Every finding on record at Heritage of Hudson

Based on observations, record review, and interviews, and review of facility policy, the facility failed to ensure timely incontinence care was provided to Resident #15, #36 and #48. This affected three residents (#15, #36, and #48) out of three residents reviewed for incontinence care. The facility census was 71. Findings include: 1. Review of the medical record for Resident #36 revealed an admitted [DATE]. Diagnoses included dementia, generalized muscle weakness, abnormalities of gait and mobility, aphasia, depression, and anxiety. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #36 was severely impaired cognitively; exhibited inattention and disorganized thinking, which fluctuated; had rejected care ; needed substantial/max assistance from staff to go from sitting to standing and for transfers to toilet; was dependent on staff to transfer from bed/chair to chair; was frequently incontinent of bladder and occasionally incontinent of bowel and was not on any toileting program. Review of Resident #36's care plan created on 10/26/23 revealed the resident had alteration in elimination related to frequently incontinent of bladder and bowel. Fluctuations in elimination could vary due to impaired cognition. Interventions included to monitor for skin redness/irritation and provide incontinence care as needed A continuous observation was conducted on 05/20/25 from 6:20 A.M. to 10:24 A.M. of Resident #36 sitting in her wheelchair either in the common area across the nurse's station or in the unit dining room for breakfast. Resident #36 was asleep in her wheelchair the majority of the time during the observation. No staff attempted to toilet or check and change the resident, and at 10:24 A.M. there was a large puddle of urine observed under Resident #36's wheelchair with staff observed placing bath blankets on the floor to soak up the urine then Certified Nursing Assistant (CNA) #543 took Resident #36 back to her room. An interview on 05/20/25 at approximately 10:30 A.M. with Certified Nursing Assistant (CNA) #528 confirmed Resident #36 was incontinent and should be offered to be toileted every two hours. She indicated the resident would often say no to being toileted, however, the staff were to make a toileting attempt unless the resident continued to refuse. During the interview, CNA #528 confirmed the resident wore briefs and there were times when she could not complete check and changes every two hours. CNA #528 did not give a reason why check and changes couldn't always be completed every two hours. An interview on 05/20/25 at 11:04 A.M. with CNA #543 revealed he had noticed the puddle of urine under Resident #36's wheelchair so he took her back to her room to be changed. CNA #543 stated he had relieved CNA #753 who told him all residents on CNA #753's assignment had been checked and changed as needed between 7:00 A.M. to 9:00 A.M. CNA #543 verified Resident #36's brief was saturated with urine and the urine had leaked onto the floor in the common area and that's why there was a puddle of urine beneath Resident #36. CNA #543 stated when he wheeled her back to her room, Resident #36 had urinated again and the urine again leaked onto the floor beneath her. An interview on 05/20/25 at 11:18 A.M. with CNA #753 revealed Resident #36 was a heavy wetter and she thought the resident was last toileted or changed around 7:30 A.M. but was not certain of the time. CNA #753 verified Resident #36 was assigned to her care. Interview on 05/20/25 at 3:57 P.M. with Administrator revealed the facility did not have a policy on how often care was to be given to a resident. She stated the staff knew residents should be checked every two hours or as needed for care needs. Review of the policy titled Skin: Incontinence Care Protocol last revised September 2017 revealed the facility would provide incontinence care for residents in order to maintain skin integrity, prevent skin breakdown, control odor, provide comfort, and to maintain resident self-esteem. 2. Review of medical record for Resident #15 revealed an admitted [DATE]. Diagnoses included Alzheimer's disease, dementia, and major depressive disorder. Review of Resident #15's quarterly MDS assessment, dated 02/28/25, revealed the resident was severely impaired cognitively; exhibited fluctuating inattention and disorganized thinking behaviors; had delusions; rejected care one to three days during the assessment reference period; was dependent on staff for toilet hygiene; was dependent on staff for transfers; and was always incontinent of bowel and bladder. Review of the care plan created on 12/04/24 revealed Resident #15 had an alteration in elimination. Interventions included monitor for skin redness/irritation, provide incontinence care as needed, and monitor for a pattern if resident able to participate. Interview on 05/19/25 at 10:55 A.M. with the son and daughter of Resident #15 revealed a concern regarding their mother not receiving timely incontinence care since the resident's room would have a urine odor at times. Interview on 05/19/25 at 12:39 P.M. with the husband of Resident #15 revealed he didn't feel the resident was being changed in a timely manner. When he visited, he would put his finger in the resident's brief to check if she had a bowel movement. He stated sometimes the brief did have a bowel movement in it, and he had concerns the resident may have been sitting in the bowel movement for an extended period of time. A continuous observation was conducted on 05/20/25 from 6:20 A.M. to 10:27 A.M. of Resident #15 who was awake and sitting in her broda chair either in the common area or the unit dining room. At no time during the observation period did a staff member remove the resident from the common area or the dining room to check the resident to see if she needed any incontinence care. Observation and interview on 05/20/25 at 10:27 A.M. with Certified Nursing Assistant (CNA) #603 revealed CNA #603 began to wheel Resident #15 to her room for incontinence care and left the resident in the room and stated she would be back with the other CNA. CNA #603 verified she had not previously provided incontinence care to Resident #15 that morning. Observation of incontinence care on 05/20/25 from 10:36 A.M. to 10:53 A.M. revealed Resident #15 was cleaned by CNA #528 for a moderate amount of urine and medium sized brown stool. The brief was wet but not oversaturated at the time of observation. Observation of the bilateral groin area that would be covered by an incontinence brief revealed Resident #15's skin in the surrounding areas was dark pink to light red with no excoriation or open areas noted. A clean brief was applied and Resident #15 was transferred back into her chair at 10:53 A.M. CNA #528 offered no information about when the resident had last been checked and changed for incontinence care. CNA #528 verified Resident #15 had been incontinent of stool and urine and skin in the groin area covered by the dirty brief was brighter pink than the rest of her skin. CNA #528 confirmed residents who were incontinent should be checked and changed every two hours, but there were times when she couldn't complete incontinence care within two hours. Interview on 05/20/25 at 3:57 P.M. with Administrator revealed the facility did not have a policy on how often care was to be given to a resident. She stated the staff knew residents should be checked every two hours or as needed for care needs. Review of the policy titled Skin: Incontinence Care Protocol last revised September 2017 revealed the facility would provide incontinence care for residents in order to maintain skin integrity, prevent skin breakdown, control odor, provide comfort, and to maintain resident self-esteem. 48567 3. Review of the medical record for Resident #48 revealed an admitted [DATE] with diagnoses including calculus of kidney, acute respiratory failure with hypoxia, abnormalities of gait and mobility, oropharyngeal dysphagia, low back pain, cholelithiasis, acute kidney failure, calculus of kidney, anxiety disorder, recurrent major depressive disorder, and muscle weakness. Review of the annual minimum data set (MDS) 3.0 assessment completed on 03/04/25 revealed Resident #48 had moderate cognitive impairment, required moderate assistance rolling left and right in bed, and was dependent for toileting hygiene and transfers. Further review of the MDS revealed Resident #48 was frequently incontinent of bladder and bowel. Review of the care plan dated 05/03/21 through 06/19/25 revealed Resident #48 had an alteration in elimination, was high risk for altered skin integrity, and had a self-care deficit in the performance of activities of daily living (ADLs) related to bowel and bladder incontinence, malnutrition, kidney failure, fragile skin, and impaired mobility. Interventions included keeping Resident #48 clean and dry, providing incontinence care as needed, keeping linen as dry and wrinkle-free as possible, and implementation of the check and change protocol. On 05/18/25 at 2:17 P.M., Resident #48 was heard yelling out for assistance. Interview with Resident #48 at that time revealed she was dripping urine which caused burning and itching on the side of the right leg/hip. Resident #48 further reported that staff were previously alerted of the need for a brief and bedding change, that the assigned aide said she would return with clean sheets but never came back, and Resident #48 could not reach the call light to request assistance again. Interview with Certified Nurse Aide (CNA) #547 on 05/18/25 at 2:20 P.M. confirmed CNA #595 was assigned to Resident #48 but was currently on a break. CNA #547 offered to assist Resident #48 with requested incontinence care. Observation on 05/18/25 between 2:20 P.M. and 2:34 P.M. of incontinence care performed by CNA #547 revealed Resident #48 had a wet brief and wet bedding. Interview on 05/18/25 at 2:34 P.M. with Certified Nurse Aide (CNA) #547 confirmed Resident #48 was laying on wet linen and the call light was not within reach. Interview on 05/20/25 at 11:00 A.M. with CNA #528 confirmed that incontinent residents should be checked and changed every two hours. Interview on 05/20/25 at 3:57 P.M. with the Administrator revealed the facility did not have a policy on how often care was to be given to a resident who was dependent for ADL assistance, including toileting hygiene. During the interview, the Administrator confirmed the staff knew residents should be checked every two hours or as needed for care needs. Interviews on 05/21/25 at 9:18 A.M. with CNA# 606, at 9:33 A.M. with CNA #600, at 9:35 A.M. with CNA #603, and at 9:42 A.M. with CNA #601 confirmed residents who were incontinent and dependent on staff for care were to be checked and changed every two hours and as needed. Interview on 05/21/25 with CNA #595 at 9:52 A.M. confirmed Resident #48 was one of the residents on her assignment on 05/18/25 and that when CNA #595 came on duty at 10:00 A.M. on 05/18/25 Resident #48 was noted to have a saturated brief that soaked through to her bedding and Resident #48 had a complete bedding change somewhere between 10:00 A.M. and 11:00 A.M. CNA #595 confirmed a check and change was not completed by them again, but CNA #547 did check and change Resident #48 later that afternoon. Review of the policy titled Skin: Incontinence Care Protocol last revised September 2017 revealed the facility would provide incontinence care for residents in order to maintain skin integrity, prevent skin breakdown, control odor, provide comfort, and to maintain resident self-esteem.

Based on record review, interview, and review of facility policy, the facility failed to ensure weekly weights were obtained as a documented intervention to monitor nutrition status for Resident #50 who had a significant weight loss. This affected one resident (#50) out of three residents reviewed for nutrition. The facility census was 71. Findings include: Review of the medical record for Resident #50 revealed an admitted [DATE]. Diagnoses included Alzheimer's disease, dysphagia (difficulty swallowing), insomnia, diabetes mellitus, and anxiety disorder. Review of Resident #50's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 05/03/25, revealed the resident was severely impaired cognitively, exhibited fluctuating inattention, disorganized thinking, and altered level of consciousness behaviors, was delusional, had behaviors not directed toward others four to six days and rejected care one to three days during the assessment reference period, was supervision or touch assistance for eating, had a significant weight loss which was not prescribed, and was on a therapeutic and mechanically altered diet. Review of the dietary assessment narrative, authored by Dietetic Technician Registered (DTR)#751 and dated 05/02/25, revealed Resident #50's current weight of 169.7 pounds had triggered a significant weight loss of 10.4 percent weight loss over 180 days. Review of the facility document Doctor Notification of Weight Change, authored by DTR #751 and dated 05/05/25, revealed the physician had been notified of Resident #50's significant loss of 19.7 pounds (10.4 percent) over the past six months and the facility was going to monitor weights weekly for four weeks, which the physician agreed with on 05/05/25. Further review of Resident #50's weights in the medical record revealed the resident's last weight was 169.7 pounds on 05/01/25 with no additional weights recorded after 05/01/25. Interview on 05/20/25 between 1:32 P.M. and 3:08 P.M. with DTR #751 revealed she had initiated weekly weights for Resident #50 as an intervention for the resident's significant weight loss and confirmed the weekly weights had not been obtained for Resident #50. Review of the facility policy Weight Monitoring, dated 02/15/24, revealed interventions would be implemented, monitored, and modified (as appropriate) consistent with the resident's assessed needs, and weights would be monitored more frequently as clinically indicated.

Based on observation, interview and record review, the facility did not ensure Resident #33 received dialysis services consistent with professional standards of practice and the person-centered care plan. This affected one resident (#33) of one resident reviewed for dialysis. The facility identified one resident (#33) as receiving dialysis services. The facility census was 71. Findings include: Review of the medical record for Resident #33 revealed a readmitted [DATE] with diagnoses including stage four chronic kidney disease and dependence on renal dialysis. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment completed on 05/01/25 revealed Resident #33 had intact cognition and medically complex conditions including renal insufficiency or renal failure. Further review of the MDS revealed Resident #33 received dialysis. Review of the physician orders revealed an order dated 08/07/24 indicating Resident #33 was to have no intravenous (IV) catheters, lab draws, or blood pressure (BP) checks in the right arm. There was no order to routinely assess Resident #33's right arm dialysis fistula graft for patency and adequate blood flow by checking for a thrill (a vibration) or a bruit (a swishing sound). Review of the care plan, date initiated 06/22/20, revealed Resident #33 received dialysis at an off-site facility every Monday, Wednesday, and Friday. Interventions included: if fistula, check thrill and bruit every shift, if no thrill and bruit notify dialysis center, and no labs draws, intravenous (IV) or blood pressure (BP) in the left arm. Review of the May 2025 Medication Administration Record (MAR) and the Treatment Administration Record (TAR) revealed no evidence nursing staff were assessing the dialysis fistula for a thrill or bruit for Resident #33. The TAR indicated lab draws, IV and BP were not to be performed on Resident #33's right arm. Review of the facility documents titled Dialysis Communication Form for the date range of 05/02/25 to 05/19/25 revealed no evidence the facility was assessing Resident #33's fistula for patency, bruit and thrill. An observation and interview was conducted on 05/18/25 at 4:45 P.M. with Resident #33 who presented as alert, oriented and able to answer questions. Resident #33 had a dialysis fistula in her upper right arm. Resident #33 stated she had the fistula in her right arm for a long time and just had another revision with a graft on 05/15/25. When asked if the nursing staff assessed her before dialysis, Resident #33 stated they weigh her and check her blood pressure. Resident #33 did not indicate her dialysis fistula was checked for patency prior to going to dialysis. An interview on 05/21/25 at 10:02 A.M. with Registered Nurse (RN) #503 was conducted to review the facility dialysis communication forms for Resident #33. RN #503 stated Resident #33's weight was obtained and recorded in the electronic medical record and on the top portion of the dialysis communication form prior to Resident #33 going to dialysis. RN #503 stated the dialysis center did a pre and post dialysis assessment and sent any pertinent information back to the facility on that same communication form which was kept in a dialysis binder at the facility. RN #503 confirmed assessment of the fistula was not included in Resident #33's assessment records so there was no evidence it had been assessed every shift as care planned. Interview on 05/21/25 at 5:15 P.M. with the Director of Nursing (DON) confirmed the care plan for Resident #33 did not specify the correct information regarding from which arm to check blood pressures, perform lab draws, or place IVs and that the care plan specified staff were to monitor the fistula for a bruit and a thrill every shift. The DON confirmed there was no documentation in the medical record that the fistula was being assessed each shift in accordance with the care plan. Review of the policy titled Dialysis Management dated 10/11/18 revealed the facility would provide appropriate interventions for residents receiving hemodialysis based on physician orders and the plan of care, including which arm to use for blood pressure monitoring and appropriate assessment of the access site.

Based on observation, record review, interview and review of facility policy, the facility failed to ensure medications for Resident #233 remained under the direct observation of the nurse administering the medication until ingested by Resident #233. This affected one resident (Resident #233) of eight residents observed for medication administration. The facility census was 71. Findings include: Review of the medical record for Resident #233 revealed an admitted [DATE] with diagnoses including esophageal obstruction, gastrostomy status, acute pyelonephritis, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left dominant side, duodenal ulcer, sepsis due to enterococcus, fibromyalgia, colostomy status, essential hypertension, and dysphagia. Review of the admission Minimum Data Set (MDS) 3.0 assessment completed on 05/09/25 revealed Resident #233 had intact cognition, medically complex conditions, and a feeding tube. Review of the active physician orders for Resident #233 revealed medication orders dated 05/16/25 for aspirin chewable tablet 81 milligrams (mg) by mouth once daily and losartan potassium oral tablet,25 mg daily. An order was dated 05/19/25 for Prevacid delayed release capsule 30 mg by mouth twice daily, and an order dated 05/20/25 for gabapentin 800 mg by mouth daily. Review of the Medication Administration Record (MAR) for May 2025 revealed documentation that on 05/20/25 the 81 mg aspirin, 800mg of gabapentin, 25 mg of losartan, and 30 mg of Prevacid had been administered by Registered Nurse (RN) #602. An observation was conducted on 05/20/25 from 9:28 A.M. to 9:35 A.M. in Resident #233's room with Resident #233 and their spouse present in the room. Resident #233's spouse picked up a medicine cup containing one capsule and three tables and said the medication had been left by the nurse (RN #602) about 15 minutes earlier because the resident and spouse were on their way out for a walk. Observation at this time revealed Resident #233's spouse proceeded to pick up each pill and administer the pills one at a time to Resident #233. An interview on 05/20/25 at 9:51 A.M. with RN #602 confirmed the medications were left in Resident #233's room, including aspirin, gabapentin, losartan, and Prevacid because Resident #233's spouse directed her to leave the medications and assured her Resident #233 would take them upon returning to the room. During the interview, RN #602 confirmed it was not the standard procedure to leave medication in a resident's room, and she should have taken the medications back to the medication cart and returned with them later so she could watch Resident #233 consume the medicines. An interview with the Director of Nursing (DON) on 05/20/25 at 10:13 A.M. revealed the DON verified prepared medications should not be left in resident's rooms. Review of the policy titled General Guidelines for Medication Administration effective 06/21/17 revealed nursing staff were to administer the ordered medication and remain with the resident while the medication was being swallowed. The policy further revealed medications were never to be left in a resident's room without orders to do so.

Based on record review and interview, the facility failed to develop a comprehensive care plan to identify triggers and effective interventions related to a diagnosis of Post-Traumatic Stress Disorder (PTSD) for Resident #36. This affected one resident (#36) of 21 residents reviewed for care plans. The facility census was 71. Findings include: Review of the medical record revealed Resident #36 was admitted to the facility on [DATE] with a diagnosis of PTSD. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #36 was severely impaired cognitively, exhibited inattention and disorganized thinking behaviors, and had rejected care. Review of the care plan, date revised 02/28/24, revealed PTSD was identified as a diagnosis for Resident #36 but there was no part of the care plan developed to identify triggers and interventions for the PTSD. Review of progress notes dated 10/18/24 to 05/20/25 in the medical record revealed Resident #36 had a history of being combative with staff. Interview with Social Services Designee (SSD) #581 on 05/21/25 at 9:39 A.M. confirmed a comprehensive care plan to identify and address PTSD triggers and interventions was absent from Resident #36's medical record. Review of the facility policy Care Conferences, revised 03/20/24, revealed the facility's interdisciplinary team shall periodically review the resident's care plan and make necessary revisions based on the goals, preferences and needs of the resident.

Based on observations, interview and policy review, the facility failed to ensure the kitchen and unit pantries were maintained in a clean and sanitary manner and ensure staff serving food wore hair restraints. This had the potential to affect 68 out of 69 residents that received meals from the facility. Resident #46 was identified as receiving nothing by mouth. The facility census was 69. Findings include: Tour of the kitchen on 08/07/23 at 8:25 A.M. with Dietary Manager (DM) #100 revealed liquid spilled on the bottom of the reach-in refrigerator located near the cooking area; the bakers rack had dried food on the shelves, and the walls near the cooking area and dish area had food splatter on them. Observation in the pantry located on 100 unit on 08/07/23 at 8:34 A.M. with DM #100 revealed a dietary aide serving breakfast without wearing a hair restraint and dried food splatter in the inside of the microwave. DM #100 verified the observations and stated that the microwave should have been cleaned. Observation in the pantry located on 300 unit on 08/07/23 at 8:40 A.M. with DM #100 revealed dried food splatter in the inside the microwave. DM #100 verified findings and stated the microwave should have been cleaned. Observation in the pantry located on the second floor on 08/07/23 at 8:50 A.M. with DM #100 revealed dried food splatter in the inside the microwave. DM #100 verified findings and stated the microwave should have been cleaned. Review of the facility policy dated March 2016 titled, Infection Control- Dietary/Food Handling, revealed the kitchen should be cleaned, and employees should wear hairnets.

Based on record review and interviews the facility failed to ensure fall interventions were in place as ordered/planned to prevent further falls for Resident #74. This affected one of three residents reviewed for falls. Findings include: Review of the medical record revealed Resident #74 was admitted to the facility on [DATE] with the diagnoses including metabolic [CONDITION(S)], [CONDITION(S)], diabetes, [CONDITION(S)], rhabdomyolysis, weakness, dementia, congestive heart failure, [CONDITION(S)], [CONDITION(S)] and major depressive disorder. Review of the fall risk assessment on admission, dated 05/29/21, revealed Resident #74 was at high risk for falls. Review of the admission Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #74 had moderately impaired cognition, required extensive assistance from staff for bed mobility, toilet use, extensive assistance of one staff for transfers, personal hygiene, and was totally dependent on two staff for transfers. Review of the fall investigation dated 07/12/21 at 3:35 A.M. revealed Resident #74 had fallen out of bed. The resident was found on the left side of the bed on his left side. Resident #74 was assessed and had a small red mark on the right side of his forehead, a linear abrasion measuring four inches on the left temple area with a bruise-like discoloration and ice was applied. The family and physician were updated and neurological checks were started. The investigation indicated the suspected cause of the fall was Resident #74 was repositioning himself in bed and fell out of bed. Resident #74 had scooted to low in the bed to use the grab bar to assist with repositioning. The new intervention to prevent further falls was to remove the left side grab bar and replace it with a half siderail. Review of the progress notes dated 07/12/21 at 5:34 A.M. revealed staff responded to the call light and found Resident #74 on the floor on the left side of his bed on his left side and the grab bar was in the down position. The resident had a small red mark on the right side of his forehead. A linear abrasion approximately four inches was noted in his hair near the left temple area. His skin was intact. A hematoma (a collection or pooling of blood under the skin) was also noted, and ice was applied, the fall protocol was initiated. The new intervention was to place a half side rail on the left side of the bed. The certified nurse practitioner (CNP) and Resident #74's Power of Attorney were notified. Review of the physician's orders revealed Resident #74 had an order dated 07/12/21 for a side rail to the left side of the bed for repositioning every shift. Review of the maintenance slip dated 07/12/21 revealed they were to add a side rail to left side of the bed, however there were large letters written in black marker which said, ? RM #, (questioning the room number). There was no name to indicate who filled out the maintenance slip or which resident was to have a side rail placed on their bed. Review of the progress note dated 07/14/21 at 1:20 P.M. revealed Resident #74 was helped back to bed, neurological checks were started, and he had no complaints of pain. The CNP and Resident #74's son were contacted. Review of the fall investigation dated 07/14/21 at 1:20 P.M. revealed Resident #74 was found in his room, lying on the floor on his left side next to the closet/bathroom. Resident #74 was tangled in the sheets with his call light attached to his gown. He had no complaints of pain, neurological checks were normal, no injuries were noted and his son and the CNP were notified. Resident #74's water from his bedside table was spilled on the floor. The investigation indicated the suspected cause of Resident #74's fall was he attempted to get out of the bed without assistance. The new interventions were for staff to give frequent reminders to ask for assistance and to not attempt to self-transfer. Review of the handwritten witness statement from Licensed Practical Nurse (LPN) #105 dated 07/14/21 at 1:20 P.M. revealed the Stated tested Nursing Assistant (STNA) informed the nurse Resident #74 was on the floor. The nurse went to the room and Resident #74 was lying on the floor closest to the bathroom door, lying on his left side. The resident was tangled in his sheet and his call light was attached to his gown but was not activated. Resident #74 denied pain and the STNA and nurse assisted the resident back into bed via the Hoyer (mechanical) lift. Neurological checks were started and the CNP and son were notified. LPN #105 indicated the incident was discussed with the Director of Nursing for a new intervention and decided that the grab bar on that side of the bed needed to be tightened. LPN #105 indicated the side/grab bar was loose due to the cords being wrapped around the base of it. The staff placed a floor mat on the that side of the bed until the grab bar was fixed. Interview on 11/10/21 at 10:30 A.M. Family Member #110 indicated he was on his way to the facility when the facility called him and told him Resident #74 had fallen out of bed. He stated when he got there the receptionist said she was so sorry this happened because they were supposed to fix the side rail when he fell the first time. He stated he asked her what had happened the first time and she indicated he had done the same thing, rolled out of bed and the siderail came down. Family Member #110 indicated they never notified him of the prior fall. He indicated he was told happen the side rail would not stay in the upright position and when his father would roll over to reach for the call light the side rail would collapse. He stated he had questioned them on sending his father out to the hospital due to him just having a history of a seven-vertebra surgical fusion, but facility indicated he had been checked out by the nurse and doctor and he did not need to be sent out to the hospital. Family Member #110 said a month later he had a follow up appointment for his surgery, and the x-ray showed he has a cracked titanium screw and three loose screws as a result of one of the falls. Family Member #110 said they knew about the side rail, but they did not fix the side rail. He indicated he went to the facility on [DATE] and hunted down the maintenance director and watched as he replaced the side rail and he tested it himself to make sure it was working properly. Interview on 11/10/21 at 11:28 A.M. with Maintenance Director #102 indicated there was a book at each of the nurse's station for the staff to write down any issues or they would just tell him. He indicated the staff would fill out the slip in the book. He indicated he would look at the book, fix anything that needed fixed and initial the slip when it was completed. He indicated it usually only took a day or two to fix something unless he had to order a part. He indicated he had seen the slip in the 300-hall book for the siderail to the left of bed, but he did not know who it was for because it did not have a room number on it. He stated he wrote on the slip asking what room number it was. He stated he found out which resident it was and fixed it. Interview on 11/15/21 at 12:20 P.M. with LPN #105 indicated Resident #74 had an unwitnessed fall on 07/14/21 and when she went into the room, he was laying on the floor and his bed was turned around. The aides were already in the room when she got there, and his call light was on. She verified Resident #74 still had a grab bar on his bed and it was a little loose. LPN #105 verified she had written the witness statement the day of the fall and filled out an incident report. Review of the facility policy titled, Fall Management, dated 10/17/16, revealed understanding the significance of mobility, movement, and the ingrained nature of walking, it was the facility's intention to promote programs geared to improving mobility, stamina, and reduced the risk of falls through a comprehensive, interdisciplinary process of assessment, care plan development and implementation with ongoing monitoring and review. Each resident would be assessed throughout the course of treatment for different parameters such as: cognition, safety awareness, fall history, mobility, medications, or predisposing health conditions that may contribute to fall risk. An interdisciplinary plan of care would be developed, implemented, reviewed, and updated as necessary to reflect each resident's current safety needs and fall reduction interventions. The interdisciplinary team would attempt to balance safety needs, resident rights, and quality of life issues that would positively impact each resident's individual situation and reduce the risk of occurrence. This deficiency substantiates Complaint Number OH 275.

Based on record review, interview and policy review, the facility failed to ensure medications were transcribed to the resident's medical record from hospital paperwork for Resident #323 and failed to ensure medications were administered according to the physician's order for Resident #72. This affected two residents (Resident #72 and Resident #323) of seven (Resident's (#18, #42, #49, #62, #72, 173 and #323) reviewed for unnecessary medication. The facility census was 75. Findings include: 1. Review of the medical record revealed Resident #323 was admitted to the facility on [DATE]. Her admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had moderate cognitive impairment. Functionally, she required extensive assistance of one staff for most activities of daily living including toilet use and personal hygiene. Review of the resident's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] · [MEDICATION(S)] (a medication to reduce the risk of stroke and blood clots in people who have [CONDITION(S)]) 2.5 milligrams (mg) by mouth twice daily · [MEDICATION(S)] (treats cancer by stopping the growth of cancer cells) 500 mg one capsule by mouth to be given two times a day. Review of the facility's physician orders in the facility, showed [MEDICATION(S)] 2.5 mg to be given two times a day but the [MEDICATION(S)] order was not listed. Review of the residents Medication Administration Record (MAR) for the month of May 2021 revealed the resident did receive the [MEDICATION(S)] as ordered but did not receive her [MEDICATION(S)]. Further review of this MAR revealed this medication was not listed on the MAR. Interview on 06/16/21 at 1:50 P.M. with the Director of Nursing and Regional Clinical Services Manager #174 verified the MAR and stated that there was no policy stating that what a nurse should do for an admission, it is standards of nursing practice. Phone interview with this resident's physician, Physician #180 on 06/16/21 at 3:56 P.M. revealed the resident was on [MEDICATION(S)]. He then stated, probably discontinued the [MEDICATION(S)] because her labs were good. Review of the physician's orders from admission to present revealed no order verbal or written to stop the [MEDICATION(S)]. 2. Review of Resident #72's medical record revealed an admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an admission/5-day MDS 3.0 assessment dated [DATE] revealed Resident #72 had moderate cognitive impairment, was totally dependent for transfers, required extensive assistance of two staff for bed mobility and required extensive assistance of one staff for hygiene. Resident #72 was on a scheduled pain regimen, and the pain assessment in the MDS indicated Resident #72 had frequent pain and described his worst pain as severe. Review of Resident #72's physician's orders revealed an order dated 05/30/21 for [MEDICATION(S)] tablet 200 milligram (mg), give one tablet by mouth two times a day for pain and an order dated 06/01/21 for [MEDICATION(S)] tablet 50 mg, give one tablet by mouth every six hours as needed (PRN) for pain greater than a six out of ten. Review of Resident #72's May 2021 and June 2021 MARs revealed [MEDICATION(S)] was not documented as administered during the rise time (7:00 A.M. to 10:00 A.M) on 06/04/21, 06/07/21, 06/08/21, 06/09/21 and 06/14/21. Review of the nurses' notes revealed no concerns regarding Resident #72's pain and did not show any medication refusals. Interview on 06/16/21 at 1:35 P.M. with Regional Clinical Services Manager (RCSM) #174 verified the lack of [MEDICATION(S)] for Resident #72 on 06/04/21, 06/07/21, 06/08/21, 06/09/21 and 06/14/21 and could not explain why these doses were not administered and/or documented. Review of the facility policy titled Documentation: Charting, revised 09/16/19, revealed team members shall document assessments, observations and services provided in the resident's medical record in accordance with state law and facility policy. Documentation may be completed at the time of service or during the shift in which the assessment, observation or care service occurred. This deficiency substantiates Complaint Number OH 894.

Based on record review, observation and interview, the facility failed to ensure infection control was maintained during the wound care observation of Resident #28. This affected one (Resident #28) of ten (Resident's #11, #13, #28, #32, #62, #66, #68, #71, #72 and #325) residents reviewed for pressure wounds who received wound care. The facility census was 76. Findings include: Record review revealed Resident #28 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #28 had moderately impaired cognition. A skin grid dated 06/15/21 revealed Resident #28 developed an in-facility acquired coccyx wound that progressed to an unstageable pressure ulcer (full-thickness tissue loss that is covered by necrotic tissue). A dietary note dated 06/16/21 revealed a decline in the pressure ulcer was noted, and Resident #28 went on hospice services. Observation on 06/15/21 at 3:50 P.M. of the dressing change on Resident #28 by Registered Nurse (RN) #148 revealed supplies were gathered (except for the foam outer dressing) and placed on a barrier on the bedside table. The table was not disinfected prior to or after the dressing change. RN #148 washed her hands, applied gloves and cleansed the wound. RN #148 the was given a foam outer dressing from Resident #28's top dresser drawer by State tested Nursing Assistant (STNA) #171 and opened it. RN #148 then dug in her scrub shirt pocket and pulled out a black marker and initialed and dated the foam dressing then laid it on the bedside table. RN #148 then picked up the medication cup of Santyl medicated ointment (removes dead tissue from wounds), swirled her index finger in the cup, gathering all the medication on her gloved finger and applied it to a piece of calcium alginate (highly absorbent dressing). RN #148 was in motion to place it on the cleansed wound bed when this surveyor stopped her. Interview with RN #148 on 06/15/21 at 3:55 P.M. verified she broke infection control by reaching for a permanent marker from her scrub shirt pocket, opening the foam dressing package that was handed to her by STNA #171 who retrieved it from Resident #28 dresser drawer, wrote on the foam dressing then did not wash her hands or change gloves before continuing with the dressing change.

Based on observation, interview and record review the facility failed to ensure staff washed their hands to prevent cross contamination during incontinence care for Resident #57. This affected one out of three residents reviewed for incontinence care. Findings include: Resident #57 was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #57's clinical record revealed a Minimum Data Set (MDS) assessment dated [DATE] which indicated Resident #57 was frequently incontinent of bowel and had a suprapubic catheter (a drainage tube inserted through the lower abdominal wall into the bladder to allow urine to drain into a collection bag). The assessment indicated there was no pattern to the bowel incontinence and Resident #57 was not on a scheduled toileting program. Resident #57's current plan of care, initiated upon admission, had a plan to address her bowel incontinence with individualized interventions implemented. Resident #57's current plan of care indicated Resident #57 had frequent urinary tract infections (UTI's) infections related to chronic disease, suprapubic catheter, history of multiple UTIs with colonized extended spectrum beta-lactamases (ESBL), an infectious bacteria resistant to antibiotics. Review of Resident #57's urology physician progress notes [REDACTED]. An interview with Resident #57 on 01/06/20 at 9:25 [NAME]M. indicated she was admitted four years ago to the facility due to her inability to care for herself at her apartment. Resident #57 indicated she needed two staff members to assist her with her bowel incontinence. She said staff didn't clean her perineal area well enough and the feces entered her vaginal canal causing her to have a yeast infection. An observation of incontinence care was completed on 01/06/20 at 2:18 P.M. for Resident #57, provided by State tested Nurse Aid (STNA) #1 and Licensed Practical Nurse (LPN) #2. STNA #1 used soapy water and cleaned feces from Resident #57's perineal area. After cleaning the feces from the buttock area, without washing her hands or changing her gloves, STNA #1 reached in Resident #57's bedside drawer to obtain moisture barrier cream. Resident #57's bedside drawer contained personal items in addition to the moisture barrier cream. STNA #1 applied the moisture barrier cream to her buttocks and perineal area and then placed the cream back in the drawer with the same gloved hands. STNA #1 and LPN #2 assisted Resident #57 with rolling onto her back to clean the front groin area. While waiting for additional linens being brought in by another staff member, STNA #1 walked in to the bathroom and opened the vanity drawer and obtained a washcloth without removing the soiled gloves. STNA #1 touched various surfaces in Resident #57's room with her soiled gloved hands. After cleaning Resident #57's front groin and labial area she removed her gloves and donned a clean pair of gloves, but without washing her hands. Resident #57's groin area skin was red and excoriated. Resident #57 complained of burning in her labial folds. STNA #1 applied an antifungal cream to the groin area and indicated she would notify the LPN assigned to care for Resident #57. Immediately following the observation on 01/06/20 at 2:18 P.M., STNA #1 verified she touched various objects in the resident's room and bathroom while wearing the same soiled gloves used to clean the resident of feces and failed to wash her hands when changing gloves. The facility policy and procedure titled, Hand Hygiene, revised 11/17/17, indicated hand hygiene would be properly performed to assist in prevention of spreading infections. Staff were to perform hand hygiene before and after contact with a resident, after contact with blood or body fluids, after removal of personal protective equipment and before performing a procedure. This deficiency substantiates Complaint Number OH 063.

Based on observation, interview and record review, the facility failed to ensure staff was available to meet the needs of the residents in a timely manner. This affected nine residents (Resident #21, #10, #18, #25, #30, #32, #52, #64 and #222) but had the potential to affect all residents residing in the facility. The census was 71. Findings include: 1. Resident #21 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) 3.0 assessment, dated 01/02/19, revealed Resident #21 required extensive assistance with activities of daily living including hygiene, toileting, mobility, and eating. Resident #21 was incontinent of bowel and bladder. Review of an Interdisciplinary Plan of Care, dated 01/31/19, revealed the resident's Power of Attorney (POA) expressed a concern that two nurse aides on the secured memory impaired unit, were not enough staff to meet the needs of the residents. An interview was completed with the POA on 02/25/19 at 1:24 P.M. The POA verified the concern had not been resolved. The resident's POA revealed the nurse and two nurse aides were consistently answering call lights, feeding residents, providing hygiene needs and all the other care and services required. However, there were usually 20 to 25 residents living on the unit. The residents required a high level of care and supervision. The POA revealed she frequently found her mother incontinent of urine at the time of her visits. In addition, meals arrived hot but by the time everyone was fed, the meal had cooled. Resident #21 has had several falls. The POA believed some of the falls could have been prevented if the facility was able to respond quicker. 2. The Resident Council Task was completed 02/26/19 at 3:15 P.M. Seven residents attended the meeting. These residents included the Resident Council President, Resident #64, as well as, the former Resident Council President, Resident #52. Residents #64, #52 and #10 revealed each resident unit had two nurse aides per shift. Resident #64, #52 and #10 revealed two aides were not enough staff to meet their needs. Residents #18, #25, #30 and #32 nodded in agreement. Seven of seven residents verified they had voiced their concerns to the Administrator on several occasions but the problem continued. Resident #64 revealed the call light response is often 15 or 20 minutes. At times, the nurse aides answer the call light, turn it off and never come back to meet their needs. Resident #64 described the staff as, they are caring, considerate, hard working, but just to busy. Resident #64 gave an example as, Last night I woke up in the middle of the night and wanted to take a sip of water. There's no water in my cup. Resident #64 explained that frequently, the less important things get missed. Evening snacks might not be passed. Resident #64 stated, Staffing is the biggest problem. If there were more aides or nurses, the problems would be resolved. The remaining residents in attendance called out, or nodded in agreement. 3. Resident #222 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #222's MDS 3.0 assessment was still in progress due to her recent admission. Review of a nurses' note dated 02/24/19 revealed Resident #222 was not cognitively impaired and required the assistance of one staff for transfers, bed mobility and toileting. Interview with Resident #222 on 02/25/19 starting at 11:00 A.M. revealed her meal tray had been sitting on her over-bed tray since 9:00 A.M. that morning. Resident #222 stated she needed to use the bathroom and required staff assistance to do so and so hit her call light for help. Resident #222 complained it was hard to find someone when she needed help at the facility. Observation of Resident #222's call light on 02/25/19 starting at 11:00 A.M. revealed no staff response during the resident interview. A podiatry aide entered the room at 11:20 A.M. but did not assist Resident #222. The surveyor left the room to continue observing Resident #222's call light from a bench two doors down from the resident's room. Staff did not address Resident #222's call light until 11:25 A.M. at which time the door was closed for the provision of care.

Based on interview and record review, the facility failed to ensure residents were aware of a grievance committee, and the process to file a formal grievance when concerns and/or complaints were not resolved. This affected seven of seven residents attending a Resident Council meeting, Residents #10, #18, #25, #30, #32, #52 and #64. The facility census was 71. Findings include: The Resident Council Task was completed 02/26/19 at 3:15 P.M. Seven residents attended the meeting. These residents included the Resident Council President, Resident #64, as well as, the former Resident Council President, Resident #52. Resident #64, #52 and #10 revealed each resident unit had two nurse aides per shift. Resident #64, #52 and #10 revealed two aides were not enough staff to meet their needs. Residents #18, #25, #30 and #32 nodded in agreement. Seven of seven residents verified they had voiced their concerns to the Administrator on several occasions but the problem continued. Seven of seven residents were asked if they had considered filing a formal grievance. Seven of seven residents were not aware of a Grievance Committee, the members of the Grievance Committee, the purpose of the Grievance Committee or the process to file a grievance. The facility postings were observed in the main entrance area. These included identifying the members of the Grievance Committee as the Administrator, the Director of Nursing (DON) and the Social Service Designee (SSD). An interview with the Administrator at the time of the observation, verified there was no resident or resident representative on the committee.

Based on observation, menu review and interview, the facility failed to ensure kitchen staff followed the menu spreadsheets during meal service. This affected 35 residents residing on the 100 and 200 units (Residents #1, 2, 3, 5, 6, 10, 11, 14, 15, 16, 18, 21, 22, 23, 24, 26, 30, 34, 36, 37, 40, 42, 43, 44, 55, 59, 61, 63, 65, 67, 68, 74, 171, 221 and 222). The facility census was 71. Findings include: Review of the menu spreadsheet titled Week 2, Day 2 which correlated to 02/26/19 revealed residents on regular diets were to receive eight ounces of beef chili, four ounces of coleslaw, one cornbread muffin and a 3 inch by x2 inch portion of cobbler. Eight ounces of beef chili was the designated portion for residents also receiving pureed, mechanical soft and low concentrated sweets diets. Observation of the dinner meal with Food Service Director (FSD) #403 on 02/26/19 starting at 4:43 P.M. revealed staff on the 100 and 200 units were using a teal spoodle (portion control serving spoon) to serve the beef chili. Interview during the observation on 02/26/19 at 4:53 P.M. with FSD #403 revealed the teal spoodle served six ounces. At 5:10 P.M., FSD #403 verified residents on the 100 and 200 units received six ounces of chili instead of the eight ounces indicated on the menu spreadsheet.

Based on observation, interview and record review, the facility failed to ensure a well-maintained and home-like environment. This affected seven (Resident #2, Resident #9, Resident #14, Resident #18, Resident #27, Resident #28 and Resident #68) of 21 residents on the 100 unit. The facility census was 71. Findings include: Observation of resident rooms on the 100 unit during an environmental tour on 02/28/19 from 9:09 A.M. to 9:30 A.M. with the Administrator revealed the following areas of concern: · Resident #9 had a three foot gouge in the wall at eye level above her in room refrigerator. · Resident #27 had a six-inch area of metal corner guard exposed on the bottom corner of the room closest to the bathroom with drywall pieces on the floor. · Resident #14 had two, two-inch circular punctures in the wall to the left of his dresser. · Resident #18 had five areas varying from one to two inches in length on the base of the front wall left of the entry door with the paint chipped away. · Resident #2 had a corner in the room with three to four inches of metal exposed. · Resident #28 had paint chipping off the corner of the room to the right of her bathroom about one foot long and the vinyl floor trim was peeling away from the base of the floor. · Resident #68 had damage to corner tile trim to the left of the bathroom where the tile had eroded away and chipped. Interview with the Administrator at the time of the above observations revealed the facility was always patching hoyer lift rooms. Interview on 02/28/19 at 9:18 A.M. with Resident #14 during the observation revealed the punctures in the wall were from his wheelchair handles and he had told staff a while ago regarding the need for wall repair. Observational tour and interview with Maintenance Director #402 starting on 02/28/19 at 10:15 A.M. revealed staff were to log any repairs needed in the book on the unit. Maintenance Director #402 stated he was not aware of Resident #9's wall gouge but did share the gouge was from the resident's recliner which had been moved to the opposite wall of her room at least two weeks ago. Maintenance Director #402 stated Resident #27's room corner damage should have been logged by staff and addressed immediately. Maintenance Director #402 stated he did environmental rounds but no formal documentation of these rounds was available for review by the surveyor. Maintenance Director #402 verified he had not been made aware of the above observations and concerns until the environmental tour with the surveyor. Review of the 100 unit's Maintenance Request Book from 01/09/18 through 02/22/19 revealed only one related entry; on 04/01/18, Resident #14's room had holes in the drywall made by the resident's wheelchair. The book had no further evidence for any of the repairs needed for the rooms of Resident #2, Resident #9, Resident #18, Resident #27, Resident #28 and Resident #68. A follow-up interview on 02/28/19 at 11:09 A.M. with the Administrator revealed he felt two weeks was a reasonable timeframe to repair the wall in Resident #9's room. When asked about Resident #14's room and the maintenance log book, the Administrator provided the surveyor with an observation dated 02/07/19 stating the room lacked areas of concern. The Administrator stated Resident #14's wall must have been re-damaged since the provided observation. The Administrator also stated many maintenance requests were text-messaged to Maintenance Director #402. There was no additional evidence available regarding any repeated damage to Resident #14's room, completion of previous maintenance work or failure of any prior repairs.

Based on interview and record review, the facility failed to ensure the personal property of Resident #58 was secured to prevent loss. This affected one of twelve residents interviewed for missing items. The facility census was 71. Findings include: Review of the record of Resident #58 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of her most recent Minimum Data Set (MDS) 3.0 assessment, dated 01/28/19, revealed she was moderately cognitively impaired, felt down and depressed with trouble concentrating, and had verbal behaviors at times. She required extensive assistance of one to two staff for her activities of daily living (ADL). Review of a state self-reported incident (SRI), dated 01/23/19, revealed the resident's son stated her necklace was missing. Review of the investigation revealed the resident's son had given her a necklace for Christmas. A statement by a State tested Nursing Assistant (STNA) #400 removed a necklace from the resident's neck when she asked for help and stated she did not want to wear the necklace. STNA #400 indicated she placed the necklace in a cup in the drawer of her night stand, per the resident's request. Review of statement by Registered Nurse (RN) #401 revealed the resident's son came to the facility on [DATE] and asked about his mother's necklace. The necklace could not be found initially, but after the resident's son left, RN #401 found the necklace in the cup in the drawer. She called the resident's son, who said he could be in to pick it up the next day. RN #401 indicated in her statement that she indicated she would secure the necklace a the nurse's station. She indicated when she left that night, at the end of the shift, the necklace was sitting on the counter of the locked medication room, in a folded, taped and labeled yellow paper. Review of the investigation revealed the resident's son did not return to the facility to pick up the necklace until 01/21/19. The necklace could not be found in the medication room. The investigation included statements by seven other nurses who had access to the medication room. Three nurses indicated they had not seen the necklace in the medication room when they worked on their shifts. Four nurses indicated they had seen the necklace in the room. An interview with the facility Administrator on 02/27/19 at 3:45 P.M. revealed the nurse had secured the necklace in a post it note, folded over, secured with tape, and with the resident's son's name written on the outside. He stated she indicated she had put the necklace in the medication room on the counter. He stated only nurses had access to the locked medication room and after realizing the necklace was missing on 01/21/19, the facility began interviewing nursing staff, all of whom denied taking the necklace. He stated staff had also been cleaning the medication room during the weekend (01/19/19 through 01/20/19) and it may have been mistakenly thrown away. He verified the necklace had not been secured in a proper manner to prevent loss. The Administrator stated the facility did not have a policy regarding missing items to guide staff for reporting or searching for items. He indicated he asked RN #401 why she had not secured the necklace in a more secure area, such as the medication cart as part of the investigation, and she indicated she had always been told not to put personal items in the medication cart. He stated the investigation was reported as possible misappropriation but that was not proven, as the facility could not determine that the necklace was taken, versus thrown away mistakenly. An interview with RN #401 on 02/28/19 at 11:15 A.M. verified she had been working on 01/15/19 when the son of Resident #58 had asked about her necklace. She stated staff and the family member had initially been unable to find the necklace, but after he left, the necklace was found in a drawer. She said she called the resident's son to let him know that the necklace had been found and would be kept for him, as he said he would pick it up the next day. She stated she put the necklace in a post it note, indicating a note about three inches by five inches, and folded it in half. She said she secured it with either tape or staples and wrote the name of the resident's son on the outside of the note. She said she leaned it up in the med room where nursing staff would see it. She was asked about securing it in the medication cart, and stated she had been told years ago that personal items should not be stored in the medication cart. She did verify that items such as hearing aides are stored in the cart at times. She said she saw the necklace in the yellow paper note on 02/17/19 and 02/18/19 when she worked but then did not work on 02/19/19 or 02/20/19. She stated she did not see the note when she returned but just thought it had been picked up. An interview with Resident #58 on 02/25/18 at 12:00 P.M. revealed her in her wheelchair, slightly anxious and somewhat confused. She was distrustful of the surveyor and reluctant to answer questions. She stated only that she had lost some clothing items during her stay at the facility. Another interview with the resident on 02/28/19 at 11:20 A.M. revealed her less anxious and more willing to speak with the surveyor. She at first did not remember any other missing items, but when questioned specifically about the missing necklace, she stated oh they looked in my drawer for that. She did not offer any other details about the incident. Review of the facility Abuse policy, dated 11/21/16, revealed misappropriation was defined as the deliberate misplacement, exploitation or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. A follow-up interview with the facility Administrator on 02/28/19 at 1:47 P.M. verified the resident's necklace was discovered as missing on 01/21/19 after it was secured by staff to be returned to the resident's son. He verified the necklace was put in a locked room with access only by nurses, but the necklace had not been located when the resident's son returned for it on 01/21/19. He verified the necklace could only have been taken by staff or thrown away mistakenly as it was secured only in a folded post it note. He verified staff had agreed to secure the item but had not provided a secure chain of possession for the necklace.

Based on interview and record review, the facility failed to ensure possible misappropriation of personal property of Resident #58 was reported to state agency in the required timeframe. This affected one of twelve residents interviewed for missing items. The facility census was 71. Findings include: Review of the record of Resident #58 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of her most recent Minimum Data Set (MDS) 3.0 assessment, dated 01/28/19, revealed she was moderately cognitively impaired, felt down and depressed with trouble concentrating and had verbal behaviors at times. She required extensive assistance of one to two staff for her activities of daily living. Review of a state self-reported incident (SRI), dated 01/23/19, revealed the resident's son stated her necklace was missing. Review of the investigation revealed the resident's son had given her a necklace for Christmas. A statement by a State tested Nursing Assistant (STNA) #400 removed a necklace from the resident's neck when she asked for help and stated she did not want to wear the necklace. STNA #400 indicated she placed the necklace in a cup in the drawer of her night stand, per the resident's request. Review of statement by Registered Nurse (RN) #401 revealed the resident's son came to the facility on [DATE] and asked about his mother's necklace. The necklace could not be found initially, but after the resident's son left, RN #401 found the necklace in the cup in the drawer. She called the resident's son, who said he could be in to pick it up the next day. RN #401 indicated in her statement that she indicated she would secure the necklace a the nurse's station. She indicated when she left that night, at the end of the shift, the necklace was sitting on the counter of the locked medication room, in a folded, taped and labeled yellow paper. Review of the investigation revealed the resident's son did not return to the facility to pick up the necklace until 01/21/19. The necklace could not be found in the medication room. The investigation included statements by seven other nurses who had access to the medication room. Three nurses indicated they had not seen the necklace in the medication room when they worked on their shifts. Four nurses indicated they had seen the necklace in the room. An interview with the facility Administrator on 02/27/19 at 3:45 P.M. revealed the nurse had secured the necklace in a post it note, folded over, secured with tape, and with the resident's son's name written on the outside. He stated she indicated she had put the necklace in the medication room on the counter. He stated only nurses had access to the locked medication room and after realizing the necklace was missing on 01/21/19, the facility began interviewing nursing staff, all of whom denied taking the necklace. He stated staff had also been cleaning the medication room during the weekend (01/19/19 through 01/20/19) and it may have been mistakenly thrown away. He verified the necklace had not been secured in a proper manner to prevent loss. The Administrator stated the facility did not have a policy regarding missing items to guide staff for reporting or searching for items. He indicated he asked RN #401 why she had not secured the necklace in a more secure area, such as the medication cart as part of the investigation, and she indicated she had always been told not to put personal items in the medication cart. He stated the investigation was reported as possible misappropriation but that was not proven, as the facility could not determine that the necklace was taken, versus thrown away mistakenly. An interview with RN #401 on 02/28/19 at 11:15 A.M. verified she had been working on 01/15/19 when the son of Resident #58 had asked about her necklace. She stated staff and the family member had initially been unable to find the necklace, but after he left, the necklace was found in a drawer. She said she called the resident's son to let him know that the necklace had been found and would be kept for him, as he said he would pick it up the next day. She stated she put the necklace in a post it note, indicating a note about 3 inches by 5 inches, and folded it in half. She said she secured it with either tape or staples and wrote the name of the resident's son on the outside of the note. She said she leaned it up in the med room where nursing staff would see it. She was asked about securing it in the medication cart, and stated she had been told years ago that personal items should not be stored in the medication cart. She did verify that items such as hearing aides are stored in the cart at times. She said she saw the necklace in the yellow paper note on 02/17/19 and 02/18/19 when she worked but then did not work on 02/19/19 or 02/20/19. She stated she did not see the note when she returned but just thought it had been picked up. An interview with Resident #58 on 02/25/18 at 12:00 P.M. revealed her in her wheelchair, slightly anxious and somewhat confused. She was distrustful of the surveyor and reluctant to answer questions. She stated only that she had lost some clothing items during her stay at the facility. Another interview with the resident on 02/28/19 at 11:20 A.M. revealed her less anxious and more willing to speak with the surveyor. She at first did not remember any other missing items, but when questioned specifically about the missing necklace, she stated oh they looked in my drawer for that. She did not offer any other details about the incident. Review of the facility Abuse policy, dated 11/21/16, revealed misappropriation was defined as the deliberate misplacement, exploitation or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. Allegations of misappropriation must be reported immediately to the state agency or not later than 24 hours after the allegation was made. A follow-up interview with the facility Administrator on 02/28/19 at 1:47 P.M. verified the resident's necklace was discovered as missing on 01/21/19 after it was secured by staff to be returned to the resident's son. He verified the necklace was put in a locked room with access only by nurses, but the necklace had not been located when the resident's son returned for it on 01/21/19. He verified the necklace could only have been taken by staff or thrown away mistakenly as it was secured only in a folded post it note. He verified staff had agreed to secure the item but had not provided a , secure chain of possession for the necklace and that an investigation was started when the necklace was found to be missing on 01/21/19. He stated the report to the state was not made until 01/23/19 when the resident's son alleged the item was stolen, but verified the facility would have already suspected possible misappropriation on 01/21/19, as one of the only two ways the necklace would have not been found in the medication room.

The facility failed to ensure the staffing level in the facility was adequate to provide Resident #7's wound treatment in a timely manner. This affected one of three residents reviewed for wounds (Resident #7) and had the potential to affect an additional 28 residents residing on the 300 hall (Residents #4, #5, #6, #8, #10, #11, #13, #15, #16, #17, #22, #24, #26, #27, #29, #30, #63, #61, #60, #59, #57, #56, #54, #49, #48, #46, #45, and #39). Findings include: Tour of the facility on 11/01/17 from 12:00 P.M. to 12:45 P.M. revealed there was one licensed nurse and two state tested nursing assistants (STNAs) working on the memory care unit with a census of 21 residents. On the first floor there were two nursing units including the 100 and 300 halls. There was one licensed nurse and two STNAs on each unit with a census of 49 residents. An interview with STNA #4 on 11/01/17 at 12:55 P.M. revealed the staff were rushed when providing care because there was not enough staff to meet the care needs of the residents on the 300 unit. STNA #4 indicated there were seven residents who needed two staff members to transfer with a mechanical lift and one nurse was out on the floor trying to administer residents their medications, answer call lights and address the residents' needs when the two STNAs were busy with those transfers. STNA #4 indicated administrative staff answered call lights but did not provide the assistance the resident requested but informed the direct care staff to perform the assistance the resident requested. An interview with Resident #7 on 11/01/17 at 1:40 P.M. revealed he felt the staffing level in the facility was not adequate to ensure his care needs were met in a timely manner. Resident #7 was in bed with the head of the bed raised and had just finished lunch. Resident #70 was naked and had a sheet covering his body for modesty. Resident #7 said he was waiting for the staff to change his wound dressing. He had a shower earlier in the day and no one had changed his wound dressing. Resident #7 indicated the staff showered him with his wound dressing in place. Resident #7 complained the licensed nurse was slow to change his dressing. Resident #7 indicated he was paralyzed below the waist and needed assistance with repositioning and turning. Resident #7 indicated the staff assisted him with turning side to side intermittently but not every two hours and not consistently. Resident #7 indicated his wound dressing was not routinely changed twice a day as ordered by the physician. Resident #7 said on one occasion his leg had slid over the side of the bed and he was unable to reposition his leg back on the bed and he was afraid he would slide out of bed to the floor. The nurse who was passing medications to the residents was standing beside his open doorway. Resident #7 yelled for assistance but the nurse was intent on passing the medications and didn't respond to his call for assistance. After a prolonged period of time the nurse stopped administering medications to inform the STNA to assist him with repositioning. Resident #7 stated there was one nurse to pass the medications and provide treatments at night. His wound dressing was changed between 1:30 A.M. and 2:00 A.M. because the nurse did not have the time to change his wound dressing sooner. The nurses waited until they were finished with the medication administration to all the residents before performing his wound care. An interview with Licensed Practical Nurse (LPN) #14 on 11/01/17 at 2:00 P.M. revealed she had not changed Resident #7's wound dressing on this date. LPN #14 said the wound dressing was changed twice a day and she was scheduled to work from 7:00 A.M. to 7:30 P.M. and the dressing could be changed any time during her 12 hour shift. LPN #14 indicated she was responsible for passing medications to 26 residents and had not had time to provide the wound treatment. LPN #14 stated the facility assigned one licensed nurse and two STNAs for the residents on the 300 unit. LPN #14 indicated she was often pulled away from passing the medications to provide assistance to residents because there were several residents who needed both STNAs to transfer with the use of a mechanical lift and other care needs. LPN #14 said the staffing level was not adequate to provide the medications and treatments in a timely manner. An interview with LPN #8 on 11/02/17 at 9:35 A.M. revealed he was unsatisfied with the staffing level in the facility. LPN #8 indicated he started the day running and was worried mistakes would happen due to rushing from one task to another. LPN #8 stated recently the administration had staffed the 300 unit with one licensed nurse and two STNAs. LPN #8 indicated there were several residents which needed two staff members to transfer, provide showers and other care needs. LPN #8 stated he tried to answer call lights and address resident requests for assistance but this often left him behind on his duties and he was frustrated. An interview with the director of nursing (DON) on 11/02/17 at 11:46 A.M. revealed the facility provided staff according to the acuity of the residents; however, the DON but was unable to explain how the acuity level was determined and how those acuity levels where equated to the number of licensed nurses and STNAs scheduled. There was no system in place or tool available to calculate the number of staff needed to ensure the care needs of the residents were met. The number of staff were assigned to each area according to the number of residents on each unit. A review of the staffing schedules revealed there was one licensed nurse and two STNAs scheduled on the 300 unit each day on the 7:00 A.M. to 7:30 P.M. shift from 10/26/17 to 11/02/17. A review of the Resident Council Minutes dated 06/2017 revealed complaints of the staff hurriedly performing their morning care needs, and on 10/2017 complaints of the call light response time and not following through with the assistance the residents requested. Review of the resident census revealed Residents #4, #5, #6, #7, #8, #10, #11, #13, #15, #16, #17, #22, #24, #26, #27, #29, #30, #63, #61, #60, #59, #57, #56, #54, #49, #48, #46, #45, and #39 resided on the 300 hall. This deficiency substantiates Complaint Numbers OH 223 and OH 4203.

Based on observation and interview the facility failed to ensure Resident #7's pressure ulcer dressing was changed in a timely manner after being saturated during a shower. This affected one of three residents reviewed for wounds, Resident #7. Findings include: An interview with Resident #7 on 11/01/17 at 1:40 P.M. revealed his care needs were not met in a timely manner. Resident #7 was in bed with the head of the bed raised and had just finished lunch. Resident #7 indicated he had a shower earlier in the day and no one had changed his wound dressing; the staff showered him with his wound dressing in place. Resident #7 stated he had complained to the administrator and director of nursing a few weeks ago about the timeliness of the provision of his care needs and nothing had changed. An interview with Licensed Practical Nurse (LPN) #14 on 11/01/17 at 2:00 P.M. revealed she had not changed Resident #7's wound dressing on this date. LPN #14 said the wound dressing was ordered to be changed twice a day. LPN #14 was scheduled 7:00 A.M. to 7:00 P.M. and the dressing could be changed any time during her 12 hour shift. LPN #14 indicated she was responsible for passing medications to 26 residents and had not had time to provide the wound treatment. An observation of Resident #7's wound dressing change to the right ischium on 11/01/17 at 2:40 P.M. by LPN #13 revealed the wound dressing was dated 10/31/17 and it was saturated as a result of not having been removed prior to his shower in the morning. A review of Resident #7's wound grid documentation dated 10/27/17 revealed he had a stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) on the right ischium. The wound measured 3.5 centimeters (cm) long by 1.4 cm wide by 3.5 cm deep. The assessment indicated the wound was present upon his admission to the facility. A review of Resident #7's Medication and Treatment Administration Record dated 10/01/17 to 10/31/17 revealed documentation indicating the wound dressing was changed two times a day, once during each twelve hour shift (7:00 A.M. to 7:30 P.M. and 7:00 P.M. to 7:30 A.M.). This deficiency substantiates Complaint Number OH 223.

Based on record review and interview, the facility failed to assess residents following a decline in urinary continence, failed to have accurate urinary assessments and failed to provide identified services to maintain or improve urinary continence. This finding affected four (Residents #3, #40 #47 and #69) of four reviewed for urinary incontinence. Findings include: 1. Review of Resident #47's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #47's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment, was frequently incontinent of urine and was not on a urinary toileting program. Review of Resident #47's MDS 3.0 assessment dated [DATE] indicated the resident was occasionally incontinent of urine and not on a urinary toileting program. Review of Resident #47's restorative progress note dated 08/08/16 at 4:05 P.M. indicated bowel and bladder trackers were received and reviewed and the patient was frequently incontinent. The trackers showed incontinence occurred intermittently throughout the day and a restorative toileting program was not initiated at the time. Review of Resident #47's Bowel and Bladder Assessment 3.0 form dated 09/16/16 indicated the urinary continence plan based on the assessment included a bladder retraining program. Interview on 11/30/16 at 1:24 P.M. with the Director of Nursing (DON) confirmed a bladder retraining program was not implemented for Resident #47 to maintain or improve the resident's urinary continence. 2. Review of Resident #3's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #3's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment, was occasionally incontinent of urine and not on a toileting program. Review of Resident #3's MDS 3.0 assessment dated [DATE] indicated the resident was always continent and not on a toileting program. Review of Resident #3's Restorative Plan of Care dated 08/22/16 indicated the goal was to have decreased nocturia with scheduled hours for toileting or care from 12:00 A.M. to 1:00 A.M. and 3:00 A.M. to 4:00 A.M. to be performed by nurses or nursing assistants. Review of Resident #3's Toileting Flow Records from 09/01/16 to 09/30/16 revealed no evidence the resident was toileted as planned on 09/01/16, 09/03/16, 09/04/16, 09/05/16, 09/06/16, 09/07/16, 09/08/16, 09/09/16, 09/13/16, 09/14/16, 09/22/16, 09/27/16, 09/28/16 and 09/29/16. Review of Resident #3's Toileting Flow Record from 10/01/16 to 10/31/16 revealed no evidence the resident was toileted as planned on 10/03/16, 10/07/16, 10/12/16, 10/13/16, 10/14/16, 10/15/16, 10/16/16, 10/17/16, 10/19/16, 10/20/16, 10/22/16, 10/25/16, 10/26/16, 10/27/16, 10/30/16 and 10/31/16. Review of Resident #3's Toileting Flow Record from 11/01/16 to 11/30/16 revealed no evidence the the resident was toileted as planned on 11/01/16, 11/02/16, 11/03/16, 11/04/16, 11/06/16, 11/07/16, 11/08/16, 11/09/16, 11/10/16, 11/14/16, 11/15/16, 11/16/16, 11/18/16, 11/20/16, 11/22/16, 11/23/16, 11/27/16, 11/28/16, 11/29/16 and 11/30/16. Interview on 12/01/16 at 10:54 A.M. with the Director of Nursing (DON) confirmed the facility did not have evidence Resident #3 was toileted as indicated in the Restorative Plan of Care on the dates identified above to prevent a decline in the resident's urinary continence. 3. Review of the closed record revealed Resident #69 was admitted on [DATE] with dementia and [MEDICAL CONDITION]. Review of the admission assessment dated [DATE] indicated Resident #69 needed extensive assistance of one staff for transfers and toilet use and was occasionally incontinent of urine. A Bowel and Bladder Assessment 3.0 dated 05/16/16 indicated the resident was always continent of urine. Review of the May 2016 skilled nursing progress notes revealed Resident #69 could toilet self independently and was continent of urine. On 05/27/16, he had a decline in urinary continence. Review of the end of May and June 2016 notes revealed the resident was incontinent and needed staff assistance with toileting. There was no evidence the facility did a bladder assessment following the decline in bladder function. During an interview on 11/30/16 at 4:06 P.M., Assistant Director of Nursing (ADON) #2 and Regional Registered Nurse (RN) #4 agreed the skilled progress notes indicated Resident #69 had a decline in urinary continence at the end of May 2016. They confirmed a bladder assessment was not completed following the decline. 4. Resident #40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission comprehensive assessment (MDS 3.0) dated 08/03/16 indicated she was frequently incontinent of bladder and by the 10/13/16 MDS 3.0 assessment was always incontinent of bladder. Review of the admission bowel and bladder assessment dated [DATE] and 08/15/16 lacked the identification of the type of incontinence she was experiencing. The clinical impression was marked unable to determine and the plan was marked as an incontinence care program. There was no evidence a voiding diary was completed to determine if the resident had a pattern until 08/30/16. The voiding diary was incomplete and no determination was identified after it was completed. Interview with the DON on 12/01/16 at 11:00 A.M. verified the bowel and bladder assessments were completed prior to the voiding diary data was obtained and were not accurately completed to determine if a restorative program to maintain or improve continence would be effective.

Based on observation, interview, and record review, the facility failed to ensure pressure relieving interventions were utilized for Resident #5 who had arterial related wounds on both feet. This affected one of 35 residents observed on stage one and had the potential to affect 34 residents who were identified as needing assistance with turning and repositioning. The facility failed to provide care to meet the needs of a a resident receiving [MEDICAL TREATMENT]. This affected one (Resident #50) of one resident reviewed for [MEDICAL TREATMENT]. The facility had one resident receiving [MEDICAL TREATMENT]. Findings include: 1. Review of the record revealed Resident #5 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's plan of care for skin integrity initiated 01/04/16 included interventions for an air mattress, assist to turn and reposition every two hours, pillow between knees while in bed, and float heels when in bed. Review of the annual assessment dated [DATE] indicated the resident needed extensive assistance with bed mobility and transfers. He was at risk for development of pressure ulcers. Review of skin grids dated 11/28/16 revealed Resident #5 developed two wounds, a scab to right foot, bottom of fifth toe measuring 1.5 centimeters (cm) long by 1.0 cm wide and a suspected deep tissue injury to his left inner heel area measuring 3.5 cm long by 2 cm wide. Review of wound consult documentation dated 11/29/16 indicated the wound physician assessed the wound to Resident #5's left inner heel. The skin was described as discolored and caused by arterial deficits. On 11/30/16 at 2:05 P.M., a dressing change observation was completed. Upon entering Resident #5's room, the resident was lying on his right side with the outer surface of his right foot and the inner surface of his heel directly on the mattress surface. Licensed Practical Nurse (LPN) #6 measured the left inner heel wound as having a 6 cm long by 7 cm wide tan-colored circular area with a pink center. Inside the center there was a darker pink circular area measuring 1 cm long by 1 cm wide with a dark red line measuring 1 cm long by 0.1 cm wide. He completed the dressing change and instructed State tested Nursing Assistant (STNA) #8 to elevated Resident #5's left heel off of the mattress surface. During an interview on 11/30/16 at 2:52 P.M., STNA #8 was not aware when the wound to Resident #5's left heel developed. She indicated she discovered an area to the resident's right foot. It looked like a blood blister. Following the interview, STNA #8 showed the surveyor the wound to Resident #5's right foot. Upon entering the room, the resident was lying on his right side, there was a pillow elevating the resident's left foot off the mattress. His right outer foot was directly on the mattress. The STNA confirmed there was nothing under the resident's right foot to elevate the foot off the mattress surface and relieve the pressure. Resident #5 had a blackened colored area to his right bunion just below the fifth toe. She felt the blackened area and indicated it was thick with with defined edges. On 11/30/16 at 3:12 P.M., the surveyor accompanied LPN #6 and Assistant Director of Nursing (ADON) #2 to observe the right foot wound. LPN #6 measured the wound to right foot lateral bunion as 1.8 cm long by 1.0 cm wide. During an interview following the wound observation, ADON #2 verified the area was dark brown to black in color with non-viable tissue. She indicated the wound physician did not assess Resident #5's right foot yesterday because the documentation made the wound sound like just a scab. During an interview on 12/01/16 at 8:26 A.M. with Wound Physician #10 revealed he had difficulty palpating pulses to Resident #5's legs. The resident has vascular deficits. The physician felt the non-viable tissue/dark colored eschar to the resident's right foot was vascular in origin. 2. Review of the record revealed Resident #50 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of a physician order [REDACTED].M., 1:00 P.M., and 5:00 P.M. Review of the Medication Administration Record [REDACTED].M. dose of [MEDICATION NAME] was not administered on 11/05, 11/10, 11/12, 11/15, 11/17, 11/19, 11/21, 11/23, 11/26, and 11/29/16. The documentation indicated Resident #50 was out of facility at the time. These dates coincided with the days the resident received [MEDICAL TREATMENT]. Review of a fax transmittal letter from the [MEDICAL TREATMENT] center indicated Resident #50's November 2016 laboratory tests indicated Resident #50's phosphorus level was 6.4 milligram (mg) per deciliter (dl). The desired range for [MEDICAL TREATMENT] patients being 3.5 to 5.5 mg/dl. The [MEDICAL TREATMENT] dietician recommended to continue the [MEDICATION NAME] binder with meals. During an interview on 12/01/16 at 10:05 A.M., Diet Technician (DT) #12 indicated she received the fax last evening from the [MEDICAL TREATMENT] center. The November laboratory tests were completed on 11/03/16. She agreed the [MEDICATION NAME] level was rising and over the desired level. After reviewing the November 2016 MAR, DT #12 agreed Resident #50 did not receive several doses of the [MEDICATION NAME] binder ([MEDICATION NAME]) due to [MEDICAL TREATMENT]. During a telephone interview on 12/01/16 at 10:33 A.M., [MEDICAL TREATMENT] Dietician #16 indicated she was not aware that Resident #50 brought his lunch to the [MEDICAL TREATMENT] center. Ideally, the [MEDICATION NAME] binder should be sent to the [MEDICAL TREATMENT] center with his meal. Review of the annual nutritional assessment dated [DATE] indicated Resident #50 received no added salt, low concentrated sweets diet with no potatoes, tomatoes, citrus, or bananas, and sugar free health shakes ('Mighty Shakes') four ounces three times daily with meals. The resident was on fluid restrictions, 2000 milliliters (ML) per day. The dietician recommended double portion entrees at dinner due to the resident's gradual weight loss. On 11/30/16 at 5:01 P.M., review of Resident #50's dinner meal ticket indicated he received a no added salt, low concentrated sweets, double entree at dinner, fluid restriction, beverage of choice eight ounces, Mighty Shake four ounces, no bananas, potatoes, citrus, or tomatoes. On 11/30/16 at 5:17 P.M., Resident #50's dinner meal left the kitchenette. The resident received five chicken nuggets, broccoli, a juice drink, and a four ounce Mighty Shake. Review of other residents' meals revealed they also received five chicken nuggets. At 5:30 P.M., STNA #8 confirmed Resident #50 received the same amount of chicken nuggets as other residents. Both Diet Technician #12 and Registered Dietician #14 confirmed the observation. Resident #50 was not provided the double portion entree as ordered.