Every finding on record at Heritage Manor Jewish HM for

Based on record review, observation and interview, the facility failed to ensure food was served at palatable temperatures. This had the potential to affect all 68 of 68 residents that resided in the facility who received meals from the kitchen. Findings include: Observation of tray line on 11/19/24 from 11:44 A.M. to 12:25 P.M. revealed food was above 165 degrees Fahrenheit ( F) . A test tray was requested as the last resident's food was plated. The food cart left the kitchen at 12:25 P.M. and arrived to at the central unit at 12:29 P.M. When the last tray on the cart was delivered on 11/19/24 at 12:37 P.M., the test tray was removed from the cart where food temperatures were taken. The Dietary Manager ( DM) #316 took the temperature of the food and stated that the temperature for the pasta was 120 degrees F and the fruit cup was 52.1 degrees F. DM #316 stated pasta should be hotter. Upon tasting the pasta, it was tepid. Interview on 11/19/24 at 5:36 P.M. with Resident #61 revealed the food was always cold especially after 5:00 P.M. Interview on 11/20/24 at 12:44 P.M. with Resident #57 revealed the food was always cold. Review of facility policy titled Record of Food Temperatures dated February 2023, revealed hot foods would be held at 135 degrees F or greater and hot foods would be stirred during holding to redistribute heat throughout the food. Potentially hazardous cold food temperatures would be kept at or below 41 degrees F.

Based on review of resident funds accounts, review of surety bond, interview and review of facility policy, the facility failed to provide a surety bond large enough to cover the total amount of money in all resident personal funds accounts. This affected 20 residents (Resident #1, #2, #4, #5, #8, #9, #18, #21, #24, #25, #26, #27, #31, #36, #43, #47, #53, #55, #65, #99) of 20 residents with personal funds accounts. Findings include: A review of resident fund account for the facility dated as of 10/31/24 revealed a total amount of $35,221.26 dollars. Resident #1, #2, #4, #5, #8, #9, #18, #21, #24, #25, #26, #27, #31, #36, #43, #47, #53, #55, #65, #99 had personal funds accounts with the facility. A review of resident fund accounts revealed Resident #5 had a current total of $32,805 in their account. A review of the document by Selective Insurance Company of America, bond number B 400737, revealed an effective date of 07/10/24. The document revealed the surety bond was for $25,000 dollars. Interview on 11/19/24 at 10:08 A.M. with Director of Operations (DO) #300 revealed Resident #5 received a large amount of money each month. DO #300 verified the surety bond did not cover resident funds and asked Resident #5's guardian to wire the money into the guardianship account. Review of facility policy titled Resident Personal Funds dated January 2024, revealed the facility would purchase a surety bond to assure the security of all personal funds of residents deposited with the facility.

Based on record review and interview, the facility failed to ensure care plans were in place for high risk medications. This affected one resident (#31) out of five residents reviewed for unnecessary medications. Facility census was 68. Findings include: Review of Resident #31's medical record revealed an admitted [DATE] and diagnoses including type two diabetes, epilepsy, COVID-19, depression, sepsis, hypertension, other pulmonary embolism without acute cor pulmonale and hyperlipidemia. Review of a quarterly minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #31 had severe cognitive impairment and received antipsychotic, antidepressant, anticoagulant, antibiotic, hypoglycemic and anticonvulsant medications. Review of Resident #31's physicians' orders revealed an order dated 06/10/24 for rivaroxaban (Xarelto) oral tablet 20 milligrams, give one tablet by mouth in the evening related to other pulmonary embolism without acute cor pulmonale. Review of Resident #31's plan of care revealed no evidence she received an anticoagulant. Interview on 11/21/24 at 1:12 P.M. with the Director of Nursing (DON) verified Resident #31 was currently on an anticoagulant medication. Interview on 11/21/24 at 1:15 P.M. with MDS/Licensed Practical Nurse (LPN) #369 revealed Resident #31's previous anticoagulation care plan was resolved in July 2021 and verified Resident #31 did not have a current care plan in place for anticoagulation since her Xarelto was started on 06/10/24.

Based on medical record review, interviews, and review of facility policy the facility, the facility failed to ensure pharmacist recommendations were acted upon timely. This affected one resident (Resident #3) of five residents who were reviewed for unnecessary medications. The facility census was 68. Findings include: Review of the medical record for Resident #3 revealed an admitted [DATE] with diagnoses including unspecified dementia with agitation, type two diabetes mellitus, anorexia, atrial fibrillation, anxiety, major depressive disorder, unspecified symptoms involving cognitive functions and awareness, stage three chronic kidney disease, oropharyngeal phase dysphagia, and adult failure to thrive. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment completed on 09/27/24 revealed Resident #3 had severe cognitive impairment with continuous display of inattention and fluctuating patterns of disorganized thinking. Further review if the MDS revealed Resident #3 required substantial assistance with bathing, was dependent for toileting hygiene and bed and tub transfers, and was receiving Hospice services. Review of the physician orders for Resident #3 revealed an order dated 06/16/22 for Multivitamin Gummies Adult chewable tablets (a multiple vitamin with minerals), one tablet by mouth two times a day as a supplement. Further review of the orders also revealed an order dated 10/05/22 for PreserVision age-related eye disease study two (AREDS2) (a multiple Vitamin with minerals), one capsule by mouth one time a day related to macular degeneration. Review of the pharmacy consultant's Note To Attending Physician/Prescriber dated 03/29/24 revealed the monthly medication regimen review found duplication of multivitamins orders, the order for Multivitamin Gummy twice a day and the PreserVision daily vitamin. Further review of this note revealed it was recommended by the pharmacist for the prescribing provider to review the need for this [AGE] year-old resident to receive both vitamins and to consider discontinuing one of them. Review of the Physician/Prescriber Response section at the bottom of the Note To Attending Physician/Prescriber dated 03/29/24 revealed the provider reviewed the pharmacist's recommendation on 04/30/24, agreed with the pharmacy consultant's recommendation , and provide documentation to discontinue the Multivitamin Gummy. Further review of the document revealed the providers okay to discontinue the Multivitamin Gummy signed on 04/30/24 was noted on 05/06/24 by Registered Nurse (RN) #347. Review of the progress note dated 05/06/24 at 4:12 P.M. revealed RN #347 noted the new order to discontinue the Multivitamin Gummy and provided notification of the medication update to Resident #3's family representative. Review of the Medication Administration Record (MAR) from April 2024 and May 2024 revealed Resident #3 continued to receive both ordered multivitamins (Multivitamin Gummy twice a day and the PreserVision daily ) until after the morning dose of the Multivitamin Gummy on 05/06/24. Interview on 11/21/24 at 12:43 P.M. with Consulting Pharmacist #446 confirmed when a pharmacy recommendation was made or an irregularity was found during monthly medication regimen reviews, the recommendation was sent to the Director of Nursing (DON) via email once the review was finished. Interview on 11/21/24 at 12:49 P.M. with the DON confirmed she received emails from the Consulting Pharmacist with recommendations and it was the charge nurse's responsibility to contact Physician #343, unless he rounds that week, in which case the recommendation would be handed to Physician #343 during rounds. Further interview with the DON confirmed the prescribing providers response time to pharmacist recommendations should be a day or two at the most. During the interview, the DON confirmed Resident # 3 received both ordered multivitamins through the month of April 2024 through 05/05/24 and that the Multivitamin Gummy was discontinued after the morning dose was administered on 05/06/24. Review of the policy titled Medication Regimen Review dated February 2023 revealed the pharmacist was to communicate any recommendations and irregularities of their monthly drug regimen review via email within 10 working days of the review and the facility was to act upon all recommendations per attending physician's orders.

Based on observation, interviews, medical records review, and review of facility policy the facility failed to provide appropriate incontinence care resulting in shearing and a new open skin alteration to Resident #36. This affected one resident (Resident #36) of two residents who were reviewed for activities of daily living. The facility census was 68. Findings include: Review of the medical record for Resident #36 revealed an admitted [DATE] with diagnoses including unspecified dementia, chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, paroxysmal atrial fibrillation, ulcerative colitis, hypertension, peripheral vascular disease, and anemia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment completed on 10/18/24 revealed Resident #36 had severe cognitive impairment, was always incontinent of bowel and bladder, and dependent for toileting and personal hygiene. Further review of the MDS revealed Resident #36 was at risk for developing pressure ulcers, had no unhealed pressure ulcers, had two venous or arterial ulcers, and no other ulcers, wounds, or skin problems. Review of the care plan dated 10/18/24 revealed Resident #36 experienced urinary incontinence and urinary accidents and required assistance with toileting hygiene to keep clean and dry and maintain skin integrity. Further review of the care plan revealed Resident #36 was at risk for Impairment of skin integrity related to impaired mobility, incontinence, refusal of ROHO cushion (a wheelchair cushion that distributes pressure to minimize shear forces and prevent skin breakdown), refusals to lay down to be changed, refusal for perineal care, and thin fragile skin. Interventions included turning and repositioning every two hours when in bed, ROHO cushion to wheelchair when out of bed, reporting any reddened areas to the charge nurse, and application of barrier cream after each incontinent episode. Review of the last weekly skin assessment completed on 11/18/24 revealed Resident #36 had no new skin areas. Review of the two Weekly Non-Pressure Ulcer Reports dated 11/18/24 revealed resident #36 had two ulcers, one on his right shin and one on the medial aspect of his right shin. There were no non-pressure wounds or pressure wounds noted on the buttocks, upper thighs, or ischium on the skin and wound assessments completed on 11/18/24. Observation on 11/19/24 from 1:02 P.M. to 1:10 P.M. of Resident #36 receiving incontinence care from Certified Nursing Assistant (CNA) #396 and CNA #397 revealed CNA #396 pulled the soiled incontinence brief out from under Resident #36 while he was lying on his right side, causing friction and shearing to the skin beneath the brief. CNA #396 was observed tugging at the brief intermittently with short pauses whenever she met resistance, then resumed pulling. Further observation revealed when Resident #36 was rolled off his right side to fasten the new brief, a speck of bright red blood was noted on the new brief. CNA #397, with the assistance of CNA #396, assisted Resident #36 to roll to his left side which revealed an open area with a scant amount of fresh blood. During this observation, CNA #397 confirmed the open area was new and she left the room to notify the nurse. Interview on 11/19/24 at 1:18 P.M. with Registered Nurse (RN) #351 confirmed Resident #36 had a newly opened wound on his right ischium which measured 1.5 centimeters (cm) by 2.5 cm by 0.1 cm. During this interview, RN #351 confirmed the wound appeared to be the result of friction or shearing. Interview on 11/19/24 at 1:25 P.M. with CNA #396 confirmed she met some resistance when pulling the soiled brief from under Resident #36 and that she kept pulling, a little at a time, without attempting to roll Resident #36 to reposition or roll and tuck the brief for ease of removal. CNA #396 also confirmed she had not seen the open area prior to performing his incontinence care. Interview on 11/19/24 at 1:28 P.M. with CNA #397 confirmed the soiled brief was pulled out from under Resident #36 and that he should have been rolled back and forth to prevent any sheering during brief removal. During follow-up review of the Weekly Non-Pressure Ulcer Reports revealed a new assessment dated [DATE] of a new skin area to the right ischium which measured 1. 5cm x 2.5 cm x 0.1 cm, noted as a new area with an onset of 11/19/24 from shearing described as pink tissue with edges rolling away from wound bed. Review of the progress note dated 11/19/24 at 5:06 P.M. revealed Resident #36 was evaluated for a new skin area consisting of peeling and shearing, new wound care orders were obtained, and notification to the providers and the power of attorney were notified of the new skin concern. At 2:20 P.M. on 11/21/24, Director of Operations #300 presented wound notes regarding a skin alteration described as a deroofed blister to the right rear thigh with an onset date of 05/22/24 which was resolved on 07/02/24. At that time, Director of Operations #300 confirmed this evidence was presented to support Resident #36 already had fragile skin on the right posterior thigh area prior to the observed shearing motion observed during incontinence care on 11/19/24. Review of the policy titled Check and Change dated 09/29/21 revealed incontinence checks and incontinence care were to be performed in a manner that promoted the dignity, comfort, hygiene, and skin integrity of the resident.

Based on facility assessment review and interview, the facility failed to ensure the facility assessment was complete and accurate. This finding had the potential to affect all 68 residents who reside in the facility. Findings include: Review of the facility assessment dated [DATE] revealed under 'Part 3: Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies' section 3.1 Staff Type indicated necessary staff members are listed on our organizational chart (attached) to care for our resident population. The Infection Preventionist role was not marked on the organizational chart. Continued review of the assessment revealed under section 3.2, Staff Plan, revealed the following information: Our staffing levels will never fall below the minimum needed for each resident per day. We will never fall below the required minimum of 3.48 Nurse Hours per Resident Day (NHRD). We strive to maintain 4.0 nurse hours per resident day but adjust based on resident needs. If we are unable to meet this requirement we will enlist the support of our contracted staffing agencies partners. We will also use these contracted staffing agency partners as our contingent/emergency staff after all internal facility staff has been deployed. No specific amount of hours or number of staff needed per day were listed for any staff type including the Infection Preventionist. Interview on 11/21/24 at 12:11 P.M. with Director of Operations (DO) #300 confirmed the facility assessment provided did not list the Infection Preventionist role under the Staff Type or Staff Plan to determine the amount of hours required of the infection preventionist to assess, develop, implement, monitor, and manage the facility infection control program. DO #300 also confirmed the assessment lacked specific staffing information such as numbers or hours of various staff types per shift and per day.

Based on record review, interview, and facility policy review the facility failed to ensure resident #64's preferences were met regarding showers. This affected one resident (#64) of three reviewed for preferences and had the potential to affect all 66 residents in the facility. Findings include: Review of the medical record for Resident #64 revealed an admitted [DATE] with diagnoses including chronic kidney disease, diabetes, respiratory failure, sleep apnea, and congestive heart failure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #64 was cognitively intact. He required setup or cleanup help for eating and oral hygiene and partial or moderate assistance for showering, toileting, and personal hygiene. Review of the care plan dated 6/29/24 revealed Resident #64 had an activities of daily living (ADL) deficit due to heart failure. Interventions included assistance with toileting as needed, explaining procedures or tasks before starting and showers three times a week on Monday, Wednesday, and Friday evenings. Interview on 09/04/24 at 8:58 A.M. with Resident #64 revealed he would like to have a shower at least three times a week. He revealed his showers were inconsistent, sometimes he would receive one per week and others he would receive three. Review of the medical record revealed Resident #64 received a bath on 08/01/24 and 08/18/24 a shower on 08/15/24, 08/22/24, 08/23/24, and 08/29/24. Interview on 09/04/24 at 11:11 A.M. with the Administrator confirmed information in Resident #64's medical record did not support the residents' preference of showers three times per week. Review of the facility policy titled Activities of Daily Living, dated October 2021, revealed the facility would ensure residents ADL, including bathing and grooming, were completed based on the residents' needs and choices. This deficiency represents noncompliance investigated under Complaint Number OH00156034.

Based on interview and record review the facility failed to provide an environment free of accident hazards when an exit door with a Wander Guard alarm was reset and accidentally put in bypass mode. This affected one (Resident #17) and had the potential to affect the nine (Resident's #6, #13, #16, #17, #18, #37, #39, #45, and #50) with Wander Guards. The facility census was 57. Findings include: Review of the medical record for Resident #17 revealed an admitted [DATE]. Diagnoses included Alzheimer's disease, diabetes, and cerebral infarction. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #17 had impaired cognition. The assessment identified the resident to have behaviors of wandering. The resident was independent for ambulation. Review of the elopement risk assessment dated [DATE] revealed Resident #17 was at high risk for elopement. Review of physician orders identified an order for an ankle alarm (Wander Guard) in place to prevent elopement on 05/04/22. Review of the elopement investigation from 07/04/22 revealed Resident #17 was observed outside the building by a security guard. Resident #17 stated he went outside to watch The Fourth of July fireworks. Security contacted nursing and the resident was escorted back into the building. The resident was outside for approximately ten minutes. Resident #17 indicated to staff he went outside through the exit door by the staff dining room, so staff tested the Wander Guard station at the staff dining room exit. It was working properly. The resident's Wander Guard transmitters were tested , and they functioned properly. Further investigation revealed the door alarm did not sound when Resident #17 opened the door at the staff dining room exit. Resident #17 interview and camera footage review revealed the resident put in the Wander Guard code at the staff dining room exit door and then exited. Staff statement and camera footage review revealed the door had been alarming the previous days due to high winds. Registered Nurse (RN) #201 accidentally put the door in bypass when attempting to reset the door. The door was reset and checked for proper function by Director of Operations (DO) #200 the morning of 07/05/22. The Wander Guard reset code was changed the morning of 07/05/22. Interview on 07/13/22 at 8:58 A.M. with DO #200 revealed on 07/04/22 Resident #17 went to a staff exit door in the new part of the building and exited. The previous couple of days the door had been alarming due to the wind and nursing had reset it a couple times. When DO #200 came in on 07/05/22 he went to see what had been going on with door. He remembered the weather and the alarm going off. When DO #200 went back and watched the camera recording, he saw RN #201 with the door key trying to reset the door. He discovered the door was in bypass. Interview on 07/13/22 at 12:57 P.M. with DO #200 verified RN #201 was viewed resetting the alarm because of it going off due to wind on 07/03/11 at 7:05 P.M. Since it was alarming until that time, that was when it was accidentally disengaged. This deficiency substantiates Self-Reported Incident Control Number OH 075.

Based on record review and interview the facility failed to ensure Resident #8's medical record was maintained in a complete and accurate manner related to an incident in which the resident was found outside the facility unattended. This affected one resident (#8) of three residents reviewed for notification. Findings include: Review of Resident #8's medical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the plan of care, dated 12/19/2018 revealed the resident was at risk for elopement/wandering behavior due to confusion. Interventions included attempt to divert, check wanderguard (electronic monitoring device that triggers alarm at monitored door to prevent resident leaving unattended), keep exit door alarms on, report episodes, keep wanderguard attached to wheelchair, screen resident at least every three months and as needed. Review of an elopement risk assessment, dated 12/14/19 revealed the resident was at moderate risk for elopement. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/02/21 revealed the resident had moderate cognitive loss, required two person assist for transfers and one person assist for locomotion on and off unit. The assessment revealed the resident utilized a wheelchair for ambulation. Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] On 06/16/21 at 2:16 P.M. interview with Licensed Practical Nurse (LPN) #51 revealed on 01/13/20 at 5:00 P.M. the nurse heard an alarm going off at the employee entrance (ancillary door) and responded. Resident #8 was found with an African American male in the vestibule area. LPN #51 assessed the resident and checked vital signs. Mud was found on the resident's wheelchair, right arm, and right leg with no evidence of injury. Review of Resident #8's medical record revealed no evidence this incident was documented in the record and no written evidence the physician or resident's responsible party were notified of the incident On 06/16/21 at 11:02 A.M. and 2:05 P.M. interview with the DON revealed Resident #8 had left the facility unattended on 01/13/20. The DON verified the incident was not included in the resident's medical record. This deficiency is an incidental finding to Complaint Number OH 907.

Based on record review and interview the facility failed to ensure Resident #8's physician and responsible party were notified timely following an incident where the resident was found outside the facility unattended. This affected one resident (#8) of three residents reviewed for notification. Findings include: Review of Resident #8's medical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the plan of care, dated 12/19/2018 revealed the resident was at risk for elopement/wandering behavior due to confusion. Interventions included attempt to divert, check wanderguard (electronic monitoring device that triggers alarm at monitored door to prevent resident leaving unattended), keep exit door alarms on, report episodes, keep wanderguard attached to wheelchair, screen resident at least every three months and as needed. Review of an elopement risk assessment, dated 12/14/19 revealed the resident was at moderate risk for elopement. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/02/21 revealed the resident had moderate cognitive loss, required two person assist for transfers and one person assist for locomotion on and off unit. The assessment revealed the resident utilized a wheelchair for ambulation. Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] On 06/16/21 at 2:16 P.M. interview with Licensed Practical Nurse (LPN) #51 revealed on 01/13/20 at 5:00 P.M. the nurse heard an alarm going off at the employee entrance (ancillary door) and responded. Resident #8 was found with an African American male in the vestibule area. LPN #51 assessed the resident and checked vital signs. Mud was found on the resident's wheelchair, right arm, and right leg with no evidence of injury. Review of Resident #8's medical record revealed no evidence this incident was documented in the record and no written evidence the physician or resident's responsible party were notified of the incident On 06/16/21 at 11:02 A.M. and 2:05 P.M. interview with the DON revealed Resident #8 had left the facility unattended on 01/13/20. The DON verified the lack of written evidence to support the resident's physician and responsible party were notified of the incident at the time it occurred. This deficiency substantiates Complaint Number OH 907.

Based on record review and interview the facility failed to ensure Resident #8, who was cognitively impaired and at risk for elopement was provided adequate supervision to prevent the resident from exiting the facility unattended and without staff knowledge. At the time of the incident, the facility identified the wanderguard system was not properly functioning. In addition, following the incident the facility failed to complete a comprehensive and thorough investigation to determine the circumstances surrounding the incident. This affected one resident (#8) of three residents reviewed for accidents. Findings include: Review of Resident #8's medical record revealed an admitted [DATE] with diagnoses including [CONDITION(S)] and [CONDITION(S)] following cerebral infarction affecting right side, [CONDITION(S)] and [CONDITION(S)]. Review of the plan of care, dated 12/19/2018 revealed the resident was at risk for elopement/wandering behavior due to confusion. Interventions included attempt to divert, check wanderguard (electronic monitoring device that triggers alarm at monitored door to prevent resident leaving unattended), keep exit door alarms on, report episodes, keep wanderguard attached to wheelchair, screen resident at least every three months and as needed. Review of an elopement risk assessment, dated 12/14/19 revealed the resident was at moderate risk for elopement. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/02/21 revealed the resident had moderate cognitive loss, required two person assist for transfers and one person assist for locomotion on and off unit. The assessment revealed the resident utilized a wheelchair for ambulation. Review of physician's orders for June 2021 revealed Resident #8 had an order for a wanderguard to the wheelchair. On 06/16/21 at 2:16 P.M. interview with Licensed Practical Nurse (LPN) #51 revealed on 01/13/20 at 5:00 P.M. the nurse heard an alarm going off at the employee entrance (ancillary door) and responded. Resident #8 was found with an African American male in the vestibule area. LPN #51 assessed the resident and checked vital signs. Mud was found on the resident's wheelchair, right arm, and right leg with no evidence of injury. LPN #51 attempted to find the African American male after assessing Resident #8, but the male was gone. LPN #51 remembered it being a warm day that day and not wearing a jacket to work. A handwritten statement from LPN #51 was handed directly to the Director of Nursing (DON) and former Administrator. During the interview, LPN #51 revealed it was unknown at what time the resident had exited the facility. The LPN verified neither she or any other staff had knowledge of the resident leaving the facility unattended and were alerted to the incident at the time the resident was returned. Review of the handwritten statement from LPN #51 revealed Resident #8 returned to the facility by an unknown individual. Individual was wheeling resident into building at employee entrance and alarm was sounding. Individual left before nurse could question him further. Review of Resident #8's medical record revealed no evidence this incident was documented in the record and no written evidence the physician or resident's responsible party were notified of the incident. In addition, the facility failed to provide any type of investigation related to this incident. There was no evidence all staff working at the time of the incident or assigned to care for Resident #8 were interviewed or provided staff statements, no evidence the individual who returned the resident to the facility was interviewed or provided a statement to detail the circumstances of where exactly the resident was found, his condition or what interaction this individual had with the resident, no evidence the facility determined which exit the resident left the facility from or at an approximate time the resident left the facility. There was no evidence the facility determined who had last seen the resident and at what time to determine the length of time the resident had been outside the facility unattended. On 06/16/21 at 11:02 A.M. and 2:05 P.M. interview with the DON verified Resident #8 had left the facility unattended on 01/13/20. However, the DON did not consider the incident an elopement as the resident was found by a staff member of a neighbor facility and brought back in with no evidence of any injuries. In addition, the DON revealed at the time of the incident, the facility wanderguard system was not working properly. The DON verified the facility did not complete any type of investigation of the incident to determine the above information, nor obtain any witness statements of any other staff members as she did not feel it was an elopement or a reportable incident. The DON stated she was not sure of the identity of the person who returned Resident #8 to the facility on [DATE]. The DON revealed the facility provided in-service training to staff between 01/14/20 and 02/03/20 including directions to not disable the wanderguard system or the door alarm system at any time as a possible correction to the wanderguard alarm system. The DON revealed they had no evidence the alarm system was turned off or disabled by anyone, but it was a possibility. During the interview, the DON also verified the lack of written evidence to support the resident's physician and responsible party were notified of the incident at the time it occurred and verified the incident was not documented in the resident's medical record. On 06/16/21 at 2:32 P.M. interview with the Administrator revealed the African American male was a garbage man employed by a sister facility next door at the time of the incident, he was no longer employed at the facility and the facility had no contact information for him. The Administrator revealed this male reported finding Resident #8 in a wheelchair in the parking lot prior to returning him to the facility and that was all of the information that was provided. The Administrator stated they assumed the wanderguard system had failed at the time Resident #8 exited the facility on 01/13/20, but they had no evidence of such. The Administrator revealed there had been a discussion about the wanderguard not detecting a single transmitter attached to wheelchairs, so they implemented the use of two transmitters until a new wanderguard system was installed. This deficiency substantiates Complaint Number OH 907.

Based on record review, review of a facility Self-Reported Incident, and interview the facility failed to ensure Resident #2 was free from physical abuse by a staff member. This affected one (Resident #2) of three residents reviewed for abuse. The facility census was 59. Findings include: Review of the medical record for Resident #2, revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had impaired cognition and required extensive assistance of one staff for bed mobility, transfers, and ambulation. The resident rejected care and displayed verbal and physical behaviors directed toward others. Review of the comprehensive plan of care revealed Resident #2 had altered behavior patterns. He was resistant to and combative with care, was known to hit and kick at staff and called staff derogatory names. Interventions included praise positive behavior, use soft tone of voice and redirect behavior as able. Review of the nurses' notes dated 02/02/21 at 11:00 P.M. revealed there was an incident with an allegation of abuse and the investigation was started and submitted to the Ohio Department of Health. Review of the Self-Reported Incident (SRI) dated 02/02/21 at 11:30 P.M. and associated investigative documentation revealed two State tested Nurse Aides (STNA) #303 and #305, reported to Registered Nurse (RN) #202 that they witnessed STNA #300, hit Resident #2 multiple times on the leg. RN #202 immediately escorted STNA #300 out of the building and notified the Director of Nursing (DON). RN #202 did a head to toe assessment on the resident, no signs of injury was found and started collecting statements. An investigation was initiated, and STNA #300 was informed she would not be permitted back inside the building until the investigation was completed. A thorough investigation including statements from relevant staff, resident interviews and assessments for residents who could not be interviewed were completed. The resident's guardian, medical doctor and psychiatrist were notified along with the Veteran's Administration. The local police and Ohio Board of Nursing were notified. During interviews Resident #2 insisted he was not assaulted. However, upon completion of the facility's investigation it was their belief that STNA #300 did slap the resident during care and the allegation of abuse was substantiated. As a result of the investigation the facility terminated the employment of STNA #300, and reeducation was provided to all staff on the Prevention of Abuse policy and procedures. Review of the time punch card 02/02/21 at 10:20 P.M. revealed STNA #300 punched out approximately four to five minutes after the incident occurred. Review of the local law enforcement report dated 02/04/21 at 1:54 P.M. revealed the facility reported the incident to local law enforcement. The report completed by Law Enforcement Officer (LEO) #500 indicated Resident #2 stated no abuse had taken place, however, other interviews corroborated STNA #300 had slapped the resident on the upper thigh. The Assistant Director of Nursing said two aides (STNA #303 and #305) reported Resident #2 had yelled racial slurs and attempted to strike STNA #300 who in turn struck him on the upper thigh with her hand. A nurses' notes dated 02/06/21 at 4:30 P.M. revealed the facility's investigation was completed. The resident's Physician and Power of Attorney (POA) were notified. Interview on 03/04/21 at 2:46 P.M. with STNA #303 revealed she and STNA #305 were taking care of Resident #2 when STNA #300 came into assist. Resident #2 became combative and started calling STNA #300 derogatory names and kicking at her. STNA #300 then slapped him on the upper thigh four to five times in retaliation. STNA #303 and STNA #305 told STNA #300 that she should leave the room and she did. They finished care for the resident and immediately reported it to the charge nurse, RN #202. RN #202 immediately pulled STNA #300 off the floor, and had her punch out and leave the building. Interview on 03/04/21 a 3:07 P.M. with STNA #305 confirmed STNA #303's account of the incident. Interview on 03/04/21 at 3:50 P.M. with RN #202 revealed STNA #303 and #305 came out of Resident #2's room and reported to him that STNA #300 had slapped the resident on the upper thigh four to five times after being kicked and sworn at. RN #202 stated he pulled STNA #300 off the floor immediately and told her to punch out. He called the DON who came into the facility within the hour to start the abuse investigation. Interview on 03/04/21 a 4:10 P.M. with the DON revealed she was notified on 02/02/21 at 10:24 P.M. by RN #202, via phone that at 10:15 P.M. STNAs #303 and #305 reported they witnessed STNA #300 hit Resident #2 multiple times on the leg. STNA #300 was escorted out of the building at 10:19 P.M. and did not return. The DON reiterated details as described in the SRI and investigation and verified although Resident #2 denied abuse the facility believed STNA #300 did hit him several times. They substantiated abuse, terminated STNA #300 and education was provided to all staff on the Abuse policy. Interview was attempted via phone on 03/04/21 at 01:22 P.M. and 3:44 P.M. and messages were left on voicemail for STNA #300, however, no return contact was made. Review of the undated facility policy titled Abuse, Neglect, and Misappropriation, revealed it is the facility's policy to absolutely prohibit abuse, neglect, exploitation and/or misappropriation of a resident. This deficiency substantiates Complaint Number 0.

Based on observation and interview, the facility failed to ensure one (Resident #2) of a in-facility census of 65 residents was treated with dignity and respect. Findings include: During an interview on 06/03/19 at 10:09 A.M., Resident #2 stated staff were very rude sometimes and did not listen to what she had to say. Review of Resident #2's medical record revealed [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #2 was able to make herself understood and was usually able to understand others. Resident #2 was assessed as moderately cognitively impaired and required supervision for eating. On 06/03/19 at 12:18 P.M., Resident #2 arrived in the dining room. Resident #2 was served baked fish with lemon and a side of butter, watermelon, and a broccoli/cheese/rice casserole. Resident #2 attempted to get attention of staff several time by waving her hand before State tested Nursing Assistant (STNA) #100 asked what was wrong. Resident #2 responded the fish was just stringy. STNA #100 offered Resident #2 a peanut butter and jelly sandwich. When STNA #100 asked dietary staff about an alternate, someone (not seen but heard) replied the fish was what Resident #2 requested. Resident #2 stated she did not like that kind of fish. Resident #2 complained, see when you don't like something you can't get anything else. STNA #100 asked Resident #2 if she wanted breaded fish and Resident #2 agreed stating maybe it would be better. At 12:27 P.M., Resident #2 was provided a piece of breaded fish and Resident #2 stated no and reported she did not like the cod, stating staff should know that. At 12:32 P.M., Resident #2 continued to complain about the fish crumbling but ate her watermelon. At 12:34 P.M., Dietary Staff #101 approached Resident #2 and asked Resident #2 what she wanted to eat. Resident #2 responded she did not like the cod but liked other kinds of fish. Resident #2 asked if salmon was available and Dietary staff #101 stated the salmon was frozen. Dietary staff #101 stated it would take a long time to defrost salmon and she would see what she could do. Resident #2 agreed to wait. On 06/03/19 at 12:41 P.M., Dietary Manager #102 approached Resident #2 and sat down beside her. Resident #2 voiced her concerns about the food she had been served. Dietary Manager #102 stated he had sent the cook down to talk to Resident #2 that morning and fixed the fish the way she wanted. Resident #2 stated she had told staff previously she did not like cod. Dietary Manager #102 stated cod was what was on the menu. Dietary Manager #102 informed Resident #2 he had taken sole fish out and and it would take 15-20 minutes to thaw in cold water. Resident #2 stated she just wanted a piece of fried fish with no breading. On 06/03/19 at 12:49 P.M., while Dietary Manager #102 and Resident #2 sat talking, Clinical Social Worker #103 approached, leaning over the table, and asked, in what sounded like accusatory manner, if Resident #2 was having a scene. Clinical Social Worker #103 stated staff spent a long time in Resident #2's room earlier that day talking about the fish. Clinical Social Worker #103 stated to Resident #2 if staff was fixing cod for everybody else they could not fix salmon just for her. Resident #2 stated when she filled out her menu she crossed out cod and wrote in salmon. At 12:55 P.M., Dietary Manager #102 stated he would provide Resident #2's fish when it was done. At 12:57 P.M., Dietary Staff #101 arrived with a piece of fish and Resident #2 stated it looked better. Resident #2 stated she appreciated it although she did make the statement the fish was soft but not crisp. Dietary Manager #102 stated he was going to leave and stated Resident #2 was not always going to get everything she wanted all the time. Resident #2 asked if fish was the only thing she got and if it was considered a meal. Dietary Staff #101 asked if Resident #2 wanted the broccoli and cheese casserole like she had been served earlier but had not eaten and asked if Resident #2 wanted noodles. Clinical Social Worker #103 stated those were her two options. Resident #2 agreed to try noodles. Dietary Manager #102 excused himself. As Dietary Staff #101 walked away, she stated here I go again. Resident #2 complained she did not believe the fish was cooked thoroughly and Clinical Social Worker #103 disagreed, stating there were too many people to cook for to cook everything exactly as everyone wanted. Resident #2 responded, stating maybe she was in the wrong place as there were too many people to provide food according to her preference. At 1:07 P.M., Dietary Staff #101 delivered the noodles. At 1:08 P.M., Resident #2 stated to Dietary Staff #101 that now she would remember she did not like cod fish and Dietary Staff #101 stated she already knew that. Resident #2 stated she liked the noodles. At 1:10 P.M., STNA #100 had approached and sat at the table with Resident #2 and Clinical Social Worker #103. Clinical Social Worker #103 stated it was impossible to please everyone. On 06/03/19 at 1:11 P.M., Clinical Social Worker #103 was interviewed and stated Resident #2 was never going to be pleased. Clinical Social Worker #103 stated she worked for Jewish Family Services and has visited with Resident #2 since her admission focusing on the appropriate way to interact with others. Clinical Social Worker #103 stated she was walking down the hall when someone told her Dietary Manager #102 was in the dining room because Resident #2 was having a hissy fit. Clinical Social Worker #2 verified after she had approached Resident #2 and asked about her creating a scene (without taking the time to observe what was happening) she discovered Resident #2 was actually calm. Clinical Social Worker #103 stated maybe it was an assumption on her part when she heard Dietary Manager #102 was speaking with Resident #2 as he was not usually in the dining room. Clinical Social Worker #103 was informed eye rolling had been noted between staff during the conversations with Resident #2 and the statement from Dietary Staff #101 regarding Here I go again when she left to prepare noodles. Clinical Social Worker #103 agreed interactions could have been more respectful. Clinical Social Worker #103 stated she had spoken to Resident #2 about showing more appreciation or if she was more pleasant when asking for things staff would be happy to do things for her. Clinical Social Worker #103 agreed regardless of Resident #103's behavior, staff were expected to show respect and consideration. Clinical Social Worker #103 repeated stated Resident #2 could not be pleased.

Based on record review and interview the facility failed to limit the use of as needed [MEDICAL CONDITION] medications as required for Resident #59 and Resident #26 and failed to attempt non-pharmacological interventions prior to the administration of anti-anxiety medication for Resident #26. This affected one of five residents reviewed for unnecessary medications and one of three residents reviewed for Hospice care. The in-house facility census was 65. Findings include: 1. Resident #59 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She received Hospice services. The resident had an order dated 05/04/19 for [MEDICATION NAME] concentrate (an antipsychotic medication) 2 milligrams (mg) orally every six hours as needed for agitation for an indefinite time period. There was no evidence the physician examined the resident and determined the need to continue the as needed antipsychotic medication after 14 days. On 06/06/19 at 11:43 A.M. interview with the Director of Nursing (DON) verified the order for the antipsychotic medication exceeded the 14 day limit. 2. Review of Resident #26's medical record revealed [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #26 had short and long term memory problems and severely impaired cognitive skills for daily decision making. The MDS also indicated Resident #26 had delusions. On 05/10/19, a physician's orders [REDACTED]. There was no limitation in the number of days the [MEDICATION NAME] could be used. Review of (MONTH) 2019 and (MONTH) 2019 Medication Administration Records (MAR) revealed the [MEDICATION NAME] ordered on an as necessary basis was administered 13 times with the most recent dose being administered 06/03/19. Documentation regarding the administration of [MEDICATION NAME] did not consistently revealed staff attempted non-pharmacological interventions prior to its administration. On 06/06/19 at 11:43 A.M., the DON verified Resident #26 had an order to administer [MEDICATION NAME] on an as necessary basis without a limit to the number of days the order could be used. On 06/06/19 at 12:15 P.M., the DON was informed a spot check of documentation regarding the administration of [MEDICATION NAME] ordered on an as necessary basis during (MONTH) and (MONTH) 2019 was performed and revealed a lack of documentation regarding interventions attempted prior to the [MEDICATION NAME] use. The DON stated the computerized charting system should prompt the staff to enter interventions and would see if could find additional information. On 06/06/19 at 1:20 P.M., Registered Nurse (RN) #104 provided three Behavior Monitoring assessments stating they were in a system not accessible to surveyors. RN #104 verified the three assessments did not correspond with dates/times the [MEDICATION NAME] was administered. RN #104 stated nurses filled the behavior monitoring out each shift and verified some of the interventions listed such as offering toileting and food/fluids would be interventions provided to every resident every shift and not specifically geared toward behaviors. Review of the facility's Anti-Psychotic Drug Use policy, effective (MONTH) (YEAR), revealed as needed orders for [MEDICAL CONDITION] drugs were limited to 14 days, except as provided if the attending physician or prescribing practitioner believed that it was appropriate for the as needed order to be extended beyond 14 days. He or she should document their rationale in the resident's medical record and indicate the duration for the as needed order. As needed orders for antipsychotic drugs were limited to 14 days and could not be renewed unless the attending physician or prescribing practitioner evaluated the resident for the appropriateness of that medication

Based on observation, record review and interview the facility failed to implement effective interventions to prevent resident to resident altercations resulting in the physical abuse of Resident #63. Actual Harm occurred when Resident #66, who had a history of [REDACTED].#63 on 08/19/18 at 2:10 A.M. when the resident was in his room in bed. Staff responded to a resident yelling and upon arriving to Resident #63's room found Resident #66 assaulting him by hitting him in the face. Resident #63 was assessed to have bruises over the right eye, left eye, left cheek, and an open area on the left lower lip. Resident #63 subsequently refused to be transported to the emergency room for treatment and ice was applied to the area. This affected one resident (Resident #63) of three sampled residents. Findings include: Record review revealed Resident #63 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review revealed Resident #63 was receiving palliative care services. Review of a Brief Interview for Mental Status (BIMS) score assessment, dated 07/20/18 revealed Resident #63 had severe cognitive impairment. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #63 had disorganized thinking and fluctuating attention. Review of the facility provided list of alert, oriented and interviewable residents revealed Resident #63 was not interviewable. Review of a facility self-reported incident (SRI) revealed Resident #63 was assaulted by Resident #66 on 08/19/18. In addition, a self-reported incident dated 08/10/18 revealed Resident #66 had been previously involved in an incident with Resident #16 on 08/10/18. Record review revealed Resident #66 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a MDS 3.0 assessment dated [DATE] revealed Resident #66 required limited assistance with walking and transfers. Resident #66 walked with a walker and slow, steady gait. The same MDS revealed no maladaptive behaviors. Review of nurse progress notes from admission through 08/09/18 revealed no evidence of maladaptive behaviors. The same nurse progress notes described Resident #66 as pleasant and cooperative. Review of a facility SRI initiated with an event dated 08/10/18 and completed with the final report 08/14/18, revealed a visitor (visiting across the hall from Resident #66) witnessed and reported immediately to a nurse, that Resident #16 was sitting in the hallway outside of Resident #66's room. The visitor witnessed Resident #66 exit his room and raise his hand to hit Resident #16. The visitor (a private caregiver for Resident #63) intervened and separated the residents. Review of the investigation revealed the incident occurred at 6:40 P.M. Resident #66 stated He made me mad. He keeps coming in my room. Both residents were assessed and no injuries were identified. Following the incident between Resident #66 and Resident #16 the facility implemented interventions for Resident #66 including behavior monitoring by nursing staff on each shift, physician notification of the incident and a psychiatric consult, which was completed on 08/17/18 and assessed Resident #66 to have dementia with behavioral disturbance. Review of an incident report, interdisciplinary progress notes and an SRI revealed a second incident occurred on 08/19/18 at 2:10 A.M. involving Resident #66. Facility documentation revealed the unit nurse heard yelling, went down the hallway and found Resident #66 in Resident #63's room. Resident #63 was in bed and Resident #66 was standing over him and hitting him in the face. The nurse was able to separate the residents and staff arrived to redirect Resident #66 back to his room and remained with him while the nurse assessed Resident #63. Resident #63 was assessed to have bruises over the right eye, left eye, left cheek, and an open area on the left lower lip. Ice was applied. The note indicated Resident #63 was assessed as alert and oriented. Following the incident, Resident #66 was discharged from the facility to the hospital where he was evaluated for a urinary tract infection and admitted to the gero-psychiatric unit. As of 08/27/18 the resident had not returned to the facility. A staff member remained with Resident #63 to provide comfort and support until his private caregiver arrived at 11:00 A.M. The incident was reported to the State Agency at 3:55 A.M. The nurse met with (name of policeman) from the local police department at 6:45 A.M., to file a police report. At 8:00 A.M., the Power of Attorney for Resident #63 was notified a police report had been made and the police stated that the POA would have to go down to the police department if she wished to file charges. The POA was also notified that the report was filed with the State Agency and an investigation was being conducted. At 9:00 A.M., cold packs were ordered by the physician and applied to both eyes of Resident #63. Continued cold packs were to be applied for 10 minutes four times a day for 48 hours. At 5:49 P.M., the physician was notified Resident #63 had increased swelling and pain about his face. Resident #63 was medicated for pain and an x-ray of the facial bones was ordered and completed. The X-rays were negative. Review of nurse progress notes from 08/20/18 through the time of the complaint survey on 08/27/18 revealed a one-to-one nursing staff was at Resident #63's bedside at all times to ensure comfort and reassurance related to the assault. Review of the nurse's progress notes, the SRI and investigation revealed Resident #63 declined a room change and declined seeing a psychiatrist or counselor to provide additional emotional support. Review of the nursing notes and interview with the Director of Nursing (DON) on 08/27/18 at 9:30 A.M. revealed the nurse on duty at the time of the incident between Resident #66 and Resident #63 reported the incident to the local police. The nurse also also notified the resident's daughter she had reported the incident to the police and the police said she could file charges at the police station. Following the incident, one on one was initiated for Resident #63 because the facility believed he was traumatized and wanted to reassure him since the incident did occur in the middle of the night. The facility also offered a room change for Resident #63, however that was declined. The resident was notified that Resident #66 had been discharged from the facility. On 08/27/18 at 10:22 A.M., Resident #63 was observed in his room, reclined in a lounge chair, and asleep. State tested Nurse Aide (STNA) #75, was observed at his side. An interview was completed with STNA #75 at the time of the observation. STNA #75 revealed she was sitting with the resident and documenting his activities and mood. STNA #75 revealed she was instructed to watch for any anxiety, stress or depression because he had had some kind of argument with another resident. STNA #75 revealed the yellow-brown fading bruise under the resident's eye and over the right side of his face was the result of being struck by another resident. In addition, interviews were completed with eight staff, Housekeeper #76, Dietary Aide (DA) #77, STNA #78, Licensed Practical Nurse (LPN) #79, LPN #80, STNA #81, Registered Nurse (RN) #82 and STNA #83, consecutively. Eight of eight staff verified they were aware of both of the above incidents involving Resident #66. Eight of the eight staff revealed sadness and regret the incidents occurred, identifying the victim Resident #63, as calm, quiet and pleasant. Review of the facility Abuse, Neglect, Misappropriation policy and procedure, revised 11/28/16 revealed abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. This deficiency substantiates Master Complaint Number OH 778 and Complaint Number OH 763.

Based on record review and interview the facility failed to ensure Resident #52's physician was notified of anti-hypertensive medications not being administered resulting in an additional anti-hypertensive medication being ordered by the resident's [MEDICAL TREATMENT] physician. This affected one resident (Resident #52) of six residents reviewed for unnecessary medication use. Findings include: Record review revealed Resident #52 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission physician's orders [REDACTED].M. and 8:00 P.M. and [MEDICATION NAME] HCL 50 mg three times a day at 8:00 A.M., 12:00 P.M. and 8:00 P.M. for hypertension. Further review of the medication administrator records from 07/13/17 until 05/30/18 revealed the resident did not receive any of the 8:00 A.M. doses of the medications on Tuesdays, Thursdays or Saturdays because the resident was out of the facility at [MEDICAL TREATMENT]. Review of the resident's blood pressures (BP) monitoring revealed the following from the [MEDICAL TREATMENT] center- the resident had a history of [REDACTED]. The [MEDICAL TREATMENT] physician ordered [MEDICATION NAME] five mg to be administered in the evening. Further review of resident's blood pressure on HD days revealed on 04/21/18 -BP was 165/80, on 05/01/18- BP was 161/82, on 05/05/18 -BP was 163/96, on 05/10/18- BP was 170/74 and on 05/17/18 -BP was 135/99 and 156/92. Review of the medical record revealed there was no evidence the resident's attending physician was notified of the resident not receiving the antihypertensive medications as ordered since admission nor the addition of the antihypertensive medication on 03/29/18 by the HD physician. On 06/01/18 at 10:50 A.M., interview with the director of nursing verified she was not aware the resident was not receiving the medications as ordered and there was no evidence the attending physician was notified of such nor was the attending physician notified of the new order from the [MEDICAL TREATMENT] physician on 03/29/18. Due to the facility not administrating the medications as ordered she could not verify the need for the addition of the antihypertensive medication on 03/29/18.

Based on record review and interview the facility failed to ensure the Notice of Medicare Non-Coverage (NOMNC) issued to residents contained the required information. This affected three residents (Resident #156, #157 and #158) of three residents reviewed for liability notices. Findings include: 1. Review of the NOMNC form dated 05/07/18 revealed the Medicare services for Resident #156 would end 05/10/18. The same form revealed Resident #156 had the right to appeal the decision and the directions on the appeal process. However, the form read: You must make your request to the Quality Improvement Organization (also known as a QIO). Call your QIO at: {insert QIO name and toll-free number of QIO} to appeal, or if you have questions. 2. Review of the NOMNC form dated 02/26/18 revealed the Medicare services for Resident #157 would end 03/01/18. The same form revealed Resident #157 had the right to appeal the decision and the directions on the appeal process. However, the form read: You must make your request to the Quality Improvement Organization (also known as a QIO). Call your QIO at: {insert QIO name and toll-free number of QIO} to appeal, or if you have questions. 3. Review of the NOMNC form dated 02/02/18 revealed the Medicare services for Resident #158 would end 03/01/18. The same form revealed Resident #158 had the right to appeal the decision and the directions on the appeal process. However, the form read: You must make your request to the Quality Improvement Organization (also known as a QIO). Call your QIO at: {insert QIO name and toll-free number of QIO} to appeal, or if you have questions. An interview was completed with Business Office Manager (BOM) #81 on 05/30/18 at 11:27 A.M. BOM #81 verified the name and contact information for the QIO organization (KEPRO) had never been inserted or added to the NOMNC form for Resident #156, #157 or #158.

Based on record review and interview the facility failed to ensure a comprehensive interdisciplinary team (IDT) meeting was held to include the resident and ensure an individualized plan of care was in place for Resident #52 and #55. This affected two residents (Resident #52 and #55) of 15 residents reviewed for IDT meetings. Findings include: 1. Record review revealed Resident #55 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the skilled occupational therapy (OT) plan revealed participation from 02/21/18 until 05/15/18. Further review of the discharge summary revealed the resident was to wear the left hand splint but the resident stated she had a splint bud did not know where it was or the last time she wore it. The resident was referred to restorative therapy for application of the hand splint for six to eight hours a day. Review of the team conference report, dated 03/20/18 revealed there was no evidence a representative from therapy was present, nor was a floor nurse, a state tested nursing assistant (STNA) or the resident. There was no evidence therapy was discussed in the IDT meeting. Review of the 05/16/18 quarterly Minimum Data Set (MDS) 3.0 assessment revealed the resident was cognitively intact and had limited range of motion on one side both upper and lower extremities. On 5/30/18 at 1:05 P.M., interview with registered nurse (RN) #100 verified she did not have the resident on a splinting program as planned by OT. Further interview at 4:30 P.M. verified the resident had a decline in mobility of the left hand and had been on a splinting program in the past for the contracture. On 05/31/18 at 11:06 A.M., interview with the resident revealed she used to have a splint with a strap across the top of her fingers on the left hand due to her contractures but she did not know where it was and had not seen it for a long time. She did not recall being at an IDT meeting or discussing therapy or restorative nursing for management of the contracture or for splinting. On 05/31/18 at 12:50 P.M., interview with the director of nursing verified there the IDT meeting on 03/20/18 was not comprehensive to include the resident and all disciplines to ensure the resident had an accurate individualized plan of care. 2. Record review revealed Resident #52 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the (MONTH) (YEAR) medication administrator record revealed the resident did not receive his medications as ordered on [MEDICAL TREATMENT] days. Review of the (MONTH) (YEAR) restorative grids revealed the resident did not receive restorative services as planned. Review of the 01/17/18 nutrition progress note revealed the resident had significant weight gains in one and six months. Review of the IDT note dated 03/02/18 revealed neither the dietitian, nor a floor nurse or state tested nursing assistant attended or had input for the meeting. There was no evidence they discussed the resident not receiving restorative therapy as planned, significant weight gains or medications not being received as ordered or coordination of [MEDICAL TREATMENT]. On 06/01/18 at 10:55 A.M., interview with licensed practical nurse (LPN) #101, who coordinated the IDT meetings, verified no one from dietary attended the 03/02/18 IDT meeting including the dietitian, no floor staff attended the meeting or had input for the residents individualized plan of care. She verified there was no evidence the team discussed the residents significant weight gains, the coordination of [MEDICAL TREATMENT] nor medications and restorative services not being received as ordered.

Based on observation, record review and interview the facility failed to ensure Resident #52 received restorative services for activities of daily living (ADL's) as planned. This affected one resident (Resident #52) of two residents reviewed for restorative services. Findings include: Record review revealed Resident #52 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the physical therapy (PT) discharge note dated 02/14/18 and the occupational therapy (OT) discharge note dated 02/16/18 revealed the resident was referred to restorative therapy. Review of the restorative therapy participation grids from February, (MONTH) and (MONTH) (YEAR) revealed the resident had programs for Active Range of Motion (AROM) to the bilateral upper extremities (BUE), bilateral lower extremities and strengthening for balance and standing for 15 minutes a day six to seven days a week. Further review of the grids revealed he received the programs three of the 28 days in February, 19 of the 31 days in (MONTH) and 14 of the 30 days in April. Further review revealed the resident restarted skilled PT on 04/29/18 and skilled OT on 05/01/18. Review of the physician's orders [REDACTED]. Review of the 05/11/18 quarterly Minimum Data Set (MDS) 3.0 assessment revealed the resident was cognitively intact and was not able to steady when standing. On 05/30/18 at 1:05 P.M., interview with Registered Nurse (RN) #100 verified the resident did not receive restorative therapy as planned to due staffing issues and the amount of residents who were to receive restorative services. On 05/31/18 at 5:40 P.M., interview with the resident revealed he did not receive his restorative therapy as desired and he wanted to get stronger to be able to stand and transfer himself. Review of the restorative nursing programs policy, dated 09/01/17, revealed it was designed to maintain or improve a resident's abilities to the highest practicable level.

Based on observation, record review and interview the facility failed to ensure pressure ulcer treatments were in place as ordered and pressure reducing interventions were implemented as ordered and care planned for Resident #12 who had a pressure ulcer to his coccyx. This affected one resident (Resident #12) of three residents reviewed for pressure ulcers. Findings include: Record review revealed Resident #12 was admitted to the facility with [DIAGNOSES REDACTED]. Review of quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact, required extensive two person assistance with bed mobility, transfers, dressing, personal hygiene and toileting, had no stage one or greater pressure ulcers. The Quarterly MDS 3.0 assessment, dated 03/29/18 revealed the resident had one Stage II (partial-thickness skin loss with exposed dermis) pressure ulcer since 12/28/17, was cognitively intact and was extensive two person assist with bed mobility, transfers, dressing, personal hygiene and toileting. Review of the physician's orders [REDACTED]. The resident also had physician orders [REDACTED]. A skin/wound note dated 04/24/18 revealed the resident had a pressure ulcer to the coccyx measuring 0.9 centimeters (cm) in length by 0.3 cm in width with 0.1 cm depth. The ulcer was assessed to have a pink wound base with a dry granular crust that covers approximately 30% of wound. Periwound was normal for this resident. Scant serous drainage noted to dressing. No odor. No pain noted with dressing change. A skin/ wound note dated 05/01/18 revealed the area to the coccyx was dry granular tissue and no longer open. The note indicate the treatment would continue at this time to ensure that the wound stayed closed. A skin wound note dated 05/08/18 revealed dressing to coccyx completed per orders on 05/08/18. Area remains dried granular closed tissue with no drainage and no pain noted. A skin/wound note dated 05/22/18 revealed the resident's buttocks and coccyx area were evaluated while doing preventative treatment. Scabbing was no longer present over previous left side wound which now had scattered [MEDICATION NAME] tissue present. Area measured 0.8 cm by one cm by 0.2 cm with periwound normal. Review of the care plan, dated 05/24/18 revealed the resident was at risk for pressure ulcers/ had a pressure ulcer related to impaired mobility due to [MEDICAL CONDITION], incontinence, recurring wound, refusals for hands on care, treatments and interventions. Interventions included assist with hygiene and general skin care. Keep skin clean and dry, cleanse perineal area, buttocks, and coccyx with soap and water, apply inzo cream with incontinence and as needed, ensure adequate hydration, keep resident's nails short. Toilet per schedule. Report any reddened areas to charge nurse. Encourage to be out of bed as much as possible, lay resident down after meals, low air loss mattress, monitor Braden Scale quarterly. A skin/wound note dated 05/29/18 revealed a wound of 0.6 centimeter (cm) by 0.1 cm now had scattered [MEDICATION NAME] tissue present that was moving inwards and creating a scab like covering with scant serous drainage noted and no pain noted. periwound normal. Observations on 05/29/18 between 11:45 A.M. to 12:20 P.M. and 2:00 P.M. to 3:30 P.M. and 05/30/18 from 6:30 A.M. to 9:00 A.M. and 3:32 P.M. to 5:00 P.M. revealed Resident #12 sitting in a wheelchair with a Roho cushion without attempts of repositioning of the resident by staff while he was seated in the chair. Interview on 05/30/18 at 3:32 P.M. with Resident #12 revealed he was aware he had a reoccurring wound to his buttocks and stated he repositioned himself sometimes on his own and when staff reminded him. He stated he had a special bed and cushion on his wheelchair to prevent wounds. Review of a progress note, dated 05/31/18 reveal skin/wound notes with consultation with physician regarding appearance of wound to Resident #12's coccyx region. The note indicated the buttocks region was cleansed and foam dressing was applied as needed. Observation on 05/31/18 at 6:44 A.M. of incontinence care provided by State tested nursing assistant (STNA) staff revealed there was no wound dressing present to the resident's coccyx region and there was no old dressing in the resident's bedding or clothing. Interviews on 05/31/18 at 6:44 A.M. with STNA #82 and STNA #83 verified there was no wound dressing covering the residents coccyx region nor in his clothing or bed and they were not aware of where the wound dressing might have been. Interview on 05/31/18 at 7:01 A.M. with Licensed Practical Nurse (LPN) #50, who was the facility wound care nurse revealed she had performed the dressing change to Resident #12's coccyx region on 05/29/18 and the dressing was to remain in place until the next dressing change scheduled for 06/05/18 and/or was supposed to be replaced by the charge nurse if the dressing came off between scheduled dressing changes. LPN #50 reported Resident #12 had the coccyx wound since 05/22/18. She stated he had a recurring pressure ulcer to the coccyx region since his admission in (MONTH) (YEAR). She reported the resident had orders for an air mattress on his bed, Roho cushion to his wheelchair and turning and reposition, but the resident was non-compliant with their orders and refused care related to his turning and repositioning at times. This deficiency substantiates Complaint Number OH 143.