Every finding on record at Covington Skilled Nursing & Rehab Center

Based on record review, policy review, and interview, the facility failed to provide timely treatment for a urinary tract infection (UTI). This affected one (Resident #1) of three residents reviewed for UTI. The facility census was 56. Findings include: Review of the medical record for Resident #1 revealed a re-admission date of 02/05/26. Diagnoses included dementia, aortic valve stenosis, congestive heart failure, chronic obstructive pulmonary disease, and lupus.Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/22/26, revealed Resident #1 had intact cognition, required staff assistance with activities of daily living, and was incontinent of urine. Review of the Care Plan dated 11/02/22 revealed Resident #1 was incontinent of bowel and bladder which increased her risk of urinary tract infections (UTI) and history of bacteremia. Interventions included to assess resident for complaints of burning, pain and itching when urinating, to assess urine for color, odor, clarity, frequency, and amount, and to monitor abdomen for distention, complaints of fullness or discomfort. Review of nursing progress note dated 05/21/26 at 8:24 A.M. revealed the resident complained of burning when she voids and is nauseated at times with no appetite. New order received for urine analysis (UA) and culture and sensitivity (C&S). Review of a physician order dated 05/21/26 revealed the order for UA/C&S to rule out UTI. Review of nursing progress note dated 05/24/26 at 5:32 P.M. revealed family had concerns regarding urine and wanted it to be tested. Review of nursing progress note dated 05/25/26 at 1:49 A.M. revealed resident's urine dipped this shift showing positive for leukocytes, nitrates, protein, and blood. New order for UA C&S to be sent to lab this morning per nurse practitioner (NP). Review of nursing progress note dated 05/28/26 at 1:14 P.M. revealed urinalysis completed but sensitivity has not returned. NP notified. Review of a UA/C&S laboratory report, dated 05/29/26, revealed the specimen was collected on 05/25/26 at 6:10 A.M. The urine culture revealed Escherichia Coli.greater than 100,000 CFU/ml. Review of nursing progress noted dated 06/01/25 at 3:05 P.M. revealed C&S results back. Order for Macrobid 100 milligrams (mg) twice daily for seven days for UTI. Review of a physician order dated 06/01/26 revealed the order Macrobid 100 mg one capsule by mouth two times per day for seven days for UTI. Interview with the Director of Nursing (DON) confirmed the NP ordered a UA/C&S on 05/21/26, however, it was not collected until 05/25/26 with the result received on 05/29/26. The DON confirmed the physician was not notified of Resident #1's UA/C&S result until 06/01/26. She further stated the unit manager discovered and reported the UA/C&S result on Monday, 06/01/26, after realizing the nursing staff had not reported the laboratory results to the physician. Review of the facility policy titled, Antibiotic Stewardship, dated December 2016, revealed when a culture and sensitivity (C&S) is ordered lab results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued. This deficiency represents non-compliance investigated under Complaint Number OH3045588.

Based on record review, observation and interview, the facility failed to ensure a physician's order for oxygen was in place for Resident #37. This affected one (Resident #37) of one resident reviewed for oxygen use. The facility had a total of nine residents who were on oxygen. The facility census was 56. Findings include: Review of the medical record for Resident #37 revealed an admitted [DATE] with diagnoses including respiratory failure, hypertension and diabetes mellitus. Review of the care plan dated 12/17/21 for Resident #37 revealed she had an alteration in respiratory function related to respiratory failure with hypoxia and oxygen use. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #37 had oxygen therapy. Review of the physician's orders for April 2025 for Resident #37 revealed there were no oxygen orders in place after 04/22/25. There was an order for staff to change the oxygen tubing/cannula every week on night shift dated 02/29/24. Review of the nursing progress note dated 04/22/25 at 8:39 A.M. revealed Resident #37's oxygen saturation was stable with oxygen and the nurse practitioner provided an order to discontinue every shift checks of oxygen and to monitor oxygen monthly with routine vital signs. Observation on 04/28/25 at 12:54 P.M. of Resident #37 revealed she had oxygen on via nasal cannula at 2.5 liters. Observation on 04/29/25 at 9:19 A.M. revealed Resident #37 was wearing a nasal cannula, however, her oxygen concentrator was turned off. Observation on 04/29/25 at 9:22 A.M. with the Director of Nursing (DON) verified Resident #37 was ordered oxygen and the oxygen concentrator should be turned on. The DON stated Resident #37 would turn off the oxygen at times. Interview on 04/29/25 at 9:29 A.M. with the DON verified Resident #37 should have had an oxygen order in place for 2.5 liters via nasal cannula. She stated on 04/22/25 the nurse practitioner had discontinued oxygen saturation checks daily and ordered the checks monthly. The DON stated on 04/22/25 when the nursing staff discontinued the order for oxygen saturation checks, they also discontinued the oxygen order. Review of the facility policy titled, Oxygen Administration, revised October 2010, revealed the staff should verify there was a physician's order in place

Based on record review and interview, the facility failed to ensure residents and or responsible parties received room change notifications in writing. This affected three residents (Resident #4, Resident #17, Resident #18) of six residents reviewed for room change notifications. The census was 56. Findings include: 1. Review of the medical record for Resident #4 revealed an admitted [DATE] with the diagnoses of adult failure to thrive, diabetes and spinal stenosis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Review of Resident #4's medical record revealed a progress note dated 03/28/25 and 04/01/25 that the resident moved rooms. There was no indication the resident and/or representative received the notification in writing. Review of Resident #4's Room Change Notification Forms revealed the resident moved 03/28/25 and 04/10/25. There was no indication the resident and/or representative received the notification in writing. Interview on 04/28/25 at 10:26 A.M. with Resident #4 during initial screening revealed she had been in three different rooms since being at the facility and was not sure why she had been moved. Interview on 04/30/25 at 5:04 P.M. with Social Service Designee (SSD) #504 revealed she notified residents verbally of any room changes and put a note in the chart. She was not aware of any form that was completed or that notification should be in writing. 2. Review of the medical record for Resident #17 revealed an admitted [DATE] with the diagnoses of ventricular fibrillation, dementia and acute kidney failure. Review of Resident #17's Room Change Notification form revealed the resident moved rooms on 10/11/24. There was no indication the resident and/or representative received the notification in writing. Review of the quarterly MDS dated [DATE] revealed Resident #17's had cognitive impairment. Interview on 05/01/25 at 11:15 A.M. with Resident #17's son revealed the facility left a phone message but he did not receive anything in writing about a room notification. Interview on 04/30/25 at 5:04 P.M. with SSD #504 revealed she notified residents verbally of any room changes and put a note in the chart. She was not aware of any form that was completed or that notification should be in writing. 3. Review of the medical record for Resident #18 revealed an admitted [DATE] with the diagnoses of heart failure, diabetes and osteoarthritis. Review of the annual MDS dated [DATE] revealed the resident was cognitively intact. Review of Resident #18's medical record revealed no evidence Resident #18 received written notice of a new roommate. Review of Resident #16's Room Change Notification form revealed the resident moved into Resident #18's room on 04/02/25. Interview on 05/01/25 at 11:23 A.M. with Resident #18 revealed she was not notified in writing when receiving a new roommate, Resident #16. Interview on 04/30/25 at 5:04 P.M. with SSD #504 revealed she notified residents verbally of any room changes and put a note in the chart. She was not aware of any form that was completed or that notification should be in writing. Interview on 04/30/25 at 5:46 P.M. with Regional Nurse (REG) #599 revealed room notifications were in the progress notes. Interview on 04/20/25 at 6:06 P.M. with REG #599 revealed a copy of a blank room notification form and revealed nursing completed the form. REG #599 was not sure were the completed forms were kept. Interviews on 04/30/25 from 6:10 P.M. to 6:17 P.M. with floor nurses, Licensed Practical Nurse (LPN) #529, LPN #531 and LPN #560 revealed they were unaware of what the room change process was and denied completing any form for room notification. Interview on 04/30/25 at 7:09 P.M. with Assistant Director of Nursing (ADON) #501 revealed the team discussed room changes at their morning or afternoon meetings. She stated SSD #504 placed the phone call to responsible parties for notification of room changes. ADON #501 stated she gave her opinions on room changes but did not have anything else to do with it. She stated she thought SSD #504 kept the forms and believed SSD #504 started them during the morning or afternoon meetings. Interview on 04/30/25 7:15 P.M. at with SSD #504 revealed she had seen the form before after being shown a room notification form stating she thought the Director of Nursing (DON) and ADON filled them out. Interview on 05/01/25 at 12:40 P.M. with DON revealed prospective roommates were informed verbally. Review of policy titled Transfers, Room to Room, revised December 20216 revealed no mention of written notification to the resident. Under the area of documentation it indicated the room change should be documented in the resident chart.

Based on record review and interview, the facility failed to ensure the facility assessment was accurately completed. This had the potential to affect all 56 residents residing in the facility. Findings include: Review of the facility assessment dated [DATE] and signed by the Administrator, Regional Director of Operations #591 and the Director of Nursing (DON) revealed it was reviewed at the Quality Assurance Agency (QAA) in January 2025. The facility assessment did not have the facility's capacity or average daily census included in the assessment. Interview on 04/30/25 at 2:10 P.M. with the Administrator verified she had provided the facility assessment as noted above on 04/30/25 and this assessment was in the emergency preparedness book since the QAA meeting in January 2025. She verified the assessment did not have the capacity and average daily census listed. She stated the facility assessment she had provided was not the correct version. The Administrator then provided a second facility assessment dated [DATE] that was unsigned and did not match the original facility assessment. She verified she had just printed off the correct version.

Based on review of the personnel files and interview with staff the facility failed to ensure the activities program was directed by a qualified professional. This had the potential to affect all 56 residents. Findings include: Review of the personnel file for Activity Director (AD) #505 revealed no evidence to support AD #505 had the appropriate qualifications for holding the position of activity director. AD #505 was hired as an activity assistant on 04/20/23 and was promoted to AD on 02/01/25. AD #505 signed the job description on 02/01/25. The checklist in the personnel file revealed AD #505 had a 90 day evaluation due for the Activity Director position on 05/01/25. Interview and record review on 04/30/25 at 4:07 P.M. with AD #505 and Administrator revealed AD #505 was initially hired as an activity assistant on 04/20/23. AD #505 stated she had no prior experience in an activity position. She was promoted to the activity director position on 02/01/25 after the position was unexpectedly vacated. Administrator stated Director of Clinical Services/Registered Nurse (DCS/RN) #592 oversaw the activity calendars and program. AD #505 stated she recently went to a training called Activity Director Bootcamp in March for 13.5 continuing education hours and provided the certificate. When asked what the requirements for an activity director were they could not provide the information except to say she had almost two years experience under a certified activity director. They verified AD #505 was not enrolled in any program to obtain her certification. Interview on 05/01/25 at 10:53 A.M. with DCS/RN #592 revealed she had been overseeing the activity programming since 2021 and communicated with AD #505 weekly. DCS/RN #592 verified she was not a certified activity director stating she had [AGE] years experience in healthcare field with about one and half years experience in an activity position years ago. When asked if AD #505 was enrolled in a program, DCS/RN #592 stated she needed to look up the information. She responded over an hour later by forwarding an email at 11:58 A.M. showing an email dated 05/01/25 and timed at 11:49 A.M. from Ohio Health Care Association (OHCA) acknowledging enrollment in a program. Interview on 05/01/25 at 12:25 P.M. with the OHCA representative in above email revealed she was not sure when the facility signed up for the certification program but it was either 04/30/25 or 05/01/25. She verified AD #505 was enrolled in the self-pace program which could be started immediately. She stated it consisted of 90 hours of training. She stated most people take the classes then take an exam to become certified. The OHCA representative stated the bootcamp training already done by AD #505 would not go toward the certification. Review of the job description for Activity Director dated 10/2017 revealed the applicant must be certified through an accredited source.

Based on interview, record review, and policy review, the facility failed to ensure Resident #1's medical record was accurate regarding documentation of a wound treatment for a pressure ulcer. This affected one (Resident #1) of three residents reviewed for pressure wounds. The facility identified seven residents with pressure ulcers. Findings include: Review of the medical record for Resident #1 revealed an admitted [DATE]. Diagnoses included diabetes mellitus, history of cerebral vascular accident (CVA), cognitive social or emotional disorder following CVA, stage 4 pressure ulcer, major depressive disorder, anxiety, muscle weakness, and dysphagia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/08/23, revealed the resident had intact cognition. The resident required extensive assistance of two staff for bed mobility, dressing. and personal hygiene. The resident was totally dependent on the assistance of two staff for transfers, toileting, and bathing. The resident required supervision and set-up assistance for eating. The assessment indicated the resident had a Stage 4 pressure ulcer on admission. The resident had a urinary catheter and was always incontinent of bowel. Review of the plan of care, dated 03/30/22, revealed the resident had a pressure ulcer and often declined wound treatments. Interventions included to provide treatments as ordered, pressure relieving interventions as ordered, and to provide nutritional interventions as ordered. Review of physician orders, dated February 2023, revealed a treatment to cleanse sacrum with 0.25% acetic acetic acid cleanse, pat dry, fill the wound cavity with 0.25% acetic acid moistened gauze, and cover with an ABD pad twice daily and as needed every day and night shift for wound care. Review of the Skid Grid Pressure 3.0 assessment, dated 01/30/23, revealed the resident had a Stage 4 pressure ulcer located on the sacrum. The wound measured 3.3 centimeters (cm) length by 2.5 cm width by 1.5 cm depth. The wound was described as an irregular, ovoid shaped full thickness wound with a base comprised of 1% bone centrally and 99% pink granulation tissue; mild biofilm noted, edges are defined and unattached. The wound was present on admission to the facility. Review of a facility investigation, dated 01/02/23, included a signed witness statement authored by the Director of Nursing (DON) and dated 01/02/23. The witness statement revealed an investigation was initiated concerning Resident #1's wound treatment, after it was brought to the DON's attention by the wound care nurse, that the wrong treatment was found in the resident's wound bed during rounds with the wound physician. Resident #1 told the physician her friend, Friend #1 came into the building and changed her dressing the night before. Upon discussion with the staff, Licensed Practical Nurse (LPN) #40 stated that the resident told him Friend #1 completed her pressure ulcer wound treatment, so he signed off the treatment administration record (TAR). Immediate education was provided to remind LPN #40 that only the treatments he completed should be signed off as such. LPN #40 was also educated to notify the DON if a non-staff member performs wound care. LPN #40 verbalized understanding. Review of Resident #1's TAR, dated January 2023, indicated on 01/01/23, LPN #40 completed the treatment to Resident #1's sacral pressure ulcer. During interview on 01/31/23 at 12:58 P.M., Friend #1 revealed that she did complete Resident #1's sacral pressure ulcer dressing change on 01/01/23. Review of Resident #1's Skid Grid Pressure 3.0 assessment, dated 01/02/23, revealed no decline or worsening of the sacral wound following Friend #1's wound treatment on 01/01/23. During interview on 02/01/23 at 10:03 A.M., the DON confirmed LPN #40 did not complete Resident #1's sacral pressure ulcer wound care on 01/01/23, however, his documentation on the TAR indicated that he had completed the wound care. During interview 02/01/23 at 10:07 A.M., the Administrator confirmed once the facility received information of an incorrect dressing change, an investigation was initiated, and it was determined that Friend #1 had completed the wound care and not LPN #40. LPN #40 and the nursing staff were in-serviced on proper wound care following the incident. Review of facility policy titled, Wound Care, dated October 2010, revealed the purpose of the procedure is to provide guidelines for the care of wounds to promote healing. The following information should be recorded in the resident's medical record as indicated: the type of wound care given, the date and time the wound care was given, the position in which the resident was placed, the name and title of the individual performing the wound care, any change in the resident's condition, all assessment date obtained when inspecting the wound, how the resident tolerated the procedure, any problems or complaints made by the resident related to the procedure, if the resident refused the treatment and the reason why, and the signature and title of the person recording the data. Notify the supervisor if the resident refuses the wound care and report other information in accordance with the facility policy and professional standards of practice. This deficiency represents non-compliance investigated under Complaint Number OH00139389.

Based on interview, record review, and policy review, the facility failed to ensure wound treatment for a pressure ulcer was completed as ordered by the physician. This affected one (Resident #1) of three residents reviewed for pressure ulcers. The facility identified seven residents with pressure ulcers. Findings include: Review of the medical record for Resident #1 revealed an admitted [DATE]. Diagnoses included diabetes mellitus, history of cerebral vascular accident (CVA), cognitive social or emotional disorder following CVA, Stage 4 pressure ulcer, major depressive disorder, anxiety, muscle weakness, and dysphagia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/08/22, revealed the resident had intact cognition. The resident required extensive assistance of two staff for bed mobility, dressing, and personal hygiene. The resident was totally dependent on the assistance of two staff for transfers, toileting, and bathing. The resident required supervision and set-up assistance for eating. The assessment indicated the resident had a Stage 4 pressure ulcer (defined as full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) on admission. The resident had a urinary catheter and was always incontinent of bowel. Review of the plan of care, dated 03/30/22, revealed the resident had a pressure ulcer and often declined wound treatments. Interventions included to provide treatments as ordered, pressure relieving interventions as ordered, and to provide nutritional interventions as ordered. Review of physician orders, dated February 2023, revealed a treatment to cleanse sacrum with 0.25% acetic acetic acid cleanse, pat dry, fill the wound cavity with 0.25% acetic acid moistened gauze, and cover with an ABD pad twice daily and as needed every day and night shift for wound care. Review of the Skid Grid Pressure 3.0 assessment, dated 01/30/23, revealed the resident had a Stage 4 pressure ulcer located on the sacrum. The wound measured 3.3 centimeters (cm) length by 2.5 cm width by 1.5 cm depth. The wound was described as an irregular, ovoid shaped full thickness wound with a base comprised of 1% bone centrally and 99% pink granulation tissue; mild biofilm noted, edges are defined and unattached. The wound was present on admission to the facility. Review of a facility investigation, dated 01/02/23, included a signed witness statement authored by the Director of Nursing (DON) and dated 01/02/23. The witness statement revealed an investigation was initiated concerning Resident #1's wound treatment, after it was brought to the DON's attention by the wound care nurse, that the wrong treatment was found in the resident's wound bed during rounds with the wound physician. Resident #1 told the physician her friend, Friend #1 came into the building and changed her dressing the night before. Upon discussion with the staff, Licensed Practical Nurse (LPN) #40 stated that the resident told him Friend #1 completed her pressure ulcer wound treatment, so he signed off the treatment administration record (TAR). Immediate education was provided to remind LPN #40 that only the treatments he completed should be signed off as such. LPN #40 was also educated to notify the DON if a non-staff member performs wound care. LPN #40 verbalized understanding. Review of Resident #1's TAR, dated January 2023, indicated on 01/01/23, LPN #40 completed the treatment to Resident #1's sacral pressure ulcer. During interview on 01/31/23 at 12:58 P.M., Friend #1 revealed that she did complete Resident #1's sacral pressure ulcer dressing change on 01/01/23. Review of Resident #1's Skid Grid Pressure 3.0 assessment, dated 01/02/23, revealed no decline or worsening of the sacral wound following Friend #1's wound treatment on 01/01/23. During interview on 02/01/23 at 10:03 A.M., the DON confirmed the incorrect wound treatment was observed in Resident #1's wound bed by the wound nurse and wound physician in 01/01/23. During interview 02/01/23 at 10:07 A.M., the Administrator confirmed once the facility received information of an incorrect dressing change, an investigation was initiated, and it was determined that Friend #1 had completed the wound care for Resident #1 and not LPN #40. LPN #40 and the nursing staff were in-serviced on proper wound care following the incident. Review of facility policy titled, Wound Care, dated October 2010, revealed the purpose of the procedure is to provide guidelines for the care of wounds to promote healing. The following information should be recorded in the resident's medical record as indicated: the type of wound care given, the date and time the wound care was given, the position in which the resident was placed, the name and title of the individual performing the wound care, any change in the resident's condition, all assessment date obtained when inspecting the wound, how the resident tolerated the procedure, any problems or complaints made by the resident related to the procedure, if the resident refused the treatment and the reason why, and the signature and title of the person recording the data. Notify the supervisor if the resident refuses the wound care and report other information in accordance with the facility policy and professional standards of practice. This deficiency represents non-compliance investigated under Complaint Number OH00139397 and OH00139389.

Based on observation, record review, interview, drug manufacture review, and facility policy review the facility failed to ensure drugs in the medication storage room refrigerator were stored at the proper temperatures and dated when opened. This affected eight (Resident's #1, #4, #10, #23, #36, #40, #41, #194) and had the potential to affect all 44 residents residing in the facility. Findings include: Observation during the tour of the facility's medication storage room on 08/04/22 at 8:30 A.M. with Licensed Practical Nurse (LPN) #605 and Director of Clinical Services #668 revealed the medication room refrigerator's internal thermometer read 31 degrees Fahrenheit (F). Stored inside the refrigerator was one [MEDICATION(S)] ([MEDICATION(S)]) insulin pen for Resident #1, one [MEDICATION(S)] ([MEDICATION(S)]) insulin pen for Resident #4, one [MEDICATION(S)] insulin pen for Resident #10, one [MEDICATION(S)] ([MEDICATION(S)]) insulin pen for Resident #23, one unopened vial of [MEDICATION(S)] insulin for Resident #36, three boxes of house stock Acetaminophen suppositories, one opened and undated vial of [MEDICATION(S)] (used to test for [CONDITION(S)]), and one unopened vial of [MEDICATION(S)]. Interview at the time of observation of the medication storage refrigerator with LPN #605 confirmed the vial of [MEDICATION(S)] was undated and opened, and the Acetaminophen suppositories were inadvertently put in the refrigerator. Record review revealed Resident #1 was admitted on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician order dated 05/04/22 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed Resident #4 was admitted on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician order dated 07/14/22 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed Resident #10 was admitted on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician order dated 07/13/22 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed Resident #23 was admitted on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician order dated 10/19/20 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed Resident #36 was admitted on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician order dated 08/01/22 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed Resident #40 was admitted on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician order dated 07/01/22 revealed an order to administer step one Mantoux (test for [CONDITION(S)]). Physician order dated 07/08/22 revealed an order to administer step two Mantoux. Record review revealed Resident #41 was admitted on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician order dated 07/21/22 revealed an order to administer step one Mantoux. Physician order dated 07/28/22 revealed an order to administer step two Mantoux. Record review revealed Resident #194 was readmitted on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician order dated 07/19/22 revealed an order to administer step one Mantoux on 07/19/22. Review of facility document titled Refrigerator Temp Log revealed the refrigerator in the medication room from 07/01/22 through 07/31/22 had temperature readings between 30 degrees (F) and 34 degrees (F) and from 08/01/22 through 08/04/22 had temperature readings between 30 degrees (F) and 32 degrees (F). Review of the drug manufacturing packaging for [MEDICATION(S)] indicated to store between 35 degrees (F) and 46 degrees (F). Review of the drug manufacturing packaging for Acetaminophen suppositories indicated to store between 68 degrees (F) and 78 degrees (F). Review of the drug manufacturing packaging for insulin [MEDICATION(S)] solution indicated to store between 36 degrees (F) and 46 degrees (F) until first use. Interview on 08/04/22 at 9:28 A.M. with Director of Clinical Services #660 confirmed the medications stored in the medication room refrigerator were not stored under the proper temperature range of 36 degrees (F) and 45 degrees (F). Review of the facility policy titled Storage of Medications, revised April 2019, revealed drugs are to be stored under proper temperatures.

Based on record review and interview, the facility failed to ensure a representative of the Office of the State Long-Term Care Ombudsman was notified of facility initiated discharges. This affected 19 residents (Residents #35, #46, #244, #245, #246, #247, #248, #249, #250, #251, #252, #253, #254, #255, #256, #257, #258, #259 and #260). The facility census was 44. Findings include: 1. Review of the medical record for Resident #46 revealed an admitted [DATE] and discharge date of [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Discharge Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #46 was discharged with return not anticipated. Review of nursing progress notes dated 06/13/22 revealed Resident #46 was transported to the hospital for a change in condition, and then admitted . Interview on 08/03/22 at 8:44 A.M. with Administrator verified the facility did not timely notify a representative of the Office of the State Long-Term Care Ombudsman of the facility initiated discharge of Resident #46 on 06/13/22. The Administrator provided a folder and a facility admission/discharge report dated 08/03/22 for review. 2. Review of the facility admission/discharge report, dated 08/03/22, for residents discharged from 02/01/22 to 08/03/22 revealed the following residents received a facility-initiated discharge to a hospital: · Resident #36 was discharged on [DATE] · Resident #255 was discharged on [DATE] · Resident #256 was discharged on [DATE] · Resident #257 was discharged on [DATE] · Resident #258 was discharged on [DATE] · Resident #259 was discharged on [DATE] · Resident #260 was discharged on [DATE] Attached to the admission/discharge report was a fax confirmation report of pages received, dated 08/03/22 at 7:73 A.M. to the ombudsman office regarding discharge notices. Review of the folder contained a facility admission/discharge report, dated 02/17/22, for residents discharged from 01/01/21 to 12/31/21 revealed the following residents received a facility-initiated discharge to a hospital: · Resident #254 was discharged on [DATE] · Resident #244 was discharged on [DATE] and again on 06/12/21 · Resident #245 was discharged on [DATE] · Resident #246 was discharged on [DATE] · Resident #247 was discharged on [DATE] · Resident #248 was discharged on [DATE] · Resident #249 was discharged on [DATE] · Resident #250 was discharged on [DATE] · Resident #251 was discharged on [DATE] · Resident #252 was discharged on [DATE] · Resident #253 was discharged on [DATE] Attached to the admission/discharge report was a fax confirmation report of pages received, dated 02/22/22 at 1:17 P.M. to a representative of the Office of the State Long-Term Care Ombudsman regarding discharges. Interview on 08/03/22 at 8:52 A.M. with Administrator verified the above reports were sent to the representative of the Office of the State Long-Term Care Ombudsman for the facility initiated discharges for the year 2021 on 02/22/22 and for discharges from 02/01/22 through the current date on 08/03/22. Administrator confirmed it was not timely notification as required. This deficiency substantiates Complaint Number OH 608.

Based on interview and record review the facility failed substantiate self-reported incident (SRI) tracking number (#) 0 dated 06/27/22 after resident personal checks written to the facility were compromised. This affected six (Residents #5, #19, #22, #27, #29, and #44) of six residents reviewed for misappropriation. The facility census was 44. Findings include: Review of the medical record for Resident #5 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record for Resident #19 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record for Resident #22 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record for Resident #27 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record for Resident #29 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the closed medical record for Resident #44 revealed an admitted [DATE] and a discharge date of [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility SRI tracking # 0 dated 06/27/22 revealed the investigation of misappropriation the incident was unsubstantiated due to Resident's #5, #19, #22, #27, #29, and #44 not losing any money. Interview on 08/01/22 at 10:29 A.M. with Resident #22 revealed he did remember his checking account being compromised. He was unsure of the details but reported he did not lose any money because the bank refunded it all. Interview on 08/03/22 at 1:30 P.M. with the Administrator revealed Resident #5's family member came forward on 06/27/22 and reported a personal check that was written to the facility was compromised after it cleared the bank. The check information was altered to only leave the signature and banking information. That check was then rewritten to a new payee and made out for a larger amount of money. The family member reported the bank caught the fraud and stopped payment on the check. He also had to open a new checking account. The Administrator revealed they then learned of five other residents affected. She reported all family members filed police reports and all opened new checking accounts with their own personal banks. The Administrator reported since the bank stopped all payments on the fraudulent checks and no residents lost money the allegation was unsubstantiated. Interview on 08/02/22 at 2:40 P.M. with Resident #19's Power of Attorney (POA) reported she did make a payment to the facility from her sister's joint account on 05/27/22. She reported in June 2022 she heard from the bank that 14 checks had been attempted to be cashed from the one check written to the facility on [DATE]. She revealed each check was written over 1,000 dollars. She confirmed the bank did stop all payments on those checks, and a new account was opened. She also confirmed she did file a police report. Resident #19's POA reported she now purchases cashier's checks for eight dollars apiece to pay for her sister's room and board because she does not want the facility knowing her sister's new checking account number. Interview on 08/03/22 at 2:52 P.M. with Resident #44's guardian reported her bank notified her in June of 2022 that Resident #44's personal checking account had insufficient funds. When she reached out to the bank, she was told three checks each written over 2,500 dollars had been attempted to be withdrawn from his account. Resident #44's guardian reported the bank pinpointed the check as being copied from the original check written to the facility in May 2022. She confirmed the bank did refund all the money and a new account was opened. She did file a police report. Interview on 08/03/22 at 3:35 P.M. with Resident #27's daughter and POA revealed she checks Resident #27's bank account daily. She reported one morning she went on to check and found it was overdrawn 800 dollars. She immediately called the bank, and they reported multiple checks had been attempted to be withdrawn for over 2,700 dollars. The bank confirmed the checks were copied from the original check written to the facility. She also confirmed the bank did stop all payments and a new account was opened. Resident #27's daughter reported she did file a police report. She also reported she does not want her mother to know that her checking account was compromised because it would cause her too much anxiety. Interview on 08/03/22 at 3:49 P.M. with Resident #29's son-in-law and POA revealed scammers got a copy of the check written to the facility and copied it 11 times in the amount of 29,400 dollars total. He reported the bank caught it immediately and reversed all the charges. The bank confirmed the 11 copied checks were from a check written to the facility. He also confirmed a new account was opened and a police report was filed. Resident #29's son-in-law also reported he now makes all payments electronically to the facility to protect his banking account information. Interview on 08/04/22 at 10:19 A.M. with Chief of Police #670 confirmed all six families of residents affected did file police reports and an investigation was ongoing. Interview on 08/04/22 at 10:30 A.M. with Resident #5's son confirmed he did hear his father tell him something about his checking account being compromised and a new account was opened but his father had since passed away.

Based on interview and record review, the facility failed to ensure closed resident accounts were refunded within 30 days. This affected two (Resident's #145 and #261) of two residents reviewed for closed accounts. The facility census was 44. Findings include: 1. Review of the medical record for Resident #145 revealed the resident was admitted on [DATE] and discharged [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Discharge Minimum Data Summary (MDS) 3.0 assessment dated [DATE] revealed Resident #145 was moderately cognitively impaired, required limited assistance for activities of daily living (ADL). Review of Resident #145's care plan dated 02/15/22 revealed care areas for nutrition, pacemaker, alteration/potential alteration in cardia output, breast cancer, and discharge planning to return home to live with her son. Review of the census for Resident #145 revealed the resident's payer source was Medicare until 05/11/22 when the resident became private pay. She was transferred from a private to a semi-private room on 05/24/22. Review of the 06/01/22 monthly statement for Resident #145 revealed statement for 06/01/22 with charges for May 11-31, 2022, for $6,930- and 30-days room and board July 1-30, 2022, for $9,900, totaling $16,830. Review of the 07/01/22 statement for Resident #145 revealed new charges of $3,960 and $2,070, payments of $16,830, credits for $6,930, $910, and $6,000 with an ending credit balance (overpayment) of $7,810. Interview on 08/03/22 at 9:25 A.M. with Business Office Manager (BOM) #650 verified if a resident or their representative paid for a private room and then was transferred to dual occupancy room, they would be due a refund. She reported no knowledge of any instances of this happening since she started in her position in November 2021. When asked about the Resident #145, she verified the resident was due a refund and stated the facility was waiting for all insurance claims to be processed, despite the resident being private pay. She could not specify a time frame for when the refund would be issued. Review of the Review of Ohio 2019 Admission Agreement revealed if an over payment has occurred, the amount of overpayment would be refunded within 30 days. Interview with the Administrator on 08/03/22 at 11:45 A.M. verified the refund should have been processed within 30 days, per the facility policy. 2. Review of medical record for Resident #261 revealed an admitted [DATE] and a discharge date of [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility business records for Resident #261 revealed Resident #261 had $1,459.55 in his facility account. A check numbered 1940 for $1459.55 was written to Resident #261's son on 02/09/22. Interview on 08/08/22 at 10:55 A.M. with the Administrator and Regional Director of Operations #671 verified Resident #261 was discharged on [DATE] and Resident #261's funds were conveyed outside of the required timeframe of 30 days. This deficiency substantiates Master Complaint Number OH 633.

Based on interview and record review the facility failed to provide documented evidence indwelling urinary catheter care was provided to Resident #22. This affected one (Resident #22) of two (Resident's #5 and #22) the facility identified as having an indwelling urinary catheter. The facility census was 44. Findings include: Review of the medical record for Resident #22 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #22 had moderate cognitive impairment. Resident #22 required extensive one-staff physical assistance for bed mobility, transfers, dressing, toileting, and personal hygiene; and supervision with set-up help only for eating. Resident #22 had an indwelling urinary catheter (a flexible tube that passes through the urethra and into the bladder to drain urine) was always incontinent of bowel. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Another order dated 06/03/22 stated to provide indwelling urinary catheter care every day at bedtime for infection prevention. Review of the treatment administration record (TAR) for Resident #22 for June 2022 revealed no documented evidence indwelling urinary catheter care was provided on 06/03/22, 06/04/22, 06/05/22, 06/06/22, 06/07/22, 06/08/22, 06/09/22, 06/10/22, 06/11/22, and 06/12/22. Interview on 08/02/22 at 2:00 P.M. with Corporate Nurse #668 confirmed there was no documented evidence of indwelling urinary catheter care from 06/03/22 to 06/12/22. Corporate Nurse #668 also confirmed Resident #22 was sent to the hospital on 06/15/22 and was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 08/01/22 at 10:29 A.M. with Resident #22 revealed he was unsure if any care was done to his catheter.

Based on record review and interview, the facility failed to ensure Resident #9's annual assessment was submitted within 14 days after completion. This affected one (Resident #9) of one resident reviewed for assessments. The facility census was 44. Findings include: Review of the medical record for Resident #9 revealed an admitted [DATE]. Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Annual Minimum Data Set (MDS) 3.0 assessment was completed with an assessment reference date of 06/05/22. Review of the facility batch status report dated 08/04/22 revealed the Annual assessment dated [DATE] was submitted and accepted on 08/04/22. Interview on 08/04/22 at 11:22 A.M. with Licensed Practical Nurse (LPN) #669 verified Resident #9's Annual MDS 3.0 assessment dated [DATE] was not submitted until 08/04/22, which was not within the required timeframe.

Based on observation, interview, and record review the facility failed to ensure Resident #28's hearing aid was replaced in a timely manner. This affected one (Resident #28) of one resident reviewed for hearing. The facility census was 44. Findings include: Review of the medical record revealed Resident #28 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the significant change Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #28 had moderate difficulty hearing and wore hearing aids, required extensive assist of two staff for activities of daily living (ADL), use of a wheelchair for mobility and was on hospice. Review of Resident #28's care plan of 08/03/22 revealed care areas included communication deficit related to a hearing deficit as evidenced by highly impaired hearing and requiring two hearing aids. Interventions included audiology consult as needed, monitoring effectiveness of communication strategies and hearing aids and monitoring/documenting/reporting hearing impairment. Review of the nursing progress note of 06/03/22 at 10:03 A.M. revealed per midnight report- residents hearing aid shattered last evening. Called son to inquire about who Resident #28 sees for audiology. Resident #28's son stated he hasn't seen anyone in Ohio since he got the hearing aids in Tennessee. This nurse then asked if residents son had a preference as to whom his father sees for hearing aid replacement- he stated he does not have a preference. Information communicated to scheduling to have resident set up with an audiologist. Observations on 08/02/22 at 8:45 A.M., 08/03/22 at 8:59 A.M. and 08/03/22 at 2:40 P.M. revealed Resident #28 was very hard to engage in conversation and was not wearing hearing aids. He had difficulty hearing accurately, and understanding simple phrases and commands, even at a loud volume. The facility provided an appointment sheet dated 06/06/22 appointment as soon as possible (ASAP) with audiologist for broken hearing aide, spoke with resident's son; states he is waiting for audiology apt visit with 360. Interview on 08/04/22 at 10:05 A.M. with Resident #28' son reported it was reported to him when his father's hearing aid was crushed, over eight weeks ago, and it seemed to be taking a pretty long period of time to get it replaced. Not having the hearing aid makes it difficult to communicate when he and his family visit, which is about three times a week. He tried to put the other hearing aid in, but his father's hearing loss required both hearing aids for effective communication. The son reported the care was good, but some of the appointments, like for a replacement hearing aid, could have been handled better. He was told the facility would schedule an audiology appointment to replace the hearing aid. He verified no other options were discussed with him and his father had not received a replacement hearing aid. Interview on 08/04/22 at 10:43 A.M. with State tested Nursing Assistant (STNA) #626 revealed as he was getting Resident #28 up on 06/03/22, he found the hearing aid in pieces on the floor, next to the bed. It appeared that it was either crushed by the mechanical lift or stepped on. The STNA immediately reported it to the nurse and called the resident's son who said he would like to get the hearing aid replaced. Review of the February 2018 policy Hearing Impaired Resident, Care of revealed staff will help residents who have lost or damaged hearing devices in obtaining services to replace a hearing aid. Review of the audiologist list for 08/16/22 revealed Resident #28 was on the list to be seen on that date. This deficiency substantiates Complaint Number OH 608.

Based on observation, record review and interview the facility failed to maintain sufficient levels of staff to meet the total care needs of all residents. This had the potential to affect all 52 residents residing in the facility. Findings include: 1. On 07/18/21 at 8:30 P.M. the surveyor entered the facility to conduct the complaint investigation. There were two licensed nurses and two State tested Nursing Assistants (STNAs) on duty to provide care for 52 residents currently residing in the facility. Review of the facility completed Centers for Medicare and Medicaid (CMS) Census and Condition form 672 revealed the facility had no residents who were independent for activity of daily living (ADL) care. The facility provided ADL information for 53 residents (52 in the facility and one bed hold). The facility identified 50 residents who required the assist of one or two staff for bathing and dressing and three residents who were totally dependent on staff. The facility identified 48 residents who required the assist of one or two staff for transfers and five residents who were totally dependent on staff. The facility identified 45 residents who required the assist of one or two staff for toileting and eight residents who were totally dependent on staff. The facility identified 49 residents who required the assist of one to two staff for eating and four residents who were totally dependent on staff. The 672 form also identified 38 of 53 residents who were occasionally or frequently incontinent of bladder and 22 of 53 residents who were occasionally or frequently incontinent of bowel. Review of the facility staffing information revealed the facility had been without a Director of Nursing (DON) since 04/22/21. The Assistant Director of Nursing (ADON) has been functioning as Interim Director of Nursing (DON) #64 since that time. On 07/10/21 the previous Administrator quit without notice. A new Administrator was currently scheduled to start but not until 07/26/21. On 07/18/21 at 8:20 P.M. interview with Interim DON #64 revealed on Saturday 07/10/21 there was only one nurse for part of night shift when there were supposed to be two nurses. Interim DON #64 revealed there should also be at least two State tested Nursing Assistants (STNA) on the night shift (for the current census of 52). Interim DON #64 revealed there had only been one STNA on duty on this night but stated a second STNA stayed over and another came in early. Interim DON #64 also shared there had been another night when there was only one STNA (date not provided) working for part of the shift. Interim DON #64 revealed multiple staff had quit. During the interview, Interim DON #64 revealed the facility was having a hard time finding a DON. At the time of the survey, the facility indicated a new DON had been hired but would not be starting until 08/23/21. On 07/19/21 at 6:14 P.M. interview with Regional Registered Nurse (RN) #74 and the Interim Administrator verified the facility was in need of more staff. The administrative staff revealed staff had quit without notice and recruiting had been challenging. The facility currently had six full time and two part time STNA positions open, three full time and one part time Licensed Practical Nurse positions open, and a Social Service Designee (SSD) position open. The previous SSD worked three days and quit 07/14/21. Review of the facility Staffing Assessment revealed it was not specific to the number of staff that would be on duty. Review of facility policy titled Staffing, dated October 2017 revealed the policy was not specific to the number of staff required based on resident census or resident acuity. 2. The following resident concerns were lodged during the complaint investigation related to facility staffing: a. On 07/19/21 at 11:26 A.M. interview with Resident #17 revealed the resident voiced staffing concerns. The resident revealed sometimes he gets the care he needs, other times not and indicated this was due to a lack of staff. b. On 07/19/21 at 11:30 A.M. interview with Resident #37 revealed concerns related to staffing. The resident shared an incident where her roommate had fallen and she rang the call light for her and it took 15-20 minutes before anyone came. c. On 07/19/21 at 1:02 P.M. interview with Resident #1 revealed concerns related to staffing. The resident stated he believed staff thought answering call lights was optional when there was not an investigation going on (referring to the State agency investigation). The resident had a concern he had laid in bed wet/incontinent (date not provided) a couple hours on one day. The resident revealed staff come in and turn his call light off telling him they will be back but then don't come back. He also shared an incident when he said he was in the bathroom (date not provided) and STNA #63 came in and turned the call light off, although the STNA did not stay to provide care. The resident indicated he turned the call light back on and STNA #63 got mad and turned it off again. The resident revealed he told STNA #63 he wanted the light kept on in case someone else could come and help him. During the interview the resident also reported he wanted to go to bed at 8:00 P.M. but there was only one STNA working at times at that time and when that occurred he was not assisted to bed until 10:00 P.M. d. On 07/19/21 at 1:22 P.M. interview with Resident #5 revealed concerns related to staffing. The resident shared an incident (date not provided) when she had to wait a half hour for her call light to be answered as she needed to use the bathroom. The resident indicated due to the extended response time she had been incontinent and had to change her pants. 3. The following staff concerns were lodged during the complaint investigation related to facility staffing: a. Interview with an employee who wished to remain anonymous revealed there were times when there are only two STNAs working on day shift and it took a long time to complete incontinence care and provide showers/baths. The employee revealed care was not completed timely for residents with only two STNAs working. The employee revealed she was aware of a day in June (date not provided) when there was only one STNA working for a whole 12 hour shift for over 50 residents in the facility. b. Interview with an employee who wished to remain anonymous revealed this employee was aware of a day in June (date not provided) when there was only one STNA working on day shift. The employee revealed care was not provided timely on this date. The employee revealed therapy staff tried to pitch in and help out but even with two STNAs working, with over 50 residents it was hard to meet the care needs of the residents related to meals, bathing, incontinence care and answering call lights. c. Interview with an employee who wished to remain anonymous revealed staffing concerns. The employee revealed it was difficult to provide resident care with only two STNAs scheduled for over 50 residents. The employee revealed if a resident had a fall, it could be delayed in finding the resident. The employee revealed with only two STNAs, the STNA staff typically made rounds together. The employee revealed showers could not be completed because there wasn't enough time. The employee revealed they would try to just wash them up while they were in bed or sitting on the toilet. The employee revealed it was hard to know how long call lights had been activated for because staff were just to busy to notice. 4. During the onsite complaint investigation concerns were identified residents were not provided routine showers/baths. This concern was correlated to a lack of staff as noted per the interviews above. a. Review of Resident #1's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) 3.0 assessment, dated 10/15/20 revealed it was very important for the resident to choose between a tub bath, shower, bed bath, or sponge bath. However, the question did not follow up with a frequency. Review of the 11/20/20 activities of daily living (ADL) self care performance deficit plan of care revealed the resident had a deficit related to activity intolerance, impaired balance and limited mobility secondary to impaired neurological status. The care plan indicated the resident required extensive assist (from staff) for personal hygiene. The plan did not identify a bathing preference or frequency. Review of the 06/19/21 quarterly MDS 3.0 assessment revealed the resident was moderately impaired for daily decision making, required extensive assist of two staff for bed mobility, transfers and toilet use. The assessment revealed the resident required the physical assist of one staff in part for bathing with assist of one. The assessment also revealed the resident was frequently incontinent of urine and occasionally incontinent of stool. Review of the State tested Nurse Aide (STNA) TASK section in Point Click Care (PCC), the facility electronic documentation system, revealed the bathing section was to be personalized to the resident's preferences. However, there was no personalized preference entered into the system. Review of STNA TASK documentation from 06/21/21 to 07/20/21 revealed the resident was bathed nine times: On 06/21/21 at 6:19 A.M., 06/22/21 at 1:10 A.M., 06/23/21 at 3:58 A.M. and 8:41 P.M., 06/27/21 at 5:03 P.M., 07/14/21 at 9:08 A.M., 07/16/21 at 1:16 A.M., 07/17/21 at 7:00 A.M. and 07/19/21 at 7:44 A.M. Record review revealed no evidence of a shower documented in the electronic record between 06/27/21 and 07/14/21 (the response no was checked marked as to whether a bath was provided during this time period). On 07/19/21 at 1:02 P.M. interview with Resident #1 revealed the resident indicated he didn't know when he would ever get a bath. The resident indicated he was a morning person and liked to get up in the five o'clock hour. The resident shared no one (at the facility) had asked him how often he would like a bath but he thought three times a week wouldn't be asking too much. On 07/20/21 at 4:57 P.M. interview with Regional Registered Nurse (RN) #74 revealed when preferences were entered into the electronic documentation system the preference then prompted staff when it was the day and shift a shower was to be provided. RN #74 verified the resident's electronic medical record reflected only the nine dates/times of care being provided. The facility then located two additional hand written shower sheets. RN #74 was then unable to find any evidence of Resident #1 receiving a shower/bath between 06/28/21 and 07/04/21 (a seven day time period). b. Review of Resident #11's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 05/03/21 quarterly MDS 3.0 assessment revealed the resident was severely impaired for daily decision making, required extensive assist of two staff for bed mobility, transfers and toileting. The MDS 3.0 assessment indicated personal hygiene only occurred once or twice in the seven day review period and bathing activity did not occur. At the time of the review, the MDS entry was locked by a facility staff member. Review of the STNA TASK documentation for the 04/27/21 through 05/03/21 look back period revealed no evidence Resident #11 received a bath during this time period. Entries during this time period were marked no (as to care being provided). There were no yes entries indicating a bath was provided during this seven day time period. On 07/21/21 at 11:11 A.M. the Administrator verified the above finding. c. Review of Resident #30's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 07/27/18 ADL self performance deficit plan of care indicated the resident required assistance from staff for bathing. The care plan did not specify when, how often or what type of bathing the resident preferred. Review of the quarterly 04/03/21 MDS 3.0 assessment revealed the resident was severely impaired for daily decision making, required total dependence from two staff for bathing and was always incontinent of bowel and bladder. Review of the STNA TASK electronic documentation revealed the resident preferred a Wednesday and Saturday night shift bath. The documentation did not indicate whether the resident preferred a bed bath or shower. Review of the STNA TASK documentation from 06/22/21 to current revealed the resident was bathed on Tuesday 06/22/21 at 1:33 A.M., Wednesday 06/23/21 at 10:09 P.M., Tuesday 06/29/21 at 5:59 A.M. and Friday 07/16/21 at 5:59 P.M. There was no evidence of the resident being bathed in the 16 days between 06/29/21 and 07/16/21. On 07/20/21 at 4:57 P.M. interview with Regional Registered Nurse (RN) #74 revealed the facility had no other documentation as to when the resident was bathed. The resident was receiving Hospice services and the facility did not have any additional information as to whether Hospice staff was providing bathing for the resident. This deficiency substantiates Complaint Number OH 061.

Based on observation, record review and staff interview the facility failed to ensure oxygen was provided as ordered for Resident #33. This affected one resident (#33) of one resident observed with her oxygen turned off. The facility identified eight residents receiving respiratory treatments. Findings include: Review of Resident #33's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 11/22/18 plan of care revealed the resident had ineffective breathing patterns related to asthma. Review of the 04/21/21 quarterly Minimum Data Set (MDS) 3.0 assessment revealed the resident was moderately impaired for daily decision making, required extensive assist of one staff for eating and physical help from one staff for bathing. The assessment revealed the resident received oxygen. Review of the current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 07/19/21 at 11:28 A.M. Resident #33 was observed in the activity room at a table looking through a magazine. The resident had a nasal cannula in place with a cloth mask over it covering her nose and mouth. Observation of the oxygen canister hanging on the back of her wheelchair revealed the oxygen liters was set at zero. The needle for the oxygen gauge was pointed in the red indicating empty. At the time of the observation, Registered Nurse (RN) #64 was alerted. RN #64 verified the oxygen canister was turned off. She turned the oxygen on to 3 LPM. The needle on the oxygen level gauge remained on empty. On 07/19/21 at the time of the observation, interview with RN #64 verified the resident was ordered continuous oxygen and was in the activity room with the oxygen canister turned in the off, zero, position. The resident had a nasal cannula in place and a cloth mask covering her nose and mouth. RN #64 further verified when she turned the oxygen on the canister was empty. This deficiency substantiates Complaint Number OH 061.

Based on record review and interview the facility failed to ensure Resident #1, #11 and #30, who required staff assistance for activities of daily living (ADLs) received routine showers. This affected three residents (#1, #11 and #30) of four sampled residents reviewed for ADL and incontinence care. Findings include: 1. Review of Resident #1's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) 3.0 assessment, dated 10/15/20 revealed it was very important for the resident to choose between a tub bath, shower, bed bath, or sponge bath. However, the question did not follow up with a frequency. Review of the 11/20/20 activities of daily living (ADL) self care performance deficit plan of care revealed the resident had a deficit related to activity intolerance, impaired balance and limited mobility secondary to impaired neurological status. The care plan indicated the resident required extensive assist (from staff) for personal hygiene. The plan did not identify a bathing preference or frequency. Review of the 06/19/21 quarterly MDS 3.0 assessment revealed the resident was moderately impaired for daily decision making, required extensive assist of two staff for bed mobility, transfers and toilet use. The assessment revealed the resident required the physical assist of one staff in part for bathing with assist of one. The assessment also revealed the resident was frequently incontinent of urine and occasionally incontinent of stool. Review of the State tested Nurse Aide (STNA) TASK section in Point Click Care (PCC), the facility electronic documentation system, revealed the bathing section was to be personalized to the resident's preferences. However, there was no personalized preference entered into the system. Review of STNA TASK documentation from 06/21/21 to 07/20/21 revealed the resident was bathed nine times: On 06/21/21 at 6:19 A.M., 06/22/21 at 1:10 A.M., 06/23/21 at 3:58 A.M. and 8:41 P.M., 06/27/21 at 5:03 P.M., 07/14/21 at 9:08 A.M., 07/16/21 at 1:16 A.M., 07/17/21 at 7:00 A.M. and 07/19/21 at 7:44 A.M. Record review revealed no evidence of a shower documented in the electronic record between 06/27/21 and 07/14/21 (the response no was checked marked as to whether a bath was provided during this time period). On 07/19/21 at 1:02 P.M. interview with Resident #1 revealed the resident indicated he didn't know when he would ever get a bath. The resident indicated he was a morning person and liked to get up in the five o'clock hour. The resident shared no one (at the facility) had asked him how often he would like a bath but he thought three times a week wouldn't be asking too much. On 07/20/21 at 4:57 P.M. interview with Regional Registered Nurse (RN) #74 revealed when preferences were entered into the electronic documentation system the preference then prompted staff when it was the day and shift a shower was to be provided. RN #74 verified the resident's electronic medical record reflected only the nine dates/times of care being provided. The facility then located two additional hand written shower sheets. RN #74 was then unable to find any evidence of Resident #1 receiving a shower/bath between 06/28/21 and 07/04/21 (a seven day time period). 2. Review of Resident #11's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 05/03/21 quarterly MDS 3.0 assessment revealed the resident was severely impaired for daily decision making, required extensive assist of two staff for bed mobility, transfers and toileting. The MDS 3.0 assessment indicated personal hygiene only occurred once or twice in the seven day review period and bathing activity did not occur. At the time of the review, the MDS entry was locked by a facility staff member. Review of the STNA TASK documentation for the 04/27/21 through 05/03/21 look back period revealed no evidence Resident #11 received a bath during this time period. Entries during this time period were marked no (as to care being provided). There were no yes entries indicating a bath was provided during this seven day time period. On 07/21/21 at 11:11 A.M. the Administrator verified the above finding. 3. Review of Resident #30's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 07/27/18 ADL self performance deficit plan of care indicated the resident required assistance from staff for bathing. The care plan did not specify when, how often or what type of bathing the resident preferred. Review of the quarterly 04/03/21 MDS 3.0 assessment revealed the resident was severely impaired for daily decision making, required total dependence from two staff for bathing and was always incontinent of bowel and bladder. Review of the STNA TASK electronic documentation revealed the resident preferred a Wednesday and Saturday night shift bath. The documentation did not indicate whether the resident preferred a bed bath or shower. Review of the STNA TASK documentation from 06/22/21 to current revealed the resident was bathed on Tuesday 06/22/21 at 1:33 A.M., Wednesday 06/23/21 at 10:09 P.M., Tuesday 06/29/21 at 5:59 A.M. and Friday 07/16/21 at 5:59 P.M. There was no evidence of the resident being bathed in the 16 days between 06/29/21 and 07/16/21. On 07/20/21 at 4:57 P.M. interview with Regional Registered Nurse (RN) #74 revealed the facility had no other documentation as to when the resident was bathed. The resident was receiving Hospice services and the facility did not have any additional information as to whether Hospice staff was providing bathing for the resident. This deficiency substantiates Complaint Number OH 061.

Based on record review and staff interview the facility failed to ensure a comprehensive plan of care was developed for Resident #11 related to activities of daily living (ADL) and incontinence care. This affected one resident (#11) of four sampled residents reviewed for ADL and incontinence care. Findings include: Review of Resident #11's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the 05/03/21 quarterly Minimum Data Set (MDS) 3.0 assessment revealed the resident was severely impaired for daily decision making, required extensive assist of two staff for bed mobility, transfers and toileting. The MDS 3.0 assessment revealed personal hygiene only occurred once or twice in review period and bathing activity did not occur. The assessment revealed the resident was always incontinent of bowel and bladder. A 07/04/21 Bowel and Bladder assessment indicated the resident was severely impaired, had hypertension, [CONDITION(S)], was on an antidepressant and had mixed incontinence. Review of the resident's plan of care revealed there was no comprehensive incontinence or ADL plan of care developed. An incontinence plan of care was initiated on 07/19/21 after a request was made by the surveyor for a list of incontinent residents in the facility. On 07/19/21 at 4:30 P.M. interview with Registered Nurse (RN) #74 verified it was part of her job duty to audit care plans. RN #74 verified she had completed and entered an incontinence care plan for Resident #11 on this date. During a follow up interview on 07/20/21 at 4:52 P.M. RN #74 verified a comprehensive and individualized plan of care had not been developed and implemented for Resident #11 related to incontinence care or ADL care. RN #74 indicated a new MDS nurse had just started on 07/19/21 and she would be trained to enter care plans. This deficiency is an incidental finding to Complaint Number OH 061.

Based on record review and interview the facility failed to ensure Resident #1, Resident #11 and Resident #30's preferences were timely identified and/or honored related to personal care/bathing/showering needs. This affected three residents (#1, #11 and #30) of four sampled residents. Findings include: 1. Review of Resident #1's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set Assessment (MDS) 3.0 assessment, dated 10/15/20 revealed it was very important for the resident to choose between a tub bath, shower, bed bath or sponge bath. The question did not follow up with a preferred frequency. Review of the 11/20/20 Activities of Daily Living (ADL) Self Care Performance Deficit plan of care revealed the resident had a deficit related to activity intolerance, impaired balance and limited mobility secondary to impaired neurological status. The care plan revealed the resident required extensive assist (from staff) for personal hygiene. The plan did not identify a bathing preference or frequency. Review of the 06/19/21 quarterly MDS 3.0 assessment revealed the resident was moderately impaired for daily decision making, required extensive assist of two staff for bed mobility, transfers and toilet use. The assessment revealed the resident required set up supervision for eating and physical help from one staff in part for bathing. The resident was frequently incontinent of urine and occasionally incontinent of stool. Review of the State tested Nurse Aide (STNA) TASK section in Point Click Care (PCC), the facility electronic documentation system, revealed the bathing section was to be personalized to the resident's preferences. However, there was no personalized preference entered into the system. On 07/19/21 at 1:02 P.M. interview with Resident #1 revealed the resident indicated he didn't know when he would ever get a bath. The resident indicated he was a morning person and liked to get up in the five o'clock hour. The resident shared no one (at the facility) had asked him how often he would like a bath but he thought three times a week wouldn't be asking too much. On 07/20/21 at 4:57 P.M. during an interview with Regional Registered Nurse (RN) #74, no additional information was provided to support the resident was asked his preferences to the type and frequency of bathing he would like. The MDS indicated it was very important for him to choose this. However, there was no follow up documented. 2. Review of Resident #11's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 09/18/20 admission MDS 3.0 assessment revealed it was very important for the resident to choose between a tub bath, shower, bed bath or sponge bath. Review of the 05/03/21 quarterly MDS 3.0 assessment revealed the resident was severely impaired for daily decision making and required extensive assist of two staff for bed mobility, transfers and toileting. Review of the MDS 3.0 assessment revealed personal hygiene had only occurred once or twice in the seven day review period and bathing activity did not occur at all. Review of the STNA TASK electronic documentation revealed there was no personalized preferences entered for Resident #11 to trigger staff to know when to shower or bathe the resident. On 07/20/21 at 4:57 P.M. during an interview with RN #74, no additional information was provided to support the resident and/or her family were asked the resident's preferences to the type and frequency of bathing she would like. The MDS indicated it was very important for the resident to choose and there was no follow up documented. 3. Review of Resident #30's medical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 07/27/18 ADL self performance deficit plan of care revealed the resident required assistance (from staff) for bathing but did not specify when, how often or what type of bathing the resident preferred. Review of the quarterly 04/03/21 MDS 3.0 assessment revealed the resident was severely impaired for daily decision making and required total dependence from two staff for bathing. The MDS 3.0 assessment revealed the resident was always incontinent of bowel and bladder. Review of the STNA TASK electronic documentation revealed the resident preferred a Wednesday and Saturday night shift bath. It did not indicate whether the resident preferred a bed bath or shower. Review of the STNA documentation from 06/22/21 to present date revealed the resident was bathed on Tuesday 06/22/21 at 1:33 A.M., Wednesday 06/23/21 at 10:09 P.M., Tuesday 06/29/21 at 5:59 A.M. and Friday 07/16/21 at 5:59 A.M. The record revealed the resident had received four baths during this time period, two baths on a Tuesday, one on a Wednesday and one on a Friday. However, documentation contained in the resident's medical record revealed the resident preferred Wednesday and Saturday night shift baths. On 07/20/21 at 4:57 P.M. interview with RN #74 revealed the facility had no other documentation as to when the resident was bathed. The resident received Hospice services and the facility did not have any Hospice information as to when or if bathing was provided by Hospice staff. This deficiency substantiates Complaint Number OH 061.

Based on record review and staff interview the facility failed to prevent the development of, obtain comprehensive treatment orders for, to complete dressings as ordered and to assess pressure ulcers. This affected one (Resident #17) of three residents reviewed for staffing related care issues. The facility census was 47. The facility identified six residents with pressure ulcers. Findings include: Review of the medical record for Resident #17 revealed the resident was admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling.), [CONDITION(S)], [CONDITION(S)], and acute [CONDITION(S)]. The resident was admitted with a pressure ulcer to the coccyx measuring 6.2 centimeter (cm) x 4.3 cm x unable to determine (Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed /UTD) and an open area to the scrotum 1.0 cm x 1.0 cm x <0.1 cm. The in facility wound doctor was to follow the wound care. Admission physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 02/05/21 Santyl Ointment 250 UNIT/GM (gram) (Collagenase) apply to sacrum topically every day shift for wound care. Review of the 02/07/21 Annual Minimum Data Set (MDS) revealed the resident was moderately impaired for daily decision making, and required extensive assist of two for bed mobility, transfers, dressing, toilet use, and personal hygiene and physical help of two for bathing. There was no upper or lower extremity impairment. Review of the February and March treatment record revealed the sacrum dressing was not signed off as completed 02/13/21, 02/16/21, 03/02/21 or 03/05/21. A 02/05/21 order for Santyl ointment 250 UNIT/GM apply to sacrum topically every day shift for wound care was written. There was no indication as to what type of dressing was to cover the Santyl ointment to the sacrum. The order was signed off as completed until discontinued on 02/13/21. The wound physician consult indicated the sacral wound was to be cleansed with normal sterile saline, pat dry, apply Santyl to the wound base in a nickel-thick layer, and cover with a large silicone foam dressing daily and as needed. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse progress note dated 03/07/21 and Pressure Ulcer Skin Grid indicated the resident had two new pressure ulcers: Left heel 5.0 cm x 1.5 cm x <0.1 cm Stage II. (shallow with a reddish base. Adipose (fat) and deeper tissues are not visible, granulation tissue, slough and eschar are not present.) Right heel 7.0 cm x 4.0 cm x 0.1 cm Stage II open blister with 1.5 cm dark purple area. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Bilateral Prafo boots (padded for protection) were ordered at all times, and bilateral heels: cleanse with normal sterile saline, apply triple antibiotic ointment, ABD (large padded dressing) and kerlix (gauze wrap) daily for wound care. There was no order, care plan, or evidence heels were floated prior to the development of the bilateral heel pressure ulcers. Review of the 03/11/21 wound physician consult for pressure ulcers indicated the heel pressure ulcers were likely due to poor offloading in bed. The left heel was unstageable (Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.) at 1.8 cm x 1.9 cm and the right heel an unstageable 4.0 cm x 4.3 cm pressure ulcer. The sacral ulcer remained a Stage IV. The March treatment record revealed the bilateral heel dressings were not signed off as completed 03/19/21. The March treatment record revealed after the development of the bilateral heel pressure ulcers the bilateral knee-high support hose continued to be signed off as donned in the morning and doffed in the evening. Review of the April treatment record revealed the sacral dressing was not signed off as changed on 04/05/21 or 04/16/21. Review of the Pressure Ulcer Skin Grids revealed there were no skin grids completed on 04/22/21. The weekly assessments of the sacrum and bilateral heels were not completed. Review of the 05/11/21 wound clinic consult revealed the sacral ulcer remained a Stage IV at 5.4 cm x 3.8 cm x 0.8 cm deep. The resident reported a pain level of two on a scale of 0-10 for the sacrum. The right heel was now a Stage III (full-thickness skin loss potentially extending into the subcutaneous tissue layer) pressure ulcer measured at 2.6 cm x 2.4 cm x 0.5 cm depth. The left heel a Stage III pressure ulcer was 0.9 cm x 0.6 cm x 0.1 cm depth. Interview 05/14/21 at 2:35 P.M. with Registered Nurse (RN) #51 verified there was not an order to elevate/offload heels until after pressure ulcers developed. Verified bilateral compression hose continued to be signed off as being put on daily after the pressure ulcers developed to bilateral heels. At 5:10 P.M. verified there were treatments signed off for application of ointment to sacrum without an indication of what dressing was to cover the area. There were days the heel and sacrum dressings were not signed off as being changed as ordered. The pressure ulcers were assessed on 04/15/21 and 04/29/21 but there was no weekly pressure ulcer skin assessment or grid completed for 04/22/21. On 05/17/21 at 3:43 P.M. after the deficient practice was found the facility provided a typed statement from RN #51 indicating the order for the dressing on 02/05/21 to the Sacral Stage IV pressure ulcer was deleted in error. RN #51 indicated the dressing was changed per the wound physician order. Review of the treatment sheet from 02/05/21 through 02/12/21 revealed RN #51 signed off the treatment once. RN #51 was not the nurse who competed the dressing changes for seven of the eight days during that period. Other staff signed off the treatment sheet line Santyl Ointment 250 UNIT/GM (gram) (Collagenase) apply to sacrum topically every day shift for wound care. There was no indication of what dressing the staff used to cover the Santyl.

Based on review of closed medical record and hospital records, facility policy and procedure for Skin Condition-Notification/ Reporting and Skin Inspection, staff interviews and interviews with Certified Nurse Practitioner (CNP) #50 and Physician #51 the facility failed to prevent the development of an avoidable pressure ulcer for one resident (Resident #60) identified as requiring assistance with bed mobility and incontinence care. This resulted in Immediate Jeopardy for Resident #60 who was admitted with no open pressure areas and developed an unstageable pressure ulcer (full thickness skin or tissue loss, depth unknown as wound is obscured by slough or eschar) to the sacrum. Actual harm occurred when the pressure area, which was found as unstageable became infected and caused pain resulting in the hospitalization of Resident #60. This affected one resident of three residents reviewed for pressure ulcers. The facility identified five residents currently with pressure ulcers in the facility. The facility census was 59. On 03/08/18 at 11:22 A.M., the Administrator, Director of Nursing, Vice President of Operations #52 and Corporate Quality Assurance Nurse #53 were notified that Immediate Jeopardy began on 02/10/18 when staff documented Resident #60 had a small open area measuring 0.5 centimeters (cm) in length by 0.5 cm width with 0.1 cm depth to his coccyx with no evidence of a formal wound assessment being completed, no physician notification or treatment orders obtained and no evidence of the implementation of comprehensive pressure ulcer care to promote healing and prevent further breakdown. On 02/26/18 Resident #60 was assessed to have an 8.0 cm by 12.0 cm unstageable pressure ulcer to his sacrum. On 02/27/18 Resident #60 was transferred to the hospital for care of the pressure ulcer. Hospital records revealed the resident required surgical debridement with discussion of a diverting [MEDICAL CONDITION] to decrease fecal contamination in the wound. The Immediate Jeopardy was removed on 03/02/18 when the facility implemented the following corrective action: · Beginning on 02/26/18 and continuing through 03/26/18, the Director of Nursing is completing random daily audits of residents with wound care orders to ensure compliance with wound care as ordered by the physician. · On 02/27/18 Resident #60 was discharged to the emergency room and hospitalized for [REDACTED]. · On 02/27/18 the DON reviewed the five current residents, Resident #4, #14, #21, #26 and #43 with pressure ulcers to determine accurate assessments, treatment orders and delivery of care was in place to meet their needs. · On 03/02/18 a facility wide skin sweep of all 59 residents was completed by the Director of Nursing, Registered Nurse (RN) #40, and Licensed Practical Nurses (LPNs) #10, #20 and #30 to identify any pressure related skin breakdown. No new areas of pressure related skin breakdown were identified. · On 03/02/18 all nursing staff including three RNs and 11 LPNs were educated by the Director of Nursing on skin impairments and documentation including assessments, skin impairments and physician orders for wound care and skin impairments and physician notification. The facility wound nurse, LPN #10, also received this education. · On 03/02/18 the facility implemented a system where the Assistant Director of Nursing, RN #40, would serve as the back-up wound care nurse when the wound care nurse, LPN #10, was not available to ensure continuity of care. · Review of disciplinary actions revealed on 03/02/18 LPN #11, LPN #20 and LPN #21 received counseling regarding the application of wound care without physician orders, failure to complete a wound assessment and failure to notify the physician of a wound involving Resident #60. · On 03/07/18 and 03/08/18 review of two additional resident records, Resident #26 and #43 revealed appropriate wound identification, assessment and wound care was completed as ordered by the physician. · Interview with the facility wound care nurse, LPN #10, on 03/07/18 at 1:40 P.M. revealed understanding of the need for wound identification, assessment, physician notification and obtaining wound care orders. · On 03/08/18 at 11:30 A.M., interview with the Assistant Director of Nursing, RN #40, verified she was now the back-up wound care nurse, who would complete wound assessments and ensure wound care was completed in the absence of the wound care nurse, LPN #10. RN #40 also voiced an understanding of the in-service that was provided related to wound identification, assessment, notification and obtaining wound care orders. · On 03/08/18 at 12:40 P.M., and 1:05 P.M. interview with LPN #11 and LPN #20 revealed an understanding of in-service that was provided related to wound identification, assessment, notification and obtaining orders. Although the Immediate Jeopardy was removed on 03/02/18 the facility remained out of compliance at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings include: Review of Resident #60's closed medical record revealed the resident was admitted to the facility on [DATE] with admission [DIAGNOSES REDACTED]. Upon admission a skin assessment, dated 02/06/18 was completed which reflected the resident's coccyx had a 10 centimeter (cm) in length by 18 cm wide reddened area. This entry was removed from the resident's medical record and noted to have been documented in error on 02/26/18 with no further explanation provided. The nursing assessment revealed the resident required staff assistance/dependence for bed mobility, transferring and toileting. A skin risk assessment completed upon admission revealed the resident was at low for skin breakdown. Record review revealed no care plan for risk for skin breakdown was implemented until 02/26/18. Review of a nursing progress note, dated 02/10/18 and authored by LPN #20, revealed on 02/10/18 at 11:33 P.M. Resident #60 was found with a soiled dressing to his coccyx and the dressing was removed. Resident #60's coccyx was noted to be red with a small open area measuring approximately 0.5 cm in length by 0.5 cm in width with less than 0.1 cm depth. The wound bed was pink in color with no drainage noted. The note indicated a new dressing was applied to the coccyx area. However, record review revealed no evidence the physician was notified of the open area and there was no written evidence of a physician ordered treatment in place for an area to the coccyx at that time. A note on 02/11/18 identified the same open area to the coccyx. The note indicated the area was cleansed with normal saline, and hydrogel (wound healing aid) was applied to the wound and a foam dressing covered the wound. However, there was no assessment of the ulcer and no physician ordered treatment for [REDACTED]. On 02/16/18 and 02/19/18 notes indicated a dressing to the coccyx was intact. Nursing progress notes, dated 02/21/18 revealed the dressing to the coccyx was changed due to it being soiled. On 02/21/18 the resident was examined by Physician #51, who performed a digital exam and stool removal for Resident #60 due to constipation, a note verified an intact dressing to the coccyx was in place. On 02/23/18 and 02/25/18 nursing progress notes revealed a dressing to the coccyx was soiled and replaced. However, record review revealed there was no written evidence of a treatment order or any type of assessment of the resident's coccyx during this time period. Record review revealed a nursing progress note, dated 02/25/18 that reflected when the dressing was replaced the wound was identified as necrotic (black, dead tissue). There was no evidence the physician was notified at that time and no evidence a treatment order was in place. On 02/26/18 at 9:44 A.M. CNP #50 entered a progress note identifying Resident #60 had an area of excoriation to his buttocks and was referred to the facility wound care nurse, LPN #10. The CNP note did not include an assessment of the pressure ulcer at that time. On 02/26/18 at 9:59 A.M., record review revealed LPN #10 completed an initial assessment of the wound, which was noted to have a six inch by six inch foam dressing to the sacrum/coccyx area observed. Drainage was noted to the dressing; however there was no odor present. Physician #51 was updated on Resident #60's condition and an order was received to cleanse the area with normal saline, apply [MEDICATION NAME] (a wound healing aid that removes necrotic tissue) and cover with foam dressing. On 02/26/18 at 6:17 P.M., the dressing was changed due to being soiled. On 02/26/18 at 8:00 P.M., the wound dressing was again changed due to being soiled. The wound was noted as necrotic and had a strong odor at that time. Review of the pressure ulcer assessment, dated 02/26/18 and completed by LPN #10 revealed Resident #60 was assessed to have an unstageable pressure ulcer to the sacrum measuring 8.0 cm in length by 12.0 cm in width that was dark and hard, with no odor present. The peri-wound was assessed as dark purple in color measuring 10.0 cm in length by 18.0 cm in width. Record review revealed no written physician treatment orders had been in place until 02/26/18 when the ulcer was first assessed to be unstageable despite nursing progress notes dated between 02/10/18 and 02/26/18 which noted an intact dressing to the area or the application of a dressing. On 02/27/18 at 10:48 A.M., a nursing progress note revealed LPN #10 changed the dressing to Resident #60's ulcer and assessed the ulcer had an odor present with a moderate amount of dark brown drainage that had not been present at the time of her assessment on 02/26/18. Resident #60 was also complaining of increased pain. CNP #50 was updated on the wound condition. On 02/27/18 at 5:03 P.M. (six hours later), CNP #50 assessed the wound and noted a strong odor. The dressing was changed at that time as it was saturated with drainage. Large amounts of dark exudate were observed and the wound bed was assessed as dark and hard. CNP #50 gave a new order to send Resident #60 to the emergency room for evaluation and treatment due to possible wound infection. Review of the hospital records dated 02/27/18 at 6:03 P.M. revealed Resident #60 was sent to the emergency room due to a wound. Examination revealed an 8.0 cm in length by 1.0 cm in width, Stage II pressure ulcer to the resident's [MEDICATION NAME] area with foul odor and drainage and an 8.0 cm in length by 10.0 cm in width, Stage III (full thickness skin loss, subcutaneous fat may be visible, but not bone tendon or muscle is exposed) pressure ulcer to the sacrum with black eschar (dead tissue). Subsequent hospital records revealed Resident #60 was admitted to the hospital with [REDACTED]. A general surgery consult, dated 03/08/18 at 11:22 A.M. revealed Resident #60 was recovering from surgical debridement (removal of dead tissue) from an extensive Stage IV pressure ulcer with discussion regarding the need for a diverting [MEDICAL CONDITION] to decrease fecal contamination in the wound. On 03/07/18 at 12:55 P.M., telephone interview with Resident #60's brother revealed Resident #60 was admitted to the facility for therapy following a 30 day hospital stay for pneumonia. Resident #60's brother indicated he was visiting on 02/26/18 when Resident #60 complained of pain in his buttocks. The resident's brother stated he advised CNP #50, who looked at the area. The brother indicated, LPN #10 then completed an assessment and found the wound. The brother stated he was called the next day by the facility advising him Resident #60 was going to the emergency room for an evaluation of the wound. He added the hospital staff took pictures of the wound because it was so bad and voiced concerns that Resident #60 even had a wound on his back the facility didn't know about. The brother indicated the resident remained in the hospital as of this date after having surgery on his wounds to remove dead tissue and was awaiting another surgery to have a [MEDICAL CONDITION] placed to try to help the wounds heal. On 03/07/18 at 11:40 A.M., and during a follow up interview on 03/08/18 at 10:20 A.M. interview with CNP #50 revealed she was not notified of any skin breakdown for Resident #60 until 02/26/18 when she examined the resident and found excoriation. At that time she advised LPN #10 to do a formal assessment, physician notification was made and wound care orders were obtained. CNP #50 acknowledged she did observe an intact dressing to the sacral/coccyx area at the time of the observation on 02/26/18, which she did not remove. Resident #60 was noted to have excoriation in addition to the intact dressing. CNP #50 stated she did not remove the dressing on 02/26/18, but informed LPN #10 to complete an assessment. CNP #50 also indicated she was notified of an extreme decline in the wound the next day, on 02/27/18 and assessed the area at that time and ordered Resident #60 be sent to the emergency room for evaluation and treatment as she believed the pressure ulcer was most likely infected. On 03/08/18 at 12:20 P.M., telephone interview with Physician #51 revealed he personally examined Resident #60 on 02/21/18 due to complaints of constipation and possible fecal impaction. The physician stated he performed a digital rectal exam and removed a large amount of stool. The physician indicated he recalled a dressing was in place to the coccyx area, which he did not remove. He stated he did not observe any evidence of skin breakdown at that time. He reported he was unaware of any wounds to Resident #60's coccyx/sacrum until 02/26/18. On 03/07/18 at 10:15 A.M. interview with LPN #10 revealed she was employed as the facility wound nurse. During the interview LPN #10 indicated she was unaware the resident had any areas of skin impairment until being notified by CNP #50 on 02/26/18 with a request to assess the coccyx area. During the interview LPN #10 also indicated she was unavailable to provide wound care in the facility between 02/12/18 and 02/27/18 as she was conducting STNA training classes and not providing wound care for residents in the facility. On 03/07/18 at 12:15 P.M., telephone interview with LPN #22 revealed she completed the admission skin assessment for Resident #60 which incorrectly identified a reddened area to the coccyx. LPN #22 stated she later wrote a progress note on 02/26/18 which stated she entered the information in error as there was no skin impairment present at the time of admission. On 03/07/18 at 1:20 P.M., interview with LPN #23 revealed Resident #60 required total staff assistance with transfers including the use of a mechanical lift and was dependent upon staff for turning and repositioning in bed. On 03/07/18 at 1:30 P.M., interview with State tested Nurse Aide (STNA) #24 revealed Resident #60 required total assist with transfers including the use of a mechanical lift, required assistance with bed mobility and used a bed pan for toileting. STNA #24 also stated she did not observe any open areas to Resident #60's coccyx until either 02/21/18 or 02/22/18. On 03/07/18 at 1:35 P.M., interview with Physical Therapy Assistant (PTA) #54 revealed Resident #60 was dependent upon staff for transfers and bed mobility and required the use of a mechanical lift. On 03/07/18 at 1:40 P.M., interview with LPN #40 verified Resident #60 was admitted to the facility with no skin breakdown of the coccyx/sacral area on 02/06/18. LPN #40 revealed an open area was identified to the coccyx, as documented in the nursing progress notes, on 02/10/18. However, there was no evidence the physician or CNP were notified, no evidence of any wound care treatment orders being initiated and no evidence of any skin interventions to promote healing or prevent additional decline in the ulcer. LPN #40 verified the documentation as noted above between 02/10/18 through 02/25/18 referencing a dressing being in place and/or dressing change being completed. However, LPN #40 was unable to provide any evidence of what type of dressing was being applied or what the condition of Resident #60's skin was on any of those dates. LPN #40 verified Resident #60 developed an unstageable pressure ulcer to the sacral/coccyx area which resulted in his discharge to the hospital on [DATE] due to the severity of the ulcer and presence of an infection. LPN #40 verified no evidence of pressure ulcer reducing interventions were in place such as barrier cream, turning and repositioning, specialty pressure reducing mattress or evidence of toileting or checking and changing every two hours Review of the undated facility policy titled, Skin Condition-Notification/Reporting revealed the facility would inform the resident, consult with the resident's physician or Medical Director, if the attending physician was not available, and/or notify the resident's family and/or legal representative as applicable when there is: pressure ulcer upon admission, development of a new pressure ulcer, change in condition or status of the pressure ulcer, lack of improvement in a wound after two to four weeks of treatment or a need to alter treatment significantly. Notification was to be documented in the medical record to include the name of the resident's sponsor and/or authorized representative, if it was not the resident. Review of the facility policy, dated 05/2009 and titled, Skin Inspection revealed skin would be inspected a minimum of once a week for pressure ulcers. The facility did not have a policy and procedure for pressure ulcer prevention available to review during the time of the onsite investigation. This deficiency substantiates Complaint Number OH 557.

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 prevent a significant medication error for one resident(Resident #29). This resulted in actual harm when Resident #29 was administered the wrong medications resulting in an acute drop in blood pressure requiring emergency room treatment and intravenous fluids. This affected one resident (Resident #29) of three sampled residents. Findings include. Review of Resident #29's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment revealed Resident #29 was moderately cognitively impaired. A review of the nursing progress note, dated 05/10/17 at 8:28 A.M.(as a late entry note) revealed on 05/09/17 between 7:00 P.M. and 7:30 P.M. Licensed Practical Nurse (LPN) #103 administered Resident #29 another resident's medications. The medications that were administered to Resident #29 included: Atorvastatin (lipid lowering agent) 20 milligrams (mg), [MEDICATION NAME] 100 mg (stool softener), [MEDICATION NAME] (blood pressure medication) 1 mg, [MEDICATION NAME] 40 mg (antipsychotic medication), [MEDICATION NAME] 15 mg (anti-depressant), [MEDICATION NAME] (blood pressure medication) 0.1 mg, [MEDICATION NAME] (blood pressure medication) 100 mg, [MEDICATION NAME] (pain medication) 50 mg, [MEDICATION NAME] (blood pressure medication) 100 mg and Tylenol (pain medication) 500 mg. At 9:05 P.M., when the error was realized, Resident #29's blood pressure was checked and assessed to be 68/48 LPN #103 notified the on-call physician and left a message and then at 9:30 P.M. called Nurse Practitioner (NP) #104. NP #104 gave a telephone order for Resident #29 to be sent to the hospital. The resident's family was notified of the medication error and the order to send the resident to the hospital. The ambulance was called and they notified the facility that their estimated arrival time was approximately 20 minutes. NP #104 was called again at 9:45 P.M. because Resident #29's blood pressure dropped lower to 50/24. NP #104 gave a telephone order to provide one liter of normal saline solution intravenously using the biggest gauge needle the facility had available. A 20 gauge intravenous access line was started in the resident's right hand. Resident #29 left the facility at 10:25 P.M. and prior to her leaving her blood pressure was 65/35. Resident #29 complained of feeling funny, dizzy and nauseated prior to her transfer to the hospital. During a telephone interview on 05/31/17 at 4:00 P.M. LPN #103 indicated it was her third or fourth night working in the facility and she was training the night the medication error happen. She indicated there were a few admissions that day and the nurse she was training with had told her she was going to help the supervisor with the admissions and she wanted LPN #103 to start the medication pass. LPN #103 stated all the nurses had worked at the facility for a while and they usually passed out the medications to the resident's in the common area and she knew she should not have tried to passed them out in there but she did. Resident #29 was sitting out in the common area and she asked her what her first name was and she told her, however LPN#103 did not realize the resident had the same first name as another resident. LPN #103 indicated there was no reason why she would not believe this was the right resident. She indicated she then went down the hall way and when she got to Resident #19's room, she realized she had given the wrong resident her medications. She immediately told the nurse she was training with what had happened and they then called the nurse practitioner. Resident #29 was sent out to the hospital. LPN #103 verified at this time she had given the wrong medication to Resident #29 which caused her to become hypotensive and required her to be sent to the hospital for treatment. Review of the facility's Medication Error Report, dated 05/09/17 at 7:00 P.M. revealed Resident #29 was given another resident's medications. The outcomes of the investigation revealed the resident's blood pressure became very low, 68/48 at 9:00 P.M., and she was sent out to the emergency room . Review of the Investigation Summary for Resident #29 dated 05/09/17 revealed LPN #103 reported she observed Resident #29 in the common area and was thinking it was Resident #19, so she approached her and called her by her first name and she replied hello. There was nothing to trigger her that this was the wrong resident. (both had the same first name). LPN #103 indicated she administered the medication and proceeded down the hall to finish the remainder of her evening medications. When she arrived to Resident #19's room and found her in the room ,she realized she had administered medications in error and had given Resident #19's medications to Resident #29. She immediately went to the nurse in charge of the resident and notified her then went past her straight to the resident's room to assess the resident. Review of the physician's progress note, dated 05/12/17 revealed Resident #29 was seen by NP #104 for a follow up to a recent hospital admission for severe [MEDICAL CONDITION] due to being given the wrong medications and also lactic acidosis likely from the low blood pressure. Review of the facility policy on Medication Administration dated 10/01/12 revealed before administering the dose of medication the nurse must make certain to correctly identify the resident to whom the medication was being administered. Medications prescribed for one resident were not to be administered to any other resident. All medication errors and adverse drug reactions were immediately reported to the resident's physician and responsible party. An entry was to be made in the resident's clinical record and a incident report completed. Review of the facility policy on Medication Error dated 05/2009 revealed all medication and treatment errors would be reported. The nurse would assess the resident for any possible adverse reactions, the physician would be notified, notification would be documented in the nurses notes, the resident and family would be notified of the error, the nurse would complete all sections of the medication error report at the time the error was discovered, the report would be given to the Director of Nursing by the end of the shift of the occurrence, the pharmacy would be notified, and the individual making the error would be reeducated as appropriate. This deficiency substantiates Complaint Number OH 270.

Based on observation, interview and record review, the facility failed to ensure accurate assessments were completed and interventions were in place to prevent significant weight loss for Residents #76 and #74. Actual Harm occurred when Resident #76 experienced weight loss and no interventions were put into place, resulting in the resident losing 13.3% of her weight in 6 months, and when Resident #74 experienced a significant weight loss of 8.1% in 1 month, and effective interventions were not put into place and the resident continued to lose weight. This affected two of four residents reviewed for significant weight loss. Findings include: 1. Resident #76 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the minimum data set (MDS) 3.0 assessment dated [DATE] revealed the resident was moderately cognitively impaired. Weight was126 pounds with no weight loss noted and no altered diet. Review of the weight history log for Resident #76 revealed the following weights: on 11/01/12 - 129.6 pounds; on 12/01/12 - 127 pounds; and on 01/01/13 - 120.6 pounds. The weight history log indicated the resident had a 5% weight loss in 30 days in January 2013. Review of the Nutritional Therapy plan of care initiated on 09/18/12 noted the problem dated 01/02/13 of a 5% weight loss in one month but no interventions were added at that time. Review of a note to the attending physician from the pharmacist dated 01/23/13 revealed Resident #76 was on a high dose of [MEDICATION NAME], 150 milligrams (mg), and has had a significant weight loss. "[MEDICATION NAME] is known to decrease appetite. Consider reducing the dose." On 02/01/13 the physician responded and disagreed with reducing the dose because the benefits outweighed the risks. Review of the weight history log revealed Resident #76 weighed 119.6 pounds on 02/01/13, which was documented on the log as a 7.7% weight loss in 90 days. The Nutritional Therapy plan of care noted the problem dated 02/11/13 as a significant weight loss in three months but no interventions were added at that time. Review of the laboratory levels of [MEDICATION NAME], which indicated visceral protein stores revealed on 03/12/13, Resident #76's level was 3.4 grams per deciliter (g/dl). Normal range for [MEDICATION NAME] was between 3.2 and 4.8 g/dl. Review of the medical nutritional therapy re-assessment dated [DATE] indicated Resident #76 was on a regular diet. Concerns listed indicated weight was decreasing and family brought in food and snacks between meals. Resident #76 fed herself independently. Oral intake was 42% and Resident #76 was to have weekly weights. There was no documented evidence the weekly weights were initiated at that time. Review of the weight history log revealed Resident #76 weighed 117.8 pounds on 03/01/13, 118 pounds on 04/01/13, 117.2 pounds on 05/01/13, 114 pounds on 06/01/13, 112.2 pounds on 06/08/13, 111 pounds on 06/15/13 and 111.6 pounds on 06/22/13. The log indicated the resident had a 12.3% weight loss in 180 days as of June 2013. Review of Resident #76's Meal Intake form, which also documented chewing/swallowing problems, revealed the following. In April 2013 the resident ate 75-100% of meals and had no problems with chewing. In May 2013 the resident ate 50-100% of meals and had no problems with chewing. In June 2013 the resident ate 25-100% of meals and had no problems with chewing. A note dated 06/01/13 indicated the resident did not have lower dentures. Review of the medical nutritional therapy plan of care updated through October 2013 revealed it listed a problem dated 06/03/13 of a significant weight loss (no time frame or percentage documented). The interventions included in June 2013 were the diet was changed to mechanical soft, monitor laboratory values as available, monitor weights, re-assess significant changes, cater to known preferences and education as needed. A hand-written note on the care plan indicated the resident was to receive high vitamin C juice three times a day. The unavoidability form for weight loss dated 06/01/13 revealed Resident #76 had dementia and depression. The summary statement indicated the resident had a 12.3% decrease in weight in six months. The physician's orders [REDACTED]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The clinical nurse practitioner (CNP) note dated 06/12/13 revealed the resident had a recent psychiatrist visit. Staff reported the resident felt depressed and had a poor appetite. The resident was currently on 100 mg of [MEDICATION NAME]. The doctor was advised to increase to 200 mg and add [MEDICATION NAME] in the evening. Review of the physician orders [REDACTED]. Review of the medication administration records for June thru September 2013 revealed the [MEDICATION NAME] was given as ordered. Review of the medical nutritional therapy re-assessment dated [DATE] revealed Resident #76 received a regular diet and had decreased weight. Concerns listed indicated Resident #76 had nausea and emesis and family brought in food and snacks for between meals. Resident #76 fed herself independently. Review of laboratory values dated 05/26/13 indicated no [MEDICATION NAME] level was obtained. Review of a hand written note dated 06/20/13 by Certified Dietary Manager (CDM) #15 revealed they would try super cereal at breakfast. Review of the current meal ticket for breakfast did not include the super cereal. Review of the laboratory [MEDICATION NAME] level obtained on 06/24/13 revealed the resident's visceral protein stores were moderately depleted at 2.9 g/dl. Review of the weight history log revealed Resident #76 weighed 112 pounds on 07/01/13, 111.6 pounds on 07/08/13, 110 pounds on 07/15/13, 110.7 pounds on 07/22/13 and 113.2 pounds on 07/29/13. Resident #76's meal intake for July 2013 was from 50-100%, with no chewing problems. Review of the communication sheet dated 07/17/13 indicated Resident #76 had recent weight loss and had misplaced her bottom dentures. The sheet indicated Resident #76 had increased difficulty with chewing; was to be screened by speech; diet change to mechanical soft and thin liquids; and added to weekly weights. Review of the speech therapy assessment for the period from 07/16/13 through 08/05/13 revealed upon discharge on 08/05/13, Resident #76 was able to tolerate mechanical soft with thin liquids. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #76 was moderately cognitively impaired, weight was 111 pounds with no weight loss noted and no altered diet. Review of the medical nutritional therapy re-assessment dated [DATE] revealed Resident #76 received a mechanical soft diet and meal intakes were 39%. Concerns listed included weight was decreasing, resident with nausea and family brought in food. The assessment indicated Resident #76 was on a medication pass supplement, and laboratory values for [MEDICATION NAME] and calcium dated 06/21/13 were low. There was no documented evidence Resident #76 was receiving any medication pass supplement which was verified by the physicians orders and the medication administration record. Review of Resident #76's meal intake record revealed the resident ate from 50-100% in August 2013, with no chewing problems; and ate from 75-100% in September 2013, with no chewing problems. On 09/07/13 at 5:50 P.M., interview with Resident #76 revealed she wore upper dentures but the lower dentures had been missing. The facility had her fitted for lower dentures but she did not have them yet. She could chew fine without the lower dentures. She said she did not have any problems with chewing with or without her lower dentures. Her daughter took care of her and brought her food because she did not always like what the facility served. On 09/08/13 at 8:30 A.M., interview with the director of nursing (DON) verified Resident #76 was not on any type of nutritional supplement or snacks. On 09/08/13 at 5:20 P.M., Resident #76 was observed in the dining room eating a plain mechanical meat inside a hot dog bun, about 10 potato chips, coffee and water. Resident #76 ate all the sandwich and all of the chips. No high vitamin C juice was provided. On 09/09/13 at 8:05 A.M., Resident #76 was observed in the dining room. The breakfast meal consisted of cream of wheat, coffee, milk and one piece of toast. Resident #76 ate all the cream of wheat, toast and coffee and 25% of the milk. No super cereal was observed on the plate. No high vitamin C juice was provided at breakfast as care planned. On 09/09/13 at 8:06 A.M., interview with Resident #76 indicated she would like more coffee but there was no staff in the dining room to obtain the coffee. Resident #76 verified that after passing the trays, the staff left the dining room to pass the hall trays. On 09/09/13 at 10:00 A.M., the surveyor and Registered Dietitian (RD) #19 calculated a 13.3% significant weight loss in six months from the weight in December 2012 of 127 pounds to the weight in June 2013 of 114 pounds. RD #19 verified she did not assess calorie needs or the amount Resident #76 was consuming. RD #19 indicated Resident #76 had a weight gain of one pound while on the medication pass supplement and so the medication pass supplement was not necessary. RD #19 verified Resident #76 was not eating well with 50% intakes. RD #19 verified she did not assess the decrease in [MEDICATION NAME] because as people age the [MEDICATION NAME] woulf continue to decrease so the [MEDICATION NAME] level was irrelevant. RD #19 verified Resident #76's weight had stabilized the past seven weeks and had very much improved. During the same interview, RD #19 and CDM #15 verified they did not review the pharmacy review for 01/23/13 which indicated high dosage of [MEDICATION NAME] could cause weight loss. RD #19 verified that was the physician's responsibility. RD #19 verified that the 07/23/13 medical nutritional therapy assessment was inaccurate because the medication pass supplement had been discontinued on 07/03/13. RD #19 verified Resident #76 was not receiving super cereal as indicated in the 06/20/13 hand written note by CDM #15. CDM #15 verified there was no documentation that Resident #76's preferences were obtained to ensure optimal intake. CDM #15 verified any supplements or preferences would be listed under "Special Requests" on the meal tickets.. Review of the meal tickets revealed there were no special requests or supplements listed on Resident #76's meal tickets. "HVC tid" was hand written on the side without a date. RD #19 verified this was high vitamin C juice with meals due to low hemoglobin and hematocrit. Review of the meal ticket revealed there was no evidence the juice was to be provided with meals. RD #19 verified there was no documented evidence the weekly weights were obtained after the 03/26/13 medical nutritional therapy re-assessment indicated to do so. 2. Resident #74 had [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] revealed the resident had severe cognitive impairment. The assessment revealed the resident had a swallowing disorder which included coughing and choking during meals or when swallowing medications. The assessment indicated the resident was totally dependent with the assistance of one person for eating. The facility weight history log revealed Resident #74 weighed 153 pounds on 07/11/13 when he was admitted to the facility. Restorative nursing progress notes dated 07/12/13 revealed Resident #74 was admitted to the facility status [REDACTED]. The resident was admitted with a [MEDICAL CONDITION] tube for continuous tube feeding. The resident removed the tube twice. The physician ordered to discontinue the tube feeding. The resident was ordered a pureed diet with pudding thick liquids with restorative dining. The resident and family were updated and agreeable. The resident continued with speech therapy. The resident would be in restorative dining for close supervision and assistance of one staff person due to chewing and swallowing difficulties. Restorative dining was initiated for verbal cueing, encourage double swallowing and quick swallowing and verbal cueing for clearing of the right cheek (tongue sweeps) in between bites. The resident and family were agreeable. Resident #74's restorative nursing eating/swallowing deficit care plan dated 07/12/13 contained interventions that included eating/swallowing instructions seven days a week for 15 minutes. The level of staff assistance revealed the resident was to have supervision, verbal cueing and assistance of one person. The speech therapy evaluation and plan of treatment dated 07/12/13 revealed Resident #74 required aspiration and swallowing precautions. The recommendations included pureed consistency for food and pudding thick liquids because the family refused to have the resident remain nothing by mouth and a tube for feeding. The strategies included the resident perform a lingual sweep, alternations of liquids and solids, effortful swallow, second dry swallow and general swallow techniques and precautions with an upright posture during and after meals. There was success with counting during oral intake to increase timing and success of a-p transit. The impressions included the resident had severe oral-pharyngeal dysphagia and moderate to severe dysarthria. Restorative nursing progress notes dated 07/19/13 revealed the resident continued eating in the restorative dining room with the dining program in place. There were no voiced complaints. The facility weight history revealed the resident weighed 151 pounds on 07/20/13. The medical nutrition therapy assessment dated [DATE] revealed Resident #74 was six feet tall and weighed 153 pounds. The assessment data revealed the intravenous fluids were discontinued on 07/12/13. The resident pulled the [MEDICAL CONDITION] tube and it was discontinued due to the resident pulled it out twice. The resident was receiving [MEDICATION NAME] HN 1.2 tube feeding at 30 milliliters (ml) to 65 ml per hour through the [MEDICAL CONDITION] tube prior to the discontinuation of the tube. The resident's calculated needs indicated the resident was not meeting his required needs. It indicated a two ounce supplement would be given to the resident three times a day from 07/25/13 through 08/23/13. The July and August 2013 medication administration records (MARs) revealed the resident received a two ounce supplement three times from 07/25/13 through 08/23/13 without any difficulty. Restorative nursing progress notes dated 07/26/13 revealed the resident continued with the restorative dining program. There were no noted complaints or decline. The facility weight history log revealed the resident weighed 144 pounds on 07/28/13. The dietary progress notes dated 07/30/13 indicated the resident weighed 146 pounds which was a 4.9% weight loss for one week. Restorative nursing progress notes dated 08/02/13 revealed the resident continued with the restorative dining program. There were no voiced complaints. The dietary progress notes dated 08/05/13 indicated Resident #74 weighed 144 pounds which was a nine pound, or 5.9% weight loss since admission which was a significant weight loss for one month. The facility weight history log revealed the resident weighed 144.2 pounds on 08/04/13 and 140.6 pounds on 08/11/13. The physician orders [REDACTED]. A fax dated 08/14/13 to the physician indicated the resident continued to decrease in weight. The resident lost 3.8 pounds in one week. The resident had 52% meal intakes. The facility weight history log revealed the resident weighed 143 pounds on 08/18/13. The MAR indicated [REDACTED]. The facility weight history log revealed the resident weighed 140.2 pounds on 08/28/13. The comments on the weight history form indicated a significant weight loss. The monthly restorative dining grids for August 2013 indicated the resident required limited to extensive physical assistance during meals. The grids indicated the resident was in restorative dining for all meals. The restorative dining information revealed the resident was to receive assistance with meals for verbal cueing and encouragement for double swallowing, quick swallowing and clearing the right cheek (tongue sweeps) in between each bite seven days a week. The facility weight history log revealed the resident weighed 138.2 pounds on 09/01/13. Restorative nursing progress notes dated 09/03/13 revealed the resident requested to eat in the main dining room. Speech therapy was notified. The resident would eat in the restorative dining room for breakfast and the main dining room for lunch and supper. The dietary progress notes dated 09/05/13 revealed the resident weighed 138 pounds. The note revealed the resident had a significant weight loss over time but not this month. The resident ate in the restorative dining room for breakfast and the main dining room for lunch and supper meals. The nutrition care plan updated on 09/05/13 revealed a weight of 138 pounds which was a significant weight loss of 7.5%. The facility weight history revealed the resident weighed 138.4 pounds on 09/09/13. The dietary progress note dated 09/09/13 authored by CDM #15 revealed the resident's wife expressed concern that the resident was not eating, losing weight and not receiving the nutrition he needed. The CDM indicated she referred the resident's wife to the speech therapist. The monthly restorative grid for September 2013 indicated the resident required limited to extensive physical assistance during meals. The grid also revealed the resident had eaten in his room for lunch and supper on 09/01/13, ate in his room for breakfast and supper on 09/02/13 and ate in his room for breakfast on 09/04/13. The grid had no documentation regarding where or the amounts the resident ate for supper on 09/04/13 through 09/07/13. The percentage of meals eaten were incomplete for 09/01/13, 09/02/13, 09/04/13, 09/05/13, 09/06/13 and 09/07/13. The restorative dining information revealed the resident was to receive assistance with meals for verbal cueing and encouragement for double swallowing, quick swallowing and clearing the right cheek (tongue sweeps) in between each bite seven days a week. The orders revealed the texture of the resident's food was changed to mechanical soft with all bread items served on the side and continue with pudding thick liquids and other dietary orders on 09/05/13. Observations made on 09/07/13 at 12:15 P.M. and on 09/08/13 at 5:15 P.M. revealed the resident was not in restorative dining. An interview on 09/09/13 at 1:45 P.M. with Registered Dietitian (RD) #19 revealed Resident #74 was only on the supplement from 07/25/13 through 08/23/13. She verified the supplement was discontinued on 08/23/13 and the resident continued to lose weight. She verified the physician orders [REDACTED]. She verified there were no laboratory results regarding nutritional status since 07/12/13. She verified there were no calorie counts that indicated if the resident was achieving his caloric requirements. She stated the family brought in food, but did not know what the resident ate from that food. She verified the meal intakes were incomplete for September 2013 and the percentages did not reflect if the resident was meeting caloric and protein needs. The RD stated she was "not concerned" with the weight loss due to the resident had not lost any further weight this month. She verified the resident had a significant weight loss since his admission on 07/11/13. She verified there was no documentation that indicated the resident was meeting his nutritional needs. She verified the resident only ate breakfast in the restorative dining room. She verified the resident did not receive any direct supervision and cueing from the staff when he ate in the main dining room or his room. An interview on 09/09/13 at 4:55 P.M. with Speech Therapist (ST) #22 verified she assessed the resident on 07/12/13. She stated she recommended the resident should not have anything by mouth due to swallowing difficulties. She stated the family and the resident refused the nothing by mouth and refused a gastrostomy tube for tube feedings. She stated the resident was put on a pureed diet with pudding thick liquids. She stated that was the safest diet for the resident. She verified the resident sometime refused to go into the restorative dining room within the past week. She stated the resident usually ate his meals in the main dining room for lunch and supper. She verified there were no staff who followed Resident #74's plan of care to closely supervise and cue the resident when he ate in the main dining room. Resident #74 was observed on 09/10/13 at 8:40 A.M. in a wheelchair with his wife pushing him down the hall. The resident's wife stated the resident usually ate in the main dining room. She stated the staff did not closely supervise, instruct or cue the resident during his meals when he ate in the main dining room or his room.