #24 verified Resident #57 did not have a activities plan of care completed. She stated she and AD #124 had just gone through and completed activity care plans because they were not up to date. On 11/02/22 at 3:00 P.M. interview with AD #124 revealed when they record attendance they write on a blank piece of paper and then transfer it onto the resident's attendance log in the electronic medical record in point click care. She verified there was only a few activities documented for Resident #57 as noted above. On 11/07/22 at 10:00 A.M. interview with the Administrator revealed activity staff were asking residents to attend activities, however they were not capturing who they asked and who refused. He stated the activity staff had been in-serviced on documentation. Review of the facility policy titled, Activity/Community Life Programs, dated 12/18/18 revealed an ongoing program of activities was designed to meet the needs of each resident. The resident had a right to participate and attend activities. Activity programs consisted of individual, small/large group and indoor and outdoor activities and outing which are designed to meet the needs and interests of each resident. 4. Review of the medical record revealed Resident #171 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Activity Assessment, dated 10/16/22 revealed Resident #171 enjoyed reading, sports, exercise, music, special events, cards, conversing, outdoors, social gatherings, television and movies. Review of the admission MDS 3.0 assessment, dated 10/16/22 revealed Resident #171 had severely impaired cognition. Review of the plan of care revealed Resident #171 did not have a activities plan of care. Review of the October 2022 activity attendance records revealed Resident #171 attended one activity, on 10/16/22 at 2:59 P.M. with no refusals documented for the whole month. On 11/01/22 at 4:22 P.M., 11/02/22 at 9:35 A.M., 11:20 A.M., 3:15 P.M. and 11/03/22 at 9:50 A.M. Resident #171 was observed in his room with no music playing, no television on and no activities being attempted with him. On 11/01/22 at 2:45 P.M. interview with Activity Director (AD) #124 revealed there were three activity personnel. They worked 8:00 A.M. to 4:00 P.M. or 9:00 A.M. to 5:00 P.M. She stated they rotated every week who conducted activities in the Memory Care Unit. She stated there were no times on the memory care activity calendars for activities because they were self-guided activities or the nursing staff provided the activities. She stated she just took coloring pages down to the unit for the residents to do. She placed them in the common area. She verified there was no Halloween craft on 10/31/22 because they had a Halloween party on the Long-Term Care (non memory care) side. She also verified there was no Let's Move on 11/01/22 in the morning because there was only one activity staff working and he had to be on the nursing home (non secured side) for exercise. On 11/02/22 at 11:00 A.M. interview with State tested Nursing Assistant (STNA) #54 revealed nursing assistant staff did not have time to do activities for residents on the memory care unit. She indicated they just give the resident(s) coloring paged to color and turn music on. On 11/02/22 at 11:05 A.M. interview with STNA #78 revealed the nursing assistant try to do activities with the resident(s) when they had time but it was really hard when there was only one nursing assistant; it was hard to do. On 11/02/22 at 2:10 P.M. interview with Social Service Designee (SSD) #24 verified Resident #171 did not have a activities plan of care completed. She stated she and AD #124 had just gone through and completed activity care plans because they were not up to date. On 11/02/22 at 3:00 P.M. interview with AD #124 revealed when they record attendance they write on a blank piece of paper and then transfer it onto the resident's attendance log in the electronic medical record in point click care. She verified there was only one activity noted for Resident #171 during October 2022. On 11/07/22 at 10:00 A.M. interview with the Administrator revealed activity staff were asking residents to attend activities, however they were not capturing who they asked and who refused. He stated the activity staff had been in-serviced on documentation. Review of the facility policy titled, Activity/Community Life Programs, dated 12/18/18 revealed an ongoing program of activities was designed to meet the needs of each resident. The resident had a right to participate and attend activities. Activity programs consisted of individual, small/large group and indoor and outdoor activities and outing which are designed to meet the needs and interests of each resident. 5. Review of medical record revealed Resident #51 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of activity participation documentation from August 2022 revealed Resident #51 attended seven group activities with 12 days of no documentation of the resident participating or refusing activities. The activity participation documentation from September 2022 revealed the resident did not attend any group activities with 25 days of no documentation of the resident participating in or refusing activities. The activity participation documentation from October 2022 revealed Resident #51 attended one group activity, and had 19 days with no documentation of the resident participating in or refusing activities. Review of the quarterly MDS 3.0 assessment, dated 10/04/22 revealed Resident #51 was cognitively intact and had moderately impaired vision. The assessment revealed the resident required (staff) supervision for bed mobility and transfers and extensive assistance from one staff for locomotion off the unit. On 10/31/22 at 10:13 A.M. interview with Resident #51 revealed her husband was no longer able to push her wheelchair to activities. The resident stated she was unable to attend any activities unless someone took her in her wheelchair. A care plan, initiated on 11/02/22 revealed Resident #51 was dependent on staff for activities, cognitive stimulation, and social interaction due to being blind. Interventions included the need for assistance to attend out-of-room activities as desired and staff to assist with activities of choice. On 11/02/22 at 2:59 P.M. interview with the Life Enrichment Director revealed Resident #51 sometimes attended happy hour and live music. The Life Enrichment Director revealed activity aides were to go to the resident's room and ask if the resident would like to attend an activity. If the resident did not want to attend an activity, the activity staff were to document the resident refused. The Life Enrichment Director verified Resident #51 was unable to attend activities without assistance. On 11/07/22 at 9:58 A.M. interview with the Administrator revealed activity staff had been educated on documenting if a resident did not want to attend an activity. The Administrator felt the documentation provided might not have reflected if Resident #51 was offered and refused to attend activities or if the resident was not offered assistance to activities.

Based on observation and staff interview the facility failed to maintain sufficient levels of staffing to ensure adequate supervision was provided to residents during meal service on the memory care unit. This affected nine residents (#1, #2, #6, #28, #33, #56, #64, #171 and #172) of 16 residents on the Memory Care Unit (Willow). Findings include: On 11/02/22 at 8:40 A.M. observation of the breakfast meal revealed there was one nurse, two State tested Nursing Assistants and one Hospice aide in the Lakeside dining room assisting residents to eat On 11/01/22 from 8:50 to 9:05 A.M. there were no staff observed on the Willow (secured memory care) unit to provide supervision for Resident #1, #2, #6, #28, #33, #56, #64, #171 and #172 who were observed with their breakfast trays in front of them. On 11/01/22 at 9:10 A.M. interview with State tested Nursing Assistant (STNA) #9 verified there were no staff on the Willow unit while the residents had their food. She indicated the staff had been pulled to help assist with feeding residents in the Lakeside dining room. On 11/07/22 at 10:45 A.M. interview with the Director of Nursing verified there should be a staff member on the Willow (secured care) unit at all times.

Based on observation, review of the facility menu, review of the facility spreadsheet, review of facility policy and procedure and staff interview the facility failed to ensure all residents on the Lakeside unit and Willow unit were served the correct/proper serving size of meat during the lunch meal on 10/31/22. This affected 11 residents (#1, #6, #25, #32, #33, #42, #45, #49, #57, #61 and #171) of the 28 residents on the Lakeside and Willow units. The facility census was 72. Findings include: Review of the menu for 10/31/22 revealed residents were to receive herb pork loin, red skinned mashed potatoes, corn and apple dump cake. Review of the facility spreadsheet for 10/31/22 revealed the serving size for the pork loin was three ounces. On 10/31/22 at 11:45 A.M. observation in the Lakeside dining room revealed Dietary Aide #37 was serving pork loin to the residents which did not appear to be an appropriate portion size. On 10/31/22 at 11:58 A.M. interview with Dietary Aide #37 revealed she did not know what the appropriate serving size for the meat was supposed to be. Two meal carts had left the Lakeside serving area to be delivered to the units for residents, including Resident #1, #6, #25, #32, #33, #42, #45, #49, #57, #61 and #171. On 10/31/22 at 12:05 P.M. review/observation of the pork loin with Dietary Manager #20 revealed it should be three ounces or more. A pork loin from the main dining room on the first floor was weighed and noted to be 3.4 ounces. Dietary Manager #20 then went to the Lakeside/Willow dining room and weighed the pork loin which was only 1.8 ounces. Dietary Manager #20 verified Dietary Aide #37 was not serving the residents on the Lakeside and Willow units the correct amount/portion of pork loin. Dietary Manager #20 instructed the dietary aide to serve the remaining residents one and half pieces of meat. On 11/03/22 at 11:15 A.M. interview with Dietitian #67 revealed it was very important for the staff to follow the spreadsheet for the amount of protein because she calculated the daily protein intake for residents as part of weight loss interventions. Review of the facility policy titled, Food and Drink, dated 12/11/19 revealed the facility would provide each resident with a nourishing, palatable, well-balanced diet that met his/her daily nutritional and special dietary needs and drinks, including water and other liquids to maintain resident hydration, taking into consideration the preferences of each resident. This deficiency represents non-compliance investigated under Complaint Number OH 226.

Based on observation, record review and interview the facility failed to ensure Resident #171's urinary catheter drainage bag was properly covered to promote the dignity of the resident. This affected one resident (#171) of three residents reviewed for dignity. Findings include: Review of the medical record revealed Resident #171 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the October 2022 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 10/16/22 revealed Resident #171 had severely impaired cognition. The assessment revealed the resident required extensive assistance from two staff for toilet use, one staff assist for personal hygiene and he had an indwelling (urinary) catheter. On 10/31/22 at 9:47 A.M. and 11:35 A.M. Resident #171 was observed in bed with the urinary catheter drainage bag was not covered and visible from the doorway of the room. On 10/31/22 at 3:05 P.M. State tested Nursing Assistant (STNA) #78 was observed pushing Resident #171 down the hallway. At the time of the observation, the resident's urinary catheter urine collection bag was visible with no covering in place to promote the resident's dignity. There was urine visible in the collection bag. An interview with STNA #78 verified his urinary drainage bag was not covered. The STNA indicated she would stop at central supply and get one for him. On 11/03/22 at 9:50 A.M. Resident #171 was observed in bed with the urinary collection bag uncovered and visible. An interview at this time with Licensed Practical Nurse #57 verified the urinary drainage bag for Resident #171 was not covered and should have been. On 11/07/22 at 10:45 A.M. interview with the Director of Nurisng verified catheter bags were to be covered.

Based on observation, record review and interview the facility failed to ensure Resident #24 was positioned properly in bed and had her meal tray placed within reach to allow the resident to eat in a timely manner following meal tray delivery. This affected one resident (#24) of seven residents reviewed for nutrition. Findings include: Review of medical record revealed Resident #24 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 08/17/22 revealed Resident #24 required limited assistance fro two staff for bed mobility, limited assistance from one for transfers, and (staff) supervision for eating. The assessment revealed Resident #24 had moderately impaired cognition. On 11/02/22 at 11:56 A.M. observation revealed Resident #24 was lying in bed with the head of the bed up. The resident's lunch tray was observed sitting on the over bed table. The over bed table was on the right side of the resident's bed, about an arm length away. At the time of the observation, Resident #24 stated she needed pulled up in bed and could not reach the food on her tray. On 11/02/22 at 12:00 P.M. interview with State tested Nursing Assistant (STNA) #95 revealed dietary staff passed the resident meal trays. STNA #95 verified Resident #24 needed repositioned/pulled up in bed and the over bed table placed in front of the resident so the resident could eat lunch. STNA #95 verified there were no plate warmers to help keep the food warm until the nursing staff were able to make sure residents were positioned properly and able to reach their food. A delay in ensuring the resident's positioning needs were met had the potential in the resident's food becoming cold before they ate it. On 11/02/22 at 12:10 P.M. interview with Dietary Aide #99 verified dietary staff took meal trays into residents rooms and placed them on the over bed tables. Dietary Aide #99 revealed dietary staff were not permitted to reposition/pull any residents up in bed. Nursing staff were responsible for uncovering the resident's food and making sure residents were in the correct position and able to reach their food.

Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure Resident #171 was provided privacy during personal (catheter) care. This affected one resident (#171) of one resident reviewed for privacy. Findings include: Review of the medical record revealed Resident #171 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the October 2022 physician's orders revealed Resident #171 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 10/16/22 revealed Resident #171 had severely impaired cognition. The assessment revealed the resident required extensive assistance from two staff for toilet use, one staff assist for personal hygiene and he had an indwelling catheter. On 11/02/22 at 3:15 P.M. State tested Nursing Assistant (STNA) #39 was observed to provide catheter care to Resident #171. During the observation, the STNA failed to close the curtains to the outside windows for privacy. On 11/02/22 at 3:22 P.M. interview with STNA #39 verified she had not closed the curtains to the room for privacy during catheter care. On 11/07/22 at 10:45 A.M. interview with the Director of Nursing (DON) verified the curtains to the resident's room should have been closed during care. Review of the facility policy titled,Resident Rights, dated 01/20/19 revealed the facility would take measures to ensure each resident had the right to personal privacy. Personal privacy included accommodation, medical treatment, written and telephone communication, personal care, visits and meeting with family and resident groups but did not include the right to a private room.

Based on record review and interview the facility failed to ensure Resident #10 and Resident #41 had an accurate Pre-admission Screening and Resident Review (PASARR) completed. This affected two residents (#10 and #41) of three reviewed for PASARR. Findings include: 1. Review of the medical record revealed Resident #41 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the PASARR identification screen, dated 07/14/22 revealed Resident #41 did not have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The PASARR indicated within the last six months the resident had not been prescribed any [CONDITION(S)] medications which included antidepressants, antianxiety, antipsychotics, or mood stabilizers. Review of significant change Minimum Data Set (MDS) 3.0 assessment, dated 10/01/22 revealed Resident #41 had severely impaired cognition. Record review revealed Resident #41 received [MEDICATION(S)] (antidepressant) 60 milligrams (mg) daily, [MEDICATION(S)] (antidepressant) 100 mg daily, and [MEDICATION(S)] (anticonvulsant/[CONDITION(S)] disorder) 500 mg four times a day. On 11/02/22 at 1:41 P.M. interview with the Administrator verified Resident #41's PASARR was not completed correctly. The Administrator verified Resident #41 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Review of Resident #10's medical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record for Resident #10 revealed no evidence a Pre-admission Screening and Resident Review (PASARR) was completed following the addition of the 08/13/20 diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 08/06/22 quarterly Minimum Data Set (MDS) 3.0 revealed the resident was noted to be moderately cognitively impaired. The assessment revealed the resident required extensive assistance from two staff for bed mobility, extensive assist from one staff for transfers, dressing, toileting, personal hygiene and bathing. Resident #10 was noted to be occasionally incontinent of bladder. On 11/02/22 at 12:31 P.M. interview with Director of Nursing (DON) #62 confirmed a PASARR was not previously completed for Resident #10 following the mental health diagnosis. The facility initiated a new PASARR on 11/02/22.

Based on observation, record review and interview the facility failed to ensure Resident #10, who required staff assistance for activities of daily living, received adequate and proper assistance with meals. This affected one resident (#10) of 22 sampled residents. Findings include: Review of Resident #10's medical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 08/06/22 quarterly Minimum Data Set (MDS) 3.0 assessment revealed Resident #10 was moderately cognitively impaired. The assessment revealed the resident required extensive assistance from two staff for bed mobility and extensive assistance from one staff for transfers, dressing, eating, toileting, personal hygiene, and bathing. Review of the 09/06/22 speech therapy notes for Resident #10 revealed modified [MEDICATION(S)] swallow results indicated significant aspiration on all oral intakes including thin liquids, nectar thick liquids, honey thick liquids and puree solids. Precautions listed were aspiration, purred foods and thin liquids with no straw. Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/02/22 at 8:32 A.M. observation of the second-floor dining room revealed Resident #10 being assisted with breakfast by State tested Nursing Assistant (STNA) # 74. The resident was observed to have glasses of liquids with straws in them. Interview at the time of the observation with STNA # 74 confirmed she had been using a straw in Resident #10's beverages. STNA #74 stated she was told by other staff to use straws for drinks for the resident because it was easier. On 11/02/22 at 10:17 A.M. interview with Director of Nursing (DON) #62 confirmed Resident #10's diet order included a regular diet with pureed texture and thin liquids with no straws.

Based on record review, facility policy and procedure review and interview the facility failed to follow the bowel protocol for Resident #51. This affected one resident (#51) of six residents reviewed for bowel function. Findings include: Review of medical record revealed Resident #51 was admitted on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of care plan, dated 11/12/21 revealed Resident #51 had the potential for constipation related to decreased mobility. Interventions included to monitor/document/report to medical doctor signs and symptoms of complications related to constipation, and to encourage resident to sit on toilet to evacuate bowels if possible. Review of quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/04/22 revealed Resident #51 was cognitively intact, continent of bowel, and required supervision for toilet use. Review of the bowel continence documentation revealed Resident #51 did not have a bowel movement from 10/30/22 to 11/03/22. On 10/31/22 at 10:32 A.M. interview with Resident #51 revealed the resident voiced a concern he/she had not had a bowel movement for over a week. On 11/07/22 at 10:35 A.M. interview with the Director of Nursing (DON) verified Resident #51 went five days without a bowel movement and had not been given any as needed medication for constipation during the time period. The DON revealed if a resident did not have a bowel movement for three days, they were usually given Milk of Magnesia (MOM). If that was not effective, then a suppository was given. If the suppository was not effective, then an enema would be given. Review of bowel function policy, dated 01/2019 revealed all resident bowel movements would be recorded. If a resident had not had a bowel movement in three consecutive days, the nurse would check the residents as needed orders to see if a [MEDICATION(S)] or suppository was ordered. If so, the as needed order would be administered as ordered. If the resident had no as needed order for a [MEDICATION(S)] or suppository, the physician would be notified. Once orders were received, the orders would be followed as written.

Based on Self-Reported Incident review, record review, personnel file review and staff interview, the facility failed to ensure residents were provided transfer assistance by properly trained staff members. Actual Harm occurred on 08/05/21 when Resident #58 was transferred from her wheelchair to bed by an untrained staff member, resulting in a fall with fracture to the left femoral neck which required surgical repair This affected one (Resident #58) of three residents reviewed for accidents. The facility census was 75. Findings include: Review of Self-Reported Incident (SRI) # 1 revealed on 08/05/21 Resident #58 was assisted by Maintenance Assistant #88 to transfer from the wheelchair to her bed and suffered a fall with fracture. Review of Resident #58's medical record revealed an admitted [DATE] with admission diagnoses that included dementia, muscle weakness and history of falls. Further review of the medical record revealed Resident #58 was identified as being a high fall risk and required extensive assist of one to two staff members for all transfers. Review of Resident #58's progress notes revealed on 08/05/21, Resident #58 fell to the floor landing on her left hip and buttocks. Resident #58 was assessed at that time and found no injuries or pain. Approximately one hour later, Resident #58 was observed by staff with non-verbal signs of pain. The nurse practitioner was notified at this time and a x-ray was ordered. X-rays identified a fracture to the left femoral neck. The nurse practitioner was notified and ordered to send Resident #58 to the local emergency room for evaluation. Further progress notes revealed Resident #58 was readmitted to the facility on [DATE] after surgical repair to the fractured left femoral neck. Review of Maintenance Assistant #88's personnel file revealed no evidence of any training for transferring residents. Interview with the Director of Nursing on 08/26/21 at 9:45 A.M. verified Maintenance Assistant #88 assisted Resident #58 with transferring from her wheelchair to her bed when a fall occurred that resulted in a fracture which required hospitalization and surgical repair. The DON further verified Maintenance Assistant #88 should not have assisted Resident #58 due to having no training for resident transfer assistance.

Based on record review, resident interview and staff interview, the facility failed to ensure that pain medications were delivered and administered in a timely manner to prevent and control significant pain. This resulted in Actual Harm for Residents #5 and #103 who had to wait 10 hours and 18 hours respectively for pain medication to address their significant pain. This affected two residents (Residents #5 and #103) of four residents reviewed for medications. Findings include: 1. Review of the medical record revealed Resident #103 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. There was a physician order [REDACTED]. There was a physician order [REDACTED]. There was a physician order [REDACTED].M. for Tylenol 1000 mg by mouth every four hours as needed for pain. Review of an admitting nursing assessment dated [DATE] at 8:15 P.M. indicated the resident stated he was having pain, with a score of eight on the zero to ten pain scale. A nursing progress note dated 09/12/14 at 11:55 P.M. indicated the resident had pain in the leg with a score of eight of ten. A nursing progress note dated 09/13/14 at 2:00 P.M. indicated the resident had pain in the left leg that measured eight of ten. Resident #103 was in severe pain for at least 18 hours after admission. A nursing note dated 09/13/14 at 5:04 P.M. indicated the resident did not have pain. Review of the Medication Administration Record [REDACTED].M., 12 hours after admission. Resident #103 received the first dose of the as needed [MEDICATION NAME] 5 mg by mouth every six hours as needed for pain on 09/13/14 at 8:54 P.M. There was no documentation the resident received Tylenol. In a meeting with the director of nursing (DON) on 10/06/14 at 11:45 A.M., the DON stated that when a resident was admitted to the facility, the admitting orders were verified with the physician and sent to pharmacy electronically. If there was an order for [REDACTED].M., also at 5:00 A.M., and would also make special deliveries for new admissions (drop ship), if needed. The facility starter kit did not have the dosage of [MEDICATION NAME] that was ordered for Resident #103. In a meeting with the DON on 10/07/14 at 10:06 A.M., the DON stated if a person was admitted after hours, a reasonable drop ship time for their medications would be three to four hours. The DON stated if it were very late, 11:00 P.M. for example, the medications may not arrive until 4:00 A.M. or 5:00 A.M. The DON stated if the resident had significant pain, the policy would be to call the physician and obtain an order for [REDACTED].#103 called her at home at about 5:00 A.M. and notified her that Resident #103's medications had not yet been delivered from the pharmacy. The DON advised the nurse to call the physician and get an order for [REDACTED]. Pharmacy told the DON the facility nurse signed for delivered medications at 5:00 A.M. The DON called the nurse and was notified the ordered pain medications were not in the 5:00 A.M. delivery. The DON called the pharmacy back and was told the medications would be delivered to the facility. The medications were delivered at around 7:00 A.M. The DON stated that the pharmacy told her the medications were inadvertently left out of the 5:00 A.M. delivery tote. The information in Resident #103's record regarding pain medication orders and when they were administered was verified with the DON on 10/07/14 at 12:30 P.M. 2. Resident #5 was admitted to the facility on [DATE] at 2:12 P.M. with [DIAGNOSES REDACTED]. There was a surgical incision on the resident's back that was open to air. There was a physician order [REDACTED]. There was a physician order [REDACTED]. There was a physician order [REDACTED]. There was a prescription from the hospital for [MEDICATION NAME] 5 mg take two tablets by mouth every four hours as needed for pain. There was a prescription from the hospital for [MEDICATION NAME] 10 mg by mouth every 12 hours. Review of the hospital record revealed Resident #5 stated she fell in July and fractured her spine, and had pain ever since. A nursing admission assessment dated [DATE] at 2:11 P.M. indicated the resident appeared to be in pain, but did not indicate a score or severity level. A nursing progress note dated 10/04/14 at 2:40 P.M. indicated the medication orders were faxed to the pharmacy. Review of the Medication Administration Record [REDACTED].M. and 8:00 P.M. The entry for 10/04/14 at 8:00 P.M. documented the medication was not yet delivered from pharmacy and was not given. A nursing note dated 10/05/14 at 12:17 A.M. indicated the resident received [MEDICATION NAME] (Tylenol) 650 mg per resident request for severe pain. A nursing note dated 10/05/14 at 12:35 A.M. indicated the resident received [MEDICATION NAME] 5 mg, two tablets per resident request for severe pain, ten of ten on the pain scale. The medication was pulled from the e-box (starter kit), verbal authorization obtained from the pharmacist over the phone. Nursing notes dated 10/05/14 at 2:16 A.M. documented the medication was effective. Review of the medication list for the facility starter kit revealed the ordered [MEDICATION NAME] was in the facility starter kit. On 10/06/14 at 4:14 P.M., Resident #5 and the resident ' s spouse stated that on Saturday, 10/04/14 her pain medication was very late because the nurse told her it was not in the facility and it was the pharmacy's fault. Resident #5 stated the nurse told her the hospital should have sent the medications with her. Resident #5 stated she was in severe pain until the medication was delivered. On 10/07/14 at 10:06 A.M. the DON verified the above information. The DON stated that she was not aware of the above incident until this meeting. The DON stated Resident #5 should not have had to wait for pain medication from 2:11 P.M. until 12:17 A.M. This deficiency substantiates Complaint Number OH 488.

Based on observations, record review and interviews, the facility failed to ensure pressure ulcer risk assessment and preventative measures were identified and implemented resulting in an unstageable pressure ulcer for one resident (Resident #111). This affected one of two residents sampled for pressure of four residents with pressure sores. The facility census was 101. Findings include: Resident #111 was a [AGE] year-old female admitted [DATE], with [DIAGNOSES REDACTED]. Review of the admission skin assessment dated [DATE], revealed Resident #111 had no pressure sores on admission. Review of interdisciplinary progress notes indicated that on 08/14/12, a nurse aide brought the nurses' attention to the right heel. The nursing assessment dated [DATE], indicated "suspected Deep Tissue Injury" of the right heel, which measured 7.2 centimeters (cm) by 6.6 cm (length by width). On 08/23/12, the wound was classified as unstageable and measured 7.3 cm by 6.6 cm. The wound was observed on 09/06/12 at 1:20 P.M., during a dressing change performed by Licensed Practical Nurse (LPN) #1 and the unit manager, Registered Nurse (RN) #5. The wound presented as a darkened, black/red circular area, which was measured at 8.8 cm by 6.2 cm, and categorized as unstageable, according to RN #5. The resident did not have a pressure risk assessment performed on admission, despite her heightened risk factors of post-operative repair to the right hip and impaired mobility. The admission comprehensive assessment of 08/06/12, identified the resident with impaired bed mobility, requiring extensive assist of two staff. The director of nursing and corporate nurse both confirmed on 09/06/12 at 1:50 P.M., that a pressure risk assessment should have been completed on admission. The care plan developed on admission included interventions of pressure-reduction mattress and turning every two hours. However, there were no proactive interventions to address bony prominence or heel off-loading, areas typically at risk of breakdown with lack of mobility. Multiple skin care assessments conducted after admission (08/09/12, 08/10/12, 08/11/12, 08/12/12, 08/14/12), all failed to address possible proactive interventions which were pre-printed on the assessment tool, such as pillows, wedges, sheep skin /lambs wool, floating heels/heels up, and/or alternating pressure/low air loss mattress. After the development of the deep tissue injury, interventions were instituted including a physician's orders [REDACTED].M., for right heel boot at all times except hygiene and therapy. The resident was observed on 09/05/12 at 2:35 P.M., and 2:45 P.M., in bed napping, with no pressure relieving devices on her feet. This was confirmed by the speech therapist who stated, "sometimes she uses them." Two such devices (EZ boots) were noted laying on the bedside stand. Further observations were made on 09/06/12 at 10:10 A.M., 11:15 A.M., and 1:20 P.M., with the resident sitting in an easy chair and her feet resting directly on the floor. No EZ boot was on the right foot, and the dressing was unsecured, not protecting the heel wound. This was confirmed by RN #5 and LPN #1 who were present to do the dressing change. The above findings were confirmed by the director of nursing (DON) on 09/06/12 at 1:50 P.M.

Based on observation, interview and record review, the facility failed to ensure that interventions and assistance were in place to prevent a fall resulting in a fractured humerus for Resident #2 and a fall with bruising and skin tears for Resident #1. This affected two of five residents reviewed for falls. The facility census was 102. Findings include: 1. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of his quarterly minimum data set (MDS 3.0) dated 12/03/11, revealed the resident was cognitively impaired and required extensive assistance with two staff members for bed mobility and transfers. Additionally, he required total assist of two staff for toileting. Review of fall risk assessments dated 10/13/11, 12/12/11 and 02/03/11, indicated Resident #2 was at high risk for falls. Review of a care plan dated 04/30/10, and updated through 05/02/12, revealed the resident was a fall risk due to unsteady gait, poor safety awareness and medication side effects. Interventions included a wanderguard and physical therapy as ordered. In addition, the care plan indicated that a fall prevention plan was located in the treatment record. Review of the fall management plan in the treatment record revealed it was initiated on 04/30/10. Interventions were dated to signify their use as an intervention to prevent falls. The most current interventions were dated 11/22/11-bowel and bladder tracking, 03/04/12-new non-skid socks, and 03/11/12-refer to physical therapy. Observation of Resident #2 on 04/02/12 at 8:45 A.M., revealed he was in a tilted back wheelchair in his room. He had a large, healing bruise of his left eye and a full arm hard cast on his left arm. The unit manager, Licensed Practical Nurse (LPN) #3, revealed the resident had a recent fall resulting in the injuries. Review of the medical record revealed Resident #2 had multiple falls prior to the significant injury. Review of a nurse's note dated 02/11/12, and timed 10:39 P.M., revealed Resident #2 was found on the floor of the bathroom. Upon assessment he had sustained no injury. Review of a nurse's note dated 03/04/12, and timed 4:15 A.M., revealed the resident was found on the floor, sitting next to his roommate's bed. The note indicated the resident was not injured. Review of a nurse's note dated 03/11/12, and timed 3:00 P.M., revealed the nurse observed a resident attempting to help Resident #2 up from the floor. He was found sitting on the floor. The nurse's note indicated the resident said he had been walking and had fallen. The nurse's note revealed the new intervention for fall prevention was a physical therapy referral. Review of a nurse's note dated 03/16/12, and timed 5:31 A.M., revealed Resident #2 was found on his back on the floor in his room. The note indicated the resident had "got up from bed without assist." In addition, the nurse's note stated that the dresser in the room and the television were knocked over onto the floor next to the resident. Resident #2 was gripping his left forearm expressing pain. The nurse's note indicated an assessment of the resident revealed swelling to the left elbow area, an abrasion, swelling to his left forehead above the eye and a small abrasion to the top of his right forearm. The nurse's note dated 03/16/12, and timed 5:35 A.M., revealed Resident #2 was transferred back to the bed, and was unable to explain how he fell . The note stated "it was apparent he was up without assist or any assistive devices. Possibly used the dresser and TV to help stabilize himself ambulating back from the bathroom." Review of the nurse's notes indicated that Resident #2 was sent to the hospital on [DATE] at 6:23 A.M., and returned to the facility at 1:00 P.M. on that day. The note indicated the resident had a cast intact to his left arm. Review of the hospital note dated 03/16/12 indicated Resident #2 had sustained a non-displaced left humeral fracture. An interview was conducted on 04/03/12 at 8:30 A.M. with LPN #3, to review the recurrent falls sustained by Resident #2. LPN #3 verified that the record, including the falls management plan in the treatment record, did not indicate current interventions were reviewed or new interventions implemented following the fall on 02/11/12. LPN #3 verified that the falls management plan did indicate that on 03/04/12, an intervention of new non-skid socks was put in place. LPN #3 verified that the record did not indicate what footwear the resident was wearing at the time of the fall on 03/16/12 and confirmed that non-skid socks were previously implemented as a fall intervention on 07/11/11. Interview with LPN #3 confirmed that the nursing note and the falls management plan following the 03/11/12 fall indicated an intervention for a physical therapy evaluation. LPN #3 verified the record did not contain evidence of a referral or that physical therapy had evaluated Resident #2. LPN #3 stated that since Resident #2 was on hospice services, they would have to approve the therapy request. She confirmed the record contained no evidence of their approval or disapproval or of other interventions to prevent falls if the physical therapy was not initiated. LPN #3 verified Resident #2 had an increase in edema, and had his diuretic medication increased to double the dose on 03/15/12. She verified that the effects of the medication would lead to an increase in urination, and confirmed that the record did not contain evidence of attempts to assess or assist the resident to the bathroom more frequently. She stated Resident #2 fell and fractured his left arm in a noted attempt to return from the bathroom without assistance. 2. Review of the record revealed that SR1 (Resident #1) was admitted to the facility memory support unit (secured unit) on 09/27/11 with [DIAGNOSES REDACTED]. Review of the MDS 3.0 dated 10/06/11 revealed Resident #1 was cognitively impaired, with his speech garbled at times. He required extensive assistance of two staff members to transfer and walk about the unit. His balance was unsteady but he was able to stabilize without assistance. Review of nursing notes revealed the resident was ambulating without assistance and exit seeking since the date of admission. He would become agitated, refuse assistance or care, push staff away, and wander and pace about the unit. The resident would also lower himself to the floor at times. Review of the fall risk assessments completed on 10/11/11 and 12/02/11 revealed Resident #1 was at high risk for falls. The fall risk assessment dated [DATE] was incomplete. Review of the fall care plan dated 10/18/11, and updated through 02/16/12, revealed the resident was at risk due to impaired cognition, unaware of safety needs, confusion and wandering. Interventions included provide a safe environment, call light in reach, assistance when resident was upset, and allow resident to wander in the hallways with supervision. All interventions were dated 10/18/11. Review of the clinical record revealed Resident #1 sustained multiple falls. Review of a nurse's notes dated 10/09/11, revealed the resident sustained [REDACTED].M., when he was witnessed pushing a chair in the lounge, losing his balance and falling to his left side. No injury was noted at the time of the fall. Review of nurse's notes dated 11/14/11, revealed Resident #1 sustained a fall at 6:31 P.M., when he was found on the floor on his right side. A small purple bruise was noted on the top of his buttock. The nurse's notes dated 11/15/11, revealed that the resident was found on the floor of another resident's room at 9:20 A.M. His wheelchair was in the room. No injuries were noted and neurological checks were initiated. Review of the nursing notes revealed the resident was also found on the floor of his room on his right side on 12/01/11 at 8:30 A.M. He sustained a skin tear measuring 3 centimeters (cm) by 2.0 cm by less than 0.1 cm deep to his right upper extremity. Neurological checks were initiated after the fall. Review of the four falls with LPN #3 on 04/03/12 at 9:45 A.M. revealed that falls were investigated by an interdisciplinary team. She stated that fall prevention interventions were indicated on a "falls management" form that was kept in the treatment administration record. She was unable to provide a copy of the falls management form for Resident #1. She verified that the record, including nursing notes and care plans, did not indicate that fall prevention interventions were implemented after the falls. This citation substantiates Complaint Number OH 909.

Based on observation, record review and interview, the facility failed to ensure one of three sampled residents (Resident #1) was free from abuse from Resident #2, who pushed Resident #1 into a door frame resulting in a closed head injury and a laceration that required hospital treatment. This affected one of 39 residents located on the secured dementia unit, within a facility census of 105 residents. Findings include: Resident #1 was an [AGE] year old female, admitted [DATE] to the secured dementia unit. She was ambulatory but non-verbal, confused and frequently wandered in and out of other residents' rooms and throughout the hallways. According to a nursing note in Resident #1's medical record written on of 02/12/11 at 10:50 A.M., "staff witnessed another female resident push this resident on the floor. The female resident that pushed her stated, 'if you don't move I will punch you down.' Resident did not have time to move or respond and the other female resident then pusher her. Resident landed face first on the floor in front of room [ROOM NUMBER]." An ambulance was summoned via 911, and the resident was transferred to the hospital at 11:15 A.M. The hospital report indicated that "she was pushed by another patient into a door frame." She was admitted with [DIAGNOSES REDACTED]. She remained in the hospital for nine days. The facility investigation revealed that Resident #2 was the physical aggressor. Resident #2, who also lived on the secured dementia unit, had [DIAGNOSES REDACTED]. Her care plan noted that she, "is easily annoyed at times, is restless, wanders; can escalate verbally and physically at times." She was observed on 09/12/11 at 10:15 A.M. and on 09/14/11 at 8:10 A.M. in her room, and disengaged from social interaction or stimuli. Review of nursing notes indicated that Resident 2 had demonstrated physical aggression toward Resident #1 on previous occasions: ? On 06/05/10 at 10:45 A.M. Resident #2 hit Resident #1 with a picture frame, which caused a minimally displaced [MEDICAL CONDITION] wrist. ? On 11/06/10 at 3:06 P.M., Resident #2 pushed Resident #1, causing her to fall to the ground. This was witnessed by another resident's family member. ? On 12/21/10 at 4:30 P.M., Resident #1 was walking in the dining room during supper and was pushed by Resident #2, causing her to fall to the floor on her right side. Despite these previous incidents, there was no documented acknowledgement in the incident tracking that all four altercations were caused by the same resident (Resident #2); no identification of antecedent or precipitating events; no updates to the plans of care for either resident after the first or subsequent physical assaults; and no proactive interventions developed to address or minimize further altercations. This was confirmed through interview with the unit manager and the director of the dementia unit on 09/14/11 at 11:10 A.M. and by the director of nursing on 09/14/11 at 12:15 P.M. This deficiency substantiates Complaint Number OH 170.