Every finding on record at Concord Ridge Health and Rehabilitation

Based on interview, record review, and facility policy review the facility failed to ensure pre and post dialysis assessments were completed as ordered for Resident #3. This affected one resident (#3) of one resident review for dialysis services. The facility census was 77. Findings include: Review of the medical record for Resident #3 revealed an admitted [DATE]. Diagnosis included heart failure, diabetes, end stage renal disease, obesity, anemia, and insomnia. Review of the physician's orders for August 2024 revealed an order for dialysis Monday, Wednesday, and Friday. A dialysis communication form was to be sent with Resident #3 for each visit. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 was cognitively intact. She required supervision or touch assistance for eating and oral hygiene and substantial or maximum assistance for toileting, showering, and personal hygiene. Resident #3 received dialysis. Review of the care plan dated 07/29/24 revealed Resident #3 received dialysis on Mondays, Wednesdays, and Fridays. Interventions included checking for new orders upon return from dialysis, monitoring labs, and maintaining communication with the dialysis physician. Further review of the medical record revealed Resident #3 revealed no pre or post dialysis assessments had been completed since 06/07/24. There was no documented evidence the resident had missed any scheduled dialysis days since that time. Interview on 08/15/24 at 3:12 P.M. with the Administrator confirmed there was no documented evidence pre and post dialysis assessments were completed for Resident #3 since 06/07/24. Review of the undated facility policy titled Hemodialysis revealed the facility would provide necessary care and treatment for the provision of dialysis to following physician's orders and monitoring for complications before and after dialysis treatments.

Based on record review, interview, and facility policy review the facility failed to ensure clear instruction was in place for the use of opioid pain medication and did not ensure nonpharmacological interventions were attempted prior to the administration of pain medication for Resident #33. This affected one resident (#33) of five residents reviewed for unnecessary medications and had the potential to affect all residents. The facility census was 77. Findings include: Review of the medical record for Resident #33 revealed an admitted [DATE] with diagnoses including heart failure, respiratory failure, asthma, and diabetes. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #33 was cognitively intact. She required set up or clean up help for eating, supervision or touch assistance for oral hygiene, substantial or maximum assistance for personal hygiene and was dependent for toileting and showering. Review of the physician's orders for August 2024 revealed an order for Acetaminophen 325 milligrams (mg) every six hours as needed (prn) pain and Tramadol (an opioid pain medication) 50 mg every six hours prn for pain. Review of the medication administration record (MAR) for June 2024 revealed Resident #33 received one dose of Tramadol on 06/22/24 for a pain level of 7, one dose on 06/25/24 for a pain level six, one dose on 06/26/24 for a pain level of three, one dose on 06/26/24 for a pain level of five, one dose on 06/28/24 for a pain level of three, one dose on 06/28/24 for a pain level of five, one dose on 06/29/24 for a pain level of six, and one dose on 06/30/24 for a pain level of seven. Review of the MAR for July 2024 revealed resident #33 received one dose of Tramadol on 07/01/24 for a pain level of eight, one dose on 07/03/24 for a pain level of six, one dose on 07/03/24 for a pain level of seven, one dose on 07/05/24 for a pain level of seven, one dose on 07/09/24 for a pain level of six, one dose on 07/09/24 for a pain level of five, one dose on 07/12/24 for a pain level of nine, one dose on 07/13/24 for a pain level of five, one dose on 07/14/24 for a pain level of five, one dose on 07/15/24 for a pain level of three, one dose on 07/16/24 for a pain level of four, one dose on 07/16/24 for a pain level of five, one dose on 07/18/24 for a pain level of eight one dose on 07/18/24 for a pain level of five, two doses on 07/19/24 for a pain level of six, one dose on 07/20/24 for a pain level of five, one dose on 07/22/24 for a pain level of eight, one dose on 07/23/24 for a pain level of 10, one dose on 07/25/24 for a pain level of eight, one dose on 07/26/24 for a pain level of six, two doses on 07/30/24 for a pain level of five, and one dose on 07/31/24 for a pain level of nine. Resident #33 received one dose of Acetaminophen on 07/08/24 for a pain level of five, one dose on 07/09/24 for a pain level of four, one dose on 07/20/24 for a pain level of five, and one dose on 07/31/24 for a pain level of seven. Review of the MAR for August 2024 revealed Resident #3 received one dose of Tramadol on 08/03/24 for a pain level of four, one dose on 8/04/24 for a pain level of five, one dose on 8/05/24 for a pain level of three, and one dose on 8/13/24 for a pain level of six. Resident #3 received one dose of Acetaminophen on 08/02/24 for a pain level of four. Review of the progress notes dated 06/01/24 through 08/15/24 revealed nonpharmacological interventions were attempted prior to the administration of pain medications on 06/01/24, 06/04/24, 06/05/24, 06/06/24, 06/10/24, 06/11/24, 06/12/24, 06/15/24, 06/16/24, 06/18/24, 06/22/24, 06/25/24, 07/05/24, 07/09/24, 07/22/24, and 08/01/24. There was no other documented evidence of nonpharmacological interventions were attempted prior to the use of the above pain medications. Interview on 08/15/24 at 11:46 A.M. with the Director of Nursing (DON) confirmed nonpharmacological interventions should be attempted prior to the administration of pain medications and could provide no further evidence attempts were made for the above-mentioned pain medications. The DON also confirmed Tramadol is usually given for a pain level of five to six on a pain scale of one to ten, with ten being the worst. Acetaminophen should be administered for a pain level of one to four. Review of the facility policy titled Pain Assessment and Management, dated 03/31/16, revealed the facility would use a one to ten scale, with ten being the worst, to determine the intensity of pain. In addition, the facility would attempt non-pharmacological pain reduction techniques prior to administering pain medications.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review and staff interview, the facility failed to provide timely notification of Medicare non-coverage and inform residents of the costs of continuing non-covered services. This affected two residents (#43 and #80) of three reviewed for beneficiary notification. The facility census was 77. Findings include: 1. Review of the medical record for Resident #43 revealed an admitted [DATE] and readmitted [DATE]. Diagnoses included acute and chronic respiratory failure with hypoxia, morbid obesity, chronic obstructive pulmonary disease, type two diabetes mellitus, and congestive heart failure. Review of the progress note dated 06/11/24 at 5:31 P.M. revealed Resident #43 was provided the Notice of Medicare Non-Coverage (NOMNC) and planned to stay in the facility long-term. The note did not specify whether the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) was provided. Review of the NOMNC, not dated, revealed Resident #43's services would end on 06/12/24 and it was not signed by Resident #43 or a representative. There was no evidence the facility provided Resident #43 with a SNF ABN. As of 08/15/24, Resident #43 continued to reside in the facility. 2. Review of the medical record for Resident #80 revealed an admitted [DATE] and discharge date of [DATE]. Diagnoses included presence of right artificial knee joint, type two diabetes mellitus, muscle weakness, and hypertension. Review of the NOMNC, dated 05/08/24, revealed Resident #80's services would end on 05/08/24 and Resident #80 signed the NOMNC on 05/08/24. On 08/14/24 at 4:26 P.M., an interview with the Administrator verified the former Social Services Designee (SSD) did not provide NOMNC and SNF ABN notices to Residents #43 and #80 in a timely manner. The deficient practice was corrected on 07/02/24 when the facility implemented the following corrective actions: On 05/17/24, the Administrator identified NOMNC and SNF ABN notices were not being provided to residents as required. Between 05/17/24 and 06/10/24, the Administrator and regional support staff added social services job duties to their Quality Assurance (QA) monitoring and conducted audits. On 06/10/24, the former SSD was educated on job responsibilities and timeliness of completing NOMNC and SNF ABN notices. On 06/14/24, the former SSD turned in a notice of immediate resignation. On 06/17/24, SSD #509 was hired as the new SSD. Review of the NOMNCs and SNF ABNs provided by SSD #509 between 07/02/24 and 08/09/24 were provided in a timely manner.

Based on the interview, record review, and facility policy review the facility failed to ensure Resident #29's repeated concern regarding receiving timely incontinence care was addressed. This affected one resident (#29) out of six residents reviewed for properly addressing complaints/ grievances. The facility census was 81. Findings include: Review of the medical record for Resident #29 revealed an admitted [DATE] with diagnoses including multiple sclerosis, diabetes, need for assistance with personal care, and morbid obesity. Review of the care plan dated 09/11/23 revealed Resident #29 had urinary incontinence and was at risk for altered dignity, skin breakdown, and urinary tract infections. Interventions included checking and providing incontinence care as needed, applying barrier cream after each incontinent episode, and observing and reporting redness, excoriation and/or open areas with incontinence care. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #29 had intact cognition. She required extensive assistance from two staff with bed mobility and toileting. She was unable to ambulate. She was frequently incontinent of bowel and bladder. Review of the assessment labeled, Bladder Observation, dated 10/10/23, and completed by Registered Nurse (RN) #614 revealed Resident #29 was incontinent of urine due to impaired mobility. The assessment revealed she had incontinence without sensation of urine loss. Interview on 10/16/23 at 1:28 P.M. and 10/17/23 at 12:35 P.M. with Resident #29 revealed she had notified several nurses including RN #608 that night shift had not been providing timely incontinence care and at times she had gone the whole shift not being changed and laid in urine. She revealed the nurses including RN #608 had continued to report that they had notified Acting Director of Nursing (DON) #600 but that nothing happened as night shift continued to frequently not change her. She revealed on 10/11/23 from 11:00 P.M. to approximately 8:30 A.M. she was not provided incontinence care, and her skin was burning from not being changed. She revealed RN #608 came into her room to check on her, turned her over and saw that she was lying in a puddle of urine. She revealed RN #608 had notified the Acting DON #600 and had her come to her room to show her the incontinence product and how she had not been changed for over nine hours. Resident #29 revealed Acting DON #600 stated she would check into it but that she never got back to her regarding the complaint and/or how the complaint would be resolved. She revealed she felt that she would continue to not be changed timely especially on night shift despite making the nurses and Acting DON #600 aware of her concern as it had been happening since her admission, 08/30/23. Interview on 10/16/23 at 1:38 P.M. and 10/17/23 at 7:48 A.M. with RN #608 revealed she had received several complaints over the last month from residents, including Resident #29, and staff that night shift had not been providing timely incontinence care including at times going the entire shift. She revealed first shift staff also brought it to her attention that when they came on duty several residents had not been changed as their incontinence products were saturated in urine, and they required complete linen changes due to urine soaked through their incontinence products to the linen. She revealed she had notified the Acting DON #600 several times of the residents, including Resident #29, and staff's concerns. She revealed she had gone to the Acting DON #600 again as the concerns continued and told her that she was going to start marking the resident's incontinence products to track if the residents were being changed. She revealed on 10/11/23 at approximately 11:00 P.M. she had State tested Nursing Assistant (STNA) #615 mark a few residents' incontinence products, including Resident #29. She revealed on 10/12/23 at appropriately 8:30 A.M. she checked on Resident #29 to see if she received proper incontinence care, but she still had the same marked incontinence product that had been applied on 10/11/23 and it was evident she had not been changed all night shift as her incontinent product was saturated in brown urine, her sheets were saturated with brown dried rings, her buttocks were red and excoriated, and she could smell a strong urine smell from the hallway and in her room. She revealed she had Acting DON #600 come to Resident #29's room and showed her that she was still wearing the same marked incontinence product applied on 10/11/23 and was saturated in urine. She revealed it was frustrating as the issue continued to happen regarding night shift staff not changing the residents properly including, Resident #29, and that she felt her hands were tied as despite reporting the continued issue to the Acting DON #600, she did not feel that the issue had been addressed as she felt nothing had been done about it. Interview on 10/17/23 at 8:29 A.M. with Scheduler/ Human Resources (HR) #611 revealed she maintained the employee personnel files and had not received any disciplinary actions and/or education that staff had received from 10/01/23 to 10/17/23 for not providing timely incontinence care. Interview on 10/17/23 at 9:15 A.M. with Acting DON #600 verified last week RN #608 came and got her to show her Resident #29's incontinence product and concern that she had not been changed by the previous shift (night shift). She verified her incontinence product was saturated in urine. She verified Resident #29 was cognitively intact, and Resident #29 stated that she had not been changed on night shift, 10/11/23. She revealed that she did not know off hand which aide was assigned to Resident #29 on 10/11/23 through 10/12/23 night shift. She revealed she had no evidence that the staff involved was educated and/or received disciplinary action for not changing Resident #29 all night. She revealed that she had no documented evidence that she had investigated the concern voiced by Resident #29 and/or that she had gotten back to Resident #29 regarding how she had addressed the concern, and/or that she had checked with Resident #29 if the concern was resolved. Interview on 10/17/23 at 10:03 A.M. with STNA #612 revealed she worked on first shift and frequently when she came on duty several of the residents, including Resident #29, had not been properly changed by the previous shift as their incontinence products were saturated in urine and/or bowel movement, required complete bed changes and/or had dried brown urine rings on their sheets. She revealed she had reported the issue to the nurses and Acting DON #600 several times regarding the residents' lack of timely incontinence care. Review of the grievance log dated 09/01/23 to 10/16/23 revealed the facility had no grievances including Resident #29's complaint voiced on 10/12/23. Review of the undated facility policy labeled, Resident Grievance revealed all complaints and grievances would be investigated and the result of the investigation shall be reported back to the individual registering the concern within a reasonable time. The policy revealed individuals may express complaints to staff or administration verbally or in writing at any time. The policy revealed a complaint was defined as an expression of dissatisfaction with a committed or omitted action. The policy revealed a response was to be given in a timely manner as follow up and would be documented and logged as part of the Quality Assurance Program. The policy revealed if the complainant was not satisfied with the response a formal written grievance may be submitted to the grievance committee. This deficiency represents non-compliance investigated under Master Complaint Number OH00147275 and Complaint Number OH00146748.

Based on the interview, record review and review of facility policy, the facility did not ensure Resident #29 received timely incontinence care. This affected one resident (Resident #29) out of six residents ( Resident #13, #20, #28, #29, #47, and #72) reviewed for timely incontinence care and had the potential to affect 59 residents (Resident #1, #2, #3, #6, #7, #8, #9, #11, #13, #14, #15, #17, #18, #19, #20,#21, #22, #23, #27, #28, #29, #31, #32, #33, #34, #35, #36, #37, #38, #40, #43, #44, #45, #46, #47, #48, #49, #50, #51, #52, #54, #55, #56, #59, #60, #61, #62, #63, #65, #68, #69, 70, #71, #72, #74, #75, #78, #80, #82) who were identified as incontinent of bowel and/ or urine. Findings included: Review of medical record for Resident #29 revealed an admitted [DATE] and her diagnoses included multiple sclerosis, diabetes, need for assistance with personal care, and morbid obesity. Review of nursing notes dated from 08/30/23 to 10/17/23 revealed no concerns documented in her medical record regarding refusal of incontinence care. Review of care plan dated 09/11/23 revealed Resident #29 had urinary incontinence and was at risk for altered dignity, skin breakdown, and urinary tract infections. Interventions included checking and providing incontinence care as needed, applying barrier cream after each incontinent episode, and observing and reporting redness, excoriation and/ or open areas with incontinence care. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #29 had intact cognition. She required extensive assist of two staff with bed mobility and toileting. She was unable to ambulate. She was frequently incontinent of bowel and bladder. Review of assessment labeled, Bladder Observation dated 10/10/23 and completed by Registered Nurse (RN) #614 revealed Resident #29 was incontinent of urine due to impaired mobility. The assessment revealed she had incontinence without sensation of urine loss. Interview on 10/16/23 at 1:28 P.M. and 10/17/23 at 12:35 P.M. with Resident #29 revealed she had notified several nurses including RN #608 that night shift had not been providing timely incontinence care and at times she had gone the whole shift not being changed and laid in urine. She revealed the nurses including RN #608 had continued to report that they had notified Acting DON #600 but that nothing happened as night shift continued to frequently not change her. She revealed on 10/11/23 from 11:00 P.M. to approximately 8:30 A.M. she was not provided incontinence care and that her skin was burning from not being changed. She revealed RN #608 came into her room to check on her, turned her over and seen that she was lying in a puddle of urine. She revealed RN #608 had notified the Acting DON #600 and had her come to her room to show her the incontinence product and how she had not been changed for over nine hours. Resident #29 revealed Acting DON #600 stated she would check into it but that she never got back to her regarding the complaint and/ or how the complaint would be resolved. She revealed she felt that she would continue not to be changed timely especially on night shift despite making the nurses and Acting DON #600 aware of her concern as it had been happening since her admission, 08/30/23. Interview on 10/16/23 at 1:38 P.M. and 10/17/23 at 7:48 A.M. with RN #608 revealed she had received several complaints over the last month from residents including Resident #29 and staff that night shift had not been providing timely incontinence care. She revealed first shift staff also brought it to her attention that when they came on duty several residents had not been changed as their incontinence products were saturated in urine, and they required complete linen changes due to urine soaked through their incontinence products to the linen. She revealed she had notified the Acting Director of Nursing (DON) #600 several times of the residents including Resident #29 and staff's concerns. She revealed she had gone to the Acting DON #600 again as the concerns continued and told her that she was going to start marking the resident's incontinence products to track if the residents were being changed. She revealed on 10/11/23 at approximately 11:00 P.M. she had State tested Nursing Assistant (STNA) #615 mark a few residents the incontinence products including Resident #29. She revealed on 10/12/23 at appropriately 8:30 A.M. she checked on Resident #29 to see if she received proper incontinence care but she still had the same marked incontinence product that had been applied on 10/11/23 and it was evident she had not been changed all night shift as her incontinent product was saturated in brown urine, her sheets were saturated with brown dried rings, her buttocks was red and excoriated and that she could smell a strong urine smell from the hallway and in her room. She revealed she had Acting DON #600 come to Resident #29's room and showed her that she was still wearing the same marked incontinence product applied on 10/11/23 and was saturated in urine. She revealed it was frustrating as the issue continued to happen regarding night shift staff not changing the residents properly including Resident #29 and that she felt her hands were tied as despite reporting the continued issue to the Acting DON #600 she did not feel that the issue had been addressed as she felt nothing had been done about it. Interview on 10/17/23 at 8:29 A.M. with Scheduler/ Human Resources (HR) #611 revealed she maintained the employee personnel files and had not received any disciplinary actions and/ or education that staff had received from 10/01/23 to 10/17/23 for not providing timely incontinence care. Interview on 10/17/23 at 9:15 A.M. with Acting DON #600 verified last week RN #608 had come and got her to show her Resident #29's incontinence product and concern that she had not been changed by the previous shift (night shift). She verified her incontinence product was saturated in urine. She verified Resident #29 was cognitively intact and that Resident #29 had stated that she had not been changed on night shift, 10/11/23. She revealed that she did not know off hand which aide was assigned to Resident #29 on 10/11/23 through 10/12/23 night shift. She revealed she had no evidence that the staff involved was educated and/ or received disciplinary action for not changing Resident #29 all shift or had an investigation regarding the incident. Interview on 10/17/23 at 10:03 A.M. with State tested Nursing Assistant (STNA) #612 revealed she worked on first shift and frequently when she came on duty several of the residents including Resident #29 had not been properly changed by the previous shift as their incontinence products were saturated in urine and/ or bowel movement, required complete bed changes and/ or had dried brown urine rings on their sheets. She revealed she had reported the issue to the nurses and Acting DON #600 several times regarding the residents' lack of timely incontinence care. Review of facility policy labeled, Perineal Care dated November 2019 revealed it was the facility's responsibility to provide cleanliness and comfort to the resident, prevent infections, and skin irritation. The policy revealed if resident refused the staff was to notify the supervisor if the resident refused perineal care. The policy did not reveal anything about how often incontinence care should be provided. This deficiency represents non-compliance investigated under Master Complaint Number OH00147275 and COMPLAINT NUMBER OH00146748.

Based on record review, interview, and facility policy review, the facility failed to reasonably accommodate the desire of Resident #11's family to install an electronic video device in Resident #11's room. This affected one resident (#11) of three residents reviewed for resident rights. This had the potential to affect all residents. The facility census was 79. Findings include: Review of medical record revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including hemiplegia (one sided paralysis) affecting right side, unspecified dislocation of left hip, unspecified fracture of left acetabulum (concave service of the pelvis), and cerebral infarction (stroke) due to thrombosis (blood clot) of unspecified carotid artery. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #11 was severely cognitively impaired and required total dependence from two staff for all of his activities of daily living, except eating. Interview with the Responsible Party (RP) of Resident #11 on 07/10/23 at 11:18 A.M. revealed approximately two weeks after admission, the RP wanted to install a camera in Resident #11's room since Resident #11 had developed a broken and dislocated hip from a previous facility. The facility told the RP it would cost $700.00 to install a camera, since the camera had to run off the facility's Wi-Fi and required installation of wires behind the walls. The RP offered to get their own hot spot, but the facility declined that option. The RP stated she could not afford the $700.00 to install the camera. Interview on 07/10/23 at 11:45 A.M. with the Administrator revealed residents were allowed to have a camera in their room, but they must follow the facility's policy and procedures on how it is placed. The camera must be in a fixed location, come from an approved list, and be installed by someone the facility hired. The family could not use their own hotspot since it interfered with the electronic medical record. The cost of the installing the camera was at the expense of the RP/resident. Random intermittent observations throughout the facility on 07/10/23 noted numerous residents using facility Wi-Fi on various electronics, including but not limited to cell phones and other electronic devices. Review of the policy entitled Electronic Monitoring in Resident's Rooms Policy, dated November 2022, revealed the facility will permit residents and legally authorized people to install and use fixed electronic monitoring devices in accordance with applicable laws .The facility has an approved device that meets all the criteria of the law and can be installed at the request of the Authorized Person (a competent resident with the capability to make informed decisions, a person designated as the residents attorney in fact when the resident has lost capacity to make informed health care decisions, or a court appointed guardian) .Only authorized facility personnel are permitted to install electronic monitoring devices in residents rooms. The Authorized Person is responsible for all costs of the electronic monitoring devices, except the cost of procuring electricity. This deficiency represents noncompliance investigated under Complaint Number OH00143860.

Based on interview, review of daily staffing sheets, and review of the Facility Assessment the facility did not ensure they had Registered Nurse (RN) Coverage at least eight consecutive hours on 11/20/22. This had the potential to affect all 78 residents residing at the facility on 11/20/22. Findings include: Review of daily staffing sheets from 11/06/22 to 11/20/22 revealed there was no RN coverage on 11/20/22. Interview on 11/28/22 at 12:48 P.M. with Human Resource/ State tested Nursing Assistant (STNA)/ Staffing Coordinator #606 revealed she completed the nurses and STNA schedule at the facility. She verified the facility did not have any RN coverage on 11/20/22. Interview on 11/28/22 at 3:21 P.M. with the Administrator verified the facility was to have at least eight hours of RN coverage per day and that on 11/20/22 the facility had no RN coverage. Review of Facility assessment dated [DATE] revealed under the area regarding staffing plan there was no plan regarding ensuring the facility had at least eight consecutive hours of RN coverage every day. This deficiency represents non-compliance investigated under Complaint Number OH 296.

Based on interview, observation, record review, and policy review the facility failed to serve meals in a timely manner and per resident preference. This affected four residents (Resident's #21, #70, #71 and #55) of six residents (Resident's #21, #55, #59, #70, #71 and #82) reviewed for timeliness of meals. This had the potential to affect 85 residents of the 87 residents residing at the facility as Resident's #17 and #73 did not receive a meal tray. Findings include: 1. Review of the medical record for Resident #70 revealed an admitted d of 05/11/21 with diagnoses including [CONDITION(S)] of coronary artery without [CONDITION(S)], dysphagia, chronic obstructive pulmonary disease, and [CONDITION(S)] and [CONDITION(S)] following cerebral infarction affecting right dominant side. Review of the care plan dated 05/23/21 revealed Resident #70 was at risk for altered nutritional status related to inadequate oral intake, he refused weights and nutritional interventions. Interventions included supplements as ordered, provide diet per physician order, and provide a substitute of equal nutritional value if intake less than 50 percent. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #70 had impaired cognition. He required supervision with set-up help for eating. Observation on 07/26/22 at 1:34 P.M. revealed the 400 hall unit trays arrived at the unit and Resident #70 received his tray at 1:49 P.M. This was verified by Agency State tested Nursing Assistant (STNA) #607. Interview on 07/26/22 at 1:57 P.M. with Resident #70 and Resident #70's daughter who was present in the room, revealed meals were always late. Resident #70 revealed he preferred to get his lunch around 12:00 P.M. Resident #70's daughter revealed she felt getting lunch at almost 2:00 P.M. was unacceptable as he was supposed to get his lunch by 12:45 P.M. 2. Review of the medical record revealed Resident #71's admitted was 05/11/21 with diagnoses including [CONDITION(S)] following [CONDITION(S)] disease, diabetes, cognitive deficit, restlessness, and agitation. Review of the care plan dated 05/23/21 revealed Resident #71 was at risk for altered nutrition related to a therapeutic diet and had a history of swallowing difficulty. Interventions included monitor for signs of aspiration, provide diet per physician order, and offer substitute if intake was less that 50 percent. Review of the annual MDS 3.0 assessment dated [DATE] revealed Resident #71 had intact cognition. She required supervision and set-up with eating. Observation on 07/26/22 at 1:34 P.M. revealed the 400 hall unit trays arrived at the unit and Resident #71 received her tray at 1:47 P.M. This was verified by Agency STNA #607. Interview on 07/26/22 at 1:50 P.M. with Resident #71 and Resident #71's daughter who was present in the room revealed meals were always late and caused Resident #71 to have increased anxiety as she did not want to miss BINGO which started at 2:00 P.M. Resident #71 revealed she was upset as they always brought her lunch late which caused her to be late to BINGO which was an activity she looked forward to. 3. Review of the medical record for Resident #21 revealed an admitted [DATE] with diagnoses including acute and chronic [CONDITION(S)], [CONDITION(S)], and heart failure. Review of the care plan dated 01/24/21 revealed Resident #21 was at risk for altered nutrition related to a therapeutic diet and was morbidly obese. Interventions included provide diet as ordered. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #21 had intact cognition. He required extensive assist of two people with bed mobility and was independent with eating with set-up help. Observation on 07/26/22 at 1:34 P.M. revealed the 400 hall unit trays arrived at the unit and Resident #21 received his tray at 1:52 P.M. This was verified by Agency STNA #607. Interview on 07/26/22 at 1:57 P.M. with Resident #21 revealed he always got his tray late as he revealed he was supposed to get his tray approximately 12:30 P.M. He revealed today, 07/26/22, he almost got his lunch tray at 2:00 P.M. He revealed it was hard just lying in bed waiting as the facility should have some type of organized system in place. Interview on 07/26/22 at 1:44 P.M. with Agency Registered Nurse (RN) #612 who was the nurse on the 400-hall unit revealed meal trays were frequently delayed as the 400 hall was supposed to get their trays, she thought around 12:30 P.M. but was unsure. She revealed when she had worked at the facility, they received their trays anywhere from 12:30 P.M. to 2:00 P.M. and the resident's voiced concerns to her regarding the meals being late especially because BINGO started at 2:00 P.M. She revealed Agency STNA #607 did not know the meal process as she was supposed to go down and get the tickets from the kitchen, go around, and ask each resident if they wanted an alternative and then take the tickets back down to the kitchen. She revealed this had not occurred until later than usual causing the meals to be late. Interview on 07/26/22 at 2:00 P.M. with Activities #613 revealed meals being late happened often, especially on the 400-hall unit as that was the unit to receive their trays last and many times the residents voiced their frustration as she started BINGO at 2:00 P.M. She revealed Resident #71 was sometimes late to BINGO because she had not received her lunch tray, and Resident #71 enjoyed BINGO. She revealed she tried to delay BINGO if she could like she was today, 07/26/22, by at least 10-15 minutes but at times that was hard as the residents on the other units that already came down and got upset that BINGO did not start on time. Interview on 07/26/22 at 2:05 P.M. with Dietary Manager #611 verified the 400 hall was supposed to get their lunch trays at 12:45 P.M. but they did not arrive to the 400-hall unit until 1:34 P.M. She revealed the aide on the floor was to pick up the tickets from the kitchen in the morning and ask each resident if they wanted the regular meal or an alternative. She revealed the aide was to write it down on the ticket and bring the ticket back to the kitchen allowing time to make the alternatives. She revealed the aide was from agency (STNA #607) and did not know the process of the facility and that the kitchen was late getting the tickets and then was late preparing the 400-hall trays. Interview on 07/26/22 at 4:03 P.M. with Resident #55 revealed he resided on the 400 hall and revealed his meals were always late especially at lunch he was frustrated as he enjoyed playing BINGO but sometimes his lunch tray did not come before BINGO started which was at 2:00 P.M. He revealed it was frustrating waiting around from 12:00 P.M. to 2:00 P.M. for his lunch not knowing when it would come. Review of the undated facility form labeled Meal Time revealed the 400 unit was the last unit to receive their meal trays at the facility. The form revealed the 400-hall was to be served lunch at 12:45 P.M and dinner at 6:15 P.M. Review of the facility policy labeled Room Tray Service, dated November 2017, revealed residents unable to come to the dining room or who preferred to eat in their room shall be provided with a meal to their room. The policy does not identify anything regarding timeliness of meals to be served per mealtimes scheduled. This deficiency substantiates Complaint Number OH 527.

Based on observation, interview, and record review the facility failed to maintain a clean and sanitary kitchen area. This had the potential to affect 88 residents who received meals in the facility. The facility identified Residents #22 and #26 as receiving no food from the kitchen. Findings include: Observation of the kitchen during the initial tour with Corporate Certified Dietary Manager (CDM) #399 on 06/13/22 at 9:55 A.M. revealed the steamer and stove range with food debris and splatter running down sides. Dark blackened grease build up was observed on stove top grates. There was a dark sticky substance on the floor around and behind the steamer, oven, and grill top. Behind the equipment was a food preparation container three quarters full of dark grease like substance on floor and two pieces of foil. Interview with Corporate CDM #399 on 06/13/22 at 10:00 A.M. confirmed all observations. Corporate CDM #399 indicated there was no current dietary manager as the previous manager had quit unexpectedly last week. Follow up observation of the kitchen on 06/14/22 at 12:05 P.M. revealed the convection oven, pellet warmer, and plate warmer with floor residue and splatter running down outsides of equipment. The lower shelves of preparation tables had food particles and sticky residue. The floors under preparation tables and kitchen equipment had a dark residue and food particles. There was an unidentified brown substance dripping from bottom of preparation table by can opener and the substance was observed dripping down the leg of preparation table. Interview with Corporate CDM #399 on 06/14/22 at 12:12 P.M. confirmed all observations. Interview with Registered Dietitian (RD) #400 on 06/15/22 at 3:14 P.M. revealed they had no time for routine oversight in the kitchen and routine sanitation audits had not been completed. Review of a list of resident diets provided by the facility revealed Residents #22 and #26 as receiving no food from the kitchen. Review of facility policy, Dietary Department Cleaning Schedule, dated March 2016, revealed the dietary manager was responsible for ensuring cleaning schedules are completed, cleaning schedules shall be posted and available to all dietary employees, and all cleaning assignments shall be reviewed by dietary manager. Review of facility policy, Operation and Cleaning Procedures, dated March 2022, revealed the director of food services or designee was responsible for developing operating and cleaning procedures for all dietary equipment. All areas of the kitchen were to be cleaned daily to insure proper sanitation in the operation. Director shall conduct weekly audits of all areas and ensure proper sanitation.

Based on interview and record review the facility failed to provide Resident #77 with a Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNFABN) and Notice of Medicare Non-Coverage (NOMNC) upon skilled services ending. This affected one resident (Resident #77) of three residents reviewed for liability notices. Findings include: Review of the medical record for Resident #77 revealed and admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was still admitted to the facility. Review of facility beneficiary notice form completed on 06/13/22 by the facility revealed residents discharged from skilled services in the last six months revealed a notice was sent on 02/22/22 to Resident #77 for skilled services ending. Review of the medical record for Resident #77 revealed no evidence the resident received or signed a SNFABN or NOMNC. Interview on 06/14/22 at 9:30 A.M. with Registered Nurse (RN) #398 confirmed no SNFABN or NOMNC was given to Resident #77 upon skilled services ending. Interview on 06/14/22 at 11:19 A.M. with State tested Nursing Assistant/Social Services Liaison #359 confirmed Resident #77 was not given a SNFABN or NOMNC upon skilled services ending.

Based on record review and staff interview, the facility failed to ensure bed hold notices were given to Resident #28 and Resident #46 and/or their representatives upon transfer to the hospital. This affected two residents (Resident #28 and #46) of two residents reviewed for bed hold notices. Findings include: 1. Review of the medical record for Resident #28 revealed admitted [DATE] and a discharge to the hospital on 06/12/22. Review of Resident #28's quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #28 had cognitive impairment. Review of Resident #28's medical record revealed the resident required hospitalization on [DATE] for [CONDITION(S)]. The medical record identified no evidence the resident or resident representative was provided written notification of a bed hold upon Resident #28's transfer to the hospital. Interview on 06/16/22 at 9:09 A.M. with Corporate Nurse #394 verified the facility did not provide a bed hold notice to Resident #28. 2. Review of the medical record revealed Resident #46 was admitted to the facility on [DATE]. Review of Resident #46's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact. Review of Resident #46's medical record revealed Resident #46 required hospitalization on [DATE] for symptomatic [CONDITION(S)] and insertion of a pacemaker. The medical record identified no evidence the resident or resident representative was given a bed hold notice by the facility as required. Resident #46 was readmitted to the facility following the hospitalization . On 06/16/22 at 9:09 A.M. Corporate Nurse #394 verified the facility did not provide a bed hold notice to Resident #46.

Based on interview and record review, the facility failed to provide bed baths/showers routinely and as scheduled. This affected two residents (Resident #5 and Resident #21) of five residents reviewed for activities of daily living. Findings include: 1. Review of Resident #5's medical record revealed an admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #5's quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #15 was cognitively intact and was totally dependent on two or more staff for bathing. Review of the undated 300/400 shower schedule revealed Resident #5 was to be bathed Mondays and Thursdays on evening shift. Review of 30 days of shower data for Resident #5 revealed one bed bath was recorded on 05/14/22 (Saturday). No refusals were marked on the shower sheet and no data was available for 05/16/22 (Monday), 05/19/22 (Thursday), 05/23/22 (Monday), 05/26/22 (Thursday), 05/30/22 (Monday), 06/02/22 (Thursday), 06/06/22 (Monday), 06/09/22 (Thursday) and 06/13/22 (Monday). Review of 30 days of nurses' notes for Resident #5 revealed no refusals were documented and no evidence pertaining to bathing was available for 05/16/22, 05/19/22, 05/23/22, 05/26/22, 05/30/22, 06/02/22, 06/06/22, 06/09/22 and 06/13/22. Interview on 06/13/22 at 10:21 A.M. with Resident #5 revealed he was not getting bed baths and did not get bathed last week (06/05/22 to 06/11/22). Resident #5 stated he was supposed to get bathed on second shift but there was not often a shower aide for second shift so he would not get bathed. Interview on 06/14/22 at 10:40 A.M. with State tested Nursing Assistant (STNA) #343 indicated if there was just one STNA scheduled it was hard to get showers done. Interview on 06/14/22 at 3:13 P.M. with Registered Nurse (RN) #381 revealed if all of the scheduled staff showed up they would have a shower aide to do resident showers. However, on second shift there was not a shower aide so STNAs had to do their own showers. Interview on 06/15/22 at 4:20 P.M. with Licensed Practical Nurse (LPN) #318 indicated there was currently one STNA on the hall instead of two and indicated showers on second shift were not getting done. LPN #318 indicated Resident #5 did refuse showers at times but also indicated charting did not get done due to staffing levels. Interview on 06/15/22 at 4:33 P.M. with STNA #396 revealed showers were an issue and did not always get done three out of seven days of the week. STNA #396 indicated Resident #5 would refuse showers at times, it depended on him. Interview on 06/16/22 at 8:48 A.M. with Regional Nurse Consultant (RNC) #395 verified Resident #5's showers were not completed per schedule and Resident #5 was not bathed routinely. Interview on 06/16/22 at 8:58 A.M. with RN #397 revealed if residents refused showers, this was to be documented in a progress note. RN #397 stated showers were only documented on the paper shower sheets at the facility. Interview on 06/16/22 at 9:29 A.M. with Corporate Registered Nurse (CRN) #398 revealed there was no specific facility policy addressing showers. Shower preferences were obtained on admission and that drove the days and shifts listed on the facility's shower schedule. 2. Review of Resident #21's medical record revealed an admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #21's quarterly MDS assessment dated [DATE] revealed Resident #21 was cognitively impaired. Bathing was coded as did not occur on the MDS assessment. Review of the undated 300/400 shower schedule revealed Resident #21 was to be bathed Tuesdays on day shift and Fridays on evening shift. Review of 30 days of shower data for Resident #21 revealed showers were provided on 05/10/22 (Tuesday) and 05/24/22 (Tuesday); a bed bath was provided on 05/31/22 (Tuesday); a shower was provided on 06/07/22 (Tuesday) and a bed bath was refused on 06/14/22 (Tuesday). No data was available for 05/13/22 (Friday), 05/17/22 (Tuesday), 05/20/22 (Friday), 05/27/22 (Friday), 06/03/22 (Friday) and 06/10/22 (Friday). Review of 30 days of nurses' notes for Resident #21 revealed no refusals were documented and no evidence pertaining to bathing was available for 05/13/22, 05/17/22, 05/20/22, 05/27/22, 06/03/22 and 06/10/22. Interview on 06/13/22 at 12:03 P.M. with Resident #21 revealed she did not get bathed and could smell herself. Interview on 06/14/22 at 10:40 A.M. with STNA #343 indicated if there was just one STNA scheduled it was hard to get showers done. Interview on 06/14/22 at 3:13 P.M. with RN #381 revealed if all of the scheduled staff showed up they would have a shower aide to do resident showers. However, on second shift there was not a shower aide so STNAs had to do their own showers. Resident #21 refused showers at times. Interview on 06/15/22 at 4:20 P.M. with LPN #318 indicated there was currently one STNA on the hall instead of two and indicated showers on second shift were not getting done. LPN #318 indicated Resident #21 did refuse showers at times so staff would need to go back and reapproach her. LPN #318 also indicated charting did not get done due to staffing. Interview on 06/15/22 at 4:33 P.M. with STNA #396 revealed showers were an issue and did not always get done three out of seven days of the week. Interview on 06/16/22 at 8:48 A.M. with RNC #395 verified Resident #21's showers were not completed per schedule and Resident #21 was not bathed routinely. Interview on 06/16/22 at 8:58 A.M. with RN #397 revealed if residents refused showers, this was to be documented in a progress note. RN #397 stated showers were only documented on the paper shower sheets at the facility. Interview on 06/16/22 at 9:29 A.M. with CRN #398 verified there was no specific facility policy addressing showers. Shower preferences were obtained on admission and that drove the days and shifts listed on the facility's shower schedule.

Based on observation, interview, and record review, the facility failed to implement appropriate fall interventions related to assistance with toileting to prevent Resident #49's falls. This affected one resident (#49) of four residents reviewed for falls. Findings include: Review of the medical record for Resident #49 revealed admitted [DATE] with diagnoses including fracture of left femur, left femur intramedullary nailing, unspecified falls, muscle weakness, difficulty walking, lack of coordination, altered mental status, [CONDITION(S)], restlessness and agitation, age related [CONDITION(S)], and history of left hip fracture in 2016. Review of care plan initiated 06/05/20 revealed Resident #49 was at risk for falls related to confusion, history of falls, incontinence, medications, and impaired gait. Interventions included bed against wall, deep perimeter mattress to bed, encourage resident to wear bilateral hipsters, non-skid strips by bed, reinforce use of call light, utilize pillows to position in bed, bed in lowest position, non-skid socks, half side rail on right side of bed, identify non-compliance, monitor resident when in room for safety, and monitor for side effects from medications. Resident #49 had urinary incontinence. Interventions included assess quarterly for changes in elimination patterns, check and provide incontinence care as needed, refer to restorative for toileting program or scheduled toileting if applicable, and provide physical support or assistance for toileting safety as indicated. Review of Fall Risk assessment dated [DATE] revealed Resident #49 was at high risk for falls related to disorientation, required use of assistive devices, use of antidepressant and antipsychotic medications, and cardiovascular/cognitive/orthopedic/perceptual contributing factors. Review of physician's orders dated 04/07/22 revealed order for bed against wall and half side rail on right side. Physician's orders dated 04/19/22 revealed an order for bed in lowest position when in use. Physician's order dated 04/27/22 revealed an order for bilateral hipsters daily. Physician's orders dated 04/28/22 revealed orders for deep perimeter mattress. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #49 had impaired cognition. Resident #49 required extensive one staff assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. The assessment indicated Resident #49 had falls since prior assessment and a recent major surgical repair of fracture. Review of progress notes from June 2021 to June 2022 revealed Resident #49 had falls on 03/21/22, 04/03/22, 04/11/22, and 04/25/22. Review of progress note dated 03/20/22 revealed Resident #49 was noted to wander around unit, redirection with limited success, and self-transferring. Review of progress note dated 03/21/22 revealed Resident #49 was found sitting on bathroom floor. Resident #49 reported I fell asleep and fell off the toilet. Resident #49 complained of back pain and was noted to be anxious. Resident #49 was noted not to be bearing weight on left side. There was slight rotation and shortening of left leg. Resident #49 was sent to hospital for evaluation. Review of facility Fall with Injury Event report dated 03/21/22 revealed at 7:20 A.M. Resident #49 was found on floor in the bathroom. The fall was unwitnessed and Resident #49 had ambulated unassisted to bathroom. Resident #49 reported she must have fallen asleep and fell off the toilet. Resident #49 was found to have abnormal alignment of left leg, Resident #49 was alert, range of motion was painful and limited in lower extremity, and Resident #49 reported 10 out of 10 excruciating pain. Resident #49 had history of orthopedic conditions and use of antipsychotic medications. Resident #49 was transferred to hospital via ambulance. Hospital report revealed Resident #49 had left hip fracture and was scheduled for surgical repair on 03/22/22. Interventions upon return to facility were identified as refer to therapy services, monitor and manage pain, and room assignment closer to nursing station for monitoring. Review of progress note dated 03/24/22 revealed Resident #49 returned to facility post left hip surgery for fracture. Review of progress note dated 04/03/22 revealed Resident #49 was found on the floor in room stating, I have to go to the bathroom. No injuries were noted. Physician gave order to complete neurological checks and obtain a stat x-ray of left hip. Interventions included three-day bowel and bladder program. Review of facility Fall without Injury Event report dated 04/03/22 revealed at 5:15 P.M. Resident #49 was found lying on floor on right side next to bed. The fall was unwitnessed. Resident #49 was alert, normal extremity movements, and no pain or injury was noted. Interventions included hip x-ray related to recent fracture, utilize pillows for positioning when in bed, and monitor neurological status. Review of progress note dated 04/04/22 revealed Resident #49's left hip x-ray was negative. Resident #49 was assisted to bathroom and incontinence care provided. Review of progress note dated 04/11/22 revealed Resident #49 continued to be restless and making attempts to self-transfer. Resident #49 was offered toileting, snacks, and fluids. Redirection ineffective. Resident #49 had episode of incontinence. Resident #49 was having severe pain to left hip and back and was medicated with as needed pain medication. At 9:00 P.M. Resident #49 was found on bathroom floor and stated she was trying to go to bathroom, with no injuries noted. Review of facility Fall without Injury Event report dated 04/11/2 revealed at 9:00 P.M. Resident #49 was found on floor in bathroom. The fall was unwitnessed and Resident #49 has ambulated unassisted to bathroom. Resident #49 was alert, normal extremity movements, and no pain or injury was noted. Interventions included to reinforce use of call light. Review of progress note dated 04/20/22 revealed Resident #49 was found to be sitting on toilet in bathroom and the floor was noted to be covered in urine. Resident #49 had transferred unassisted and ambulated to bathroom without use of mobility devices or call light. Review of progress note dated 04/25/22 revealed Resident #49 was observed on floor in front of bed stating she was trying to go to bathroom. Post fall Resident #49 was noted to continue to attempt to self-transfer. No injuries were noted. Review of facility Fall without Injury Event report dated 04/25/22 revealed at 4:00 A.M. Resident #49 was found on floor in room. The fall was unwitnessed and Resident #49 had attempted to transfer without assistance from staff. Resident #49 was alert, normal extremity movements, and no pain or injury was noted. Interventions included to place non-skid strips in front of bed. Review of Occupational Therapy (OT) Discharge Summary dated 05/11/22 revealed Resident #49 was started on OT services on 04/13/22. Resident #49 was noted to have been hospitalized after unwitnessed fall in bathroom and found to have hip fracture. Resident #49 had OT goal to safely complete all toileting tasks. Resident #49 was discharged from therapy with stand by assistance required for toileting. Review of Physical Therapy (PT) Discharge Summary dated 05/17/22 revealed Resident #49 was started on PT services on 04/25/22. Resident #49 had PT goal to safely perform all functional transfers. Resident #49 was discharged from therapy with improvements to transfers however goals were not met as assistance levels fluctuate. Observation on 06/15/22 at 11:29 A.M. of Resident #49 revealed resident was sitting at edge of bed then stood up and self-transferred to wheelchair. Resident #49 then came out of room and headed down to dining room with no staff assistance or intervention. Interview on 06/15/22 at 11:33 A.M. with Registered Nurse (RN) #332 revealed Resident #49 was not on a toileting program. RN #332 indicated Resident #49 knows when she has to go to the bathroom and the aides take her. RN #332 indicated Resident #49 was commonly known to self-transfer. Interview on 06/16/22 at 12:11 P.M. with Licensed Practical Nurse (LPN) #326 and Regional Nurse #403 revealed Resident #49 had fascination with bathroom and she had a three-day bowel and bladder evaluation when she fell on upstairs unit. LPN #326 indicated they believe it would be helpful to Resident #49 to have some sort of toileting program. LPN #326 indicated they have a routine with Resident #49 and have been trying to keep closer to nurses' station but there was no scheduled routine for toileting in place. Regional Nurse #403 indicated the Director of Nursing (DON) would typically go over each fall and complete a root cause analysis then implement appropriate interventions, however there had been an interim DON so they were unable to confirm if any review of Resident #49's falls were completed. LPN #326 and Regional Nurse #403 verified the noted pattern for Resident #49 falls surrounding bathroom use and there were no interventions in place for toileting to prevent further falls. Follow up interview on 06/16/22 at 12:44 P.M. with LPN #326 and Regional Nurse #403 revealed Resident #49 was noted to continue to be up late at night and have periods of restlessness. Resident #49 continued to need reminders to use call light however Resident #49 had difficulty remembering reminders related to impaired cognition. Review of facility policy Fall Investigation dated 06/03/19 revealed post falls a root cause analysis would be conducted by interdisciplinary team and safety interventions would be implemented based on findings.

Based on observation, interview and policy review revealed the facility failed to ensure residents were served hot and cold foods at appropriate and appetizing temperatures. This had the potential to affect 95 of 96 residents currently residing in the facility with the exception of Resident #23 who received nutrition by tube feeding. Findings include: Observation on 11/09/21 at 12:10 P.M. of tray line revealed low food temperatures. Temperatures taken by the surveyor and Dietary Manager (DM) #809 revealed the macaroni and cheese was 109 degrees Fahrenheit (F) and the pureed chicken was 121 degrees F. DM #809 verified the cold foods and removed them from tray line to be warmed to appropriate temperatures. Observation on 11/09/21 from 1:45 P.M. through 2:15 P.M. while staff delivered room trays revealed multiple residents were seen returning trays due to cold foods. Interview with Resident #73 revealed she sent her food back because it was cold. A test tray was completed on 11/09/21 at 2:15 P.M., after all room trays were served. Temperatures taken by the surveyor and DM #809 revealed the following low temperatures for hot foods; chicken was 134 degrees F, chicken soup was 118 degrees F, vegetable soup was 133 degrees F, and carrots were 124 degrees F. The following high temperatures for cold foods included; fruit cocktail was 52 degrees F, juice was 46 degrees F and milk was 49 degrees F. Each food item was tasted by the surveyor and DM #809 who verified the hot foods were all cold and the cold foods were all warm including the drinks, and did not taste appetizing. Interviews on 11/09/21 at 9:56 A.M. through 11:45 A.M. and on 11/10/21 at 10:32 to 2:45 P.M. with Licensed Practical Nurse (LPN) #801, LPN #802, LPN #804, State tested Nurse Aide (STNA) #805, STNA #806, Registered Nurse (RN) #807, STNA #808, and STNA #811 revealed residents had come to them to complain about the temperatures of the food, these concerns were relayed to the dietary staff. Interviews on 11/09/21 from 10:00 A.M. to 1:00 P.M. and on 11/10/21 from 11:30 A.M. through 2:30 P.M. with Residents #1, #3, #15, #16, #28, #31, #35, #38, #43, #51, #54, #59, #60, #68, #82 and #95, revealed their food was cold on a daily basis, during at least one meal. Interview on 11/10/21 at 1:36 P.M. with Registered Dietician (RD) #813 revealed residents have complained to her that hot foods were cold and verified dietary staff failed to provide hot foods. Interview on 11/10/21 from 2:00 P.M. through 3:00 P.M. with Cook #812, Dietary Aide (DA) #814, DA #815, and DA #816 revealed residents complain about cold foods at least once a day. Interview on 11/10/21 at 1:36 P.M. with Registered Dietician (RD) #813 stated she has had residents express to her issues with hot foods were cold and verified the dietary staff are having issues with providing the food at the correct temperatures and the facility is failing to provide hot foods. Review of the facility Grievance log revealed there were two complaints about food temperatures in August 2021, five complaints about food temperatures in September 2021, and three complaints about food temperatures in October 2021. Review of Resident Council meeting minutes from 08/12/21, 09/08/21, and 10/13/21 revealed resident concerns related to the facility failing to provide hot foods. Review of the Food Committee notes, dated 08/12/21, 09/08/21 and 10/13/21 revealed residents voiced concerns related to the facility failing to provide hot foods. Review of the facility policy dated Tray Line Food Prep Temps and Guidelines dated November 2019, revealed the facility failed to provide hot foods at 140 degrees F or higher and cold foods at 41 degrees F or lower. This deficiency substantiates Complaint Number OH 929.

Based on interview, review of self-reported incident report and closed medical record review, the facility failed to ensure Resident #70 was free from verbal abuse. This affected one resident (Resident #70) of four residents reviewed for abuse. The facility census was 88. Findings include: Review of the closed medical record for Resident #70 revealed an admission date of [DATE] and a discharge date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #70's care plan, dated 10/08/18, revealed she had behavioral symptoms including agitation, throwing items, yelling and screaming, wandering in and out of rooms, rummaging and hoarding other residents' items. Interventions included: maintain a calm environment and consistent approach with her, avoid over-stimulation, encourage resident to accept assistance with care as needed but if resident refused care staff were to stop and allow that choice, make resident safe and place the call light within reach, and provide interesting activities. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/15/19, revealed Resident #70 had impaired cognition. Her behaviors included rejection of care and wandering. She required supervision of one person assist with bed mobility and walking in the corridor. She required limited assist of one person with transfers. Review of self-reported incident (SRI) with a discovery date of 11/11/19 and tracking number # 7 revealed Physical Therapy Assistant (PTA) #615 reported to the Administrator that State tested Nursing Assistant (STNA) #616 used a stern and loud voice towards Resident #70. The SRI revealed Resident #70 was unable to answer any questions regarding the incident due to her dementia. Review of undated interview completed by the Administrator with STNA #617 revealed her back was turned towards STNA #616. STNA #617 revealed STNA #616 stated to Resident #70, I swear to God I will end your life and then she stated, I don't care if I get fired, I wish I could hit you back. STNA #617 revealed she did not witness STNA #616 hit Resident #70. STNA #617 revealed STNA #616 walked away, and then STNA #617 assisted Resident #70 to the dining room. Review of undated interview completed by the Administrator with PTA #615 revealed PTA #615 heard a verbal confrontation in the secured dementia unit between two residents. She revealed STNA's #616 and #617 assisted in separating the two residents. She revealed STNA #616 stated, I swear to God, if you hit me one more time, I will end your life. I am not afraid to get fired. PTA #615 revealed STNA #616 walked away from Resident #70. Review of interview dated 11/11/19 completed by the Administrator with STNA #616 revealed STNA #616 stated Resident #70 was in the common area and she tried to take another resident's drinks and plates to her room. STNA #616 revealed she told Resident #70 to leave them on the table and then she revealed Resident #70 smacked her in the face. STNA #616 verified she reacted wrong as she stated to Resident #70, I wish I could hit you back, I swear to God, I'm going to lose my job. STNA #616 denied hitting Resident #70. STNA #616 was suspended pending the investigation. Review of an interview dated 11/11/19 completed by the Administrator with Resident #70 revealed she had asked her if anyone had yelled at her, and Resident #70 began to babble about things that were not related to the question. Resident #70 was asked if anyone hit her, and she stated no. Interview on 02/10/20 at 1:22 P.M. with the Administrator verified STNA #616 had stated she lost control and yelled at Resident #70 threatening Resident #70 that she wished she could hit her back and threatened to end her life in front other residents. The Administrator revealed the facility terminated STNA #616. Interview on 02/10/20 at 2:14 P.M. with PTA #615 revealed she was taking another resident back to the secured dementia unit in the facility. She revealed Resident #70 was taking items from another resident and that resident was getting upset. She revealed she heard STNA #616 state in a loud tone that she swore to God if Resident #70 hit her one more time, she was going to end Resident #70's life, and STNA #616 was not afraid to get fired. PTA #615 revealed other residents were in the area and heard STNA #616 threaten Resident #70. She revealed she felt it was verbal abuse and reported the incident immediately to the administrator. Review of undated facility policy titled, Abuse, Mistreatment, Neglect, Misappropriation of Resident Property and Exploitation, revealed the facility would not tolerate abuse of residents. The policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish which included verbal abuse. This deficiency substantiates Master Complaint Number OH 900.

Based on observation, interviews with staff and residents, review of the medical record, and review of the facility Elopement Risk Assessment Policy and Procedure, the facility failed to provide adequate supervision to prevent the elopement of one resident (Resident #55), who had severe cognitive impairment, a legal guardian and exit seeking behaviors. This resulted in Immediate Jeopardy on 04/22/19 at approximately 9:45 P.M. when Resident #55 exited the facility without staff knowledge. The likelihood of Actual Harm that is Immediate Jeopardy occurred as Resident #55, dressed in dark clothing, was seen pushing his wheelchair along a busy, two lane road at approximately 9:50 P.M. by a staff person driving to work. This affected one of four residents reviewed for elopement risk and wandering behaviors. The facility has identified 25 residents at risk for elopement. The facility census was 91 residents. On 04/25/19 at 1:00 P.M., the Administrator and Corporate Nurse were notified Immediate Jeopardy began on 04/22/19 at 9:45 P.M. when Resident #55, who was at risk for elopement and exhibited a desire to leave the facility, went out the front door of the facility. The Immediate Jeopardy was removed on 04/26/19 when the facility implemented the following corrective actions: · On 04/22/19 at approximately 9:52 P.M., Licensed Practical Nurse (LPN) #416 received a telephone call from an employee driving to work to report someone who looked like a resident was walking down the street. LPN #416 initiated the facility elopement policy which included staff searching the facility and surrounding area and discovered Resident #55 was not inside the facility. · On 04/22/19 at 10:03 P.M., Resident #55 was returned by staff to the facility and assessed to have no injury. Resident #55 indicated he went out the front door of the facility. He was immediately placed on one-to-one supervision by staff, and his physician and guardian were notified. · On 04/22/19 from 10:03 P.M. until 10:30 P.M. the front door was continually monitored by State tested Nursing Assistant (STNA) #404, Registered Nurse (RN) #434, or Licensed Practical Nurse (LPN) #406 until Director of Maintenance (DM) #425 arrived to reset the alarm code on the front door. · On 04/22/19 at approximately 10:30 P.M., DM #425 discovered the front door was not secured when entering the facility. DM #425 reset the alarm code on the door and checked all remaining doors to ensure they closed and were secured and/or alarmed when opened. · On 04/22/19 at 10:30 P.M., DM #425 began door code function checks, which will continue daily indefinitely. · On 04/22/19 at 10:45 P.M. the Administrator, DM #425, and RN #450 began in-servicing all second and third shift staff on the facility Elopement Policy and Procedure. · On 04/23/19 at 7:54 A.M., Resident #55 was moved to the secured unit. · On 04/23/19 at 1:59 P.M., RN #600 completed elopement reassessments of all facility residents, with care plans and interventions updated as needed. Twenty-four residents were found to be at risk for elopement and all but two (Residents #21 and #62) resided on the secured unit. There was no evidence that Residents #21 and #62 had made attempts to exit the building, and care plans were in place with interventions to prevent elopement. · On 04/23/19, RN #450 reviewed and updated the resident identification books for those residents who were at risk for elopement (Happy Feet Club). · On 04/23/19, the contracted door security company inspected all doors in the facility, including the front door. The door security system was cleared and reset to ensure no additional codes provided to staff or emergency personnel would be able to override the door security code. · On 04/24/19 at 7:30 P.M., an elopement drill was conducted with 18 staff members participating. · On 04/25/19 by 10:10 P.M., the Administrator and DON had in-serviced one RN, nine LPNs, 25 STNAs, five housekeeping staff, eight dietary staff, two activity staff, one social service, five therapy, one receptionist, one maintenance staff, and nine administrative staff either in person or by phone, regarding the facility policy and procedure for a missing resident/elopement; checking residents for safety every two hours; and reporting suspicious or unsafe activity to the Administrator, DON, or Nursing Supervisor immediately. In-services will continue until all remaining 19 staff are in-serviced as they return to work. · On 04/26/19 at 2:30 P.M., the contracted door security company installed a mag lock on the social service office exit door and a new security key pad to control the exit access to the parking lot from the stairwell side exit door. Although the Immediate Jeopardy was removed on 04/26/19, the deficiency remains at a Severity Level 2 (no actual harm with the potential for minimal harm that is not Immediate Jeopardy) as the facility was continuing with staff in-services and was in the process of monitoring staff and exit doors to ensure compliance and determine if further action is required. Findings include: Review of Resident #55's medical record revealed he was admitted to the facility from the hospital on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #55 was severely cognitively impaired; he did not have behaviors; and he required limited to extensive assistance of staff for activities of daily living. An elopement risk assessment completed by RN #605 on 03/28/19 indicated Resident #55 was at high risk for elopement due to his [DIAGNOSES REDACTED]. However, at that time that he was unable to ambulate or propel himself in a chair or wheelchair. A progress note written by LPN #406 on 04/09/19 at 2:57 A.M. revealed the resident took the elevator to the lower level saying he was looking for the party he had to go to and was redirected back to his unit. On 04/13/19 at 5:00 P.M., LPN #610 wrote in a progress note that Resident #55 was again on the elevator, and a telephone call from the elevator company was received saying that the resident used the phone in the elevator, saying he was going to a party. A progress note written by RN #615 on 04/14/19 at 4:25 A.M. revealed the resident was wandering with a wheeled walker throughout the shift and needed constant re-direction and reassurance. The note indicated the resident was exit seeking and said he wanted to go get a beer and attempted to go out the door leading to the patio. He became combative initially with redirection but was able to be assisted to bed. A subsequent elopement assessment completed by RN #620 dated 04/15/19 revealed Resident #55 was still at high risk for elopement and was now able to ambulate or propel himself in a wheelchair. The assessment indicated the resident was staying near windows or exit doors. Resident #55's care plan dated 04/15/19 through 07/17/19 revealed he was at risk for elopement due to his dementia and exit seeking behaviors. Interventions included completing a resident identity sheet due to risk factors; informing facility staff of potential for elopement; and checking the resident frequently and re-directing him from exit doors as needed. Other interventions included encouraging activity involvement; attempting to determine the resident's needs; and try to convince him that there is no need to look outside. A progress note written by Licensed Social Worker (LSW) #625 on 04/17/19 at 12:47 P.M. revealed the social worker spoke with the resident's mother who was his guardian, and she indicated she did not feel the resident should be living independently. The surveyor observed Resident #55 on 04/22/19 throughout the day. He was mobile in his wheelchair in the hall near his room. He was pleasant but confused when the surveyor attempted to speak with him around 3:00 P.M. A progress note written by RN #434 on 04/22/19 at 11:07 P.M. revealed the resident was seen outside the facility. The note indicated a staff member brought him back and no concerns were noted. The resident's guardian and the physician were notified. On 04/23/19 at 1:30 P.M., interview with Resident #55 revealed he was confused but pleasant. He said he had only been at the facility for about 35 minutes, and said he worked all day at the big house. He was unsure of where his room was, saying he did not live at the facility and was waiting for someone to pick him up. Interview with the Administrator on 04/23/19 at 4:20 P.M. confirmed Resident #55 had been found outside the facility on 04/22/19. She said an investigation was in progress, including interviews with staff. She said STNA #414 was coming to work and observed Resident #55 on the road in front of the facility about 0.25 miles away. She said the resident was confused and could not say exactly how he was able to leave the building but said he went out the front door. The Administrator said when DM #425 came to the facility on [DATE] around 10:30 P.M, he found the front door of the building, which had a key pad coded entry, was unsecured and open. She said the key pad code for the door was then reset at 10:30 P.M., and the door was locking when closed. The Administrator said an investigation was in process to determine how the door became unlocked, and Resident #55 was moved to the secured unit on 04/23/19 at 8:00 A.M. On 04/23/19, the facility began an audit of new admissions or re-admissions to the facility to review the Clinical Admission Documentation Observation for the Elopement score and ensure the appropriate protocol had been implemented. Nursing progress notes for all residents would also be reviewed to ensure any exit seeking or wandering behaviors would be addressed with proper interventions implemented. These audits will be completed daily Monday through Friday during the clinical meeting by the Nursing Management Team and Social Services staff for four weeks then would become part of the quality assurance program. Charge nurses will be responsible to notify administrative staff of any new exit seeking behaviors by any resident that occurred Friday through Monday morning An interview with STNA #404 on 04/24/19 at 6:10 P.M. revealed she worked on 04/22/19. She said she was familiar with Resident #55 who needed redirection frequently and was usually confused and wandered in his wheelchair in the hallways and at the front lobby of the facility, at times talking about leaving the facility. She said on 04/22/19 she saw the resident about 9:40 P.M. or 9:45 P.M. as she was leaving the building to go on a dinner break. She said the resident was not in the immediate area of the door. She said she entered the code to get out of the door and was not sure that the door was locked. She said she went to her car and returned around 10:00 P.M., when she was told a resident was missing. She went out again to her car and drove around the facility to help search for the resident. She said she was only outside a couple minutes when she was called by another staff member who said the resident was found. On 04/24/19 at 6:30 P.M., interview with LPN #406 revealed she was the nurse on duty on 04/22/19. She said Resident #55 frequently needed redirection but generally responded positively to staff intervention. She said around 9:35 P.M. or 9:40 P.M. she saw Resident #55 in the hall near his room. She said STNA #404 had gone on her break, and STNA # 401 was in the nurse's station when she went into a resident's room to do a dressing change. She said about 15 minutes later, she heard the elopement call over the intercom indicating a resident was missing. She quickly finished her task and exited the room and saw STNA #401 looking in the hall for the missing resident, so she went outside. She said she was not outside more than a couple minutes when she got a phone call that the resident had been found. She returned to the nursing unit and was there to greet Resident #55 when he returned with staff. She said Resident #55 said he left the facility out of the front door and was unclear as to where he was going. Resident #55 was not injured. She said Resident #55 was placed on one-to-one monitoring after he returned to the facility. An interview with STNA #401 on 04/25/19 at 9:00 A.M. revealed she was assigned to the unit with STNA #404 on 04/22/19. She stated STNA #404 went on a break and she was at the nurses station when LPN #406 went into in a resident room to change a dressing. She said Resident #55 was in his doorway about 9:45 P.M. when a call light went off, so she went to answer it. STNA #401 went into another room on her way back to the nurse's station and then heard the call about a missing resident. She said she was told to go outside and look for the resident, so she did, and within a few minutes she was told the resident had been found. STNA #401 said she talked to Resident #55 when he returned, and said he thought the whole incident was not a big deal and was funny. STNA #401 said Resident #55 was always able to be redirected away from doors and she assumed the front doors were secured. An interview with STNA #414 on 04/25/19 at 9:15 A.M. revealed as she was driving to work on 04/22/19 about 9:55 P.M., she saw someone walking away from the facility. She said the person was pushing a wheelchair and was walking facing traffic on the pavement on the side of the road, but not in the roadway. She said by the time she recognized the person as a resident, she was already at the facility, so she pulled in and called to let them know to check for all residents, as she thought she saw a resident walking on the road outside. She said she did not know the name of the resident because she works nights, the resident was new, and she did not work on that unit. However, she recognized the resident from the facility. STNA #414 said she did not go into the facility right away because it was not actually time for her shift. She said she usually comes early to drink coffee and relax in her car before going in to start her shift. Review of the statement by STNA #414, dated 04/24/19, revealed while sitting in the parking lot after making the phone call, she saw staff members coming out the facility to search for the resident, including STNA #401, and STNA #410 and LPN #412 who got into a car and drove in the direction of the resident. LPN #416 was not able to be reached by phone. Review of her statement dated 04/24/19 revealed she answered the facility phone when STNA #414 called in to say she saw a resident outside the facility. LPN #416 indicated she did not ask which direction the resident was walking. She indicated she told STNA #410 and LPN #412 to go look for the resident. LPN #416 then tried to reach LPN #406 who did not answer her phone. She then called the overhead page to alert staff of a missing resident (Dr. Walker) and called LPN #430 who helped her identify the resident missing as Resident #55. An interview with LPN #412 on 04/25/19 1:48 P.M. revealed he was newly employed by the facility and 04/22/19 was one of his first days. He said when he heard a resident had been seen outside the facility, and he was sure that the residents on the secured unit were accounted for, he left with STNA #410 to go look for the resident. LPN #412 said the resident was found seated in his wheelchair self-propelling along the road not far from the facility. He said STNA #410, who was driving, turned around and stopped near the resident, who appeared unharmed and was cooperative in getting into the car. LPN #412 said Resident #55 told him he was going home but was agreeable to returning to the facility. Review of STNA #410's statement, dated 04/25/19, revealed she was instructed by LPN #416 to go look for the resident when it was reported that a resident had possibly left the facility. She went with LPN #412 who saw the resident sitting in his wheelchair near a school down the street from the facility. STNA #410 said Resident #55 was cooperative and they were able to return him easily to the facility. An interview with DM #425 on 04/25/19 revealed the administrator notified him of the incident on 04/22/19 around 10:09 P.M. and he was asked to go to the facility to check on the doors. He said he arrived about 10:30 P.M. and upon entering the front door of the building, noted the alarm was not set and he was able to open the front door without the alarm sounding. He immediately re-set the alarm from the keypad inside the door. He said he did not check if the front door, when opened from inside the facility, was locked but had been told that it was open. Observation and interview with Resident #55 on 04/25/19 at 3:15 P.M. revealed he was on the secured unit, standing in the common area with his walker. He was dressed neatly and was confused. He denied concerns but said he was thinking he should leave and go check on his car and dog. He was encouraged to remain at the facility and was agreeable. Resident #55 was not actively exit seeking at that time and was able to point toward his room and talk about what he had for lunch. The administrator, director of nursing, social worker and three registered nurses, who were part of the Nursing Management Team, were in-serviced on 04/26/19 by the regional nurse. Education for the charge nurses was started on 04/26/19 and would continue until all were educated. On 04/26/19 between 10:30 A.M. and 11:30 A.M., interview with three LPNs, four STNAs, one laundry staff, and one receptionist revealed they were knowledgeable regarding the facility policy and procedure for elopement, including the identification of residents at risk for elopement (Happy Feet Club), use of the door key pad security system, what to do if the door security system didn't function properly, the code for elopement, and reporting anything unusual to the Administrator, DON, or Nursing Supervisor immediately. Interview with the administrator on 04/26/19 at 10:36 A.M. confirmed an interview statement written by Occupational Therapist (OT) #428, which indicated she observed Resident #55 in the administrative office area on 04/22/19 at 9:30 P.M., and she redirected the resident out of the area. The administrator verified that if Resident #55 had been in that area, it would have indicated the French doors to the administrative offices were not locked. She further verified although it was unknown how the resident exited the building, he most likely exited through the front door, but may have had access to the unlocked, unsecured door off the administrative area and could have exited there. Observation on 04/26/19 at 2:30 P.M. revealed the contracted door security company was completing the installation of a mag lock on the social service office exit door and a new security key pad to control the exit access to the parking lot from the stairwell side exit door. These exit doors were accessible from the front lobby through the French doors leading into the administrative offices. Review of the facility's Elopement Risk Assessment Policy and Procedure, updated on 02/23/18, revealed all residents should be assessed on admission to the facility. If a resident was determined to be low risk, they would be monitored and reassessed if they had a significant change to their condition. If a resident was assessed as moderate or high risk, they would have a care plan to address their risk factors and have a resident identification form completed and put in a notebook at each of the nurse's station and at the receptionist's desk.

Based on observation, interview, and record review, the facility failed to ensure medications were stored in a secured manner. This affected one (Resident #9) resident, and had the potential to affect two (Residents #15 and #140) cognitively impaired and independently mobile residents who reside on the same floor as Resident #9. The facility also failed to ensure expired medications were disposed of as required. This had the potential to affect 15 residents who have their blood sugars tested in the facility, and any residents who may receive a suppository or [MEDICATION NAME] testing in the facility. The facility census was 91 residents. Findings include: 1. On 04/23/19 at 11:05 A.M., the door to Resident #9's room was observed shut. The surveyor knocked on the door, and entered when the resident gave permission. As the surveyor spoke with the resident, who had been dozing in her bed, the surveyor observed a small plastic cup of pills and tablets sitting on the bedside table. One of the tablets appeared to be a large tablet resembling a potassium chloride (treats low levels of potassium) tablet. Next to the cup on the table was a small, flat tablet that looked like a Tums, (an antacid). The resident stated the cup of medication had been left by the nurse and stated I will take it, I promise. The surveyor completed the interview and went to the nursing station. The nurse at the nearest nurse's station indicated the resident was actually assigned to a nurse at the other end of the hall, so the surveyor went to that nursing station. Licensed Practical Nurse (LPN) #400, was in the station and said she had prepared the morning medication for Resident #9. She initially said she had no concerns with the resident's medication pass, but when the surveyor indicated there was a cup of pills in the room, LPN #400 stated, she was taking the medication as I left the room. LPN #400 and the surveyor entered Resident #9's room together at 11:15 A.M. Resident #9 was sitting up in bed and medication cup was empty. The tums tablet and the large tablet of Potassium Chloride were laying on the bedside table. Resident #9 said she had just taken all the other pills but said she could not take the big one (Potassium) because it was too large. LPN #400 asked the resident about the tums tablet and the resident stated she thought another nurse had brought it in for her, but she was not sure when. LPN #400 verified the large tablet was Potassium Chloride and the smaller flat tablet was a tums. She removed both medications from the room. Review of the resident's orders revealed her morning medications included an aspirin tablet, [MEDICATION NAME] (a medication for [MEDICAL CONDITION]), [MEDICATION NAME] (an anti-depressant), [MEDICATION NAME] ( a blood pressure medication), potassium chloride, and [MEDICATION NAME] (a vitamin supplement). The record did not reveal an order for [REDACTED]. An interview with LPN #400 on 04/23/19 at 3:00 PM confirmed the morning medications as ordered. She stated she thought the resident was starting to take the medications when she left the room, but verified the medications in the room must have been from the morning medication pass. She also verified there was no order for the tums and she did not know where it came from. 2. Observation on 04/25/19 at 8:50 A.M. with Registered Nurse (RN) #440 of the medication room on the 400 unit revealed one [MEDICATION NAME] Purified Protein Derivative five milliliter (ml) vial in the refrigerator dated 03/16/19 as opened. Interview on 04/25/19 at 8:51 A.M. with RN #440 verified the [MEDICATION NAME] Purified Protein Derivative vial was expired. Review of undated facility pharmacy procedure, Pharmacy Expiration Date of Perishable Medication Policy revealed [MEDICATION NAME] vials expired after 30 days of opening. Review of facility policy labeled, Medication Storage in the Facility dated 06/02/15 revealed medications that were outdated were to be removed immediately from stock and disposed of according to procedures for medication destruction. 3. Observation on 04/25/19 at 9:01 A.M. with RN #440 of the medication room the facility called the Passport Room which contained the facility over the counter medications, revealed a plastic bag that contained six [MEDICATION NAME] ten milligram (mg) suppositories, all with the expiration date of 03/20/19 and one Level Two High Control glucometer testing solution with an expiration date of (MONTH) (YEAR). Interview on 04/25/19 at 9:04 A.M. with RN #440 verified the [MEDICATION NAME] suppositories and the glucometer high testing solution were expired. Review of facility policy labeled, Medication Storage in the Facility dated 06/02/15 revealed medications that were outdated were to be removed immediately from stock and disposed of according to procedures for medication destruction.

Based on interview and record review, the facility failed to report a possible occurrence of neglect to the State agency when a resident eloped from the facility. This affected one (Resident #55) resident reviewed for elopement. The facility census was 91 residents. Findings include: Review of the record of Resident #55 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #55 was severely cognitively impaired; he did not have behaviors; and he required limited to extensive assistance of staff for activities of daily living. Review of the record revealed an elopement risk assessment completed on 03/28/19 which indicated the resident was at high risk for elopement due to his [DIAGNOSES REDACTED]. The assessment indicated, however, at that time that he was unable to ambulate or propel himself in a chair or wheelchair. A subsequent elopement assessment dated [DATE] revealed the resident was still at high risk for elopement but was now able to ambulate or propel himself in a wheelchair. He was also noted staying near unit windows or exit doors. Review of a care plan dated 04/15/19 through 07/17/19 revealed the resident was at risk for elopement due to his dementia and exit seeking. Interventions included completing a resident identity sheet due to risk factors; informing facility staff of potential for elopement; and checking the resident frequently and re-directing him from exit doors as needed. Other interventions included encouraging activity involvement; attempting to determine the resident's needs; and try to convince him that there is no need to look outside. A note on 04/22/19 at 11:07 P.M. revealed the resident, was seen outside the facility. The note indicated a staff member brought him back and no concerns were noted. The resident's guardian and the physician were notified. An attempt to interview the resident was made on 04/23/19 at 1:30 P.M. He was confused but pleasant. He stated he had only been at the facility for about 35 minutes, and indicated he worked all day at the big house. He was unsure of where his room was, stating he did not live at the facility and was just waiting for someone to pick him up. He mentioned several times that he had attempted to call friends and family members and was having trouble making arrangements to have them pick him up. He was unable to identify any persons on the unit as staff or residents but denied any concerns with care or treatment at the facility. An interview with the facility administrator on 04/23/19 at 4:20 P.M. confirmed the resident had been found outside the facility on 04/22/19. She said an investigation was in process, including interviews with staff. She said an employee coming to work had observed the resident on the road in front of the facility about 0.25 miles away. She said the resident was confused and could not say exactly how he had been able to leave the building, but he said he had gone out the front door. The administrator indicated when the maintenance supervisor came to the facility on [DATE] around 10:30 P.M., he found the front door of the building unsecured. This door required a key pad code to open the door. She said the doors had been re-set and were currently functional, but an investigation was in process to determine how the door remained unlocked. Review of the facility policy on Abuse, Mistreatment, Neglect, Misappropriation of Resident Property and Exploitation, dated (YEAR), revealed Neglect was defined as the failure of the facility to provided good and services to a resident necessary to avoid physical harm, pain, mental anguish, or emotional distress. An interview with the facility administrator and corporate nurse (Registered Nurse #600) on 04/25/19 at 5:30 P.M. confirmed the facility had not submitted a facility-reported incident to the State agency to indicate an investigation into possible neglect was being conducted regarding the circumstances of Resident #55's elopement.

Based on observation, interview, and record review, the facility failed to ensure the necessary equipment and/or services were provided for comfort and possible prevention of a decline in range of motion. This affected one (Resident #5) of one resident reviewed with limited range of motion The facility census was 91 residents. Findings include: Review of the medical record for Resident #5 revealed an admission date of [DATE], and [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/17/19, revealed the resident had severely impaired cognition. Resident #5 required the extensive assistance of two staff members for bed mobility, dressing, toilet use and personal hygiene. The resident was totally dependent on staff for transfers and locomotion. The resident needed supervision for eating. Review of the plan of care with a start date of 01/13/17 and a review date of 04/22/19 revealed there was a care plan for the left lower leg contracture, but no care plan for the left hand contracture. Review of physician orders [REDACTED]. Review of past orders revealed an order for [REDACTED]. Staff were to provide gentle range of motion before and after removal. The order was in place from 05/14/2018 through 12/18/2018. Observations on 04/23/19 at 9:59 A.M. and on 04/24/19 at 9:17 A.M. revealed the resident's left hand was very contracted. There was no palm protector on the resident's hand. On 04/23/19 at 1:28 P.M. an interview with the resident's wife revealed there was a palm protector for Resident #5's hand in the room on the window sill. It hadn't been used recently and she did not know why. On 04/24/19 at 10:27 A.M. an interview with State tested Nursing Assistant (STNA) #453 revealed there was no order for the STNA to do any range of motion or put a palm protector on the resident's left hand. On 04/24/19 at 10:31 A.M. an interview with Registered Nurse (RN) #452 revealed there was no order for a splint or palm protector. The nurse thought it was because resident was too contracted to wear the splint, and it caused too much pain. On 04/25/19 at 10:15 A.M. an interview with the DON revealed the palm protector was was temporarily discontinued in (MONTH) (YEAR). The facility was checking on some bruising and problems with residents left hand. Communication had been missed to reactivate the order. The ADON was now putting in an order for [REDACTED].

Based on observation, interview, and record review, the facility failed to ensure oxygen therapy was provided, monitored, and documented as ordered. This affected one (Resident #134) of three residents reviewed for oxygen therapy. The facility census was 91 residents. Findings include: Review of the medical record for Resident #134 revealed an admission date of [DATE], and [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment, dated 04/18/19 revealed the resident had moderately impaired cognition. Resident #134 required extensive assistance for bed mobility, transfers, locomotion on the unit, dressing, toilet use, and personal hygiene. The resident was on oxygen therapy. Review of physician orders [REDACTED]. The order included the instructions to record oxygen saturation every shift. Review of medication administration records (MARs) and treatment administration records (TARs) for (MONTH) 2019 revealed Resident #134's oxygen saturation levels were not recorded until 04/25/19. Review of the care plans revealed no care plan for oxygen therapy. Review of the nursing progress notes from 04/11/19 through 04/25/19 revealed four notes containing oxygen saturation. On 04/15/19 at 2:21 A.M. oxygen saturation was 96 percent (%). On 04/14/19 at 12:53 P.M. oxygen saturation was 88% - 89%. On 04/14/19 at 7:51 A.M. oxygen saturation was 92% - 93%. On 04/11/19 at 11:10 A.M. the resident's oxygen saturation was 88%. There were no progress notes from 04/16/19 through 04/25/19 mentioning the resident's oxygen saturation percentages. Observations of Resident #134 on 04/22/19 at 11:09 A.M., 04/24/19 at 5:47 P.M. and 04/25/19 at 8:31 A.M. revealed the resident was in her room not wearing oxygen equipment. Interview on 04/25/19 at 8:33 A.M. with LPN #454 revealed the electronic medical record didn't allow for an oxygen saturation level to be entered. There was no space to enter that information. The LPN said she had taken the oxygen saturation level but had not recorded it anywhere or reported that the level was not able to be entered. Interview on 04/25/19 at 10:15 A.M. with the DON verified the order needed to be clarified and entered in a way to enable space to document the oxygen saturation level.

Based on review of resident medical records, behavior logs and a facility investigation report, and interviews with staff, the facility failed to provide adequate supervision to prevent Resident #33 from inappropriately/sexually touching another resident. This affected Resident #8, one of four residents reviewed and one of 25 residents who reside on the 500 dementia unit. The administrator, director of nursing and corporate nurse were notified on 05/09/13 at 2:00 P.M. that Immediate Jeopardy began on 04/17/13 at 2:00 P.M. when Resident #33 returned from a psychiatric hospital stay for treatment of [REDACTED]. The facility failed to implement interventions to address the inappropriate behavior of Resident #33 and provide for the safety of residents on the dementia unit where he resided. On 04/21/13 at 9:50 P.M., Resident #33 was observed in the room of Resident #8, leaning over her. Her gown was pulled up and Resident #33 was rubbing the resident's breast with his hand. The Immediate Jeopardy was removed when Resident #33 was sent to the hospital on [DATE] at 10:15 P.M. This reduced the potential for imminent danger as no other residents in the facility exhibited sexually inappropriate behaviors. Although the Immediate Jeopardy was removed, the facility remains out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy), because the facility had not yet completed review of their Abuse policy and procedures, made revisions as needed, and in-serviced staff on the facility's Abuse policy and procedures. Findings include: Resident #33 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly minimum data set assessment, dated 03/11/13, revealed the resident was assessed as severely cognitively impaired, ambulatory in the unit with only limited assistance to supervision and did not exhibit any physical, verbal or other behavioral symptoms. Review of the nursing notes dated 03/20/13 at 8:38 P.M. revealed Resident #33 received [MEDICATION NAME] for increased "sexual statements to female staff." A nursing note on 03/23/13 at 6:57 P.M. revealed the resident was trying to look down a female resident's shirt. Resident #33 was redirected. Interview with the facility administrator on 05/07/13 at 4:00 P.M. verified the resident affected by this action had not been identified and the incident had not been investigated. A nursing note dated 03/25/13 at 7:29 P.M. revealed the resident was "inappropriate with staff." No specific information about his behaviors were documented. A nursing note dated 03/29/13 at 6:27 A.M. revealed Resident #33 was "very sexually inappropriate with staff member to the extent that nurse had the aide escort the resident to his room." A nursing note on 03/29/13 at 9:27 P.M. revealed the resident made sexually inappropriate comments to staff and "attempted to enter a resident room across the hall a couple times." The resident was redirected. Nursing notes dated 03/30/13 at 7:52 P.M. revealed the resident used inappropriate language with staff, and he was "inappropriate with another female resident." He was redirected "without positive results," and medicated with [MEDICATION NAME]. This nursing note was amended on 04/01/13 at 5:05 P.M. to indicate it was later clarified that the resident did not direct his inappropriate action at any specific resident. A nursing note dated 03/30/13 at 8:46 P.M. revealed Resident #33 was "out in hall talking inappropriate to a female resident." This note was amended on 4/01/13 at 5:00 P.M. to indicate the resident was standing at the nursing station making sexual comments out loud, but not directed at any specific resident. A nursing note dated 03/31/13 at 8:38 P.M. revealed Resident #33 spoke inappropriately to staff, and tried to touch staff and a resident "inappropriately." He was redirected but this was not effective. The facility administrator verified on 05/07/13 at 4:00 P.M. that this incident had not been investigated and the resident affected had not been identified. A nursing note dated 03/31/13 at 10:47 P.M. revealed the resident used increasingly profane language with female staff and residents and "redirection is difficult." A nursing note dated 03/31/13 at 11:10 P.M. revealed the resident asked State tested Nurse Aide (STNA) #20 if "there is somewhere he could stick his (penis)," asking staff to show him their private parts. "I will stick something in it." He was redirected, but continued to yell out that he was "horny." Male STNA #30 spoke with him, but after STNA #30 left, the resident stood in the doorway of a resident's room where STNA #20 was taking vitals, and again spoke inappropriately. The note indicated the nurse told staff "to deal with the R (resident) in pairs and not to enter his room alone." He was also medicated with [MEDICATION NAME]. The next nursing note in the record dated 04/01/13 at 2:28 P.M. indicated the nurse asked the social worker to get a psychiatric consult regarding Resident #33's increased behavior. The nursing note dated 4/01/13 at 7:25 P.M. revealed the physician called with orders to send the resident to a geropsych unit and he left the facility at 7:20 P.M. There was no documentation in the record to indicate the resident was monitored after making the statements on 03/31/13 at 11:10 P.M. and the record did not provide a specific indication of the reason for his transfer on 04/01/13. Resident #33 returned to the facility on Wednesday 04/17/13 at 2:00 PM. Review of his transfer orders from the geropsych unit indicated the resident had been ordered [MEDICATION NAME] (a female hormone) every day to "curb sexual focus." The hospital physician progress notes [REDACTED].M. indicated the resident would be started on [MEDICATION NAME] ([MEDICATION NAME]) 5 milligrams once a day. The hospital Discharge Medications List dated 04/17/13 indicated his next dose was due on 04/18/13. The section of the transfer orders written by the social worker revealed the resident "may need specialized services for sexual inappropriate behaviors in the future," and provided four names of facilities as options. Review of the April 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M. An entry in a behavior tracking log dated 04/18/13 at 2:05 P.M. revealed Resident #33 exhibited "behaviors." The note was signed by STNA #15. Interview with STNA #15 on 05/08/13 at 12:45 P.M. revealed she remembered the incident. She stated the resident had a history of [REDACTED]." She stated that on 04/18/13, she heard the resident say to a nurse, "pull down your pants," which was an unusual statement for him, so she documented it as a "behavior." She stated she worked with the resident frequently, but she was primarily a day shift staff member. She stated she heard reports from the other shifts that Resident #33 generally had increased behaviors on the evening shift. A nursing note dated 04/19/13 at 2:08 P.M. revealed Resident #33 was "sexually inappropriate to a nurse." An interview on 05/08/13 at 1:40 P.M. with Licensed Practical Nurse (LPN) #20, who wrote that note, revealed that another nurse had told her the resident had said something inappropriate to her. She was unaware of what exactly was said. Interview with the other nurse, LPN #21, on 05/08/13 at 3:15 P.M. revealed that she was unsure exactly of what the resident had said to her but that he generally asked to "see your boobs." A nursing note dated 04/21/13 at 10:28 P.M. stated that an order was received to send Resident #33 to the geropsych unit at 10:00 P.M. due to "inappropriate behaviors." There was no documentation of the specific behaviors that led to the transfer. Review of the facility's investigation report of the incident revealed that Resident #33 was found at 9:40 P.M. in the room of a confused resident across the hall from his room, "leaning over (Resident #8)." The resident's gown was pulled up, and he was rubbing her breasts with his hand. Review of the record of Resident #8 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Her minimum data set assessment dated [DATE] revealed the resident was severely cognitively impaired and required the extensive assistance of two staff to transfer and the extensive assist of one staff member to move in bed and to move on the unit in a wheelchair. The resident was assessed to sometimes understand others and sometimes able to be understood, with limited ability in making concrete requests. Review of a care plan dated 07/13/09 and updated through 05/30/13 revealed Resident #8 had difficulty making herself understood due to [MEDICAL CONDITION] and altered thought processes. Interventions included encouraging verbalization, allowing the resident time to speak and provide a quiet, non-hurried environment, free of background noises and distractions. A care plan dated 02/20/13 and updated through 05/20/13 revealed the resident had short and long term memory problems and disorganized thinking at times. Interventions included ensuring the resident's areas were free of hazards and providing care in a calm and unhurried manner. Resident #8's record contained a nursing note dated 04/21/13 at 10:08 P.M. that indicated, "at 9:50 P.M., resident from across the hall noted coming out of (Resident #8's) room." The note stated a body check was performed by the nurse, and no new areas of redness or bruises had been found. Interview on 05/08/13 at 2:35 P.M. with LPN #10, who documented the note, revealed she was not the nurse assigned to Resident #8 or Resident #33 that evening, but STNA #16 had approached her at 9:50 P.M. to state he had observed Resident #33 in the room of Resident #8 and rubbing her breasts. LPN #10 stated Resident #33 was taken to his room and she assessed Resident #8. She stated when she entered the room, Resident #8 was lying in bed with her eyes closed. The resident was unable to relate what had happened. LPN #10 stated she assessed the resident physically and then called the physician of Resident #33 to facilitate his transfer out of the facility. She stated Resident #33 did not make any statements or comments related to the incident prior to his transfer. Interview with STNA #16 on 05/08/13 at 3:25 P.M. revealed he had not cared for Resident #33 prior to 04/21/13 and was not actually assigned to care for him on that evening. He stated he had just walked down the hall and observed Resident #33 in the room of Resident #8, leaning over her in bed. Resident #8's gown was raised and Resident #33 was rubbing her breasts with his hand. Resident #8 had her eyes closed and Resident #33 was startled by STNA #16's entry into the room. The STNA covered Resident #8, and escorted Resident #33 to the nursing station so he could notify the nurse. STNA #16 said he stayed with Resident #33 until the resident transferred out of the facility. Interview with STNA #7 on 05/06/13 at 3:35 P.M. revealed she had witnessed Resident #33 in the hall of the unit with his hands on the breasts of Resident #50. She stated she told a nurse about this incident after taking Resident #33 back to his room, but she had just been walking through the unit and returned to her unit after telling a nurse. STNA #7 could not remember the date of the incident or the name of the nurse to whom she reported the incident. Review of the record of Resident #50 did not reveal any documentation related to this incident. Interview with the facility administrator on 05/06/13 at 4:00 P.M. revealed she had been unaware of the incident described by STNA #7 and the incident had not been investigated. Interview with the administrator on 05/07/13 at 4:55 P.M. verified Resident #33 had increasing sexual behaviors directed toward other residents. She verified he was sent to the hospital on [DATE] for inappropriate sexual behaviors and returned on 04/17/13 with an order for [REDACTED]. The administrator verified the transfer orders from the hospital indicated Resident #33's sexual focus may be better managed in a specialty facility. She verified the absence in the record of a care plan to monitor the frequency and content of the resident's sexual behaviors or to provide interventions to address the resident's increasing sexual behaviors. She verified that on 04/21/13, Resident #33 was found rubbing the breasts of Resident #8, who was severely cognitively impaired and unable to remove herself from the situation. She verified there was no evidence of monitoring or interventions to ensure the safety of confused residents on the dementia unit related to the inappropriate sexual behaviors of Resident #33. This deficiency substantiates Complaint Number OH 068.

Based on record review and interview, the facility failed to ensure Resident #198 did not develop an avoidable Stage III pressure ulcer to the thigh caused by tight undergarments. This affected one of four residents (Resident #198) reviewed for pressure ulcers. The facility census was 133 residents. Findings include: Review of the medical record for Resident #198 revealed she was admitted to the facility on [DATE] after a hospitalization and surgical repair of a [MEDICAL CONDITION]. Resident #198 had [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) admission assessment dated [DATE], revealed Resident #198 was admitted to the facility with "one or more unhealed pressure ulcers," she was at risk for pressure ulcer development and she required extensive assistance of at least two staff members for dressing. Review of a care plan initiated on 10/28/11, revealed Resident #198 was at risk for pressure ulcer development related to her hypertension, impaired mobility, bowel and bladder incontinence and a [MEDICAL CONDITION]. Review of an additional care plan initiated on 10/23/11, revealed Resident #198 was receiving care for pressure ulcers to her right heel, right inner buttock, and left buttock. Review of a nurse's note dated 11/20/11 at 4:28 P.M., revealed a nursing assistant observed a bruise on Resident #198's right inner thigh "consistent with brief positioning." The note revealed the nurse educated the staff regarding proper size briefs and ensuring proper fit prior to placing a resident in their wheelchair. Review of a nurse's note dated 11/23/11 at 10:57 P.M., revealed "bruise to right inner thigh, currently open blister." Review of a "wound tracking grid" initiated on 11/23/11, revealed Resident #198 had a Stage II pressure wound (partial thickness skin loss involving epidermis, dermis, or both) on her right inner thigh measuring 7.0 centimeters (cm) long by 0.5 cm wide by less than 0.1 cm deep. The wound grid revealed Resident #198 reported to have pain at the wound site, a number three on the pain scale (a scale of one to 10). Review of a wound assessment dated [DATE], revealed the pressure sore on Resident #198's thigh was a Stage III (full thickness skin loss involving damage to or necrosis of subcutaneous tissue), and measured 14 cm long by 0.3 cm wide by 0.1 cm deep. The wound was described as "a linear pressure area likely secondary to tight elastic briefs." The note also revealed the wound contained slough (yellow dead tissue). Review of a wound assessment dated [DATE], revealed the wound was a Stage III pressure ulcer and was 80% slough tissue. Review of a wound assessment note dated 12/08/11, revealed Resident #198 was admitted to the hospital. On 03/06/12 at 10:32 A.M., an interview with the wound nurse, who was also the assistant director of nursing (ADON), verified Resident #198 was found with a bruise on her right anterior inner thigh on 11/20/11. The ADON verified the bruise developed into an open pressure wound on the resident's anterior thigh and the bruise/wound was caused from the staff dressing the resident in elastic undergarments that were too small. The ADON verified Resident #198 required staff assistance to get dressed. The ADON verified the nursing assistants were educated on ensuring proper size and fit of briefs after the pressure area was identified. The ADON revealed Resident #198 was admitted to the hospital on [DATE] for an unrelated health issue.