Every finding on record at Darby Glenn Nursing and Rehabilitation Center

Based on interview, medical record review, and review of facility policy the facility failed to ensure pain parameters were in place for Resident #1, #30, and #66, who received multiple as needed pain medications. This affected three of four residents reviewed for pain management. The facility census was 93. Findings include:1. Review of Resident #30's medical record revealed an admission date of 08/22/25 and diagnoses including ataxia, mild neurocognitive disorder due to known physiological condition without behavioral disturbance, anxiety disorder, and major depressive disorder.Review of Resident #30's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had moderately impaired cognition.Review of Resident #30's plan of care revised 10/15/25 revealed the resident was at risk for alteration in comfort due to diagnoses, generalized pain, and impaired mobility. Interventions included administering medications as ordered, offering backrub or warm blankets, offering nonpharmacological interventions, pain assessment according to policy, and quiet environment and rest periods as needed.Review of Resident #30's physician order dated 01/13/26 revealed an order for Acetaminophen (analgesic) 325 milligrams (mg) two tablets by mouth every six hours as needed for mild pain or discomfort. Roxicodone (an opioid) five mg one tablet by mouth every six hours as needed for moderate pain or discomfort. Methocarbamol (a muscle relaxer) 500 mg, 0.5 tablet every eight hours as needed for pain, discomfort, or muscle spasms.Review of Resident #30's Medication Administration Record from 01/01/26 to 01/27/26 revealed Roxicodone was given on 01/02/26 for a pain of eight, on 01/08/26 for a pain of five, on 01/09/26 for a pain of six, on 01/16/26 for a pain of two, on 01/17/26 for pain of zero, and on 01/18/26 for pain of zero. Methocarbamol was administered on 01/16/26 for pain of two, on 01/17/26 for pain of zero, and on 01/18/26 for a pain of zero.Interview on 01/28/26 at 10:20 A.M. with Licensed Practical Nurse (LPN) #175 revealed when a resident reported pain they assessed location, type of pain, and attempted nonpharmacological interventions. She indicated all this information should be documented in the progress notes. LPN #175 reported as needed pain medication was given according to resident preference and not according to the scale of the pain. 2. Review of Resident #1's medical record revealed an admission date of 01/07/25 with diagnoses including parkinsonism, generalized anxiety disorder, psychotic disorder with delusions, unspecified dementia, gout, dysphagia, rheumatoid arthritis, and alcohol abuse.Review of Resident #1's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he had intact cognition.Review of Resident #1's plan of care dated 07/08/25 revealed the resident was at risk for alteration in comfort related to diagnoses and degenerative changes of the left hip. Interventions included acknowledging presence of pain and discomfort, administering medications as ordered, encouraging and assisting to maintain proper body alignment, monitoring for increased level of pain, monitoring for side effects, offering nonpharmacological interventions, and repositioning the resident for comfort.Review of Resident #1's physician order dated 04/11/25 for Tylenol 500 mg two tablets by mouth every eight hours as needed for pain or discomfort.Review of Resident #1's physician order dated 06/16/25 revealed an order for Oxycodone (opioid) five milligrams (mg) one tablet by mouth every four hours as needed for pain.Review of Resident #1's Medication Administration Record (MAR) from 01/01/26 to 01/28/26 revealed Oxycodone was administered on 01/01/26 for a pain of seven, on 01/02/26 or a pain of seven, on 01/04/26 for a pain of one, on 01/06/26 for a pain of six, and on 01/06/26 for a pain of three, on 01/08/26 for a pain of six, on 01/09/26 for a pain of zero, on 01/11/26 for a pain of three, on 01/13/26 for pain of six and on 01/13/26 for a pain of five, on 01/14/26 for a pain of three, on 01/16/26 for pain of six and on 01/16/26 for a pain of zero, on 01/17/26 for a pain of zero, on 01/18/26 for a pain of zero, on 01/20/26 for a pain of three, on 01/23/26 for pain of zero, on 01/27/26 for a pain of three, and on 01/28/26 for a pain of six. Acetaminophen was given once on 01/16/26 for a pain of six.Interview on 01/28/26 at 10:20 A.M. with Licensed Practical Nurse (LPN) #175 revealed when a resident reported pain they assessed location, type of pain, and attempted nonpharmacological interventions. She indicated all this information should be documented in the progress notes. LPN #175 reported as needed pain medication was given according to resident preference and not according to the scale of the pain. 3. Review of the medical record for Resident #66 revealed an initial admission date of 01/14/25 and readmission on [DATE], with diagnoses of secondary malignant neoplasm of prostate, benign prostatic hyperplasia, muscle wasting and atrophy, and primary generalized osteoarthritis.Review of Resident #66's quarterly Minimum Data Score (MDS) 3.0 completed on 12/05/25, revealed normal cognitive function.Review of Resident #66's physician order revealed an order dated 08/20/25 for Oxycodone Hydrochloride (HCl) 5 mg tablet, half a tablet by mouth every six hours as needed for pain.Review of Resident #66's physician order on 01/28/26 revealed an order dated 09/08/25 for Acetaminophen tablet 325 mg, two tablets by mouth every six hours as needed for pain/discomfort.Neither order contained parameters for administration of the pain medication.Review of Resident #66's Medication Administration Record (MAR) revealed Oxycodone was administered on 01/19/26 and 01/21/26 for a recorded pain level of five, and Acetaminophen was administered on 01/26/25 for a recorded pain level of five. Further review of the MAR also revealed Oxycodone was administered on 11/13/25 for a recorded pain level of zero.Interview on 01/29/26 at 10:25 A.M. with LPN #121 confirmed the Resident #66 is prescribed both Acetaminophen and Oxycodone as needed (PRN) for pain without parameters. LPN #121 revealed the nurse passing the medication would use their clinical judgement to decipher which medication should be given. LPN #121 reported if the pain was more severe Oxycodone may be administered instead of Acetaminophen. LPN #121 confirmed Resident #66 reported a pain of five on 01/19/26 and was administered Oxycodone but on 01/26/26 reported a pain level of five and was administered Acetaminophen. Additionally, LPN #121 confirmed a resident should not be administered as needed Oxycodone with a reported pain level of zero.Review of the facility policy with the subject Pain Assessment and Management, revised 04/02/24, revealed if more than one pain medication is prescribed as needed the nurse may consider several factors to determine which medication to administer, including the resident's current pain level and the resident's medical condition and current medication regimen.

Based on interview, medical record review, and review of facility policy, the facility failed to ensure non-pharmacological interventions were provided prior to the administration of as needed pain medications for Resident #5, #1 and #30, this affected three of four residents reviewed for pain management. The facility failed to ensure descriptions of pain were documented for Resident #1 and #30 which affected two of four residents reviewed for pain management. The facility census was 93.Findings include:1. Review of Resident #30's medical record revealed an admission date of 08/22/25 and diagnoses including ataxia, mild neurocognitive disorder due to known physiological condition without behavioral disturbance, anxiety disorder, and major depressive disorder. Review of Resident #30's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had moderately impaired cognition. Review of Resident #30's plan of care revised 10/15/25 revealed the resident was at risk for alteration in comfort due to diagnoses, generalized pain, and impaired mobility. Interventions included administering medications as ordered, offering backrub or warm blankets, offering nonpharmacological interventions, pain assessment according to policy, and quiet environment and rest periods as needed. Review of Resident #30's physician order dated 01/13/26 revealed an order for Acetaminophen (analgesic) 325 milligrams (mg) two tablets by mouth every six hours as needed for mild pain or discomfort. Nonpharmalogical interventions were to be offered or attempted prior to medication administration. Review of Resident #30's physician order dated 01/13/26 revealed an order for Roxicodone (an opioid) five mg one tablet by mouth every six hours as needed for moderate pain or discomfort. Nonpharmalogical interventions were to be offered or attempted prior to medication administration. Review of Resident #30's physician order dated 01/13/26 revealed an order for Methocarbamol (a muscle relaxer) 500 mg, 0.5 tablet every eight hours as needed for pain, discomfort, or muscle spasms. Nonpharmalogical interventions were to be offered or attempted prior to medication administration. Review of Resident #30's Medication Administration Record from 01/01/26 to 01/27/26 revealed Roxicodone was given on 01/02/26 for a pain of eight, on 01/08/26 for a pain of five, on 01/09/26 for a pain of six, on 01/16/26 for a pain of two, on 01/17/26 for pain of zero, and on 01/18/26 for pain of zero. Methocarbamol was administered on 01/16/26 for pain of two, on 01/17/26 for pain of zero, and on 01/18/26 for a pain of zero. Review of Resident #30's progress notes dated 01/01/26 to 01/27/26 revealed there was no description of pain or documentation of attempted nonpharmacological interventions for the administration of as needed medications on 01/02/26, 01/08/26, 01/09/26, 01/16/26, 01/17/26, or 01/18/26. Interview on 01/28/26 at 10:20 A.M. with Licensed Practical Nurse (LPN) #175 revealed when a resident reported pain they assessed location, type of pain, and attempted nonpharmacological interventions. She indicated all this information should be documented in the progress notes. 2. Review of Resident #1's medical record revealed an admission date of 01/07/25 with diagnoses including parkinsonism, generalized anxiety disorder, psychotic disorder with delusions, unspecified dementia, gout, dysphagia, rheumatoid arthritis, and alcohol abuse. Review of Resident #1's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he had intact cognition. Review of Resident #1's plan of care dated 07/08/25 revealed the resident was at risk for alteration in comfort related to diagnoses and degenerative changes of the left hip. Interventions included acknowledging presence of pain and discomfort, administering medications as ordered, encouraging and assisting to maintain proper body alignment, monitoring for increased level of pain, monitoring for side effects, offering nonpharmacological interventions, and repositioning the resident for comfort. Review of Resident #1's physician order dated 04/11/25 for Tylenol 500 mg two tablets by mouth every eight hours as needed for pain or discomfort. Nonpharmacological interventions were to be offered or attempted prior to medication administration. Review of Resident #1's physician order dated 06/16/25 revealed an order for Oxycodone (opioid) five milligrams (mg) one tablet by mouth every four hours as needed for pain. Review of Resident #1's Medication Administration Record (MAR) from 01/01/26 to 01/28/26 revealed Oxycodone was administered on 01/01/26 for a pain of seven, on 01/02/26 or a pain of seven, on 01/04/26 for a pain of one, on 01/06/26 for a pain of six, and on 01/06/26 for a pain of three, on 01/08/26 for a pain of six, on 01/09/26 for a pain of zero, on 01/11/26 for a pain of three, on 01/13/26 for pain of six and on 01/13/26 for a pain of five, on 01/14/26 for a pain of three, on 01/16/26 for pain of six and on 01/16/26 for a pain of zero, on 01/17/26 for a pain of zero, on 01/18/26 for a pain of zero, on 01/20/26 for a pain of three, on 01/23/26 for pain of zero, on 01/27/26 for a pain of three, and on 01/28/26 for a pain of six. Acetaminophen was given once on 01/16/26 for a pain of six. Review of Resident #1's progress notes from 01/01/26 to 01/28/26 revealed prior to the administration of as needed pain medications there was no documented descriptions of pain or attempted nonpharmacological interventions. Interview on 01/28/26 at 10:20 A.M. with Licensed Practical Nurse (LPN) #175 revealed when a resident reported pain they assessed location, type of pain, and attempted nonpharmacological interventions. She indicated all this information should be documented in the progress notes. 3. Review of Resident # 5's medical record revealed she was admitted on [DATE] with diagnoses that included mild protein malnutrition, bipolar disorder and restless leg syndrome. She received hospice services for a diagnosis of terminal diagnosis of protein-calorie malnutrition. Review of Resident # 5's Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 7 indicating a cognitive impairment. The assessment indicated the resident received scheduled and as needed medications, however, did not receive non-pharmacological interventions for pain. The resident required assistance from staff with eating, dressing, toileting and transfers. Review of Resident # 5's most recent care plan dated January 2026 revealed she was at risk for alteration in comfort care plan related to generalized pain, restless leg syndrome, impaired mobility and disease process/condition with interventions that included administer medications, encourage and assist resident to maintain proper body alignment, encourage and assist resident to turn and reposition every two hours as needed, offer back rubs or warm blankets, reposition for comfort, offer non-pharmacological interventions ( quiet environment, repositioning, back rubs, diversional activities) and monitor for effectiveness of interventions. Review of Resident # 5's physicians orders dated 01/27/26 revealed orders for Morphine Sulfate (Concentrate) Oral Solution (opioid pain medication) 20 milligrams/milliliter (mg/ml) administer 0.5 ml by mouth every six hours for pain, Morphine Sulfate (Concentrate) Oral Solution 20 mg/ml administer 0.5 ml by mouth every one hour as needed for pain, Acetaminophen Oral Tablet 325 mg administer three tablets by mouth three times a day for pain with the special instruction may take with Morphine, and Ropinirole HCL Oral Tablet one milligram administer one tablet by mouth at bedtime for restless leg syndrome. There was no evidence in the orders to offer non-pharmacological pain interventions. Review of Resident # 5's Medication Administration Record (MAR) dated January 2026 revealed she received Morphine Sulfate 0.5 ml every six hours daily and Morphine Sulfate 0.5 ml as needed (PRN) on 01/03/26, 01/10/26, 01/12/26, 01/18/26 and 01/22/26 with no documented non-pharmacological interventions being attempted prior to the administration of the as needed medication. Review of Resident # 5's progress notes revealed no documented evidence on 01/10/26, 01/12/26 or 01/18/26 related to non-pharmacological interventions being provided prior to the administration of the as needed pain medication, and a progress note dated 01/22/26 that stated the resident received scheduled pain medications. No PRN medications have been administered over the last 5 days. Non-medication interventions are in place, however the resident had received PRN medications in the last five days, and no provided non-pharmacological interventions were documented. Interview on 01/29/2026 at 11:33 A.M. with LPN # 168 revealed any non-pharmacological interventions provided should be documented in the progress notes when giving PRN medications. Review of January 2026 Medication Administration Record (MAR) and progress notes dated 01/18/26 and 01/22/26 with LPN # 168 revealed she administered Morphine Sulfate 0.5 ml PRN on 01/18/26 and 01/22/26 and she confirmed there were no documented non-pharmacological intervention in her note. Review of facility for titled Pain Management Program Best Practice dated July 2019 revealed under nursing actions: identify location, nature, cause and severity of pain, implement non-pharmacological interventions alone or in combinations with medication as appropriate (eg. repositioning, comfort measures, relaxation and therapy. Review of facility titled Pain Assessment and Management Policy dated 03/31/16 revealed the alert and oriented resident may be asked to describe his/her pain status. Pertinent information may include numeric rating scale of 0-10; with zero being no pain and ten being the most severe pain the resident can imagine, verbal descriptor scale; mild, moderate, severe, very severe/horrible and the resident's expectation for pain relief is needed to live comfortably. Also, non- pharmacological methods to reduce pain in resident may be implemented and provide pharmacological interventions in accordance with physician's order (s).

Based on observation, medical record review, interviews and facility policy review, the facility failed to ensure one resident (#69) received a nutritious vegetarian diet. This affected one resident (#69) of four residents reviewed for nutrition. The facility census was 93. Findings Include:Review of the medical record for resident #69 revealed an initial admission date of 02/09/17 with the diagnoses including but not limited to moderate protein calorie malnutrition, hypertension, anemia, major depression disorder, osteoarthritis, spinal stenosis, hyperlipidemia, constipation, polyneuropathy and hypothyroidism. Review of the plan of care dated 02/15/17 revealed the resident had the potential for alteration in nutrition and hydration related to at moderate risk for malnutrition, followed a vegetarian diet related to cultural patterns. Interventions included assist with set up of meal items as needed/requested, honor food preferences as able, medications as ordered, monitor consistency of diet served and resident's family provides food from home routinely along with supplement. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. Review of the mood and behavior revealed the resident displayed no behaviors including rejection of care. The resident required set-up assistance with eating. Review of the resident's monthly physician orders for January 2026 identified an order dated 01/27/26 vegetarian diet, mechanical diet soft texture. Review of the resident's meal ticket revealed the resident was to receive a vegetarian diet a magic cup, a fruit cup, six ounces of coffee with four sugar packets, eight ounces of beverage of choice and eight ounces of whole milk. Further review revealed the resident disliked cheese, eggs, pasta, grapes and butter. Review of the facility's weekly menu titled 2025-2026 Foundation Fall/Winter week three menu revealed under the vegetarian diet the resident would received one serving of vegetarian entree, however no entree was listed. On 01/27/26 at 12: 50 P.M., observation the resident's lunch revealed the meal consisted of cheesy scalloped potatoes, carrots, pears and a magic cup. The resident had no alternate protein source on her meal tray. On 01/28/26 at 11:15 A.M., interview with the Dietary Manager (DM) #166 revealed residents on a vegetarian diet would receive a protein replacement for an entree including grilled cheese, peanut butter and jelly sandwich (PBJ), yogurt, or cottage cheese. On 01/28/26 at 12:25 P.M., observation of the resident's lunch meal revealed she had a serving of carrots on her plate, a cup of yogurt, a fruit cup, a magic up and a roll. The resident voiced that she did not like what she was served. On 01/28/26 at 12:32 P.M., an interview with DM #166 revealed she was served a protein of yogurt for lunch. She said they provide grilled cheese, cottage cheese, yogurt, and PBJ for the protein entree. DM #166 was informed the resident did not like yogurt. She said she was unaware the resident did not like the yogurt. She said it was the aides responsibility to inform the kitchen the resident did not like the food sent and ask for an alternative. She was asked to walk to the resident's room. DM #166 pointed to the yogurt and said see there is her protein. The resident replied no when asked if she liked yogurt. She said dietary does not know if the resident doesn't like something unless nursing informs them. Review of the facility policy titled, Religious, Ethic and Cultural Food Preferences, dated 08/07/14 revealed the facility will identify, honor and accommodate each resident's nutritional needs, cultural practices, religious beliefs and personal food preferences as part of a resident centered approach to care.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on interview, medical record review, review of facility investigation, and review of facility self-reported incidents (SRI's) revealed the facility failed to ensure Resident #59's money was not misappropriated by facility staff. This affected one resident (#59) of three residents reviewed for misappropriation. The facility census was 94. Findings include: Review of the medical record for Resident #59 revealed an admitted [DATE] with diagnoses including Parkinson's disease, type two diabetes mellitus, bipolar disease, anxiety disorder, dementia, and major depressive disorder. Review of Resident #59's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he had intact cognition. Review of the SRI created 12/18/24 and completed 12/26/24 revealed an incident of misappropriation had been substantiated. Resident #59's wallet had been missing. Review of the narrative revealed on 12/18/24 Resident #59 notified the assistant director of nursing (ADON) he could not find his wallet. The ADON notified social services and together they searched the resident's room and wheelchair for his wallet and were unable to locate it. Resident #59 stated he was going to go out to lunch with his power of attorney (POA) and would continue to look when he returned. When he returned, he stated he and his POA had gone to the bank and learned there had been a charge on his card at an automated teller machine (ATM) and he felt his card had been stolen. Social services notified the Administrator and an investigation was started. The residents' bank card was canceled, and it was confirmed the ATM withdrawal occurred at a gas station near the facility. The police were notified, and images were obtained from the gas station placing three facility housekeepers (#107, #113, and #117) at the gas station at the time of the withdrawal, the images revealed Housekeeper #113 was at the ATM located in the gas station. All three housekeepers were suspended immediately. Housekeeper #113 had been assigned to Resident #59's room on that day, and all three had been clocked out for lunch at the time of the withdrawal. When the Administrator interviewed the staff, they all declined being at the gas station at all. When informed they were observed on security footage, they denied using Resident #59's bank card. Housekeeper #107 indicated Housekeepers #113 and #117 were responsible and she had nothing to do with it. Hilliard Police arrived on 12/18/24 at 6:14 P.M. to file a report and are investigating the incident. All three housekeepers were no longer employed at the facility. Review of Resident #59's personal bank statement revealed on 12/18/24 there was a withdrawal of $400.00 from a ATM that was not at his bank location. There was a pending reversal of the ATM withdrawal. Written on this document was a statement that said a phone call with the back confirmed the withdrawal occurred at 12:26 P.M. at a gas station near the facility. Review of the police case report printed 12/23/24 revealed an incident was reported on 12/18/24 at 6:07 P.M. and had occurred that day from 12:10 P.M. to 12:30 P.M. The offense was stolen property and theft. The three suspects were redacted but Resident #59 was identified as the victim and the Administrator as an involved party. The offer reported he was dispatched to the facility on [DATE] at 6:14 P.M. and met with Resident #59 and the Administrator. Resident #59 had reported to the administrator that his wallet was lost or stolen, and he called the bank to report his debit card missing. The bank asked if he had made a $400.00 ATM withdrawal at a gas station, and he denied it. The withdrawal was considered fraudulent and done on another bank's ATM. The administrator had gone to the gas station and was provided with security camera photos. The photos were time stamped and showed three females inside the store, one of the females was at the ATM. The Administrator called all three employees, one staff member said she used her own debit card at the ATM, one staff member admitted that the other was using Resident #59's card, and the third denied knowing anything or being at the gas station at all. The Administrator provided the staff's time sheets and confirmed one of the housekeepers had been assigned to clean Resident #59's room that day. She verified all three staff were suspended while the incident was investigated and Resident #59 wished to pursue criminal charges. There were two additional redacted sheets attached to the police report as well as the security footage screenshots. There were six total screenshots, time stamped from 12:27 P.M. to 12:30 P.M. and someone had written the housekeeper's name on them. Housekeeper #113 was observed at the ATM, Housekeepers #113 and #107 were observed together in several pictures, and Housekeeper #117 was observed checking out with Housekeeper #107 standing behind her. Review of the SRI documents related to Housekeeper #117 revealed a disciplinary action form dated 12/19/24 indicating she was suspended beginning on 12/18/24 as she had been found on camera using an ATM with a resident's missing card. An additional disciplinary action form dated 12/26/24 revealed she was terminated related to an incident on 12/18/24 where she was found on camera with an employee who was using a resident's debit card at an ATM machine and did not report the incident. Review of Housekeeper #117's time stamps revealed on 12/18/24 she had a lunch break from 12:14 P.M. to 12:54 P.M. Her statement indicated on 12/18/24 she went to work and worked a normal day. Later in the day she got a call from the Administrator about a missing wallet, and she did not know anything about it. Review of the SRI documents related to Housekeeper #107 revealed a disciplinary form dated 12/19/24 indicating she was suspended beginning 12/18/24 due to being found on camera using an ATM with a residents missing credit card. An additional disciplinary action form dated 12/26/24 revealed she was terminated related to an incident on 12/18/24 where she was found on camera with an employee who was using a resident's debit card at an ATM machine and did not report the incident. Review of Housekeeper #107's time stamps revealed on 12/18/24 she had a lunch break from 12:15 P.M. to 12:56 P.M. Review of Housekeeper #107's statement revealed she went to the gas station to get lunch, she saw Housekeeper #113 at the ATM and saw her give Housekeeper #117 money. She denied any involvement. Review of the SRI documents related to Housekeeper #113 revealed a disciplinary form dated 12/19/24 indicating she was suspended beginning 12/18/24 due to being found on camera using an ATM with a residents missing credit card. An additional disciplinary action form dated 12/26/24 revealed she was terminated related to an incident on 12/18/24 where she was found on camera using an ATM with residents missing debit card. Review of Housekeeper #113's time stamps on 12/18/24 revealed she went to lunch from 12:16 P.M. to 12:52 P.M. Her statement revealed she denied any wrongdoing and had nothing to do with a wallet or card. Interview on 01/14/25 at 9:30 A.M. with the Administrator revealed Resident #59 had been out on 12/18/24 so she had gone to the gas station to ensure he had not taken any money out and forgotten. She had spoken to the cashier who helpfully looked at the camera and reported there had not been an old man at the ATM but there had been three females, and she provided screenshots. They then called the police and the housekeepers. Housekeepers #113 and #117 had always denied involvement, at one point Housekeeper #107 reported that she had nothing to do with it and it had been Housekeeper #113. She reported they had sufficient evidence that the staff were responsible for the theft or had knowledge of the theft and had not reported it, so they were all terminated. Interview on 01/14/25 at 11:52 A.M. with Resident #59 revealed 'those three girls' had stolen his money. He reported his money had since been returned to him. Interview on 01/14/25 at 12:08 P.M. with Social Worker #150 revealed her and the ADON had just searched for his wallet at first because he has dropped things like his wallet before. She reported once it became clear it was gone and money had been taken, she helped him call the bank, cancel his card, and start the refund process. The deficient practice was corrected on 12/20/24 when the facility implemented the following corrective actions: Housekeepers #107, #113, and #117 were suspended on 12/18/24 and did not work again through their termination on 12/26/24. On 12/19/24 an audit of all residents was completed to ensure there were no further concerns related to misappropriation with no negative findings. From 12/19/24 to 12/20/24 all staff were educated on the abuse and misappropriation policy On 12/27/24 the Administrator or designee began weekly audits to ensure there were no concerns related to misappropriation. On 01/14/25, the review of resident council, grievances, and SRI's, and interview with residents and staff revealed no further misappropriation concerns from 12/20/24 to 01/14/25. This deficiency represents non-compliance investigated under OH00161059.

Based on observation, interview, and record review, the facility failed to ensure pests were not in the kitchen. This deficient practice had the potential to affect all residents. The census was 91. Findings include: Observation on 07/22/24 at 10:06 A.M. with Dietary Supervisor #104 revealed one flying insect around the clean dishware storage in the kitchen. Observation on 07/22/24 at 10:26 A.M. with Dietary Supervisor #104 revealed four flying insects located around the windowsill near the handsink in the kitchen. Interview on 07/22/24 at 10:27 A.M. with Dietary Supervisor #104 confirmed four flying insects around the windowsill and one flying insect around clean dishware storage in the kitchen. Dietary Supervisor #104 said they will call pest control. Observation on 07/23/24 at 11:09 A.M. revealed one flying insect flying around the handsink in the kitchen. Interview on 07/25/24 at 09:04 A.M. with Dietary Supervisor #104 confirmed the facility is aware of the pest issue and pest control should be on their way. Dietary Supervisor #104 also said pest control comes every month and as needed. Observation on 07/25/24 at 09:28 A.M. with [NAME] #29 revealed one flying insect by the handsink and stand mixer in the kitchen. Interview on 07/25/24 at 09:28 A.M. with [NAME] #29 confirmed the flying insect by the handsink and stand mixer in the kitchen. Observation on 07/25/24 at 09:29 A.M. with Dietary Supervisor #104 revealed one flying insect near the juice machine in the kitchen. Interview on 07/25/24 at 09:29 A.M. with Dietary Supervisor #104 confirmed one flying insect near the juice machine in the kitchen. Review of the, Infection Control - Dietary/Food Handling, policy dated March 2016 revealed a pest control plan must be in place. Review of the, Pest Control Program, policy dated 08/17/18 states The facility will maintain effective pest control that eradicates and contains common household pests and rodents . Review of the last 12 months of pest control service revealed the kitchen was not inspected or serviced in June. Further review revealed a call back order on 06/19/24 for flying ants.

Based on resident interview, family interview, staff interview, and policy review the facility failed to ensure care conferences were held quarterly. This affected four residents (#22, #68, and #79) of six residents reviewed for care conferences. The facility census was 91. Findings include: 1. Review of medical record for Resident #22 revealed admitted [DATE] with diagnoses including but not limited to paraplegia, congestive heart failure, cognitive communication deficit, and need for assistance with personal care. Review of Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact. Review of social service note dated 02/28/23 revealed care conference was held on this date with the resident. Review of social service note dated 10/04/23 revealed spoke with the resident and offered care conference. The resident declined. Social Worker let her know we would offer quarterly, and they could request one at anytime. Further review of the medical record revealed no further notes or care conferences held since 02/28/23. 2. Review of medical record for Resident #68 revealed admitted [DATE] with diagnoses including but not limited to hydronephrosis, type two diabetes, chronic obstructive pulmonary disease, hypertension, hallucinations, anxiety, and sleep disorder. Review of Interdisciplinary Team (IDT) plan of care review summary dated 10/11/23 revealed daughter could not be present for care conference and needed to reschedule or have a phone care conference. Review of social service note dated 01/08/24 revealed the resident and/or responsible party offered care conference and they denied the care conference Proceed to care plan and monitor resident for social service needs. Review of social service note dated 03/22/24 revealed care conference was held with the IDT and the Power of Attorney (POA). No further care conferences were documented and no phone care conference was documented in October of 2023. Interview on 07/22/24 at 11:30 A.M. with family member of Resident #68 revealed the facility does not call her for care conferences. Family member stated that she always has to call the facility to get information and to set up meetings. Interview on 07/24/24 at 2:56 P.M. with the Director of Nursing (DON) verified the care conference was not held on 10/11/23 and phone care conference was not documented as being held. The DON verified there have been periods where the resident has not had care conferences quarterly. The DON stated the facility has been through several social workers in the past year. 3. Review of medical record for Resident #79 revealed admitted [DATE] with diagnoses including but not limited to chronic obstructive pulmonary disease, type two diabetes, moderate protein-calorie malnutrition, dysphagia, kidney disease, hypertension, major depressive disorder, malignant neoplasm of unspecified part of right bronchus or lung, and acquired absence of lung. Review of MDS dated [DATE] revealed the resident was cognitively intact. Review of social service note dated 09/25/23 revealed resident and/or responsible party offered care conference. No response and no voicemail left due to voicemail not being set up. Social services to continue to follow. Review of social service note dated 12/29/23 revealed social worker reached out to resident times two in regard to scheduled care conference on 12/28/23. The resident did not answer. Social worker left voicemail. Review of IDT plan of care review dated 04/17/24 revealed the resident declined care conference at this time. IDT to review accordingly. Signed by social worker and therapy. Interview on 07/25/24 at 11:12 A.M. with Resident #79 verified he has never attended a care conference. The resident stated that he was bed bound when he was admitted to the facility so he could not get out to attend meetings. Interview on 07/24/24 at 1:47 P.M. with Social Services (SS #31) verified that prior to her coming to the facility the care conferences were not held quarterly for Resident #22, #68, and #79. SS #31 stated that in regards to setting up care conferences she would communicate with the resident and would call the families to schedule a date and time for care conference. SS #31 stated that the MDS triggers when the care conferences need to be held. SS #31 verified the care conferences are documented in point click care (PCC) under the social service note when held. SS #31 verified the social service summary is the MDS assessment that is completed. Review of policy titled, Care Conference, revised on 03/20/24 revealed the facility shall inform the resident and, if applicable responsible party of the right to participate in the resident's plan of care in a manner that facilitates his/her participation which may include reminders posted in conspicuous locations in the facility, notices sent via mail and/or email, recorded phone messages, reminders during Resident Council, and reminders during routine communications and/or visits. The facility's IDT shall periodically review the resident's care plan and make necessary revisions based on the goals, preferences, and needs of the resident. At routine intervals and after significant changes, the resident and, if applicable the resident's representative shall be given an opportunity to participate in the plan of care.

Based on interview and observation, the facility failed to ensure Resident #65's bed was set to the proper setting to ensure comfort. This affected one resident (#65) of 18 reviewed for speciality mattresses. The facility census was 91. Findings include: Review of the medical record for Resident #65 revealed an admitted [DATE] with diagnoses including cerebral infarction due to thrombosis of other cerebral artery, type 2 diabetes mellitus, need for assistance with personal care, anxiety, insomnia, lower back pain, hemiplegia, and major depressive disorder. Review of Resident #65's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she required maximal assistance for bed mobility. Review of Resident #65's medical record revealed an order dated 03/26/24 for a low air loss (LAL) mattress. Staff required to check placement and function every shift. Review of Resident #65's care plan dated 06/26/24 found she was at risk for alteration in comfort due to pain and hemiplegia. Interventions did not include a special air mattress. She was also at risk for alteration in skin integrity related to diabetes, hemiplegia, incontinence, mobility impairment and interventions included encourage resident to elevate heels, turn and reposition, and maintain low air loss mattress per physician order. Review of Resident #65's medical record revealed on 07/24/24 at 5:01 P.M. Resident #65 weighed 132.6 lbs. Interview and observation on 07/24/24 at 9:56 A.M. with Admin Nurse #113 in Resident #65's room confirmed the resident's bed was at an incorrect weight of 300 lbs. Admin Nurse #113 would reach out to bed company to ensure the weight was set correctly. Interview on 07/25/24 at 2:05 P.M. with Admin Nurse #55 said Resident #65 prefers her bed at a firmer setting that is why her bed is not set to the correct weight. Interview on 07/25/24 at 2:12 P.M. with Resident #65 said she does not like the pressure of the bed, it is too hard per her preference. Interview on 07/25/24 at 2:15 P.M. with Admin Nurse #113 and Resident #65 said her bed was hard and she was uncomfortable in it. Admin Nurse #113 confirmed Resident #65 correct weight was 132 pounds, Admin Nurse #113 adjusted Resident #65 bed to the correct weight. Interview on 07/25/24 at 2:29 P.M. with Maintenance Director #50 revealed Med-Aire Plus 8 Low Air Loss System (mattress) should be set to a minimum of 50 pounds higher than a residents weight. He confirmed if her weight is 132 pounds the bed should set to 200 pounds to prevent the bed from being too hard. Interview on 07/25/24 at 2:32 P.M. with Resident #65 confirmed after the bed weight was adjusted her bed was much more comfortable. Interview conducted on 07/25/24 at 5:50 P.M. with Admin Nurse #113 confirmed residents with special air mattresses are set per residents' comfort preference.

Based on interview, record review, and policy review, the facility failed to provide and offer Resident #65 activities per preference. This affected one resident (#65) of one resident reviewed for activities. The facility census was 91. Findings include: Review of the medical record for Resident #65 revealed an admitted [DATE] with diagnoses including cerebral infarction due to thrombosis of other cerebral artery, type 2 diabetes mellitus, need for assistance with personal care, anxiety, insomnia, lower back pain, hemiplegia, and major depressive disorder. Review of Resident #65's activity assessment completed 03/11/24 revealed she prefers one-on-one (1:1) and small group activities. She enjoys bingo, television, pop music, and socializing. In line with her preferences, Resident #65 participates in bingo, crafts, happy hour/live music, and special events when she is up from bed. Activity staff will continue to invite, encourage, and assist her with activities as needed. Resident #65, who was recently admitted to hospice services, occasionally attends group activities but does not stay long due to pain. Listening to music she likes is very important to her. She finds it somewhat important to engage in group activities, pursue her favorite hobbies, and go outside. Review of Resident #65's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she was moderately cognitively impaired and dependent on staff for ambulation. Review of Resident #65's care plan dated 10/04/24 revealed the resident is a sociable person who enjoys participating in a variety of activities. Important activities for Resident #65 include arts and crafts, bingo, visits, reading, religious activities, and watching TV or movies. The goal is for her to participate in group activities twice per week. Interventions include assisting Resident #65 with sitting on the porch/courtyard/patio when weather permits and giving verbal reminders of activities before, they start. Review of Resident #65's medical record revealed that she was not invited to or did not attend arts and crafts, bingo, or party/social hour during June or July. Review of Resident #65's activity documentation from 06/01/24 to 07/23/24 revealed that she was not invited to or did not attend arts and crafts, bingo, or party/social hour. Interview on 07/23/24 at 9:30 A.M. with Resident #65 revealed that she did not have any activities scheduled. She expressed a desire to color or attend bingo on that day (07/23/24). Observation on 07/23/24 at 3:10 P.M. revealed that Resident #65 was not invited or taken to bingo. Interview on 07/24/24 at 9:56 A.M. with Admin Nurse #113 and Resident #65 confirmed she likes to go to bingo and staff can assist her with attending activities. Interview on 07/24/24 at 2:00 P.M. with Resident #65 revealed that she was outside with a family friend. She said direct care staff rarely assist her in getting out of bed and taking her outside, despite her love for watching people from outside. Interview on 07/25/24 at 8:33 A.M. with Activity Director (AD) #24 confirmed Resident #65 is very sociable and used to attend group activities daily before transitioning to hospice care. Since the transition, she has faced limitations such as mobility and pain management. AD #24 acknowledged that her preferred group activities were not offered, and she did not attend them. AD #24 plans to communicate with direct care staff to ensure Resident #65 is offered and included in her preferred activities. Review of Program Planning/Scheduling policy dated 05/2007 revealed that the activity department is responsible for planning and scheduling an activity program that includes stimulating and therapeutic activities, diverse in focus, and consistent with the residents' wishes and needs.

Based on observations, staff interviews, and record review, the facility failed to identify and assess new skin impairment timely. This affected one resident (#62) of four reviewed for skin. Facility census was 91. Findings include: Review of the medical record for Resident #62 revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease, kidney disease, hypertension, pulmonary embolism, atrial flutter and delusion disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #62 was cognitively intact and had no impairment in range of motion. The MDS revealed the resident was on an anticoagulant medication. Review of physician orders dated 06/25/23 for Eliquis (anticoagulant) 2.5 Milligrams (mg) tab with instructions to give one tab twice daily for atrial fibrillation. Facility had no orders for monitoring of bruising or bleeding. Review of the plan of care dated 05/14/24 revealed the resident was at risk of bleeding and bruising from anticoagulant medication with interventions to administer medications as ordered and monitor for adverse side effects of anticoagulant therapy and monitor for and report abnormal bruising or prolonged bleeding. Review of the progress notes dated 07/21/24 night shift assessment revealed no changes to skin. Review of the progress note dated 07/22/24 at 11:11 A.M. of assessment revealed no changes to skin. Review of the progress note dated 07/22/24 at 8:35 P.M. of assessment revealed no changes to skin. Interview and observation on 07/22/24 at 10:05 A.M. with Resident #62 revealed he noticed a bruise on his hand the previous evening (07/21/24). The bruise appeared to be about the size of hockey puck and was reddish purple in the middle with darker purple edges. Resident #62 revealed he told an aide about an hour ago and wanted the nurse practitioner to look at it as he was afraid due to the blood thinner he would have to go to the hospital. The resident stated staff were already at bedside several times including bringing his breakfast tray and when the nurse brought his morning medications and they were aware of his bruise. Interview on 07/22/24 at 10:14 A.M. with Licensed Practical Nurse (LPN) #107 revealed she was not informed by any aides of the bruise on the resident's hand. LPN #107 revealed she would assess the bruise and notify the nurse practitioner to evaluate the bruise per resident request. Interview on 07/23/24 at 9:05 A.M. with Nurse Practitioner (NP) #206 confirmed the resident had a bruise and revealed the resident was anxious about going to the hospital after recent complications from eye surgery. He revealed the resident reported to him he hit his hand on the bedside table and appeared to be a bruise as a result from blood thinners. NP #206 revealed he would see the resident again today and revealed he would put in orders to monitor the bruise. NP #206 confirmed he did not document anything about the bruise in his visit note and confirmed nursing had no documentation of resident having a large bruise on his hand. Interview on 07/24/24 at 10:42 A.M. with the Director of Nursing (DON) revealed the facility did not have any documentation related to Resident #62's bruise. She revealed the expectation was for staff to document any skin impairments including bleeding or bruising and should include a description of the bruise including size location and appearance. The DON confirmed the skilled note written on 07/22/24 at 11:11 A.M. and 07/22/24 at 8:35 P.M. both stated no skin impairment. The DON also confirmed the nursing staff did not document any assessment or progress note acknowledging a large bruise on the resident's hand. Review of facility policy titled, Wound Assessment, dated 09/29/17 revealed wounds shall be assessed and monitored to determine if treatment plan was working or should be reevaluated.

Based on observation, resident interview, and staff interview, the facility failed to ensure tube feed was labeled and dated. This affected one resident (#79) of one reviewed for tube feed. The facility census was 91. Findings include: Review of medical record for Resident #79 revealed admitted [DATE] with diagnoses including but not limited to chronic obstructive pulmonary disease, type two diabetes, moderate protein-calorie malnutrition, dysphagia, kidney disease, hypertension, major depressive disorder, malignant neoplasm of unspecified part of right bronchus or lung, and acquired absence of lung. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. The resident was set up/supervision for meals. The resident rejected care one to three days during the seven day look back period. No weight loss or gain noted. Fifty one percent or more calories received from tube feeding and 501 milliliters a day or more average fluid intake per day provided by tube feeding. Review of current physician orders revealed diabetisource AC tube feed to run at 75 milliliters per hour for 22 hours via pump to provide 1650 milliliters per day to be on at 4:00 P.M. and off at 2:00 P.M. Observation on 07/22/24 at 10:27 A.M. revealed clear bag of tube feed hanging on a pole with no date or indication of what type of tube feed is in the bag. Interview on 07/22/24 at 10:34 A.M. with Nurse Manager (NM) #27 verified the tube feed bag was not labeled with tube feed solution or dated when it was hung. NM #27 stated she would discard the tube feed.

Based on observation, medical record review, staff interview and review of manufacturer's instructions, the facility failed to ensure medication error rates were not five percent or greater when staff failed to prime two insulin pens for Resident #7. There was 32 medication administration opportunities with two errors, for a medication error rate of 6.25%. This affected one (Resident #7) of three residents reviewed for medication administration. The facility census was 93. Findings include: Review of Resident #7's medical record revealed an admitted [DATE]. Diagnoses included type II diabetes mellitus, chronic congestive heart failure (CHF), hyperlipidemia, hypertension, atherosclerotic heart disease of native coronary artery, atrial fibrillation, hypothyroidism, anxiety disorder, major depressive disorder, low back pain, chronic kidney disease, and gastro-esophageal reflux disease (GERD). Review of a physician order dated 03/22/23 revealed humalog kwikpen subcutaneous solution pen-injector 100 unit/milliliter insulin lispro inject 15 units subcutaneously three times a day related to type II diabetes mellitus, with additional units ordered based on blood sugar levels. Further review of a physician order dated 07/14/23 revealed lantus solostar 100 unit/milliliter solution pen-injector inject 40 units subcutaneously two times a day related to type II diabetes mellitus. Observation on 04/29/24 at 9:54 A.M. revealed Licensed Practical Nurse (LPN) #14 used a lantus solostar pen injector to draw up 40 units of insulin for Resident #7. LPN #14 did not prime the insulin pen before use. Observation on 04/29/24 at 10:00 A.M. revealed LPN #14 used a humalog kwikpen pen injector to draw up 17 units of insulin for Resident #7. LPN #14 did not prime the insulin pen before use. The dose was scheduled 15 units of insulin and two additional units for coverage based on blood sugar levels. Interview on 04/29/24 at 10:25 A.M. with LPN #14 verified she did not prime the humalog kwikpen or lantus solostar insulin pen prior to administration to ensure Resident #7 received the appropriate dosages. LPN #14 stated she was unaware of how to prime the insulin pens. Review of the humalog kwikpen instructions, undated, revealed to prime the pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. To prime your pen, turn the dose knob to select two units. Hold your pen with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top, push the dose knob in until it stops and a zero is seen in the dose window. Hold the dose knob in and count to five slowly. You should see insulin at the tip of the needle. If you do not see insulin repeat priming steps no more than four times. Review of the lantus solostar instruction guide, undated, revealed to always perform the safety test before each injection. This ensures that you get an accurate dose by ensuring the pen and needle work properly and removing any air bubbles. To complete the safety test, select a dose of two units. Take off the outer needle cap and keep it to replaced on the used needle after injection. Take off the inner needle cap and discard it. Hold the pen with the needle pointing upwards. Tap the insulin reservoir so that any air bubbles rise up towards the needle. Press the injection button all the way in. Check if insulin comes out of the needle tip. You may have to perform the safety test several times before the insulin is seen. If no insulin comes out, the needle may be blocked. Change the needle and try again. You must perform safety tests before you use the pen until you see insulin coming out of the needle tip. If you do not see insulin coming out before taking your dose, you could get an underdose or no insulin at all. This could cause high blood sugar. This deficiency represents non-compliance investigated under Complaint Number OH00153387.

Based on observation, medical record review, staff interview, and review of insulin pen manufacturer's instructions, the facility failed to ensure residents were free from significant medication errors when staff failed to prime two insulin pens for Resident #7. This affected one (Resident #7) of three residents reviewed for medication administration. The facility census was 93. Findings include: Review of Resident #7's medical record revealed an admitted [DATE]. Diagnoses included type II diabetes mellitus, chronic congestive heart failure (CHF), hyperlipidemia, hypertension, atherosclerotic heart disease of native coronary artery, atrial fibrillation, hypothyroidism, anxiety disorder, major depressive disorder, low back pain, chronic kidney disease, and gastro-esophageal reflux disease (GERD). Review of a physician order dated 03/22/23 revealed humalog kwikpen subcutaneous solution pen-injector 100 unit/milliliter insulin lispro inject 15 units subcutaneously three times a day related to type II diabetes mellitus, with additional units ordered based on blood sugar levels. Further review of a physician order dated 07/14/23 revealed lantus solostar 100 unit/milliliter solution pen-injector inject 40 units subcutaneously two times a day related to type II diabetes mellitus. Observation on 04/29/24 at 9:54 A.M. revealed Licensed Practical Nurse (LPN) #14 used a lantus solostar pen injector to draw up 40 units of insulin for Resident #7. LPN #14 did not prime the insulin pen before use. Observation on 04/29/24 at 10:00 A.M. revealed LPN #14 used a humalog kwikpen pen injector to draw up 17 units of insulin for Resident #7. LPN #14 did not prime the insulin pen before use. The dose was scheduled 15 units of insulin and two additional units for coverage based on blood sugar levels. Interview on 04/29/24 at 10:25 A.M. with LPN #14 verified she did not prime the humalog kwikpen or lantus solostar insulin pen prior to administration to ensure Resident #7 received the appropriate dosages. LPN #14 stated she was unaware of how to prime the insulin pens. Review of the humalog kwikpen instructions, undated, revealed to prime the pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. To prime your pen, turn the dose knob to select two units. Hold your pen with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top, push the dose knob in until it stops and a zero is seen in the dose window. Hold the dose knob in and count to five slowly. You should see insulin at the tip of the needle. If you do not see insulin repeat priming steps no more than four times. Review of the lantus solostar instruction guide, undated, revealed to always perform the safety test before each injection. This ensures that you get an accurate dose by ensuring the pen and needle work properly and removing any air bubbles. To complete the safety test, select a dose of two units. Take off the outer needle cap and keep it to replaced on the used needle after injection. Take off the inner needle cap and discard it. Hold the pen with the needle pointing upwards. Tap the insulin reservoir so that any air bubbles rise up towards the needle. Press the injection button all the way in. Check if insulin comes out of the needle tip. You may have to perform the safety test several times before the insulin is seen. If no insulin comes out, the needle may be blocked. Change the needle and try again. You must perform safety tests before you use the pen until you see insulin coming out of the needle tip. If you do not see insulin coming out before taking your dose, you could get an underdose or no insulin at all. This could cause high blood sugar. This deficiency represents non-compliance investigated under Complaint Number OH00153387.

Based on medical record review, staff and resident interview, and policy review the facility failed to ensure care conferences were provided quarterly for the residents. This affected three (#6, #20, and #42) of three residents reviewed for care conferences. The facility census was 97. Findings included: 1. Medical record review for Resident #6 revealed an admitted to the facility on [DATE]. Diagnosis included multiple sclerosis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 was cognitively intact. Review of a progress note dated 05/09/23 revealed Resident #6 and the family were offered a care conference. Review the progress notes from 08/01/23 through 09/24/23 revealed there was not any evidence a care conference was offered to the resident and family. Interview with Resident #6 on 09/25/23 at 10:37 A.M. revealed she had not received a care conference since she had been a resident at the facility. Interview with the Director of Nursing (DON) on 09/25/23 at 9:43 A.M. revealed Resident #6 and family were offered a care conference on 05/09/23. The DON confirmed there was not a care conference held for Resident #6 since 05/09/23. 2. Medical record review for Resident #20 revealed an admitted [DATE]. Diagnosis included multiple sclerosis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 was severely cognitively impaired. Further review of Resident #20's medical record 09/15/22 to 09/24/23 revealed there was not any evidence of care conferences since 09/15/22. Interview with the Director of Nursing (DON) on 09/25/23 at 9:43 A.M. confirmed Residents #20 did not have evidence a care conference held this year from 01/01/23 to 09/24/23. The DON confirmed the last conference for Resident #20 was on 09/15/22. 3. Medical record review for Resident #42 revealed an admitted [DATE]. Diagnoses included multiple sclerosis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 had moderately impaired cognition. Further review of Resident #42's medical record 09/15/22 to 09/24/23 revealed there was not any evidence of care conferences since 12/30/22. Interview with the Director of Nursing (DON) on 09/25/23 at 9:43 A.M. confirmed Residents #42 did not have evidence a care conference held this year from 01/01/23 to 09/24/23. The DON confirmed the last conference for Resident #42 was on 12/30/22. Review of the facility policy titled Resident/Resident Representative Care Conference, dated 08/08/06, revealed the purpose was to provide the resident and/or resident representative the opportunity to participate in the resident's plan of care. On admission, the resident and/or resident representative will be informed of the facility's care conference protocols. They will be offered an initial care conference meeting. They will also be informed of a projected schedule for quarterly care conferences for the year, and that they may request a care conference at any time. This deficiency represents non-compliance investigated under Complaint Number OH00146155.

Based on medical record review, staff interview, observation, and policy review, the facility failed to ensure a resident, who was incontinent of bowel and bladder and dependent on staff for toileting, received the appropriate treatment and services for incontinence care. This affected one (#42) of three residents reviewed for incontinence care. The facility identified there were 22 residents who were incontinent of bowel and/or bladder. The facility census was 97. Findings include: Medical record review for Resident #42 revealed an admitted [DATE]. Diagnosis included multiple sclerosis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 had moderately impaired cognition. Resident #42 was totally dependent on staff for toileting. Review of the care plan dated 06/01/23 revealed Resident #42 was completely incontinent for bowel and bladder. Observation on 09/21/23 at 10:37 A.M. with State tested Nursing Aide (STNA) #132 revealed she provided the incontinence care for Resident #42 while STNA #138 assisted with the repositioning Resident #42. STNA #132 took a washcloth, sprayed wash on the front part of Resident #42, and proceeded to wipe down the right and left side of the legs in a downward motion but STNA #138 didn't wash the scrotum or the penis. Interview with the STNA #132 on 09/21/23 at 10:56 A.M. verified she did not wash Resident #42's penis or scrotum during incontinence care and stated it was not her practice to not wash the penis or the scrotum. She stated at times the men will get an erection but stated she should still clean the area to prevent infection. Interview with STNA #138 on 09/21/23 at 11:00 A.M. revealed she did not see anything wrong with the way the aide cleaned Resident #42. Review of the facility policy titled Incontinence Care Protocol, dated 09/01/17, revealed the facility will provide incontinence care for the resident to assist in maintaining skin integrity, preventing skin breakdown, controlling odor, and providing comfort and self-esteem for the resident. The policy further revealed after each incontinence episode to cleanse the ate area with perineal wash and pat dry. This deficiency represents non-compliance investigated under Complaint Number OH00146155.

Based on observation, record review, medication instruction sheet review, and staff interview, the facility failed to ensure residents were free from significant medication errors. This affected one (#51) of four residents reviewed for medication administration. The facility census was 93. Findings include: Record review revealed Resident #51 was admitted on [DATE], with diagnoses of: osteomyelitis left ankle and foot and type two diabetes mellitus with neuropathy. Review of physicians order dated 04/11/23 revealed an order for Insulin Glargine subcutaneous solution pen-injector 100 unit/milliliter (ML) inject 40 units subcutaneously two times a day for hyperglycemia. Review of physicians orders dated 04/19/23 revealed an order for Humalog Kwikpen 100 unit/ml solution pen-injector inject as per sliding scale, if blood sugar (BS): 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units, >401 give 12 units and notify med one, subcutaneously before meals and at bedtime for diabetes mellitus type two. Observation on 05/22/23 at 8:34 A.M., revealed Licensed Practical Nurse (LPN) #14 administering medications to Resident #51 including insulin glargine insulin injection pen and Humalog Kwikpen insulin injection pen. LPN #14 took Resident #51 blood sugar, and it was 457 milligrams/deciliter (mg/dL). LPN #14 called the physician and got a verbal order to give 14 units sliding scale Humalog insulin and recheck the blood sugar in an hour. LPN #14 dialed the insulin glargine pen to 40 and the Humalog Kwikpen to 14 per the doctor's instruction, LPN #14 failed to prime either insulin pen before giving the injection. Interview on 05/22/23 at 10:00 A.M., with LPN #14 verified she did not prime the insulin glargine pen and the Humalog Kwikpen insulin pens for Resident #51 prior to administration. LPN #14 stated she thought you only primed the insulin pens when you first open a new pen. Review of an undated Humalog Kwikpen instructions revealed to prime the pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. To prime your pen, turn the dose knob to select two units. Hold your pen with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top. Push the dose knob in until it stops and a 0 is seen in the dose window. Hold the dose knob in and count to five slowly. You should see insulin at the tip of the needle. If you do not see insulin, repeat priming steps no more than four times. Review of an insulin glargine lantus instruction guide dated 2022 revealed to perform a safety test dial a test dose of two units. Hold pen with the needle pointing up and lightly tap the insulin reservoir so the air bubbles rise to the top of the needle. This will help you get the most accurate dose. Press the injection button all the way in and check to see that insulin comes out of the needle. The dial will automatically go back to zero after you perform. the test. If no insulin comes out, repeat the test two more times. If there is still no insulin coming out, use a new needle and do the safety test again. Always perform the safety test before each injection and never use the pen if no insulin comes out after using a second needle. This deficiency is an example of noncompliance for Complaint Number OH00142706.

Based on observation, record review, medication instruction sheet review, and staff interview, the facility failed to ensure the medication error rate was less than five percent. There were 30 opportunities with two errors for a medication error rate of 6.66 percent. This affected one (#51) of four residents reviewed for medication administration. The facility census was 93. Findings include: Record review revealed Resident #51 was admitted on [DATE], with diagnoses of: osteomyelitis left ankle and foot and type two diabetes mellitus with neuropathy. Review of physicians order dated 04/11/23 revealed an order for Insulin Glargine subcutaneous solution pen-injector 100 unit/milliliter (ML) inject 40 units subcutaneously two times a day for hyperglycemia. Review of physicians orders dated 04/19/23 revealed an order for Humalog Kwikpen 100 unit/ml solution pen-injector inject as per sliding scale, if blood sugar (BS): 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units, >401 give 12 units and notify med one, subcutaneously before meals and at bedtime for diabetes mellitus type two. Observation on 05/22/23 at 8:34 A.M., revealed Licensed Practical Nurse (LPN) #14 administering medications to Resident #51 including insulin glargine insulin injection pen and Humalog Kwikpen insulin injection pen. LPN #14 took Resident #51 blood sugar, and it was 457 milligrams/deciliter (mg/dL). LPN #14 called the physician and got a verbal order to give 14 units sliding scale Humalog insulin and recheck the blood sugar in an hour. LPN #14 dialed the insulin glargine pen to 40 and the Humalog Kwikpen to 14 per the doctor's instruction, LPN #14 failed to prime either insulin pen before giving the injection. Interview on 05/22/23 at 10:00 A.M., with LPN #14 verified she did not prime the insulin glargine pen and the Humalog Kwikpen insulin pens for Resident #51 prior to administration. LPN #14 stated she thought you only primed the insulin pens when you first open a new pen. Review of an undated Humalog Kwikpen instructions revealed to prime the pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. To prime your pen, turn the dose knob to select two units. Hold your pen with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top. Push the dose knob in until it stops and a 0 is seen in the dose window. Hold the dose knob in and count to five slowly. You should see insulin at the tip of the needle. If you do not see insulin, repeat priming steps no more than four times. Review of an insulin glargine lantus instruction guide dated 2022 revealed to perform a safety test dial a test dose of two units. Hold pen with the needle pointing up and lightly tap the insulin reservoir so the air bubbles rise to the top of the needle. This will help you get the most accurate dose. Press the injection button all the way in and check to see that insulin comes out of the needle. The dial will automatically go back to zero after you perform. the test. If no insulin comes out, repeat the test two more times. If there is still no insulin coming out, use a new needle and do the safety test again. Always perform the safety test before each injection and never use the pen if no insulin comes out after using a second needle. This deficiency is an example of noncompliance for Complaint Number OH00142706.

Based on observations, review of pest control service reports, and staff interview, the facility failed to maintain an effective pest control program. This could effect 92 of 92 residents residing in the facility. Findings include: Review of a pest control service report 09/19/22 revealed it stated sanitation needs drastically improved upon in the kitchen and serverys throughout (the facility has four serverys, two on each side of the building, which are small kitchenettes from which meals are served). The report further stated there was debris, spillage, trash, and other sanitation factors creating breeding sites and attractants for pests specifically flying pests. Be sure to use actizyme as this will help breakdown oils, grease, etc that pests like to breed in and feed off of. There is a large stock pile of actizyme indicating it is not being used. The report further stated there was food and debris buildup underneath sink and in tile in the dishwashing area, drain debris and food in prep drains in kitchen areas, and grease build up and food underneath sink in kitchen. The recommendations were to clean and sanitize the areas. Review of a pest control service report for 10/05/22 revealed it stated be sure to keep floor and drains free from debris and be sure to use actizyme on a regular basis as product has excessive stock pile indicating it is not being used regularly. It further stated there was food and debris buildup underneath sink and in tile in the dishwashing area, drain debris and food in prep drains in kitchen areas, and grease build up and food underneath sink in kitchen. The recommendations were to clean and sanitize the areas. Review of a pest control service report for 11/09/22 revealed it stated there was food and debris buildup underneath sink and in tile in the dishwashing area, drain debris and food in prep drains in kitchen areas, and grease build up and food underneath sink in kitchen. The recommendations were to clean and sanitize the areas. Interview with Housekeepers #501 and #502 on 12/07/22 between 10:30 A.M. and 10:40 A.M. revealed it was the responsibility of the kitchen staff to clean the kitchen and the four serverys. Interview with Maintenance Director #503 on 12/08/22 at 9:25 A.M. revealed he had worked at the facility since the end of October 2022. He stated he was aware of the pest control reports. He stated he had talked to the Dietary Manager when he first started about cleaning up the kitchen and serverys. Observations on 12/08/22 between 9:30 A.M. and 9:55 A.M. revealed the following: 800 Hall Servery: Three metal pans in the steam table with a heavy build up of black residue and hard water build up inside the pans. Crumbs and grease residue inside the cabinet under the steam table. Dirt and debris under the sink. 600 Hall Servery: Three metal pans in the steam table with a heavy build up of black residue and hard water build up inside the pans. Crumbs inside the cabinet under the sink. Food debris in the bowl and drain of the sink. 400 Hall Servery: Three metal pans in the steam table with a heavy build up of black residue and hard water build up inside the pans. Food debris in the sink bowl. Crumbs in the drawers. Sticky drawer handle pulls. 200 Hall Servery: Three metal pans in the steam table with a heavy build up of black residue and hard water build up inside the pans. Debris and grease under the sink. Food and debris in the sink bowl. Main Kitchen: In the dry food storage area there were multiple (at least 20) single serve food packets (ketchup, mustard, jelly) on the floor with a heavy build up of brown material on the floor. Also in the dry food storage area there was an area of black debris on the floor and going up the wall that appeared to be mold. The chemical room floor had a heavy build up of brown material. The walk in refrigerator floor had a heavy build up of brown material. The white drain under the big sink in the kitchen had a build up of food debris and black material. The floor in the main kitchen under the spice rack and all around the perimeter of the kitchen was dirty with food debris and black build up. The floor under the dishwasher area had a heavy build up of dirt and debris. The floor under the clean pots and pans had a heavy build up of dirt and debris. The observations were confirmed by Dietary Manager #504 and the Administrator at the time of the observations. Interview with Dietary Manager #504 on 12/08/22 at 9:30 A.M. revealed she did not have enough staff in the kitchen to clean the kitchen and the serverys. She confirmed meals are served from each servery. She stated she did not know anything about Actizyme or who is to use it as recommended by pest control. Maintenance Director #503 was present and did not know anything about Actizyme use either. This deficiency represents non-compliance investigated under Complaint Number OH00136225.

Based on observation and interviews the facility failed to ensure adequate staffing levels to ensure the resident's had a clean and homelike dining experience. This had the potential to affect 92 of 92 residents residing in the facility. Findings included: 1. Interview on 12/08/22 at 11:40 A.M., with Dietary Aide (DA) #401 revealed the dietary department has been short staffed because the dietary department have lost a lot of staff. The facility had been utilizing Styrofoam due to being short staffed in the kitchen. DA #401 reported last Monday she was the only server for the entire building. She served one side of the building, and she was not sure who served the other side since she was the only server. The facility has four kitchenette they serve from when they are fully staffed. DA #401 stated the residents have voiced concerns the food has been cold. Interview on 12/08/22 at 12:02 P.M., with State tested Nurses' Aides (STNA's) #402, #403, and #404 verified the dietary department has been short staffed. The kitchen has been serving residents on Styrofoam when they are short staffed. The STNA's were responsible for putting the drinks and condiments on the meal trays and placing them in the carts to be distributed. They stated the residents have voiced concerns the food had been cold. Observation on 12/08/22 at 12:12 P.M., of lunch dining revealed DA #401 was the only staff member in the kitchenette. The DA was not able to take temperatures of the food due to the thermometer was broken and she could not find another one. The DA handed the meal trays to the STNA's, and the STNA's placed the drinks and condiments on the meal trays and placed them in the cart. After the cart was full of 200 halls meal trays, the STNA's then went to deliver the trays to the unit. After the STNA's delivered 200 meal trays they returned to the kitchenette and repeated the same procedure for 300 hall. The last meal tray was placed on the cart at 12:45 P.M. 07316 Interview with a resident who wished to remain anonymous on 12/07/22 at 8:45 A.M. revealed the food is cold a lot of the time. She stated the food is served on styrofoam at times. She stated the Thanksgiving meal was served on styrofoam and she would have preferred regular dishes. Interview with Resident #7 on 12/07/22 at 10:45 A.M. revealed the food is served luke warm. He confirmed the use of styrofoam to serve meals at times. Interview with Resident #16 on 12/07/22 at 11:10 A.M. revealed the food is served cold. He confirmed the use of styrofoam to serve meals at times. Interview with Cook #505 on 12/08/22 at 12:44 P.M. revealed staff serve meals on styrofoam at times because there is not enough dietary staff to wash the dishes. Interview with STNA #506 on 12/07/22 at 9:15 A.M. revealed breakfast service was to start in the serverys for the 100 and 400 halls at 8:00 A.M. She stated there are typically one dietary staff to dip up the meals in each of the two serverys on the 100-400 side of the building. However, due to staff shortages, there was only one dietary staff to dip up the meals for breakfast for all four halls on the 100-400 side of the building. She stated they didn't get started until 8:15 A.M. and was now working on preparing the trays for the 300 hall. She stated the 200 hall had not received their breakfast trays as of 9:15 A.M. Meal times provided stated breakfast would be served for 200/300 hall at 8:30 A.M. (dining rooms closed). Interview with Dietary Aide #507 on 12/07/22 at 9:30 A.M. revealed he was dipping up the breakfast meal on the 500-800 side of the building. He stated there are normally two dietary staff on each side of the building but he was the only one dipping up meals on the 500-800 side of the building this morning. He stated it took longer to get the meals out with only one person. Review of a pest control service report 09/19/22 revealed it stated sanitation needs drastically improved upon in the kitchen and serverys throughout (the facility has four serverys, two on each side of the building, which are small kitchenettes from which meals are served). The report further stated there was debris, spillage, trash, and other sanitation factors creating breeding sites and attractants for pests specifically flying pests. Be sure to use actizyme as this will help breakdown oils, grease, etc that pests like to breed in and feed off of. There is a large stock pile of actizyme indicating it is not being used. The report further stated there was food and debris buildup underneath sink and in tile in the dishwashing area, drain debris and food in prep drains in kitchen areas, and grease build up and food underneath sink in kitchen. The recommendations were to clean and sanitize the areas. Review of a pest control service report for 10/05/22 revealed it stated be sure to keep floor and drains free from debris and be sure to use actizyme on a regular basis as product has excessive stock pile indicating it is not being used regularly. It further stated there was food and debris buildup underneath sink and in tile in the dishwashing area, drain debris and food in prep drains in kitchen areas, and grease build up and food underneath sink in kitchen. The recommendations were to clean and sanitize the areas. Review of a pest control service report for 11/09/22 revealed it stated there was food and debris buildup underneath sink and in tile in the dishwashing area, drain debris and food in prep drains in kitchen areas, and grease build up and food underneath sink in kitchen. The recommendations were to clean and sanitize the areas. Interview with Housekeepers #501 and #502 on 12/07/22 between 10:30 A.M. and 10:40 A.M. revealed it was the responsibility of the kitchen staff to clean the kitchen and the four serverys. Interview with Maintenance Director #503 on 12/08/22 at 9:25 A.M. revealed he had worked at the facility since the end of October 2022. He stated he was aware of the pest control reports. He stated he had talked to the Dietary Manager when he first started about cleaning up the kitchen and serverys. Observations on 12/08/22 between 9:30 A.M. and 9:55 A.M. revealed the following: 800 Hall Servery: Three metal pans in the steam table with a heavy build up of black residue and hard water build up inside the pans. Crumbs and grease residue inside the cabinet under the steam table. Dirt and debris under the sink. 600 Hall Servery: Three metal pans in the steam table with a heavy build up of black residue and hard water build up inside the pans. Crumbs inside the cabinet under the sink. Food debris in the bowl and drain of the sink. 400 Hall Servery: Three metal pans in the steam table with a heavy build up of black residue and hard water build up inside the pans. Food debris in the sink bowl. Crumbs in the drawers. Sticky drawer handle pulls. 200 Hall Servery: Three metal pans in the steam table with a heavy build up of black residue and hard water build up inside the pans. Debris and grease under the sink. Food and debris in the sink bowl. Main Kitchen: In the dry food storage area there were multiple (at least 20) single serve food packets (ketchup, mustard, jelly) on the floor with a heavy build up of brown material on the floor. Also in the dry food storage area there was an area of black debris on the floor and going up the wall that appeared to be mold. The chemical room floor had a heavy build up of brown material. The walk in refrigerator floor had a heavy build up of brown material. The white drain under the big sink in the kitchen had a build up of food debris and black material. The floor in the main kitchen under the spice rack and all around the perimeter of the kitchen was dirty with food debris and black build up. The floor under the dishwasher area had a heavy build up of dirt and debris. The floor under the clean pots and pans had a heavy build up of dirt and debris. The observations were confirmed by Dietary Manager #504 and the Administrator at the time of the observations. Interview with Dietary Manager #504 on 12/08/22 at 9:30 A.M. revealed she did not have enough staff in the kitchen to clean the kitchen and the serverys. She confirmed meals are served from each servery. This deficiency represents non-compliance investigated under Complaint Number OH00137903.

Based on observations, review of pest control service reports, and staff interview, the facility failed to store, prepare, and serve food under sanitary conditions. This could affect 92 of 92 residents residing in the facility. Findings include: 1. Review of a pest control service report 09/19/22 revealed it stated sanitation needs drastically improved upon in the kitchen and serverys throughout (the facility has four serverys, two on each side of the building, which are small kitchenettes from which meals are served). The report further stated there was debris, spillage, trash, and other sanitation factors creating breeding sites and attractants for pests specifically flying pests. Be sure to use actizyme as this will help breakdown oils, grease, etc that pests like to breed in and feed off of. There is a large stock pile of actizyme indicating it is not being used. The report further stated there was food and debris buildup underneath sink and in tile in the dishwashing area, drain debris and food in prep drains in kitchen areas, and grease build up and food underneath sink in kitchen. The recommendations were to clean and sanitize the areas. Review of a pest control service report for 10/05/22 revealed it stated be sure to keep floor and drains free from debris and be sure to use actizyme on a regular basis as product has excessive stock pile indicating it is not being used regularly. It further stated there was food and debris buildup underneath sink and in tile in the dishwashing area, drain debris and food in prep drains in kitchen areas, and grease build up and food underneath sink in kitchen. The recommendations were to clean and sanitize the areas. Review of a pest control service report for 11/09/22 revealed it stated there was food and debris buildup underneath sink and in tile in the dishwashing area, drain debris and food in prep drains in kitchen areas, and grease build up and food underneath sink in kitchen. The recommendations were to clean and sanitize the areas. Interview with Housekeepers #501 and #502 on 12/07/22 between 10:30 A.M. and 10:40 A.M. revealed it was the responsibility of the kitchen staff to clean the kitchen and the four serverys. Interview with Maintenance Director #503 on 12/08/22 at 9:25 A.M. revealed he had worked at the facility since the end of October 2022. He stated he was aware of the pest control reports. He stated he had talked to the Dietary Manager when he first started about cleaning up the kitchen and serverys. Observations on 12/08/22 between 9:30 A.M. and 9:55 A.M. revealed the following: 800 Hall Servery: Three metal pans in the steam table with a heavy build up of black residue and hard water build up inside the pans. Crumbs and grease residue inside the cabinet under the steam table. Dirt and debris under the sink. 600 Hall Servery: Three metal pans in the steam table with a heavy build up of black residue and hard water build up inside the pans. Crumbs inside the cabinet under the sink. Food debris in the bowl and drain of the sink. 400 Hall Servery: Three metal pans in the steam table with a heavy build up of black residue and hard water build up inside the pans. Food debris in the sink bowl. Crumbs in the drawers. Sticky drawer handle pulls. 200 Hall Servery: Three metal pans in the steam table with a heavy build up of black residue and hard water build up inside the pans. Debris and grease under the sink. Food and debris in the sink bowl. Main Kitchen: In the dry food storage area there were multiple (at least 20) single serve food packets (ketchup, mustard, jelly) on the floor with a heavy build up of brown material on the floor. Also in the dry food storage area there was an area of black debris on the floor and going up the wall that appeared to be mold. The chemical room floor had a heavy build up of brown material. The walk in refrigerator floor had a heavy build up of brown material. The white drain under the big sink in the kitchen had a build up of food debris and black material. The floor in the main kitchen under the spice rack and all around the perimeter of the kitchen was dirty with food debris and black build up. The floor under the dishwasher area had a heavy build up of dirt and debris. The floor under the clean pots and pans had a heavy build up of dirt and debris. The observations were confirmed by Dietary Manager #504 and the Administrator at the time of the observations. Interview with Dietary Manager #504 on 12/08/22 at 9:30 A.M. revealed she did not have enough staff in the kitchen to clean the kitchen and the serverys. She confirmed meals are served from each servery. 32801 2. Observation on 12/08/22 from 12:12 P.M. to 12:48 P.M. of lunch meal dining service revealed the lids that covers each meal plate was wet. Interview on 12/08/22 at 12:24 P.M., with Dietary Aide (DA) #401 confirmed the lids just came out of the dishwasher and they were still wet. This deficiency represents non-compliance investigated under Complaint Number OH00136225.

Based on observation, review of the menu and spread sheet, review of resident diets, and interview, the facility failed to ensure resident's received lunch meal as per the menu. This had the potential to affect all 24 residents residing on 200 and 300 hallways. The facility census was 92. Findings included: Review of the menu and spread sheet for lunch dining dated 12/08/22 revealed the regular, mechanical, pureed diets would receive one diner roll for regular and mechanical soft diet and #16 scoop pureed dinner roll/bread. Review of 200 and 300 residents' diets dated 12/08/22 revealed all 24 residents received a meal tray. There were 17 regular diets, four mechanical diets, and three pureed. Observation on 12/08/22 from 12:12 P.M. to 12:48 P.M. of lunch meal dining revealed none of the 24 resident's received bread. State tested Nurse's Aide (STNA) # 405 asked Dietary Aide (DA) #401 for a roll for one resident because he always complains he never gets everything that was listed on the meal ticket. There was no evidence pureed bread was prepared for the lunch dining. Interview on 12/08/22 at 12:58 P.M., with DA #401 verified she forgot to give residents a diner roll per the menu. The DA reported the kitchen usually don't have rolls and this was the first time she had rolls to serve since she started. The DA also confirmed the pureed bread was not prepared to serve. This deficiency represents non-compliance investigated under Complaint Number OH00136225.

Based on medical record review, observations, interviews with staff, a family member and Nurse Practitioner (NP) #263, and review of information from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to implement pressuring relieving interventions for a resident at risk for further skin breakdown due to existing pressure ulcers and failed to complete weekly skin assessments. This resulted in Actual Harm when staff failed to implement pressure relieving interventions to prevent further skin breakdown for Resident #49 resulting in the development of an avoidable Deep Tissue Injury (DTI) to the left heel. Resident #49 also had increased measurements in the coccyx and heel pressure ulcers and experienced discomfort during a dressing change. This affected one (#49) of four residents reviewed for pressure ulcers. The facility identified 10 current residents with pressure sores. Facility census was 91. Findings include: Review of the medical record for the Resident #49 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Braden skin scale (an assessment tool to measure resident risk for developing skin impairments) dated 11/19/21 revealed Resident #49 scored a 14 and was at a moderate risk for developing pressure injuries. Review of the plan of care dated 11/30/21 revealed Resident #49 is at risk for alteration in skin integrity as evidence by pressure ulcer of the right heel with interventions to encourage and assist resident to elevate heels in bed as needed and tolerated, encourage resident to turn and reposition as needed, provide assistance with activities of daily living and positioning as tolerated. The care plan also documented alteration in skin integrity as evidenced by pressure ulcers present to left and right buttock, and according to the focus section of the care plan, since this care plan was written, the two wounds on the buttock have combined to form one on the coccyx, with interventions to assess and complete wound care, encourage resident to turn and reposition as needed, provide assistance with activities of daily living and positioning as tolerated. There is no mention on the care plan of resident having behaviors, refusals of care and non-compliance. No updates have been made to the care plan since the development of the new coccyx wound and new left heel wound. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #49 had cognitive impairment and required extensive assistance of two staff members for bed mobility and transfers and required extensive one person assist with ambulation, toileting, and hygiene. The MDS revealed Resident #49 had two unstageable pressure wounds that were facility acquired, one of which presented as a DTI. Resident #49 has a pressure reducing device for his bed, was not involved in a turning or repositioning program, has nutrition and hydration interventions and wound care including ointments and application of dressings. Resident #49 has a urinary catheter and is always incontinent of bowels. Review of Resident #49's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #49's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #49's Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #49's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Pat dry. Apply [MEDICATION(S)] to wound bed and cover with foam dressing with instructions to complete every night shift and as needed. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #49's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #49's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #49's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #49's progress notes revealed no mention of resident or family behaviors, refusals, or non-compliance with interventions for pressures reduction. Review of Physician/NP notes dated 01/24/22 revealed Resident #49 presented for wound assessment. The barriers to wound healing include resident cannot self-position, cannot always verbalize needs, and chronic disease state. The medical provider recorded the resident with Stage 3 wound on right heel with wound treatment order. The NP provided education on the importance of offloading and good nutrition to prevent re-injury with the recommendation to continue offloading boots. It is mentioned new and worsening wounds may be unavoidable due to non-compliance with positioning. To note, there is no additional documentation of resident non-compliance and behaviors in the medical record besides what the NP is reported being told. Review of the skin grid assessment dated [DATE] revealed Resident #49 had a left buttock wound with origination date of 11/29/21, described as unstageable with length and width measuring at 0.7 centimeters (cm) x 0.7 cm with serosanguineous drainage and was noted to be unchanged from the previous assessment. Review of the skin grid assessment dated [DATE] revealed Resident #49 had a right buttock wound with origination date of 10/08/21, described as unstageable with length and width measuring at 1.5 cm x 0.5 cm with serosanguineous drainage and was noted to be unchanged from the previous assessment. Review of skin grid assessment dated [DATE] revealed Resident #49 had a coccyx wound with origination date of 11/29/21 described as unstageable with length and width measuring at 3.5 x 3.5 cm with serosanguineous drainage and was noted to be unchanged from the previous assessment with note left buttock and right buttock have connected making one pressure area to coccyx. Review of skin grid assessment dated [DATE] revealed Resident #49 had a coccyx wound with origination date of 11/29/21 described as unstageable with length and width measuring at 8.0 cm x 4.5 cm with serosanguineous drainage and was noted to have declined from the previous assessment with note to continue current treatment. There was no skin grid assessment available for the week of 01/17/22. Review of the skin grid assessment dated [DATE] revealed Resident #49 had a coccyx wound with origination date of 11/29/21 described as unstageable with length and width measuring at 8.0 cm x 4.5 cm with serosanguineous drainage and was noted to have declined from the previous assessment with note to continue orders. Review of the skin grid assessment dated [DATE] revealed Resident #49 had a coccyx wound with origination date of 11/29/21 described as unstageable with length and width measuring at 3.0 cm x 4.2 cm with serosanguineous drainage and was noted to be unchanged from the previous assessment with note to continue current treatment. Review of the skin grid assessment dated [DATE] revealed Resident #49 had a right heel wound with origination date of 10/08/21 described as Stage II with length and width measuring at 0.3 cm x 0.5 cm with scant serosanguineous drainage and was noted to be improved from the previous assessment. Review of the skin grid assessment dated [DATE] revealed Resident #49 had a right heel wound with origination date of 10/08/21 described as a DTI with length and width measuring at 3.0 cm x 3.5 cm with no drainage and was noted to be improved from the previous assessment. Review of the skin grid assessment dated [DATE] revealed Resident #49 had a right heel wound with origination date of 10/08/21 described as a DTI with length, width and depth measuring at 2.5 cm x 4.0 cm x 0.1 cm with no drainage and was noted to be improved from the previous assessment. There was no skin grid assessment available for the week of 01/17/22. Review of the skin grid assessment dated [DATE] revealed Resident #49 had a right heel wound with origination date of 10/08/21 described as a DTI with length, width and depth measuring at 2.0 cm x 4 cm x 0.1 cm with no drainage and was noted to be improved from the previous assessment. Review of the skin grid assessment dated [DATE] revealed Resident #49 had a right heel wound with origination date of 10/08/21 described as a DTI with length, width, and depth measuring at 1.0 cm x 3.0 cm x 0.2 cm with no drainage and was noted to be improved from the previous assessment. Review of the skin grid assessment dated [DATE] revealed Resident #49 had a new left heel wound with origination date of 02/01/22 described as a DTI with length and width measuring at 5.0 cm x 2.5 cm with no drainage with note for 100% intact blister noted. Review of the Behavior tasks tracking revealed Resident #49 had no documented behaviors daily from 01/06/22 to 02/03/22, except on 01/25/22, when the resident was documented to have repeated movements and was comforted and redirected. Review of the Ulcer/Injury unavoidability checklist dated 07/29/21, 11/29/21 and 02/01/22 revealed a Registered Nurse (RN) and Licensed Practical Nurse (LPN) signed the form with e-signatures. The checklist marks the implemented interventions that were consistent with residents needs and goals and included turning and repositioning as needed or resident turning themselves independently or the pressure ulcer is not related to turning. Review of the facility provided timeline of the wound revealed on 01/31/22, Resident #49 and spouse revealed the resident would not wear the offloading boots due to being too bulky and new boots were given to the resident. Resident #49 continues to refuse, and spouse is known to remove the boots after staff place them on resident. There was no mention of any of these events documented in progress notes or the behavior section of the resident's electronic medical record. Observation on 01/31/22 at 12:00 P.M., revealed Resident #49 lying in bed flat on his back looking up at the ceiling. Resident #49 did not have any pillows in bed for repositioning and offloading of his coccyx or heel wounds. Interview on 01/31/22 at 3:30 P.M., with Resident #49's family member revealed concerns related to the resident's wounds. Resident 49's family member revealed he has a new wound on his left heel, that the family member informed staff about, and expressed concerns the resident is not turned and repositioned throughout the day. Observation on 01/31/22 at 4:20 P.M., revealed Resident #49 sitting in his wheelchair and wearing gray non-slip socks. Resident #49 was observed to be holding his feet up off the ground. Observations on 02/01/22 at 8:05 A.M., revealed Resident #49 was lying in bed flat on his back with no pillow or devices for offloading the heals. Resident #49 had blue pressure relieving boots sitting on a chair in his room. Observation on 02/01/22 at 8:56 A.M., revealed Resident #49 was sitting in his wheelchair, he did not have the wheelchair foot rests on his chair or the blue pressure relieving boots on his feet, but did have non-slip socks on both feet. Observation on 02/01/22 at 12:25 P.M., revealed Resident #49 remained in his wheelchair and was eating lunch. Resident #49 did not have blue pressure relieving boots on and was wearing non-slip socks. Observation on 02/01/22 at 1:55 P.M., revealed LPN #151, LPN #159, and Assistant Director of Nursing (ADON) #109 entered Resident #49's room and washed their hands. LPN #151 cleansed the resident's bedside table with a bleach wipe and allowed to dry. LPN #159 pulled the resident's blankets back and the resident was noted to have one gray non-skid sock on the right foot with red drainage to the sock. Resident #49 had no heel protectors in place. Pillows were placed under the resident's calves; however, the resident's heels were observed to be pressing into the resident's bed. Resident #49 was positioned on his back with no offloading of the coccyx or his heels. Resident #49 was placed on his right side by LPN #159. LPN #151 removed the soiled dressing dated 02/01/22. ADON #109 measured the coccyx wound at 3.0 cm by 5.0 cm by 0.2 cm with 50% slough with a pinkish-red wound bed. ADON #109 sanitized her hands, donned gloves, and cleansed the coccyx wound with normal saline (NS) and four by four gauze. ADON #109 sanitized her hands, donned gloves and applied calcium alginate and covered with a foam dressing. The nurses washed their hands and donned gloves, LPN #151 attempted to remove the non-skid sock from his right foot, however the sock was stuck to the wound to his heel. LPN #151 soaked the sock off the wound using normal saline (NS). Resident #49 was observed moaning out in pain while LPN #151 removed the sock from the wound. ADON #109 cleansed the wound with NS and four by four gauze, sanitized her hands, covered the wound with calcium alginate, padded with ABD pad and secured with [MEDICATION(S)] wrap and tape. Resident #49 was also noted to have a DTI to his left heel measuring 5.0 cm by 2.5 cm with a 100% intact blister. ADON #109 padded the left heel with an ABD pad, wrapped with [MEDICATION(S)] and secured with tape. ADON #109 verified the facility was unaware of the newly developed DTI to his left heel, the heels not being elevated and the lack of off-loading to his coccyx. Observation on 02/01/22 at 2:54 P.M., of Resident #49's room revealed a black wheelchair footrest on the couch and had light blue padded booties also sitting on the couch. Interview on 02/01/22 at 3:28 P.M. with LPN #159 revealed Resident #49 has wounds on his coccyx and right heel and a newly found left heel wound. LPN #159 revealed facility is looking at getting an air mattress and revealed Resident #49's family puts pillows under the resident's legs. LPN #159 revealed Resident #49 had large green boots, but the resident and his family did not like them due to being too big. LPN #159 confirmed Resident #49 does not have pillows, or a device used to off load pressure from his coccyx or his heels. Interview on 02/01/22 at 3:49 P.M. with Resident #49's family revealed she has never seen the resident wear the blue pressure relieving boots sitting on the chair and revealed she has never actually seen them in his room before. Observation on 02/01/22 at 3:49 P.M., revealed Resident #49 was lying in bed with pillows under his feet with wound bandages on both heels and his feet were without any covering such as socks or pressure relieving boots. Resident #49 was lying flat on his back with no devices or interventions for coccyx offloading. Observation on 02/02/22 at 8:40 A.M., revealed Resident #49 was sitting in his wheelchair with non-slip socks on and holding his feet up off the ground. Observation on 02/02/22 at 12:27 P.M., revealed Resident #49 sleeping in his wheelchair. Resident #49 was wearing non-slip socks and his blue pressure relieving boots were sitting on the chair in the resident's room. Interview on 02/02/22 at 1:20 P.M., with Director of Nursing (DON) #130 and Corporate RN #107 revealed Resident #49 had orders for the blue relieving boots to be worn only at nighttime, which was why he has not worn them during any observations. DON #130 and Corporate RN #107 confirmed during interview and observation, the blue medial boots were sitting on Resident #49's chair and were not being worn. DON #103 and Corporate RN #107 stated Resident #49 is non-complaint with interventions but could not provide further information why offloading was not being used for his wounds and could not provide examples of Resident #49's non-compliance. DON #130 and Corporate RN #107 revealed Resident #49 has pillows available for offloading and pointed to a closet (when asked where they were). DON #130 and Corporate RN #107 were unable to explain why the pillows have not been used during any observations for off-loading of his coccyx wounds or heels. Interview on 02/02/22 at 4:00 P.M., with Corporate RN #107 revealed the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 02/03/22 at 3:50 P.M., with the facility NP #263 revealed the previous facility NP recently resigned from her position and NP #263 is filling in for the interim. NP #263 revealed her expectations for a resident with confusion would be for staff to check on resident every two hours and staff should be providing offloading support for wound healing. NP #263 revealed a pressure reducing sock is a type of medical device and confirmed it is different than the pressure relieving boots that were present in Resident #49's room. NP #263 revealed the typical treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . NP #263 revealed if a resident was resistant to care, showing signs of aggression, or signs of non-compliance, she would expect this to be clearly documented in the medical record. NP #264 confirmed at times staff will tell the NP's or physician about a resident's behaviors during visits, and this may be documented in their record but was not necessarily first-hand knowledge. NP #263 revealed Resident #49 was assessed on Monday for wound care and denied seeing any aggressive behavior or compliance concerns during this visit. Review of information from the NPUAP revealed an unstageable pressure injury is a full thickness skin and tissue loss and the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar (dead dry [NAME] tissue). If slough or eschar is removed a stage three of stage four is revealed. This injury results from intense and or prolonged pressure and shear force at the bone-muscle interface. A DTI is intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION(S)] separation revealing a dark wound bed or blood-filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. The NPUAP indicated to use a structured risk assessment such as the Braden scale to identify individuals at risk for pressure injury as soon as possible (but within eight hours of admission) and based on the identified risk factors a care plan should be developed and implemented. Further review of the NPUAP revealed the facility should assess pressure points, such as the buttocks, heels, ischium, trochanter's elbow, and beneath medical devices. The NPUAP also indicated that the heels are free from the bed and use of heel offloading devices or [MEDICATION(S)] foam dressing on individuals at risk for heel ulcers.

Based on observation, staff and resident interview and record reviews, the facility failed to provide an adequate pain management program for one resident (#5) of three resident reviewed for pain. This resulted in actual harm for Resident #5 as the resident had uncontrolled, unbearable pain with movement of the right hand. The pain interfered with staff's ability to complete hand hygiene, range of motion and a splint program to the right hand. In addition, the facility failed to coordinate care with the [MEDICAL TREATMENT] center for one of one residents (#77) reviewed for [MEDICAL TREATMENT]. The census was 95. Findings Include: 1. Review of Resident #5's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. [DIAGNOSES REDACTED]. Review of Resident #5 therapy evaluation screen showed a therapy evaluation was performed for concerns related to skin integrity and a contracture of the right hand on 01/03/14. The therapy note stated the resident declined therapy services due to pain. Review of Nurse Practitioner (NP) progress note dated 01/15/14 stated Resident #5 had chronic pain of her right hand/arm. The progress note stated that any movement of the right hand/arm was unbearable and the pain was rated at a 10 of 10 on a numeric pain scale indicating severe pain. Review the medical record revealed the NP had written an order for [REDACTED]. Review of the Primary Care Physician (PCP) note dated 03/19/14 stated the resident was confused, yelling out and complained of hand pain. The note did not contain any plan to address the pain. The note stated the pain interfered with day to day activity and was aggravated with movement. Review of Resident #5's comprehensive assessment dated [DATE] showed the resident was dependent on staff for bed mobility, bathing, transfer and toileting. The assessment revealed the resident required extensive assistance of one person for eating, personal hygiene and dressing. The assessment showed the resident had limited range of motion to both upper and lower extremities. The resident was moderately cognitively impaired. Weekly Nursing Documentation dated 04/25/14, 04/18/14, 04/11/14, 04/04/14 revealed there was no change in the residents pain. The pain was documented as being constant and daily. The pain was documented to be aggravated by movement and interfered with day to day activities. Weekly Nursing documentation dated 05/02/14 stated the resident has not had a change in pain and the pain continued to be constant and daily. Review of the NP progress note dated 05/09/14 stated the nursing staff reported the resident had right hand pain that is uncontrolled. The note stated the pain was severe, numerically scaled at a 10 of 10, indication severe pain, any movement of the right hand was was unbearable and the resident cried out when her hand was touched. Weekly Nursing Documentation dated 05/16/14 revealed the resident had constant, daily pain and the pain was aggravated by contractures. Review of the specialty clinic visit note dated 05/20/14 revealed Resident #5 was seen for chief complaint of [DIAGNOSES REDACTED]. The report stated the right fist was closed and severely painful. Recommendations included implementing additional pain medication, range of motion and daily stretching of all joints and possible minor surgical procedure. Review of NP note dated 05/23/14 revealed the resident had been seen at at a specialty clinic for evaluation and there were no new orders from the visit. Weekly Nursing Documentation dated 05/23/14 revealed the resident had constant pain, daily with an intensity of 4-6 on a numeric pain scale and the pain was aggravated with movement and did interfere with day to day function. Nursing Documentation dated 05/30/14 showed the resident had constant, daily pain of a 4-6 on a numeric pain scale indicating moderate pain. The documentation stated the movement aggravated the pain and the pain did interfere with day to day function. Review of the resident's weekly nursing documentation dated 06/07/14 stated the resident had constant pain, daily that was at a moderate intensity of 4 to 6 on a numeric pain scale indicating moderate pain. Observation of Resident #5 on 06/10/14 at 2:30 P.M. revealed a strong, foul smelling odor from the residents right hand. Observation of the resident's right hand revealed the thumb was wrapped tightly around three of her fingers. The resident's thumb was disfigured with an approximate 0.8 cm. ragged edged, long nail. A tan yellow substance was caked under the thumb nail. The index finger was tightly pressed against the resident's palm, and twisted under the thumb. The fingernail on the index finger was also jagged and had a tan yellow substance under the nail. No other finger nails were visible as they were tucked under themselves against the palm. Observation of the right hand showed a dry yellow substance within the creases between the fingers and palm. The resident was observed to draw her right hand up close to her chest in a guarding position when the surveyor asked to see it. Interview with Resident #5 on 06/10/13 at 2:30 P.M. stated the right hand hurt and she did not want anyone to touch it. Interview with Licensed Practical Nurse (LPN) #13 on 06/10/14 at 2:35 P.M. confirmed Resident #5 had pain to her right hand. She confirmed the resident did not allow staff to provide any care to the hand including hygiene, range of motion or splinting because the resident stated it hurt too much. LPN #13 stated the odor was from the residents hand as staff were unable to wash it. Interview with State tested Nursing Assistant (STNA) #18 on 06/11/14 at 3:30 P.M. revealed Resident #5 always had pain to her right hand when it was touched or moved. STNA #18 stated the resident would not let staff wash her hand or apply her hand splint because it hurt too much. Interview with STNA #45 on 06/11/14 at 3:30 P.M. confirmed the resident would not let staff provide any care to the right hand because it hurt too much. Resident #5 was observed on 06/11/14 at 3:30 P.M. receiving incontinence care from two STNA's. The resident yelled out and had facial grimacing when turned to her right side. Interview with LPN #13 on 06/11/14 at 4:40 P.M. confirmed an outside consult order had been written to evaluate the residents pain on 02/05/14. She confirmed there was no documentation in the medical record regarding recommendations from the outside consultant She stated she did not know when the residents hand was last washed, the condition of the residents skin under the closed hand or when the residents fingernails had been cut. Observation on 06/12/14 at 8:05 A.M. revealed Resident #5 lying in bed on her back. The right hand was pulled up against the chest in a guarded position. The right hand continued to show a yellow tan dried substance within the creases where the fingers, thumb and palm met. The right hand continued to have a foul odor. Interview with Resident #5 at this time revealed the hand hurt when it was touched and/or moved. The resident became tearful when speaking of care related to the right hand. The resident confirmed the right hand was fixed in the closed position and the resident was not able to move the fingers. Interview with the DON on 06/12/14 at 8:15 A.M. confirmed the facility had not followed up on the clinic recommendations as they were waiting on the consulting physician to follow-up with the PCP and the residents family. The DON confirmed the resident did have pain with any movement of the right hand and staff had not been able to provide hand hygiene, range of motion or splinting due to the resident's pain. 2. Review of the medical record revealed Resident #77 was originally admitted on [DATE]. Review of the [DIAGNOSES REDACTED]. This resident received [MEDICAL TREATMENT] three times a week. The medical record only contained three communication sheets, from the [MEDICAL TREATMENT] center ( 04/29/14, 05/01/14, and 05/15/14). Resident #77 was interviewed on 06/10/14 at 2:00 P.M. and stated she received [MEDICAL TREATMENT] three times a week on Tuesdays, Thursdays, and Saturdays. This resident stated the [MEDICAL TREATMENT] center did not always send communication sheets regarding her [MEDICAL TREATMENT] session back with her to the facility. Resident #77 stated the nurse at the [MEDICAL TREATMENT] center told her she would complete communication sheets if she had time. Interview with Assessment Nurse #4 and Assessment Nurse #5 on 06/10/14 at 3:30 P.M., revealed the [MEDICAL TREATMENT] center did not consistently send communication sheets back to the facility on the days Resident #77 received [MEDICAL TREATMENT]. Interview with Unit Manager #13 on 06/12/2014 at 10:00 A.M. revealed the [MEDICAL TREATMENT] center did not consistently send communication sheets to the facility. She stated that she was told that they used to send them, but with apparent staff changes, the facility often had to call and request them to be faxed. This deficiency substantiates Complaint Number OH 282.