Every finding on record at Enniscourt Nursing Care

Based on closed medical record review, interview, review of the emergency medical services (EMS) run report, and facility policy review, the facility failed to provide timely, necessary and adequate care and services following an acute change in condition. Resident #45 had a recent hospitalization and a significant cardiac history including cardiac coronary disease, history of a heart attack, atrial fibrillation, and congestive heart failure. The facility failed to ensure changes in the resident's medical condition were adequately assessed, failed to have documented evidence of notification to the physician and that adequate care and services were implemented for Resident #45 when the resident had repeatedly complained of chest pain and tightness. This resulted in Immediate Jeopardy with subsequent death beginning on [DATE] when Resident #45's repeated complaints of chest pain and tightness were not adequately addressed. This affected one (Resident #45) of three residents reviewed for change in condition. The facility census was 42. On [DATE] at 4:27 P.M. the Administrator, Director of Regulatory Compliance Nurse (DRCN) #123, and Director of Nursing (DON) were notified Immediate Jeopardy began on [DATE] when staff identified Resident #45 exhibited a change in condition which included repeated complaints of chest pain and tightness on [DATE] between 11:00 P.M. and early morning of [DATE]. On [DATE] at 5:22 A.M. per the EMS report, upon their arrival Resident #45 was unresponsive and not breathing, had rigor mortis in his jaw, had mottling (refers to a patchy, lace-like, or marbled discoloration of the skin, typically appearing reddish-blue or purple, signifying decreased circulation) and was pronounced dead at 5:28 A.M. The EMS report also indicated the nursing staff reported the resident had complained of chest pain earlier in the night. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following actions: RN #207 has not worked since the time of the incident, [DATE]. On [DATE] the change in condition policy was reviewed on Thursday, [DATE], by the DON and Administrator before staff were educated on it. No changes were made. On [DATE], the DON reviewed the last two weeks of records of all residents in the facility for changes in condition and to ensure that they were properly reported and addressed. No issues were identified. On [DATE], the DON ran a report for all residents with cardiac diagnoses and reviewed for any need for reassessment or recent change in condition. No concerns were identified. On [DATE] and [DATE], the DON in-serviced all certified nursing assistants (CNA) on the need to immediately notify the nurse if there is a change in condition or emergency and on the facility protocol for obtaining assistance during an emergency situation, including what to do if a nurse is unavailable or not responding. CNAs were instructed to escalate up the chain to the charge nurse or DON if a nurse is unavailable or not responding. Nine CNAs have been in-serviced at this time. Any CNA not in-serviced on [DATE] will not be permitted to work until in-servicing is completed. On [DATE] and [DATE], the DON in-serviced all licensed nurses on the facility policies and procedures related to change in condition, appropriate assessments and documentation of the same, timely notification to physician of change in condition and how to respond to emergency situations. 11 nurses have been in-serviced at this time. Any licensed nurses who are not in-serviced by [DATE] will not be permitted to work until in-servicing is completed. On [DATE], an ad hoc QAPI meeting was held with the Medical Director #300, Administrator, DON, RN #123, RN #121, and RN #118 to discuss the incident, follow-up measures and action plan and to review any relevant policies. No policy updates were needed. On [DATE], the DON and designees will begin monitoring all shift reports and nurse's notes daily to ensure all changes in condition are timely reported to the physician and appropriately addressed. The audits will be conducted daily for two weeks and then three times a week for six weeks. The QA Committee will monitor the results of the audits will and follow-up as needed.Although the Immediate Jeopardy was removed on [DATE] the deficiency remains at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance.Findings include:Review of the closed medical record revealed Resident #45 was admitted to the facility on [DATE]. Resident #45 expired in the facility on [DATE]. Diagnoses included acute on chronic congestive heart failure, atrial fibrillation, atherosclerotic coronary heart disease, hypertensive heart disease with heart failure, muscle weakness, and ischemic cardiomyopathy. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #45's memory was intact, and he had modified independence for cognitive skills for daily decision making. The resident required supervision with eating, was dependent on staff for toileting hygiene and required partial/moderate assistance with bed mobility and transfers. The baseline care plan was in progress. Review of the physician orders dated [DATE] revealed an order for aluminum and magnesium hydroxide suspension (often branded as Maalox or Mylanta) 200-200 milligrams (mg)/5 milliliters (ml) to give 10 ml every six hours as needed (PRN) for antacid. There were no physician orders for PRN medications for chest pain.Review of the progress notes revealed an electronic medication administration record (eMAR) note dated [DATE] at 12:28 A.M. revealed Registered Nurse (RN) #207 administered the PRN Maalox.Review of the medical record revealed no documented evidence of an assessment or vital signs for Resident #45 around the time the administration of the Maalox and no documentation related to chest pain.Review of the device activity report revealed Resident #45 rang the call light on [DATE] at 11:07 P.M., 11:14 P.M., 11:28 P.M., 11:29 P.M. and on [DATE] at 12:14 A.M., 12:32 A.M., and at 12:48 A.M. Review of the eMAR noted dated [DATE] at 4:21 A.M. RN #207 indicated the PRN Maalox was effective. Review of the health status note dated [DATE] at 5:13 A.M. revealed Resident #45 was found by RN #207 lying in bed absent of vital signs. RN #207 called out for staff assistance and 911 was called and cardiopulmonary resuscitation (CPR) was started immediately. Medics and police arrived at the bedside for assessment and provided all appropriate information. All parties were made aware.Review of the EMS run report dated [DATE] revealed the call came in at 5:14 A.M., EMS was dispatched at 5:15 A.M. and EMS was with Resident #45 at 5:21 A.M. Upon arrival, Resident #45 was found lying in bed. He was unresponsive and not breathing. Nursing staff on scene started performing CPR approximately five minutes prior to EMS arrival. Nursing staff stated that they came to check on Resident #45 and found him unresponsive and not breathing. Resident #45 had a wrist band on that stated he was a Full Code (if a person's heart stops beating or they stop breathing, medical staff will do everything possible to try to save their life). EMS checked multiple sites for a pulse such as radial and carotid and found the resident to be pulseless. Nursing staff claim to have checked on the resident at 4:00 A.M. Nursing staff claim that the resident had stated he was having chest pain earlier in the night. Resident #45 had rigor in his jaw and mottling throughout his body. Due to rigor mortis, mottling, and confirmed asystole in multiple leads, EMS contacted the physician at the local hospital who announced time of death at 5:28 A.M. During an interview on [DATE] at 4:55 P.M., RN #207 stated she was part-time but had not been back to the facility since [DATE]. RN #207 stated the DON had called her and stated she needed to take her off the schedule and needed a statement regarding Resident #45. RN #207 stated she reached out to the DON with no response and had not heard anything since. RN #207 stated she could not recall exactly when, but the aide came to her and stated Resident #45 needed to see her due to having chest pain. RN #207 stated she first looked at Resident #45's physician's orders in the computer and saw orders for Maalox but nothing PRN for chest pain. RN #207 stated she then went to see the resident and asked how he was feeling and asked if he was having chest pain or indigestion and discomfort. RN #207 stated Resident #45 told her he was having indigestion, and she gave him the PRN Maalox. She recalled when she entered the resident's room, he was trying to get up and go to the bathroom. She stated that she took his blood pressure, and it was elevated. She then helped Resident #45 settle back into bed and retook his blood pressure, and it was normal. She stated she did not document the assessment or vital signs in the medical record. RN #207 stated the next time she walked by Resident #45 he was fine and was sleeping. She stated that she knew he was sleeping because she saw his chest rise and fall. RN #207 stated she did not recall what time that was. She stated she knew the aide had taken the resident to the bathroom, and she did not hear anything else in the evening. When she was about to do medication pass, she walked past Resident #45's room and saw him lying in bed but tilted to the side. She stated he didn't look right, which prompted her to go to his room. She asked the aide to get everyone to help, and she called 911. She put 911 on speaker and began CPR on Resident #45 until EMS arrived. EMS announced that Resident #45 was deceased . She stated that she felt like she should have checked on Resident #45 more frequently but felt everything was okay since the aide did not say anything else to her.During an interview on [DATE] at 7:13 P.M., CNA #208 stated she had worked a double shift on [DATE], came in at 3:00 P.M. but was not assigned Resident #45 until 11:00 P.M. Initially Resident #45 complained that he had not had a bowel movement since he was in the hospital and felt he needed to go. He was too weak to sit on bedside commode, so she got him on a bed pan. Resident #45 sat on the bed pan for a while and nothing happened, so she took him off. Approximately 20 minutes later, he rang and asked for the bed pan again. Resident #45 was alert and oriented and able to make his needs known. The second time she put him on bed pan, he had a large bowel movement. CNA #208 stated she got him cleaned up and reported to the nurse that Resident #45 had a large bowel movement. Approximately 20 minutes later, Resident #45 rang the call light and told her he was having chest pain, and she told RN #207. The nurse did not get up right away, and she did not see her get up and go to Resident #45's room. She had gone to care for another resident. Approximately 20 minutes went by, and Resident #45 rang his call light again. CNA #208 stated she went to see what the resident needed, and he again complained about chest pain. CNA #208 stated the resident appeared to be in distress, and she told RN #207. She didn't know if RN #207 had been in since she had told her the first time, but when she told the nurse again, the nurse told her that she had given him Maalox, and he needed to give it time to work. CNA #208 stated Resident #45 stayed on his call light approximately every 20 minutes and stated between her and the other two aides, CNA #136 and #153, they answered and he repeatedly complained of chest pain. She stated at one point, he told her he was feeling chest tightness. CNA #208 stated she did not tell the nurse chest tightness; she told her chest pain and thought it was all the same because they usually send residents out to the hospital with complaints of chest pain. She repositioned the resident in bed when he rang and only told the nurse twice of his complaints of chest pain, but she knew the other two CNA told the nurse as well. CNA #208 stated Resident #45 rang his call light up until between 2:20 A.M. and 2:30 A.M. on [DATE], and that was the last time she went into his room. She stated when she had repositioned him in bed and he seemed to be more comfortable. CNA #208 stated after that she checked in on him between 3:30 A.M. and 3:45 A.M. and she assumed he was sleeping because he was still in the same position that she had last repositioned him between 2:20 A.M. and 2:30 A.M. At approximately 4:00 A.M. she started to do her rounds, and the nurse started to pass medications. When the nurse found Resident #45 unresponsive, she called her. Resident #45 was slumped over in bed. When the first shift nurse came in, she asked what happened and she told her. CNA #208 stated she was off the next night and when she returned Friday, [DATE], at around 3:00 P.M. the nurse on duty told her what she said sounded concerning and asked her to tell the DON. CNA #208 stated she talked to the DON and was told that if she was unsure about something or had concerns, she could call her. CNA #208 stated she did not write a statement and stated she felt like she should have done more. CNA #208 stated the Administrator was usually in the building up until 3:00 A.M. to 4:00 A.M. but she left early, and that she may have told her, but may not have because she thought the RN knew something she didn't. CNA #208 stated Resident #45 looked so uncomfortable, like he was in distress, and he said more than once he had chest pain. During an interview on [DATE] at 12:30 P.M., the Administrator stated Resident #45 was in the TV room and this was his fifth stay at the facility. The Administrator stated the resident was more debilitated this time than he had been during prior stays. She stated she usually worked late into night shift and left sometime around 2:00 A.M. to 2:30 A.M. on [DATE]. The Administrator stated nobody said anything to her prior to her leaving. She was aware of what CNA #208's story was. The Administrator stated earlier in the day she knew Resident #45 used his call light and sometimes he called out because he needed to have a bowel movement. The Administrator stated CNA #208 was on duty and informed Resident #45's aide at that time that he needed to go to the bathroom. The Administrator stated Resident #45 was very weak, and his aide at the time needed help getting the resident up on the bedside commode. After 11:00 P.M., CNA #208 was assigned to Resident #45. The Administrator stated CNA #208 stated Resident #45 had complained of having discomfort in his chest and went to tell the nurse, and the nurse didn't seem concerned. She was in her office, and if he had been calling out, she would have heard him. The Administrator stated she understood the resident had chest discomfort and knew he had a large bowel movement. Resident #45 had to do a lot of pushing and felt better after. The Administrator stated Resident #45 was alert and oriented and he would have said he wanted to go to the hospital. During an interview on [DATE] at 12:30 P.M., the DON stated RN #207 called her on [DATE] around 5:00 A.M. and said Resident #45 was complaining of indigestion and pressure in his chest. The DON stated RN #207 stated she had repositioned the resident in bed and gave him Mylanta (Maalox). RN #207 informed her around the time of her medication pass that Resident #45 had passed away. The DON asked RN #207 if she took vital signs, and RN #207 told her that she took vital signs and said they were fine, but she did not document them in the medical record. The DON stated that RN #207 had only documented the resident's temperature. The DON stated when there was a change in condition it was individual based on the situation, and Resident #45 was alert and oriented, and able to make his needs known. At that time the resident wanted to try the Mylanta (Maalox), and it was effective and that would be something she would have done as well with no further distress. The DON stated decisions would be based on nursing judgement, and the difference would be if the resident was not alert or oriented then they would likely send them out. The DON stated it was the very next day when CNA #208 came to her and reported that the nurse didn't do anything regarding Resident #45's complaints. During an interview on [DATE] at 1:08 P.M., CNA #135 stated she was not working in the hall that Resident #45 resided on, but the aide that was assigned to him had to be stationed outside another resident's room. CNA #136 stated Resident #45 was in the TV room and rang his call light often that night. CNA #153 stated she knew Resident #45 rang his call light frequently because they have pagers, and when a call light rings, it goes to all their pagers. CNA #136 stated she only answered his call light once, and he complained of chest tightening. She did not recall the time, but it was before 4:00 A.M. She told RN #207 and went back to her assigned area. CNA #136 stated RN #207 did tell her that she had given Resident #45 something and he needed to let it kick in. CNA #136 stated whatever the nurse gave Resident #45 was not working. CNA #136 stated sometime after 4:30 A.M., CNA #208 ran to her and said Resident #45 was gone. CNA #136 stated she went to the assisted living to get the nurse and when she came back to the skilled side, CNA #208 and RN #207 were in Resident #45's room. CNA #136 stated that she and RN #207 switched off on doing CPR, and she believed the assisted living nurse called 911 and the Administrator. CNA #136 stated EMS arrived around 5:00 A.M. CNA #136 stated she heard RN #207 tell the assisted living nurse that Resident #45 had complained of chest burning, but that was not true. CNA #136 stated Resident #136 said it was chest pain, and he had his hand on his chest. Resident #45 looked like he was in distress like he was having heart attack or stroke, and the nurse had no sense of urgency.During an interview on [DATE] at 1:25 P.M. with CNA #153 via telephone revealed she had walked past Resident #45's room and he was yelling out. She and CNA #136 went into Resident #45's room and he wanted water and stated his chest was feeling tight. She and CNA #136 went to tell the nurse, but she could not recall what time that was, and that was her only interaction with Resident #45. CNA #153 stated she helped clean up after he passed away. CNA #153 stated Resident #45 rang his call light, and she also heard him yelling out. Review of the policy titled Acute Condition Changes-Clinical Protocol, undated, revealed under the section titled Assessment and Recognition revealed the physician will help identify individuals with a significant risk for having acute changes of condition during their stay. In addition, the nurse shall assess and document/report the following baseline information: vital signs, neurological status, current level of pain, and any recent changes in pain level, level of consciousness, cognitive and emotional status, resident's age and sex, onset, duration, severity, recent labs, history of psychiatric disturbances, mental illness, depression, etc., all active diagnoses; and all current medications. Direct care staff, including nursing assistants, will be trained in recognizing subtle but significant changes in the residents and how to communicate these changes to the nurse. Under the section of the policy titled Treatment/Management revealed the physician will help identify and authorize appropriate treatments. The physician and staff will identify relevant resident/patient wishes, including advanced directives and physician orders for life sustaining treatment (POLST) orders related to life-sustaining treatments. If it is decided, after sufficient review, that care or observation cannot reasonably be provided in the facility, the physician will authorize transfer to an acute hospital, emergency room, or another appropriate setting. Under the section titled Monitoring and Follow-Up the staff will monitor and document the resident/patient's progress and responses to treatment, and the physician will adjust treatment accordingly.This deficiency represents non-compliance investigated under Complaint Number 2723415.

Based on the medical record review, review of the emergency medical services (EMS) run report, facility policy and procedure review and interview, the facility failed to report an allegation of neglect to the State agency. This affected one (Resident #45) of three residents reviewed for change in condition. The facility census was 42.Findings include:Review of the closed medical record revealed Resident #45 was admitted to the facility on [DATE] and expired in the facility on [DATE]. Diagnoses included acute on chronic congestive heart failure, atrial fibrillation, atherosclerotic coronary heart disease, hypertensive heart disease with heart failure, muscle weakness, and ischemic cardiomyopathy. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #45's memory was intact, and he had modified independence for cognitive skills for daily decision making. The assessment indicated the resident required supervision with eating, was dependent on staff for toileting hygiene, and required partial/moderate assistance with bed mobility and transfers. The baseline care plan was in progress. Review of the physician orders dated [DATE] revealed an order for aluminum and magnesium hydroxide suspension (often branded as Maalox or Mylanta) 200-200 milligrams (mg)/5 milliliters (ml) to give 10 ml every six hours as needed (PRN) for antacid. There were no physician orders for PRN medications for chest pain.Review of the progress notes revealed an electronic medication administration record (eMAR) note dated [DATE] at 12:28 A.M. revealed Registered Nurse (RN) #207 administered the PRN Maalox.Review of the eMAR noted dated [DATE] at 4:21 A.M. RN #207 indicated the PRN Maalox was effective.Review of the health status note dated [DATE] at 5:13 A.M. revealed Resident #45 was found by RN #207 lying in bed absent of vital signs. RN #207 called out for staff assistance and 911 was called, the head of the bed (HOB) was lowered, and cardiopulmonary resuscitation (CPR) was started immediately. Medics and police arrived at the bedside for assessment and provided all appropriate information. All parties were made aware.Further review of the closed medical record for Resident #45 revealed no documented evidence of an assessment or vital signs around the time the administration of the Maalox.Review of the EMS run report dated [DATE] revealed the call came in at 5:14 A.M., EMS was dispatched at 5:15 A.M. and EMS was at the resident at 5:21 A.M. Upon arrival, Resident #45 was found lying in bed. He was unresponsive and not breathing. Nursing staff on scene started performing CPR approximately five minutes prior to EMS arrival. Nursing staff stated that they came to check on Resident #45 and found him unresponsive and not breathing. Resident #45 had a wrist band on that stated he was a Full Code (if a person's heart stops beating or they stop breathing, medical staff will do everything possible to try to save their life). EMS noted to have checked multiple sites for a pulse such as radial and carotid and found the resident to be pulseless. Nursing staff claim to have checked on the resident at 4:00 A.M. Nursing staff claim that the resident had stated he was having chest pain earlier in the night. Resident #45 had rigor in his jaw and mottling throughout his body. Due to rigor mortis, mottling, and confirmed asystole in multiple leads, EMS contacted the physician at the local hospital who announced time of death at 5:28 A.M. Review of the device activity report dated [DATE] at 12:00 A.M. to [DATE] at 11:59 P.M. revealed Resident #45 was located in the television (TV) room which was set up as a private resident room. Resident #45 rang the call light on [DATE] at 11:07 P.M., 11:14 P.M., 11:28 P.M., 11:29 P.M. and on [DATE] at 12:14 A.M., 12:32 A.M., and at 12:48 A.M. Interview on [DATE] at 4:55 P.M., RN #207 stated she was part-time but had not been back to the facility since [DATE]. RN #207 stated the DON had called her and stated she needed to take her off the schedule and needed a statement regarding Resident #45. RN #207 stated she reached out to the DON with no response and had not heard anything since. RN #207 stated she could not recall exactly when, but the aide came to her and stated Resident #45 needed to see her due to having chest pain. RN #207 stated she first looked at Resident #45's physician's orders in the computer and saw orders for Maalox but nothing PRN for chest pain. RN #207 stated she then went to see the resident and asked how he was feeling and asked if he was having chest pain or indigestion and discomfort. RN #207 stated Resident #45 told her he was having indigestion, and she gave him the PRN Maalox. She recalled when she entered the resident's room, he was trying to get up and go to the bathroom. She stated that she took his blood pressure, and it was elevated. She then helped Resident #45 settle back into bed and retook his blood pressure, and it was normal. She stated she did not document the assessment or vital signs in the medical record. RN #207 stated the next time she walked by Resident #45 he was fine and was sleeping. She stated that she knew he was sleeping because she saw his chest rise and fall. RN #207 stated she did not recall what time that was. She stated she knew the aide had taken the resident to the bathroom, and she did not hear anything else in the evening. When she was about to do medication pass, she walked past Resident #45's room and saw him lying in bed but tilted to the side. She stated he didn't look right, which prompted her to go to his room. She asked the aide to get everyone to help, and she called 911. She put 911 on speaker and began CPR on Resident #45 until EMS arrived. EMS announced that Resident #45 was deceased . She stated that she felt like she should have checked on Resident #45 more frequently but felt everything was okay since the aide did not say anything else to her.Interview on [DATE] at 7:13 P.M., CNA #208 stated she had worked a double shift on [DATE], came in at 3:00 P.M. but was not assigned Resident #45 until 11:00 P.M. Initially Resident #45 complained that he had not had a bowel movement since he was in the hospital and felt he needed to go. He was too weak to sit on bedside commode, so she got him on a bed pan. Resident #45 sat on the bed pan for a while and nothing happened, so she took him off. Approximately 20 minutes later, he rang and asked for the bed pan again. Resident #45 was alert and oriented and able to make his needs known. The second time she put him on bed pan, he had a large bowel movement. CNA #208 stated she got him cleaned up and reported to the nurse that Resident #45 had a large bowel movement. Approximately 20 minutes later, Resident #45 rang the call light and told her he was having chest pain, and she told RN #207. The nurse did not get up right away, and she did not see her get up and go to Resident #45's room. She had gone to care for another resident. Approximately 20 minutes went by, and Resident #45 rang his call light again. CNA #208 stated she went to see what the resident needed, and he again complained about chest pain. CNA #208 stated the resident appeared to be in distress, and she told RN #207. She didn't know if RN #207 had been in since she had told her the first time, but when she told the nurse again, the nurse told her that she had given him Maalox, and he needed to give it time to work. CNA #208 stated Resident #45 stayed on his call light approximately every 20 minutes and stated between her and the other two aides, CNA #136 and #153, they answered and he repeatedly complained of chest pain. She stated at one point, he told her he was feeling chest tightness. CNA #208 stated she did not tell the nurse chest tightness; she told her chest pain and thought it was all the same because they usually send residents out to the hospital with complaints of chest pain. She repositioned the resident in bed when he rang and only told the nurse twice of his complaints of chest pain, but she knew the other two CNA told the nurse as well. CNA #208 stated Resident #45 rang his call light up until between 2:20 A.M. and 2:30 A.M. on [DATE], and that was the last time she went into his room. She stated when she had repositioned him in bed and he seemed to be more comfortable. CNA #208 stated after that she checked in on him between 3:30 A.M. and 3:45 A.M. and she assumed he was sleeping because he was still in the same position that she had last repositioned him between 2:20 A.M. and 2:30 A.M. At approximately 4:00 A.M. she started to do her rounds, and the nurse started to pass medications. When the nurse found Resident #45 unresponsive, she called her. Resident #45 was slumped over in bed. When the first shift nurse came in, she asked what happened and she told her. CNA #208 stated she was off the next night and when she returned Friday, [DATE], at around 3:00 P.M. the nurse on duty told her what she said sounded concerning and asked her to tell the DON. CNA #208 stated she talked to the DON and was told that if she was unsure about something or had concerns, she could call her. CNA #208 stated she did not write a statement and stated she felt like she should have done more. CNA #208 stated the Administrator was usually in the building up until 3:00 A.M. to 4:00 A.M. but she left early, and that she may have told her, but may not have because she thought the RN knew something she didn't. CNA #208 stated Resident #45 looked so uncomfortable, like he was in distress, and he said more than once he had chest pain.Interview on [DATE] at 12:30 P.M. with the Administrator revealed the Administrator stated she knew what CNA #208's story was. The Administrator stated CNA #208 stated Resident #45 had complained of having discomfort in his chest and went to tell the nurse and the nurse didn't seem concerned. The Administrator stated CNA #208 told everyone that the nurse didn't do anything regarding Resident #45's complaints. The Administrator stated she didn't report it to the State agency because when CNA #208 first came to them she was saying the nurse was lazy and not doing anything; it did not seem to be truly a concern. Interview on [DATE] at 12:30 P.M. the DON stated it was the very next day when CNA #208 came to her and reported that the nurse didn't do anything regarding Resident #45's complaints. The DON stated she didn't report it to the State agency. The DON stated she could not remember what exactly CNA #208 said, but the resident was complaining to her about pressure and discomfort. Interview on [DATE] at 1:08 P.M., CNA #135 stated she was not working in the hall that Resident #45 resided on, but the aide that was assigned to him had to be stationed outside another resident's room. CNA #136 stated Resident #45 was in the TV room and rang his call light often that night. CNA #153 stated she knew Resident #45 rang his call light frequently because they have pagers, and when a call light rings, it goes to all their pagers. CNA #136 stated she only answered his call light once, and he complained of chest tightening. She did not recall the time, but it was before 4:00 A.M. She told RN #207 and went back to her assigned area. CNA #136 stated RN #207 did tell her that she had given Resident #45 something and he needed to let it kick in. CNA #136 stated whatever the nurse gave Resident #45 was not working. CNA #136 stated sometime after 4:30 A.M., CNA #208 ran to her and said Resident #45 was gone. CNA #136 stated she went to the assisted living to get the nurse and when she came back to the skilled side, CNA #208 and RN #207 were in Resident #45's room. CNA #136 stated that she and RN #207 switched off on doing CPR, and she believed the assisted living nurse called 911 and the Administrator. CNA #136 stated EMS arrived around 5:00 A.M. CNA #136 stated she heard RN #207 tell the assisted living nurse that Resident #45 had complained of chest burning, but that was not true. CNA #136 stated Resident #136 said it was chest pain, and he had his hand on his chest. Resident #45 looked like he was in distress like he was having heart attack or stroke, and the nurse had no sense of urgency.Interview on [DATE] at 1:25 P.M. with CNA #153 via telephone revealed she had walked past Resident #45's room and he was yelling out. She and CNA #136 went into Resident #45's room and he wanted water and stated his chest was feeling tight. She and CNA #136 went to tell the nurse, but she could not recall what time that was, and that was her only interaction with Resident #45. CNA #153 stated she helped clean up after he passed away. CNA #153 stated Resident #45 rang his call light, and she also heard him yelling out.Review of the undated facility policy Abuse, Mistreatment, Neglect, Exploitation, & Misappropriation of Resident Property, revealed all incidents and allegations of Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Resident Property and all injuries of unknown source must be reported immediately to the Administrator or designee. Allegations involving neglect, exploitation, misappropriation of Resident Property and injuries of unknown source will be reported to ODH (Ohio Department of Health) immediately, but in no event later than 24 hours from the time the incident/allegation was made known to the staff member. Once the Administrator and ODH are notified, an investigation of the allegation violation will be conducted. This deficiency represents non-compliance investigated under Complaint Number 2723415.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, interview, record review, review of facility self-reported incidents (SRI) and facility policy review, the facility failed to ensure Resident #4 was free from misappropriation. This affected one resident (#4) of three residents reviewed for abuse, neglect and misappropriation of property. The facility census was 44. Findings include: Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses that included dementia, recurrent urinary tract infection (UTI), chronic kidney disease, atrial fibrillation and peripheral vascular disease. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #4 was cognitively impaired and required extensive assistance with activities of daily living. Review of a facility self-reported incident (SRI) control number 260103 dated 05/06/25 revealed Resident #4's daughter had called the facility and notified them that a check had been written from Resident #4's account in the amount of $3,225.00 dollars. The check was written to a former employee who had attempted to deposit the check. Resident #4's daughter had been notified by the bank of the attempted deposit. The SRI referenced that the police were involved and were investigating. The facility substantiated that misappropriation occurred. Review of the facility's SRI investigation dated 05/06/23 revealed on 05/06/25 the Resident #4's daughter was notified by the bank that check #4413 was attempted to be deposited on 05/02/25 by mobile deposit and was pending. On 05/06/25 at 3:30 P.M. Resident #4's daughter notified the facility of the incident. The facility filed a SRI and notified the local police department. The check was dated 05/02/25 and was made out to former Certified Nursing Assistant (CNA) #100 with a signature of Resident #4. The back of the check was signed by STNA #100 and there was a handwritten statement that the check was for mobile deposit only. Review of the CNA #100's employee status revealed she was hired on 02/09/24 and terminated on 01/19/25 for unrelated attendance concerns. Review of the local police report dated 05/06/25 revealed the police arrived at the facility at 4:53 P.M. and filed a report of theft with a note stating Resident #4 had a check stolen from her room. Interview on 06/12/25 at 11:10 A.M. with Resident #4's daughter stated a former CNA had taken one of Resident #4's checks and had attempted to deposit funds in the CNA's personal account. Resident #4's daughter reported she was notified, and the blank flagged the check. The check did not clear and there had been no transfer of funds. Interview with the Administrator on 06/12/25 at 11:45 A.M. revealed CNA #100 was hired on 02/09/24 and was terminated on 01/19/25. CNA #100 worked the 7:00 P.M. to 7:00 A.M. shift. The Administrator stated they were not aware of Resident #4's check being missing until they received a call from Resident #4's daughter on 05/06/25. Interview with the Director of Nursing (DON) on 06/12/25 at 12:30 P.M. revealed the facility reached out several times to former CNA #100, however she never responded. The DON stated she compared the writing on the check, and it appeared to be CNA #100's handwriting. The DON reported CNA #100 signed the letter A in a unique manner that appeared the same on the check and other documents she had signed. Observation and interview on 06/12/25 at 3:49 P.M. of Resident #4's checkbook revealed the check numbers remaining in the checkbook started at 4414. There was no handwritten ledger. Interview with the Administrator at this time revealed there was only one check missing, check number 4413. Resident #4's daughter was the only one who has access to monthly statements. The Administrator stated the facility was unable to identify when the check went missing. CNA #100 could have taken the check when Resident #4 was sleeping. She stated Resident #4's daughter lived out of town and was adamant that Resident #4 had her checkbook. Since the incident, the facility had secured the checkbook in the office but ensured Resident #4 could have access to her checkbook whenever needed. The Administrator stated the SRI was substantiated due to the CNA #100 taking the check while she was employed at the facility. Review of the facility policy titled Abuse, Neglect, Misappropriation Policy, revised November 2010 revealed the facility defined misappropriation as the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. The police state the facility will not tolerate verbal, sexual, physical or mental abuse, involuntary seclusion or neglect of its resident or misappropriation of resident's funds or property by anyone. This violation represents non-compliance investigated under Complaint Number OH00165844. The deficient practice was corrected on 05/30/25 when the facility implemented the following corrective actions: - On 05/06/25, the police were notified of the potential theft and misappropriation of Resident #4's checkbook. The investigation remains ongoing. - On 05/07/25 the DON and the Assistant Administrator interviewed all in-house residents for misappropriation with no negative finding. - On 05/12/25, the DON and Assistant Administrator conducted night shift observations of staff. Night shift observations will continue twice monthly by the Administrator or designee and will be ongoing. - On 05/13/25, the facility's abuse, neglect, and misappropriation policy was briefly discussed during their monthly staff meeting. Ongoing re-education of the facility's abuse, neglect, and misappropriation policy will continue at the monthly staff meeting for a duration of six months. - On 05/22/25, all staff were re-educated on the facility's abuse, neglect, and misappropriation policy. - On 05/30/25, the DON and Assistant Administrator reviewed resident council meeting minutes for any concerns related to misappropriation or missing items. There were no concerns identified. This will continue monthly on an ongoing basis. - The DON and Assistant Administrator will conduct weekly audits of residents for abuse, neglect, and misappropriation. These weekly audits will conclude on 07/03/25. The results of the audits will be reported to the Administrator.

Based on record review, interview and review of the facility policy, the facility failed to correctly transcribe and record oxygen orders upon admission to ensure oxygen was administered properly. This affected one resident (#43) of three residents reviewed for oxygen. Facility census was 40. Findings include: Review of Resident #43's closed medical record revealed an admitted [DATE] and diagnoses including right arm humorous fracture, acute on chronic congestive heart failure, hypertensive heart disease with heart failure, hyperlipidemia, chronic obstructive pulmonary disease, type two diabetes and chronic kidney disease stage four. Resident #43 expired in the facility on [DATE]. Review of Resident #43's 5-day minimum data set (MDS) 3.0 assessment dated [DATE] revealed he was cognitively intact and was dependent on staff for toileting and transfers. The assessment indicated Resident #43 expired in the facility. Review of Resident #43's hospital paperwork dated [DATE] revealed additional discharge instructions of oxygen to be administered at 2 liters/minute. Review of Resident #43's physicians' orders revealed an order dated [DATE] for apply oxygen in order to keep oxygen saturation at or above 92% as needed. The order was timed [DATE] at 1:34 P.M. and was put in by Previous Director of Nursing (PDON) #109. Review of the order audit details revealed PDON #109 created and confirmed the order on [DATE] at 2:19 P.M. No other oxygen orders were noted for Resident #43 during this admission. Review of Resident #43's Medication Administration Record (MAR) for [DATE] revealed his oxygen was not signed off as being administered on [DATE] or [DATE]. Interview on [DATE] at 8:48 A.M. with Family Member (FM) #111 revealed an autopsy was done after Resident #43 passed away and recalled they were told Resident #43 did not have oxygen supplied to him for five hours. Interview on [DATE] at 9:45 A.M. with FM #112 revealed Resident #43's death certificate reported his cause of death to be congestive heart failure for three years and cardiorespiratory failure for three hours. Interview on [DATE] at 10:44 A.M. with Licensed Practical Nurse (LPN) #110 revealed she was responsible for Resident #43's admission documentation on [DATE]. LPN #110 explained the Director of Nursing (DON) handled a new resident's admission orders including verifying the orders with the physician but floor nurses like herself did the head-to-toe assessments, initial vital signs, fall assessment and wandering assessment. Interview on [DATE] at 11:03 A.M. with the DON revealed she was the facility's DON as of [DATE]. The DON explained orders from the after visit summary from the hospital were reviewed with the physician and then she would put the orders in to the electronic medical record. The DON stated if she did not put in the orders, other administrative nurses would do so for a new admission. The DON indicated ancillary orders, such as oxygen, were handled in the same way. The DON was asked about Resident #43's oxygen orders from the hospital on [DATE] and at the facility on [DATE] during the interview and confirmed the facility's orders for PRN oxygen did not match the continuous rate of oxygen as indicated on Resident #43's hospital paperwork. Interview on [DATE] at 11:21 A.M. with PDON #109 revealed she was the DON at the time Resident #43 resided in the facility during [DATE]. PDON #109 explained she verified Resident #43's hospital orders with the physician and the orders were transcribed into the computer and then activated when the resident was in the building. PDON #109 stated she always put oxygen into the electronic medical record as a PRN order as the facility had a standing order for oxygen and would do this unless otherwise indicated in the referral information or other documentation from the hospital. PDON #109 explained unless the nurse had told her about the continuous oxygen after the resident arrived, the order would have been changed over to a continuous rate first thing the next morning after admission. PDON #109 was unaware Resident #43 had an order for continuous oxygen from the hospital at the time of the interview. Review of the facility policy, Admissions - from Other Healthcare Facilities, revised [DATE] revealed residents from other healthcare facilities may be admitted upon receipt of appropriate documentation. The following information will be provided to the facility prior to or upon the resident's admission . physician orders for immediate care. Review of the facility policy, Medication and Treatment Orders, revised [DATE] revealed orders for medications must include: name and strength of the drug; number of doses, start and stop date, and/or specific duration of therapy; dosage and frequency of administration; route of administration; clinical condition or symptoms for which the medication is prescribed and interim follow-up requirements. This deficiency represents noncompliance investigated under Complaint Number OH00161291.

Based on interviews, review of the Payroll Based Journal (PBJ) staffing report, review of facility staffing schedules and timecard punches revealed the facility failed to submit accurate staffing information to the Centers for Medicare and Medicaid Services (CMS). This had the potential to affect all 39 residents residing in the facility. Findings include: Review of the PBJ Staffing Data Report for Fiscal Year Quarter one for 2024 revealed the facility triggered for failing to have licensed Nursing Coverage 24 hours per day for 12/16/23 (Saturday), 12/17/23 (Sunday), 12/23/23 (Saturday), 12/24/23 (Sunday) and 12/31/23 (Sunday). Review of facility schedules and assignments sheets for the above listed dates revealed there was nursing staff present 24 hours for each day listed in the PBJ report. Review of the December 2023 timecard punch details report submitted for the PBJ report revealed inconsistencies between the actual time punches and the information on the submitted report. Interview on 04/23/24 at 10:30 A.M. with Financial Officer (FO) #47 and the Administrator revealed FO #47 ran a report from their timecard system and uploaded the report for submission to the PBJ quarterly report. FO #47 and the Administrator confirmed there were inconsistencies between the time punches report and review of the actual time punches for the scheduled nursing staff.

Based on record review, observation and interview, the facility did not ensure private and confidential handling of resident medical information for Residents #14, #15, #19, #20, #29 and #31. This affected six residents ( #14, #25, #19, #20, #29 and #31) of six residents reviewed for weights and had the potential to affect all residents living in the facility. The facility census was 42. Findings include: Record review of weight documentation and physician orders for weights revealed Residents #14, #15, #19, #20, #29, and #31 each had an order to be weighed at least once a month and each had multiple weights missing from the medical record of weights. Interview on 09/06/23 at 8:50 A.M. with the Director of Nursing (DON) revealed the system in place for recording resident weights consisted of weights obtained by State tested Nursing Assistant (STNA) #944 who recorded the weights in a paper logbook and those weights were then transposed into the electronic medical record (EMR) by the DON. Interview on 09/06/23 at 2:18 P.M. with STNA #944 revealed he was the staff person who was responsible for weighting the residents and he kept a paper copy of the resident weights which would then be given to the DON to enter into the EMR. Observation and interview on 09/06/23 at 4:22 P.M. with STNA #944 revealed STNA #944 voluntarily entered an unlocked employee break room and returned to the hallway a few minutes later holding loose papers that were folded in quarters and piled together in a stack. STNA #944 verified the papers were the monthly weight logs dated from 01/2023 to 08/2023 and each page contained resident names, room numbers, dates and body weights of all the residents he had to weigh each month. STNA #944 verified the information was not secure, as other employees also used the breakroom where he was keeping the weight logs. Review of the United States Department of Health and Human Services Office for Civil Rights Health Insurance Portability and Accountability Act (HIPAA) indicated residents to be provided with assurances their sensitive health data will remain confidential, sets rules and places limits on who can look at and receive health information. The Privacy Rule applies to all forms of an individuals' protected health information, whether electronic, written, or oral.

Based on record review, observation and interview, the facility failed to ensure adequate and sufficient documentation of residents' weights in the medical record for the monitoring of residents at nutrition risk and identification and assessment of significant weight changes. This affected six residents (#14, #15, #19, #20, #29, and #31) of six reviewed for nutrition. The facility census was 42. Findings include: 1. Review of the medical record for Resident #14 revealed an admitted [DATE]. Diagnoses included feeding tube, muscle weakness, hypothyroidism, lupus, dementia, and history of cancer of the uterus. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident had impaired cognition, required supervision with set up help for eating, weight was 124 pounds, with no weight changes, received mechanically altered diet, and received 26%-50% of calories and 501 ml or more per day of fluids from a feeding tube. Review of Resident #14 weight history revealed on 12/04/22 the resident weighed 124 pounds (lbs.), next weight documented was dated 06/21/23 and the resident weighed 111.4 lbs. Weight on 07/28/23 was 113.4 lbs., and on 08/31/23 was 110.8 lbs. Review of the nutrition assessment dated [DATE] revealed Resident #14 received a mechanically soft diet with honey thickened liquids and 250 milliliters (ml) of Isosource 1.5 with 100 ml of water when 50% of meals were consumed. The assessment also indicated under weight history, current body weight was 124 pounds on 12/04/22 and N/A was noted for 30 day weight and 90 day weight. Also noted on the assessment under recommendations was to monitor monthly weights. Interview on 09/06/23 at 2:18 P.M., State tested Nurse Aide (STNA) #944 stated over the past [AGE] years he had obtained the residents' weights monthly and weights other than monthly weights when asked by the nurse. STNA #944 verified the missing weights for Resident #14 for January 2023 through May 2023. STNA #944 stated at one time they had two scales; one was a chair scale and the other was a walk-up scale. STNA #944 stated because Resident #14 could not bend her legs well, he had a hard time weighing her on the chair scale and she could not stand to use the walk-up scale. STNA #944 stated once they received the Hoyer lift with the scale, he was then able to weigh Resident #14. STNA #944 stated he was not sure when they had received the Hoyer lift with the scale. Review of monthly weight sheets provided by STNA #944 from the weight sheets in his locker revealed weights were obtained for Resident #14 dated between January 2023 to May 2023. The weights obtained indicated Resident #14's weight was consistent between 110 lbs. to 113 lbs. during those months. STNA #944 verified he had kept the weights in his locker. Review of the delivery ticket for the Hoyer lift with scale revealed it was delivered on 01/30/23. Interview on 09/06/23 at 3:17 P.M. with the Director of Nursing (DON) revealed when STNA #944 obtained the resident weights she would put them in the resident's electronic medical record. DON stated STNA #944 did not always give her the weights to enter in the electronic medical record and that he kept the log of residents' weights in his locker. Interview on 09/07/23 at 11:57 A.M. with Registered Dietitian (RD) #850 revealed she looked at residents' weight as part of her assessments. RD #850 stated the facility had one person that obtained residents' weights and the DON entered the weights into the resident's electronic medical record. RD #850 stated she used the last weight available in the electronic medical record with the date of when the weight was obtained in her assessments. RD #850 verified there were no weights available for her to review for Resident #14 between January 2023 through May 2023, and on her assessment dated [DATE] for the 30 day and 90 day weight history she put N/A. RD #850 stated when they finally got a weight in June 2023, Resident #14's body mass index (BMI) was at the low end of normal but the interventions in placed were acceptable and no changes were needed. RD #850 stated she looked at the resident's intakes, received feedback from nursing, and the interventions during that time frame included tube feeding bolus when Resident #14's meal intakes were less than 50%. 45753 2. Review of the medical record for Resident #19 revealed an admitted [DATE]. Diagnosis included morbid obesity due to excess calories. The record revealed multiple monthly weights were missing from the medical record. Review of the plan of care dated 07/28/23 for Resident #19 revealed an alteration in nutrition status secondary to diagnosis of DMII (diabetes mellitus type two) with long term insulin use, requires a therapeutic diet. Diagnosis of GERD (Gastroesophageal reflux disease), potential for gastrointestinal (GI) distress. History of weight refusals, last available weight (LAW) is indicative of obesity III (morbid) per BMI (body mass index). Interventions included to report significant weight gain or loss of five % or more to MD (physician) and/or Registered Dietician; weigh per policy. Review of the admission MDS assessment, dated 08/21/23, revealed Resident #19 was cognitively impaired and required extensive assist of one to two staff for activities of daily living (ADL's). Review of the physician order dated 08/12/22 revealed Resident #19 was ordered weekly weights for two weeks and then monthly. Review of the monthly weight logs provided by STNA #944 who kept the logs in his locker revealed monthly weights were obtained for Resident #19 but STNA #944 had not made those weights available to the other health care staff to enter into the medical records. Interview on 09/06/23 at 2:18 P.M., State tested Nurse Aide (STNA) #944 verified the above findings. Interview on 09/07/23 at 11:57 A.M. with RD #850 revealed when completing assessments she utilized residents diet orders, height and weight, labs, change in medications and change in condition. RD #850 revealed there was one staff member, STNA #944, responsible for resident weights and the DON was responsible for entering weights into the electronic medical record. RD #850 revealed she received all her weights from the electronic medical record and based interventions on the last documented weight. The RD #850 confirmed missing weights for Resident #19. 3. Review of the medical record for Resident #31 revealed an admitted [DATE]. Diagnosis included Alzheimer's disease. Review of the physician order dated 07/28/22 revealed Resident #31 had order for weekly weights times two weeks and then monthly. Review of the admission MDS assessment, dated 08/04/23, revealed Resident #31 was cognitively impaired and required extensive assist of one to two staff for ADL's. Review of the plan of care dated 08/04/23 revealed Resident #31 had an alteration in nutrition secondary to diagnosis of: CKD (chronic kidney disease) and hypertension, requires a therapeutic diet. Diagnosis of GERD, potential for GI distress. Interventions included to report significant weight gain or loss of five % or more to MD (physician) and/or Registered Dietician; weigh per policy. Review of the electronic medical chart (EMR) for Resident #31 revealed the following weights: 09/22/22 - 140.6 lbs, 11/10/22 146.4 lbs, 06/08/23 - 155.8 lbs, 06/21/23 - 155.0 lbs and 08/31/23 - 160.4 lbs. Review of the weight log kept by STNA #944 and provided by the Director of Nursing (DON), revealed Resident #31 had weights obtained in December 2022, January through May 2023 ranging between 154.0 lbs and 158.2 lbs which had not been recorded in Resident #31's resident records. Interview on 09/06/23 at 8:50 A.M. with the Director of Nursing (DON) revealed weights were documented in the electronic medical record and if weights were missing, State tested Nursing Assistant (STNA) #944 kept them in his logbook. Interview on 09/06/23 at 2:18 P.M. with STNA #944 revealed he weighed residents monthly and turned the logs over to the nursing staff. Interview on 09/06/23 at 3:17 P.M., the DON stated STNA #944 kept the weight logs in his personal locker. The DON confirmed the monthly weight log had not been received from STNA #944 and therefore, resident weights were not entered into the EMR. Interview on 09/06/23 at 4:22 P.M., the STNA #944 confirmed the residents monthly weights were located in his personal locker. The STNA #944 confirmed the monthly weight logs had not been turned in to the DON and the resident weights had not been entered in the EMR. Observation on 09/06/23 at time of interview, STNA #944 voluntarily entered the unlocked employee break room and returned to the hallway with a stack of loose papers folded in quarters. The STNA #944 provided the weight logs dated from 01/2023 to 08/2023. Each monthly weight log contained the resident name, room number, date, and body weight. Interview on 09/07/23 at 11:57 A.M. with RD #850 revealed when completing assessments she utilized residents diet orders, height and weight, labs, change in medications and change in condition. RD #850 revealed there was one staff member, STNA #944, responsible for resident weights and the DON was responsible for entering weights into the electronic medical record. RD #850 revealed she received all her weights from the electronic medical record and based interventions on the last documented weight. RD #850 confirmed missing weights for Resident #31. 42730 4. Review of the medical record for Resident #15 revealed an admitted [DATE] with diagnoses including fracture of right femur, mood disorder, and dysphagia. Review of the physician orders for Resident #15 revealed she was to be weighed twice a week and then monthly starting 07/15/23. Further review of the medical record revealed two weights recorded, a weight of 128 pounds on 07/15/23 and 119.4 pounds on 07/18/23 resulting in a 6.72 percent loss. Review of the medical record revealed no other documented weights as of 09/06/23. Review of the admission MDS assessment, dated 07/21/23, revealed Resident #15 had a Brief Interview for Mental Status (BIMS) score of eight indicating she had long-term and short-term cognition impairment. Further review of the MDS assessment revealed Resident #15 was a two-person extensive assist for ADLs and was on a therapeutic diet. Review of the care plan dated 07/18/23 revealed Resident #15 was at risk for alteration in nutrition status, required a therapeutic diet, had a poor appetite, and had potential weight loss with interventions that included monitor weight per policy. Review of the physician orders dated 07/18/23 revealed Resident #15 had an order to provide an additional 120 milliliters of clear liquid at medication pass by mouth three times a day. Review of the physician orders dated 07/19/23 revealed Resident #15 had an order for six ounces fortified juice by mouth every breakfast meal one time a day and four ounces ice cream every lunch meal one time a day. Review of the physician orders dated 08/22/23 revealed Resident #15 had an order to utilize built-up utensils for all meals for increased independence in self-feeding. Review of the physician orders dated 09/02/23 revealed Resident #15 had an order for a health shake one time a day for supplement and Hi-cal shake provided by dietary three times a day for supplement and poor appetite. Review of the admission Medical Nutrition Therapy Assessment, dated 07/18/23, revealed Resident #15 was fed by staff at all meals, had poor appetite, and potential for weight loss. Review of the progress note dated 07/25/23 at 12:59 P.M. revealed Resident #15 had a weight change warning indicating a weight loss of 6.7 percent over the past three days. Review of the logged paper weights provided by STNA #944 and the DON revealed on 08/31/23 Resident #15 had a recorded weight of 107 pounds. Interview on 09/06/23 at 7:50 A.M. with Registered Nurse (RN) #972 revealed Resident #15 was supervised for feeding but most days requested only oatmeal for breakfast, had a poor appetite, and had orders for a lot of supplements. RN #972 revealed Resident #15 needed her weights monitored. Interview on 09/06/23 at 8:50 A.M. with the Director of Nursing (DON) revealed weights were documented in the electronic medical record and if weights were missing STNA #944 kept them in his logbook. Interview on 09/06/23 at 2:18 P.M. with STNA #944 revealed he weighed residents monthly and turned the logs over to the nursing staff. STNA #944 revealed nursing staff kept the records of resident weights. STNA #944 revealed if nursing staff informed him of residents with special cases, he would weigh them accordingly. STNA #944 revealed Resident #15 utilized a sitting chair scale and was weighed monthly. STNA #944 revealed he sometimes did not get a chance to weigh residents as ordered due to being busy with another task. Interview on 09/07/23 at 11:57 A.M. with RD #850 revealed when completing assessments she utilized residents diet orders, height and weight, labs, change in medications and change in condition. RD #850 revealed there was one staff member, STNA #944, responsible for resident weights and the DON was responsible for entering weights into the electronic medical record. RD #850 revealed she received all her weights from the electronic medical record and base interventions on the last documented weight. RD #850 revealed Resident #15 was at risk for weight loss and had multiple interventions in place. RD #850 verified Resident #15 had only two documented weights located in the electronic medical record so had not assessed any other weights obtained for the resident. 5. Review of the medical record for Resident #29 revealed an admitted [DATE] with diagnoses including heart failure, chronic kidney disease, and dysphagia. Review of the physician orders dated 02/02/23 revealed an order for weekly weights, twice a week, then monthly. Further review of the medical record revealed a weight of 185 pounds on 02/13/23 and 181.2 pounds on 08/31/23. Review of the medical record revealed no other documented weights as of 09/06/23. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/11/23, revealed Resident #29 had a BIMS score of 12 indicating he was alert and oriented to person, place, and time. Further review of the MDS assessment revealed Resident #29 was a two-person extensive assist to total dependence for ADLs and was on a therapeutic diet. Review of the care plan dated 08/11/23 revealed Resident #29 was at risk for alteration in nutrition status, required a therapeutic diet, monitor for need for mechanically altered diet, and had potential for weight fluctuations with interventions that included monitor weight per policy. Review of the quarterly Medical Nutrition Therapy Assessment, dated 08/23/23 revealed Resident #29 required staff supervision for meals, required 88 percent consumption for weight maintenance with potential for weight fluctuations and history of fluid volume overload. Review of the logged paper weights provided by STNA #944, and the DON revealed Resident #29 had monthly documented weights from 03/13/23 to 05/27/23. Interview on 09/06/23 at 8:50 A.M. with the DON revealed weights were documented in the electronic medical record and if weights were missing, State tested Nursing Assistant (STNA) #944 kept them in his logbook. Interview on 09/06/23 at 2:18 P.M. with STNA #944 revealed he weighed residents monthly and turned the logs over to the nursing staff. STNA #944 revealed nursing staff kept the records of resident weights. STNA #944 revealed if nursing staff informed him of residents with special cases, he would weigh them accordingly. STNA #944 revealed Resident #29 utilized a Hoyer scale and was weighed monthly. STNA #944 revealed he sometimes did not get a chance to weigh residents as ordered due to being busy with another task. Interview on 09/07/23 at 11:57 A.M. with RD #850 revealed when completing assessments she utilized residents diet orders, height and weight, labs, change in medications and change in condition. RD #850 revealed there was one staff member, STNA #944, responsible for resident weights and the DON was responsible for entering weights into the electronic medical record. RD #850 revealed she received all her weights from the electronic medical record and base interventions on the last documented weight. RD #850 revealed Resident #29 was at risk for weight fluctuations and had a history of fluid overload. RD #850 verified Resident #29 had only two documented weights located in the electronic medical record. 6. Review of the medical record for Resident #20 revealed an admitted [DATE] with diagnoses that included dementia, muscle weakness, and dysphagia. Review of the physician orders for Resident #20 revealed she was to be weighed monthly by the 10th of each month starting 04/10/17. Further review of the medical record revealed a weight of 105.6 pounds documented on 02/07/23, on 06/21/23 a weight of 95.6 pounds and no other weights entered until 08/31/23 of 93.4 pounds. Review of the quarterly MDS assessment, dated 08/09/23, revealed Resident #20 had a short-term and long-term memory problem and was severely impaired for task of daily living. Further review of the MDS assessment revealed Resident #20 was a two-person extensive assist to total dependence for activities of daily living ADLs and was on a therapeutic diet that included a mechanically altered diet for textures of food and liquids. Review of the care plan dated 08/09/23 revealed Resident #20 had a history of weight loss requiring a therapeutic diet that was mechanically altered with interventions that included maintain current body weight plus and/or minus five pounds and monitor weight per policy. Review of the physician orders dated 06/03/22 revealed an order to provide additional 180 cubic centimeters of clear liquid with medication pass two times a day. Review of the physician orders dated 03/01/21 revealed an order for health shake two times a day as a supplement. Review of the physician orders dated 04/18/23 revealed an order for no added salt diet, pureed texture, thin liquids with regular solids at breakfast and mechanical soft solids at lunch and dinner. Review of the quarterly, Medical Nutrition Therapy Assessment, dated 08/14/23 revealed Resident #20 had a loss of 12.3 percent body weight over 172-day period. Resident #20 had varying appetite intake averaging 51 to 100 percent consumptions of most meals. Review of the assessment revealed Resident #20 diet and supplements remained adequate and appropriate to meet nutrition needs with interventions to monitor as appropriate. Interview on 09/06/23 at 8:50 A.M. with the Director of Nursing (DON) revealed weights were documented in the electronic medical record and if weights were missing, State tested Nursing Assistant (STNA) #944 kept them in his logbook. Interview on 09/06/23 at 2:18 P.M. with STNA #944 revealed he weighed residents monthly and turned the logs over to the nursing staff. STNA #944 revealed nursing staff kept the records of resident weights. STNA #944 revealed if nursing staff informed him of residents with special cases, he would weigh them accordingly. STNA #944 revealed Resident #20 utilized seated scale and was weighed monthly. STNA #944 revealed he sometimes did not get a chance to weigh residents as ordered due to being busy with another task. Interview on 09/07/23 at 11:57 A.M. with RD #850 revealed when completing assessments she utilized residents diet orders, height and weight, labs, change in medications and change in condition. RD #850 revealed there was one staff member, STNA #944, responsible for resident weights and the DON was responsible for entering weights into the electronic medical record. RD #850 revealed she received all her weights from the electronic medical record and base interventions on the last documented weight. RD #850 verified Resident #20 was at risk for weight loss and had multiple missing weights not documented in the electronic medical record. Review of the facility document titled Nutrition (Impaired) Unplanned Weight Loss revised September 2017, revealed the facility had a policy in place to monitor and document the weight and dietary intake of residents in a format in which permits comparisons over time, identify individuals with weight loss and/or gain and significant risk for impaired nutrition. Review of the document revealed the facility did not implement the policy.

Based on observation, record review, staff and resident interviews, and policy review, the facility failed to ensure call lights were within reach and accessible. This affected two residents (#5 and #31) of two residents reviewed for call light placement. The facility census was 42. Findings Include: 1. Review of the medical record for Resident #5 revealed she was admitted to the facility on [DATE] with diagnoses including dementia, dysphagia and difficulty walking. Review of the annual, Minimum Data Set (MDS) assessment, dated 07/16/23, revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 10 indicating she was alert and oriented with long-term and short-term cognition impairment. Review of the MDS assessment revealed Resident #5 was a one-person extensive assist for activities of daily living (ADLs). Review of the care plan dated 07/14/23 revealed Resident #5 was at risk for falls and falls with injury due to a history of falls with interventions including call light within reach. Interview on 09/05/23 at 9:30 A.M. with Resident #5 revealed she needed to sit up due to her back pain, needed to use the bathroom, but could not reach staff due to not being able to reach her call light. Observation on 09/05/23 at 9:30 A.M. revealed no call light in reach. Interview on 09/05/23 at 9:33 A.M. with Physical Therapist (PT) #982 revealed all residents had call lights push buttons to request staff assistance and should be within reach. Observation and interview on 09/05/23 at 9:36 A.M. with State tested Nurse Assistant (STNA) #934 revealed STNA #934 was searching for Resident #5's call light. STNA #934 verified Resident #5's call light was not in reach and placed on top of a tissue box on the nightstand adjacent to the bed. STNA #934 stated to Resident #5 it does you no good over there on the nightstand. 2. Review of the medical record for Resident #31 revealed he was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease, dementia, and dysphagia. Review of the annual MDS assessment, dated 08/04/23, revealed Resident #31 had a BIMS score of 4 indicating he had long-term and short-term cognition impairment. Review of the MDS revealed Resident #31 was a one-person extensive assist for ADLs. Review of the care plan dated 08/04/23 revealed Resident #31 had a self-care deficit related to cognitive deficits, dementia, and weakness and was at risk for falls with interventions including call light within reach. Observation on 09/06/23 at 8:14 A.M. revealed Resident #31 call light was on side table and not within reach. Interview and observation on 09/06/23 at 9:06 A.M. with STNA #944 verified Resident #31's call light was on the side table and out of reach. STNA #944 revealed Resident #31 needed to have his call light on the right side of the bed. Review of the facility document titled Answering the Call Light revised September 2022, revealed the facility had a policy in place to ensure timely responses to the resident's request and needs. Further review of the policy revealed the facility staff would ensure the call light was accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor.

Based on record review and interview, the facility failed to ensure a physician order was written for dialysis treatments, a dialysis contract was in place between the facility and the dialysis center, and also failed to ensure assessments before and after dialysis treatments were completed for Resident #145. This affected one resident (#145) of one resident reviewed for dialysis services. The facility census was 42. Findings include: Review of the medical record for Resident #145 revealed an admitted [DATE]. Diagnoses included end stage renal disease (ESRD), dependence on renal dialysis, and congestive heart failure. Review of the 48 hour care plan dated [DATE] revealed the resident received dialysis on Tuesdays, Thursdays, and Saturday. Review of the care plan dated [DATE] revealed the resident was on dialysis and received treatments two to three times per week. At risk for infection, diagnosis of ESRD. Resident had a history of choosing not to go to dialysis as scheduled. Review of the [DATE] physician orders revealed no orders for dialysis. Further review of Resident #145's medical record revealed no evidence of communication forms between the facility and the dialysis center or evidence of before and after dialysis assessments. Interview on [DATE] at 2:58 P.M., the Minimum Data Set (MDS) Nurse #949 verified there was no order for dialysis and stated they knew she was on dialysis when she was admitted . MDS Nurse #949 stated they dropped the ball, but they were putting in the order at this time. Interview on [DATE] at 3:39 P.M., Registered Nurse (RN) #964 stated they were in the process of negotiating a new contract because he believed the old one expired. RN #964 stated he would try to get a copy of the old contract. RN #964 stated they normally don't have anyone on dialysis. Interview on [DATE] at 4:23 P.M., Licensed Practical Nurse (LPN) #976 stated the dialysis center would call with changes and stated they called a couple weeks ago to inform him that Resident #145 was tired and nauseous. LPN #976 stated Resident #145 was skilled care, vitals were taken daily in the morning, and they checked for the presence of bruit and thrills each shift. LPN #976 stated there were no communication forms between the facility and the dialysis center. Interview on [DATE] at 4:57 P.M., the Director of Nursing (DON) stated she had called the dialysis center and was told they emailed the dialysis contract to her when Resident #145 was admitted . DON stated she was waiting for the dialysis center to re-send it. DON stated she never got the original contract when Resident #145 was admitted and was not sure who they sent it to. DON stated after a while she didn't think anything else about it. DON stated Resident #145 was already established at that dialysis center. DON stated they had communication forms at the facility for dialysis, but they did not send them with Resident #145. DON stated the dialysis center also did not ask for them. DON stated the dialysis center did not call the facility except for one time to inform them that the resident had refused, and they were sending her back to the facility. DON stated resident #145 was skilled and they charted on her daily. DON stated vitals were done daily regardless and on dayshift either before or after she returned from dialysis but this did not get communicated in writing to the dialysis center. Follow up interview on [DATE] at 9:50 A.M., the RN #964 stated they were still in process of getting the dialysis contract. RN #964 stated they had one that was still active and there were no changes. RN #964 stated the dialysis center was looking for it and was not able to locate it. RN #964 stated the facility was unable to locate it. Interview on [DATE] at 11:57 A.M., the Registered Dietitian (RD) #850 stated when residents were admitted , she would make a call to the dialysis center and request monthly labs so that they could coordinator with dialysis. RD #850 state she was at the facility once weekly but had not gotten anything on her from the dialysis center. RD #850 stated the dialysis center normally sends them through the fax and nursing gets it. RD #850 stated the nurse would then put it in her mailbox. On [DATE] at 1:36 P.M. the facility still had not provided the dialysis contract to the surveyor.

Based on record review and staff interview the facility failed to ensure the state ombudsman and resident/representatives were notified in writing of all resident transfers to the hospital. This affected two (Resident #40 and #43) of two residents reviewed for hospitalization and had the potential to affect all residents living in the facility. The facility census was 42. Findings include: 1. Review of Resident #40's medical record identified admission to the facility occurred on 06/06/23 with medical diagnoses including sepsis, dementia, and dysphagia. The record identified Resident #40 discharged to the hospital on 06/25/23 returning on 06/28/23, discharged on [DATE] and returned on 07/11/23, and discharged on [DATE] and returned on 07/20/23. Review of both the electronic record and hard charts revealed no evidence the state ombudsman was notified of Resident #40's transfer to the hospital on 07/04/23 and 07/17/23. Further review revealed Resident #40 and/or representative did not receive notification in writing for transfers to the hospital dated 06/25/23, 07/04/23, and 07/17/23. 45753 2. Review of Resident #43's medical record identified admission to the facility occurred on 01/17/22 with medical diagnoses including stroke, dementia, alzheimer's, skin cancer, and depression. The record identified Resident #43 discharged to the hospital on 07/12/23 and did not re-enter the facility. Review of both the electronic medical record and hard chart revealed no evidence Resident #43 and/or representative received notification in writing for transfer to the hospital dated 07/12/23. Interview on 09/07/23 at 9:30 A.M. with Registered Nurse (RN) #964 revealed he was responsible for notifying the ombudsman of discharges and transfers to the hospital and did so via email. RN #964 said he was also responsible to give bed hold notices to residents/resident respresentativees when discharging or transferring to the hospital, but was not doing this because instead all residents were provided the policy on bed holds, discharges and transfers during the admission process and no follow-up information was provided to them. RN #964 verified no evidence the Ombudsman was notified of Resident #40's transfer to the hospital on 07/04/23 and 07/17/23 or Resident #40 and/or representative receiving notification in writing for transfers to the hospital dated 06/25/23, 07/04/23, and 07/17/23. RN #964 also verified he had no evidence Resident #43 and/or representative received notification in writing for transfer to the hospital dated 07/12/23.

Based on medical record review, review of facility bed hold policy and staff interviews, the facility failed to ensure Resident #40 and #43 were provided bed hold notices. This affected two residents (#40 and #43) of two residents reviewed for hospitalization and had the potential to affect all residents living in the facility. The facility census was 42. Findings include: 1. Review of Resident #40's medical record identified admission to the facility occurred on 06/06/23, with medical diagnoses that included sepsis, dementia, and dysphagia. The record identified Resident #40 required hospitalization on [DATE], 07/04/23, and 07/17/23. Review of both the electronic and hard charts revealed no evidence Resident #40 or her family/representative were given information regarding bed hold days remaining and other related procedures for her return to the facility upon each discharge to the hospital. 45753 2. Review of Resident #43's medical record identified admission to the facility occurred on 01/17/22, with medical diagnoses that included stroke, dementia, Alzheimer's, skin cancer, and depression. The record identified Resident #43 discharged to the hospital on 07/12/23 and did not re-enter the facility. Review of both the electronic medical record and hard chart revealed no evidence Resident #43 and/or representative received information regarding bed hold days. Interview with Registered Nurse (RN) #964, occurred on 09/07/23 at 9:30 A.M., verified the lack of bed hold notice given to Resident #40, Resident #43 or their family/representative. RN #964 indicated he was responsible for the bed hold notices but had not been giving them to the residents or their representatives as required when they discharged to the hospital. Review of the facility document titled Bed-Holds and Returns revised October 2022, revealed the facility had a policy in place that residents and/or representatives would be informed (in writing) of the facility and state (if applicable) bed-hold policies. Review of the document revealed the facility did not implement the policy.

Based on record review and staff interview the facility failed to ensure the pre admission screen and resident review status was coded correctly on the Minimum data set (MDS) assessment. This affected two (Residents #1 and #2) of two residents with a level two mental illness currently residing at the facility. The facility census was 42. Findings Include: 1. Record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder, type two diabetes and hypothyroidism. Review of the pre-admission screen and resident review (PASRR) level two evaluation from the state department of mental health dated 11/06/97 revealed Resident #8 had level two mental illness. Review of section A of the most recent comprehensive MDS 3.0 assessment dated [DATE] revealed the facility answered no to the question of Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability (mental retardation in federal regulation) or a related condition? 2. Record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder, major depressive disorder and severe anxiety disorder . Review of the pre-admission screen and resident review (PASRR) level two evaluation from the state department of mental health dated 07/23/15 revealed Resident #13 had level two mental illness. Review of section A of the most recent comprehensive MDS 3.0 assessment dated [DATE] revealed the facility answered no to the question of Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability (mental retardation in federal regulation) or a related condition? MDS Coordinator #949 verified that Resident #1 and #2's PASRR status was coded incorrectly on the MDS in an interview on 09/06/23 at 1:45 P.M.

Based on staff interview, review of personnel files and the abuse policy and procedure, the facility failed to develop and implement policies and procedures to include screening of all employees against the State of Ohio Nurse Aide Registry to identify if an employee had a finding concerning abuse, neglect, exploitation, mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] #570, Maintenance Director (MD) #505, Activities Assistant (AA) #533 and State tested Nursing Assistants (STNAs) #507, #526, #536, #540, #567). This had the potential to affect all 43 residents residing in the facility. Findings include: Review of the personnel files for DA #587 , RN #570, MD #505, AA #533 and STNA's #507, #526, #536, #540, #567 revealed no evidence they were screened using the State of Ohio Nurse Aide Registry. The identification of findings would be necessary to determine if any employee had actions identified that would validate allegations of abuse, neglect, exploitation, mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Interview with the Assistant Director of Nursing on 06/17/21 at 12:50 P.M. verified their was no evidence that DA #587 , RN #570, MD #505, AA #533 and STNA's #507, #526, #536, #540, #567 were screened using the State of Ohio Nurse Aide Registry. Review of the policy entitled Abuse, Mistreatment, Neglect Exploitation and Misappropriation of Resident Property dated 01/01/17 revealed the facility will do the following prior to hiring a new employee Check with the Ohio nurse registry and any other registries for unlicensed persons that the Facility has reason to believe contain information on an individual, prior to the use of that individual.

Based on review of Notice of Medicare Non-Coverage (NOMNC) letters and staff interviews, the facility failed to provide the correct Quality Improvement Organization (QIO) information to residents who were completing therapy. This affected three (Resident #22, Resident #243 and Resident #244) of three reviewed for liability notices. The facility also failed to provide 48-hour notice of the non coverage to the residents. This affected two (Resident #243 and Resident #244) of three reviewed for liability notices. The census was 43. Findings include: 1. Review of Resident #22's medical record revealed the resident was admitted to the facility on [DATE]. A Notice of Medicare Non-Coverage letter revealed services were ended on 06/10/21. The letter did not provide the correct QIO information if the resident wanted to appeal. 2. Review of Resident #243's medical record revealed the resident was admitted to the facility on [DATE]. A Notice of Medicare Non-Coverage letter revealed services were ended on 12/15/20. The letter did not provide the correct QIO information if the resident wanted to appeal. Resident #243 signed his NOMNC on 12/15/20. 3. Review of Resident #244's medical record revealed the resident was admitted to the facility on [DATE]. A Notice of Medicare Non-Coverage letter revealed services were ended on 04/26/21. The letter did not provide the correct QIO information if the resident wanted to appeal. Resident #244 signed her NOMNC on 04/26/21. On 06/16/21 11:10 P.M. Receptionist #511 and Physical Therapist #586 verified the letters to the residents did not provide the correct QIO information and Resident's #243 and #244 signed their NOMNC's on the last covered day of therapy.

Based on record review and staff interview the facility failed to ensure Pre Admission Screen and Resident Review (PASRR) forms were completed timely as required and addressed all applicable mental health and developmental disability diagnoses. This affected two of three residents reviewed for PASRR compliance. The facility census was 43. Findings Include: 1. Resident #12 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the medical record revealed Resident #12 was admitted to the facility on a hospital exemption form which in turn required the completion of the PASRR form within thirty days of admission. Review of the PASRR in the medical record revealed Resident #12's PASRR was completed on 06/16/21. 2. Resident #19 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the medical record revealed Resident #19 was admitted to the facility on a hospital exemption form which in-turn requires the completion of the PASRR form within thirty days of admission. Review of the PASRR in the medical record revealed Resident #19's PASRR was completed on 05/12/21 and the PASRR did not address Resident #19's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the Assistant Director of Nursing on 06/16/21 at 10:10 A.M. verified that Resident #12 and Resident #19 PASRRs were not not completed within the 30 day time frame as required and that Resident #19's PASRR did not address her [CONDITION(S)] diagnosis.

Based on record review and staff interview the facility failed to ensure resident care plans were revised to reflect current resident medical/behavioral conditions. This affected one (Resident #5) of two residents reviewed for elopement. The facility census was 43. Findings Include: Resident #5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #5 was cognitively intact and exhibited no physical, verbal or wandering behaviors. Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the elopement/wandering assessment for 12/16/19 revealed Resident #5 was at a high risk for wandering. Review of subsequent elopement/wandering assessments from 06/10/21, 03/12/21, 12/11/20, 09/21/20 and 06/22/20 revealed the resident was at a low risk for wandering and elopement. The medical record was also absent of any wandering behaviors. Review of the care plan dated 01/03/20 revealed Resident #5 exhibits exit-seeking behavior as evidenced by: Family has voiced concerns that would indicate the resident may have wandering tendencies or try to leave., Resident displays distress over placement., Resident displays restlessness or agitation., Resident has history of verbally expressing the desire to go home, packed belongings to go home. has also been known to walk up to the alarm system to see if it locks when she approaches it. Interview with the Assistant Director of Nursing (ADON) on 06/15/21 at 11:30 A.M. verified Resident #5's care plan was not updated to reflect current wandering behaviors.

Based on record review and staff interview the facility failed to ensure physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This affected two (Residents #5 and #42) of fifteen sampled residents. The facility census was 43. Findings Include: 1. Resident #5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #5 was cognitively intact and exhibited no physical, verbal or wandering behaviors. Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of both the electronic and paper medical records revealed no evidence of monitoring of the placement of Resident #5's Wanderguard. Interview with the Assistant Director of Nursing (ADON) on 06/15/21 at 11:30 A.M. verified their was no evidence of monitoring of the Wanderguard placement. The ADON explained that the paper order was never transcribed in to the electronic system for appropriate documentation and monitoring. 2. Resident #192 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #192 was cognitively intact and required supervision for activities of daily living. Resident #192 was discharged home with home health services on 01/09/20 Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #42 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #42 was cognitively intact and required extensive assistance of two staff persons for activities of daily living. Resident #42 was discharged home with home health services on 01/27/20. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . No other orders were noted in the medical record to address pain related issues/concerns Review of self reported incident (SRI) tracking # 9 on 01/05/20, revealed it was reported a staff nurse used Resident #192's medication for another resident . Review of the facility investigation revealed Resident #42 was complaining of left leg/hip pain, and Registered Nurse #590 indicated that she borrowed a [MEDICATION(S)] patch (pain reliving patch) that had been ordered and dispensed for Resident #142. The facility concluded that the [MEDICATION(S)] patch was in fact applied to Resident #42 without a valid physicians order. The facility Administrator verified the events of the SRI in an interview on 06/16/21 at 12:05 P.M. Review of the policy entitled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property dated 01/01/17 revealed Residents have the right to be free from abuse, neglect, exploitation, and misappropriation of resident property.

Based on record review and staff interview the facility failed to ensure a Wanderguard (device used for alerting staff of exit seeking from a resident) was functioning properly. This affected one (Resident #5) of two residents reviewed for elopement. The facility census was 43. Findings Include: Resident #5 was admitted to the facility on [DATE] with diagnoses that included dementia, major depressive disorder and psychotic disorder. Review of the Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #5 was cognitively intact and exhibited no physical, verbal or wandering behaviors. Review of the physician order dated 12/17/19 revealed an order for a wanderguard to right wrist and to check placement every shift. Observation of Resident #5 ambulating on 06/15/21 at 11:20 A.M. with the Director of Nursing revealed Resident #5's Wanderguard bracelet did not set off any alarms as designed when Resident #5 was near an exit door. The Director of Nursing verified Resident #5's Wanderguard was not functioning properly at the time of observation. Review of the policy entitled Wanderguard System dated 06/12/12 revealed When alarms are utilized, additional monitoring shall be provided, including but not limited to. Verifying alarms are working properly.

Based on record review, policy review and resident interview the facility failed to ensure Resident #5 was free from unnecessary restraint. This affected one (Resident #5) of two residents reviewed for elopement. The facility census was 43. Findings Include: Resident #5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment and exhibited no physical, verbal or wandering behaviors. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Wanderguard Bracelet triggers alarms and locks monitored doors to prevent the wearer from leaving an area unattended. Review of the policy entitled Wanderguard System dated 06/12/12 revealed ongoing assessment of the resident shall occur to identify changes in patterns, routines, or medical symptoms of the resident. Interventions shall be modified, as needed, to address any changes. Interview with the Assistant Director of Nursing (ADON) on 06/15/21 at 11:30 A.M. revealed the facility used an elopement/wandering assessment to assess the need for a Wanderguard. The ADON also explained Resident #5 came in with numerous behavioral issues (including exit seeking behaviors), a medication adjustment was done and Resident #5 stopped having wandering and related behaviors. The ADON further stated that he felt as if the facility never fully trusted her again and never removed the Wanderguard. Review of the elopement/wandering assessments for 06/10/21, 03/12/21, 12/11/20, 09/21/20 and 06/22/20 revealed the resident was at a low risk for wandering and elopement. Interview with Resident #5 on 06/15/21 at 1:10 P.M. revealed she hated the Wanderguard bracelet and found it to be totally unnecessary and felt like she was being treated as a bank robber. Review of the policy entitled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property dated 01/01/17 revealed Residents have the right to be free from abuse, neglect, exploitation, and misappropriation of resident property. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint that is not required to treat the resident's medical symptoms.

Based on observations, staff interview and review of the facility's Coronavirus (COVID-19) policy, the facility failed to ensure personal protective equipment (PPE) was doffed properly prior to exiting rooms of residents diagnosed with COVID-19 to potentially prevent the spread of COVID-19 infections. This had the potential to affect residents residing in the facility. The facility census was 41. Findings include: 1. Observation on 12/28/20 at 8:49 A.M. revealed Maintenance Assistant #100, working as a housekeeper, coming out of Resident #31's room with his gown on. The room was clearly marked See Nurse and had a droplet precaution sign. There was a sign posted to demonstrate donning and doffing of PPE for droplet precautions. Interview at time of the observation with Maintenance Assistant #100 revealed he was just helping because housekeeping was short staffed, and he always wears a gown. He did not know he had to doff the gown prior to exiting the room. 2. Observation on 12/28/20 at 8:57 A.M. revealed Housekeeping Aide #101 coming out of Resident #27's room with her gloves and gown on. Housekeeping Aide #101 took off her gloves and disposed of them in the garbage can attached the housekeeping cart and proceeded to get another pair of gloves to wear. The room was clearly marked See Nurse and had a droplet precaution sign. There was a sign posted to demonstrate donning and doffing of PPE for droplet precautions. Interview at the time of observation with Housekeeping Aide #101 revealed she did not know she had to doff the gown prior to exiting the room. Interview on 12/28/20 at 10:00 A.M. with Infection Control Preventionist #108 revealed all staff were in-serviced on donning and doffing of PPE on 12/08/20 and 12/19/20. Review of facility policy titled PPE and COVID-19, dated 03/21/20, revealed that PPE to be removed before exiting the rooms and wash hands.

Based on record review and interview the facility failed to ensure Resident #57 did not develop avoidable pressure ulcers. This affected one of three residents reviewed regarding pressure ulcers. The census was 46 residents. Harm occurred when interventions were not initiated to prevent the development of an unstageable left heel pressure ulcer. Findings include: Resident #57 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Braden Scale for predicting pressure sore risk dated 05/15/15 indicated the resident was not at risk for skin breakdown. The admission nursing evaluation dated 05/15/15 revealed the resident had no pressure ulcers upon admission. The care plan initiated on 05/25/15 regarding skin integrity indicated the resident did not have any pressure ulcers upon admission on 05/15/15. There were no specific interventions that addressed the prevention of the development of a pressure ulcer. The Minimum Data Set (MDS) assessment dated [DATE] revealed the resident required extensive to minimal assistance of one person for activities of daily living. The MDS also revealed the resident was at risk for the development of pressure ulcers. The MDS tracking indicated the resident was discharged to the hospital on [DATE] and returned to the facility on [DATE]. The nurses note dated 06/02/15 revealed the resident was readmitted to the hospital to repair the left hand. The admission nursing evaluation dated 06/05/15 revealed the resident did not have any pressure ulcers on readmission to the nursing facility from the hospital. The nurses notes dated 06/16/15 revealed an unstageable pressure ulcer was discovered on the resident's left heel. The wound evaluation flow sheet revealed the left heel was discovered on 06/16/15 as an unstageable ulcer the was 0.8 centimeters (cm) long, 1.0 cm with and no depth. The wound bed was covered in 100% slough. The physician ordered on [DATE] for the left heel unstageable pressure ulcer wound to cleanse with normal saline, pat dry, apply Santyl (nickel thick layer bed) and cover with [MEDICATION NAME] once a day and as needed. The update care plan regarding skin integrity dated 06/16/15 indicated an unstageable left heel ulcer was discovered on 06/16/15. The care plan indicated the resident had risk factors that included end stage [MEDICAL CONDITION] and severe protein malnutrition. There were no interventions included in the care plan in an effort to prevent a pressure ulcer from developing. The MDS tracking revealed the resident was discharged again to the hospital on [DATE]. An interview with the Director of Nursing (DON) and Registered Nurse (RN) #1 on 07/23/15 at 2:05 P.M. verified the resident was not identified as at risk for pressure ulcers on the Braden, but was identified as a risk on the MDS assessment. The DON revealed the resident had many severe co-morbidities. He verified the resident had alterations in skin integrity on bilateral lower extremities related to [MEDICAL TREATMENT]. The DON verified the care plan interventions did not address resident specific skin concerns and risks. There were no interventions initiated to prevent pressure ulcers.