Every finding on record at Grand Rapids Care Center

Based on observation, staff interview, and review of facility policy, the facility failed to ensure food and drink items were stored in a manner to prevent spoilage. This had the potential to affect all 28 residents who received food and drink from the kitchenette. The facility identified one (#8) resident who received nothing by mouth. The facility census was 29.Findings include:Observation on 06/14/26 at 8:05 A.M. of the kitchenette refrigeration unit revealed pizza stored in an unlabeled and undated pizza box and a sandwich in an unlabeled and undated baggie. Further observation revealed outdated yogurt cups, expired juices, a large container of spaghetti that was unlabeled and not dated, leftover food containers not labeled with a name or date, two half full twenty-ounce soda pops not labeled or dated, an open bottle of seltzer water that expired December 2025, pretzels in individual snack bags not dated, and an onion wrapped in foil and not dated.Interview on 06/14/26 at 8:10 A.M. with Dietary Aide #317 verified all of the above food and drink items that were not properly labeled and dated, outdated, and expired.Interview on 06/14/26 at 8:34 A.M. with Dietary Manager (DM) #316 confirmed the kitchenette refrigerator was intended for use only by residents of the facility. DM #316 also confirmed all food items should be properly dated and labeled, and only food belonging to residents should be stored in the kitchenette refrigerator.Review of the facility policy titled, Food Brought in From Outside the Facility Policy, with a last review/revision date of 11/18/24, revealed if the food brought in from an outside source needs refrigeration the container will be labeled with the name of food item, resident name, dated, and placed in an appropriate non-dietary refrigerator floor/unit fridge, neighborhood refrigerator, or activities refrigerator; and food dated by facility staff will be discarded within seven days from the date mark, with the exception of condiments.

Based on observation, staff interview, review of the medical record, review of infection control signage, and review of the facility policy, the facility failed to ensure enhanced barrier precautions (EBP) were followed. This affected one (#1) of one resident reviewed for EBP. The facility census was 29.Findings include:Review of Resident #1's medical record revealed an admission date of 05/04/23. Diagnoses included paraplegia, non-pressure chronic ulcer of the left heel and midfoot with unspecified severity, chronic obstructive pulmonary disease, peripheral vascular disease, chronic kidney disease, and major depression. Review of Resident #1's current physician orders for June 2026 revealed an order dated 06/15/26 for the antibiotic daptomycin in 0.9 percent (%) sodium chloride piggyback 1000 milligrams (mg) per 100 milliliters (mL) intravenously (IV) for acute hematogenous osteomyelitis of the left ankle and foot once per day. Further review revealed an order for the antibiotic meropenem 500 mg IV for acute hematogenous osteomyelitis of the left ankle and foot once daily. Review of the care plan revised June 2026 for Resident #1 revealed he was care planned for enhanced barrier precautions (EBP; an infection control measure to protect residents that have multi-drug resistant organisms and those residents with implanted medical devices from infection) with all close contact care.Observation on 06/14/26 at 11:25 A.M. of Resident #1's room revealed a sign posted on the outside of the door that indicated EBP for Resident #1 and inside the resident's room was a display that held protective personal equipment (PPE) including gowns, gloves, and masks. Resident #1 was resting in his bed with an IV medication infusing into a peripheral inserted central catheter (PICC; a central line inserted at a point that was farther from the heart that runs to the top of the heart for use for infusions for a person that was difficult to maintain a regular peripherally inserted catheter for IV medication). Further observation revealed Registered Nurse (RN) #385 entered the room, put on gloves, and proceeded to stop the antibiotic infusion due to completion of the infusion and clean the IV end cap and dismantle the IV medication.Interview on 06/14/26 at 11:39 A.M. with RN #385 verified Resident #1 was in EBP and verified he did not put on the correct PPE while he completed tasks for the resident's IV antibiotics and the PICC line. Review of the facility policy titled, Enhanced Barrier Precautions, revised 04/26 revealed Enhanced Barrier Precautions (EBP) are intended to prevent transmission of multi-drug resistant organisms (MRDO's) via contaminated hands and clothing of healthcare workers to high risk residents during high contact care. High-risk residents are those with chronic wounds and indwelling devices (such as central lines, urinary catheters, and tracheostomy) and for all those colonized or infected with a MDRO currently targeted by the Center for Disease Control (CDC). High contact care activities include any activity that may result in transfer of MDRO to hands and clothing of healthcare personnel, even when bloody and body fluids is not anticipated. These include dressing, bathing/showering, transferring, hygiene, changing linens, changing briefs, assisting with toileting, device care or use, and wound care.Review of the facility signage posted for EBP revealed a gown and gloves must be worn for high-contact resident care which includes device care or use including central line, urinary catheter, feeding tube, and tracheostomy.

Based on observation, medical record review, staff interview, and review of a facility policy, the facility failed to ensure a resident centered care plan was developed in a timely manner for a resident who smoked. This affected one (#5) of two residents reviewed for smoking. The facility census was 29.Findings included:Review of the medical record for Resident #5 revealed an admission date of 08/09/17. Diagnoses included chronic obstructive pulmonary disease (COPD), vascular dementia, and cerebral vascular accident (CVA). Review of the current physician orders for June 2026 for Resident #5 revealed the resident was admitted to hospice services on 12/05/25. Review of the smoking assessment dated [DATE] for Resident #5 revealed the resident was a current smoker and anticipated to continue to smoke. Review of the medical record for Resident #5 revealed no care plan was implemented to address the residents smoking status and interventions.Observation on 06/15/26 at 3:17 P.M. revealed two (#4 and #5) residents were smoking outside on the patio supervised by a staff member. Interview on 06/15/26 at 3:24 P.M. with Licensed Practical Nurse (LPN) #342 verified Resident #5 was a supervised smoker and was not able to locate a care plan to address the resident's smoking. LPN #342 suggested to speak with the Social Service Designee (SSD) #389 about the care plan. Interview on 06/15/26 at 3:31 P.M. with SSD #389 stated Resident #5 just started smoking after she admitted to hospice services. SSD #389 further stated Resident #5 was care planned for smoking. Review of the care plan for Resident #5, with SSD #389, revealed a smoking care plan was created on 06/15/26. Further interview with SSD #389 verified the care plan was just updated. Continued interviewed with SSD #389 revealed he would not verify the smoking care plan was just created and insisted the care plan was updated. Review of the facility policy titled, Comprehensive Care Planning, revised 02/26, revealed the facility will develop a comprehensive person-centered care plan for each resident that includes measurable goals and timetables to [NAME] the resident' medical, nursing, mental and psychosocial needs.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on medical record review, review of a facility initiated Self-Reported Incident (SRI), review of the facility incident log, review of witness statements, staff interview, and review of the facility policy, the facility failed to ensure staff reported allegations of staff-to-resident verbal abuse timely. This affected one (#15) of three residents reviewed for abuse. The facility census was 30. Findings include: Review of the medical record for Resident #15 revealed an admission of 08/16/24. Diagnoses included vascular dementia, generalized anxiety disorder, and cerebral infarction (stroke).Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 had moderate cognitive impairment. Resident #15 was assessed to require total care for Activities of Daily Living (ADLs).Review of the care plan dated 11/19/24 revealed Resident #15 had behaviors of throwing (incontinence) briefs on the floor, smearing stool on himself and/or the bed, unplugging the bed, disconnecting his feeding tube, anger, irritation, crawling on the floor, kicking/tipping over the bed table, throwing object(s) at others, restlessness, laying on the floor, attempting to sleep on the floor, impulsiveness, eating other people's food, putting himself on the floor for attention, attention seeking behaviors, and making himself-vomit. Interventions included encouraging Resident #15 to express concerns about care and the disease process, clarify misunderstandings, and maintain a calm environment and approach. Review of the facility incident log revealed an entry dated 09/11/25 at 8:45 P.M. related to an allegation of abuse against Resident #15.Review of Resident #26's family member's statement, dated 09/11/25, revealed she was in the dining room and Resident #15 attempted to leave. Certified Nursing Assistant (CNA) #133 was inappropriate, cussing, and saying stop being so stupid. The family member revealed Dietary Aide (DA) #131 was present in the dining room at the time of the incident.Review of the facility submitted SRI, initiated on 09/12/25, revealed a visitor reported an allegation of verbal abuse against Resident #15 that occurred on 09/09/25. The SRI stated Resident #15 was having behaviors of disconnecting his tube feeding multiple times and transferring himself in the room to different chairs without assistance. The visitor reported that CNA #133 used explicit language towards Resident #15. During the investigation, residents who were in the dining room were interviewed. Resident #24 stated that CNA #133 told Resident #15 he better behave and stop acting like a toddler. Resident #29 stated that CNA #133 talked to Resident #15 like an animal when he tried to leave the dining room and CNA #133 was making fun of Resident #15, stating If you want to act like a toddler, I will treat you like one. Interview with Dietary Aide (DA) #131 revealed CNA #133 directed an expletive word to Resident #15 to describe his behavior and told the resident he was acting like a fool and a toddler. CNA #103 stated CNA #133 told Resident #15 he was acting like a toddler, and that she would treat him that way.Review of the facility's investigation interview with DA #131, dated 09/12/25, revealed she was serving dinner in the dining room and CNA #133 called Resident #15 stupid in front of everyone present. DA #131 reported that Resident #15 kept leaving the dining room and CNA #133 became frustrated with the resident. DA #131 stated CNA #133 coached Resident #15 into apologizing to everyone.Interview on 09/30/25 at 8:50 A.M. with the Administrator confirmed he was not notified of the alleged staff to resident verbal abuse that occurred on 09/09/25 until 09/11/25, when Resident #26's family member, who was present at the time of the incident, reported it. The Administrator stated the family member was concerned with how CNA #133 was speaking to Resident #15 and reported CNA #133 called Resident #15 an explicative. The Administrator reported DA #131 and Resident #29 were also present at the time of the incident and confirmed the family member's report of what CNA #133 had stated to Resident #15. Interview on 09/30/25 at 2:08 P.M. with DA #131 revealed CNA #133 appeared frustrated with Resident #15. DA #131 stated that CNA #133 put Resident #15 across from the dining room and told him to stay put but the resident kept going back and forth from his room to the dining room. DA #131 stated CNA #131 was upset about Resident #15's behavior and confirmed CNA #133 called the resident stupid and made him apologize to the entire dining room. DA #131 stated she felt uncomfortable with the way CNA #133 was speaking to Resident #15. DA #131 verified she did not report the incident to facility management. Review of the facility policy titled, Ohio Resident Abuse Policy, revised 07/11/24, revealed it was the facility's policy to investigate all allegations, suspicions, and incidents of abuse, neglect, involuntary seclusion, exploitation of residents, misappropriation of resident property and injuries of unknown source. Facility staff must immediately report all such allegations to the Administrator/Abuse Coordinator.The deficiency was corrected on 09/29/25 when the facility implemented the following corrective actions: On 09/12/25, the Director of Nursing (DON) or designee assessed Resident #15, with no negative findings. On 09/12/25, CNA #133 was suspended pending an investigation. CNA #133 resigned on 09/13/25. On 09/12/25, The Administrator or designee initiated an investigation, including staff and resident interviews. On 09/12/25, the DON or designee completed skin checks for residents who could not be interviewed, with no negative findings. On 09/12/25, the DON or designee educated all staff on the facility's abuse policy, including the timely reporting of alleged incidents. On 09/12/25, the Administrator or designee completed all staff education on elements of abuse and customer service. Newly hired staff would be educated on abuse via the onboarding procedure. Beginning on 09/12/25, the DON or designee would interview three residents weekly for four weeks to ensure there are no issues related to abuse/neglect/customer service. Results of the audits would be taken to the Quality Assurance and Performance Improvement (QAPI) committee for review and to determine if additional action was needed. Beginning on 09/12/25, the DON or designee would conduct observations of three residents weekly for four weeks to ensure there were no issues related to abuse. Results of the audits would be taken to the QAPI committee for review and to determine if additional action was needed. On 09/30/25, verification was received verifying corrective action was completed and no new concerns were identified.This deficiency represents noncompliance investigated under Complaint Number 2621856.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on medical record review, review of a facility submitted Self-Reported Incident (SRI), review of the facility incident log, review of witness statements, staff and resident interview, and review of the facility policy, the facility failed to ensure residents were free from staff-to-resident verbal abuse. This affected one (#15) of three residents reviewed for abuse. The facility census was 30.Findings include:Review of the medical record for Resident #15 revealed an admission of 08/16/24. Diagnoses included vascular dementia, generalized anxiety disorder, and cerebral infarction (stroke).Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 had moderate cognitive impairment as evidence by a Brief Interview for Mental Status (BIMS) score of 9. Resident #15 was assessed to require total care for Activities of Daily Living (ADLs).Review of the care plan dated 11/19/24 revealed Resident #15 had behaviors of throwing (incontinence) briefs on floor, smearing stool on himself and/or the bed, unplugging the bed, disconnecting his feeding tube, anger, irritation, crawling on the floor, kicking/tipping over the bed table, throwing object(s) at others, restlessness, laying on the floor, attempting to sleep on the floor, impulsiveness, eating other people's food, putting himself on the floor for attention, attention seeking behaviors, and making himself-vomit. Interventions included encouraging Resident #15 to express concerns about care and the disease process, clarify misunderstandings, and maintain a calm environment and approach. Review of the facility incident log revealed an entry dated 09/11/25 at 8:45 P.M. related to an allegation of abuse against Resident #15.Review of Resident #26's family member's statement, dated 09/11/25, revealed she was in the dining room and Resident #15 attempted to leave. Certified Nursing Assistant (CNA) #133 was inappropriate, cussing, and saying stop being so stupid. The family member revealed Dietary Aide (DA) #131 was present in the dining room at the time of the incident.Review of the nursing progress note dated 09/12/25 revealed social services met with Resident #15 for follow up regarding allegations, and Resident #15 was in good spirits and denied any ill effects. Additional review of the nursing progress notes revealed on 09/12/25 at 10:37 A.M. the Certified Nurse Practitioner (CNP) was notified of the allegation.Review of the facility submitted SRI, initiated on 09/12/25, revealed a visitor reported an allegation of verbal abuse against Resident #15 that occurred on 09/09/25. The SRI stated Resident #15 was having behaviors of disconnecting his tube feeding multiple times and transferring himself in the room to different chairs without assistance. The visitor reported that CNA #133 used explicit language towards Resident #15. During the investigation, residents who were in the dining room were interviewed. Resident #24 stated that CNA #133 told Resident #15 he better behave and stop acting like a toddler. Resident #29 stated that CNA #133 talked to Resident #15 like an animal when he tried to leave the dining room and CNA #133 was making fun of Resident #15, stating If you want to act like a toddler, I will treat you like one. Interview with Dietary Aide (DA) #131 revealed CNA #133 directed an expletive word to Resident #15 to describe his behavior and told the resident he was acting like a fool and a toddler. CNA #103 stated CNA #133 told Resident #15 he was acting like a toddler, and that she would treat him that way.Review of the facility's investigation interview with CNA #103, dated 09/12/25, revealed Resident #15 was unplugging his feeding tube and was self-transferring. After Resident #15 unplugging the tube feeding multiple times, the staff left it unplugged and left him in the hallway. CNA #103 stated the staff told Resident #15 to stop unplugging the tube feeding and he would smile and say to call his family. CNA #103 stated that Resident #15 then tried to elope out of the front door. CNA #103 stated that CNA #133 asked Resident #15 if he felt stupid yet and then stated if the resident wanted to act like a kid, she would treat him like one and moved him by her. CNA #103 stated that Resident #15 went with CNA #133 to take the trash out and came back into the dining room and Resident #15 apologized to everyone in the dining room.Review of the facility's investigation interview with DA #131, dated 09/12/25, revealed she was serving dinner in the dining room and CNA #133 called Resident #15 stupid in front of everyone present. DA #131 reported that Resident #15 kept leaving the dining room and CNA #133 became frustrated with the resident. DA #131 stated CNA #133 coached Resident #15 into apologizing to everyone.Review of the facility's investigation interview with Resident #29, dated 09/12/25, revealed Resident #15 was being uncooperative with staff. The staff was saying bad things to Resident #15. Resident #29 stated CNA #133 was talking to Resident #15 like he was an animal when he tried to leave the dining room. Resident #29 stated the way CNA #133 was talking to Resident #15 was like she was making fun of him. Resident #29 stated CNA #133 stated he was acting stupid a couple times, and she pushed him into the dining room and made him apologize to everyone. Resident #29 stated CNA #133 repeated several times that Resident #15 was acting stupid.Review of the facility's investigation interview with CNA #133, dated 09/12/25, revealed she told Resident #15 he was acting like a toddler. CNA #133 stated she took Resident #15 out of the dining room then brought him back in to apologize to everyone.Interview on 09/30/25 at 8:50 A.M. with the Administrator revealed he was notified on 09/11/25 of an incident that occurred in the dining room on 09/09/25 involving CNA #133 and Resident #15 by Resident #26's family member. The Administrator stated the family member was concerned with how CNA #133 was speaking to Resident #15 and reported CNA #133 called Resident #15 an explicative. The Administrator reported Resident #29 was also present at the time of the incident and confirmed the family member's report of what CNA #133 had stated to Resident #15. The Administrator stated that CNA #133 was suspended pending the investigation but resigned on 09/13/25.Interview on 09/30/25 at 1:20 P.M. with Resident #24 confirmed CNA #133 was in the dining room with Resident #15 and stated that Resident #15 was acting a fool, acting like a baby, and stated he needed to apologize to the entire dining room for his behavior.Interview on 09/30/25 at 2:08 P.M. with DA #131 revealed CNA #133 appeared frustrated with Resident #15. DA #131 stated that CNA #133 put Resident #15 across from the dining room and told him to stay put but the resident kept going back and forth from his room to the dining room. DA #131 stated CNA #131 was upset about Resident #15's behavior and confirmed CNA #133 called the resident stupid and made him apologize to the entire dining room. DA #131 stated she felt uncomfortable with the way CNA #133 was speaking to Resident #15.Review of the facility policy titled, Ohio Resident Abuse Policy, revised 07/11/24, revealed verbal abuse was defined as the use of oral, written, or gestured language that willfully included disparaging and derogatory terms to residents, or within hearing distance, regardless of their age, ability to comprehend, or disability. The deficiency was corrected on 09/29/25 when the facility implemented the following corrective actions: On 09/12/25, the Director of Nursing (DON) or designee assessed Resident #15, with no negative findings. On 09/12/25, CNA #133 was suspended pending an investigation. CNA #133 resigned on 09/13/25. On 09/12/25, The Administrator or designee initiated an investigation, including staff and resident interviews. On 09/12/25, the DON or designee completed skin checks for residents who could not be interviewed, with no negative findings. On 09/12/25, the DON or designee educated all staff on the facility's abuse policy. On 09/12/25, the Administrator or designee completed all staff education on elements of abuse and customer service. Newly hired staff would be educated on abuse via the onboarding procedure. Beginning on 09/12/25, the DON or designee would interview three residents weekly for four weeks to ensure there are no issues related to abuse/neglect/customer service. Results of the audits would be taken to the Quality Assurance and Performance Improvement (QAPI) committee for review and to determine if additional action was needed. Beginning on 09/12/25, the DON or designee would conduct observations of three residents weekly for four weeks to ensure there were no issues related to abuse. Results of the audits would be taken to the QAPI committee for review and to determine if additional action was needed. On 09/30/25, verification was received verifying corrective action was completed and no new concerns were identified.This deficiency represents non-compliance investigated under Complaint Number 2621856.

Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure resident care plans were revised to included supports and interventions for depression and related antidepressant use. This affected one resident (#3) of five residents reviewed for unnecessary medications. The facility census was 30. Findings Include: Review of Resident #3's medical record revealed an admitted [DATE]. Diagnoses included type II diabetes, heart disease, peripheral vascular disease, depression, osteomyelitis, pain, kidney cancer, prostate cancer, and lymphedema. Review of Resident #3's Minimum Data Set (MDS) assessment, 04/07/24, revealed Resident #3 was cognitively intact. Resident #3 displayed no behaviors during the review period. Review of Resident #3's physician orders revealed an order dated 12/18/23 for mirtazapine tablet 7.5 milligrams (mg), administer one tablet at bedtime for depression. An order dated 01/22/24 included Zoloft 25 mg and 50 mg for a total of 75 mg once a day for diagnosis of depression. Review of Resident #3's care plan revised 03/04/24 revealed no care plan support or intervention was found related to Resident #3's depression or antidepressant use. Interview on 04/11/24 at 10:53 A.M. with the Director of Nursing (DON) verified there were no care plan supports for Resident #3's depression. Review of the facility policy titled,Comprehensive Care Planning Policy revised 03/02/21 revealed the facility must develop a comprehensive person centered care plan for each resident which included measurable objectives and timetables to meet the resident's medical, nursing, and mental and psychosocial needs. The comprehensive care plan was to be reviewed and updated at least every 90 days.

Based on review of the medical record, observation, interview, and policy review, the facility failed to ensure a resident was timely referred for dental services for missing dentures. This affected one (#5) of one resident reviewed for dental services. The facility census was 30. Findings include Review of the medical record revealed Resident #5 had an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease, congestive heart failure, chronic kidney disease stage three, atrial fibrillation, vascular dementia, hypertension, osteoarthritis, and fibromyalgia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. Review of the plan of care initiated 01/24/24 revealed the resident had impaired dental/oral hygiene related to no natural teeth and the resident wore full dentures. Interventions included to encourage the resident to remove dentures at bedtime and store dentures in proper container to soak, obtain dental consult as needed, and provide assistance for oral hygiene as needed. Review of an oral cavity observation assessment dated [DATE] at 11:39 A.M. revealed the resident's dentures were described as having a good fit. Observation on 04/09/24 at 11:08 A.M. revealed the resident was edentulous (no teeth) and was not wearing dentures. Interview on 04/09/24 at 11:08 A.M., Resident #5 revealed her dentures were lost and she had not seen the dentist. Resident #5 revealed she lost her dentures a couple of months ago. Resident #5 revealed she reported the lost dentures to Social Services Designee (SSD) #536. Resident #5 revealed she was able to put in her own dentures and take them out but staff assisted her by getting the storage container. Interview on 04/10/24 at 11:41 A.M., SSD #536 revealed he was not aware the resident was missing her dentures. SSD #536 revealed he would get the resident a dental consult. Interview on 04/10/24 at 2:33 P.M. State tested Nursing Assistant (STNA) #530 revealed Resident #5 required set up for oral care. STNA #530 revealed staff provided the resident her dentures and the resident was able to apply them. STNA #530 revealed the last time she cared for the resident a couple of weeks ago the resident's dentures were missing. STNA #530 was unaware how long the resident's dentures were missing. STNA #530 revealed she reported the missing dentures to the Director of Nursing (DON). Interview on 04/11/24 at 9:37 A.M., the DON revealed staff had not reported the resident's missing dentures recently. The DON revealed the resident had lost her dentures a couple of times but they had been found. Interview of 04/11/24 at 3:38 P.M., STNA #522 revealed the resident's dentures had been missing since the end of February or the beginning of March. STNA #522 revealed she notified the DON about the missing dentures. Interview on 04/12/24 7:35 A.M., Licensed Practical Nurse (LPN) #512 revealed she completed the resident's oral cavity assessment on 03/20/24. LPN #512 verified the assessment documentation was incorrect. LPN #512 verified she never saw the resident's dentures during the assessment. Review of the policy titled Dental Services Policy, last revised 04/02/24, revealed the would make prompt referrals for residents with lost or damaged dentures. Further review of the policy revealed the Director of Nursing Services or designee or any clinical staff member was responsible for notifying Social Services of a resident's need for dental services. The facility would promptly, within three days, refer residents with lost or damaged dentures for dental services.

Based on the review of the facility's Payroll-Based Journal (PBJ) Staffing Data Report, staffing schedule, posted daily staffing sheets, staff time sheets, and staff interview, the facility failed to submit accurate information in the PBJ for the first quarter of 2024. This had the potential to affect all residents. The facility census was 30. Findings Include: Review of the Payroll-Based Journal (PBJ) Staffing Data Report revealed the facility triggered for not having licensed nursing coverage 24 hours a day in the first quarter of 2024. The specific days identified were 10/05/24, 12/24/23, 12/25/23, 12/26/23, 12/27/23, 12/28/23, 12/29/23, 12/30/23, and 12/31/23. Review of the Staffing Schedule, Posted Daily Staffing sheets, and corresponding time cards for nursing staff for 10/05/24, 12/24/23, 12/25/23, 12/26/23, 12/27/23, 12/28/23, 12/29/23, 12/30/23, and 12/31/23 revealed there was 24 hour nursing coverage for all the specified days indicated in the PBJ staffing data report. Interview on 04/10/24 at 8:13 A.M. with the Director of Nursing (DON) verified there was 24 hour nursing coverage for the days indicated in the PBJ as not having coverage. The DON reported it was corporate who entered the PBJ data and verified the data was not entered correctly.

Based on observation, medical record review, and staff interview, the facility failed to ensure physical therapy treatments and range of motion interventions were consistently implemented for a resident to prevent contracture and decreased joint mobility. This affected one (#28) of one residents reviewed for range of motion. The facility census was 28. Findings include: Review of Resident #28's medical record revealed and admitted [DATE] with the diagnosis including, encephalopathy, diabetes mellitus type II, stage three sacral pressure ulcer, COVID-19, necrotizing fasciitis, neuropathic bladder, malnutrition, prothrombin gene mutation, dysphagia, anemia, thrombophilia, nephrotic syndrome, hypertension, and cerebral infarction. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 was assessed with severely impaired cognition, was dependent on staff for the completion of activities of daily living including bed mobility and transfers, was incontinent of bowel, had an indwelling urinary catheter, received all nutrition via tube feeding, and was at risk for pressure ulcer development with a stage IV pressure ulcer (full-thickness skin and tissue loss) present on admission. Review of admission progress notes dated 02/25/23 at 1:11 A.M. revealed Resident #28 was assessed with unequal strength to bilateral arms and the resident was unable to squeeze hands due to unresponsiveness and unable was to follow command. Review of a nursing plan of care dated 03/31/23 revealed a plan was implemented to address Resident #28's provision of activities of daily living due to a self care deficit related to a cerebral vascular accident. Interventions included to evaluate needs for adaptive equipment, educate and direct the use of assistive devices, and refer to physical therapy (PT), occupational therapy (OT), and speech therapy (ST) as needed. Review of a progress note on 04/12/23 revealed Resident #28 returned from a hospitalization and the assessment noted Resident #28 had abnormal hand-grasps, contractures, and was unable to follow commands. Review of PT discharge summary documentation dated between 04/18/23 and 05/16/23 noted the reason for was Resident #28 achieved the highest practical level. Resident #28's PT included a goal to increase left elbow, bilateral knee, and hip extension by 10 degrees and implement a stretching program to reduce skin breakdown and preserve muscle length to not impair ability to achieve sitting and lying positions. On 04/18/23 Resident #28's baseline was assessed as dependent, and on 05/16/23 a discharge assessment documented Resident #28 improved to tolerating 15 degrees at the knees and hips. Discharge recommendations for a home exercise program with a prognosis to maintain current level of function was listed as good with consistent staff follow through. There was no documentation provided which indicated the specific exercises to implement, if staff was trained to perform the exercises, or assistive devices to utilize to prevent potential contractures. Observation on 05/21/23 at 10:07 A.M. noted Resident #28 in bed with lower extremities in the fetal position (legs to chest) and hands with washcloth rolls. On 05/22/23 at 7:40 A.M. the resident was in bed with no washcloth rolls in hands with his left hand closed and legs in the fetal position. On 05/22/23 at 10:05 A.M. interview with State tested Nurse Aide (STNA) #229 and Licensed Practical Nurse (LPN) #200, while observing resident care, revealed no knowledge of Resident #28 being provided with specific exercises including range of motion or a home exercise program. Staff also confirmed no assistive devices were in place to address contractures, and staff indicated washcloth rolls or foam balls were placed to the resident's bilateral hands at the family direction. On 05/22/23 at 11:00 A.M. interview with Certified Occupational Therapy Assistant, identified as Therapy Director (TD) #400, revealed when Resident #28 was discharged from therapy an unidentified STNA was informed of the exercise program. TD #400 confirmed the staff's lack of knowledge regarding Resident #28's home exercise program. TD #400 was unable to provide evidence indicating which STNA was provided education on the resident's exercise program. TD verified the resident was noted with progressive decrease in range of motion; however, no physical device to implement was determined at the time of therapy discharge. On 05/22/23 at 11:05 A.M. interview with the Director of Nursing was unable to provide information confirming staff was provided with education regarding Resident #28's exercise program or interventions to address the resident's range of motion.

Based on medical record review, staff interview, and facility policy review, the facility failed to ensure the resident and resident representative were notified of changes in medication and test results. This affected two (#5 and #19) of two residents reviewed for notification of change. The facility census was 28. Findings include: 1. Review of the medical record revealed Resident #5 was admitted on [DATE]. Diagnoses included chronic obstructive pulmonary disease, spinal stenosis lumbar region, essential hypertension, fibromyalgia, ulcer of esophagus without bleeding, dysphagia, mixed hyperlipidemia, major depressive disorder, generalized anxiety disorder, chronic kidney disease stage three, and chronic diastolic (congestive) heart failure. Review of the Minimum Data Set (MDS) assessment, dated 05/05/23, revealed the resident was cognitively intact. Review of a pharmacy recommendation, dated 05/02/23, revealed Resident #5 was prescribed the antidepressant Doxepin by mouth every night at bedtime for depression and anxiety and also took the antidepressant Zoloft 50 milligrams (mg) by mouth daily. The recommendation was to re-evaluate the continued use of Doxepin and consider if the medication can be discontinued as it was an anticholinergic and high risk medication in the elderly. On 05/08/23 the physician accepted the recommendation to discontinue the medication. Review of Resident #5's physician orders revealed an order dated 03/17/23 for Doxepin oral capsule 10 mg. The order was discontinued on 05/08/23. The medical record was silent of resident notification. Review of a nursing progress note, dated 05/11/23, revealed Resident #5 was noted, during a care conference, with shortness of breath, a loose productive cough, and lung sounds were noted with inspiratory and expiratory wheezes. A rescue inhaler was given as ordered with some relief and the physician was notified and waiting a response. Review of a nursing progress note, dated 05/11/23, revealed a new order received for a chest x-radiation (x-ray) and the diuretic Lasix 20 mg for three days. Resident #5 was updated on the order. Review of Resident #5's nursing progress note, dated 05/12/23, revealed x-ray results revealed no acute cardiopulmonary process. The medical record was silent for resident notification of the results. Interview on 05/21/23 at 9:27 A.M. with Resident #5 revealed she was not informed of medication changes stating one medication was discontinued with no explanation. Resident #5 stated she wanted to be involved in her health status updates as she did prior to living in a facility. Resident #5 further stated she recently had a x-ray and never received an update of the results. 2. Review of the medical record revealed Resident #19 was admitted on [DATE]. Diagnoses included major depressive disorder, Alzheimer's disease with late onset, unspecified dementia with other behavioral disturbance, and gastro-esophageal reflux disease without esophagitis. Review of the MDS assessment, dated 04/13/23, revealed the resident was severely cognitively impaired. Review of Durable Power of Attorney documentation, dated 11/03/14, revealed Resident #19 had two named durable power of attorneys-in-fact. Review of a physician progress note, dated 02/15/23, revealed Resident #19 wandered, exhibited irritability, and reported lack of interest in food. The note stated the facility would start the cognition-enhancing medication Aricept five (5) milligrams (mg) by mouth nightly for management of behavioral and psychological symptoms associated with dementia. The medical record was silent for notification to Resident #19's representative of notification. Review of a physician order, dated 02/15/23 and continued on 04/05/23, revealed Resident #19 had an active order for Aricept oral tablet 5 mg by mouth. Interview on 05/22/23 at 5:17 P.M. with Resident #19's representative reported they were notified by pharmacy on an unknown date that Resident #19's insurance approved Resident #19 to receive Aricept. Resident #19 representative stated she never was notified of the new medication and it would not have been a medication Resident #19 would have wanted. Interview on 05/23/23 at 3:18 P.M., with the Director of Nursing (DON) verified there was no documentation of notification for Resident #5 and Resident #19's medication changes and Resident #5's x-ray results. Review of the policy titled, Resident Change in Condition, revised 07/02/21, revealed the resident/physician or the provider/family/responsible party will be notified when there has been a need to alter the resident's medical treatment including a change in provider orders.

Based on review of resident personal fund account documentation and staff interview, the facility failed to ensure witness signatures were obtained when personal fund accounts were opened. This affected two (#6 and #7) of five residents reviewed for personal fund accounts. The census was 28. Findings include: 1. Review of Resident #6's resident fund management authorization to handle resident funds revealed an undated and unwitnessed signature by the resident. Review of resident fund balance activity revealed a current balance as of 05/21/23 to be $698.62. 2. Review of Resident #7's resident fund management authorization to handle resident funds revealed an undated and unwitnessed signature by the resident's guardian. Review of the resident fund balance activity revealed a current balance as of 05/21/23 to be $1,100.31. On 05/24/23 at 8:30 A.M., interview with the Business Office Manager verified Resident #6 and Resident #7 did not have witness signatures to authorize management of resident funds.

Based on medical record review, observation, and staff interview, the facility failed to ensure resident rooms were maintained in good repair. This affected one (#6) of 28 residents reviewed. The facility census was 28. Findings include: Review of the medical record revealed Resident #6 was admitted on [DATE]. Diagnoses included schizophrenia, chronic obstructive pulmonary disease, and bilateral primary osteoarthritis. Review of the Minimum Data Set (MDS) assessment, dated 04/25/23, revealed the resident was moderately cognitively impaired. Observation on 05/21/23 at 8:30 A.M. revealed a wall in Resident #6's room had large scrapes and holes in the wall measuring approximately three feet long by one foot wide. Interview on 05/23/23 at 1:35 P.M. with Licensed Practical Nurse (LPN) #206 indicated she was not aware how long the scrapes and holes were present and appeared alarmed at the size of the wall damage. Interview on 05/23/23 at 1:42 P.M. with Maintenance #236 verified the holes in Resident #6's room started off as a small poke of a hole and became worse over time. Maintenance #236 reported the hole was there for an unknown amount of time but at least three months.

Based on medical record review, review of a self-reported incident, resident representative interview, staff interview, and facility policy review, the facility failed to timely report allegations of misappropriation to the State Survey Agency. This affected one (#19) of one resident reviewed for misappropriation. The facility census was 28. Findings include: Review of the medical record revealed Resident #19 was admitted on [DATE]. Diagnoses included major depressive disorder, Alzheimer's disease with late onset, unspecified dementia with other behavioral disturbance, and gastro-esophageal reflux disease without esophagitis. Review of the Minimum Data Set (MDS) assessment, dated 04/13/23, revealed the resident was severely cognitively impaired. Review of self-reported incident (SRI) #235054, dated 05/16/23, revealed Resident #19's family reported Resident #19 was missing a ring. The facility searched for the ring and could not find it. The report stated Resident #19 had dementia and could have taken the ring off anywhere, but the facility would continue to look for the ring. Social Services #206 was notified on 05/14/23 at 10:45 A.M. of the missing ring and notified the Administrator. The SRI was not created and submitted to the State Survey Agency until 05/16/23. Interview on 05/22/23 at 5:17 P.M. with Resident #19's representative reported while visiting Resident #19 on Sunday, 05/14/23, it was noticed that Resident #19's sapphire ring was not on her finger. Resident #19's representative reported the ring had high sentimental value and was monetarily valued at $2,500.00 over [AGE] years ago. It was reported a physician order was put in place every shift as a safety net to monitoring the ring, and the last time Resident #19's representative observed the ring was in March 2023. Interview on 05/23/23 at 9:51 A.M. with the Administrator verified the facility did not initiate a SRI within 24 hours related to Resident #19's ring. It was reported initially the facility considered the ring missing, and after a couple of days considered it under possible misappropriation. Review of the policy titled, Ohio Resident Abuse Policy, revised 10/03/22, verified all allegations of abuse, neglect, involuntary seclusion, injuries of unknown source, and misappropriation of resident property must be reported immediately to the Administrator, Director of Nursing, and to the applicable state agency. This deficiency represents non-compliance investigated under Complaint Number OH00143098.

Based on observation, medical record review, staff interview, and facility policy review, the facility failed to ensure interventions were implemented to prevent pressure ulcer development or worsening of a current pressure ulcer. This affected one (#28) of two residents reviewed for pressure ulcers. The facility census was 28. Findings include: Review of Resident #28's medical record revealed an admitted [DATE] with the diagnosis including, encephalopathy, diabetes mellitus type II, stage three sacral pressure ulcer, COVID-19, necrotizing fasciitis, neuropathic bladder, malnutrition, prothrombin gene mutation, dysphagia, anemia, thrombophilia, nephrotic syndrome, hypertension, and cerebral infarction. Review of the Minimum Data Set assessment dated [DATE] revealed Resident #28 was assessed with severely impaired cognition, was dependent on staff for the completion of activities of daily living including bed mobility and transfers, was incontinent of bowel, had an indwelling urinary catheter, received all nutrition via tube feeding, and was at risk for pressure ulcer development with a stage IV pressure ulcer (full-thickness skin and tissue loss) present on admission. Review of a pressure ulcer risk assessment completed on 05/03/23 scored Resident #28 at very high risk for pressure ulcer development. Review of a nursing plan of care developed on 02/22/23 to address Resident #28 potential for skin breakdown related to immobility, diabetes mellitus type II, and incontinence revealed interventions included to turn and reposition as indicated, use pressure relieving devices as indicated, bilateral heel protectors as tolerated while in bed, bilateral pressure relieving boots as tolerated, elevate heels off the mattress per routine and/or as needed as resident allows, a specialty air mattress with bed bolsters as ordered, and a specialty wheelchair cushion as ordered. Review of wound specialist evaluation documentation on 05/15/23 revealed Resident #28 was evaluated for a stage IV pressure ulcer to the coccyx present on admission of 02/21/23. The wound description included measurements 6.5 centimeters (cm) long by 4.5 cm wide by 2.0 cm deep with undermining tissue measuring 3.0 cm at the 9:00 o'clock position. The wound was documented as improving. The wound specialist interventions included off loading heels, pressure reducing cushion, barrier cream each shift, plan of care discussed with nursing, reposition every two hours, limit time in the chair, and a low air loss mattress. On 05/21/23 at 10:07 A.M., Resident #28 was observed in bed with off loading boots placed to the overbed table in the corner of the room. Observation on 05/22/23 at 7:40 A.M., 8:55 A.M., and 9:29 A.M. noted Resident #28 in bed and positioned to the left with both legs in the fetal position (legs flexed toward chest) without offloading boots or interventions in place to bilateral heels. Resident #28's pressure relieving boots remains in the chair in his room. On 05/22/23 at 9:50 A.M., interview with State tested Nurse Aide (STNA) #229 stated she assumed care for Resident #28 at 6:00 A.M. and had not checked the resident for incontinence not had repositioned him. STNA #229 stated Resident #28 was to be checked every two hours due to frequent loose stools and current skin breakdown. STNA #229 also stated the off going staff was observed exiting the residents room at 6:00 A.M. On 05/22/23 at 9:58 A.M. observation noted STNA #229 and Licensed Practical Nurse (LPN) #200 to provide care to Resident #28. STNA #229 verified the resident was positioned in the same position for approximately four hours and had not been checked for incontinence or repositioned during her shift. STNA #229 proceeded to remove Resident #28 adult incontinence brief and discovered the resident incontinent of a large amount of liquid stool. Further observation confirmed stool was dried to the resident's buttocks. STNA #229 cleansed the stool from the resident and confirmed no barrier cream was in place. The resident's bilateral buttocks was observed with reddened tissue. Interview with LPN #200 at the time of observation on 05/22/23 at 9:58 A.M. verified no barrier cream was observed in place. Observation at that time revealed LPN #200 proceeded to remove a soiled pressure ulcer dressing to Resident #28's coccyx and replaced it with a clean dressing as ordered. Following the treatment the resident was positioned to the right side. Observation of the residents skin revealed indentation of bed linens to the resident's skin. On 05/22/23 at 11:05 A.M. interview with the Director of Nursing verified Resident #28 was required to be repositioned every two hours with pressure relief interventions implemented. Additional observations on 05/23/23 at 6:15 A.M. and 7:30 A.M. noted Resident #28 in bed without off loading boot or interventions to the bilateral heels. Resident #28's pressure relieving boots were observed in the room on the chair. Observation on 05/23/23 at 7:31 A.M. revealed LPN #206 assessed Resident #28's coccyx wound and it measured 6.2 cm long by 3.5 cm wide by 2.0 cm deep with 3.2 cm undermining. There were no observed pressure ulcers on Resident #28's heels. Review of the facility skin and wound care best practices, revised 06/10/22, revealed skin care and pressure injury prevention for residents at risk included to offload or suspend heels for at risk residents and reposition at a frequency determined by risk assessment to avoid pressure to bony prominence's.

Based on observation, medical record review, staff interview, and facility policy review, the facility failed to ensure dependent residents received timely care and services to address bowel incontinence. This affected one (#28) of one residents reviewed for incontinence. The facility identified eleven residents as occasionally or frequently incontinent of bowel. The facility census was 28. Findings include: Review of Resident #28's medical record revealed an admitted [DATE] with the diagnosis including, encephalopathy, diabetes mellitus type II, stage three sacral pressure ulcer, COVID-19, necrotizing fasciitis, neuropathic bladder, malnutrition, prothrombin gene mutation, dysphagia, anemia, thrombophilia, nephrotic syndrome, hypertension, and cerebral infarction. Review of the Minimum Data Set assessment dated [DATE] revealed Resident #28 was assessed with severely impaired cognition, was dependent on staff for the completion of activities of daily living including bed mobility and transfers, was incontinent of bowel, had an indwelling urinary catheter, received all nutrition via tube feeding, and was at risk for pressure ulcer development with a stage IV pressure ulcer (full-thickness skin and tissue loss) present on admission. Review of a nursing plan of care dated 02/22/23 revealed the facility developed a plan to address Resident #28's bowel movement pattern. The plan of care goal included Resident #28 would receive assistance with toileting, would be comfortable, clean, and dry, and free from skin breakdown. Interventions included to administer medications per physician order, assess resident pattern of bowel movement and episodes of incontinence, monitor rectal area for redness, irritation, skin excoriation or breakdown, barrier cream or ointment after incontinence as needed, and provide incontinence care as needed. Review of a late entry progress note on 02/24/23 at 6:00 P.M. revealed Resident #28 was incontinent of bowel. The resident's assessment revealed his abdomen was non-tender with loose stools and bowel sounds in all four quadrants. Review of a physician order noted on 05/09/23 revealed the physician ordered a general surgery consult for Resident #28 for a diverting colostomy (a piece of the colon is surgically diverted to an artificial opening in the abdominal wall) due to a stage four pressure ulcer and loose stools. Further review of Resident #28's medical record lacked documentation indicating a frequency established to monitor bowel patterns and episodes of bowel incontinence. Observation on 05/22/23 at 7:40 A.M., 8:55 A.M., and 9:29 A.M. noted Resident #28 in bed and positioned to the left with both legs in the fetal position (legs drawn up to the chest). On 05/22/23 at 9:50 A.M. interview with State tested Nurse Aide (STNA) #229 revealed she assumed care for Resident #28 at 6:00 A.M. and had not checked the resident for incontinence. STNA #229 stated the resident was to be checked every two hours due to frequent loose stools and the off going staff was observed exiting the resident's room at 6:00 A.M. On 05/22/23 at 9:58 A.M., observation noted STNA #229 and Licensed Practical Nurse (LPN) #200 to provide care to Resident #28. STNA #229 verified the resident was positioned in the same position for approximately four hours and had not been checked for incontinence during her shift. STNA #229 proceeded to remove Resident #28 adult incontinence brief and discovered the resident was incontinent of a large amount of liquid stool. Further observation confirmed stool was dried to the resident's buttocks. STNA #229 cleansed the stool from the resident and confirmed no barrier cream was in place. The residents bilateral buttocks was observed with reddened tissue. Interview with LPN #200 at the time of observation verified no barrier cream was observed in place. On 05/22/23 at 11:05 A.M. interview with the Director of Nursing (DON) verified Resident #28 required frequent incontinence care due to frequent loose stools and skin breakdown. The DON confirmed no documentation contained in the medical record indicated a specific schedule or pattern related to the resident's bowel habits was established. Review of an undated policy related to identifying incontinence, revealed the licensed nurse will instruct nursing assistants to fill out the 72 hour diary using their observations. The nursing assistants fill out the bowel and bladder continence evaluation for after providing care. The resident is monitored hourly and findings are documented.

Based on medical record review, resident representative interview, staff interview, review of witness statements, and review of a self-reported incident, the facility failed to maintain accurate documentation in the medical record. This affected one (#19) of 13 resident records reviewed. The facility census was 28. Findings include: Review of the medical record revealed Resident #19 was admitted on [DATE]. Diagnoses included major depressive disorder, Alzheimer's disease with late onset, unspecified dementia with other behavioral disturbance, and gastro-esophageal reflux disease without esophagitis. Review of the Minimum Data Set (MDS) assessment, dated 04/13/23, revealed the resident was severely cognitively impaired. Review of a physician order, dated 04/28/19 to 05/17/23, revealed an order to observe that Resident #19's had a ring (sapphire and diamond) every shift. Review of Resident #19's May 2023 treatment administrative record revealed nursing staff documented the ring was in place on each shift 05/01/23 through first shift on 05/14/23. On 05/14/23, on night shift the ring was not documented as checked, and again on 05/15/23 and 05/16/23, both shifts the ring was documented as observed to be in place by staff. Review of self-reported incident (SRI) #235054, dated 05/16/23, revealed on 05/14/23 Resident #19's family reported Resident #19 was missing a ring. Review of a witness statement, dated 05/17/23, revealed Licensed Practical Nurse (LPN) #211 reported on 05/14/23 Resident #19's daughter came in and asked about a ring the resident did not have on. LPN #211 reported Resident #19 was seen with the ring on and off at times and had not seen the ring in over a month. Review of a witness statement, dated 05/16/23, revealed Registered Nurse (RN) #222 stated she had not seen Resident #19's ring since 05/12/23. Review of a witness statement, dated 05/18/23, revealed LPN #242 had not seen Resident #19's ring and did not recall the last time she saw it. Interview on 05/22/23 at 5:17 P.M. with Resident #19's representative reported when visiting Resident #19 on Sunday 05/14/23 they realized the sapphire ring was not on Resident #19's finger. Resident #19's representative reported the ring had high sentimental value and was monetarily valued at $2,500.00 over [AGE] years ago. It was reported a physician order was put in place every shift to help ensure the ring was observed. The last time Resident #19's representative observed the ring was in March 2023 when visiting last. Interview via telephone on 05/23/23 at 10:38 A.M. with RN #222 verified a documented check mark on the TAR indicated staff observed the ring was observed on Resident #19's finger. RN #222 stated the last time the ring was observed was on 05/12/23 as indicated on the May 2023 TAR. RN #222 did not observe the ring on Resident #19's finger on 05/15/23 as indicated on the TAR. Interview via telephone on 05/23/23 at 10:02 P.M. with LPN #242 verified the documentation on the May 2023 TAR on 05/14/23 and 05/15/23 on night shift indicated staff observed Resident #19's sapphire and diamond ring. LPN #242 stated staff saw a ring on Resident #19's finger for those days, but did not verify it was a sapphire and diamond ring.

Based on review of employee personnel files and staff interview, the facility failed to complete performance reviews for state tested nurse aides (STNAs) at least once every 12 months. This affected two (#230 and #240) of two STNAs reviewed for annual performance evaluations. This had the potential to affect all 28 residents in the facility. The census was 28. Findings include: 1. Review of STNA #230's employee personnel record revealed a hire date of 11/21/17. Further review of the employee personnel file revealed a performance evaluation had not been completed since November 2021. 2. Review of STNA #240's employee personnel record revealed a hire date of 08/07/19. Further review of the employee personnel file revealed a performance evaluation had not been completed since November 2021. Interview on 05/24/23 at 10:43 A.M., with Office Coordinator #213 confirmed STNA #230 and STNA #240 did not have performance reviews completed in the past 12 months. Office Coordinator #213 stated the former Director of Nursing did not complete performance reviews for STNAs as required.

Based on medical record review, review of resident trust fund statements, review of facility policy and staff interview, the facility failed to ensure resident funds were returned to the resident in a timely manner upon discharge from the facility. This affected one (Resident #1) of four residents reviewed for closed resident trust funds. The facility identified 20 residents with personal trust funds. The facility census was 26. Findings include: Review of the closed medical record for Resident #1 revealed the resident was admitted to the facility on [DATE]. Resident #1 discharged to another facility on 02/18/22. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #1 had no cognitive deficits. Review of Resident #1's personal fund statement dated 03/24/22 revealed the resident opened the account on 10/20/15. Review of the discharge instructions dated 02/16/22 revealed Resident #1 was to be discharged on [DATE] to another skilled nursing facility. Review of a Trial Balance sheet dated 03/24/22 revealed Resident #1 had an open balance of $341.00. Interview with the Administrator on 03/24/22 at 3:50 P.M. revealed the resident trust funds for Resident #1 were not closed until 03/24/22 when the Administrator called her corporate office for a statement. The Administrator stated a check was going to be mailed to Resident #1 today (03/24/22). The Administrator verified it had been greater than 30 days since Resident #1 had been discharged and it had been missed. Review of the facility's policy titled Resident Personal Funds Management Policy, dated 04/09/21, revealed upon receipt of the resident's written request, the facility would hold, safeguard, manage and account for the funds. The balance of the funds in the trust account were to be promptly refunded upon discharge of the resident, in accordance with the Facility Refund Policy. This deficiency substantiates Complaint Number OH 306.

Based on medical record review, review of the facility's policy, and staff and resident interview, the facility failed to timely report an allegation of resident abuse to the Administrator. This affected one (Resident #5) of three residents reviewed for abuse. The facility census was 26. Findings include: Review of the medical record for Resident #5 revealed the resident was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #5 had no cognitive deficits, had clear speech, was understood and could understand. There were no abnormal behaviors or rejection of care. Resident #5 required extensive assistance with bed mobility, transfers, and toileting. Resident #5 was frequently incontinent of bladder and was always incontinent of bowel. Review of a written statement by Licensed Practical Nurse (LPN) #65 dated 03/14/22 revealed on 03/12/22, State tested Nursing Aide (STNA) #50 came to LPN #65 during the 4:00 A.M. rounds and stated Resident #5 has complained that STNA #50 had been rough with her during her rounds. LPN #65 stated within two minutes, she had gone into Resident #5's room to check on her and talk with her. She wrote that Resident #5 was resting in bed with eyes closed. LPN #65 woke Resident #5 up and Resident #5 asked her what was going on. Resident #5 stated she was okay and did not appear to be in any distress or crying at that time or throughout the remainder of the shift. Interview with Resident #5 on 03/24/22 at 9:10 A.M. stated she did have an STNA who was rude to her and she felt it was abusive. She stated the STNA made statements about her speech being hard to understand and it made her feel bad about herself. Resident #5 was observed to become very tearful during the interview and said she felt guilty for saying anything about it. Resident #5 also stated the STNA was rough with her when she changed her brief that night and pushed her over in the bed. Resident #5 was unable to say the name of the STNA or the date. Interview with STNA #45 on 03/24/22 at 1:35 P.M. revealed she had taken care of Resident #5 on 03/12/22 and had gone in at 4:00 A.M. to check on Resident #5. STNA #45 stated she was able to provide the care for Resident #5 by herself, so she rolled Resident #5 back and forth to change her. STNA #45 stated she went on to the next room and another STNA came and told her Resident #5 was crying. STNA #45 went back in with Resident #5 and asked her what was wrong and she told me 'I was rough with her'. STNA #45 stated she immediately went to the nurse on duty (LPN #65) and reported the allegation. LPN #65 went in to talk with Resident #5, who was sleeping, and Resident #5 said she was fine. STNA #45 stated she finished her shift and got a call from the administration on the next Monday (03/14/22). STNA #45 stated there was an investigation and she was off for five days and then told she could return to work on 03/21/22. She stated she has worked with the resident since and has not had any issues. She stated they were using two staff now with her care. Interview with STNA #60 on 03/24/22 at 2:00 P.M. revealed she had seen Resident #5 crying and told the STNA (#45) who had been working with her. She stated Resident #5 was crying loudly but did not want to talk about it. She stated she never said anything to her about anyone being rough. Interview with the Administrator on 03/24/22 at 2:45 P.M. revealed Resident #5 came to them on the morning of 03/14/22 and reported STNA #45 had been rough with her over the weekend. At that point, they suspended STNA #45 and started an investigation. A report was immediately filed with the Ohio Department of Health and filed a self reported incident. Staff were in-serviced on 03/14/22 for the 11 people on duty at that time on the abuse policy and the need to immediately report any allegations of abuse and called the remaining staff and provided the inservice over the phone. The Administrator verified STNA #45 was allowed to complete her shift after Resident #5 had reported the allegation. The Administrator verified LPN #65 did not report the allegation to the Administration or to any other staff, and allowed the STNA to keep working. Review of the facility's policy titled Ohio Resident Abuse Policy, dated 07/14/20, revealed the facility would not tolerate abuse, neglect, mistreatment, exploitation of residents, misappropriation of resident property and injuries of unknown source. Facility staff were to immediately report all allegations to the Administrator, who was to immediately begin an investigation and notify the applicable local and state agencies in accordance with the policy. If a staff member was accused of abuse, neglect, mistreatment, exploitation, involuntary seclusion and or misappropriation of property, the facility was to immediately remove the staff member from the resident care area and request a written statement from the accused staff member and then the accused staff member was to be removed from the facility and schedule pending the outcome of the investigation. Social services was to be notified. Next of kin were to be notified of allegations of abuse or misappropriation. The attending physician was to be notified of any allegation of abuse. Initial reports of allegations of abuse or serious bodily injury must be reported immediately to the Administrator but no later than two hours after the allegation was made. An investigation must be initiated and completed within five working days from the alleged occurrence. This deficiency substantiates Complaint Number OH 991.

Based on observation of medication administration, resident record review, and staff interview; the facility failed to administer insulin according to the physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The census was 31. Findings include: Observation on 07/07/21 at 8:49 A.M. of medication administration with Registered Nurse (RN) #50 revealed Resident #1 was administered the injectable medication [MEDICATION(S)] insulin seven units (two units per sliding scale for finger stick blood sugar of 176 and five units routine dose), subcutaneously. Review of the medical record for Resident #1 revealed the resident was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician orders revealed there was no active order for insulin [MEDICATION(S)]. Review of a physician order dated 06/28/21, revealed Resident #1 was to be administered the insulin [MEDICATION(S)] 100 units per milliliter (ml) pen (three ml); inject 5 units subcutaneously three times a day related to diabetes mellitus and insulin [MEDICATION(S)] 100 units/ml (three ml) inject as per sliding scale subcutaneously before meals and at bed time for diabetes mellitus. Sliding scale was 151 - 200 give 2 units, 200 - 250 give 4 units, 251 - 300 give 6 units, 301 - 350 give 8 units, 351 - 400 give 10 units, greater than 401 call the physician. Interview on 07/07/21 at approximately 10:10 A.M. with RN #50 verified the insulin administered to Resident #1 during the medication observation was the insulin [MEDICATION(S)]. RN #50 further verified the physician order was for insulin [MEDICATION(S)]. This is an incidental deficiency cited during the complaint investigation.

Based on medical record review, staff interview, resident interview, review of fire drill reports, review of emergency response reports, and review of the facility policy for smoking, the facility failed to follow their policy for retention of smoking materials. This resulted in Immediate Jeopardy when Resident #10 ignited his mattress on fire with a lighter left unsecured at the nurses' station by an independent smoker. This placed all 29 residents (#2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, and #30) residing in the facility at risk for the likelihood of serious injury, impairment, or death due to [MEDICAL CONDITION]/or smoke inhalation as a result of the fire. On 05/17/18 at 4:00 P.M., the Administrator and Regional Nurse #600 were notified Immediate Jeopardy began on 05/05/18 at 4:37 P.M. when Resident #29 returned from smoking independently and was unable to locate any staff to take his lighter. Resident #29 then laid his lighter on the lower level of the nurses' station desk, leaving it unsecured. Resident #10 retrieved the lighter from the nurses' station, returned to his room, and ignited his mattress on fire. Resident #10 then shut the door and left the room. The mattress fire caused smoke to fill the room and activate the smoke detector, alerting the facility staff of the presence of the fire. The fire caused the entire facility to be evacuated while first responders extinguished the fire. Immediate Jeopardy was removed on 05/06/18 when the facility discharged Resident #10 from the facility. The deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) until it was corrected on 05/23/18 when the facility implemented the following corrective actions: · On 05/05/18 at 4:37 P.M., staff responded to an alarming smoke detector in room [ROOM NUMBER] and evacuated all the residents from the facility by 4:50 P.M. The fire department arrived at the facility at 4:50 P.M. and extinguished the mattress fire. The Director of Nursing (DON) was notified of the fire at 4:55 P.M · On 05/05/18, all residents, visitors and facility staff were assessed for injury and any adverse effects related to smoke inhalation, or psychological effects. Assessments included, but were not limited to skin, lung sounds, pulse oximetry readings, evaluation of shortness of breath and emotional state. · On 05/05/18, Resident #10 was assessed for injury and his statement was obtained by the DON. Resident #10 remained on one-on-one supervision until he was transferred to the hospital for psychological evaluation at 5:30 P.M. on 05/05/18. The guardian of Resident #10 was informed of the incident and was notified that an immediate discharge notice would be issued. · On 05/05/18, Safe Smoking Assessments were completed on all current residents (#1, #8, #9, #14, #16, #29, and #30) in the facility who smoked by the DON and Licensed Practical Nurse (LPN) #1. Residents who smoked were re-educated on the smoking policies and procedures by Social Service Designee #300 and smoking contracts were re-signed by smoking residents on 05/05/18. · On 05/05/18, facility staff notified all resident families of the fire incident. · On 05/05/18 at 8:00 P.M., a hazardous materials assessment of the facility was conducted by Maintenance Director #200 and no additional findings were noted. · On 05/05/18, supervised smoking was initiated for all resident smokers (#1, #8, #9, #14, #16, #29, and #30); all of which were notified by the Administrator of the change and who voiced understanding. The facility smoking schedule was adjusted with additional times and the times were reviewed with the residents as well. · On 05/05/18, the facility implemented an inventory of lighters log and began utilizing the lighter count log to ensure compliance with stewardship of the facility's lighter. · On 05/05/18, all residents were interviewed and observed for any outward signs or symptoms of self-harm or destructive behaviors by the DON and the findings were negative. The DON/designee completed a review of residents within the facility. The review included self-harm destructive behaviors observed, interventions, care plan and monitoring. The review was completed by the DON, LPN #1, and Registered Nurse (RN) #5. No negative findings or revisions were needed at that time. · On 05/05/18, all staff were re-educated on the smoking policy and procedures, supervised smoking times, fire drills, signs and symptoms of destructive behaviors or self-harm ideation. Education was provided by the DON and the Administrator and was completed on 05/05/18. · The Administrator conducted a fire drill on 05/05/18 at 11:00 P.M. Staff response was appropriate. · The DON interviewed employees regarding any change in behavior with Resident #10 prior to the incident involving the fire. Interviews began on 05/05/18 and concluded 05/08/18. Staff reported no changes in Resident #10's behavior. · An ad hoc Quality Assurance Performance Improvement meeting was held on 05/05/18 to develop a plan of corrective action. The medical director was present at the meeting. · On 05/05/18, the facility began utilizing a monitoring tool completed by the Administrator or designee requiring observation of supervised smoking daily for one week and then weekly for four weeks. This was completed daily from 05/05/18 through 05/17/18. · On 05/05/18, the facility began utilizing a monitoring tool completed by the Administrator or designee requiring observation of lighters present during each smoke break daily for one week and then weekly for four weeks. This was completed daily from 05/05/18 through 05/17/18. · On 05/06/18, Resident #10 received an immediate discharge notice at the county jail via jail personnel. · On 05/07/18, the Administrator conducted fire drills at 2:50 P.M. and 9:55 P.M. to monitor staff response to the drill. · On 05/08/18, the facility began utilizing a daily monitoring tool completed by the licensed nurses to count the number of lighters present with the locked smoking materials on each shift. This was completed daily from 05/08/18 through 05/17/18. · On 05/08/18, the DON or designee began utilizing a monitoring tool recording interviews with three staff to include knowledge of smoking policy, identification of warning signs and early interventions to de-escalate behaviors once a week for four weeks, then three times a month for two months. This was completed on 05/08/18 and 05/17/18. · On 05/08/18, the DON or designee began utilizing a monitoring tool for audits to monitor three residents for potential self-harm or destructive behaviors once a week for four weeks, then three times a month for two months. This was completed on 05/08/18 and 05/17/18. · On 05/14/18, the facility revised the smoking policy to indicate specific interventions to protect resident safety if residents should violate the policy for turning in smoking material. · Observation of the nurse's station on 05/17/18 at 8:10 A.M. revealed there were no lighters present on the desk, in the cabinet, or in the file cabinet drawers. · Review of the medical record for two additional residents (#9 and #29), both independent smokers, revealed no concerns related to smoking hazards. · Interviews on 05/17/18 at 10:30 A.M. with Resident #9 and at 11:09 A.M. with Resident #29 verified education on the new smoking policy. · Interview on 05/17/18 at 2:25 P.M., State tested Nurse Aide (STNA) #100 verified education on the new smoking policy. · Interviews on 05/23/18 at 4:44 P.M. with STNA #101, at 4:51 P.M. with Dietary Manager #400, and at 4:53 P.M. with LPN #2 verified education on the new smoking policy. Findings Include: Review of Resident #29's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #29's smoking assessment, dated 09/29/17, revealed the resident had no memory deficits and was safe to smoke independently. A smoking evaluation on 03/29/18 indicated Resident #29 was able to safely smoke unsupervised. Review of Resident #10's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #10 resided in room [ROOM NUMBER]. Review of Resident #10's admission Minimum Data Set (MDS) 3.0 assessment, dated 03/19/18, revealed the resident had intact cognition. The assessment did not identify the resident to have any delusions, hallucinations or behaviors during the review period. The resident required supervision for all activities of daily living, with the exception of eating, which the resident did independently. Resident #10 was coded as not using tobacco products. Resident #10 received anti-psychotic and antidepressant medications routinely. Review of Resident #10's care plan dated 03/13/18, revealed a focus for psychiatric disorder, compulsiveness with purchasing drinks, and repetitive verbal behaviors. Interventions included to allow the resident to voice frustrations on paper, encourage the resident to express his feelings of anger, sadness, and guilt and help him come up with alternative ways to handle feelings of anger and frustration, and one-on-one supervision during behaviors. The plan of care indicates on 04/03/18, Resident #10 attempted to throw a chair through the window. Interventions added at this time included staff to provide one-on-one supervision until calm and then provide fifteen minute checks until the behavior resolved. The plan of care documented on 04/05/18, Resident #10 drank a bottle of lotion. Interventions following the incident included the resident was assessed at the hospital, remove all ingestible items from the room, and remove all items used for potential destruction. Review of the medical record revealed Resident #10 was assessed by the psychiatric nurse practitioner on 04/06/18 after the resident tore skin off his own hand and drank a bottle of lotion, because the nurse could not get the resident his medications at the exact moment he requested them. The note explains the resident was sent to the emergency room and returned the same day. The resident's medications were adjusted. Review of the nursing progress note written on 04/12/18 revealed Resident #10 had behaviors when he was upset. The resident wanted to return to his previous place of living. Resident #10 was noted to have cut his wanderguard off, flushed it down the toilet and called emergency services. Review of the medical record revealed Resident #10 was seen by the psychotherapist on 04/17/18 after an argument with another resident. Resident #10 subsequently urinated on the floor as a behavior to the argument. The therapist note revealed the resident was having a hard time adjusting to his long-term placement. Review of the progress note from psychological services, dated 05/01/18, revealed Resident #10 refused to talk with the counselor on this date stating he was fine. Review of the facility Fire/Disaster Drill form revealed on 05/05/18 at 4:37 P.M., the smoke detector alarmed in room [ROOM NUMBER] from a mattress fire. The alarm was transmitted to the fire protection company at 4:38 P.M. All residents were evacuated from the facility. Review of the Event Report from the local emergency response system (911) revealed a call came through on 05/05/18 at 4:41 P.M. regarding smoke in room [ROOM NUMBER]. The report indicates the emergency services were dispatched at 4:42 P.M. and arrived at 4:48 P.M. Notations in the comments section revealed Resident #10 was mad about something, went to the nurses' station, found a lighter and set his mattress on fire. The resident was transported to the local county hospital. room [ROOM NUMBER] was taped off with the door closed and an exhaust fan was running in the window. The mattress was removed from the room. Interview on 05/17/18 at 8:20 A.M., State tested Nursing Assistant (STNA) #100 revealed the facility smoking materials were locked in the medication room. The staff get the materials out and distribute them to the residents during scheduled smoking times. The STNA stated the facility used to have independent smokers who would get their smoking supplies from the staff and when the residents were finished smoking they would return their smoking supplies to the staff or place them on the nurse's desk and staff would lock them up. Interview on 05/17/18 at 8:50 A.M., the DON stated on 05/05/18 she had interviewed Resident #10, who was the resident who started the fire. He stated he was mad because his brother would not come and visit him. Resident #10 told the DON he got a lighter from the nurses' station and took the lighter to his room, set his mattress on fire, shut the room door, and went to sit in the dining room. The DON stated during her investigation of the incident she discovered the lighter was placed at the desk by Resident #29 who had not returned his smoking materials to the nurse after he had come back in from smoking, but instead left his lighter on the nurses' desk. The DON verified the facility used to have independent smokers, but independent smoking was no longer allowed at the facility since the incident involving the fire on 05/05/18. The DON stated all residents are supervised with smoking, which occurs on the front porch. The DON stated at no time since the incident of the fire on 05/05/18 have residents been allowed to smoke without supervision. The residents who were assessed to be able to smoke independently before 05/05/18 were Resident #8, Resident #9, and Resident #29. Observation on 05/17/18 at 9:15 A.M. revealed Resident #16 was smoking with staff present. The staff gave the resident a cigarette, lit the resident's cigarette, and the resident was observed to safely smoke the cigarette. When Resident #16 was finished smoking the resident was scheduled to go to an outside facility and was placed on the transport vehicle. The facility staff member re-entered the facility and gave the smoking materials to the nurse who immediately locked the cigarettes and the lighter up in the medication room. Interview on 05/17/18 at 10:30 A.M., Resident #9, who the facility identified as a previously independent smoker, revealed initially he was allowed to get his smoking materials from staff and go smoke on the front porch by himself. The resident stated when he returned from smoking he would return his smoking materials to the staff. Resident #9 did verify there were a few times no staff were visible on the hallway so he left the smoking materials on the nurses' desk since residents were not allowed to keep the material with them. Resident #9 indicated this changed a few weeks ago. Interview on 05/17/18 at 11:09 A.M., Resident #29 verified at this time all smoking materials are managed by facility staff. Prior to the fire a few weeks ago the independent smokers were able to get their smoking materials from the staff that would lock them up. After smoking, they would return their smoking materials to the nurse, to be kept by the facility staff. Resident #29 stated most of the time staff were present to take the smoking material, which included the lighters, but not always. Resident #29 verified the few times when staff were not visible on the hallway to collect the smoking materials he would lay the smoking materials on the lower part of the nurses' desk. The resident stated the night of the fire the staff were busy with other duties when he came in from smoking. He did not see any staff on the hallway to return the smoking materials to. Resident #29 verified he laid the cigarettes and the lighter on the lower part of the nurses' desk. Resident #29 stated the resident who started the fire at the facility had apparently picked up his lighter from the desk and used it to start the fire. Interview on 05/17/18 at 11:45 A.M., the Administrator and the DON verified staff working at the time of the fire included two STNAs, one nurse, and one dietary staff. The DON verified during the time the lighter was left unsecured at the desk, the staff were getting residents up from bed to the dining room for the evening meal, and the nurse was passing medications. An interview with STNA #100 on 05/17/18 at 2:25 P.M. revealed prior to the fire, there were occasions the residents who smoked independently would lay their lighters at the desk if a staff member was not available to take it. Review of the facility policy titled Smoking Policy, revised 04/28/17, indicated resident smoking materials will be retained and distributed by the facility staff to the resident during the designated smoking times and/or when independent residents chose to smoke. Nursing staff are to provide smoking materials within a timely manner for independent smokers. No resident is permitted to maintain or store smoking materials on their person or in their room. Review of the facility policy titled Smoking Policy, revised 05/14/18, revealed the policy was updated after the incident of involving the fire to include at Bullet H; any failure to adhere to provisions outlined in the smoking protocol will result in 1: progressive restrictions as outlined in governance procedure which includes possible risk for discharge if resident imposes on safety of other residents and 2: additional interventions that may occur to ensure safety of others, i.e. room searches, one-on-one observation as needed, behavior contracts, or every 15/every 30 minute checks as needed. Interview on 05/17/18 at 2:21 P.M., the DON and the Administrator revealed they had no knowledge of residents who were independent smokers laying smoking materials at the nurses' desk if there were no staff present to return smoking materials to when they were finished smoking. Both the DON and Administrator stated no staff or residents saw Resident #10 take the lighter from the nurses' station on the evening of 05/05/18. This deficiency substantiates Complaint Number OH 035.