Every finding on record at Grande Lake Healthcare Center

Based on medical record review, review of hospital documentation, staff interview, nurse practitioner interview, and review of the Centers for Disease Control and Prevention (CDC) website, the facility failed to ensure medication orders for treatment of Influenza (Flu) Type A were timely initiated for a resident which caused a significant medication error. Actual harm occurred to Resident #13 when the resident exhibited a change in condition, tested positive for Influenza Type A, and was evaluated by a nurse practitioner who recommended the implementation of an antiviral medication which was not ordered timely or administered. This resulted in Resident #13 becoming difficult to arouse and responded only to painful stimuli. Resident #13 required hospitalization and was diagnosed with renal insufficiency, hypoxia, and pneumonia. This affected one (#13) of three residents reviewed for Influenza Type A infections. The census was 41. Findings include: Review of the medical record for Resident #13 revealed an admitted [DATE]. The resident was admitted with diagnoses including chronic obstructive pulmonary disease (COPD), bipolar disorder, chronic kidney disease stage three, heart failure, and atherosclerotic heart disease. The resident was hospitalized on [DATE]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 had moderately impaired cognition, required set up assistance for meals, and maximum assistance with toileting hygiene, bed mobility, and transfers. Review of a progress note dated 02/14/25 documented by Certified Nurse Practitioner (CNP) #907 revealed Resident #13 had an acute visit due to increased cough and shortness of breath. Further review revealed the resident tested positive for Influenza Type A with a plan to start Resident #13 on the antiviral medication Tamiflu 30 milligrams (mg) daily. Review of Resident #13's physician orders revealed no order for Tamiflu until 02/20/25. Review of a nursing progress note dated 02/20/25 revealed a change in condition report for Resident #13 which indicated she was difficult to arouse and only responded to painful stimuli. It was recommended the resident be sent out to the emergency room (ER). Review of a subsequent entry note revealed Resident #13 was sent to the hospital at 10:28 A.M. Review of the hospital admission documentation dated 02/20/25 revealed Resident #13 had an admitting diagnoses of acute on chronic renal insufficiency, hypoxia (decreased perfusion of oxygen to the tissues), pneumonia, and Influenza Type A. Review of a chest x-ray image revealed the resident had patchy airspace opacities (increased density) in the bilateral lower lobes (of the lungs) concerning for multifocal pneumonia. Interview on 02/25/25 at 12:34 P.M. with CNP #907 verified she assessed Resident #13 on 02/14/25 and normally put her own orders in for residents, but acknowledged she forgot to put in the Tamiflu order for Resident #13. CNP #907 stated she discussed her plan with nursing staff prior to her leaving the facility, and later in the day she realized she forgot to place the order into the electronic chart. CNP #907 stated she then called the facility and spoke with Registered Nurse (RN) #610 and requested she enter the Tamiflu order for Resident #13. Interview on 02/25/25 at 2:12 P.M. with the Director of Nursing (DON) verified Resident #13 tested positive for Influenza Type A on 02/14/25. The DON stated she was unsure why Tamiflu was not started at the time of the positive testing. The DON stated CNP #907 spoke to RN #816 prior to leaving the facility on 02/14/25 and suggested the nurse be interviewed. The DON stated Resident #13's Tamiflu order dated 02/20/25 was ordered facility wide for prophylaxis. Interview on 02/25/25 at 2:15 P.M. with RN #816 verified CNP #907 did discuss Resident #13 with her prior to CNP #907 leaving the facility on 02/14/25. RN #816 verified CNP #907 did not indicate to her that she wanted Resident #13 to start on Tamiflu. RN #816 acknowledged nursing staff should have inquired why Resident #13 was not started on Tamiflu after her positive Influenza Type A test. Interview on 02/26/25 with Infection Preventionist (IP) #417 revealed the expectation for residents who test positive for Influenza Type A was to place them in droplet isolation, contact the physician, and start the residents on Tamiflu. IP #417 verified Resident #13 tested positive for Influenza Type A on 02/14/25 and neither she nor her nurse contacted the physician on 02/14/25 for medication orders. Interview on 02/27/25 at 8:40 A.M. with the DON acknowledged Resident #13 tested positive for Influenza Type A on 02/14/25. The DON stated CNP #907 would put in her own orders, but failed to do so for Resident #13. The DON acknowledged IP #417 had Resident #13's positive Influenza Type A test result, and stated IP #417 should serve as an additional means of ensuring proper treatments were in place. Review of the CDC website at, https://www.cdc.gov/flu/treatment/index.html, revealed a webpage titled, Treatment of the Flu, dated 09/09/24. Further review of the CDC guidance revealed antiviral drugs should be started as soon as possible after symptoms begin. Studies show that treatment of flu with antiviral medications works best when started within two days after flu symptoms begin and can lessen symptoms and shorten the time you are sick by about a day. Antiviral drugs can make illness milder and shorten the time a person is sick. They might also prevent some flu complications, like pneumonia. Starting antiviral treatment shortly after symptoms begin also can help reduce some flu complications. This deficiency represents non-compliance investigated under Master Complaint Number OH00161598 and Complaint Number OH00160883.

Based on observation, medical record review, review of infection control tracking documents, staff interview, and facility policy review, the facility failed to ensure proper infection control monitoring was timely and accurately maintained during an active influenza outbreak and failed to ensure a urinary catheter was maintained in a manner to prevent infection. This had the potential to affect all 41 residents residing in the facility. The census was 41. Findings include: 1. Review of the facility's infection control surveillance tracking revealed the document was not completed for February 2025. Interview on 02/26/25 at 124 P.M. with Infection Preventionist (IP) #417 acknowledged the facility was in an influenza outbreak and the method the facility utilized to track the infections was not updated for February 2025. IP #417 stated an employee was the first person to test positive for influenza on 02/11/25 and the next positive test was a resident on 02/13/25. IP #417 was not able to provide tracking information for the influenza outbreak at the time of the interview. IP #417 stated the physician was in the facility weekly on Thursdays and was made aware of the positive tests on 02/13/25. Interview on 02/27/25 at 8:40 A.M. with the Director of Nursing (DON) acknowledged the infection control surveillance tracking record was not accurately completed for February 2025. Review of the facility policy titled, Antibiotic Stewardship Plan, dated 05/01/17, revealed the Infection Preventionist (IP) would collect and analyze infection surveillance data to monitor and support antibiotic stewardship activities. The IP nurse would follow, track, and monitor residents for the purpose of treatment follow up. 51516 2. Review of Resident #195's medical record revealed the resident was admitted on [DATE] with diagnoses of hypertension, lymphedema, and cellulitis. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #195 was cognitively intact and was admitted with an indwelling urinary catheter. Observation of Resident #195 on 02/24/25 at 11:39 A.M. revealed the resident's urinary catheter collection bag was bag laying on the floor without a barrier. Further observation revealed Certified Nurse Aide (CNA) #704 walked into the room with a lunch tray and rolled a bedside table over the resident's urinary catheter collection bag. Interview with CNA #704 on 02/24/25 at approximately 11:40 A.M. verified Resident #195's urinary catheter collection bag was laying directly on the floor with no barrier and the bedside table was rolled over it. Review of an undated catheter care policy revealed the catheter bag should not be on the floor.

Based on record review, observation, staff interview, and policy review, the facility failed to determine if residents were clinically appropriate to self-administer their medications. This affected two (#7 and #10) of four residents observed during medication administration. The facility census was 41. Findings include: 1. Review of the medical record for Resident #7 revealed an admitted [DATE] with diagnoses including type two diabetes, chronic kidney failure, bipolar disorder, long term (current) drug therapy, and hypertension. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was cognitively intact and required setup or clean-up assistance for activities of daily living (ADLs). Review of Resident #7's current physician orders revealed no order for self-administration of medication. Review of Resident #7's care plan dated 02/21/25 revealed no care plan for self-administration of medications. Review of assessments revealed no self-administration of medications assessment was completed for Resident #7. Observation of medication administration with Licensed Practical Nurse (LPN) #905 on 02/25/25 at 7:50 A.M. revealed Resident #7 administered her own Lantus (long-acting insulin) 50 units subcutaneous (SQ) without priming the insulin pen prior to dialing up the dose, Humalog (short acting insulin) 15 units SQ without priming the insulin pen prior to dialing up the dose, the inhaled medication for chronic obstructive pulmonary disease (COPD) Trelegy 100/62.5/25 micrograms (mcg), and cyclosporine 0.05 percent (%) eye drops. LPN #905 dialed up two extra units and primed the insulin pens prior to the resident administering the dose into her abdomen. Resident #7 also checked her own blood sugar with the glucometer handed to her by the nurse and checked her blood pressure with the wrist cuff provided by the nurse. Interview on 02/25/25 at 10:37 A.M. with the Director of Nursing (DON) verified Resident #7 did not have a self-administration of medication assessment or physician order to self-administer medications. 2. Review of the medical record for Resident #10 revealed admitted [DATE] with diagnoses including end stage renal disease, type two diabetes, major depressive disorder, anxiety, fibromyalgia, insomnia, and convulsions. Review of the MDS assessment dated [DATE] revealed Resident #10 was cognitively intact. Review of the care plan dated 01/07/25 revealed Resident #10 had no care plan or mention of self-administration of medication. Review of Resident #10's current physician orders revealed the resident was ordered the anesthetic medication Lidocaine patch to apply one patch to the right thigh daily and the inhaled decongestant medication fluticasone (Flonase) nasal suspension 50 mcg twice daily with instructions the medication may be left at the bedside. There were no orders for self-administration of medications. Review of assessments revealed no self-administration medication assessment completed for Resident #10. Interview on 02/25/25 at 7:30 A.M. with LPN #905 revealed Resident #10 kept her Flonase at the bedside and will administer it after breakfast. LPN #905 stated the resident usually administered her own insulin and placed her Lidocaine patches on her body where she wanted them. Observation and interview on 02/25/25 at 7:35 A.M., during medication administration for Resident #10, revealed the resident did not administer her own insulin, but did placed two Lidocaine 4% patches to her left lower extremity after removing the old patches. Interview with LPN #905 verified the resident removed her old patches from yesterday prior to placing the new patches. Interview on 02/25/25 at 10:41 A.M. with the DON verified Resident #10 did not have a self-administration assessment completed prior to today. The DON verified Resident #10 was not documenting the administration of her Flonase as the nurses were doing that. The DON verified the resident had no physician order to self-administer medications. Review of the undated policy titled, Resident Self-Administration of Medications, revealed the interdisciplinary team (IDT) will assess for safety of self-administrating of medications or use of a continuous monitoring device including the following cognitive functioning, physical ability, and emotional ability. Assessments will include addressing the following and documenting in the care plan storage of the medication, responsible party for storage of medication, documenting the administration of drugs, location of where the drug will be administered, and the residents' ability to apply and monitor a continuous glucose monitoring device. A physician or provider order is required for residents to self-administer medication.

Based on observation, medical record review, and staff interview, the facility failed to ensure urinary catheter collection bags were covered to maintain dignity. This affected one (#195) of four residents reviewed for respect and dignity. The census was 41. Findings included: Review of Resident #195's medical record revealed the resident was admitted on [DATE] with diagnoses of hypertension, lymphedema, and cellulitis. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #195 was cognitively intact and admitted with indwelling urinary catheter. Observation of Resident #195 on 02/24/25 at 11:39 A.M. revealed the resident had no cover in place on the urinary catheter collection bag. Interview with Certified Nurse Aide (#704) verified Resident #195's urinary catheter collection bag did not have a cover to maintain dignity at the time of the observation. This deficiency represents non-compliance investigated under Complaint Number OH00160883.

Based on observation, medical record review, staff interview, and facility policy review, the facility failed to ensure residents were provided assistive drinking devices as care planned. This affected one (#15) of one residents reviewed for assisted eating devices. The census was 41. Findings include: Review of Resident #15's medical record revealed the resident was admitted on [DATE]. Diagnoses included nontraumatic intracerebral hemorrhage, contracture of the right hip, contracture of the left hip, diabetes mellitus type II, neuromuscular dysfunction of the bladder, and left hand pain. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 was cognitively impaired required assistance with activities of daily living (ADLs), and had frequent pain. Review of a care plan dated 12/03/24 revealed Resident #15 had a potential for altered nutrition and had interventions for build up utensils for eating and a Kennedy cup (a lightweight, spill-proof drinking cup) for liquids at bedside table and with all meals. Observation on 02/24/25 at 12:30 P.M. revealed Resident #15 did not have a Kennedy cup on the tray with the resident's meal. Further observation revealed Resident #15 had an open, half-full can of soda pop and a 64 ounce cup with a handle and lid, but no straw, on the overbed table in front of the resident. Interview with Certified Nurse Aide (CNA) #604 verified Resident #15 did not have a Kennedy cup at the time of the observation. Observation on 02/24/25 at 5:30 P.M. revealed Resident #15 did not have a Kennedy cup in the dining room and the resident was served three separate drinks all contained in regular cups. Interview with CNA #604 verified Resident #15 did not have Kennedy cups at the time of the observation. Interview on 02/24/25 at 5:40 P.M. with Dietary Manager (DM) #718 revealed no staff came into the kitchen to request a Kennedy cup for Resident #15 to use in his room. DM #718 verified Kennedy cups were available every day at all times. Review of the undated policy titled, Assistive Eating Devices, revealed it is the policy of the facility to provide assistive eating devices to residents with limited arm mobility, grasp, range of motion or coordination as recommended by nursing or therapy to promote independence in drinking and eating to their maximum ability. Staff are to be educated for placement and use to assist the resident.

Based on medical record review, review of arbitration agreements, and staff and resident interviews, the facility failed to ensure arbitration agreements were explained and presented to residents with appropriate cognition to understand the document content. This affected one (#145) of four residents reviewed for arbitration agreements. The census was 41. Findings include: Review of the medical record for Resident #145 revealed an admitted [DATE] with diagnoses including moderate dementia with agitation, atrial fibrillation, chronic obstructive pulmonary disease (COPD), hypertension, legal blindness, bilateral unspecified hearing loss, heart failure, cognitive communication deficit, and unspecified hearing loss bilateral. Review of a previous admission Minimum Data Set (MDS) assessment, completed 12/16/24 while Resident #145 in a different facility, the resident was assessed with severe cognitive impairment. Review of an arbitration agreement document revealed the parties understand, acknowledge, and agree by entering into this arbitration agreement they are voluntarily selecting arbitration as the method of resolving their disputes without resorting to lawsuits or the courts, and they are giving up and waving their constitutional right to have their disputes decided in a court of law before a judge and jury, the opportunity to present their claims as a class action and/or to appeal any decision or award of damages resulting from the arbitration as provided herein. By checking this box and signing this arbitration agreement, they acknowledge they understand the terms of the arbitration agreement. Further, by signing this arbitration agreement, they are agreeing to have any claims or disputes between the resident or his or her representative and the facility as set forth herein, decided through binding arbitration and they are giving up their right to a jury or court trial. An X was placed on this box. Review of the arbitration agreement document revealed Resident #145 signed the agreement on 02/06/25. Review of the resident signature line revealed a first name that was legible and the last name was illegible. Review of an admission MDS assessment dated [DATE] revealed Resident #145 was assessed with severe cognitive impairment. Review of a care plan dated 02/20/25 revealed Resident #145 had impaired cognitive function with interventions including to administer medications as ordered, communicate with the resident, family, or caregiver regarding the resident's capabilities and needs, discuss concerns about confusion, disease process, nursing home placement with resident, family, or caregiver, offer two to three step instructions when completing basic tasks, and keep routines as consistent as possible in order to decrease confusion. Review of a resident profile revealed Resident #145 had a Durable Power of Attorney (DPOA). Interview on 02/25/25 at 3:27 P.M. with Resident #145 revealed the resident was alert and oriented to self only. Resident #145 did not know what day or month it was and thought he was at the hospital. Resident #145 could not state what town he was in. Resident #145 stated he remembered signing paperwork when he came to the building, but did not know what an arbitration agreement was. Interview on 02/26/25 at 3:53 P.M. with Admissions Director (AD) #723 revealed she attempts to review previous facility or hospital documentation to determine a resident's cognition or asked questions such as the resident's name, the day of the week, and where they are to gauge cognitive function. AD #723 stated she would also get family input as well to determine a resident's ability to sign paperwork. AD #723 stated she obtained Resident #145's information from documentation from entities where the resident received care prior to admission to the facility. AD #723 stated Resident #145's DPOA lived out of state and she contacted her as well. AD #723 verified there was no documentation regarding the conversation. AD #723 stated Resident #145 was a lot different when he came in from how he was now. AD #723 stated the resident was able to tell her his name, where he was, what day it was, and appeared to understand what she was asking. AD #145 stated she sat beside the resident's, placed the iPad (handheld electronic device) in front of the resident, and read the admission packet off to him and have the resident sign the documents after each section. AD #145 verified the resident had diagnoses of legal blindness, dementia, and hearing loss in bilateral ears. AD #723 stated Resident #145 heard better in the right ear. AD #723 stated the resident did not have his hearing aides as they were lost in the transition from nursing homes, but new ones were ordered. AD #723 stated if Resident #145 was the way he was now she would have never had him sign his own paperwork.

Based on observation, medical record review, staff interview, and policy review, the facility failed to provide privacy during a mechanical lift transfer. This affected one (#27) of one residents reviewed for privacy. The census was 41. Findings included: Review of Resident #27's medical record revealed the resident was admitted on [DATE] with diagnoses of myocardial infarction, dysphagia, Alzheimer's disease, and depression. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #27 was cognitively impaired, had limited range of motion with the upper and lower extremities, and was wheelchair bound. Review of Resident #27's current plan of care revealed Resident #27 was to be transferred by a mechanical (Hoyer) lift at all times and was dependent with all care using one to two helpers. Observation on 02/24/25 at 11:11 A.M. revealed Certified Nurse Aide (CNA) #604 and CNA #704 were inside Resident #27's room with the door open while placing a Hoyer lift sling under the resident. CNA #604 and CNA #704 rolled Resident #27 from side to side with the resident's dress above her incontinence brief. After the Hoyer lift sling was in place, CNA #704 walked away from bedside to get the Hoyer lift while CNA #604 remained at the bedside opposite the open door to the hallway. Further observation revealed Resident #27 remained in bed with her dress moved further up toward her head with her full breast exposed. CNA #604 and CNA #704 lifted Resident #27 using the Hoyer lift into a wheelchair with her incontinence brief exposed all while the door remained open to the hallway. Interview with CNA #604 and CNA #704 verified they did not close the door to Resident #27's room while providing care. Review of an undated facility policy titled, Resident Rights, revealed residents have the right to have their privacy respected when treatment, medication, or care is being administered including the door closed or privacy curtain drawn.

Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure care conferences were completed as required. This affected two (#15 and #48) of three residents reviewed for care conferences. The facility census was 42. Findings include: 1. Review of the medical record revealed Resident #15 was initially admitted on [DATE], discharged on [DATE], and was readmitted on [DATE]. Diagnoses included metabolic encephalopathy, type two diabetes mellitus, colostomy status, gastrostomy status, pressure ulcer of sacral region (stage 3), anxiety disorder, and depression. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Review of care conference progress notes revealed Resident #15 care conference were completed on 02/15/24, 02/16/24, 04/10/24, and 06/27/24. There was no care conference completed in January when the resident admitted . 2. Review of the medical record review revealed Resident #48 was admitted on [DATE]. Diagnoses included unspecified sequelae of cerebral infarction, type two diabetes mellitus without complications, respiratory failure, atherosclerotic heart disease of native coronary artery, hyperlipidemia, essential primary hypertension, cognitive communication deficit, chronic kidney disease stage three. Review of the MDS assessment dated [DATE] revealed the resident was cognitively intact. Review of care conference progress notes revealed Resident #48 care conferences were completed on 08/09/23, 02/07/24, and 06/10/24. There was no care conference completed in May 2023 when the resident admitted and care conferences were not completed quarterly. Interview on 06/27/24 at 12:02 P.M. with Social Services #200 verified Resident #15 and Resident #48's care conferences were not completed timely. Review of the policy Baseline Care Plan/48 Hour Care Plan, no date, verified the baseline care plan must be completed within 48 hours of admission including weekends and holidays and will be printed and shared with the resident and/or resident representative. Review of policy Plan of Care Overview, no date, verified care plans are reviewed quarterly and/or with significant changes in care. This deficiency represents non-compliance investigated under Complaint Number OH00154224.

Based on record review, observations, resident and staff interviews, review of the activity calendar, review of activity documentation, resident council meeting minutes, and review of policy, the facility failed to provide sufficient and quality activities to meet the needs of residents. This affected seven (#5, #15, #18, #22, #23, #29, and #30) of seven residents reviewed for activities with the potential to affect all residents the facility. The facility census was 36. Findings include: 1. Review of medical record for Resident #5 revealed admission of 07/10/19 with diagnoses including chronic obstructive pulmonary disease, post-traumatic stress disorder, depression, hypertension, and dementia. Review of Minimum Data Set (MDS) assessment, dated 01/15/23, revealed Brief Interview of Mental Status (BIMS) score of six which indicated severe cognitive impairment. Resident required extensive assist of one for transfers. Resident independent for activities of daily living. Review of activity preferences interview, dated 08/01/22, for Resident #5 revealed resident was Baptist and was a member of a church prior to admission to facility, current interests included playing cards, reading magazines and newspaper, drawing, going for walks, watching football, being outside when weather is good going for sitting and relaxing, and talking and visiting family and friends. Resident prefers to participate in scheduled activities in the morning and afternoon. Review of care plan dated 01/10/23 for Resident #5 revealed resident attends activities of choice/interest and engages in self-initiated leisure activities. Interventions included encourage to attend activities, interview, and determine resident activity preferences, introduce to other residents with similar interests, provide a schedule of activities available, provide activity materials of interest such as magazines, library books, word puzzles. Residents preferred activities are listening to music in corridor and visiting with other residents. Interview on 02/07/23 at 2:05 P.M. with Resident #5 stated he would like to have more activities and is tired of sitting in his room all the time. He would like to have more residents involved in activities. Interview on 02/08/23 1:35 P.M. with Resident #5 states he attends some activities. Resident stated he would like different activities and more activities to sharpen his mind. Resident stated he was Catholic. Resident was indifferent regarding church services not being offered. Resident stated activities offered him include word search books and snacks. 2. Review of medical record for Resident #15 revealed admission 01/18/19 with diagnoses including iron deficiency anemia, anxiety, depression, other genetic related intellectual disability, and amnesia. Review of MDS assessment, dated 01/12/23, for Resident #15 revealed BIMS score of 15 which indicated cognitively intact. Resident #15 independent for activities of daily living. Review of activities preferences interview dated 07/29/22 for Resident #15 revealed resident was a member of Catholic church. Resident #15 current interests included cards, bingo, games, books, exercise, walking, jogging, sports, horror movies, keeping up with news, religious activity, bible study, spending time outdoors, talking, conversing, helping others, parties, social events, groups, and organizations. Resident #15 prefers to participate in scheduled activities in the afternoon and evening. Interview on 02/08/22 at 3:09 P.M. with Resident #15 revealed he would like to have more activities offered at the facility and have more to do. 3. Review of the medical record revealed Resident #18 was initially admitted to the facility on [DATE] with re-entry on 06/08/22. Diagnoses for Resident #18 included: fracture of base of skull left side subsequent encounter for fracture with routine healing, traumatic subarachnoid hemorrhage without loss of consciousness subsequent encounter, altered mental status, muscle weakness, acute kidney failure, Parkinson's disease, dysphagia oropharyngeal phase, type two diabetes mellitus without complications, hypercalcemia, and major depressive disorder recurrent severe with psychotic symptoms. Review of the MDS Assessment, dated 12/15/22, revealed the resident was severely cognitively impaired. Resident #18 is extensive one person assistance for bed mobility, transfers, walking in room, and locomotion on and off unit. Review of Resident #18's care plan, updated 12/21/22, revealed the resident participates in activities at times and prefers to participate in independent activities in her room. Goals include to one to one visits, participating in activities of choice, and show engagement of activities of interest through the review date. Interventions included to assist with transport to activities as needed, ensure activities are compatible with residents capabilities, encourage resident to attend, interview and determine activity preferences, provide one to one room visits if unable to attend out of room events, and other appropriate interventions. Review of activities preference interview, dated 12/14/22, revealed Resident #18 needs assistance getting to and from activities and is most active in the afternoon. Resident #18 religious preference is the Methodist Church, likes bingo games, crafts, bowling, watching programs, enjoying music, and likes to talk but is slow to respond. Resident #18 did not indicate any activities she would like the activities department to provide. Review of activity documentation, dated 01/01/23 to 02/07/23, revealed Resident #18 had a checkmark for a one on one visit three times. Observation on 02/06/23 and 02/07/23 of Resident #18 intermittently throughout the day revealed the resident laying in bed awake looking at the ceiling or out the door. The resident's side of the room was absent of a television or music. Resident #18 was only observed outside of the room for meals. Interview on 02/07/23 at 2:10 P.M., with Resident #18 indicated she would like to get out of her room sometimes and more than just for meals. Resident #18 does not want music or a television in her room. Resident #18 would like to have her nails painted or to have staff come and talk to her. Interview on 02/07/23 at 3:08 P.M., with Activities Director/Social Services Designee #529 verified Resident #18 does not have any documented participation of recent activities. 4. Review of medical record for Resident #22 revealed admission 11/15/19, with diagnoses including atherosclerotic heart disease, hypertension, glaucoma, polyosteoarthritis, gastro-esophageal reflux disease, and type two diabetes. Review of MDS assessment, dated 12/05/22, revealed BIMS score of 15 which indicated cognitively intact. Resident independent for activities of daily living. Review of activity preferences interview dated 08/01/22 for Resident #22 revealed resident was a member of Methodist church. Resident #23 current interest included solitaire, reading books, listening to the television, keeping up with news, helping others, and talking. Resident #23 prefers to participate in scheduled activities in the morning, afternoon, and evening. Review of care plan dated 12/13/22 for Resident #22 revealed resident prefers activities in her room such as reading and watching television. Resident will participate in activities of choice through review date. Resident will accept/participate in one-on-one visits. Interventions included assist with transport to activities as needed, encourage resident's representative to bring in personal items from home, encourage attendance to entertainment programs, large and small group activities, volunteer demonstrations, and religious activities, introduce to other residents with similar interests, invite to scheduled activities, provide one on one room visits if unable to attend out of room events, provide a schedule of activities available, and provide activity materials of interest. Interview on 02/08/23 at 2:59 P.M., with Resident #22 stated she would like more activities including more bingo. Resident #22 stated the facility did not provide church services on Sundays. Resident #22 would like church services on Sunday. 5. Review of medical record for Resident #23 revealed admission 07/02/21, with diagnoses including Alzheimer's with late onset, dementia with agitation, bipolar disorder, hypertension, type two diabetes, depression, post-traumatic stress disorder, anxiety, osteoarthritis, and benign prostatic hyperplasia. Review of MDS assessment, dated 01/02/23, revealed BIMS score of 11 which indicated moderately impaired cognition. Resident independent for activities of daily living. Review of activity preferences interview dated 12/20/22 for Resident #23 revealed resident was Methodist and went to weekly services on Sunday. Resident #23 current interests included reading murder mystery books, walking when back and legs are not bothering him, mystery movies, watching news daily, talking to others telling stories and jokes, and member of masonic lodge. Resident #23 prefers to participate in activities in the morning, afternoon, and evening and do independently on his own time. Review of care plan dated 12/08/22 for Resident #23 revealed person centered care. Staff to provide person centered care through the next review. Interventions included resident enjoys being up, and about at times walking, snack time, reading murder mysteries, watching murder mystery movies, and news, talking to others, and telling jokes. Resident naps at times. Interview on 02/08/23 at 2:54 P.M., with Resident #23 stated he only plays bingo at the facility. Resident stated the facility did not have church on Sundays. Resident stated he would like to attend church on Sunday. Resident stated he watches church currently on the television. 6. Review of medical record for Resident #29 revealed admission 11/11/21 with diagnoses including chronic obstructive pulmonary disease, overactive bladder, dementia, hypertension, atrial fibrillation, osteoarthritis, and history of falling. Review of MDS dated [DATE] for Resident #29 revealed BIMS score of seven which indicated severe cognitive impairment. Resident required extensive assist for activities of daily living. Review of activity preferences interview dated 11/18/22 for Resident #29 revealed resident current interests included bingo, playing cards, reading the newspaper, country music, watch television all day, and watch the news at 6:30 P.M. Resident prefers to participate in activities in the afternoon and evenings. Review of care plan dated 01/09/23 for Resident #29 revealed resident participates with activities of choice. Interventions included assist with transport to activities as needed, assure that the activities are compatible with resident's physical and cognitive capabilities, encourage attendance to entertainment programs, large and small group activities, volunteer demonstrations, and religious activities, interview and determine resident activity preferences, introduce to other residents with similar interests, invite resident to scheduled activities, provide one on one in room visits if unable to attend out of room events, provide a schedule of activities available, and provide activity materials of interest. Interview on 02/08/23 at 1:38 P.M. with Resident #29 stated she had played bingo once. Resident stated the facility did not have church on Sunday's. Resident #29 stated she would like to have church service at the facility on Sunday's. 7. Review of medical record for Resident #30 revealed admission 11/29/22, with diagnoses including hypo-osmolality and hyponatremia, volume depletion, headache, hypothyroidism, depression, and gastro-esophageal reflux disease. Review of MDS assessment, dated 12/08/22, for Resident #30 revealed BIMS score of 15 which indicated cognitively intact. Activity preference revealed the following were very important books, magazines, newspapers to read, going outside, participate in religious services or practices. The following are somewhat important doing favorite activities, doing things with groups of people, and listening to music. Resident #30 was independent for activities of daily living. Review of activity preferences interview, dated 12/06/22, for Resident #30 revealed resident is Catholic. Residents' current interests included bingo, bridge, crazy eights, documentaries, fiction, nonfiction, arts and crafts, walking, golfing, fishing, classical and country music, watching soap operas, baking, news, shopping and community outings, worship services, bible study, spending time outdoors, and talking. Resident prefers to participate in scheduled activities in the afternoon. Interview on 02/08/23 at 2:59 P.M., with Resident #30 stated she could use more activities and more bingo. Resident #30 stated the facility did not have church on Sundays and she would like to have church services. Observations on 02/06/23 to 02/09/23 over various times throughout the survey, revealed only one group activity was scheduled and offered at 1:30 P.M. No other group activities were observed being offered to meet the needs and desires of the residents. Review of the activity calendars, dated September 2022 through February 2023, revealed one activity is scheduled once per day at 1:30 P.M. The offered activity examples included resident council, games (bingo, uno, music trivia, dominoes), food (cream puff day, peppermint stick ice cream, popcorn day, muffin day, make your own pizza, pancakes, donut day), birthday party, spa day, and crafts . Every other weekend Saturday was scheduled for music and games and Sunday was scheduled for movie and games. Review of special notes on calendar revealed for resident's to participate in activities they must come to the dining room and there will be no more room to room activities. Review of large activity calendar posted in the resident hall for February 2023 revealed an activity offered every day at 1:30 P.M. only. Review of special notes on calendar revealed for resident's to participate in activities they must come to the dining room and there will be no more room to room activities. Review of the resident council meeting minutes, dated November 2022, revealed residents requested more activities. The facility response was to provide additional books, games, and movies to the cabinet in the common area available for residents to access. Interview on 02/07/23 at 3:08 P.M., with Activities Director/Social Services Designee #529 revealed there is a part-time activities assistant that comes in four day a week to offer the 1:30 P.M. resident activity. On the week days the activity aide is not here then she will complete the 1:30 P.M. activity and on every other weekend the aides fill in. Activities Director/Social Services Designee #529 verified one activity is offered per day, occasionally two. It was also verified at the November 2022 resident council resident's asked for more activities and the facility response was to provide additional books, games, and movies to the cabinet in the common area available for residents to access. Interview on 02/08/23 at 1:06 P.M., with Activities Aide #506 verified working three days a week and every other weekend. Activities Aide #506 reported she works from 11:30 A.M. to 3:00 P.M. and has time to complete the 1:30 P.M., group activity and provide one on one visits. Activities Aide #506 described the activities offered. For example, on popcorn day she will make popcorn for the residents who come to participate but she always makes extra and will deliver the extra to residents who stayed in their room if their diet allows. Activities Aide #506 verified there are no religious activities. Activities Aide #506 verified the facility has not reached out to any churches but needs to and nothing has been set up with a church prior to COVID-19. Activities Aide #506 reports she needs to reach out to an individual who provided a prayer service; another who played the piano and sang to see if they will come back. She stated her physician had offered to say the rosary with those who would want that and needs to follow up. Interview on 02/09/23 at 1:10 P.M., with the Administrator verified on the weekend when Activity Aide #506 is not working the aides will follow the activity schedule show a movie in the dining room for the activity for the day. The manager on the weekend may also assist or do a little extra. Review of the undated policy titled, Activities Program, revealed the activity program is designed to encourage restoration to self-care and maintenance of normal activity that is geared to the individual resident needs. The activity program is scheduled daily and residents are given an opportunity to contribute to the planning, preparation, conducting, cleanup and critique of the program. Activities of individual, small, and large are designed to meet the needs of residents including social activities, indoor and outdoor, religious programs, creative, intellectual and educational, exercise, individualized, in-room, and community. Activities shall reflect the cultural and religious interests of the residents.

Based on observations, review of activity calendars, review of resident council minutes, review of personnel file and staff interviews, the facility failed to ensure the activities program was directed by a qualified professional. This had the potential to affect 36 of 36 residents in the facility. Findings include: Observations on 02/06/23 to 02/09/23 over various times throughout the group survey, revealed only one activity was scheduled and offered at 1:30 P.M. No other group activities were observed being offered to meet the needs and desires of the residents. Review of the activity calendars, dated September 2022 through February 2023, revealed one activity is scheduled once per day at 1:30 P.M. The offered activity examples included resident council, games (bingo, uno, music trivia, dominoes), food (cream puff day, peppermint stick ice cream, popcorn day, muffin day, make your own pizza, pancakes, donut day), birthday party, spa day, and crafts . Every other weekend Saturday was scheduled for music and games and Sunday was scheduled for movie and games. Review of special notes on calendar revealed for resident's to participate in activities they must come to the dining room and there will be no more room to room activities. Review of large activity calendar posted in the resident hall for February 2023 revealed an activity offered every day at 1:30 P.M. only. Review of special notes on calendar revealed for resident's to participate in activities they must come to the dining room and there will be no more room to room activities. Review of the resident council meeting minutes, dated November 2022, revealed residents requested more activities. The facility response was to provide additional books, games, and movies to the cabinet in the common area available for residents to access. Review of the personnel record for Activities Director/Social Services Designee (AD/SSD) #529 revealed a hire date of 02/28/22. AD/SSD #529 personnel record had job descriptions signed for Social Services Director and Charge Nurse. The personnel record was silent for a job description for Activities Director. Review of the job employment application submitted 02/07/22 revealed the employee had formally worked as a State tested Nursing Assistant (STNA) and Licensed Practical Nurse (LPN). Interview on 02/07/23 at 3:08 P.M., with AD/SSD #529 verified she has been in the role as the Activity Director and Social Services since March 2022 and is also a LPN. AD/SSD #529 stated when they hired her they needed a nurse more then they needed activities. AD/SSD #529 verified she does not meet criteria of an Activity Director but plans to get her certificate in the future. Interview on 02/07/23 at approximately 3:45 P.M., with the Administrator verified AD/SSD #529 does not meet the criteria of an Activities Director. The Administrator stated corporate preferred the position to be held by a LPN and due to the facility being small the position is split between social services and activities. Interview on 02/08/23 at 3:00 P.M., with the Administrator verified AD/SSD #529 did not have a signed Activities Director job description in the personnel file.

Based on medical record review, staff interview and policy review, the facility failed to ensure resident assessments were complete and accurate. This affected four (#1, #17, #26, and #28) of 16 residents reviewed for accurate assessments. The facility census was 36. Findings include: 1. Review of the medical record for Resident #1 revealed an admitted [DATE] and a readmitted [DATE], with diagnoses of respiratory failure with hypoxia, morbid obesity, pain to lower extremities, dementia, congestive heart failure, and stage IV chronic kidney disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed staff determined a Brief Interview for Mental Status (BIMS) assessment for Resident #1 should be conducted. The BIMS assessment included seven questions. Review of the BIMS assessment for Resident #1 revealed four questions were completed, and the final three questions were marked not assessed. This resulted in a score of 99 indicating Resident #1 was unable to complete the interview. 2. Review of the medical record for Resident #17 revealed an admitted [DATE], with diagnoses of unspecified convulsions, anxiety, and depression. Review of the quarterly MDS assessment dated [DATE], revealed staff determined a BIMS assessment for Resident #17 should be conducted. The BIMS assessment included seven questions. Review of the BIMS assessment for Resident #17 revealed four questions were completed, and the final three questions were marked not assessed. This resulted in a score of 99 indicating Resident #17 was unable to complete the interview. 3. Review of the medical record revealed Resident #26 was admitted on [DATE]. Diagnoses included end stage renal disease, dependence on renal dialysis, heart failure, hypertension, acute respiratory failure with hypoxia, and acute respiratory failure with hypercapnia. Review of the MDS assessment, dated 11/23/22, revealed Resident #26 was cognitively intact. The medication assessment revealed Resident #26 received an anticoagulant for one day. Review of the physician orders, dated 05/16/22 to 11/23/22, revealed no anticoagulant medications. 4. Review of the medical record for Resident #28 revealed an admitted [DATE], with diagnoses of weakness, difficulty in walking, and history of transient ischemic attack. Review of the quarterly MDS assessment dated [DATE] revealed Resident #28 had intact cognition. Further review revealed he received an anticoagulant daily during the previous seven days. Review of the active orders in November 2022 revealed Resident #28 was on Plavix (an anti-platelet drug), Pletal (an anti-platelet drug), and a low-dose aspirin. Interview on 02/08/23 at 2:39 P.M., with the Regional Mobile MDS Nurse #533 confirmed the BIMS assessments for Resident #1 and Resident #17 were completed inaccurately, and should have been completed by asking the residents the final three questions rather than indicating the residents were not assessed. Further interview at that time with the Regional Mobile MDS Nurse #533 revealed the anticoagulant assessments for Resident #26 and Resident #28 were coded inaccurately based on the active orders at the time of the review. Review of the undated policy titled MDS Responsibilities revealed the assessment must be completed accurately.

Based on observation, record review, staff interview, and policy review, the facility failed to follow physician orders regarding tube feed administration. This affected one (#138) of one resident reviewed for tube feed. The facility census was 36. Findings include: Review of medical record for Resident #138 revealed admission of 02/01/23, with diagnoses of fusion of spine cervical region, spinal stenosis, unspecified cord compression, cerebral palsy, dysphagia, conversion disorder with seizures or convulsions, hypothyroidism, aphasia, pneumonitis due to inhalation of food and vomit, and anxiety. Review of Minimum Data Set (MDS) assessment dated [DATE] for Resident #138 revealed resident is rarely/never understood. Staff interview revealed resident is independent for daily decision making skills. Review of physician order dated 02/08/23 for Resident #138 revealed nepro at 45 milliliters (ml) per hour for 20 hours a day, off at 8:00 A.M. and on at 12:00 P.M. Observation on 02/08/23 at 3:04 P.M. of Resident #138 tube feed revealed tube feed not hooked up or on for resident. Interview on 02/08/23 at 3:05 P.M. with Licensed Practical Nurse (LPN #635) stated Resident #138 tube feed was to be held for four hours. Stated it was to be unhooked today from 9:15 A.M. to 1:15 P.M. LPN #138 verified tube feed had not been restarted and was unhooked. Review of policy titled Enteral Nutrition with Continuous Pump dated 01/05/22, revealed the nurse will monitor the flow rate during the shift to ensure proper functioning.

Based on medical record review, staff interview, and policy review, the facility failed to provide rationale for gradual dose reduction (GDR) not indicated. This affected one (#21) of five residents reviewed for GDR's. The facility census was 36. Findings include: Review of medical record for Resident #21 admitted on [DATE], with diagnoses including Alzheimer's with early onset, dementia, hypertension, adult failure to thrive, depression, and schizoaffective disorder. Review of Minimum Data Set (MDS) assessment dated [DATE], for Resident #21 revealed a Brief Interview for Mental Status (BIMS) score of five which indicated severe cognitive impairment. Resident #21 was independent for activities of daily living. Review of the form titled: CommuniCare: Psychotropic Medication Evaluation (Pharmacy and Therapeutics Committee), dated 02/09/22, for Resident #21 revealed GDR not indicated at this time, due since (pick one, note rational below). No rationale listed on GDR form. Review of the form titled: CommuniCare: Psychotropic Medication Evaluation (Pharmacy and Therapeutics Committee), dated 05/17/22, for Resident #21 revealed GDR is indicated at this time. No recommended dosage reduction was listed. Interview on 02/08/23 at 10:16 A.M., with Director of Nursing (DON) verified on 05/17/22, GDR was marked for dose reduction is indicated at this time with no recommendation for gradual dose. DON stated it was supposed to be marked as GDR not indicated at this time. No rationale provided. DON verified on 02/09/22, no rationale was provided for gradual dose reduction not indicated. Review of the undated policy titled: Antipsychotic Second Clinical Review, revealed documentation to support the use of antipsychotics in this setting includes prescriber is required to document use, goals, and ongoing assessments.

Based on record review, observations, resident and staff interviews, and policy review, the facility failed to ensure a resident received the care and services for daily use of alcohol. This affected one (#17) of one resident reviewed for alcohol. The facility census was 36. Findings include: Review of medical record for Resident #17 revealed admission of 01/25/20, with diagnoses including unspecified convulsions, anxiety, insomnia, depression, migraine, atrial fibrillation, cerebral infarction with right sided hemiparesis/hemiplegia, and expressive language disorder. Review of Minimum Data Set (MDS) assessment dated [DATE], for Resident #17 revealed the mental status was unable to be assessed. Staff interviews revealed the resident independent for daily decision making. Resident #17 was assessed as independent for activities of daily living. Observation on 02/06/23 at 11:30 A.M., revealed two [NAME] Lite cans on over the bed table. One can noted to be open. Interview on 02/06/23 at 12:53 P.M., with Resident #17 stated she gets two beers a day. Resident #17 stated she gets both at the same time. Two empty beer cans noted in the trash can. Review of physician orders for January 2023 and February 2023 revealed no orders for beer consumption. There was no care plan in place to address the use of alcohol. Interview on 02/06/23 at 1:48 P.M., with Licensed Practical Nurse (LPN) #632 stated Resident #17 is allowed two beers per day. LPN #632 verified the resident received two beers today. LPN #632 verified no orders were in point click care for beer. Review of the undated policy titled Alcoholic Beverage Dispensing revealed a physician's order must be obtained to dispense alcohol to a resident.

Based on medical record review, staff, resident, and resident representative interviews, and policy review; the facility failed to conducted care conferences. This affected two (#18 and #26) of two resident reviewed for care planning. The census was 36. Findings include: 1. Review of the medical record for Resident #18 revealed an initial admitted [DATE], with re-entry admission on 06/08/22. Diagnosis for Resident #18 included: altered mental status, muscle weakness, acute kidney failure, Parkinson's disease, dysphagia oropharyngeal phase, type two diabetes mellitus without complications, hypercalcemia, and major depressive disorder recurrent severe with psychotic symptoms. Review of the Minimum Data Set (MDS) Assessment, dated 12/15/22, revealed the resident was severely cognitively impaired. Review of the medical record, dated since 06/08/22 to date of survey, revealed no evidence of a care conferences being held. Interview on 02/06/23 at 2:39 P.M., with Resident #18's Representative verified they were not aware of care plan conferences being held. Interview on 02/08/23 at 5:00 P.M., with Activities Director/Social Services Designee #529 verified there were no care conferences held for Resident #26 since re-admission. 2. Review of the medical record revealed Resident #26 was admitted on [DATE]. Diagnosis included end stage renal disease, dependence on renal dialysis, heart failure, type two diabetes mellitus with other diabetic kidney complication, major depressive disorder recurrent, essential (primary) hypertension, acute respiratory failure with hypoxia, and acute respiratory failure with hypercapnia. Review of the Minimum Data Set (MDS) assessment, dated 11/23/22 revealed the resident was cognitively intact. Interview on 02/06/23 at 11:40 A.M., with Resident #26 revealed she was not familiar with care plan conferences and had never been invited nor participated in one. Review of social services progress note, dated 11/10/22, revealed she spoke with resident's sister about her upcoming care conference and the sister would like to reschedule until after they get back from vacation and will call upon return to schedule. Interview on 02/08/23 at 5:00 P.M., with Activities Director/Social Services Designee #529 revealed she had talked to the sister in the hallway after she had returned from vacation and did not reschedule the care conference. Activities Director/Social Services Designee #529 verified there were no care conferences held for Resident #26 since admission. Review of the undated policy titled Plan of Care Overview, revealed resident/representatives will be offered opportunities to voice their view in the development and implementation of his/her own plan of care. This will include holding meetings at a time when resident is functioning at his/her best, schedule meetings to accommodate a resident representative that may include conference calls, video calls or live sessions, and plan adequate meeting times. The care plan team shall include an interdisciplinary team.

Based on observation, record review, staff interview, and policy review, the facility failed to administer medications per physician order. This affected one (#25) of three residents reviewed for medication administration. The facility census was 36. Findings include: Review of medical record for Resident #25 revealed admitted [DATE], with diagnoses including wernicke's encephalopathy, unspecified mood disorder, anxiety, bipolar disorder, and cognitive communication disorder. Review of Minimum Data Set (MDS) assessment dated [DATE] for Resident #25 revealed a brief interview of mental status (BIMS) score of 14 which indicated cognitively intact. Observation on 02/07/23 at 7:34 A.M., during medication pass with Licensed Practical Nurse (LPN) #632 revealed the nurse administered Seroquel 50 milligrams (mg) and Seroquel 25 mg to Resident #25. Review of physician order dated 02/02/23 for Resident #25 revealed discontinue previous Seroquel order. Start Seroquel 25 mg by mouth twice daily for five days then discontinue on 02/07/22. Start Seroquel 25 mg by mouth at bedtime on 02/07/23 for five days then discontinue on 02/13/23. Gradual dose reduction attempt, notify physician if resident does not tolerate. Review of physician orders for February 2023 for Resident #25 revealed Seroquel 25 mg twice daily was started on 02/03/23 and discontinued on 02/08/23. Seroquel 25 mg at bedtime was started on 02/08/23 to be discontinued on 02/14/23. Interview on 02/07/23 at 9:44 A.M., with LPN #632 verified Resident #25 was given Seroquel 25 mg tablet and Seroquel 50 mg tablet for a total of 75 mg. LPN #632 verified Seroquel 25 mg was to be given per the physician orders. Review of the policy titled Medication Administration reviewed on 01/05/2022 revealed facility to administer medication only as prescribed by the provider.

Based on medical record review, resident and staff interview, and policy review, the facility failed to ensure a resident was seen by a dentist timely. This affected one (Resident #23) of one resident reviewed for dental concerns. The facility census was 36. Findings include: Review of the medical record revealed Resident #23 was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease with late onset, dementia in other diseases classified elsewhere severe with agitation, essential (primary) hypertension, hyperlipidemia, type two diabetes mellitus with diabetic neuropathy, acute kidney failure, acute kidney failure. Review of the Minimum Data Set (MDS) assessment, dated 12/09/22, revealed the resident was moderately cognitively impaired. Review of the care plan, dated 12/08/22, revealed the care plan was silent for dental needs. Review of the nurse's progress note, dated 09/17/22, revealed Resident #23 reported that while he was eating an apple four to five of his top teeth fell out. Resident's Representative reported he will call the dentist on Monday. The gum line was observed and no broken teeth were observed. Interview on 02/06/23 at 10:36 A.M., with Resident #23 revealed he bit into an apple more then 10 weeks ago and lost six teeth stating that the facility has not done anything about it. Interview on 02/27/23 at 3:08 P.M., with Activities Director/Social Services Designee #529 confirmed she was aware Resident #23 had broke or lost teeth after biting on apple in September 2022. Activities Director/Social Services Designee #529 reports it depends on the day if it is causing him problems or if he complains about it. She reports his son was trying to find in a dentist because he will take him to outside appointments and the facility was having issues finding a dentist to take Medicaid. The facility dentist came when the resident was out at the hospital in December 2022. Activities Director/Social Services Designee #529 confirmed not attempting to contact any outside dentist for services. Interview on 02/08/23 at 2:56 P.M., with Activities Director/Social Services Designee #529 revealed there is no scheduled date for the dentist to come. She did email them this morning to schedule. Activities Director/Social Services Designee #529 was able to confirm the dentist was scheduled on 12/02/22 but had a staffing issue and scheduled for 12/14/22 when the resident was out at the hospital. Review of the undated policy titled: Dental Services, stated the facility will assist the resident in obtaining routine dental services, providing emergency dental services, obtaining services to the resident to meet the needs of each resident, making appointments, and arrange for transportation.

Based on observation, staff interview, record review, and review of the policy, the facility failed to ensure fall interventions were in place for a resident at risk for falls. This affected one (#20) of three residents reviewed for falls. The facility census was 36. Findings include: Review of the medical record for Resident #20 revealed an admitted [DATE], with medical diagnoses of unspecified dementia, acute on chronic respiratory failure with hypoxia, morbid obesity, weakness, pain in lower extremities, and cerebral infarction. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 had impaired cognition and required extensive assistance of two people for bed mobility, transfers, dressing, toileting, and hygiene, and required supervision with one person assist for eating. Further review revealed Resident #20 fell two or more times without injury since the previous assessment. Review of a physician order dated 01/16/23 revealed Resident #20 needed a low bed with mats on the floor bilaterally for safety. Review of the current care plan revealed Resident #20 was at risk for falls. Interventions included having his bed in the lowest position with bilateral floor mats. Observation on 02/06/23 at 1:38 P.M., revealed Resident #20 in bed sleeping. Further observation revealed a floor mat on the right side of his bed only and the bed was not in the low position. Interview and concurrent observation with State tested Nurse Aide (STNA) #531 on 02/06/23 at 1:46 P.M., confirmed Resident #20's bed was not in the low position and floor mats were not on both sides of the bed. STNA #531 lowered the bed to the lowest position and placed a floor mat on the left side of the bed at that time. Observation on 02/08/23 at 10:06 A.M., revealed Resident #20 lying in bed asleep. Two floor mats were folded and leaning against the wall. No mats were on the floor. The bed did not appear to be in the lowest position. Interview and observation on 02/08/23 at approximately 10:01 A.M., with Licensed Practical Nurse (LPN) #530 confirmed Resident #20 should have floor mats placed on both sides of his bed and further confirmed his bed was not in the lowest position. LPN #530 placed floor mats on both sides of Resident #20's bed and lowered the bed at that time. Interview on 02/09/23 at 3:32 P.M., with the Administrator confirmed staff were expected to implement fall interventions indicated in each resident's care plan. Review of the undated facility policy titled Fall Prevention and Management revealed the resident's care plan should include fall interventions specific to the needs of each resident.

Based on observation, staff interview, and policy review, the facility failed to wear facial masks during direct resident contact. This had the potential to affect 40 of 40 residents residing in the facility. Findings include: Observation of staff working the 200 hallway between 4:00 P.M. to 5:15 P.M., revealed Licensed Practical Nurse, (LPN) #102 was administering medication to eight residents (#22,#23, #27, #29, #26, #28,#29, and #37) on the 200 hallway. LPN #102 was observed wearing a surgical mask below her nose just covering her lower lip. Personal Care Assistant (PCA) #421 and State tested Nursing Assistant (STNA) #411 were observed going in and out of resident's room passing and gathering trays with surgical masks on not covering their nose. On 05/31/22 at 5:20 PM during an interview the Director of Nursing verified the staff were to wear a surgical mask covering both their nose and mouth at all times in the building. She verified LPN #102 , PCA #421 and STNA #411 currently were wearing their surgical masks below their nose. She stated it is her expectation all staff will wear a mask that covers both their nose and mouth when caring for residents. Review of the policy titled Criteria for COVID-19 Requirements and Resident Placement, revised 03/02/22 , stated under General Care Areas and Green Rooms , employees are to wear a surgical mask and eye protection when providing care for residents. This deficiency substantiates Complaint Number OH 158.

Based on observation, staff interview and policy review, the facility failed to maintain personal health information in a confidential manner. This affected one (#22) of 40 residents who was randomly observed. The facility census was 40. Findings include: Observation on 06/01/22 at 3:22 P.M., revealed Licensed Practical Nurses (LPN) #110 and #111 were standing in the hallway just outside of Resident #22's room. LPN #111 held a cell phone while facetiming a physician and LPN #110 was discussing Resident #22's treatments and describing his wounds. Residents #26 and #38 were very near to the area and could overhear the conversation. Interview on 06/01/22 at 3:40 P.M., with LPN #111 provided verification of the lack of privacy afforded Resident #22 with the discussion with the doctor while in the hallway. Review of the undated policy titled HIPPA Confidentiality and Non-disclosure Agreement, revealed employees should refrain from communicating information about a resident in a manner that would allow others to overhear such information. This deficiency substantiates Complaint Number OH 158.