Every finding on record at Harding Pointe

Based on review of facility policy, review of water temperature logs, Center for Disease Control and Prevention (CDC) guidance, the facility failed to maintain a complete, accurate and safe water management program to prevent the spread of legionella. This had the potential to affect all 48 residents.Findings include: Interview on 12/09/25 at 3:46 P.M. with Maintenance #146 confirmed the facility uses continuous water circulation to prevent growth of legionella. Maintenance #146 confirmed the hot water tanks are set between 110-120 degrees Fahrenheit and are checked quarterly to ensure water is set at a safe level. He confirmed the water tanks which supplied water to resident rooms were documented on the water temperature logs to read as follows: on 12/02/25 the water temperature in the tank read at 113 degrees Fahrenheit, on 08/11/25 at 115 degrees Fahrenheit, and on 06/06/25 at 114 degrees Fahrenheit.Observation on 12/09/25 at 3:50 P.M. of the hot water tanks supplying resident rooms with Maintenance #146 confirmed tanks were currently reading 108 degrees Fahrenheit and 110 degrees Fahrenheit when reading the thermostat. When obtaining an actual temperature, the water read at a high of 97 degrees Fahrenheit.Interview conducted 12/10/25 at 10:42 A.M. with Regional Maintenance (RM) #200 confirmed hot water temperatures should be delivered to resident rooms below 120 degrees Fahrenheit due to scalding risk. All hot water tanks are set to 120 degrees Fahrenheit when pulling water into resident rooms. Legionella practice used to prevent growth includes continuous water circulation which is obtained by using a circulation pump. RM #200 confirms the facility follows Center for Disease Control guidance pertaining to legionella prevention and confirms the water tanks need to be at least 120 degrees Fahrenheit with continuous circulation to control legionella growth. RM #200 denied the facilities hot water system using mixing valves to decrease temperatures of water supply to resident rooms to prevent scalding.Interview conducted 12/10/25 at 2:57 P.M. with Maintenance #146 confirmed a second check of obtaining the hot water was required due to incorrect obtainment on 12/09/25 with this surveyor. When the temperatures came back lower than expected, he replaced the thermostat for tank 1 and 2, which supplied water to resident areas. Observation of the new thermostat revealed the temperature read at 113 degrees Fahrenheit, and a recollection temperature was obtained reading the water temperature at 124.1 degrees Fahrenheit.Review of facility monitoring control measures undated revealed a total of four water heaters supply heated water to resident care areas. Those areas include sinks and showers with a requirement to check temperatures and visual inspection.Review of facility legionella reduction plan completed, under section hot water tank temperatures are to be completed quarterly. In addition, supply temperature should range from 110-120 degrees Fahrenheit. Location one was identified as R and on 12/02/25 the tank read at 113 degrees Fahrenheit, on 08/11/25 at 115 degrees Fahrenheit, and on 06/06/25 at 114 degrees Fahrenheit.Review of reducing legionella risk and transmission policy dated 06/01/17 revealed prevention and monitoring mechanisms may include periodic disinfection through usage of chemicals and changing temperature regulation. In addition, current CDC recommendations are to be followed in prevention, isolation, and monitoring to prevent the spread of legionnaires disease.Review of controlling legionella in potable water systems dated 01/03/25 by the Center for Disease Control revealed facilities design recommendations include installing thermostatic mixing valves as close as possible to fixtures to prevent scalding risk while also ensuring circulating hot water temperatures remain above 120 degrees Fahrenheit. Additionally, ensure hot water in circulation does not fall below 120 degrees Fahrenheit.

Based on record review, interview and observation the facility failed to ensure advanced directives located in resident records did not contain contradictory statuses. This affected four (Resident #3, Resident #28, Resident #5 and Resident #35) out of twenty residents reviewed for advanced directives. The facility census was 48. Findings include: 1.Review of the medical record for Resident #5 revealed an admission date of [DATE] with diagnoses including intracranial injury with loss of consciousness, constipation, Type II Diabetes Mellitus, acute gastritis, persistent vegetative state, quadriplegia, chronic obstructive pulmonary disease, anxiety, major depressive disorder, encephalopathy, and convulsions. Review of undated code status paperwork for Resident #5 revealed a standardized Do Not Resuscitate Comfort Care (DNRCC) form with the resident's name written at the top and Full Code CPR handwritten in the top right corner. A large X was placed over the comfort care text, creating conflicting documentation. Review of physician order dated [DATE] for Resident #5 indicated the resident's advanced directive as Full Code. Review of the care plan dated [DATE] for Resident #5 revealed no documentation of the resident's code status. Interview conducted on [DATE] at 2:22 P.M. with Licensed Practical Nurse (LPN) #125 and LPN #121 confirmed concerns regarding Resident #5's code status documentation. Staff noted the paper record showed conflicting information, including a standard DNRCC form with text marked out and Full Code CPR handwritten at the top. They agreed this could cause confusion, especially for new or agency staff, as the form displayed both DNRCC with instructions and Full Code. Staff acknowledged the current form may be misleading and could result in incorrect assumptions about the resident's actual code status. Interview conducted on [DATE] at 2:30 P.M. with LPN Charge Nurse #136 confirmed concerns regarding Resident #5's code status documentation. LPN #136 noted the presence of a standard DNRCC form with instructions, while Full Code CPR was handwritten at the top. They agreed this conflicting information could cause confusion, especially for new or agency staff, and may lead to incorrect assumptions about the resident's actual code status. Review of the facility's policy titled, Advanced Directives dated [DATE] revealed if the resident has executed an advance directive shall be displayed prominently in the medical record. 2. Review of the medical record for Resident #35 revealed an admission date of [DATE] with diagnoses including Type II Diabetes Mellitus, schizophrenia, schizoaffective disorder, and tachycardia. Review of a physician order dated [DATE] for Resident #35 indicated Full Code status for resuscitative measures. Review of the care plan dated [DATE] for Resident #35 revealed that the resident elected Full Code status. The care plan instructed staff to call 911 for emergency help, honor the responsible party's wishes, and refer to the physician as needed. Review of the quarterly Minimum Data Set (MDS) completed on [DATE] for Resident #35 revealed the resident was cognitively intact. Review of undated code status paperwork for Resident #35 revealed a standardized DNRCC form with the resident's name written at the top and Full Code handwritten in an inconspicuous area. The record also included DNR protocol, creating conflicting documentation. Interview conducted on [DATE] at 2:22 P.M. with LPN #125 and LPN #121 confirmed concerns regarding Resident #35's code status documentation. Staff noted the paper record showed conflicting information, including a standard DNRCC form with text marked out and Full Code handwritten in an inconspicuous area. They agreed this could cause confusion, especially for new or agency staff, as the form displayed both DNRCC with instructions and Full Code. Staff acknowledged the current form may be misleading and could result in incorrect assumptions about the resident's actual code status. Interview conducted on [DATE] at 2:30 P.M. with LPN Charge Nurse #136 confirmed concerns regarding Resident #35's code status documentation. LPN #136 noted the presence of a standard DNRCC form with instructions, while Full Code was handwritten at the top. They agreed this conflicting information could cause confusion, especially for new or agency staff, and may lead to incorrect assumptions about the resident's actual code status. Review of the facility's policy titled, Advanced Directives dated [DATE] revealed if the resident has executed an advance directive shall be displayed prominently in the medical record. 3. Record review of Resident #3's medical record revealed an admission date of [DATE]. Diagnoses include cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery, epilepsy, insomnia, constipation, obesity, bilateral sensorineural hearing loss, sleep related bruxism, nonexudative age related macular degeneration- left eye and early stage, bilateral vitreous degeneration, and schizoaffective disorder bipolar type. Review of Resident #3's Minimum Data Set (MDS) 3.0 dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating cognitively intact. Review of Resident #3's care plan with a target date of [DATE] confirmed Resident #3 and/or responsible party have chosen to be a full code. Record review of Resident #3's physician order confirmed Resident has an active Advanced Directive order for full code dated [DATE]. Record review of Resident #3's code status sheet in Resident #3's physical medical chart revealed a DNR form with attempts to cross out portions of form with full code handwritten on top right corner of the DNR sheet. Interview on [DATE] at 3:30 P.M. with LPN #121 stated the facility uses either white or pink DNR sheet for code status although the resident may be full code the sheet will not be filled out but noted as full code. Interview on [DATE] at 8:57 A.M. LPN charge nurse #136 stated code status is in the physical medical chart and also in the care plan. Review of the facility's policy titled, Advanced Directives dated [DATE] confirms information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. 4. Record review of Resident #28's medical record revealed an admission date of [DATE]. Diagnoses include chronic obstructive pulmonary disease, obesity, bilateral sensorineural hearing loss, iron deficiency anemia, bipolar disorder current episode depressed mild or moderate severity, cervicalgia, unspecified psychosis not due to a substance or known physiological condition, and peripheral vascular disease. Review of Resident #28's Minimum Data Set (MDS) 3.0 dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating cognitively intact. Review of Resident #28's care plan with a target date of [DATE] confirmed Resident #28's care plan did not include code status. Record review of Resident #28's physician order confirmed Resident has an active Advanced Directive order for full code dated [DATE]. Record review of Resident #28's code status sheet in Resident #28's physical medical chart revealed a DNR form with attempts to cross out portions of form with full code handwritten on top of the right corner of the DNR sheet. Interview on [DATE] at 3:30 P.M. with LPN #121 stated the facility uses either white or pink DNR sheet for code status although the resident may be full code the sheet will not be filled out but noted as full code. Interview on [DATE] at 8:57 A.M. with the LPN charge nurse #136 stated code status is in the physical medical chart and in the care plan. Review of the facility's policy titled, Advanced Directives dated [DATE], confirms the plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive and information about whether or not the resident has executed and advance directive shall be displayed prominently in the medical record.

Based on record review and staff interview, the facility failed to ensure physician orders were dated appropriately. This affected seventeen residents (Residents #23, #6, #42, #21, #43, #55, #40, #34, #24, #20, #19, #39, #16, #4, #25, #49, and #11) out of 37 residents who were marked as consenting for the SARS-CoV-2 (COVID-19) vaccine. The facility census was 48. Findings include:Review of the physician's orders for the COVID-19 vaccine revealed Residents #23, #6, #42, #21, #43, #55, #40, #34, #24, #20, #19, #39, #16, #4, #25, #49, and #11 all had physician orders that were signed but not dated by Medical Director (MD) #153. Review of the electronic order history revealed all 17 COVID-19 vaccine orders were created on 11/24/25.During an interview on 12/10/25 at 10:12 A.M., Administrative Assistant (#127) stated when MD #153 signed the orders, he did not date them. She stated she typically reviewed the facility's physician rounding schedule to determine the date he was present in the building and then entered the date next to his signature. She stated the physician was in the building on 11/24/25, but confirmed none of the COVID-19 vaccine orders were dated by MD #153 on that date.During an interview on 12/10/25 at 12:52 P.M., MD #153 stated all residents had the option to receive the COVID-19 vaccine. He stated he assumed the resident's Power of Attorney (POA) or guardian had approved the vaccine, and during influenza season the facility asked him whether residents could receive vaccines, at which time he generally gave his approval. He stated if a resident had an adverse reaction, the vaccine would not be provided in the future. He stated residents were required to have signed consents and written risks provided prior to the vaccination. He stated he may not have signed those orders.

Based on interview, observation, and record review, the facility failed to ensure vaccines were stored in a sanitary, safe and appropriate manner. This had the potential to affect 25 residents ( #2, #3, #4, #5, #6, #10, #11, #16, #19, #20, #21, #23, #24, #25, #27, #28, #32, #34, #37, #39, #40, #42, #43, #49, & #55) who consented to receive the SARS CoV-2 (COVID-19) vaccine. The facility census was 48. Findings include: Observation and interview conducted on 12/09/25 at 4:49 P.M. with Licensed Practical Nurse (LPN) Charge Nurse #136 revealed vaccines were stored in the front office refrigerator which was observed to not have a thermometer in the refrigerator. Numerous food items were observed in the same refrigerator, including cheese, tea, bologna, Pepsi, Dr. Pepper, root beer, and dressing packets (honey mustard, ranch, and sour cream). LPN #136 confirmed no thermometer was present in the refrigerator to ensure the correct temperature was maintained. Observation of the vaccines revealed the brand Comirnaty (COVID-19 vaccine, mRNA), lot number NH9993, expiration date 09/08/26. Four vaccine doses were present in two packages and were cold to the touch.Observation and interview conducted on 12/10/25 at 9:23 A.M. of the office refrigerator with LPN Charge Nurse #136 confirmed the COVID-19 vaccines had been removed. LPN #136 acknowledged the vaccines should not have been stored in the refrigerator with food and without verification of appropriate temperature control.Review of the Comirnaty package insert revealed prefilled syringes must be stored refrigerated at 35 F to 46 F.Review of the facility's medication storage policy dated 02/2018 revealed that nursing staff are responsible for maintaining medication storage in a clean, safe, and sanitary manner. The policy states that medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secured location. Medications must be stored separately from food and labeled accordingly.

Based on observation, staff interview, and a review of a facility policy, the facility failed to prepare the correct diet texture as ordered for the residents receiving pureed diets. This had the potential to affect six residents (Residents # 4, #7, #20, #25, #37, and #39) who were receiving pureed diet textures. The facility census was 48 residents. Findings include: Observation of the preparation of the pureed diet textures on 09/30/25 at 11:31 A.M. revealed after mechanically altering ham loaf to a pureed consistency, there were visible chunks, similar to the rind of the ham, in the pureed ham loaf. Observation of the mouthfeel of the pureed ham loaf on 09/30/25 at 11:31 A.M. revealed that there were chunks that were not uniformly smooth in the pureed ham loaf. An interview with Dietary [NAME] #114 on 09/30/25 at 11:31 A.M. confirmed that there were chunks, possibly from the ham rind that was not removed prior to the pureeing process, in the pureed ham loaf. Dietary [NAME] #114 revealed the correct texture for pureed diets would be a smooth uniform texture, similar to baby food. Review of the facility policy titled, Mechanically Altered Diets, revised October 2017, revealed that pureed diets are homogenous, lump-free and cohesive foods with a smooth texture.

Based on interview, medical record review and facility policy review the facility failed to provide education and consent for the SARS CoV-2 (COVID-19) vaccine prior to administration. This affected four of six (Resident ##32, #28, #24 and #34) residents reviewed for immunizations. The census was 48.Findings include: 1. Record review of Resident #32's medical record revealed an admission date of 06/08/18. Diagnoses include other schizophrenia, bilateral age-related nuclear cataract, major depressive disorder recurrent severe without psychotic features, Parkinson's disease without dyskinesia without mention of fluctuations, anxiety disorder, insomnia, dysphagia oral phase, obsessive-compulsive disorder, neuromuscular dysfunction of bladder, essential (primary) hypertension, unspecified asthma, chronic kidney disease and tachycardia. Review of Resident #32's Minimum Data Set (MDS) 3.0 dated 11/01/25 revealed a Brief Interview for Mental Status (BIMS) score of 10. Review of Resident #32's immunization records confirmed Resident #32 received a Comirnaty Covid Vaccine on 11/24/25. No signed consent from the guardian was present for this vaccine. Interview on 12/10/25 at 3:19 P.M. with Licensed Practical Nurse (LPN) charge nurse #136 confirmed they did not send out Covid 19 vaccination education or request for consent prior to administering Covid 19 vaccinations on 11/24/25. 2. Record review of Resident # 24's medical record revealed an admission date of 05/09/22. Diagnoses include Alzheimer's disease with late onset, bilateral primary open-angle glaucoma indeterminate stage, major depressive disorder recurrent and moderate, right hip primary osteoarthritis, obesity, unspecified dementia unspecified severity with behavioral disturbance, chronic obstructive pulmonary disease, mixed- receptive language disorder, cognitive communicative deficit, schizoaffective disorder, essential (primary) hypertension, spinal stenosis and alcohol dependence with alcohol induced persisting dementia. Review of Resident #24's Minimum Data Set (MDS) 3.0 dated 11/26/25 revealed a Brief Interview for Mental Status (BIMS) score of one. Review of Resident #24's immunization records confirmed Resident #24 received a Comirnaty Covid Vaccine on 11/24/25. No signed consent from the guardian was present for this vaccine. Interview on 12/10/25 at 3:19 P.M. with LPN charge nurse #136 confirmed they did not send out Covid 19 vaccination education or request for consent prior to administering Covid vaccinations on 11/24/25 3. Record review of Resident #28's medical record revealed an admission date of 02/17/2012. Diagnoses include chronic obstructive pulmonary disease, obesity, bilateral sensorineural hearing loss, iron deficiency anemia, bipolar disorder current episode depressed mild or moderate severity, cervicalgia, unspecified psychosis not due to a substance or known physiological condition, and peripheral vascular disease. Review of Resident #28's Minimum Data Set (MDS) 3.0 dated 11/02/25 revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. Review of Resident #28's immunization records confirmed Resident #28 received a Comirnaty Covid Vaccine on 11/24/25. No signed consent from the guardian was present for this vaccine. Interview on 12/10/25 at 3:19 P.M. with LPN charge nurse #136 confirmed they did not send out Covid 19 vaccination education or request for consent prior to administering Covid vaccinations on 11/24/25. Review of the facility's policy titled, Vaccination of Residents, revised 12/2017 confirms prior to receiving vaccinations, the resident or legal representative will be provided information and education regarding the benefits and potential side effects of the vaccinations. Review of the facility's policy titled, Covid 19 Vaccine not dated, confirmed before receiving a Covid 19 vaccine, the resident or legal representative, or staff shall receive information and education regarding the benefits and potential side effects of the Covid 19 vaccine. For residents, the provision of such education shall be documented in the resident's medical record. 4. Review of the medical record for Resident #34 revealed an admission date of 12/22/14, re-entry 12/08/15, with diagnoses that included moderate persistent asthma with acute exacerbation, obstructive sleep apnea, morbid obesity due to excess calories, and schizoaffective disorder. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 00, indicating severely impaired cognition. Review of the immunization record revealed the resident received a Comirnaty COVID-19 vaccine on 11/24/25 at 1:00 P.M., administered intramuscularly in the right deltoid by Licensed Practical Nurse (LPN) #155, lot number NH9993, expiration 09/08/26. No signed consent from the guardian was present in the record for this vaccine, and documentation of education provided was not evident following interviews with the guardian. Consent forms for prior vaccines were last signed in July 2024. Interview on 12/09/25 at 3:08 P.M. with LPN Charge Nurse #135, revealed that the physician had not dated the signed orders for the COVID vaccine on 11/24/25 and confirmed that no guardian consent was obtained. She was unsure why the consent was not obtained and indicated this may have been due to a transition between DONs. Interview on 12/10/25 at 10:09 A.M. with Social Service Designee #157, revealed that risks were typically explained at the care conference and the COVID fact sheet provided, but this was not documented for this resident. Interview on 12/10/25 at 10:33 A.M. with Resident #34's Guardian, revealed that she never signed consent for any COVID vaccine and stated that if she had been asked, she would have likely declined. Education regarding risks was not evident in the record. Interview on 12/10/25 at 12:31 P.M. with LPN Charge Nurse #135 revealed that staff did not obtain guardian consent prior to administration and acknowledged a lapse in process due to administrative transitions. Review of the facility policy titled, COVID-19 Vaccine, revealed that before receiving a COVID-19 vaccine, the resident or legal representative or staff shall receive information and education regarding the benefits and potential side effects of the COVID-19 vaccine.

Based on interview, medical record review, and facility policy review the facility failed to ensure resident rights were protected by restricting phone usage for Resident #3. This affected one resident reviewed for choices. The census was 48.Findings include:Record review of Resident #3's medical record revealed an admission date of 12/26/17. Diagnoses include cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery, epilepsy, insomnia, constipation, obesity, bilateral sensorineural hearing loss, sleep related bruxism, nonexudative age related macular degeneration left eye and early stage, bilateral vitreous degeneration, and schizoaffective disorder bipolar type.Review of Resident #3's Minimum Data Set (MDS) 3.0 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition.Review of Resident #3's care plan dated 05/15/25 noted Resident #3 exhibits behavioral symptoms that are not easily altered and potential harmful to resident or others with a goal stating Resident #3's anger and verbally abusive behavior will not escalate into combative behaviors that could result in injury to self or others and Resident #3's physically abusive behavior will be decreased/eliminated with interventions and will not harm self or others including interventions as no phone calls after 3:00 P.M. per guardian (incoming and outgoing).Interview with Resident #3 on 09/29/25 at 11:08 A.M. revealed he was told by facility staff he could not make phone calls in the evening anymore.Interview with Licensed Practical Nurse (LPN) charge nurse #136 on 09/30/25 at 1:45 P.M. confirmed Resident #3's phone privileges times were limited because the facility noticed Resident #3 would become verbally abusive to staff if his family did not answer the phone.Interview with Certified Nursing Assistant (CNA) #101 on 09/29/2025 at 3:57 P.M. confirmed Resident #3 did not have a personal phone and is required to sign up daily on the facility phone list and cannot make calls after a certain time.Review of email sent from LPN charge nurse #136 to Resident #3's guardian on 05/15/25 at 10:41 A.M. confirmed LPN charge nurse #136 stated with your permission, we would like to restrict Resident #3's phone privileges in the evening time. He has continuous behaviors towards staff when his family does not answer in the evening. It happens nightly. He will still be able to use the phone before 4:00 P.M. for any calls he needs. Resident #3's guardian replied to email from LPN charge nurse #136 on 05/15/25 at 10:48 A.M. stating yes, please thank you.Review of Resident #3's verbal order for phone use restriction was dated 05/15/25 at 10:44 A.M. stating no phone calls after 3:00 P.M. every evening shift per guardian.Review of the facility policy titled, Telephones, Resident use of, dated 03/2017, confirmed Resident should have easy access to telephones. The policy continues designated telephones are available to residents to make and receive telephone calls and telephone sheets will be posted daily for residents to sign up for a time and to make phone calls. Urgent and emergency calls may be made at any time upon request.

Based on observation, resident interview, staff interview, and review of facility policy, the facility failed to ensure a call light was maintained within reach for one resident (Residents #4) who was dependent on staff for Activities of Daily Living (ADLs). This affected two of seven sampled residents who were dependent on staff for ADLs. The facility census was 48.Findings include:1. Review of the medical record for Resident #4 revealed an admission date of 03/03/20 with diagnoses that included Alzheimer's disease, major depressive disorder, chronic obstructive pulmonary disease (COPD), and psychosis.Review of the Quarterly Minimum Data Set (MDS) 3.0 assessment revealed a Brief Interview for Mental Status (BIMS) score of two, which indicated severe cognitive impairment. Review of the assessment further revealed Resident #4 utilized a wheelchair, required maximum assistance with all Instrumental Activities of Daily Living (IADLs), and required moderate assistance with all Activities of Daily Living (ADLs). Walking was not attempted due to medical concerns.Review of the Fall Risk assessment dated [DATE] revealed a high fall risk score of 14.Review of the care plan dated 03/04/20 revealed a focus on falls with an intervention dated 03/19/20 that stated, Call light in reach when in room.Observation on 09/29/25 at 1:34 P.M. revealed Resident #4 was lying in bed with the call light out of reach on the floor near the privacy curtain. During the observation, LPN #155 confirmed Resident #4 would not have been able to reach the call light independently in its observed location. LPN #155 also verified Resident #4 was able to purposefully utilize the call light when needing assistance from staff. LPN #155 was observed to relocate the call light by reattaching it to the resident's blanket.Review of the facility policy titled Answering the Call Light, dated 12/00/17, revealed the policy directed staff to ensure the call light was within easy reach of the resident when the resident was in bed or confined to a chair.

Based on observation, interview and record review the facility failed to ensure quarterly restraints assessments were completed for Resident #5. This affected one (Resident #5) out of one residents reviewed for restraint usage. The facility census was 48.Findings include: Review of the medical record for Resident #5 revealed an admission date of 08/01/05 with diagnoses including intracranial injury with loss of consciousness, constipation, Type Two Diabetes Mellitus, acute gastritis, persistent vegetative state, quadriplegia, chronic obstructive pulmonary disease, anxiety, major depressive disorder, encephalopathy, and convulsions.Review of the care plan dated 04/04/08 revealed Resident #5 required the use of a seat belt, shoulder harness, halo, and bilateral side rails. Restraints were required due to the diagnosis of persistent vegetative state. Interventions included weekly skin assessments, releasing the belt every two hours for 15 minutes, quarterly and as-needed restraint assessments, and use of safety devices when in bed and chair.Review of the restraint consent dated 10/15/13 revealed the use of a seatbelt with shoulder harness due to impaired posture and spontaneous reflexes while in the wheelchair and bed.Review of the restraint assessment dated [DATE] revealed the resident was at risk for falls, had cognitive impairment, exhibited behavioral symptoms, and had impaired communication. The assessment noted no change in condition and documented the continued need for a halo, harness, and seatbelt while in the wheelchair. It also stated the use of bilateral side rails while in bed was necessary to ensure safety. The resident was described as dependent on staff for all mobility and required proper body alignment due to diagnoses of vegetative state and quadriplegia.Review of the physician order dated 01/27/24 revealed instructions for the use of a halo, harness, and seatbelt while the resident was up in the wheelchair, with release every two hours and as needed.Review of the restraint assessment dated [DATE] again noted no change in condition and reiterated the need for a halo, harness, and seatbelt while in the wheelchair to prevent injury from spontaneous movement. It also documented the use of bilateral side rails while in bed to ensure safety. The resident remained dependent on staff for all mobility and required assistance to maintain proper body alignment.Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #5 was not coded as using any physical restraints or alarms.Observation conducted on 12/09/25 at 10:32 A.M. revealed Resident #5 was seated in a wheelchair with both a seatbelt and chest strap in place.Interview conducted on 12/10/25 at 3:30 P.M. with Licensed Practical Nurse (LPN) #136 and Registered Nurse (RN) #113 confirmed that the most recent restraint assessment for Resident #5 was completed on 07/08/25 and that no subsequent assessment had been completed.Review of restraint policy dated 02/2018 revealed a restraint is considered a device where the residents cannot remove a device in the same manner in which the staff applied it. Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints.

Based on interview, record review, and facility policy review the facility failed to ensure consistent, timely investigation and availability of records reviewed for a death for Resident #52. The facility also failed to maintain required routine checks for Resident #34. This affected two of two residents (Resident #52 and #34). The census was 48. Findings include: 1. Review of Resident #52's medical record revealed admission date of [DATE]. Resident #52 expired in the facility on [DATE]. Medical diagnoses include paranoid schizophrenia, changes in bilateral retinal vascular appearance, dementia in other disease classified elsewhere unspecified severity with mood disturbance, major depressive disorder recurrent, elevated prostate specific antigen, abnormal results of liver function studies, essential (primary) hypertension, Type II Diabetes Mellitus without complications, gastro- esophageal reflux disease without esophagitis, mixed hyperlipidemia, and benign prostatic hyperplasia without lower urinary tract symptoms. Review of Resident #52's Minimum Data Set (MDS) 3.0 dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10. Resident had no impairment in upper or lower extremities. Resident was coded to require, partial/moderate assistance for personal hygiene, supervision or touching assistance with showering, and setup or clean up assistance with eating, oral hygiene,toileting and upper and lower body dressing. Resident #52 was independent with rolling left and right, sit to stand transfer, chair to bed transfer, toilet transfer, tub/shower transfer, and walking 150 feet. Review of Resident #52's physician orders confirmed Resident #52 was a full code. Record review of Resident #52's progress notes on [DATE] Certified Nursing Assistant (CNA) #111 went to Resident #52's room at 8:00 A.M. to let him know it was time for breakfast and he did not answer, so she went to check on him and called Licensed Practical Nurse (LPN) #110 into the room and resident was unresponsive. LPN #110 checked for a pulse which was absent, turned Resident #52 over and face and lips were cyanotic, no pulse was present and Cardio Pulmonary Resuscitation (CPR) was started. Emergency services were called at 8:05 A.M. and arrived at 8:10 A.M. Resident #52 was checked by emergency services and pronounced dead. Record review of Resident #52's death investigation contained contradictory statements of how resident was found and did not contain statements from night shift nurse and CNA assigned to Resident #52's care the prior to his death. Record review of Resident #52's EMS report revealed 911 call received on [DATE] at 7:57 A.M. and arrived to Resident #52 on [DATE] at 8:05 A.M. EMS assessment of Resident #52 upon arrival was Resident #52 was cyanotic in the face, pupils were fixed and non-reactive, rigor in extremities, with lividity in the back. Resident #52 had no pulses, and 4 lead showed asystole in two leads. Time of death of was called at 8:05 A.M. Interview with DON on [DATE] at 11:00 A.M. confirmed the investigation into Resident #52's death did not include statements from staff assigned to the care of Resident #52 on night shift prior to his death, EMS report, and death certificate. The facility's policy titled, change in condition or status, dated revised February 2018, states a significant change of condition is a major decline or improvement in the resident's status that: requires interdisciplinary review and/or revision to the care plan. 2. Review of the medical record for Resident #34 revealed an admission date on [DATE] with a re-entry date of [DATE] with diagnoses that included moderate persistent asthma with acute exacerbation, obstructive sleep apnea, morbid obesity due to excess calories, and generalized muscle weakness. Review of the Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the Brief Interview for Mental Status (BIMS) score was seven indicating impaired cognition. Additionally, there were documented hallucinations with no other behaviors noted, the resident required supervision for upper-extremity and lower-extremity activities of daily living (ADLs), toileting, personal hygiene, dressing, transfers, and mobility. No impairments to upper-extremity or lower-extremity function were noted. Review of the Quarterly MDS dated [DATE] revealed a BIMS score of 00, indicating severe cognitive impairment, hallucinations were noted, with no additional behaviors, continued to require supervision and assistance for ADLs. Review of the resident's care plan revealed she required assistance with toileting related to cognitive deficits and decreased hygiene awareness. The interventions, initiated on [DATE], indicated she was to receive incontinence checks every two hours and toileting assistance as needed. The care plan also documented 15-minute checks for suicidal ideation. All toileting-related interventions were cancelled on [DATE] following the resident's death. Review of nursing documentation and the Treatment Administration Record (TAR) provided no evidence the two-hour incontinence checks were completed during the overnight hours prior to 7:00 A.M. on [DATE]. Interview on [DATE] at 3:01 P.M. with Certified nursing assistant (CNA) #111 confirmed that two-hour incontinence checks should have been performed for Resident #34 but was not sure if anyone entered the room after 7:00 A.M. until 7:30 A.M. Interview on [DATE] at 12:03 P.M. with CNA #117, revealed Resident #34 was on 15-minute checks for suicidal ideation and two-hour incontinence checks. She stated protocol required waking the resident every two hours to see if they had to use the restroom but confirmed this was not completed the night of [DATE]. Interview on [DATE] at 12:19 P.M. with CNA #116, revealed overnight two-hour incontinence checks require waking residents to assess the need for toileting. Interview on [DATE] at 12:31 P.M. with Licensed Practical nurse (LPN) Charge Nurse #135, revealed Resident #34 should have been on two-hour incontinence checks, and staff should have assisted the resident every two hours. Review of the facility policy titled, Urinary Incontinence – Clinical Protocol, dated [DATE], revealed as appropriate, based on assessment of the category and causes of incontinence, the staff will provide scheduled toileting, prompted voiding, or other interventions to improve the individuals continence status.

Based on observation, interview and record review the facility failed ensure bilateral lower extremities braces were applied and documented. This affected one (Resident #5) out of one resident reviewed for receiving a functional maintenance programming. The facility census was 48.Findings include:Review of the medical record for Resident #5 revealed an admission date of 08/01/05 with diagnoses including intracranial injury with loss of consciousness, constipation, Type Two Diabetes Mellitus, acute gastritis, persistent vegetative state, quadriplegia, chronic obstructive pulmonary disease, anxiety, major depressive disorder, encephalopathy, and convulsions.Review of the care plan dated 04/16/25 revealed Resident #5 requires braces to the ankles/feet related to dysfunction and a diagnosis of quadriplegia. Interventions included applying and removing splints/braces per schedule.Review of the physician order dated 01/27/24 revealed bilateral ankle/foot braces to be applied for four hours in the morning and four hours in the evening as tolerated. The braces were ordered to prevent contractures.Review of the restorative nursing progress note dated 11/25/25 documented that bilateral foot braces and hand splints were used per physician order, with no discomfort noted.Review of the functional maintenance program list revealed Resident #5 required bilateral ankle/foot braces to be applied for four hours in the morning and four hours in the evening as tolerated, with instructions to notify nursing staff when applied and removed.Review of the progress note dated 05/27/25 at 10:31 A.M. documented that Resident #5 utilized bilateral foot braces per physician order, with no discomfort noted.Review of the quarterly Minimum Data Set (MDS) 3.0 assessment completed on 10/11/25 revealed that Resident #5 was not coded for participation in restorative nursing programs. The assessment also documented that the resident was dependent on staff for assistance with eating, hygiene, toileting, bathing, and mobility.Observation on 09/29/25 at 9:42 A.M. revealed Resident #5 lying in a wheelchair without bilateral lower extremity braces in place. The braces were observed in a basket in front of the bed.Observation on 09/29/25 at 11:11 A.M. revealed Resident #5 lying in a wheelchair without bilateral lower extremity braces in place. The braces were again observed in a basket in front of the bed.Observation on 12/09/25 at 11:41 A.M. revealed Resident #5 lying in bed without bilateral lower extremity braces in place. The braces could not be located in the room.Observation on 12/09/25 at 2:15 P.M. revealed Resident #5 lying in bed without bilateral lower extremity braces in place. The braces were observed in a basket in front of the bed.Observation and interview conducted on 12/10/25 at 9:29 A.M. with Licensed Practical Nurse (LPN) #155 confirmed that Resident #5's bilateral lower extremity braces were not in place while lying in bed. LPN #155 stated the braces should be in place while the resident is in bed but denied knowledge of whether they had been worn earlier that morning. LPN #155 also denied having supporting documentation showing when the braces were applied, for how long, or when they were removed. She stated nursing staff document brace application on the treatment administration record.Observation on 12/11/25 at 8:32 A.M. revealed Resident #5 lying in bed without bilateral lower extremity braces in place. The braces were observed in a basket in front of the bed.Observation and interview conducted on 12/10/25 at 9:27 A.M. with Certified Nursing Assistant (CNA) #149 confirmed the bilateral lower extremity braces were not in place. CNA #149 denied knowledge of whether the braces had been applied earlier in the morning. She stated there was no specific time for placing the splints and that aides typically apply them and notify nurses. CNA #149 reported that aides do not document the time the braces are applied or removed and that they usually apply them when placing the resident's hand splints. She was unaware of any restrictions regarding when or where the braces should be placed.Review of the undated functional maintenance policy revealed that a functional maintenance program is a planned set of activities and interventions designed to help residents maintain their current level of function and prevent decline when formal therapy services are not indicated.

Based on record review, staff interview, and facility policy review review, the facility failed to identify post traumatic stress disorder triggers for Resident #9 and #34. This effected two residents of two residents reviewed for trauma informed care. The facility's census was 48.Findings include: 1.Record review for Resident #9 revealed the resident was admitted to the facility on [DATE] with diagnoses including: Chronic Obstructive Pulmonary Disease (COPD), post-traumatic stress disorder (PTSD) generalized anxiety disorder, and schizoaffective disorder. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 15. This resident was assessed to require self-care assistance due to impaired safety awareness and limited endurance. Review of the care plan of Resident #9 revealed he had a diagnosis of chronic PTSD related to a history of sexual abuse. Interventions were initiated on 07/31/24 and included listening attentively to the resident, allowing participation in psychiatric services, remaining non-judgmental, and monitoring staff emotional responses. The care plan did not include documentation of specific triggers in the medical record prior to 10/15/25. Review of the progress notes and other relevant documentation there was evidence that interventions related to PTSD were in place, including counseling services and behavioral monitoring, but specific triggers for Resident #9 were not documented. During an interview on 09/30/25 at 10:36 A.M. with licensed practical nurse (LPN) Charge Nurse #135, she confirmed the most recent trauma assessment available did not contain specific documented triggers for the resident. During a subsequent interview on 12/10/25 at 12:00 P.M. with LPN Charge Nurse #135, she revealed she added applicable triggers to Resident #9's PTSD care plan on 10/15/25. 2. Review of the medical record for Resident #34 revealed an admission date on 12/22/14 with a re-entry date of 12/08/15 with diagnoses that included post-traumatic stress disorder (PTSD), moderate persistent asthma with acute exacerbation, obstructive sleep apnea, morbid obesity due to excess calories, and generalized muscle weakness. Review of the Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the Brief Interview for Mental Status (BIMS) score was seven indicating impaired cognition. Additionally, there were documented hallucinations with no other behaviors noted, the resident required supervision for upper-extremity and lower-extremity activities of daily living (ADLs), toileting, personal hygiene, dressing, transfers, and mobility. No impairments to upper-extremity or lower-extremity function were noted. Review of the Quarterly MDS dated [DATE] revealed a BIMS score of 00, indicating severe cognitive impairment, hallucinations were noted, with no additional behaviors, continued to require supervision and assistance for ADLs. Review of the care plan revealed Resident #34 had a diagnosis of chronic PTSD related to a history of sexual abuse. Self-reported triggers included yelling, feeling out of control, and inability to discuss feelings. Interventions were initiated on 05/13/24 and included listening attentively to the resident, allowing participation in psychiatric services, remaining non-judgmental, and monitoring staff emotional responses. The care plan did not include documentation of specific triggers in the medical record prior to 10/10/25. All PTSD-related interventions were cancelled on 11/25/25 following the resident's death. Review of the trauma assessment dated [DATE] revealed no evidence of PTSD triggers being identified. Review of the progress notes and other relevant documentation there was evidence that interventions related to PTSD were in place, including counseling services and behavioral monitoring, but specific triggers for Resident #34 were not documented. Interview on 09/30/25 at 10:13 A.M. with Licensed practical nurse (LPN) Charge Nurse #135, revealed the most recent trauma assessment available was from 06/25/25 but it did not include PTSD triggers. She stated the resident attended counseling where traumas were explored in depth. She confirmed that PTSD was included in the care plan but stated there were no specific documented triggers for Resident #34's PTSD prior to 10/10/25. Interview on 12/10/25 at 10:01 A.M. with LPN Charge Nurse #135 revealed she audited all PTSD care plans on 10/10/25 and added specific triggers to the care plan on that date and confirmed prior to that audit, Resident #34 had no documented PTSD triggers in her medical record. Review of the facility policy titled, Trauma Informed care, dated March 2019, revealed all staff caregivers are taught strategies to help, eliminate, mitigate or sensitively address a residents triggers.

Based on record review and interview the facility failed to ensure pharmacy recommendations were addressed timely by the physician. This affected two residents ( #27, and #8) out of five residents reviewed for unnecessary medications. The facility census was 48. Findings include: 1.Review of the medical record for Resident #27 revealed an admission date of 10/02/20 with diagnoses including Type Two Diabetes Mellitus, schizoaffective disorder, hypertension, gastroesophageal reflux disease, major depressive disorder, dependent personality disorder, and generalized anxiety disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment completed on 06/05/25 revealed Resident #27 was receiving antipsychotic medications on a routine basis. Review of the monthly medication regimen review dated 07/07/25 revealed four of Resident #27's medications were due for evaluation, including Effexor XR (antidepressant) 150 milligram (mg) daily, Clozapine (antipsychotic) 400 mg at bedtime, Abilify (antipsychotic) 20 mg daily, and Invega (antipsychotic) 234 mg intramuscular every 28 days. The review indicated an annual evaluation was due for each medication. The physician marked a dosage change to decrease Abilify to 15 mg, dated 08/19/25. Review of the progress note dated 08/22/25 at 10:37 A.M. documented a change in Abilify dosage. Review of the physician order dated 08/23/25 revealed Abilify oral tablet 15 mg by mouth in the morning for major depressive disorder. Interview conducted on 09/30/25 at 2:32 P.M. with Licensed Practical Nurse (LPN) Charge Nurse #136 confirmed the pharmacy recommendation made on 07/07/25 was not addressed by the physician until 08/19/25. LPN #136 acknowledged that the pharmacy recommendations were not addressed timely and stated that such recommendations should be addressed within one month. 2. Review of the medical record for Resident #8 revealed an admission date of 03/25/24 with diagnoses that included catatonic schizophrenia, age-related nuclear cataract, chronic obstructive pulmonary disease, major depressive disorder, insomnia, constipation, mild intellectual disabilities, nicotine dependence, obesity, vitamin D deficiency, and anemia. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of seven, indicating impaired cognition. Review of pharmacy recommendations dated 03/05/25 revealed a physician-signed order on 04/14/25 to decrease Lunesta (sedative hypnotic) from 2 mg at bedtime to 1 mg at bedtime. The orders reflected the corrected medication adjustment on 04/14/25. Review of the monthly pharmacy medication regimen review (MRR) revealed it was not completed in a timely manner within 30 days and there was no written timeline for physician follow-up of pharmacy recommendations. Interview on 09/30/25 at 12:00 P.M. with Licensed Practical Nurse (LPN) Charge Nurse #135, revealed the policy regarding medication regimen reviews was the only documentation available. She verbally stated the physician comes in every month and the pharmacist comes in every month. She stated the review is expected to be completed the following month but confirmed there was no written timeline for when the physician is required to return the reviewed recommendations. Interview on 12/11/25 at 10:20 A.M. during the Quality Assurance and Performance Improvement (QAPI) task meeting with LPN Charge Nurse #135 revealed the monthly pharmacy reviews should be reviewed by the physician within 30 days. She confirmed this process was not being consistently completed and that there was no written timeline for their completion. Review of the facility policy titled, Medication Regimen Reviews, dated February 2018, revealed the policy did not include a written timeline for completion of the monthly pharmacy review or for the physician's follow-up of the pharmacist recommendations. Review of the facility policy Medication Regimen Review dated revised 02/2018 revealed routine reviews will be done monthly. Additionally, the facility policy Medication Regimen Review dated revised 02/2018 stated the primary purpose of this review is to help the facility maintain each resident's highest practicable level of functioning by helping them utilize medications appropriately and prevent or minimize adverse consequences related to medication therapy to the extent possible.

Based on interview, record review, and facility policy review, the facility failed to administer pneumococcal vaccines per Center for Disease Control and Prevention (CDC) recommendations. This affected two (Resident #24 and Resident #2) of five residents reviewed for immunizations. The census was 48.Findings include:1. Record review of Resident # 24's medical record revealed an admission date of 05/09/22. Diagnoses include Alzheimer's disease with late onset, bilateral primary open-angle glaucoma indeterminate stage, major depressive disorder recurrent and moderate, right hip primary osteoarthritis, obesity, unspecified dementia unspecified severity with behavioral disturbance, chronic obstructive pulmonary disease, mixed- receptive language disorder, cognitive communicative deficit, schizoaffective disorder, essential (primary) hypertension, spinal stenosis and alcohol dependence with alcohol induced persisting dementia.Review of Resident #24's Minimum Data Set (MDS) 3.0 dated 11/26/25 revealed a Brief Interview for Mental Status (BIMS) score of one indicating severe cognitive impairment. Review of Resident #24's immunization records confirmed Resident #24 did not have record of administration of any pneumococcal vaccinations. Review of Resident #24's Nursing admission assessment dated [DATE] did not note vaccination record history. Interview on 12/10/25 at 3:30 P.M. with Licensed Practical Nurse (LPN) charge nurse #136 confirmed Resident #24 did not have pneumococcal vaccinations on file in the medical record. 2. Review of Resident #2's medical record revealed and admission date of 01/29/20. Diagnoses include chronic obstructive pulmonary disease, bilateral primary open-angle glaucoma indeterminate stage, benign prostatic hyperplasia with lower urinary tract symptoms, obesity, vascular dementia unspecified severity with other behavioral disturbance, hyperlipidemia, type II diabetes mellitus without complications, essential (primary) hypertension, gastro-esophageal reflux disease without esophagitis, hypothyroidism, and recurrent major depressive disorder severe with psychotic symptoms.Review of Resident #2's Minimum Data Set (MDS) 3.0 dated 11/25/25 revealed a Brief Interview for Mental Status (BIMS) score of three indicating severe impaired cognition.Review of Resident #2's immunization records confirmed Resident #2 had a pneumovax dose one on 12/16/2019.Interview on 12/10/25 at 3:30 P.M. with LPN charge nurse #136 confirmed Resident #2 was not offered an additional dose of pneumococcal vaccination.Review of U.S. Centers for Disease Control and Prevention (CDC) Pneumococcal Vaccine Recommendations, dated 10/26/24 recommends adults 50 years and or older should have routine vaccination of PCV15, PCV20, or PCV21 for all adults 50 years or older. If PCV15 is used, administer a dose of PPS23 one year later, if needed. Their pneumococcal vaccinations are complete. The minimum interval is eight weeks and can be considered in adults with an immunocompromising condition, a cochlear implant, and cerebrospinal fluid leak. If PCV20 or PCV21 is used, a dose of PPSV23 isn't indicated. Regardless of which vaccine is used (PCV20 and PCV21), their pneumococcal vaccinations are complete. Based on shared clinical decision-making, adults 65 years or older have the option to get PCV20 or PCV21, or to not get additional pneumococcal vaccines. They can get PCV20 or PCV21 if they received both PCV13 at any age and PCV23 at or after the age of [AGE] years old.Review of the facility's policy regarding Immunizations Programs revised on 10/2007, confirmed in an effort to decrease the incidence of preventable infections all facilities will obtain informed consent for each resident/patient to participate in the facility's Immunization Program. The immunization Program shall include immunization against the influenza virus, pneumococcal infections, and any other immunizations clinically indicated. These immunizations will be provided to all residents during the admission period unless clinically contraindicated or unless resident or resident's responsible party refuses. In addition, these immunizations will be offered on a periodic basis based on clinical and manufacturers' directives.

Based on observation, staff interview, and record review, the facility failed to ensure a clean environment. This had the potential to affect all 50 residents in the facility. The facility census was 50. Findings include: Observation and interview on [DATE] at 7:20 A.M., with Certified Nursing Assistant (CNA) #100 revealed that there were two shower rooms down the hallway. The shower room on the left as you walked down the hallway was cleaned with no concerns. The hallway located to the right had three tiles off the wall, one tile off on the floor and mold in the corners of the shower stall. CNA # 100 verified the observations and time of findings. Interview on [DATE] at 8:24 A.M., with Maintenance Director (MD) #104 revealed that a few weeks ago, he was told by the employees that a grab bar was pulled off of the wall. MD #104 stated that the maintenance/housekeeping supervisor #107 was going to strip the caulk in the shower stall but MD #104 told him not to do it because he was going to do work in the shower room. MD #104 stated that the work that needed to be done. MD #104 stated that he had the tile but when he went to the hardware store, the company credit card was declined because it was expired. MD #104 stated that the regional maintenance Director said that new credit cards will be delivered. MD #104 stated that the new credit card did not come in yet. Interview on [DATE] at 12:41 P.M., via phone, with Regional Maintenance Director #108 revealed the credit card expired and the did not give the facility the new credit cards. Review of the Maintenance Request Log for [DATE] revealed on [DATE] the resident shower room had a broken grab bar. This deficiency represents non-compliance investigated under Complaint Number OH00163188.

Based on observation, record review, staff interview, and policy review, the facility failed to ensure staff maintain hand hygiene while providing dining assistance to a residents who required assistance. This affected four (#38, #4, #29, and #30) of eight residents observed for meal assistance. The facility census was 48. Findings include: 1. Review of medical record for Resident #38 revealed admitted [DATE], with diagnoses including intracardiac thrombosis, hypertensive retinopathy, dementia, slurred speech, emphysema, congestive heart failure, schizoaffective disorder, major depressive disorder, chronic obstructive pulmonary disease, and unspecified mood disorder. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #38 has severe impaired cognition and required limited assistance of one for eating. Resident #38 was on a therapeutic diet. Review of March monthly orders for Resident #38 revealed no added salt, mechanical soft/ground meat diet with thin liquids. 2. Review of medical record for Resident #4 revealed admitted [DATE], with diagnoses including dementia, chronic pulmonary disease, type two diabetes, hypertension, schizophrenia, schizoaffective disorder bipolar type, and anxiety. Review of MDS assessment dated [DATE], revealed Resident #4 has severe impaired cognition and required limited assist of one for eating and had held food in mouth/cheeks. Resident #4 is on mechanically altered diet. 3. Review of medical record for Resident #29 revealed admitted [DATE], with diagnoses including Alzheimer's disease, malignant neoplasm of breast, chronic obstructive pulmonary disease, bipolar disorder, dementia, anxiety, and major depressive disorder. Review of MDS assessment dated [DATE], revealed Resident #29 has severe impaired cognition and required limited assist of one for eating. Resident #29 is on mechanically altered diet. 4. Review of medical record for Resident #30 revealed admitted [DATE], with diagnoses including schizoaffective disorder, Alzheimer's disease, bipolar disorder, chronic obstructive pulmonary disease, overactive bladder, borderline personality disorder, anxiety, type two diabetes, gastroesophageal reflux disease, and major depressive disorder. Review of MDS assessment dated [DATE] revealed Resident #30 has severe impaired cognition and required limited assist of one for eating. Resident #30 is on therapeutic diet. Review of March 2023 monthly physician orders for Resident #30 revealed aspiration precautions: close supervision with all meals and snacks, sit up at 90 degree angle, small bites/sips alternate solid/liquid, remain up for 30 minutes following oral intake. Diet order no added salt, controlled carbohydrate, pureed texture food with honey consistency liquids. Observation on 03/20/23 at 12:15 P.M., revealed State tested Nursing Assistant (STNA) #588 touched Resident #38's sandwich with her bare hands, pulled it apart in pieces, and placed a bite into the resident's mouth with no gloves on. STNA #588 had been feeding Resident #4, Resident #29, and Resident #30, touching spoons and cups of each resident without washing hands or donning gloves prior to touching the food. At 12:45 P.M., STNA #588 left the dining room to assist Resident #38 to her room; returned to dining room; folded up a gait belt; and then proceeded to start feeding again without washing hands. Interview on 03/20/23 at 12:53 P.M., STNA #588 verified she did not wash hands prior to touching Resident #38's food with bare hands and putting a piece in the resident's mouth. STNA #588 verified she ambulated Resident #38 back to the room, folded a gait belt once she was in the dining room and placed it in her pocket and then continued to feed Resident #30 and Resident #4 without washing her hands. Review of policy titled Assistance with Meals revised December 2017, revealed residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity. All employees who provide resident assistance with meals will be trained regarding personal hygiene practices.

Based on record review, staff interview and policy review, the facility failed to provide written notification to the resident or responsible party of a resident's discharge. This affected three (#32, #98 and #31) of three residents reviewed for hospitalization . The total facility census was 48. Findings include: Review of Resident #32's medical record revealed the resident was admitted to the facility on [DATE], with diagnoses including chronic obstructive pulmonary disease, obesity, cataracts, hypertension, malaise, depression, type two diabetes, history of traumatic brain injury and psychosis. The resident medical record revealed the resident was discharged on [DATE] to a hospital in the community for evaluation and treatment and returned to the facility on [DATE]. Review of the discharge return anticipated Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was cognitively impaired, without behaviors. The resident required limited assist for bed mobility and transfers, supervision for walk in corridor and room. The resident's balance was coded as steady at all times for seated to standing, walking, turning around while walking, surface to surface transfer, and getting on and off the toilet. The resident was coded to not use a cane or a walker with ambulation. Review of the medical record revealed there was no notification in writing to either the resident or the resident guardian regarding the specific reason for the discharge, the date of discharge or the location where the resident was discharged to. 2. Review of Resident #98's medical record revealed the resident was admitted to the facility on [DATE], with diagnoses including disorder of kidney and ureter, obesity, anxiety, systemic inflammatory response syndrome of non infectious origin, heart failure, bipolar disorder, borderline personality disorder, type two diabetes, and schizophrenia. The resident medical record revealed the resident was discharged on [DATE] to a hospital in the community for evaluation and treatment. The resident returned to the facility on [DATE]. Review of the 5-day MDS assessment dated [DATE] revealed the resident had cognitive impairment, and had physical behaviors. The resident was coded as dependent on staff for transfers, locomotion on and off the unit, dressing, and personal hygiene, required extensive assist for bed mobility, and toileting, and required limited assist with eating. Review of the medical record revealed there was no notification in writing to either the resident or the resident guardian regarding the specific reason for the discharge, the date of discharge or the location where the resident was discharged to. Interview on 03/20/23 at approximately 3:45 P.M., with Administrative Charge Nurse (ACN) #478 confirmed Resident #32 and #98 did not have a written discharge notice provided upon discahrge. 45751 3. Review of Medical Record for Resident #31 revealed admitted [DATE], with diagnoses including chronic obstructive pulmonary disease, cellulitis of unspecified part of limb, hypertension, borderline personality disorder, major depressive disorder, auditory hallucinations, paranoid schizophrenia, schizoaffective disorder bipolar type, bipolar disorder, and generalized anxiety disorder. Resident #31 was discharged to the hospital on 02/22/23 and returned on 02/27/23 for renal insufficiency, shortness of breath, and Bronchitis. Review of MDS assessment dated [DATE] for Resident #31 revealed the resident has moderately impaired cognition. Resident required extensive assist for bed mobility, transfers, dressing, toileting, and personal hygiene. Resident required limited assist for ambulation and locomotion. Resident required supervision for meals. Interview with ACN #478 on 03/22/23 at 7:45 A.M., revealed the facility does not provide written notice of transfer to resident or responsible party when a transfer/discharge occurs. ACN #478 verified Resident #31 did not receive written notice of discharge. Review of the policy titled Transfer or Discharge Notice, with the last revision date of March 2021 revealed: Residents and/or representatives are notified in writing, and in a language and format they understand, at least thirty (30) days prior to a transfer or discharge. Policy Interpretation and Implementation: 1. Transfer and discharge includes movement of a resident from a certified bed in the facility to a non-certified bed in another part of the facility, or to a non-certified bed outside the facility. Transfer and discharge does not refer to movement of a resident to a bed within the same certified facility. Specifically: a. transfer refers to the movement of a resident from a bed in one certified facility to a bed in another certified facility when the resident expects to return to the original facility; and b. discharge refers to the movement of a resident from a bed in one certified facility to a bed in another certified facility or other location in the community, when return to the original facility is not expected. 5. The resident and representative are notified in writing of the following information: a. The specific reason for the transfer or discharge; b. The effective date of the transfer or discharge; c. The location to which the resident is being transferred or discharged .

Based on record review, and staff interview the facility failed to maintain an accurate medical record. This affected one (#98) of 17 resident records reviewed during the annual survey. The total facility census was 48. Findings Include: Review of Resident #98's medical record revealed the resident was admitted to the facility on [DATE], with diagnoses including disorder of kidney and ureter, obesity, anxiety, systemic inflammatory response syndrome of non infectious origin, heart failure, bipolar disorder, borderline personality disorder, type two diabetes, and schizophrenia. The resident medical record revealed the resident was discharged on [DATE] to a hospital in the community for evaluation and treatment. The resident returned to the facility on [DATE]. Review of the 5-day MDS 3.0 assessment dated [DATE] revealed the resident had cognitive impairment, and had physical behaviors. The resident was coded as dependent on staff for transfers, locomotion on and off the unit, dressing, and personal hygiene, required extensive assist for bed mobility, and toileting, and required limited assist with eating. Review of progress note dated 02/25/23 at 6:18 P.M., revealed the resident was found lying in bed not responding. pupils fixed and does perform hand grasp, blood pressure 98/60, pulse 98, temperature was 99.0 respirations were 16 and blood oxygen saturation was 94%. Resident# 98's lungs were clear to auscultation in 4 lobes. The Certified Nurse Practitioner (CNP) was notified and an order given to send Resident #98 to the Emergency Department at the community hospital for evaluation and treatment. Resident #98 was transported via squad and the nurse called and gave report to the emergency department. Review of progress note dated 02/25/23 at 9:08 P.M., revealed the community hospital was called and it was reported Resident #98 was admitted to the hospital with the diagnoses of altered mental status, urinary tract infection , acute kidney injury and systemic inflammatory response syndrome. The physician, guarding, and Administrative Charge Nurse were documented as notified. Review of a progress note dated 02/27/23 by Certified Nurse Practitioner #700 revealed Resident #98 was seen and assessed by the CNP at the facility. The assessment included the following: Physical exam, the resident is well developed and in no acute distress. Eyes: conjunctivae and lids appear normal, pupils equal round Ears, nose and throat: lips pink and moist, hearing grossly intact. Neck symmetrical with no elevation of the jugular venous pulsation. Respiratory: normal respiratory effort. Cardiovascular: regular rhythm no murmurs rubs or [NAME]. Edema/varicosities of extremities: no edema or varicosities. Chest: equal chest rise with inspiration. Gastrointestinal: abdomen soft, non tender. Genitourinary deferred. Musculoskeletal: no joint deformity, swelling, or redness. Skin: reviewed skin sweeps and wound documentation in resident chart, Agree with the assessment. Neurological cranial nerves: Cranial Nerves II-XII are grossly intact. Psychiatric: no signs or symptoms of depression or anxiety noted during exam. Plan: Zyprexa (antipsychotic) 10 milligram (mg) by mouth or intramuscularly (IM) every 6 hours as needed for 14 days. Geodon (antipsychotic) 20 mg IM every four hours as needed for 14 days with maximum dose of two in 24 hours. Prolixin (antipsychotic) 5 mg IM daily as needed, if refuses oral morning medications, for X 14 days. Thorazine (antipsychotic) 100 mg by mouth every six hours as needed for 14 days. Continue medication regime as ordered. Recheck laboratory test as previously ordered, notify CNP of any problems or concerns. Review of progress note dated 03/05/23 at 2:38 P.M., revealed the resident returned from the hospital via Emergency Medical Services, the guardian, physician and Director of Nursing were notified of the resident's return. Interview on 03/22/23 at 10:04 A.M., with Administrative Charge Nurse (ACN) revealed the CNP was in the facility every Monday. The CNP visits include reviewing and seeing residents who have as needed psychotropic medications to evaluate the need of the medication and reorder if necessary. The CNP also made practitioner visits to residents who had changes in conditions or questions regarding their current plan of care during her weekly visits. Interview on 03/22/23 at 10:32 A.M., with CNP #700 via telephone, revealed when she visits the facility she has a notebook where staff indicate residents who need to be seen and if she had received any call from the facility in the past week regarding resident changes she will also see those residents while she is in the facility. The CNP #700 stated on every other Monday she does renewal of psychotropic as needed medications. The CNP #700 stated she when she comes to the facility she will ask if there are any residents who have been discharged or are out of the facility. CNP #700 verified on visits where she she is renewing psychotropic medications she does see the resident and check in with them but does not perform an intensive assessment. The CNP #700 verified her documentation of visits are in the electronic medical record and each note documented reflects an actual practitioner to resident visit on the day documented. Interview on 03/22/23 at 10:50 A.M., with ACN #478 confirmed Resident #98 was discharged on [DATE]. ACN #478 when asked about the CNP #700 note on 02/27/23 stated let me guess the nurse practitioner made a note on the resident when the resident was out of the facility? It was stated there was a note from the CNP #700 on 02/27/23 where the resident had a documented physical assessment and the resident was not in the facility. ACN #478 verified the note was in the resident medical record with a physical assessment performed and the resident was not in the facility. ACN #478 stated the practitioner does that sometimes.

Based on observation, staff interview, review of facility documentation, and review of the facility smoking policy, the facility failed to maintain the resident outdoor smoking area and contain extinguished cigarettes within approved smoking receptacles. This had the potential to affects 12 (#1, #2, #5, #6, #7, #8, #9, #10, #11, #12, #13 and #14) resident who smoke and utilize the outdoor smoking area. The facility census was 45. Findings include: On 02/26/22 at 8:27 A.M. observation of the designated outdoor resident smoking area (smoking [NAME]) was conducted with the Assistant Director of Nursing (ADON) #1. The covered resident smoking area was constructed of a metal material with walls and a large overhead door on each end. Inside the smoking area noted metal benches, metal ash trays, and a red metal can with a lid actuated by a foot pedal. Observation inside the red metal can, discovered a large amount of extinguished cigarettes with a cardboard cigarette box located inside. On the ground next to the smoking [NAME] identified greater than 20 extinguished cigarettes. The extinguished cigarettes were scattered among dried leaves and next to a fence with dried vines. Interview with ADON #1 at the time of observation confirmed the red can is utilized for extinguished cigarettes and no combustible cardboard materials or cigarette boxes are to be placed inside. ADON #1 also verified the placement of the extinguished cigarettes on the ground within the dried ground cover and next to the dried vines. ADON #1 stated residents are monitored while smoking per policy and cigarettes are to be discarded in an approved receptacle. On 02/26/22 at 9:53 A.M. interview with the Director of Nursing (DON) and ADON #1 revealed the facility is non-smoking for staff. Review of the resident list provided by the DON at the time of the interview identified 12 (#1, #2, #5, #6, #7, #8, #9, #10, #11, #12, #13 and #14) current residents who smoke and utilize the smoking area. Additional interview with ADON #1 during review of facility policy verified there was no entry/instructions indicating the responsible staff member for maintaining the designated smoking area. According to the Smoking Policy revised 08/09 revealed staff, family members, and vendors are prohibited from smoking in the facility or on facility premises. Residents are permitted to smoke in a designated safe area and at designated times. Scheduled staff will be with residents during the designated smoking periods. At the end of the smoking break, residents will return smoking materials to staff supervising the break and be required to leave the smoking area. No documentation contained in the policy indicated the smoking area being maintained to ensure extinguished smoking materials are placed into approved smoking receptacles. This deficiency substantiates Complaint Number OH 388.

Based on medical record review, review of facility policy, and staff interview, the facility failed to notify the Ombudsman when residents were transferred/discharged from the facility. This affected three (Resident #11, #27, and #39) of three residents reviewed for hospitalization . Facility census was 45. Findings include 1. Review of the medical record revealed Resident #11 was initially admitted to the facility on [DATE] and readmitted on [DATE]. [DIAGNOSES REDACTED]. Review of the comprehensive assessment dated [DATE] revealed the resident was cognitively intact. Resident #11 was independent in activities of daily living to requiring limited assistance. Review of progress notes revealed Resident #11 began showing additional behaviors on 06/12/19. On 06/15/19, the resident was threatening staff, was out of reality, and staff were unable to redirect. The physician was notified and ordered Resident #11 to go to the emergency department for evaluation. The guardian was notified. The resident was admitted to the behavioral health unit of the hospital. Resident #11 returned to the facility on [DATE]. The facility issued a transfer/discharge notice indicating Resident #11 was transferred to the hospital on [DATE] due to a change in mental status. The facility also provided a bed hold notice to the resident. The Ombudsman was not notified of Resident #11's transfer/discharge from the facility. 2. Review of the medical record revealed Resident #27 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the comprehensive assessment dated [DATE] revealed the resident had severe cognitive impairment. Resident #27 required limited to extensive assistance for activities of daily living. Review of progress notes dated 12/16/18 revealed Resident #27 refused medication for depression and anxiety and also refused medication used to treat [MEDICAL CONDITION]. On 12/17/18, an order was received to send the resident to the emergency room for a psychiatric evaluation as Resident #27 was exhibiting agitation, was combative, and had not slept for two days. Resident #27 was admitted to the hospital's behavioral unit. The guardian was notified. The resident returned to the facility on [DATE]. The facility issued a transfer/discharge notice indicating Resident #27 was transferred to the hospital on [DATE] due to a change in mental status. The facility also provided a bed hold notice to the resident. The Ombudsman was not notified of Resident #27's transfer/discharge from the facility. Interview on 10/08/19 at 10:10 [NAME]M. with the Administrator verified the facility did not send notifications of Resident #27 and #11's transfer/discharge to the Ombudsman. 3. Resident #39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. [MEDICAL CONDITION] of the right and left lower limb, depression and heart failure. The minimum data set (MDS) 08/20/19 revealed the resident to be severely cognitively impaired and required one to two person assistance with activities of daily living. Review of the nurses progress notes on 04/10/2019 at 7:58 [NAME]M. revealed Resident #39 was sent to the hospital for treatment and evaluation for possible urinary tract infection. Resident #39 was notified of the need to go to hospital, transfer documentation was sent with Resident #39 and family was notified. There was no documented evidence the Ombudsman was notified of the transfer. On 04/10/19 12:34 P.M., Resident #39 was admitted to the hospital with [REDACTED]. On 10/08/19 at 10:10 [NAME]M., interview with the Administrator verified the facility did not send a notification of Resident #39's transfer to the hospital to the Ombudsman. Review of the facility's policy titled Transfer or Discharge Notice, (revised 02/01/18) revealed a copy of the transfer/discharge notice would be sent to the Office of the State Long-Term Care Ombudsman.