Every finding on record at Glendale Place Care Center

Based on medical record review, review of grievance forms, review of the facility Self-Reported Incident (SRI) log, staff interview, and review of the facility policy, the facility failed to timely report an allegation of misappropriation to the state agency. This affected one (Resident #15) of three residents reviewed for misappropriation. The facility census was 113 residents. Findings include:Review of the medical record for Resident #15 revealed an admission date of 06/21/24 with diagnoses including cerebral infarction, epilepsy, and chronic obstructive pulmonary disease (COPD). Review of the facility grievance form for Resident #15 dated 01/16/26 revealed the resident reported to a nurse he was missing $250.00 and last saw it on 01/11/26. There were no actions or resolutions noted on the form.Review of the facility SRIs dated 01/11/26 to 05/19/26 revealed the facility did not report the allegation of misappropriation.Interview on 05/19/26 at 2:45 P.M. with Licensed Practical Nurse (LPN) #201 stated she completed the grievance form for Resident #15 and turned it in to the social worker.Interview on 05/20/26 at 12:26 P.M. with Licensed Social Worker (LSW) #500 stated he remembered he received a voice mail from a staff member regarding Resident #15's allegation of missing money and he does not recall why he did not document further on the matter LSW #500 further confirmed he did not report the allegation to the Administrator and the allegation was not reported to the state agency. Review of the facility policy titled Abuse, Neglect, Misappropriation, and Exploitation dated 10/16/19 revealed allegations of misappropriation should be investigated and reported to the state agency. This deficiency represents noncompliance investigated under Complaint Number 2964354.

Based on medical record review, review of grievance forms, review of the facility Self-Reported Incident (SRI) log, staff interview, and review of the facility policy, the facility failed to investigate an allegation of misappropriation. This affected one (Resident #15) of three residents reviewed for misappropriation. The facility census was 113 residents. Findings include:Review of the medical record for Resident #15 revealed an admission date of 06/21/24 with diagnoses including cerebral infarction, epilepsy, and chronic obstructive pulmonary disease (COPD). Review of the facility grievance form for Resident #15 dated 01/16/26 revealed the resident reported to a nurse he was missing $250.00 and last saw it on 01/11/26. There were no actions or resolutions noted on the form.Review of the facility SRIs dated 01/11/26 to 05/19/26 revealed the facility did not report the allegation of misappropriation.Interview on 05/19/26 at 2:45 P.M. with Licensed Practical Nurse (LPN) #201 stated she completed the grievance form for Resident #15 and turned it in to the social worker.Interview on 05/20/26 at 12:26 P.M. with Licensed Social Worker (LSW) #500 stated he remembered he received a voice mail from a staff member regarding Resident #15's allegation of missing money and he does not recall why he did not document further on the matter LSW #500 further confirmed he did not report the allegation to the Administrator and the allegation was not reported to the state agency. Review of the facility policy titled Abuse, Neglect, Misappropriation, and Exploitation dated 10/16/19 revealed allegations of misappropriation should be investigated and reported to the state agency. This deficiency represents noncompliance investigated under Complaint Number 3001233.

Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure residents received adequate pain management. This affected one (Resident #12) of five residents reviewed for pain management. The census was 113 residents. Findings include: Review of the medical record for Resident #12 revealed an admission of 12/19/22 with diagnoses including Alzheimer's Disease, dementia with behavioral disturbance, and delusional disorder, and a discharge date of 02/14/26. Review of the physician's orders for Resident #12 revealed an order dated 12/19/22 for Tylenol 325 milligrams (mg) two tablets every four hours as needed for pain. Review of the Minimum Data Set (MDS) assessment for Resident #12 dated 01/13/26 revealed the resident was cognitively impaired and required assistance with activities of daily living (ADLs.) Review of care plan for Resident #12 revealed the resident was at risk for alteration in comfort related to functional limitations with an intervention to administer pain medications as ordered. Review of the Medication Administration Records (MARs) for Resident #12 dated January 2026 and February 2026 revealed the resident had a pain level of five on a scale of one to 10 with 10 being the worst pain 01/30/26 and a pain level of six on 02/09/26. There was no documentation of pain medication or other interventions provided to Resident #12 on 01/30/26 and 02/09/26. There was no documentation of a reassessment of pain for Resident #12. Interview on 05/20/26 at 2:35 P.M. with Licensed Practical Nurse (LPN) #210 stated she used the Pain Assessment in Advanced Dementia (PAINAD) scale to determine Resident #12's pain. LPN #210 stated Resident #12 paced and wandered frequently and only occasionally had a facial grimace, and a score above four on a scale of one to 10 was considered the standard point to offer medication interventions. LPN #210 verified she did give ordered pain medications to Resident #12 nor could the nurse recall if any nonpharmacological interventions were offered. Review of the facility policy titled Pain Assessment undated revealed if pain was noted nonpharmacological and pharmacological treatments would be utilized to help control resident pain. This deficiency represents noncompliance investigated under Complaint Number 2805478.

Based on interview, observation, and facility policy review, the facility failed to ensure staff performed hand hygiene during the meal service. Additionally, the facility failed to ensure staff followed sanitary practices regarding resident refrigerators. These different practices had the potential to affect all residents who received meals from the dietary department. Findings included: 1. An undated facility policy titled, General Food Preparation and Handling, indicated, Employees should wash their hands prior to putting gloves on and after removing gloves. The policy also indicated, Tongs or other serving utensils will be used to serve bread or other items to avoid bare hand contact with food.During an observation on 08/06/2025 at 4:26 PM, Dietary Aide (DA) #11 touched his facemask with his left hand, which was gloved. Without changing his glove or washing his hands, he then touched a roll of bread with the same gloved hand.During an observation on 08/06/2025 at 4:45 PM, the Assistant Dietary Director grabbed a lid that fell on the floor, then changed gloves without washing hands. The gloves she used were pulled from her pockets. At 4:50 PM, she touched a bread roll with the same gloved hands.During an interview on 08/07/2025 at 4:03 PM, DA #11 stated he had worked at the facility for the past two months. He stated he had been trained in food handling. He stated that normally, during meal service, the staff used bread tongs or a scooper to serve bread items, and he did not know why they did not have that at the beginning of the meal service on 08/06/2026. He also stated that if he touched his mask with his gloves, he should switch out the gloves and wash his hands. He stated that the staff were expected to wash their hands with every glove change.During an interview on 08/07/2025 at 4:09 PM, the Assistant Dietary Director stated she had worked at the facility since 04/2025. She stated she was trained on food handling and preparation. She stated staff were expected not to store their gloves in their pockets.During an interview on 08/07/2025 at 4:19 PM, the Certified Dietary Manager (CDM) stated that he expected staff to wash their hands with every glove change. He stated DA #11 should have washed his hands and changed his gloves after touching his mask and before touching a bread roll. He also added that staff should not be storing their gloves in their pockets.During an interview on 08/08/2025 at 8:35 AM, the Director of Nursing (DON) stated that staff should wash their hands and change gloves after touching their masks. The DON stated staff should also not store their gloves in their pockets. 2. An undated facility policy titled, Resident Refrigerators, indicated, Leftovers shall be dated upon receipt and discarded within three days.During an observation on 08/07/2025 at 1:46 PM, there was a resealable plastic bag with a container that was labeled seafood alfredo in the nourishment room refrigerator for the 100s hallway. It was dated 07/28/2025 and labeled for Resident #56.During an interview on 08/07/2025 at 1:51 PM, State Tested Nursing Assistant (STNA) #1 stated she did not know the facility policy on when food should be discarded, but she estimated four days. During an observation on 08/07/2025 at 2:11 PM, there was a resealable plastic bag of green grapes that was dated 08/01/2025 and labeled for the resident in room [ROOM NUMBER]-1.During an interview on 08/07/2025 at 2:11 PM, Licensed Practical Nurse (LPN) #4 stated that food items should be discarded after three days, and she discarded the green grapes.During an interview on 08/07/2025 at 4:03 PM, Dietary Aide (DA) #11 stated that the dietary department was responsible for the resident refrigerators. He stated that he was not sure who disposed of outdated food items.During an interview on 08/07/2025 at 4:09 PM, the Assistant Dietary Director stated that the dietary department was responsible for the unit refrigerators, and they should be clearing the food items that were past date.During an interview on 08/07/2025 at 4:19 PM, the Certified Dietary Manager (CDM) stated that the dietary department was responsible for the unit refrigerators, including discarding food items older than three days. He stated all undated food items should also be thrown out. He confirmed that the seafood pasta and grapes should have been discarded.During an interview on 08/07/2025 at 5:31 PM, the CDM stated it was the evening cook who came in at 11:00 AM who rounded on the refrigerators and was responsible for those refrigerators. During an interview on 08/07/2025 at 5:32 PM, [NAME] #11 stated she had worked at the facility since 03/2025. She stated that she usually checked on the unit refrigerators when she arrived at the facility, but she did not get to it that morning. She stated that she believed the nursing staff threw away the resident items brought in from outside, and she did not touch those items because she did not know when they were put in. During an interview on 08/08/2025 at 8:35 AM, the Director of Nursing (DON) stated the dietary department was responsible for the unit refrigerators, but she did not know who specifically in dietary handled the task. She stated that food should be thrown out after three days.

Based on record review, interview, and facility document and policy review, the facility failed to allow residents to withdraw greater than $25.00 at a time from their personal funds accounts for 2 (Resident #12 and Resident #87) of 2 residents reviewed for personal funds. This deficient practice had the potential to affect all 55 residents with personal funds accounts managed by the facility. Findings included: An undated Resident Handbook revealed the section titled, Resident Funds Policy Statement, specified, Residents/Authorized representative have access to these funds Monday-Friday from 9:00 a.m. - 5:00 p.m. Advanced arrangements may be made by the Accounting Department for funds over the weekend through the Gift Shop or Nursing Supervisor with a maximum of $25.00 dollars available for withdrawal per day. 1. An admission Record revealed the facility admitted Resident #12 on 02/01/2024. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/05/2025, revealed Resident #12 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition.During an interview on 08/04/2025 at 10:44 PM, Resident #12 stated they could only withdraw $25.00 a day from their personal funds account. A financial Trust Statement, dated 06/30/2025, revealed that Resident #12 made one Cash Withdrawal in the amount of $25.00 during the timeframe from 04/01/2025 to 06/30/2025. During an interview on 08/06/2025 at 5:58 PM, Accounts Receivable Staff stated residents could typically only withdraw $25.00 a day from their personal funds accounts. She stated that if greater than $25.00 was requested, she could possibly issue a paper check that the resident would be responsible for getting cashed. She provided an example that if a resident wanted to withdraw $75.00, the resident would have to withdraw $25.00 a day for three days. During an interview on 08/07/2025 at 2:10 PM, the Director of Nursing (DON) stated she was not very familiar with resident funds but reported that resident funds should be available for withdrawal anytime up to the amount available in a resident's personal funds account. 2. An admission Record revealed the facility admitted Resident #87 on 09/29/2023. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/02/2025, revealed Resident #87 had a Brief Interview for Mental Status (BIMS) of 14, which indicated the resident had intact cognition. During an interview on 08/04/2025 at 11:10 AM, Resident #87 stated they were only allowed to withdraw $25.00 per day from their personal funds account.A financial Trust Statement, dated 06/30/2025, revealed that Resident #87 had 30 cash withdrawals of no more than $25.00 at a time during the timeframe from 04/01/2025 to 06/30/2025. During an interview on 08/06/2025 at 10:20 AM, State Tested Nursing Assistant (STNA) #1 stated Resident #87 was the only resident who had complained to her about not being able to retrieve money from their personal funds account. During an interview on 08/06/2025 at 5:58 PM, Accounts Receivable Staff stated residents could typically only withdraw $25.00 a day from their personal funds accounts. She stated that if greater than $25.00 was requested, she could possibly issue a paper check that the resident would be responsible for getting cashed. She provided an example that if a resident wanted to withdraw $75.00, the resident would have to withdraw $25.00 a day for three days. During an interview on 08/07/2025 at 2:10 PM, the Director of Nursing (DON) stated she was not very familiar with resident funds but reported that resident funds should be available for withdrawal anytime up to the amount available in a resident's personal funds account.

Based on record review, interview, and facility policy review, the facility failed to consistently provide routine baths to 1 (Resident #112) of 5 sampled residents reviewed for activities of daily living (ADLs). Findings included: A facility policy titled, Activities of Daily Living (ADL) Care, reviewed 01/2024, indicated, Policy Interpretation and Implementation: Nursing staff will assist residents with receiving care and services for residents with ADL needs which may include (but not limited to): basic-self-care tasks such as bathing, dressing, eating, toileting and mobility, oral care based on individual needs.An admission Record revealed the facility admitted Resident #112 on 05/09/2025. According to the admission Record, the resident had a medical history that included diagnoses of hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting the left non-dominant side, acquired absence of right foot, adult failure to thrive, and chronic obstructive pulmonary disease. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/20/2025, revealed Resident #112 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS indicated the resident was dependent on staff for bathing. Resident #112's Care Plan Report included a focus area, initiated 05/22/2025, that indicated the resident had an ADL self-care performance deficit related to cerebral vascular disease, hemiparesis, chronic obstructive pulmonary disease, respiratory failure, fibromyalgia, and diabetes mellitus. Interventions initiated on 05/22/2025 directed staff to adjust the level of ADL support for fluctuations and/or declines in self-care and or mobility, assist with ADLs, and provide one-person physical assistance with bathing. The Care Plan Report did not reflect how frequently the resident was to be bathed.Resident #112's 05/2025 and 06/2025 Documentation Survey Reports revealed documentation that indicated the resident received baths on 05/12/2025, 05/13/2025, 05/22/2025, 06/05/2025, 06/07/2025, 06/08/2025, and 06/16/2025. Per the reports, a code of NA meant not applicable, a code of RX meant the resident was not available, and a code of RR meant the resident refused. The reports revealed staff documentation that indicated the resident was not available for a bath on 05/26/2025, 06/17/2025, and 06/18/2025 (per progress notes, the resident was in the hospital on these dates). The reports revealed staff documented NA for bathing on 05/17/2025, 05/20/2025, 06/03/2025, 06/13/2025 and 06/15/2025. The reports did not include documentation regarding the provision of bathing assistance on any other days and did not reflect any resident refusals. Resident #112's Progress Notes for the timeframe from 05/05/2025 through 06/17/2025 revealed no documented evidence that Resident #112 refused baths or showers. During an interview on 08/07/2025 at 10:16 AM, State Trained Nursing Assistant (STNA) #15 stated that when she documented NA on the bath/shower records, she meant that she did not offer or provide the resident a bath. During an interview on 08/08/2025 at 8:28 AM, STNA #16 stated that if a bath was not given, she documented an NA on the bath/shower records; however, she indicated she documented the same way if the resident refused their bath. During an interview on 08/08/2025 at 9:48 AM, the Director of Nursing (DON) said she expected staff to at least offer baths and document in the resident's electronic medical record (EMR). The DON stated staff should be coding the bath/shower records correctly. This deficiency represents non-compliance investigated under Complaint Number 1336365 (OH00166784).

Based on observation, interview, record review, facility document review, and facility policy review, the facility failed to ensure drugs and biologicals were stored securely in a resident room for 1 (Resident #97) of 1 resident sampled for self-administration of medications. Findings included: A facility policy titled, Self-Administration of Meds [Medications], last reviewed by the facility 03/2021, revealed, Residents may be permitted to self-administer medications when, in the judgement of the care team, it is appropriate and safe to do so. The decision to allow self-administration must be based on an interdisciplinary assessment and documented agreement that the resident has the capacity to manage their medications responsibly. The policy also revealed, Residents may be considered for self-administration of medications following an interdisciplinary review of relevant factors, which may include, but are not limited to, the resident's physical and cognitive abilities, understanding of their medications, and ability to store medications safely.A facility policy titled Medication Storage, last revised by the facility 03/2021, revealed, Except for those requiring refrigeration, medications intended for internal use are stored in a medication cart or other designated area. An admission Record revealed the facility admitted Resident #97 on 08/19/2024. According to the admission Record, the resident had a medical history that included a diagnosis of chronic obstructive pulmonary disease. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/19/2025 revealed Resident #97 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #97's Order Summary Report, with active orders as of 07/01/2025, contained the following orders: - albuterol sulfate (a bronchodilator) hydrofluoroalkane (HFA) inhalation aerosol solution 108 (90 base) micrograms per actuation (mcg/act), with instructions to inhale two puffs orally every six hours as needed for wheezing, unsupervised self-administration, dated 08/13/2024. - Fluticasone propionate suspension (a glucocorticoid steroid) two sprays in both nostrils one time a day for allergies for six months, unsupervised self-administration, dated 03/13/2025. - Incruse Ellipta (an anticholinergic) inhalation aerosol powder 62.5 mcg/act, with instructions to inhale one puff orally one time a day for shortness of breath, unsupervised self-administration, dated 08/13/2024. - Symbicort (a glucocorticoid and long-acting beta-adrenoceptor agonist) inhalation aerosol 160-4.5 mcg/act, with instructions to inhale two puffs orally at bedtime, unsupervised self-administration, dated 08/13/2024. A Self-medication Assessment, dated 10/13/2024, revealed Resident #97 was able to self-administer medications. The Self-medication Assessment also revealed Resident #97 had the dexterity to open locks and had the ability to track time, correctly state the name of medication and the use, read print on prescription labels, correctly state the proper dose of each medication, and administer inhalant medication properly. During an observation on 08/04/2025 at 1:23 PM in Resident #97's room, two inhalers were observed on the resident's bedside stand, and two medication vials were observed on the resident's nightstand near a nebulizer. During an interview concurrent with the observation, Resident #97 stated one of the inhalers was albuterol, which they took as needed, and the other inhaler was Symbicort, which they took every 12 hours. Resident #97 also stated they took the medication by the nebulizer whenever they needed it, and they had a bottle of Flonase (fluticasone) in the drawer across from their bed. Resident #97 stated they had the medication at the bedside since coming to the facility a year prior. During an interview on 08/05/2025 at 2:33 PM, State Tested Nursing Assistant (STNA) #1 stated she was not aware of any residents who self-administered their own medications or had medications in their rooms. STNA #1 also stated if she observed medications in a resident's room, she would remove the medications and inform the nurse. STNA #1 stated she had never noticed any medications in Resident #97's room. During an interview on 08/05/2025 at 3:11 PM, Licensed Practical Nurse (LPN) #2 stated she was not aware of any residents in her assignment, including Resident #97, who self-administered their own medications. LPN #2 also stated if medications were found in a resident's room, even an over-the-counter medication, she would inform the resident they were not allowed to have them in their room and notify the facility's Assistant Director of Nursing (ADON) or Director of Nursing (DON). LPN #2 stated she did not notice any medications in Resident #97's room, but that day was the first time she was assigned to the resident. During an interview on 08/05/2025 at 3:31 PM, the ADON stated the facility had residents who were able to self-administer inhalant medications, but none who were able to self-administer pills. The ADON also stated if a resident wished to self-administer medications, the nurse would complete an assessment to see if the resident could administer their own medications. After the assessment showed the resident was safe to self-administer medications and after being approved by the resident's physician, the order would be entered into the electronic chart with special instructions indicating the resident could self-administer the medication. The ADON stated the medication could be kept at the resident's bedside but was not sure if the medication needed to be locked up inside of the resident's room. The ADON also stated she was not sure if Resident #97 had medications stored in their room, but they might have an as-needed inhaler in their room. During an interview on 08/05/2025 at 4:51 PM, the DON stated the facility did not have any residents who self-administered pill form medications, but some residents self-administered medications such as eye drops, nasal spray, or inhalant medications. The DON also stated if a resident wanted to self-administer medications, an assessment would be completed to ensure the resident was able to administer the medications properly and store the medications safely with return demonstration by the resident. The DON stated if a resident were assessed as able to self-administer medications and the resident's physician approved, the medication would be kept with the resident. The DON also stated she was not sure if the medications needed to be locked up inside the resident's room. During an interview on 08/07/2025 at 9:11 AM, the ADON reviewed the facility's policy titled Self-Administration of Meds and stated storing medications safely would mean the medication would be out of reach of anyone else, and if the medication was stored in the resident's room, they would be locked in a drawer or in a lock box. The ADON also stated medications should be kept secured whether the resident was inside or outside the room. During an interview on 08/07/2025 at 9:38 AM, Resident #97 stated the facility provided the resident with a plastic lock box to store their medications. Resident #97 opened a drawer in their television stand, which contained a plastic box with a locking mechanism. The plastic lock box contained two inhalers and a container of nasal spray. An observation concurrent with the interview revealed two vials of medication sitting on the resident's bedside stand near a nebulizer, unsecured. The resident stated, I didn't even think about that. During an interview on 08/07/2025 at 1:00 PM, the DON reviewed the facility's policy titled Self-Administration of Meds and stated the ability to store medication safely meant providing the resident with a lock box or having medication in a locked drawer in the resident's room. The DON also stated medications should always be kept secure unless they were being administered.

Based on interview, record review, and facility policy review, the facility failed to ensure the medical record reflected the experiences of the resident for 1 (Resident #16) of 26 sampled residents. Specifically, Resident #16's Medication Administration Records (MARs) had several missing entries in May and June 2025. Findings included:A facility policy titled, Medication Administration, dated 02/05/2020, indicated, K. After administration, return to cart and document administration in the (MAR or TAR [Treatment Administration Record]). L. If the resident refuses medication, document refusal on the (MAR or TAR).An admission Record revealed the facility admitted Resident #16 on 09/13/2023. According to the admission Record, the resident had a medical history that included diagnoses of hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side, multiple sclerosis, and type 2 diabetes mellitus.Resident #16's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/14/2025, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment.Resident #16's Care Plan Report, included a problem statement initiated 10/10/2023, that stated Resident #16 had type 2 diabetes mellitus and would choose to decline insulin at times. Interventions directed staff to administer diabetes medication as ordered by the doctor. The Care Plan Report included a problem statement initiated 10/10/2023 that indicated the resident had altered cardiovascular status. Interventions directed staff to administer cardiac medications as ordered. The Care Plan Report included a problem statement initiated 10/10/2023 that indicated the resident was on pain medication. Interventions directed staff to administer medications as ordered.Resident #16's Order Recap [Recapitulation] Report, for the timeframe from 02/01/2025 through 08/06/2025, included the following orders: - An order dated 05/29/2025, for Cymbalta 60 milligrams (mg) delayed release capsule, with instructions to give 60 mg at bedtime for major depressive disorder. The resident's 05/2025 MAR revealed no documentation to indicate whether the medication was administered on 05/31/2025. - An order dated 04/27/2025 and discontinued 06/11/2025, for insulin glargine 100 unit/milliliter (ml), with instructions to inject 38 units subcutaneously one time a day for type 2 diabetes mellitus. The resident's 05/2025 and 06/2025 MAR revealed no documentation to indicate whether the medication was administered on 05/07/2025, 05/14/2025, 06/01/2025, 06/06/2025, and 06/11/2025.- An order dated 06/11/2025 and discontinued 07/21/2025, for insulin glargine 100 unit/ml, with instructions to inject 35 units subcutaneously one time a day for type 2 diabetes mellitus. The resident's 06/2025 MAR revealed no documentation to indicate whether the medication was administered on 06/14/2025 through 06/16/2025.- An order dated 04/27/2025 and discontinued 07/29/2025, for insulin aspart subcutaneous solution pen-injector 100 unit/ml, with instructions to administer per sliding scale for type 2 diabetes mellitus. The resident's 05/2025 MAR revealed no documentation to indicate whether the medication was administered at 9:00 PM on 05/13/2025 and 05/31/2025.- An order dated 02/13/2025, for sertraline hydrochloride (HCI) 150 mg, with instructions to give 150 mg at bedtime for major depressive disorder. The resident's 05/2025 MAR revealed no documentation to indicate whether the medication was administered 05/31/2025.- An order dated 02/13/2025, for carvedilol 12.5 mg, with instructions to give 12.5 mg twice daily for hypertension. The resident's 05/2025 MAR revealed no documentation to indicate whether the medication was administered.- An order dated 02/13/2025, for trazodone HCI 100 mg tablet, with instructions to give one tablet at bedtime for major depressive disorder. The resident's 05/2025 MAR revealed no documentation to indicate whether the medication was administered 05/31/2025.- An order dated 02/13/2025, for calcium polycarbophil 625 mg tablet, with instructions to give one tablet twice daily for preventative constipation. The resident's 05/2025 MAR revealed no documentation to indicate whether the medication was administered 05/31/2025.- An order dated 02/13/2025 and discontinued 06/24/2025, for sennosides-docusate sodium 8.6 - 50 mg tablet, with instructions to give one tablet twice daily for constipation. The resident's 05/2025 MAR revealed no documentation to indicate whether the medication was administered 05/31/2025.- An order dated 02/13/2025, for continuous positive airway pressure (CPAP) per home setting on at bedtime and off in the morning. The resident's 05/2025 MAR revealed no documentation to indicate whether the CPAP was administered 05/31/2025.- An order dated 02/13/2025 and discontinued 07/14/2025, for pregabalin 50 mg capsule, with instructions to give one capsule twice daily for muscle pain. The resident's 05/2025 MAR revealed no documentation to indicate whether the medication was administered 05/31/2025.- An order dated 02/13/2025, for pain scale every shift. The resident's 05/2025 and 06/2025 MAR revealed no documentation to indicate whether the pain scale was completed for the evening shift on 05/13/2025, 05/31/2025 and 06/05/2025, and for the day shift on 05/18/2025. - An order dated 02/13/2025, for titrating oxygen to maintain oxygen saturation of 92% or above every shift. The resident's 05/2025 MAR revealed no documentation to indicate whether supplemental oxygen was administered 05/13/2025 and 05/31/2025.- An order dated 02/13/2025 and discontinued 06/26/2025, for raising the head of bed as tolerated every shift. The resident's 05/2025 MAR revealed no documentation to indicate whether the residents head of bed was raised as tolerated for the evening shift on 05/06/2025, 05/13/2025, and 05/31/2025.- An order dated 02/13/2025, for pantoprazole sodium 40 mg delayed release tablet, with instructions to give one tablet one time a day for heartburn. The resident's 05/2025 and 06/2025 MAR revealed no documentation to indicate whether the medication was administered 05/07/2025, 05/14/2025, 06/11/2025, 06/14/2025, and 06/16/2025.- An order dated 02/13/2025 and discontinued 06/17/2025, for oxygen saturation levels to be checked every shift and as needed for shortness of breath. The resident's 05/2025 and 06/2025 MAR revealed no documentation to indicate whether the resident's oxygen saturation levels were checked for the evening shift on 05/06/2025, 05/13/2025, 05/31/2025, 06/10/2025, 06/14/2025, and 06/15/2025, and the morning shift on 05/18/2025 and 06/17/2025.- An order dated 02/13/2025, for weight-bearing as tolerated (WBAT) every shift for weight bearing status. The resident's 05/2025 and 06/2025 MAR revealed no documentation to indicate whether the staff checked the resident's WBAT during the evening shift on 05/31/2025 and 06/10/2025.During an interview on 08/06/2025 at 1:59 PM, Licensed Practical Nurse (LPN) #5 stated there should not have been blanks in the MAR. LPN #5 stated if a resident was unavailable, staff could have documented that the resident was not available in the MAR.During an interview on 08/06/2025 at 2:59 PM, LPN #9 stated there should not have been blanks in the MAR. During an interview on 08/06/2025 at 3:15 PM, LPN #13 stated there should not have been blanks in the MAR. LPN #13 stated that if a resident refused the medications or it could not be given for whatever reason, it should still have been documented in the MAR. During an interview on 08/08/2025 at 8:35 AM, the Director of Nursing (DON) stated there should never have been blanks in the MAR. The DON stated that if the resident refused, the staff could still have documented those refusals. She stated that it would be difficult to ascertain, just from a blank in the MAR, whether medications had been given and not documented or not administered at all.

Based on observation, interview, record review, and facility policy, the facility failed to ensure multi-use equipment was sanitized between residents for 1 (Resident #42) of 8 residents observed during medication administration. Additionally, the facility failed to ensure personal protective equipment (PPE) was donned prior to entering a transmission-based precautions (TBP) room for 1 (Resident #52) of 3 residents reviewed for TBP.Findings included: 1. A facility policy titled, Cleaning and Disinfecting Environment & Resident Care Equipment, last reviewed by the facility on 10/12/2020, indicated, Environmental Guidelines: Staff will use standard precautions, including appropriate personal protective equipment (PPE) for all rooms unless transmission-based precautions are identified as indicated on posted precaution signs located outside resident rooms. The policy revealed, Surface cleaning and disinfection will be conducted with focus on high touch areas to include, but not limited to: toilet seats & toilet flush handles, grab bars next to toilet, bed assist rails, overbed tray tables, call light buttons, TV and bed remotes, telephones, resident chairs, IV poles, blood pressure cuffs, sinks and faucets, light switches, door knobs and/or levers, countertops, desktops and tables. The policy specified, Resident Care Equipment Guidelines: Single-use equipment will be cleaned when visually soiled. Multi-use items will be routinely cleaned and disinfected after each use, particularly before use for another resident.During medication administration on 08/06/2025 at 8:30 AM, Licensed Practical Nurse (LPN) #4 obtained a blood pressure cuff that had been previously used on another resident and had not been sanitized between residents and started to enter Resident #42's room. LPN #4 was asked about the facility process for sanitizing blood pressure cuffs between residents, and LPN #4 stated there was not a policy to sanitize between residents. LPN #4 stated that she did not normally clean blood pressure cuffs between residents. LPN #4 stated she would sanitize the blood pressure cuffs between residents if a resident was on TBP or enhanced barrier precautions. During an interview on 08/06/2025 at 9:21 AM, LPN #5 stated she sanitized the blood pressure cuff between each resident use.During an interview on 08/07/2025 at 11:56 AM, the Assistant Director of Nursing (ADON), who was also the Infection Preventionist, stated equipment used for multiple residents should be sanitized between use; however (in contrast to her prior statement and the facility policy), she stated she would not expect staff to sanitize the blood pressure cuff between use of residents if the resident was not on any precautions.During an interview on 08/08/2025 at 8:34 AM, the Director of Nursing (DON) stated (in contrast to the facility policy), I do not expect for a multiuse item to be cleaned between residents if it is not known that they have an infection.2. A facility policy titled, Contact Precautions, last reviewed by the facility on 12/19/2020, specified, Staff will use standard precautions in addition to contact precautions as they apply. Staff will wear gloves; gowns, masks, or goggles IF there is a danger of being sprayed or splattered.An admission Record revealed the facility admitted Resident #52 on 03/08/2025. According to the admission Record, the resident had a medical history that included diagnoses of extended spectrum beta lactamase (ESBL) resistance and urinary incontinence.A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/13/2025, revealed Resident #52 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS indicated the resident was occasionally incontinent of urine and bowel.Resident #52's Order Summary Report as of 08/07/2025 revealed an order dated 08/04/2025 for contact isolation for ESBL in urine every shift.During an observation on 08/06/2025 at 11:33 AM, Licensed Practical Nurse (LPN) #6 performed a finger stick blood sugar check on Resident #52. LPN #6 obtained the supplies, performed hand hygiene, applied gloves, then entered the resident's room without donning a gown. A contact precaution sign was on the door. LPN #6 obtained the resident's finger stick blood sugar check. LPN #6 stated the resident was not on contact precautions. LPN #6 stated the PPE to be worn for contact isolation was gloves, mask, and gown. LPN #6 stated the sign read to wear a gown and gloves, but she did not wear a gown when she performed Resident #52's finger sick blood sugar check. LPN #6 stated it was important to wear PPE to protect the resident and herself from disease causing micro-organisms. LPN #6 stated she should have double checked and not assumed the resident was not on precautions when she saw the sign on the door. During an interview on 08/07/2025 at 11:56 AM, the Assistant Director of Nursing (ADON), who was also the Infection Preventionist, stated she expected staff to don PPE for contact precautions. The ADON stated the PPE was a barrier to anything that could be spread through physical contact. The ADON stated staff should have worn a gown as well as gloves when performing the resident's finger sick blood sugar check. During an interview on 08/08/2025 at 8:34 AM, the Director of Nursing (DON) stated sheexpected for PPE use to be specific to that resident and if providing care for a resident on transmission-based precautions, staff should wear gloves, a gown, and a mask. The DON stated she expected gloves, a mask, and a gown to be used to obtain a finger sick blood sugar check on a resident that was on contact precautions.

Based on interview, record review, and facility policy review, the facility failed to provide education regarding the benefits and risks of influenza, pneumonia, and COVID-19 immunizations for 1 (Resident #87) of 5 residents reviewed for infection control. Specifically, Resident #87 declined all vaccinations, but there was no documentation that education was provided regarding the risks and benefits of each immunization.Findings included: An undated facility policy titled, Pneumonia Vaccine Policy, indicated, Prior to offering the pneumococcal immunization, each resident or the resident's representative will receive education regarding the benefits and potential side effects of the immunization.An undated facility policy titled, Influenza Vaccine Policy, indicated, Prior to the administration of the influenza vaccine, the person receiving the immunization, or his/her legal representative, will be provided with a copy of CDC's [Centers for Disease Control and Prevention] current vaccine information statement relative to the influenza vaccination. An admission Record indicated the facility admitted Resident #87 on 09/29/2023. According to the admission Record, the resident had a medical history that included diagnoses of hemiplegia, type 2 diabetes mellitus, stage 3 chronic kidney disease, vascular dementia, and traumatic subdural hemorrhage without loss of consciousness.Resident #87's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/02/2025, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. Resident #87's Care Plan Report, revealed a problem statement initiated 10/23/2023, that indicated the resident's cognitive function fluctuated related to traumatic subdural hematoma. Resident #87's Immunization Audit Report revealed that the resident refused the influenza vaccination on 10/09/2024. The Immunization Audit Report revealed staff documented No in the section titled, Education Provided/By/Date.Resident #87's Immunization Audit Report revealed that the resident refused the pneumococcal vaccination on 12/15/2023. The Immunization Audit Report revealed staff documented No in the section titled, Education Provided/By/Date.Resident #87's Immunization Audit Report revealed that the resident refused the COVID-19 vaccination on 10/09/2024. The Immunization Audit Report revealed staff documented No in the section titled, Education Provided/By/Date.A nursing Health Status Note, dated 10/09/2024, revealed the facility spoke with the resident's family regarding vaccines that were to be offered to the resident that year. The note revealed the family stated it was the resident's decision. According to the note, the resident declined the influenza and COVID-19 vaccinations, but there was no mention of the pneumococcal vaccination. The note revealed no evidence that education was provided to the resident regarding the vaccinations.During an interview on 08/07/2025 at 11:56 PM, the Assistant Director of Nursing (ADON), who was also the Infection Preventionist, stated influenza vaccinations were offered annually starting in September. She stated that pneumonia vaccinations were offered annually unless the resident received a vaccination in the past five years. She stated the COVID-19 vaccinations were offered on admission or if there was a new booster. The ADON stated if residents refused vaccinations, they would document the refusal in the medical record. The ADON stated the facility educated residents and families on vaccinations. During an interview on 08/07/2025 at 1:00 PM, the ADON stated that Resident #87 was admitted to the facility before she was the Infection Preventionist, so she was not sure why the resident's education for immunizations was not documented in their medical record.

Based on record review, interview, and facility policy review, the facility failed to ensure provider orders were followed for 2 (Resident #12 and Resident # 16) of 5 residents reviewed for medication management. Findings included: A facility policy titled, Medication Administration, reviewed 03/2021, revealed, F. Follow the 5 [five] rights of medication administration when administering medications: (1) Right Drug; (2) Right Patient; (3) Right Dose; (4) Right Route; and (5) Right Time. 1. An admission Record revealed the facility admitted Resident #12 on 02/01/2024. According to the admission Record, Resident #12 had a medical history that included a diagnosis of muscle spasms. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/05/2025, revealed Resident #12 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #12's 08/2025 Order Recap [Recapitulation] Report contained an order, dated 07/29/2025, for methocarbamol (a muscle relaxer) 500 milligrams (mg) by mouth three times daily for muscle spasms. Resident #12's 08/2025 Medication Administration Record (MAR) revealed that on 08/02/2025, Licensed Practical Nurse (LPN) #8 documented a 9 for Other/See Progress Notes for the resident's 9:00 AM and 1:00 PM doses of methocarbamol. Resident #12's Progress Notes revealed Medication Administration Notes, dated 08/02/2025 at 1:47 PM and 1:49 PM, that indicated the resident's methocarbamol was on order from the pharmacy. During an interview on 08/06/2025 at 5:36 PM, LPN #8 stated she did not administer Resident #12's methocarbamol on 08/02/2025 and that she documented that it was not available. She did not recall if she reordered the medication or contacted the physician to deviate from the physician medication order. LPN #8 recalled that the medication arrived at the facility at the end of her shift on 08/02/2025. During an interview on 08/07/2025 at 10:12 AM, LPN #4 revealed she was the day shift nursing supervisor on 08/02/2025, and she was not advised that Resident #12 was out of the methocarbamol. During an interview on 08/07/2025 at 11:27 AM, the Pharmacy Consultant stated that Resident #12's methocarbamol was on automatic reorder, and per the pharmacy records, it was received at the facility on 08/02/2025. He did not want to speculate as to why two doses of the methocarbamol were missed. During an interview on 08/07/2025 at 2:22 PM, the Director of Nursing reported that the nurse was responsible for ensuring that medication orders were carried through by communicating with the pharmacy, provider, and family. She stated she did not know that two doses of the methocarbamol had not been administered to Resident #12. 2. An admission Record revealed the facility admitted Resident #16 on 09/13/2023. According to the admission Record, the resident had a medical history that included diagnoses of hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side, multiple sclerosis, and type two diabetes mellitus. Resident #16's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/14/2025, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. Resident #16's Care Plan Report included a focus area, initiated 10/10/2023, that indicated the resident had type two diabetes mellitus and chose to decline insulin at times. An intervention dated 10/10/2023 directed staff to administer diabetes medication as ordered by the doctor, to monitor/document/report to the medical doctor any signs or symptoms of hypoglycemia, and to complete fasting serum blood sugars as ordered by the doctor. Resident #16's Order Recap [Recapitulation] Report included an order, dated 04/27/2025, for insulin apart subcutaneous solution pen injector 100 units per milliliter (units/mL) per sliding scale (an order in which the dose of insulin depends upon the blood sugar value at the time of administration). The Order Recap Report also included an order, dated 02/13/2025, that indicated, If BS [blood sugar] is less than 70 [milligrams/deciliter (mg/dL)], administer glucose solution po [by mouth]; recheck BS every 30 minutes X 4. Resident #16's 06/2025 Medication Administration Record (MAR) for the month of 06/2025 revealed that on 06/09/2025 at 9:00 PM, Licensed Practical Nurse (LPN) #7 documented that no coverage of sliding scale insulin was required due to a blood sugar of 63 mg/dL. The MAR also revealed that on 06/10/2025 at 8:00 AM, LPN #9 documented that no coverage of sliding scale insulin was required due to a blood sugar of 66 mg/dL. The MAR revealed no documented evidence that glucose solution was administered or repeat blood sugar checks were performed as ordered after the resident's blood sugar was found to be less than 70 mg/dL on 06/09/2025 or 06/10/2025. Two attempts were made to interview LPN #7 on 08/06/2025 at 3:14 PM and on 08/07/2025 at 8:12 AM. Neither attempt was successful. During an interview on 08/06/2025 at 2:59 PM, LPN #9 stated if a resident's blood sugar was below 70 mg/dL, she should hold insulin and give juice, then recheck their blood sugar every 30 minutes until it came back up. She stated she had never had to give Resident #16 glucose solution and usually gave the resident something sugary, rather than the glucose solution that was ordered. LPN #9 stated that she had not talked to the physician about the order but should have. LPN #9 further stated she only did the blood sugar checks every 30 minutes if Resident #16's blood sugar fell below 60 mg/dL; however, she had not talked to the doctor about that either, but she stated she should have. During an interview on 08/07/2025 at 8:54 AM, Medical Doctor #10 stated he expected nursing staff to follow ordered parameters. He stated if a resident's blood sugar fell below 70 mg/dL, there needed to be follow-up blood sugar checks. Medical Doctor #10 stated that he preferred for staff to follow orders as written, but he would not chastise the nurse about administering a sugary beverage like orange juice rather than the glucose solution. He did state that if a nurse disagreed with the order, they needed to speak to the unit manager who could contact him, and they could fine tune the orders to improve patient care. During an interview on 08/08/2025 at 8:35 AM, the Director of Nursing stated the nursing staff should always follow the physician's orders. If the nursing staff disagreed with an order, they should discuss it with the physician.

Based on interview, record review, and facility document review, the facility failed to honor a resident's right to choose a medication administration schedule consistent with resident preferences for 1 (Resident #97) of 2 residents sampled for choices. Findings included:During an interview on 08/07/2025 at 11:21 AM, the facility's Chief Nursing Officer (CNO) stated the facility did not have a policy related to resident choices and/or resident preferences. An admission Record revealed the facility admitted Resident #97 on 08/19/2024. According to the admission Record, the resident had a medical history that included diagnoses of chronic obstructive pulmonary disease, type 2 diabetes mellitus with unspecified complications, and gastro-esophageal reflux disease without esophagitis. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/19/2025, revealed Resident #97 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #97's Order Summary Report, with active orders as of 07/01/2025, contained the following orders: - aspirin (an antiplatelet) 81 milligrams (mg) by mouth one time daily for pain dated 08/13/2024.- dexlansoprazole (a proton pump inhibitor) delayed release capsule 60 mg by mouth one time a day for ulcers dated 08/13/2024.- escitalopram oxalate (an antidepressant) 10 mg by mouth one time a day for depression dated 09/21/2024.- Lantus insulin glargine (a man-made form of human insulin) inject 20 units subcutaneously one time a day related to type 2 diabetes mellitus with hyperglycemia dated 03/13/2025.- loratadine (an antihistamine) 10 mg give one tablet by mouth one time a day for allergies dated 08/13/2024- metoprolol succinate (a beta blocker) extended release (ER) 24 hour 50 mg by mouth one time a day for hypertension dated 08/13/2024.- montelukast sodium (a leukotriene receptor antagonist) 10 mg by mouth one time a day for asthma dated 08/13/2024.- Ozempic semaglutide solution (a glucagon-like peptide-1 agonist) inject 2 mg subcutaneously one time a day every Wednesday related to type 2 diabetes mellitus without complications dated 08/26/2024.- spironolactone (a potassium-sparing diuretic) 25 mg by mouth one time a day for edema dated 08/13/2024.- gabapentin (an anticonvulsant) 300 mg by mouth two times a day related to polyneuropathy dated 10/27/2024. - Percocet oxycodone with acetaminophen (an opioid pain medication) 5 mg (oxycodone) 325 mg (acetaminophen) by mouth three times a day for pain dated 09/04/2024. Resident #97's July 2025 Medication Administration Record [MAR] revealed that on 07/26/2025, the following medications had changes to the administration times: aspirin 81 mg, dexlansoprazole 60 mg, escitalopram 10 mg, insulin glargine 20 units, loratadine 10 mg, metoprolol succinate ER 50 mg, montelukast 10 mg, and spironolactone 25 mg were changed from 6:00 AM administration to 9:00 PM administration. The MAR revealed gabapentin 300 mg two times a day was changed from 6:00 AM to 9:00 AM and from 6:00 PM to 9:00 PM, and Oxycodone with acetaminophen 5 mg/325 mg three times a day was changed from 6:00 AM to 9:00 AM, 2:00 PM to 1:00 PM, and 10:00 PM to 9:00 PM on 07/26/2025. The MAR also revealed Resident #97's administration times for Ozempic semaglutide 2 mg were changed from 6:00 AM to 9:00 AM on 07/30/2025. During an interview on 08/04/2025 at 1:23 PM, Resident #97 stated their medication administration times were changed from 6 to 9 the previous week, and they were not provided an explanation why the medication administration times were switched. Resident #97 stated they would prefer to have their medications administered at the previous times before the facility changed them. During an interview on 08/05/2025 at 2:33 PM, State Tested Nursing Assistant (STNA) #1 stated if a resident communicated a concern to her related to medication times, she would inform the nurse. STNA #1 stated she was familiar with Resident #97, and the resident was, in an uproar and was worked up about their medication administration times being changed and told STNA #1 about their concerns over one week prior. STNA #1 stated she informed the nurse, Licensed Practical Nurse (LPN) #3, after speaking with Resident #97 and told them about Resident #97's concerns. During an interview on 08/05/2025 at 3:31 PM, the facility's Assistant Director of Nursing (ADON) stated if a resident expressed a concern related to medication administration times, they would try to accommodate the resident's concern in accordance with resident rights and the resident's needs. The ADON also stated if the resident's medication administration times needed to be changed, the resident would be notified of the changes if the resident was alert and oriented. The ADON stated if a resident disagreed with the change of their medication administration times, the medication administration times would be changed back to the time the resident preferred, with approval from the resident's physician. The ADON stated sometime around the middle of August 2025, the facility would be switching pharmacies, and the resident's medication administration times were changed to keep times consistent and so the nursing staff could provide more direct care to the residents in the facility. The ADON also stated she spoke with Resident #97 a couple of days prior, and the resident wanted their medications switched back to the time they were administered before the times were changed because the medications did not sit well with the resident during meals. The ADON stated she told Resident #97 the medication administration times would be changed back to the times they were administered before the times were changed, but the change had not been implemented as of the time of the interview. The ADON stated the change was pending approval from the resident's physician.During an interview on 08/05/2025 at 4:51 PM, the facility's Director of Nursing (DON) stated if a resident had a concern related to the timeframe of their medication administration, she would expect staff to speak to the resident about the concern and contact the resident's physician to change the medication administration orders to the resident's preferred time. The DON also stated she spoke with Resident #97 the week before, regarding the resident's diuretic medication being administered at 9:00 PM and the resident's concerns related to urinating throughout the night. The DON stated she reviewed the resident's medications and did not see a diuretic medication administered at 9:00 PM. The DON also stated Resident #97 did not express concerns to her about their other medications and the administration times. The DON stated she would expect nursing staff to call the resident's physician as soon as possible if concerns were communicated related to medication administration times to change the medication administration times to the resident's preferred time if the change did not conflict with the resident's next dose of the medication. The DON stated the facility changed medication administration times, so medications were all passed around the same timeframes to allow more time for nursing staff to provide bedside care. The DON also stated the facility was just kind of moving the medication administration times unless the resident preferred a different administration time, and residents were not informed of the changes in administration times. The DON stated medication administration times should be resident-centered and would depend on the resident's preference. The DON also stated, Something that simple should not take a week.On 08/06/2025 at 5:51 PM, a telephone interview was attempted with LPN #3. The call was not answered, and a message was left for a return phone call. During an interview on 08/07/2025 at 1:00 PM, the DON stated she reached out to LPN #3 and stated, I told her to return your call. LPN #3 did not provide a return phone call.

Based on observation, staff interview, and policy review, the facility failed to ensure staff practiced appropriate hand hygiene practices while passing meals trays. This affected 11 (#19, #63, #269, #32, #64, #5, #40, #33, #46, #10, and #50) of 11 residents observed during lunch. This had the potential to affect all 29 residents residing on the 200-hall. The facility census was 78. Findings include: 1. Observation on 06/27/22 at 12:24 P.M. revealed State tested Nursing Assistant (STNA) #300 pushing a meal tray cart of lunch trays down on the 200-hall. STNA #300 retrieved a tray from the cart and entered Resident #19's room. STNA #300 was observed pushing Resident #19 in her wheelchair and repositioning her in front of the meal tray. STNA #300 then exited Resident #19's room, carrying a mug, walked down to the opposite end of the 200-hall, where another meal tray cart was stationed, and filled the mug with coffee. STNA #300 returned to Resident #19's room, delivered the mug of coffee, and exited the room. STNA #300 proceeded to retrieve another tray from the meal tray cart and delivered it to Resident #63, who was seated in the common area. STNA #300 pushed Resident #63 in her wheelchair to position her in front of her meal tray at the table, and then assisted with setting up the tray. STNA #300 was not observed completing hand hygiene at any point during the observations. Continued observation on 06/27/22 at 12:29 P.M. revealed STNA #300 retrieved another tray from the meal tray cart and delivered it to Resident #269 in her room. STNA #300 called for STNA #141 to assist with repositioning Resident #269 in bed. STNA #300 and #141 repositioned Resident #269. Observation on 06/27/22 at 12:32 P.M., STNA #300 exited Resident #269's room and hand hygiene was not performed. STNA #300 then pushed an unidentified resident in her wheelchair up to a table in the common area, proceeded to the meal tray cart, retrieved another tray from the cart and delivered the tray to the room of Residents #32 and #64. Observation on 06/27/22 at 12:37 P.M., STNA #300 performed hand hygiene. Interview on 06/27/22 at approximately 12:55 P.M., STNA #300 stated she normally performed hand hygiene after delivering, every couple of trays. STNA #300 stated she washed her hands in the sink of Resident #19's room after passing her meal tray (though not observed by the surveyor at any point during continuous observation). STNA #300 verified she continued to pass trays to multiple residents as well as reposition and/or assist residents without performing hand hygiene between each encounter. 2. Observation on 06/27/22 at 12:13 P.M. revealed State tested Nursing Assistant (STNA) #141 delivered lunch trays to Residents #5 and #40 wearing gloves. STNA #141 did not remove gloves or perform hand hygiene. At 12:15 P.M. STNA #141 continued to pass trays to Residents #33 and #46 wearing the same gloves and did not perform hand hygiene. At 12:17 P.M. STNA #141 continued to pass trays to Residents #10 and #50 wearing the same gloves and did not perform hand hygiene. STNA #141 delivered lunch trays to six residents without changing gloves or performing hand hygiene. Interview on 06/27/22 at 12:18 P.M. STNA #141 verified she wore the same gloves and did not practice hand hygiene after delivering lunch trays to six residents. STNA #141 stated she, Was not aware she needed to change gloves and cleanse her hands in-between passing lunch trays to each resident. Review of the facility policy titled, Hand Hygiene, revised 02/2021, revealed hand hygiene should be performed before and after direct resident contact, after contact with a dirty item, during meal service, and after contact with inanimate objects in the resident's room or immediate care environment. This deficiency substantiates Complaint Numbers OH 315 and OH 813.

Based on medical record review, staff interview, and review of facility policy, the facility failed to obtain and monitor residents' weights as ordered. This affected five (#49, #222, #223, #53, and #3) of five residents reviewed weights obtained as ordered. The facility census was 78. Findings include: 1. Review of medical record for Resident #49 revealed an admitted [DATE] and discharge date of [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required extensive assistance with bed mobility, dressing, toileting, and maintaining personal hygiene. The resident required supervision and set up for eating. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #49's weight records revealed there were no weights documented for 05/22/22, 05/24/22, 05/26/22, 06/02/22, 06/04/22, 06/06/22, 06/07/22, 06/08/22, 06/09/22, 06/11/22, 06/12/22, 06/15/22, 06/16/22, 06/19/22, 06/20/22, 06/21/22, 06/23/22, 06/24/22, 06/25/22, and 06/26/22. Interview on 06/28/22 at 4:00 P.M. Diet Technician (DT) #114 verified Resident #49 was not weighed before breakfast as ordered. 2. Review of the medical record for Resident #222 revealed an admitted [DATE] and discharge date of [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #222 was cognitively intact, required supervision and setup only for eating, and limited assistance for all other activities of daily living (ADLs). Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #222's weight record for June 2022 revealed the resident's weight was obtained on 06/10/22 and 06/28/22. There were no additional weights records for June 2022. Interview on 6/28/22 at 2:05 P.M. DT #114 verified there were no weights documented for Resident #222 from 06/10/22 to 06/28/22. 3. Review of the medical record for Resident #223 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident was assessed as not exhibiting any behaviors, including rejection of care. The resident required extensive assistance for bed mobility, transfers, toileting, and supervision for eating. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #223's weight record revealed the resident was weighed on 06/18/22 and again on 06/28/22, 10 days apart. There was no additional documentation of Resident #223's weight for June 2022. Interview on 06/28/22 at 1:58 P.M. DT #114 verified Resident #223 was not weighed as ordered. 4. Review of the medical record for Resident #53 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #53 was cognitively intact and required supervision and set up for eating, and extensive assistance for all other activities of daily living (ADLs). Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #53's weight record for June 2022 revealed the resident's weight was obtained on 06/03/22 and 06/29/22. There were no additional weights documented between 06/02/22 and 06/29/22. Interview on 06/28/22 at 1:58 P.M. DT #114 verified Resident #53 was not weighed weekly as ordered. 5. Review of the medical record for Resident #3 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition. Resident #3 required extensive assistance to total dependence for all activities of daily living (ADLs). Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3's weight record revealed a weight was obtained on 03/11/22 and 04/11/22. There were no weights documented between 03/11/22 and 04/11/22. Interview on 06/28/22 at 2:00 P.M. DT #114 verified weekly weights were not obtained for Resident #3 as ordered.

Based on medical record review and staff interview, the facility failed to notify the physician of residual fluid (fluid/contents that remain in the stomach), as ordered, for a resident who had a feeding tube. This affected one resident (Resident #42) of four residents reviewed for notification of change in condition and feeding tubes. The facility census was 78. Findings included: Review of the medical record for Resident #42 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 had severe cognitive impairment and required total assistance for eating, locomotion, bed mobility, transfers, dressing, toileting, and personal hygiene. Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #42's tube feeding residual levels revealed on 06/24/22 during day shift, Resident #42's residual level was 120 milliliters (ml). On 06/28/22 during day shift, Resident #42's residual level was 120 ml. Further review of the medical record revealed there was no documented the physician was notified of elevated residual levels. Interview on 06/29/22 at 12:48 P.M. Registered Dietitian (RD) #157 verified Resident #42 had tube feeding residuals documented over 60 ml and there was no documentation of physician notification. Interview on 06/29/22 at 2:47 P.M. Medical Director (MD) #400 verified facility staff had not notified him of Resident #42's elevated tube feed residuals.

Based on medical record review, review of facility Self-Reported Incidents (SRI), staff interview, and review of facility policy, the facility failed to ensure resident-to-resident verbal altercations and threats were reported to the state agency. This impacted two (#01 and #270) of four residents reviewed for abuse. The facility census was 78. Findings include: Review of the medical record of Resident #01 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderately impaired cognition. The resident required supervision for bed mobility, transfers, and toileting and was independent for eating. Review of the progress note dated 05/07/22 at 8:04 A.M. Licensed Practical Nurse (LPN) #91 documented Resident #01 was upset because another resident (Resident #270) was in her room, in the bed, yelling at her, and held his fist up at her. Review of the medical record of Resident #270 revealed an admitted [DATE]. The resident passed away in the facility on 05/16/22. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the comprehensive MDS assessment dated [DATE] revealed Resident #270 had severe cognitive impairment. The resident was assessed as exhibiting continuous inattention, daily rejection of care, and had wandering behaviors. The resident required extensive assistance of one staff for bed mobility, transfers, and toileting, and was dependent for eating. Review of the progress note dated 05/07/22 at 12:46 A.M. LPN #91 documented Resident #270 was combative with care, getting in and out of a resident's bed and yelling at another resident, and put his fist in her face (Resident #01). Review of the facility's SRIs revealed the incident occuring on 05/07/22 was not reported. Interview on 06/28/22 at 4:13 P.M. the Administrator stated the incident was investigated, however an SRI was not completed because they did not believe any type of abuse had occurred. The Administrator further verified the altercation occured between Residents #01 and #270 and Resident #270 no longer resided in the facility. Review of the facility policy titled, Abuse, Neglect, Misappropriation, and Exploitation, dated 10/16/19, revealed all alleged violations would be reported to the state agency no later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to ensure oxygen tubing was changed as ordered. This affected one (172) of three residents reviewed for dated oxygen tubing. The census was 78. Findings include: Review of the medical record for Resident #172 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. Resident #172 required extensive assistance for activities of daily living (ADLs) and supervision for eating. The resident utilized oxygen. Review of physician orders revealed an order dated 12/20/21 to change oxygen tubing weekly, every Monday. Observation on 06/27/22 at 10:15 A.M. revealed the oxygen tubing for Resident #172 was dated 06/06/22. Interview on 06/27/22 at 12:32 P.M. with Licensed Practical Nurse (LPN) #145 confirmed the oxygen tubing for Resident #172 was dated 06/06/22. Review of the facility policy titled, Oxygen Administration, dated 03/2021 revealed oxygen concentrators would be check weekly, tubing changed, and filters cleaned and rinsed.

Based on medical record review, observation and staff interview, the facility failed to follow physician treatment orders. This affected one resident (#10) of three reviewed. The facility identified 12 residents (#08, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, and #21) who have daily dressing changes. The facility census was 74. Findings include: Review of the medical record revealed Resident #10 was admitted on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set, dated dated dated [DATE] revealed Resident #10 had severe cognitive deficits, required extensive assistance to total dependence with activities of daily living and had a [CONDITION(S)] for bowels and always incontinent of bladder. Review of the care plan dated 04/30/21 revealed Resident #10 had actual skin integrity with a left breast skin lesion related to a historical site of cancer. Interventions included to provide the skin treatment as ordered. Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 04/19/22 at 10:35 A.M. with State tested Nursing Assistant (STNA) #22 and STNA #24 provided incontinence care for Resident #10 revealed a dressing on the resident's left breast dated 04/17/22 7:00 P.M. to 7:00 A.M. shift. Interview on 04/19/22 at 10:57 A.M., with the Licensed Practical Nurse (LPN) #20 verified the date on Resident #10's dressing was 04/17/22 and had not been changed. Interview on 04/19/22 at 11:28 A.M., with the Director of Nursing (DON) reported there was no specific policy on wound care they follow the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] This deficiency substantiated Complaint Number OH 707.

Based on medical record review, observation, resident and staff interview, review of a facility self-reported incident (SRI), review of a facility investigation, review of police reports and review of facility policy, the facility failed to ensure a resident medical record contained documentation regarding an allegation of sexual abuse by facility staff, including transportation of resident to the hospital for evaluation related to allegation of sexual abuse. This affected one (#65) of three residents reviewed for abuse. Facility census was 66. Findings include: Review of the medical record for the Resident #65 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the comprehensive Minimum Data Set (MDS) assessment for Resident #65, dated 09/08/21 revealed the resident had impaired cognition. The resident required extensive assistance of one staff for bed mobility, transfers, ambulation. Review of behavior and mood was silent for incidents during the assessment period. Review of the plan of care for Resident #65 dated 09/29/21 revealed resident had altered behaviors related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nurse progress notes for Resident #65 dated from 09/01/21 to 10/13/21 revealed the notes contained no documentation related to the allegation of sexual abuse or the transportation of the resident to the hospital for evaluation. Review of a SRI for Resident #65 dated 09/28/21 and time stamped 12:07 P.M. revealed the resident reported to Occupational Therapist #9 that a staff member (no further details were provided) touch his butt inappropriately during care. The facility management team investigated the incident and Resident #65 made different statements of the event with each interview. Resident #65 then reported the incident to a family member that was visiting and stated he was raped two times. The family member stated he has made comments like this in the past when he wants something changed or wanted to go home. The facility contacted the police and a report was made. The physician was notified and ordered a transfer to the hospital for evaluation. The allegation of sexual abuse was investigated and unsubstantiated. Review of the facility investigation dated 09/28/21 and timed 12:07 P.M. revealed the sexual abuse allegation was investigated. The local police department was notified and a report was filed. Resident #65 was transported to the hospital for evaluation on 09/28/21. The facility provided abuse education to all facility staff as a result of the alleged incident. Further review of the investigation revealed Resident #65 alleged rape by a facility staff member to a family member visiting the resident. Review of the local hospital record dated 09/28/21 revealed the reason for visit was assault. An examination, laboratory studies and radiography imaging were completed. Review of the local law enforcement report dated 09/28/21 at 1:22 P.M. revealed officers were dispatched to the facility for possible sexual assault. Officers noted the facility had initiated an investigation and were making arrangements to transport the resident to the hospital for evaluation. During observations made on 10/13/21 at 12:45 P.M. of Resident #65 revealed resident resting in bed in his room without apparent distress. An attempted interview with Resident #65 revealed the resident was unable to recall any incidents involving sexual abuse but stated he went to the hospital a while back. Interview on 10/13/21 at 3:17 P.M., the Administrator stated Resident #65 reported to Occupational Therapist #9 that he was touched inappropriately on his butt by a staff member caring for him. Director of Therapy #10 reported this information to the Administrator, and an investigation was started immediately. Resident #65 was sent to the hospital and the police was notified. Interview with Corporate Registered Nurse on 10/13/21 at 4:13 P.M. verified the investigation was completed as part of the risk management tab in the electronic health record and not part of the medical record assessable by all users. Interview with Licensed Practical Nurse (LPN) #212 on 10/13/21 at 4:30 P.M. verified she assisted in the transfer of Resident #65 to the hospital for evaluation and did not chart it the transfer or the information. Interview with the Unit Manager Licensed Practical Nurse (LPN) #12 on 10/13/21 at 4:41 P.M. verified she called the doctor for the order to transport Resident #65 to the hospital and did not chart it in the nursing notes. Interview on 10/13/21 at 5:25 P.M. with the Director of Nursing (DON) verified the incident or the transportation of Resident #65 was not in the nurses progress notes. The DON further stated the transportation should have been documented in the nurses notes. Additionally, the DON stated a head to toe assessment was completed prior to transfer and not documented in the progress notes. The DON stated family was notified as they were in the facility when the allegation was reported and can be found in the investigation of the incident. Review of facility policy titled Change in Condition, dated 01/21, revealed the facility will document in the medical record information relative to the residents changes and assessments. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on review of the medical record, personnel record, a facility Self-Reported Incident (SRI), witness statements, employee timecard, a social media video post, the facility's Abuse, Neglect and Exploitation policy, the facility's Social Media policy, a police report and staff interviews, the facility failed to ensure one cognitively impaired resident (Resident #20) was free from potential mental and emotional abuse by facility staff. This resulted in Immediate Jeopardy and the potential for psychosocial harm for one resident (Resident #20) when State tested Nurse Aide (STNA) #01 took a video of herself combing Resident #20's hair. STNA #01 and Resident #20 had a verbal exchange, including expletive words. Resident #20 attempted to pull the comb away from the STNA while she provided care. STNA #01 posted the video on Snap Chat (a Social Media Website) without the resident's consent, and the video was reposted to Facebook (another Social Media Website) by an unidentified person. Applying the reasonable person concept to the incident, could potentially result in the person feeling humiliated, demeaned and exploited due to being posted on Social Media Websites for others to view. This affected one of three residents reviewed for abuse. On 06/29/20 at 3:00 P.M., the Administrator, the Director of Nursing (DON) and Corporate Registered Nurse (RN) #02 were notified that Immediate Jeopardy began on 06/24/20 when STNA #01 took a video of herself combing Resident #20's hair. Review of the video revealed STNA #01 and Resident #20 had a verbal exchange, including expletive words. Resident #20 attempted to pull the comb away from the STNA while she provided care. Resident #20 was observed to be agitated and upset during the incident and cursed at the STNA. The Immediate Jeopardy was removed on 06/25/20 when the facility implemented the following corrective actions: · On 06/24/20 at 4:10 P.M., Admissions Coordinator #04 informed Licensed Practical Nurse (LPN) Supervisor #03 of a video of a resident (Resident #20) being posted on social media. On 06/24/20 at 4:13 P.M., the Administrator and the DON received notification from LPN Supervisor #03 of the video. The Administrator and the DON initiated an internal investigation involving the video. The DON notified Resident #20's family of the video being posted on social media. · On 06/24/20 at 4:15 PM, the facility began obtaining statements from staff interviews. All staff statements were obtained by 06/25/20 at 9:00 A.M. · On 06/24/20 at 4:16 P.M., STNA #01 was suspended and asked to leave the facility. LPN Supervisor #03 assessed Resident #20 with no injuries noted. · On 06/24/20 from 4:19 P.M. to 4:40 P.M., the Administrator spoke with Social Media Consultant #05 and gathered further details of the video. · On 06/24/20 at 4:23 P.M., the DON notified Medical Director #07 and Physician #06 of the incident. · On 06/24/20 at 4:30 P.M., LPN Supervisor #03 initiated education on the Health Insurance Portability and Accountability Act (HIPAA) and the abuse, neglect, the social media and resident rights policies. · On 06/24/20 at 4:45 P.M., the Administrator contacted Admissions Coordinator #04 for her witness statement and at that time provided education on HIPAA and the abuse, neglect, social media and resident rights policies. · On 06/24/20 at 4:51 P.M., the Administrator began educating administrative employees on HIPAA and the abuse, neglect, social media and resident rights policies. · On 06/24/20 at 4:56 P.M., the DON began educating nurses and STNAs on HIPAA and the abuse, neglect, social media and resident rights policies. · On 06/24/20 at 6:46 P.M., the Administrator submitted an SRI regarding the incident. The Administrator attempted to submit the SRI from 5:23 P.M. to 6:23 P.M. but had issues with the online system. · On 06/24/20 at 8:23 P.M., LPN #15 assessed Resident #20 for injuries with no negative findings. · On 06/24/20 at 9:29 P.M., LPN Supervisor #03, RN Supervisor #12 and STNA #10 interviewed and assessed Residents #17, #18, #19, #20, #21 and #22 who were assigned to STNA #01 with no negative findings. · On 06/24/20 from 8:24 P.M. to 9:34 P.M., the Administrator provided education to non-nursing employees about HIPAA and the abuse, neglect, social media and resident rights policies. · On 06/25/20 from 6:15 A.M. to 11:00 A.M., the Administrator provided re-education to all employees at the beginning and end of their shift about HIPAA and the abuse, neglect, social media and resident rights policies. · On 06/25/20 at 6:56 A.M., LPN #55 reassessed Resident #20 for injuries with no negative findings. · On 06/25/20 at 8:00 A.M., Social Services Director (SSD) #16 re-interviewed Resident #20 with no negative findings. · On 06/25/20 at 8:00 A.M., the DON initiated resident interviews and assessments for cognitively impaired residents with no negative findings. · On 06/25/20 at 9:00 A.M., the DON implemented an audit tool to include: SSD and/or designee will complete random resident interviews three to five times a week for four weeks regarding resident's safety from abuse/neglect, resident rights violations and/or HIPAA concerns. Monitoring and any issues identified will be addressed and reviewed in the Quality Assurance and Performance Improvement (QAPI) committee meeting. The DON and/or designee will complete random resident observations of grooming care three times a week for four weeks to monitor staff approach with care. Monitoring and any issues identified will be addressed and reviewed by the QAPI committee. · On 06/25/20 at 9:05 A.M., the QAPI plan was initiated and the plan of correction, education and audits were reviewed by the DON and Social Services #56. · On 06/25/20 at 9:30 A.M., SSD #16 contacted Psychologist #13 to set up a telehealth visit for Resident #20. This occurred on the same day with no negative findings. · On 06/25/20 at 10:06 A.M., the Administrator notified the local Police Department of the incident and a report was filed. · On 06/25/20 at 11:45 A.M., the DON, LPN Supervisor #03, RN Supervisor #12 and STNA #10 completed resident interviews and assessments. There were no negative findings. · On 06/25/20, the Administrator and the DON terminated STNA #01 from employment at the facility. STNA #01's disciplinary action form indicated STNA #01 posted a live video of herself on social media providing care to a resident who had a [DIAGNOSES REDACTED].#01 brushing the resident's hair. The resident was waving her arms and grabbing her own hair telling STNA #01 to stop and calling STNA #01 names. STNA #01 responded to the resident and did not stop combing her hair during the duration of the video. The video lasted for 40 seconds. The termination was completed by telephone. Although the Immediate Jeopardy was removed, the deficiency remained at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and were monitoring to ensure on-going compliance. Findings include: Medical record review revealed Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired and required extensive assistance with bed mobility, transfers, toileting and dressing. Resident #20 required total dependence with personal hygiene. Resident #20 was admitted to hospice on 06/01/20 for late [MEDICAL CONDITION] disease with dementia. Review of Resident #20's nurses progress notes dated 06/24/20 at 4:00 P.M. revealed the resident had a head to toe total assessment with no injuries noted. Resident #20 also had a head to toe total assessment on 06/24/20 at 7:36 P.M. with no tenderness, bumps or [MEDICAL CONDITION] noted to the scalp. No bruising was noted and Resident #20's skin was intact. The resident reported no complaints of pain. Review of Resident #20's geropsychiatry consultation dated 06/25/20 revealed the resident showed no signs of distress either physically or emotionally. Review of the undated social media video revealed STNA #01 was combing Resident #20's hair. STNA #01 stated girl bye and Resident #20 called STNA #01 an expletive. STNA #01 stated, Oh, I'm an expletive and she continued to comb Resident #20's hair. Resident #20 grabbed toward the comb and then clapped her hands together. STNA #01 stated Stop playing bro. You're not going to hit nothing. Resident #20 grabbed towards the comb again and STNA #01 stated, Stop playing and called the resident by her first name. STNA #01 also stated Girl your hair nappy so you're going to have to chill out. Review of the facility's SRI dated 06/24/20 revealed on 06/24/20, STNA #01 posted a live video of herself combing Resident #20's hair. A person in the community notified the facility through the facility's website in the form of private messenger of the video. STNA #01 was immediately removed from facility and placed on suspension and the employee's file was reviewed. Resident #20 was immediately assessed with [REDACTED]. The facility continued to coordinate the investigation with involvement of the medical director, family and the local police department. Social Services interviewed the resident and the resident was not able to recall details associated with the situation. The resident was noted to have cognitive impairment. Residents on the same unit were also interviewed with no concerns voiced. The facility substantiated the allegation due to the employees' individual action. STNA #01 was contacted by the Administrator, Human Resources and the DON on 6/25/20. STNA #01 stated she did not harm the resident. STNA #01 stated she posted the video with no motive and it was a joke. STNA #01 stated sometimes this resident puts her hands up and curses at staff during care. The employee was terminated. Education was completed on 06/24/20 and 06/25/20 with current employees. The facility coordinated with the psychologist for telecare on 06/25/20 without any residual effects identified related to the situation. The SRI reported the facility would continue random interviews with current residents residing in the facility three to five times a week for four weeks in regards to resident's safety from abuse, neglect, resident rights violations and HIPAA concerns. Interviews were initiated on 6/25/20. Monitoring and any issues identified with staffing would be addressed and reviewed in the QAPI committee. The SRI also indicated the local police were contacted on 06/25/20. The local police reviewed the incident and Police Officer #100 stated the incident was not abuse and no criminal charges would be filed. Police Officer #100 reported this was a procedural issue and suggested the facility report the STNA to the medical board if necessary. Review of the facility's timeline (that was included with the SRI) dated 06/24/20 revealed on 06/24/20 at 3:46 P.M., STNA #01 posted the video on SnapChat, on 06/24/20 at 4:10 P.M., LPN Supervisor #03 was made aware of the posting on social media, on 06/24/20 at 4:14 P.M., the DON and the Administrator were notified of the concern, on 06/24/20 at 4:16 P.M., Resident #20 was assessed with [REDACTED].#01 was pulled from the floor and suspended, on 06/24/20 at 4:20 P.M., STNA #01 was asked to leave the facility and on 06/24/20 at 4:29 P.M., STNA #01 punched out at the time clock. Review of Admissions Coordinator #04's witness statement dated 06/24/20 revealed she saw a notification on messenger for the facility's Facebook. Admissions Coordinator #04 read the message and started to watch the video. Admissions Coordinator #04 stopped the video and asked LPN Supervisor #03 to come to her office. LPN Supervisor #03 came to the office and watched the video with her. LPN Supervisor #03 immediately called the DON. Review of LPN Supervisor #03's witness statement dated 06/25/20 revealed on 06/24/20 at around 4:00 P.M., LPN Supervisor #03 was informed there was a video placed on social media by STNA #01 and it included Resident #20. LPN Supervisor #03 notified the DON and the Administrator immediately. The DON informed LPN Supervisor #03 to remove STNA #01 from the premises immediately and inform her that she was not able to return to the facility until she had spoken to the DON. LPN Supervisor #03 asked LPN #15 to complete a head to toe assessment on Resident #20, the resident had no injuries. Review of STNA #01's timecard revealed STNA #01 clocked in at the facility on 06/24/20 at 6:59 A.M. and clocked out at the facility on 06/24/20 at 4:29 P.M. Telephone interview with the Administrator on 6/25/20 at 4:19 P.M. revealed STNA #01 took a live video of herself combing Resident #20's hair and posted it on Snap Chat. The Administrator stated someone from Snap Chat saved the video and put it on Facebook. The Administrator stated the facility was made aware of the incident when an unidentified person from the community contacted them through Facebook messenger and informed them of the video. The Administrator reported the facility did not know how the unidentified person knew it was a resident of the facility in the video. The Administrator stated the facility investigated the incident and spoke with STNA #01. STNA #01 stated she was not harming Resident #20 or doing anything to hurt Resident #20. She states she posted the video as a joke. The Administrator stated STNA #01 was terminated on 06/25/20 but she was suspended immediately. Telephone interview on 06/29/20 at 11:21 A.M. with STNA #01 revealed STNA #01 videotaped herself providing care to Resident #20 in the resident's restroom. STNA #01 reported she did not remember the exact date that she took the video. STNA #01 stated that Resident #20 had a history of [REDACTED]. STNA #01 stated Resident #20 calls everyone expletives and Resident #20 did not want her hair brushed or oral care completed. STNA #01 stated the STNAs had to provide care to the resident because the residents daughter has requested for care to be completed. STNA #01 reported she knew she was not supposed to record any residents. STNA #01 stated she posted the video to her private Snap Chat. STNA #01 reported someone thought the video was funny and they posted it on their page. Someone else took it off the other persons page and posted it on Facebook. STNA #01 reported the video was originally posted on a private story to approximately 10 people that were STNA #01's friends. STNA #01 reported she was not trying to harm Resident #20, that she posted it as a joke. Attempted interview with Resident #20 on 06/29/20 at 2:10 P.M. revealed the resident did not respond to the surveyor's questions. Review of the police report dated 06/29/20 revealed the police department was contacted by the Administrator in reference to an employee posting on social media of her combing a resident's hair and the resident telling her to stop. Police Officer #100 viewed the video and reported there were no signs of abuse. Review of STNA #01's personnel file revealed STNA #01 was hired on 10/22/19. STNA #01 had a Bureau of Criminal Investigation (BCI) check completed on 06/18/19 and the STNA registry was checked on 06/03/19 indicating STNA #01 was in good standing. Further review of STNA #01's personnel file revealed a disciplinary action form dated 06/24/20 indicating STNA #01 was suspended and terminated. The form indicated on 06/24/20, STNA #01 posted a live video of herself on social media providing care to a resident who had a [DIAGNOSES REDACTED].#01 brushing the resident's hair. The resident was waving her arms and grabbing her own hair telling STNA #01 to stop and calling STNA #01 names. STNA #01 responded to the resident and did not stop combing the resident's hair during the duration of the video. The video lasted 40 seconds. The termination was completed by telephone. STNA #01 was immediately suspended. Review of the facility's undated Abuse, Neglect and Exploitation policy revealed abuse to include the deprivation of an individual of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. The policy also stated that abuse includes verbal abuse, sexual abuse, physical abuse and mental abuse including abuse facilitated or enabled through the use of technology. The policy also reported the facility will develop and implement written policies and procedures that prohibit and minimize the risk of abuse, neglect and exploitation of residents. Review of the facility's undated Social Media policy revealed employees may not post on any social networking sites or accounts any photographs of other employees, residents, vendors or suppliers. The policy also stated employees may not use company time or any company owned equipment including but not limited to computers, software, Internet and cell phones or other electronic devices for social media. This deficiency substantiates Complaint Number OH 644.

Based on review of a closed medical record, review of hospital records, interviews with facility staff and the county coroner, and review of the facility fall policy, the facility failed to provide adequate staff assistance for transfer and toileting of a resident who had a history of [REDACTED]. This failure resulted in Immediate Jeopardy and actual harm when Resident #203 fell off the toilet striking her mouth and head on the floor sustaining a fracture of her sinus cavity, a subarachnoid hemorrhage of the right sylvian fissure and died the following day from blunt impact to her head. This affected one (#203) of four residents reviewed for falls. The facility identified 100 residents at risk for falls. The facility census was 108. On [DATE] at 5:25 P.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on [DATE] at 2:51 P.M. when Licensed Practical Nurse (LPN) #233 failed to ensure staff providing care to Resident #203 were made aware of the increased need of assistance for transfers and toileting. On [DATE] at 1:25 A.M., State tested Nursing Assistant (STNA) #60 transferred Resident #203 to the toilet by herself. The resident fell off the toilet and hit her head. The resident sustained [REDACTED]. The Immediate Jeopardy was removed on [DATE] when the facility audited the medical records of all current residents who were identified at risk for falls to ensure the residents were receiving the correct staff assistance as assessed for transfers and toileting, and the facility implemented the following corrective actions: · On [DATE] at 1:35 A.M., Resident #203 was sent to the emergency room (ER) when she sustained a head injury related to a fall. · On [DATE] at 4:30 P.M., the DON in-serviced LPN #230 regarding the change of condition policy. · On [DATE] between 5:30 P.M. and 11:55 P.M. the DON, Registered Nurses (RN) #141 and #166, and LPN ' s #133, #234 and #130 audited the medical records of all residents at risk for falls to ensure the toileting and transfer needs were accurate on the Minimum Data Set (MDS) assessments, and were included on the Activity of Daily Living (ADL) care plans and on the Documentation Survey Report (STNA Care Tracker). · On [DATE] at 6:30 P.M., the DON in-serviced the MDS team regarding completion of the MDS, the Resident Assessment Instruction (RAI) guidelines, federal regulations, and care plan policies related to falls and ADL ' s of one to two assist. · On [DATE] at 6:30 P.M., the DON began in-services for all nurses regarding the change of condition policy, the fall policy, and the care plan policy. In-servicing was completed on [DATE] at 10:00 A.M. · On [DATE] between 6:19 P.M. and 6:29 P.M., RN #141, LPN #193 and LPN #221 were interviewed regarding the in-service they received in reference to change of condition policy, fall policy and the care plan policy. All staff interviewed were able to correctly articulate the information given in the in-service. Although the Immediate Jeopardy was removed, the facility remained out of compliance 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 of Resident #203 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the fall care plan dated [DATE] revealed Resident #203 was at risk for falls due to weakness, and being in a new environment. Interventions included assessment of standing and sitting balance, encourage resident to request assistance, and to monitor for functional decline due to medication side effects. Review of a comprehensive care plan dated [DATE] documented Resident #203 had self-care deficit related to acute infection and Alzheimer ' s disease. She was care planned as requiring one person assist for toileting and transfer. Review of the nursing notes dated [DATE] at 10:00 A.M. revealed Resident #203 was observed leaning over while sitting in the wheelchair, scratching on the floor. Staff was unable to reach Resident #203 before she fell out of the wheelchair onto the floor. The resident did not sustain any visible injury, and a new intervention was added to lower the back of the wheelchair. Review of the nursing notes, dated as a late entry on [DATE] at 9:21 A.M., revealed the daughter of Resident #203 reported the resident displayed increased confusion and inability to feed self. The daughter also reported the resident was not able to sit still. Review of the social services notes, dated as a late entry on [DATE] at 12:15 P.M., revealed Resident #203 had severe cognitive deficits creating a barrier with safety awareness and the inability to make any decisions related to care. Occupational Therapy (OT) reported goals for feeding, hygiene, and transfers. Review of the nursing notes dated [DATE] at 5:44 A.M. revealed Resident #203 attempted to self-ambulate two times during the shift. Nursing notes dated [DATE] at 6:52 P.M. revealed Resident #203 was leaning forward in her wheelchair and fell head first onto the floor. Resident #203 hit her head and had a red mark on the front side of her forehead. Neurological checks were implemented and were within normal limits. Review of the MDS assessment dated [DATE] revealed Resident #203 required the extensive assistance of one person for bed mobility, transfers, and dressing. Resident #203 required the extensive assistance of two staff for toilet use. Review of a form titled Documentation Survey Report (STNA Care Tracker) revealed on [DATE] during day shift (7:00 A.M. - 7:00 P.M.) Resident #203 was dependent on two staff for toileting. On [DATE] during night shift (7:00 P.M. - 7:00 A.M.) Resident #203 received extensive assistance of one staff for toileting and transfers. Review of the nursing notes dated [DATE] (after the resident was sent to the ER) documented as a late entry for [DATE] at 2:51 P.M., LPN #233 documented Resident #203 attempted to stand up out of the wheelchair at times. Resident #203 stiffened her body during care and a three person assist was needed to toilet the resident. Review of the nursing notes dated [DATE] at 1:25 A.M. revealed LPN #260 documented Resident #203 fell off the toilet onto the floor. An assessment was completed and a hematoma to the right side of the forehead and a laceration to the upper lip were noted. Nine-one-one (911) was called and the resident was transferred to the emergency room (ER). Review of the nursing note dated on [DATE] at 7:37 A.M. revealed Resident #203 was admitted to the hospital for further evaluation. Review of the ER report dated [DATE] indicated a computed tomography (CT) scan was completed due to forehead hematoma, facial ecchymosis (bruising) and swelling. The CT scan revealed an acute fracture of the right maxillary sinus anterior wall and an acute subarachnoid hemorrhage in the right sylvian fissure. On [DATE] at 10:10 A.M., a telephone interview was conducted with County Coroner #266 and revealed the resident expired on [DATE]. The cause of death was complications of blunt impact to the head with contributing factor of hypertensive cardiovascular disease. On [DATE] at 11:54 A.M. an interview was conducted with STNA #60. STNA #60 stated [DATE] was the first time she was responsible for the care of Resident #203. She stated she previously assisted another staff member transfer the resident off of the toilet as Resident #203 required two staff to transfer. She stated on [DATE] around 1:00 A.M., Resident #203 had a bowel movement in her bed. STNA #60 transferred Resident #203 to her wheelchair and then to the toilet by herself. STNA #60 indicated she was standing to the right of the resident at the sink preparing wash cloths so she could wash the bowel movement off of the resident. Resident #60 fell off the toilet and to the side by the sink. The resident ' s mouth was bleeding and she had a knot on her temple. STNA #60 denied being aware the resident had required the assist of three staff members on [DATE] during day shift. On [DATE] at 1:20 P.M. an interview was conducted with LPN #233 in reference to Resident #203 requiring three person assist on [DATE]. LPN #233 verified Resident #203 stiffened her body during care and three staff had to assist with toileting. She indicated this was an isolated episode. LPN #233 verified she failed to document on [DATE] the assistance Resident #203 required. She verified she made a late entry on [DATE] about the amount of care Resident #203 required on [DATE], but this was after the resident was admitted to the hospital for a head injury. On [DATE] at 2:04 P.M., an interview with STNA #106 revealed on [DATE] at 2:51 P.M. she assisted STNA #261 (who no longer works for the facility) and LPN #233 toilet Resident #203 because Resident #203 stiffened her body up. STNA #106 stated that was the only time she had provided care to Resident #203. She further stated all three staff assisted the resident back to bed after toileting her. On [DATE] at 2:40 P.M., a telephone interview was conducted with LPN #260. She stated on [DATE] at approximately 1:20 A.M., STNA #60 was assisting Resident #203 because she had a bowel movement. The resident fell off the toilet and hit her head. LPN #260 notified the supervisor and they assessed the resident. Nine-one-one was called and the resident was transferred to the ER. LPN #260 was not sure if STNA #60 was aware of Resident #203 requiring the assistance of three staff members for transfers and toileting on [DATE]. On [DATE] at 2:50 P.M., a second interview was conducted via telephone with STNA #60. STNA #60 stated she was not aware Resident #203 required the assistance of three staff members to toilet her on [DATE]. STNA #60 said if she was informed Resident #203 required three staff to transfer her on [DATE] she would have asked for help. STNA #60 stated after the fall, LPN #60 and STNA #106 assisted her to transfer the resident off of the floor and into her wheelchair. STNA #60 re-stated approximately a week prior to this fall another STNA had asked her to assist with toileting Resident #203. Review of the fall policy titled Fall Policy and Protocol, with a revision date of ,[DATE], indicated every effort will be made to provide a safe environment with minimal falls while promoting dignity and independence, through education, assessment and care plans. This deficiency substantiates Complaint Number OH 455.