Every finding on record at Deupree Cottages

Based on observation, staff interview, review of facility documents, and review of the facility policy, the facility failed to store and prepare food in a sanitary manner and the facility failed to ensure the facility dishwashers maintained a proper temperature to ensure sanitization. This had the potential to affect all of the residents residing in the facility. The facility census was 22 residents.Findings include: 1.Observation on 07/15/25 at 9:20 A.M. with Household Coordinator (HHC) #103 of kitchen #1 revealed the refrigerator contained the following unlabeled and undated items: a container of mashed potatoes, an bag containing an uncooked hamburger patty, a container of chicken salad, a half of a lemon pie, a large open container of ham lunch meat, a purple onion that had been cut wrapped in plastic, a container of cheese, a large opened container of macaroni salad, a container of opened chicken salad. The freezer contained the following unlabeled and undated items: two bowls of ice cream covered in plastic, a large bag of rolls Interview on 07/15/25 at 9:23 A.M. with HHC #103 confirmed the unlabeled and undated items in the kitchen #1 refrigerator and freezer. 2.Observation on 07/15/25 at 9:25 A.M. revealed one of the dishwashers was not functioning. HHC #103 ran the other working dishwasher, and the rinse cycle reached a temperature of 169 Fahrenheit (F.) Interview on 07/15/25 at 9:27 A.M. with HHC #103 confirmed the wash temperature should reach 160 degrees F and the rinse temperature of 180 degrees F. HHC #103 confirmed the wash rinse cycle for the one working dishwasher in kitchen #1 did not reach an appropriate temperature. 3.Review of the dishwasher temperature logs for the kitchen #1 dishwasher dated May 2025, June 2025, and July 2025 revealed the dishwasher never reached a rinse temperature of 180 degrees F for any of the log entries. Interview on 07/15/25 at 9:30 A.M. with HHC #103 confirmed the kitchen #1 dishwasher temperature logs dated May 2025, June 2025, and July 2025 revealed the dishwasher never reached a rinse temperature of 180 degrees F for any of the log entries. 4. Observation on 07/15/25 at 9:39 A.M. of kitchen #2 with HHC #103 revealed the refrigerator contained the following unlabeled and undated items: an open package of strawberries, two open containers of turkey lunch meat, a large, opened container of potato salad, a large bag of a liquid substance which HHC #103 thought might be gravy. The kitchen #2 freezer contained twenty unlabeled and undated containers of individual meals. Interview on 07/15/25 at 9:41 A.M. with HHC #103 confirmed the unlabeled and undated items in the kitchen #2 refrigerator. HHC #103 confirmed the twenty containers of individual meals were homemade meals which had been brought in by Resident #21's family but had not been labeled or dated. 5. Observation on 07/15/25 at 9:42 A.M. of kitchen #2 with HHC #103 revealed one of the dishwashers was not functioning. HHC #103 ran the other working dishwasher, and the rinse cycle reached a temperature of 159 degrees F.Interview on 07/15/25 at 9:44 A.M. with HHC #103 confirmed the wash rinse cycle for the one working dishwasher in kitchen #2 did not reach an appropriate temperature.6. Review of the dishwasher temperature logs for the kitchen #2 dishwasher dated May 2025, June 2025, and July 2025 revealed the dishwasher never reached a rinse temperature of 180 degrees F for any of the log entries. Interview on 07/15/25 at 9:47 A.M. with HHC #103 confirmed the kitchen #1 dishwasher temperature logs dated May 2025, June 2025, and July 2025 revealed the dishwasher never reached a rinse temperature of 180 degrees F for any of the log entries.Review of the facility policy titled Labeling, Dating, and Proper Sanitation dated 09/06/19 revealed all food items would be labeled with a production/opening date, and potentially hazardous foods will also be labeled with a use by date. All food items would be marked with the date they were opened or prepared. Review of the facility policy titled Food Brought in by Guest undated revealed food items prepared by the guest and brought in must be clearly labeled with the content and dated with a disposal date of three days later. The prepared food must be consumed within three days, or it would be thrown away.Review of the facility policy titled Sanitation dated 11/20/02 revealed the facility minimum temperature for the wash cycle of the dishwasher was 140-160 degrees F and rinse cycle temperature should be 180 degrees F.

Based on medical record review, staff interview, and review of the facility policy, the facility failed to complete an updated Preadmission Screening and Resident Reviews (PASARRs) for residents experiencing significant changes and new diagnoses. This affected three (Residents #3, #14, #16 of four residents sampled. The facility census was 22 residents. Findings include: 1. Review of the medical record for Resident #3 revealed an admission date of 04/06/21 with diagnosis including cerebral atherosclerosis, dementia with mood disturbance, and depression. Review of the progress note for Resident #3 dated 03/18/25 revealed the resident was admitted to hospice services. Review of the medical record for Resident #3 revealed the updated PASARR to reflect the resident's change in status was not completed until 07/17/25. Interview on 07/17/25 at 11:03 A.M. with Social Worker (SW) #102 confirmed Resident #3 admitted to hospice on 03/18/25 and the required updated PASARR was not completed until 07/17/25. 2. Review of the medical record for Resident #14 revealed an admission date of 6/19/24 with diagnoses including Alzheimer's disease, anxiety disorder, and hypertension. Resident #14 required hospice services. Review of the progress note for Resident #14 dated 10/07/24 revealed the resident was admitted to hospice services. Interview on 07/17/25 at 11:05 A.M. with SW #102 confirmed Resident #14 was admitted to hospice on 10/07/24 and the facility failed to complete an updated PASARR. 3.Review of the medical record for Resident #6 revealed an admission date of 02/29/24 with diagnoses including unspecified psychosis, dementia with anxiety, and hypertension. Review of the PASARR for Resident #6 dated 02/29/24 revealed the resident was not marked for any type of mental health diagnosis. Interview on 07/16/2025 at 2:00 P.M. with SW #102 confirmed the facility failed to complete an accurate PASARR upon admission for the resident to include the resident's mental health diagnoses. Review of the facility policy titled PASARR undated revealed PASARRs were to be completed to comply with licensing regulations and to ensure appropriate placement for residents. The Admissions/Case Management department was responsible for completing an accurate PASARR for individuals with change in mental health conditions.

Based on medical record review, observation, staff interview, review of online guidelines for enhanced barrier precautions (EBP) per the Centers for Disease Control (CDC), and review of the facility policy, the facility failed to display proper signage on the door for residents in EBP and failed to provide a proper receptacle located inside the door of the room for staff to doff personal protective equipment (PPE). This affected one Resident (#6) of one resident reviewed for EBP. The facility census was 22 residents. Findings include: Review of the medical record for Resident #6 revealed an admission date of 02/29/24 with diagnoses including dementia, hypertension, and myalgia. Review of the physician's orders for Resident #6 revealed an order dated 05/06/24 for the resident to be on EBP related to an ostomy. Review of the Minimum Data Set (MDS) assessment for Resident #6 dated 05/24/25 revealed the resident was cognitively impaired and required maximum staff assistance with activities of daily living (ADLs.) Review of the Medication Administration Record (MAR) for Resident #6 dated July 2025 for revealed the order for EBP related to ostomy was signed off as completed every shift. Observation on 07/15/25 at 11:45 A.M. revealed there was no sign outside of Resident #6's door alerting staff and visitors that resident was on EBP. There was a sign posted on the outside of the bathroom door indicating the resident was on EBP. There was a small trash receptacle inside Resident #6's bathroom for staff to doff PPE. Interview on 07/15/2025 at 11:47 A.M. with Household Coordinator (HHC) #103 confirmed there was no sign on the outside of Resident #6's door to alert staff and visitors the resident was on EBP prior to their entering the room. HHC #103 confirmed the sign regarding EBP for Resident #6 was on the resident's bathroom door, and staff and visitors could not view the sign until after they had already entered the room. HHC #103 confirmed the trash receptacle for staff to doff PPE was located inside the resident's bathroom and was not adjacent to the exit of the resident's room. Review of online guidance on EBP per the CDC at https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/ppe.html revealed the facility should post clear signage on the door or wall outside of the resident's room that indicated the type or precaution ordered and the required PPE to don prior to entering the resident's room. When long term care facilities implemented EBP the facility should position a trash can inside the resident's room near the exit for discarding PPE after removal, prior to exiting the room. Review of the facility policy titled Infection Prevention and Control Program dated 09/16/22 revealed EBP was an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. Further review of the policy confirmed isolation signs are used to alert staff, family members, and visitors of isolation precaution.

Based on medical record review, and staff and resident interview, the facility failed to ensure that when a resident formulated an advanced directive, the information regarding the advanced directive was accurate in all areas where advanced directive information was included in the medical record, and failed to document each resident's Do Not Resuscitate (DNR) order on the approved form as specified in the Ohio Administrative Code. This affected two residents (#7, #22) of resident records reviewed. The census was 22, Findings include: 1. Review of Resident #7's electronic medical record (EMR) and paper medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the residents most recent quarterly assessment dated [DATE] revealed the resident had good memory and recall. Review of the residents current physician's orders [REDACTED]. Review of Resident #7's paper record revealed a DNR order dated 07/29/14 specifying the resident's order was for DNR-CC Arrest. In addition, the paper DNR form dated 07/29/14 was not on an approved form. On 01/31/20 at 11:49 [NAME]M. the Director of Nursing (DON) was made aware of the discrepancy between Resident #7's DNR orders. On 01/31/20 at 1:30 P.M., the DON affirmed that the DNR orders for Resident #7 in the EMR and paper record did not match, and she would clarify the residents wishes and ensure her advanced directives were correct in both records. The DON also verified the DNR form in use did not include the Ohio DNR logo. 2. Review of Resident #22's paper medical record revealed a DNR form dated 12/13/16 and specified the resident's order as being DNR-CC Arrest. This was consistent with the physician's orders [REDACTED].R.C) for DNR identification. On 01/31/20 at 1:30 P.M. the DON affirmed that Resident #22's paper DNR-CC order dated 12/13/16 did not included the Ohio DNR comfort care logo. O.R.C 3701-62 DNR Protocol (A) The following items are approved as DNR identification: (1) A do-not-resuscitate order documented on the state of Ohio DNR order form depicted in appendix A to this rule. This form may be reproduced as needed. The form in appendix A is the approved form and includes all approved language and the Ohio DNR comfort care logo. This deficiency substantiates Complaint Number OH 557.

Based on observation and staff interview, the facility failed to store food in accordance with professional standards by having a hand-held scooper in the bread crumbs container and expired food items in the refrigerators. This had the potential to affect all residents that resided in the facility. The facility census was 23. Findings included: During the initial observation of the Colonial kitchen on [DATE] at 8:30 A.M., revealed a container of cottage cheese inside the commercial refrigerator that was undated and expired on [DATE]. Observations of the Colonial kitchen also revealed a clear plastic hand-held scooper inside the portable bread crumb container. Observations of the Craftsman kitchen on [DATE] at 8:35 A.M. revealed two containers of cottage cheese inside the commercial refrigerator that were undated and expired on [DATE]. Interview with versatile worker (VW) #238 on [DATE] at 8:32 A.M. verified the cottage cheese container inside the commercial refrigerator was undated and expired on [DATE]. VW #238 also verified the clear plastic hand-held scooper inside the portable bread crumb container. Interview with Household Coordinator (HC) #209 on [DATE] at 8:40 A.M. verified the two cottage cheese containers inside the commercial refrigerator were undated and expired on [DATE]. Review of [DATE] policy titled Dining Services revealed handing and storage of food delivered to the households will be in accordance with the food code.

Based upon record review, observation, staff interview, review of facility policy, review of manufacturer's recommendations, and review of online medication resources, the facility failed to date multi-use containers and vials of medication in order to determine when they should be discarded, failed to discard expired medication, and failed to store medication appropriately by storing oral medications next to externally administered medications. This had the potential to affect 8 (#1, #2, #3, #5, #7, #18, #21, #123) of 23 residents residing in the facility. Findings include: 1. Review of record for Resident #2 revealed an admission date of [DATE] with a [DIAGNOSES REDACTED]. Review of the record for Resident #2 revealed a revealed an order dated 11/15/17 for dorzolamide eye drops to the right eye three times daily. Review of manufacturer's insert for dorzoloamide revealed no recommendations for when to discard opened medication. Review of for Resident #2 revealed an order dated 06/14/19 for [MEDICATION NAME] ointment to the right eye four times per day for a duration of five days. Review of record for Resident #2 revealed an order for [REDACTED]. Observation of the medication storage cabinet in Resident #2's room on 08/19/19 at 5:39 P.M. with Licensed Practical Nurse (LPN) #206 revealed an opened container of dorzolamide eye drops that had been delivered to the facility on [DATE], but was not marked with the date the bottle had been opened, and an opened tube of [MEDICATION NAME] opthalmic ointment and a bottle of [MEDICATION NAME] tablets. Interview with LPN #206 on 08/19/19 at 5:40 P.M. confirmed that the eye drops should have been dated upon opening and discarded in 28 days and that discontinued medications should be discarded. 2. Review of record for Resident #21 revealed an admission date of [DATE] with a [DIAGNOSES REDACTED]. Review of record for Resident #21 revealed an order dated 05/20/19 for Thera tears eye drops twice daily. Review of manufacturer's insert for Thera tears eye drops revealed no recommendations for when to discard opened medication. Observation of the medication storage cabinet in Resident #2's room on 08/19/19 at 5:42 P.M. with Licensed Practical Nurse (LPN) #206 revealed an opened bottle of Thera-tears eye drops that had not been dated to indicate when they had been opened. Interview with LPN #206 on 08/19/19 at 5:43 P.M. confirmed that the eye drops should have been dated upon opening and discarded in 28 days. 3. Review of record for Resident #1 revealed an admission date of [DATE] with a [DIAGNOSES REDACTED]. Review of record for Resident #1 revealed an order dated 08/02/19 for [MEDICATION NAME] ear drops to be instilled in both ears twice daily for four days. Review of record for Resident #1 revealed an order dated 02/20/18 for vitamin B12 injection to be given once monthly. Observation of the medication storage cabinet in Resident #1's room on 08/19/19 at 5:45 P.M. with Licensed Practical Nurse (LPN) #206 revealed an opened bottle of [MEDICATION NAME] ear drops and an opened vial of B12 injectable liquid that had been dispensed on 05/22/19 and not dated when opened. Interview with LPN #206 on 08/19/19 at 5:46 P.M. confirmed that bottles of ear drops and multi-dose vials of injectable medication should be dated when opened. 4. Review of record for Resident #7 revealed an admission date of [DATE] with a [DIAGNOSES REDACTED]. Review of record for Resident #7 revealed an order dated 03/19/16 for artificial tears to both eyes four times per day. Review of record Resident #7 revealed an order dated 08/19/17 for latanaprost eye drops to both eyes once daily. Review of record for Resident #7 revealed an order dated 02/27/17 for [MEDICATION NAME] DM cough syrup 10 milliliters every four hours as needed for cough. Observation of the medication storage cabinet in Resident #7's room on 08/19/19 at 5:49 P.M. with Licensed Practical Nurse (LPN) #206 revealed an opened bottle of artificial tears eye drops which had not been dated when opened, an opened bottle of latanoprost eye drops which had not been dated when opened, and an opened bottle of [MEDICATION NAME] DM cough syrup with a manufacturer's expiration date of 12/2018. Interview with LPN #206 on 08/19/19 at 5:52 P.M. confirmed that bottles of eye drops should be dated when opened and discarded in 28 days from opening and that expired medications should be discarded. 5. Review of record for Resident #3 revealed an admission date of [DATE] with a [DIAGNOSES REDACTED]. Review of record [MEDICATION NAME] #3 revealed an order dated 06/28/19 to cleanse skin tear with normal saline wound cleanser once daily until healed. Review of record for Resident #3 revealed an order dated 04/26/19 for [MEDICATION NAME] 25 milligrams by mouth once daily with a stop date of 06/13/19. Observation of the medication storage cabinet in Resident #3's room on 08/19/19 at 5:53 P.M. with Licensed Practical Nurse (LPN) #206 revealed the residents wound cleanser and oral [MEDICATION NAME] tablets were stored together. Interview with LPN #206 on 08/19/19 at 5:54 P.M. confirmed that external medications such as wound cleanser and internal medications such as [MEDICATION NAME] tablets should be stored separate from one another. 6. Review of records for the Craftsman Cottage revealed five residents with physician orders [REDACTED].#2, #13, #18, #21, #123), one resident with an order for [REDACTED].>Observation of medication storage for Craftsman Cottage on 08/19/19 at 5:55 P.M. with LPN #206 revealed an unopened bottle of Pepto Bismol with a manufacturer's expiration date of 07/2019, two bottles of [MEDICATION NAME] tablets, one opened and one not opened both with a manufacturer's expiration date of 09/18, and an opened bottle of aspirin with a manufacturer's expiration date of 07/2019. Interview with LPN #206 on 08/19/19 at 5:56 P.M. confirmed that expired medications should be discarded. Review of policy titled Medication Storage in the Facility dated (MONTH) 2019 revealed orally administered medication are kept separate from externally used medications, outdated medications are immediately removed from inventory and discarded, and that when the original seal of a manufacturer's container or vial is broken the vial will be dated. The container or vial will then be dated with an expiration date of 30 days unless the manufacturer recommends another date. Review of The International Pharmacopeia, Seventh Edition, dated (YEAR), (http://apps.who.int/phint/2017/index.html#d/b.6.2.1.3) revealed multidose ophthalmic drop preparations may be used for up to four weeks/28 days after the container is initially opened.

Based upon record review and staff interview, the facility failed to accurately assess resident status regarding the provision of hospice services. This affected one (#11) of two residents reviewed for hospice and end of life care. The census was 23. Findings include: Review of record for Resident #11 revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Review of record for Resident #11 revealed an order dated 04/20/18 for hospice services for end-stage [MEDICAL CONDITION]. Review of care plan for Resident #11 revealed a care plan dated 04/20/18 for resident to receive hospice service for end stage [MEDICAL CONDITION]. Interventions included the following: activity as tolerated, call hospice with change in condition, hospice nurse to visit one to two times per week, pain management, offer religious support/counseling. Review of Minimum Data Set (MDS) Section O, dated 05/29/19 for Resident #11 revealed resident was coded negative for the provision of hospice services. Interview on 08/21/19 at 2:45 P.M., with the Director of Nursing (DON) confirmed the MDS for Resident #11 dated 05/29/19 was coded incorrectly for the provision of hospice services and confirmed that resident had received hospice services since 04/20/18.

Based on medical record review, policy review, resident and staff interview, the facility failed to ensure an order was obtained for oxygen. This affected one resident (#20) of the three residents whom the facility identified as being on oxygen. The facility census was 23. Findings included: Review of the medical record for the Resident # 20, revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS) assessment, dated 07/29/19 revealed resident was cognitively intact. Resident # 20 had no behaviors, did not reject care, and did not wander. Resident was a one-person physical assist, required extensive or limited assistance for activities of daily living (ADLs). MDS section 0 (special treatments) was silent for Resident #20 being on oxygen Interview with Resident #20 on 08/19/19 at 11:03 A.M., indicated she was started on oxygen when she came back from the hospital on [DATE]. Resident #20 also stated she had never witnessed the staff change her oxygen tubing and nasal cannula. Review of physician orders [REDACTED]. Review of Medication Administration Record [REDACTED]. Review of progress notes dated 08/08/19 at 11:02 P.M. indicated Resident #20 was readmitted to the facility and started on oxygen 2.5 liters per minute (LPM). Interview with Licensed Practical Nurse (LPN) #206 on 08/20/19 at 5:10 P.M. indicated Resident #20 was admitted to hospital on [DATE] and returned on 08/08/19 with [DIAGNOSES REDACTED]. LPN #206 verified there were no active orders for oxygen. Interview with Director of Nursing (DON) #216 on 08/21/19 at 1:15 P.M. verified there were no orders for oxygen for Resident #20. Review of the policy titled Quality of Care, dated 04/08/11, indicated oxygen therapy will be performed by a licensed nurse.

Based on record review and staff interview, the failed to ensure a residents antipsychotic medication ([MEDICATION NAME]) was limited to 14 days and when given, no careplanned or non-pharmacological approaches were attempted prior to [MEDICATION NAME] being administered. This affected one (#6) of the five residents reviewed for unnecessary medications. The facility census was 23. Findings included: Review of the medical record for the Resident #6, revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had moderately impaired cognition. Resident #6 had no behaviors, did not want wander but rejected care. MDS section N indicated an antipsychotic was used 7 days. Resident #6 was a one-person physical assist, required extensive assistance or limited assistance for activities of daily living (ADLs). Review of plan of care dated 11/08/18 was silent for any indication Resident was on antipsychotic. Review of physician orders [REDACTED]. Physician orders [REDACTED]. Review of progress notes dated 07/19/19 at 5:10 P.M., revealed resident was having episodes of increased behavioral and was not easily redirected. Notes indicated Licensed Practical Nurse (LPN) #206 notified the physician and received verbal orders to start [MEDICATION NAME] 0.25 mg every eight hours PRN for agitation and [MEDICAL CONDITION]. Review of monthly pharmacy review dated 07/22/19 was silent for any indication the pharmacist reviewed or provided recommendations for the PRN [MEDICATION NAME] ordered on [DATE]. Review of physician notes/monthly visit dated 07/30/19 indicated there had been no changes, behaviors or pacing issues with Resident #20. Physicians notes were silent for any indication resident was on an antipsychotic. Review of (MONTH) 2019 Medication Administration Record [REDACTED]. Review of (MONTH) MAR indicated [REDACTED]. Review of progress notes for Resident #6 on 07/31/19, 08/05/19 and 08/16/19 were silent for a clearly documented indication of an PRN antipsychotic medication to be administered. Progress notes were silent for any implemented care planned or non-pharmacological approaches before a PRN antipsychotic was administered. Progress notes were also silent for Resident #20 being assessed by a licensed nurse for need of a PRN antipsychotic when medication aide #215 administered PRN [MEDICATION NAME]. Interview with Director of Nursing (DON) #216 on 08/21/19 at 1:15 P.M. verified the PRN [MEDICATION NAME] 0.25 mg for dementia was ordered on [DATE] and contained no stop date. DON #216 also verified resident received the PRN [MEDICATION NAME] on 07/31/19, 08/05/19 and 08/16/19 by medication aide #215.

Based upon record review, observation, resident and staff interview, the facility failed to assist the resident in obtaining timely routine dental care. This affected one (#1) of one residents reviewed for dental concerns. The census was 23. Findings include: Review of record revealed Resident #1 was admitted on [DATE] with a [DIAGNOSES REDACTED]. Review of Minimum Data Set (MDS) for Resident #1 dated revealed resident was cognitively impaired and was coded as negative for dental concerns. Review of record for Resident #1 revealed resident's representative had signed a consent for resident to receive dental services from the dentist who visited the facility dated 05/31/18. Review of social service progress note for Resident #1 dated 11/26/18 revealed resident's representative inquired about resident's teeth and that arrangements would be made for resident to examined by the the in-house dentist. Review of social service progress note for Resident #1 dated 02/25/19 revealed resident's representative asked about resident's broken and missing teeth and that the household coordinator confirmed the dentist would be at the facility in (MONTH) 2019, and that the resident's representative gave consent for a dental exam. Further review of the medical record revealed no evidence of the resident seeing a physician in (MONTH) 2019. Review of oral assessment dated [DATE] for Resident #1 completed by nursing revealed the section of the form that listed the date of the resident's last dental exam was blank. Review of nurse progress note for Resident #1 dated 06/12/19 revealed nurse observed tooth decay and darkening around the resident's gumline and that resident was to be put on the list the see the facility dentist. Observation of Resident #1 on 08/19/19 at 1:36 P. M., revealed resident had multiple missing teeth and several teeth that appeared to be broken and showing signs of decay. Interview with Resident #1 on 08/19/19 at 1:38 P.M., confirmed resident did not have any mouth pain but that she had not seen a dentist since her admission to the facility in (MONTH) of (YEAR) and that she was not sure why she had not been seen. Interview with the Administrator on 08/21/19 at 11:00 A. M, confirmed the resident had not been seen by a dentist since her admission to the facility.

Based upon observation, staff interview, and facility policy, the facility failed to post daily nurse staffing information. This had the potential to affect 23 of 23 residing in the facility. Findings include: Observation of the daily staffing posting for the Craftsman Cottage on 08/19/19 at 10:15 A.M. for 08/12/19 through 08/19/19 revealed the facility did not post daily staffing posting information for the following dates: 08/16/19, 08/18/19. Observation of the daily staffing posting for the Colonial Cottage on 08/19/19 at 10:20 A.M. for 08/12/19 through 08/19/19 revealed the facility did not post daily staffing posting information for the following dates: 08/13/19, 8/17/19, 8/18/19. Interview with Household Coordinator #209 on 08/19/19 at 10:25 A.M., confirmed the facility had not posted daily staffing information on the Craftsman Cottage for 08/16/19 and 08/18/19, nor on the Colonial Cottage for 08/13/19, 8/17/19, and 8/18/19. Interview with the Administrator on 08/21/19 at 9:00 A.M., confirmed the staff are to post the daily staffing information in a location visible to residents and visitors in each cottage on a daily basis. Review of facility policy titled Posting Daily Nurse Staffing Form dated 01/01/09 revealed that the facility would post the number of registered nurses, licensed practical nurses and State tested Nursing Assistants on a daily basis.

Based on medical record review and staff interview, the facility failed to include a resident's medical [DIAGNOSES REDACTED].#4) of 12 residents reviewed for comprehensive assessments. The facility census was 24. Findings include: Record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 had severe impairment of cognitive skills for daily decisions, required extensive assistance with activities of daily living, and had [DIAGNOSES REDACTED]. The assessment did not include a [DIAGNOSES REDACTED]. Review of the psychiatry consult notes dated 01/30/18, 02/09/18, 03/19/18, 04/17/18, 04/17/18, and 06/17/18 revealed the resident had a [DIAGNOSES REDACTED]. Interview on 07/10/18 at 4:51 P.M., with Registered Nurse (RN) #60 verified Resident #4 did have the [DIAGNOSES REDACTED].

Based on medical record review and staff interview, the facility failed to complete a Level One, Preadmission Screen and Resident Review (PASARR) for a resident prior to admission to the nursing home. This affected one (#4) of two residents reviewed for PASARR. The facility census was 24. Findings include: Record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the medical record revealed a Level One PASARR was completed for Resident #4 on 07/09/18. The medical record contained no evidence a Level One PASARR was completed prior to the resident's admission to the nursing home. Interview on 07/10/18 at 11:04 A.M., with the Administrator verified a Level One PASARR was not completed prior to the resident's admission to the facility.

Based review of self reported incident (SRI), staff interview, and facility policy review, the facility failed to timely report a suspected incident of staff to resident verbal/emotional abuse immediately to facility administration and within twenty-four hours of the alleged occurrence to the state reporting agency. This affected one (#31) resident of one SRI reviewed regarding abuse. The facility census was 24. Findings include: Review of SRI # 0 revealed on 05/31/16 at 9:00 PM Versatile Worker (VW) #2 overheard Resident #31 say to VW #4 that she was mean to her and she was going to report her. VW #2 reported to the Administrator she was concerned with VW #4's response to Resident #31. The Administrator concluded the suspected staff member addressed resident inappropriately with her tone, approach, choice of words and conversation, however abuse was not substantiated. The date of report to the state agency was 06/03/16, three days after the incident. Interview with the Administrator on 05/17/17 at 12:05 PM confirmed the incident between Resident #31 and VW #4 occurred on 05/31/16. The Administrator stated on 05/31/16 VW #2 overheard Resident #31 tell VW #4 that she was not nice to her and she was going to report her. VW #4 was heard to tell Resident #31 you can report to whomever you want, you have dementia, no one will believe you. The Administrator confirmed VW #4 continued to work the rest of her shift on 05/31/16. The Administrator confirmed that the incident was not reported by VW #2 to administration until 06/02/16 and a SRI was not completed until 06/03/16. A review of the facility's policy titled Protecting Resident's from Abuse , Neglect and Misappropriation, dated 5/17/16, revealed all actual or potential incidents of abuse and/or neglect will be reported promptly to to their team leader or community mentor. In addition the facility must ensure that all alleged violations involving abuse, neglect, exploitation, or misappropriation, including injures of unknown source and misappropriation or resident property are reported immediately but not later than than two hours after the allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury or no later than 24 hours if the events that cause the allegation do not involve abuse or do not result in serious bodily injury, to the administrator of the facility and to the other official ( including the state survey agency and adult protective services where state law provides for jurisdiction in long term care facilities) in accordance with state law.

Based on review of self reported incident (SRI), staff interview, and review of facility policy, the facility failed to implement their abuse policy when an incident of staff to resident verbal/emotional abuse was alleged. This affected one (#31) resident of one SRI reviewed for abuse. The facility census was 24. Findings include: Review of SRI # 0 revealed on 05/31/16 at 9:00 PM Versatile Worker (VW) #2 overheard Resident #31 say to VW #4 that she was mean to her and she was going to report her. VW #2 reported to the Administrator she was concerned with VW #4's response to Resident #31. The Administrator concluded the suspected staff member addressed resident inappropriately with her tone, approach, choice of words and conversation, however abuse was not substantiated. The date of report to the state agency was 06/03/16, three days after the incident. Interview with the Administrator on 05/17/17 at 12:05 PM confirmed the incident between Resident #31 and VW #4 occurred on 05/31/16. The Administrator stated on 05/31/16 VW #2 overheard Resident #31 tell VW #4 that she was not nice to her and she was going to report her. VW #4 was heard to tell Resident #31 you can report to whomever you want, you have dementia, no one will believe you. The Administrator confirmed VW #4 continued to work the rest of her shift on 05/31/16. The Administrator confirmed that the incident was not reported by VW #2 to administration until 06/02/16 and a SRI was not completed until 06/03/16. A review of the facility's policy titled Protecting Resident's from Abuse , Neglect and Misappropriation, dated 5/17/16, revealed all actual or potential incidents of abuse and/or neglect will be reported promptly to to their team leader or community mentor. In addition the facility must ensure that all alleged violations involving abuse, neglect, exploitation, or misappropriation, including injures of unknown source and misappropriation or resident property are reported immediately but not later than than two hours after the allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury or no later than 24 hours if the events that cause the allegation do not involve abuse or do not result in serious bodily injury, to the administrator of the facility and to the other official ( including the state survey agency and adult protective services where state law provides for jurisdiction in long term care facilities) in accordance with state law.

Based on observation and interview, the facility failed to ensure one of two kitchens (the Colonial unit kitchen), used by the facility stored and prepared food in a sanitary manner. This had the potential to affect all 12 residents who resided on the Colonial unit out of a census of 24 residents. Findings include: During tour of the Colonial and Craftsman unit's kitchens on 02/16/16 at 9:50 A.M. with the Household Coordinator #22, the following was observed: - The Colonial Unit kitchen reach in refrigerator had a half gallon of expired milk dated 02/14/16. There was a container of cheese sauce with a use by date of 02/10/16 and a container of cheddar cheese sauce with a use by date of 02/13/16. The freezer had a plastic container of a chocolate shake with a use by date of 02/08/16. - There were four cookie jars on the kitchen counter each filled with different cookies (molasses, chocolate chip, peanut butter and oatmeal raisin all with a use by date of 02/11/16. - The stove in the kitchen had a build up of grease and food drippings around the burners. The oven which was not in use, was also heavily soiled with brown colored food drippings, grease, and soot. The back splash behind the stove was soiled with brown and red colored dried food drippings. - The shelf the microwave was located on, was soiled with dried crumbs and other food debris. - The utensil drawer to the left of the refrigerator that contained scoops and other utensils, was soiled with food debris and crumbs. - The mixer on the counter was not covered to prevent contamination. - The towel drawer under the warmer was soiled with thick, dried red and brown colored food drippings. - In the dried food storage cupboards there were opened boxes of Cream of Wheat, Special K, Chex, and Shredded Wheat cereals that were not closed to prevent contamination and spoilage. - In the kitchen storage room off of the kitchen, the two compartment sink prep area had an uncovered basket full of white and sweet potatoes. The potatoes were not protected from water droplets from the soiled sink. The sink was heavily soiled with dried food drippings and chunks of food. - The stove in the kitchen storage room was soiled with soot, grease, food drippings around the stove burners and in the oven. The back splash was soiled with brown food drippings. - The reach-in refrigerator had a bowl of egg salad that was not labeled or dated. The bowl of egg salad was covered with a torn piece of foil exposing the food to possible contamination. A box of cinnamon rolls was stored on top of the egg salad, the box was in direct contact with the food that was exposed from the bowl. - There also was a bowl of mashed potatoes that was unlabeled/undated and covered with a piece of ripped foil exposing the food. Household coordinator #22 who was present during this tour was interviewed and confirmed the above findings.

Based on observation of medication storage, review of the facility's medication storage policy, review of drug manufacture's standards for medication storage, and interview with facility staff, the facility failed to store Lorazepam (Ativan) Intensol at the proper temperature. This affected two residents (#17, #22) of two residents who had Lorazepam Intensol ordered. The facility census was 21. Findings include: Resident #17 was admitted to the facility 11/11/2010 with delirium, disorganized thinking, and moderately impaired cognition. Resident #17's [DIAGNOSES REDACTED]. Review of the Minimum Data Set, dated dated [DATE], revealed limited to total dependence for all Activities of Daily Living. Resident #17 also received hospice care. Review of the Physician's Orders for Resident #17 revealed the order, "Lorazepam Concentrate (intensol): administer 0.5 mgs sublingual as needed every hour, for anxiety/restlessness", ordered on [DATE]. Review of the Controlled Drug Record for Resident #17's Lorazepam Concentrate revealed the administration of 36 doses of Lorazepam from 09/03/14 through 11/07/14. Resident #22 was admitted to the facility 05/31/13 with disorganized thinking, and inattention. Resident #22's [DIAGNOSES REDACTED]. Review of the Minimum Data Set, dated dated [DATE] revealed Resident #22 was rarely understood, was severely cognitively impaired, and extensively to totally dependent for all Activities of Daily Living. Review of the Physician's Orders for Resident #22 revealed the order, "Lorazepam Solution (intensol): administer 0.5 mg sublingually two times daily, and every four hours, as needed for anxiety/shortness of breath", ordered 05/20/14. Review of the Controlled Drug Record revealed Resident #22 received four doses of Lorazepam from 11/11/14 through 11/12/14. On 11/13/14, observation of medication storage with staff charge nurse Registered Nurse #99 revealed one open bottle of Lorazepam intensol concentrated liquid each for Resident #17 and one for Resident #22. The Lorazepam bottle for Resident #17 was labeled "Keep Refrigerated" and "opened 09/04/14". The Lorazepam bottle for Resident #22 was labeled "Keep Refrigerated" and "opened 11/11/14". Both bottles of Lorazepam were stored at room temperature. Both bottles of Lorazepam were manufactured by Roxane Laboratories. Review of the facility policy and procedures for Drug Storage, undated, revealed "Medications will be stored at the facility in a manner consistent with manufacturers' guidelines, such as proper temperature", and "Refrigeration: 36 to 46 degrees Fahrenheit". Review of the storage guidelines by Roxane Laboratories for Lorazepam Intensol, dated October 2012, revealed, "Store at Cold Temperature - Refrigerate 36 - 46 degrees Fahrenheit". On 11/13/14 at 11:55 A.M., during interview, Registered Nurse #99 corroborated the Lorazepam intensol for Resident #17 and Resident #22 were not properly stored under refrigeration. Registered Nurse #99 further revealed the facility practice was to store all Lorazepam intensol at room temperature. On 11/13/14 at 1:30 P.M., interviews with the Administrator and the Director of Nursing affirmed the facility staff had stored Lorazepam intensol improperly at room temperature, and planned to initiate an in-service regarding the proper storage of medications that require refrigeration.

Based on observation, staff interview, and facility policy review the facility failed to label and/or discard expired multi-dose injectable vials. This had the potential to affect seven of 12 residents due for annual (2012) Mantoux screenings who reside in the Colonial Cottage. The census was 24. Findings include: On [DATE] at 9:30 A.M. observation of the Colonial Cottage medication storage refrigerator revealed three opened multi-dose injectable vials. They included a open and expired Tuberculin Purified Protein Derivative (Mantoux) (PPD) dated [DATE], a open PPD vial with no date, and a open and expired Influenza Virus Vaccine dated [DATE]. Registered Nurse (RN) #11 verified two vials were expired and one additional vial was not labeled. On [DATE] at 9:45 A.M. the facility Director of Nursing (DON) stated multi-dose injectable vials expire 28 days after opening per the facility policy. The DON verified the two open and labeled vials were expired and the one open vial was unlabeled, therefore expiration was unknown. On [DATE] at 10:00 A.M. facility policy "Drug Storage" was reviewed and documents "insulin and other multi-dose injectable vials must be discarded after 28 days or according to manufacturer's recommendations." Review of manufacturer's instructions for PPD documents discarding opened vials after 30 days. Review of manufacturer's recommendation for Influenza documents opened vials should be discarded after 28 days.

Based on observation, record review and staff interview, the facility did not ensure professional standards of quality of care were met for one resident when a Certified Medication Aide left a medication at the bedside, for one resident with a Gastrostomy (G)-tube and status [REDACTED]. This affected three (#3, #5 and #18) of 10 sampled residents. Findings include: 1. Accordingly to the Fundamentals of Nursing The Art and Science of Nursing Care 4th Addition by Lippincott, noted the resident's chart is a legal record. Only with a physician's orders [REDACTED]. Record review of the physician's progress notes for Resident #3 noted [DIAGNOSES REDACTED]. Observation during medication administration on 03/11/11 at 4:20 P.M., Certified Medication Aide (CMA) #4 prepared Calcium with Vitamin D 600 milligrams (mgs) /400 units. She proceeded to take the medication into the resident, set it on the table and left the room without the resident ingesting the medication. Interview with CMA # 4 on 03/11/11 at 4:30 P.M. revealed she usually leaves the residents medications at the bedside because she knows the resident would take them. Interview with the Director of Nursing (DON) on 03/11/11 at 5:39 P.M. revealed no residents who resident in the facility can self-administer their medications. If the residents self administers medications, it would require an assessment and a physician's orders [REDACTED]. 2. Accordingly to the Fundamentals of Nursing The Art and Science of Nursing Care 4th Addition by Lippincott, noted to check the gastrostomy tube placement by injecting 10 to 30 cc of air into the tube while listening with a stethoscope placed over the epigastrium of a "whooshing sound" Review of the facility's policy Enteral Tube Medication Administration Procedures dated 12/08 indicated to verify tube placement by inserting a small amount of air into the tube with the syringe. Listen to the stomach with the stethoscope for gurgling sounds. Aspirate stomach contents Record review of the accumulative [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Observation of medication administration on 03/12/11 at 11:20 A.M. revealed Register Nurse (RN) #26 prepared the resident's medication. She checked the placement of the [DEVICE] by inserting a syringe with 30 cc of water into the [DEVICE] by listening with a stethoscope. The syringe was placed in the tube. RN #26 poured all the medications in the tube and forcibly pushed the medications through the tube. Interview with RN #26 on 03/12/11 immediately after medication administration revealed she always pushes the medications instead of to gravity drainage. She confirmed the resident had returned two days earlier status [REDACTED]." Interview with the Director of Nursing at this time stated not to push medications through the tube. 3. According to the Ohio Standards of Safe Nursing Practice for Registered Nurses and Licensed Practical Nurses, "A licensed nurse shall, in a complete, accurate, and timely manner, report and document nursing assessments or observations, the care provided by the nurse for the client, and the clients ' response to that care." Record of physician's order [REDACTED]. The Minimum Data Set assessment, dated 03/05/11, revealed the resident required limited assistance with all functional tasks that included bed mobility and transfers. Review of nurse ' s notes dated 02/22/11, revealed the resident was admitted to the facility on [DATE] at 7:30 P.M.. Nurses notes dated 02/23/11 at 6:25 A.M. revealed a pressure area was found to the coccyx upon the skin assessment and [MEDICATION NAME] was in place. The record revealed no measurements of the pressure sore. Review of physician progress notes [REDACTED]. The progress notes indicated the resident had a sore back and a new sacral decubitus. Nurses notes dated 02/24/11 noted the pressure sore to the buttocks area was opened, cleaned and covered with [MEDICATION NAME]. Nurses notes dated 03/01/11 at 1:24 P.M. noted the pressure sore was closed on the sacrum and the dressing was changed per physician's orders [REDACTED]. Nurse ' s notes dated 03/04/11 at 9:49 A.M. noted Allevyn dressing was applied yesterday due to the previous dressing had come off. On 03/07/11 at 5:30 P.M., 911 was called due to a critical lab value and she was to have a blood transfusion. The resident's stool was positive for blood. On 03/09/11 the resident was readmitted to the facility. The facility identified the resident as having a stage I pressure ulcer to the to the coccyx when she returned from the hospital. Record review was silent to physician notification of the stage I pressure sore or orders for treatment, however the Treatment Administration Record (TAR) dated 03/09/11 ad change [MEDICATION NAME] to coccyx every three days and as needed. The TAR was signed off that the treatment was administered. Observation on 03/12/11 at 10:28 A.M., the nurse stated the resident was up in the chair and would administer the treatment later. The resident was up in the recliner chair without pressure relief at 1:15 P.M., 1:36 P.M., 2:00 P.M., 2:35 P.M., 3:10 P.M. and 3:40 P.M. A 4:45 P.M., the resident was in bed on her back. License Practical Nurse (LPN) #6 positioned the resident on her left side. No dressing was on at this time. A stage I pressure sore bright red in color measuring four centimeters (cm) in length by two centimeters in width. LPN #6 confirmed no pressure relief was in the recliner. LPN #6 cleansed the area with normal saline and place a thick [MEDICATION NAME] on the coccyx. Interview with LPN #6 on 03/12/11 at 5:05 P.M. revealed the resident had a pressure sore that healed before she left for the hospital. When she came back she had a stage I pressure sore. The record was reviewed with her at this time and she confirmed the physician had not been notified and orders not obtained for the new stage I pressure. 4. Record review of physician's order [REDACTED]. The Minimum Data Set assessment dated [DATE] revealed the resident required limited assistance with all functional tasks. Review of physician's order [REDACTED]. Observation of medication administration on 03/12/11 at 11:20 A.M. revealed Register Nurse (RN) #26 prepared the resident's medication to be given to the gastrostomy tube. All medications were available except for the [MEDICATION NAME]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'t administered. Interview with LPN #26 immediately after the medications were administered revealed she noticed by the MAR indicated [REDACTED]. She confirmed the record was silent to follow-up with the pharmacy or physician when the medication was not available. Interview with the Director of Nursing on 03/12/11 at 11:30 P.M. revealed the record was reviewed and confirmed the medication was not given and no attempts by nursing to contact the physician or pharmacist. 5. Review of the accumulative [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE] noted the cognitively impaired dependent resident required extensive assistance with all functional tasks that includes bed mobility. Record review revealed the record was silent to a pressure sore prior to hospitalization on [DATE]. The resident was re-admitted to the facility on [DATE] and review of the transfer form from the hospital was silent to the pressure sore or treatment. Review of the skin condition report without images form dated 03/10/11 noted a new stage II pressure sore was noted on the right lower buttock measuring 4.2 cm by 2.5 cm by 0.1 cm. The record was silent to standing orders for pressure sores. Standing orders were for skin tears only. The record was silent for physician notification or treatment to the pressure sore. Observation on 03/11/11 at 2:15 P.M., the resident was transferred from the wheelchair to the recliner located in the resident's room. The recliner did not have pressure relief in his chair. The resident remained in his chair without pressure relief at 2:53 P.M., 3:15 P.M., 4:55 P.M., 6:00 P.M., 6:10 P.M. and 6:25 P.M. Observation on 03/12/11 at 6:45 A.M., 7:15 A.M., 7:33 A.M., 8:55 A.M., and 10:00 A.M. revealed the resident was in bed flat on his back. At 10:00 A.M. State tested Nurse Aide (STNA) #28 entered the room to provide personal hygiene care and noticed the resident's dressing was partially off and informed the nurse. Observation on 03/12/11 at 10:31 A.M. Register Nurse (RN) of #26 entered the room to administer a treatment to the pressure sore. The resident was positioned on the left side and the [MEDICATION NAME] dressing was not securely fastened. RN #26 removed the dressing and cleansed the wound with normal saline. The stage II pressure sore located on the right inner buttock measured six centimeters (cm) (L) by 0.5 (W) cm. The wound bed was pink with no drainage or necrosis. RN #26 applied an antibiotic cream, [MEDICATION NAME], directly onto the wound bed and covered with a thick [MEDICATION NAME] covering. Interview with RN #26 on 03/12/11 at 10:44 A.M. confirmed the record was silent to physician's orders [REDACTED]. Review of standing orders with her noted for skin tears only. RN #26 stated, "I don't know, that is protocol I followed." Interview with the DON on 03/12/11 at 10:55 A.M. confirmed the record was silent to physician notification of the pressure sore and silent to a treatment. She stated the standing orders was for skin tears and not to be used on pressure sores.

Based on review of the Quality Assurance, review of medical director reports, and staff interview, the facility did not ensure the Register Nurse designated to serve in the Director of Nursing (DON) position equals 40 hours in the facility. This had the potential to affect all residents with identified nursing system problems. Findings include: Cross Reference to F 176 Self Administration of Drugs Deemed Safe. Cross Reference to F 314 Pressure Sores Cross Reference to F 315 Catheters, Urinary Tract Infections Cross Reference to F 332 Medications greater that 5 %. Cross Reference to F 333 Significant Medication Error Cross Reference to F 441 Infection Control Interview with the Director of Nursing on 03/12/10 at approximately 10:00 A.M. revealed the cottages are located on a campus with separate buildings for assisted living and independent living residents. She is responsible and active for all buildings/residents. She stated she does a walk through the cottages every day that she is working. Interview with the Administrator and the Director of Nursing (DON) on 03/13/11 at 1:45 P.M. revealed they were informed of the concern of the breakdown of systems in nursing including monitoring of the Certified Medication Aides (CMA) and nurses in the following areas; the nurses and the CMA's were leaving medications at the bed side and/or in un-locked areas accessible to residents, no follow-up with pharmacy or notifying the physician when medications were not available, not administering medications when the medication was available, physician's order [REDACTED]. [REDACTED]. The above areas affected three of three Register Nurses employed by the facility and two of two Certified Medication Aides employed in one or more of the areas listed with a census of 22. The DON was asked at this time for clarification of her time spent in the cottages and specifically how much time is a "walk through." She stated she is in the cottages four maybe 5 hours a day.