Every finding on record at Hillsboro Post Acute

Based on medical record review and staff interview, the facility failed to ensure resident Preadmission Screening and Resident Reviews (PASARRs) were accurate and included resident's mental health diagnoses and mental health services. This affected two (#05 and #14) of the three residents reviewed for PASARRs. The facility census was 71 residents. Findings include: 1) Review of the medical record for Resident #05 revealed an admitted [DATE] with diagnoses including dementia, psychosis, mood disorder. Review of the current diagnoses revealed a new diagnosis of anxiety added on 07/26/24. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #05 had severely impaired cognition. Review of the completed PASARR documents revealed the facility did not complete a new PASARR designation following the addition of the anxiety diagnosis on 07/26/24. 33023 2) Review of the medical record for Resident #14 revealed an admitted [DATE] with diagnoses including acute and chronic respiratory failure, chronic obstructive pulmonary disease, diabetes mellitus type II, congestive heart failure, acute kidney failure, hypertension, hypothyroidism, depression, diverticulosis, anemia, cerebrovascular disease, neuromuscular dysfunction of the bladder, insomnia, anxiety, unspecified psychosis, bipolar disorder, and adult failure to thrive. Review of the current diagnoses revealed a new diagnosis of unspecified psychosis not due to a substance or known physiological condition was added on 03/21/25. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 had severely impaired cognition. Review of the completed PASARR documents revealed the facility did not complete a new PASSAR designation following the addition of the unspecified psychosis diagnosis on 03/21/25. Interview with Social Services Director (SSD) #14 on 05/08/25 at 09:47 A.M., verified a new PASARR should have been completed for Resident #05 following a new diagnosis of anxiety on 07/26/24. SSD #14 also verified a new PASARR should have been completed for Resident #14 following a new diagnosis of unspecified psychosis on 03/21/25.

Based on medical record reviews, observations, and staff interviews, the facility failed to ensure the medication error rate was less than five percent, as evidenced by three medication errors out of 31 opportunities observed, resulting in 9.68 percent (%) medication error rate. This affected two (#17 and #60) of the four residents observed for medication administration. The facility census was 71. Findings include: 1) Record review for Resident #17 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included hypertension, bipolar disorder, and insomnia. Review of the physician order for Resident #17 dated 03/07/25, revealed an order for Amlodipine Besylate 10 milligrams (mg) to be administered one time a day for hypertension and to hold the medication for a systolic blood pressure (SBP) below 120 millimeters of mercury (mm/Hg) or a diastolic blood pressure (DBP) below 80 mm/Hg. Review of the physician order for Resident #17 dated 03/10/25, revealed an order for Hydralazine 25 mg to be administered twice a day for hypertension and administer the medication if the resident's SBP is over 160 mm/Hg and/or DBP over 120 mm/Hg. Observation of the medication administration on 05/06/25 at 8:28 A.M., with Licensed Practical Nurse (LPN) #517 revealed medications including Amlodipine Besylate 10 mg and Hydralazine 25 mg were prepared for administration to Resident #17. LPN #517 entered the room of Resident #17 with the prepared medications and obtained the residents Blood Pressure (BP) with results of SBP 155 mg/Hg and DBP 74 mm/Hg. LPN #517 administered all ordered medications, including the Amlodipine Besylate and Hydralazine, to the resident and exited the room. Interview with LPN #517 at the same time, verified the medications were administered to Resident #17. Interview on 05/07/25 at 10:05 A.M., with the Director of Nursing (DON) verified Resident #17 should not have been administered Amlodipine Besylate or Hydralazine by LPN #517 on 05/06/25 at 8:20 A.M. due to the residents BP reading being outside the parameters for administration. 2) Record review for Resident #60 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included paroxysmal atrial fibrillation, hypertension, and presence of a cardiac pacemaker. Review of the physician order dated 03/06/25 revealed an order for Digoxin 125 micrograms (mcg) to be administered once a day for the Heart. Observation of the medication administration on 05/06/25 at 8:20 A.M., with LPN #517 revealed medications including Digoxin 125 mcg were prepared for administration to Resident #60. LPN #517 entered the room of Resident #60 with the prepared medications and obtained the residents pulse using a pulse oximeter placed on the residents left first finger. The pulse oximeter was in place for less than 30 seconds with a result of 77 heart beats per minute. LPN #517 administered all ordered medications, including the Digoxin, to the resident and exited the room. Interview with LPN #517 at the same time, verified the medication was administered to Resident #17. Interview on 05/07/25 at 10:05 A.M., with the DON verified the facility nurses should obtain a resident's apical pulse (the pulse rate located at the apex of the heart on the left side of the chest) for one full minute prior to the administration of Digoxin. Review of the facility policy titled Administering Medications, revised 04/2019, revealed medications are administered in a safe and timely manner, and as prescribed.

Based on medical record reviews, observations, staff interview, and review of facility policy, the facility failed to ensure medications were administered per physician's order resulting in significant medication errors. This affected two (#17 and #60) of the four residents observed for medication administration. The facility census was 71. Findings include: 1) Record review for Resident #17 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included hypertension, bipolar disorder, and insomnia. Review of the physician order for Resident #17 dated 03/07/25, revealed an order for Amlodipine Besylate 10 milligrams (mg) to be administered one time a day for hypertension and to hold the medication for a systolic blood pressure (SBP) below 120 millimeters of mercury (mm/Hg) or a diastolic blood pressure (DBP) below 80 mm/Hg. Review of the physician order for Resident #17 dated 03/10/25, revealed an order for Hydralazine 25 mg to be administered twice a day for hypertension and administer the medication if the resident's SBP is over 160 mm/Hg and/or DBP over 120 mm/Hg. Observation of the medication administration on 05/06/25 at 8:28 A.M., with Licensed Practical Nurse (LPN) #517 revealed medications including Amlodipine Besylate 10 mg and Hydralazine 25 mg were prepared for administration to Resident #17. LPN #517 entered the room of Resident #17 with the prepared medications and obtained the residents Blood Pressure (BP) with results of SBP 155 mg/Hg and DBP 74 mm/Hg. LPN #517 administered all ordered medications, including the Amlodipine Besylate and Hydralazine, to the resident and exited the room. Interview with LPN #517 at the same time, verified the medications were administered to Resident #17. Interview on 05/07/25 at 10:05 A.M., with the Director of Nursing (DON) verified Resident #17 should not have been administered Amlodipine Besylate or Hydralazine by LPN #517 on 05/06/25 at 8:20 A.M. due to the residents BP reading being outside the parameters for administration. 2) Record review for Resident #60 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included paroxysmal atrial fibrillation, hypertension, and presence of a cardiac pacemaker. Review of the physician order for Resident #60 dated 03/06/25 revealed an order for Digoxin 125 micrograms (mcg) to be administered once a day for the Heart. Observation of the medication administration on 05/06/25 at 8:20 A.M., with LPN #517 revealed medications including Digoxin 125 mcg were prepared for administration to Resident #60. LPN #517 entered the room of Resident #60 with the prepared medications and obtained the residents pulse using a pulse oximeter placed on the residents left first finger. The pulse oximeter was in place for less than 30 seconds with a result of 77 heart beats per minute. LPN #517 administered all ordered medications, including the Digoxin, to the resident and exited the room. Interview with LPN #517 at the same time, verified the medication was administered to Resident #17. Interview on 05/07/25 at 10:05 A.M., with the DON verified the facility nurses should obtain a resident's apical pulse (the pulse rate located at the apex of the heart on the left side of the chest) for one full minute prior to the administration of Digoxin. Review of the facility policy titled Administering Medications, revised 04/2019, revealed medications are administered in a safe and timely manner, and as prescribed.

Based on observations, staff interview and policy review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. This affected all but two (#18 and #70) residents who received food from the kitchen. The census was 78. Findings include: Observation of the kitchen with Dietary Manager #90 on 11/15/23 at 10:50 A.M. revealed a scoop that was stored inside a bulk container of flour. The large can opener had a heavy build-up of substance on the blade and on the metal holder attached to the worktable. Interview with Dietary Manager #90 at the same time, verified the findings. Interview with the Director of Nursing (DON) on 11/15/23 at 3:15 P.M. identified two (#18 and #70) residents who received all their nutritional needs via tube feeding and consumed no food prepared in the kitchen. Review of the facility policy titled Food Storage dated 2017, revealed scoops were provided for bulk foods such as flour. The scoops were not stored in food but were kept covered in a protected area near the container. Under Hazard Analysis Critical Control Point (HACCP) Principles the policy stated to use clean and sanitized equipment. This deficiency represents non-compliance investigated under Master Complaint Number OH00147894 and Complaint Number OH00147633.

Based on medical record review and staff interview, the facility failed to provide baths/showers to dependent residents as scheduled. This affected two (#61 and #63) of three residents reviewed for bathing/showering. The census was 69. Findings include: 1. Review of the medical record for Resident #61 revealed an admitted [DATE]. His diagnoses were cerebral infarction, bipolar disorder, dementia, hemiplegia and hemiparesis, hyperlipidemia, personality disorder, psychosis, type II diabetes, obesity, cerebral atherosclerosis, mild cognitive impairment, peripheral vascular disease, anxiety disorder, insomnia, and atherosclerotic heart disease. Review of Resident #61's minimum data set (MDS) assessment, dated 02/24/23, revealed he had a mild cognitive impairment. Review of Resident #61 MDS Assessment, section G, revealed he needed a total of one-person physical assistance for bathing. Review of Resident #61's bathing schedule revealed prior to 04/11/23, his scheduled shower/bath days were Sunday and Wednesday evenings. On 04/11/23 to present, his shower/bath days were Tuesday and Saturday evenings. Review of Resident #61's bathing logs, dated 03/01/23 to 05/26/23, revealed a total of 14 missed scheduled showers/baths. 2. Review of the medical record for Resident #63 revealed an admitted [DATE]. Her diagnoses were osteoarthritis, dementia, major depressive disorder, osteoporosis, hypertension, macular degeneration, cardiomegaly, and arthropathy. Review of Resident #61's MDS assessment dated [DATE], revealed she had a significant cognitive impairment. Review of section G revealed she needed physical assistance from one person for bathing. Review of Resident #63's bathing schedule revealed her shower/bath days were Wednesdays and Saturdays. Review of Resident #63's bathing logs, dated 03/01/23 to 05/26/23, revealed a total of 10 missed scheduled showers/baths. Interview with State tested Nursing Aide (STNA) #104, STNA #105, Registered Nurse (RN) #107, and Licensed Practical Nurse (LPN) #108 on 05/26/23 at 2:30 P.M., 2:46 P.M., 2:55 P.M., and 3:03 P.M., revealed if not applicable is selected as the choice for showers in the electronic medical record, they confirmed it means the resident did not receive a bath/shower that day. They confirmed if the resident refuses a bath/shower, there is an option for that and that would be selected. They are to give each resident a bath/shower on their scheduled days, and when the resident requests them. If there was no documentation to support a bath/shower was taken, they confirmed that it was not offered or completed. Interview with Unit Manager #101 on 05/26/23 at 1:54 P.M., confirmed the shower/bath logs and documentation provided, was all they could find for each of the residents. She confirmed there was no other shower documentation available to support the fact that showers were being completed for both residents as scheduled. This deficiency represents the noncompliance discovered during investigation of Complaint Number OH00142697.

Based on observation and interview, the facility failed to maintain the kitchen walk-in freezer in operational fashion which caused an excessive build up of ice and solid ice crystals on the inside of the freezer. This had the potential to affect all residents in the facility with the exception of one(Resident #76) who did not receive food from the kitchen. The facility census was 81. Findings include: Observation of the kitchen walk in freezer on 12/12/22 at 09:13 A.M. revealed an excessive build up of ice and solid ice crystals on the inside of the door and shelving to the left. Three shelves contained multiple food items from the bottom to the top shelf which were also covered with ice. A solid ice block was also stuck to the closure side of the freezer and the door itself. Dietary Cook #1000 verified the buildup of ice on the inside of the freezer, and stated this has been this way for several months. Observation of the kitchen walk in freezer on 12/13/22 at 1:06 P.M. revealed the buildup of ice and ice crystals remain to the inside of the walk in freezer which still covers multiple food items. Interview with the Administrator and Dietary Manager #2000 on 12/13/22 at 1:06 P.M. verified there is an excessive amount of ice and ice crystals on the inside of the walk in freezer. Observation of the kitchen walk in freezer on 12/14/22 at 2:07 P.M. revealed the excessive amount of ice remains and still covers multiple food items. Ice remains on the inside of the door and the left side of the freezer. Interview with the Administrator and the Regional Quality Assurance Consultant #3000 on 12/14/22 at 2:07 P.M. verified the presence of a large amount of ice and ice crystals on the inside of the freezer.

Based on observation, interview and policy review the facility failed to maintain a record of meal substitutions that were provided in place of the approved daily menu. This had the potential to affect all residents in the facility with the exception of one(Resident #76) who did not receive food from the kitchen. The facility census was 81. Findings include: Review of the daily dinner menu for 12/14/22 revealed a meal listing of tomato basil soup, chicken salad sandwich on wheat, cucumber and onion salad, and poke cake. A substitution of a cheeseburger, french fries, green beans, and a brownie was made prior to serving the dinner meal. Interview with the Registered Dietician #4000 on 12/14/22 at 4:45 P.M. verified she was unable to provide a meal substitution log for the last three months, which included any substitutions made. Review of the facility policy regarding meal substitutions on 12/15/22 at 9:10 A.M. revealed an issue date of 11/2020. The policy states the menu substitution may be recorded on the menu or a separate log. Also, the registered dietician reviews menu substitutions and provides staff education as needed.

Based on record review, observation, interview, and facility policy review, the facility failed to ensure staff wore Personal Protective Equipment (PPE) and completed COVID-19 screening questionnaire to prevent the spread of COVID-19 infection. This had the potential to affect all 85 residents. The facility census was 85. Findings include: Review of staff vaccination records revealed Housekeeping Aide #75, Hospitality Aide #53, and Licensed Practical Nurse (LPN ) #119 were unvaccinated for COVID-19. Review of Employee Temperature and Signs/Symptoms Log dated 08/14/22 revealed five of eleven nursing staff did not complete COVID-19 screening questions and obtain temperature prior to start of work. State tested Nurse Aide (STNA) #35, #107 and #11 were not screened and were verified to be in resident care areas. LPN #109 and #200 were not screened and were verified to be in resident care areas. Observation at 8:10 A.M. on 08/10/22 revealed sign on entry door revealed the facility county was in high transmission rate for COVID-19, all staff and visitors were to be screened for signs and symptoms of COVID-19 and to wear PPE. The front desk had sign in sheets for staff and for visitors. Interview on 08/10/22 at 8:12 A.M. with Receptionist #86 verified all staff were to wear face shields or goggles and surgical mask if vaccinated and N95 mask if unvaccinated due to high transmission rate in resident care areas. She stated the PPE was available at the sign in area for staff and visitors. She stated all visitors were to ring the doorbell for staff to assist visitors to complete the sign in screening log. Observation and interview on 08/10/22 from 8:30 A.M. through 8:55 A.M. revealed three unvaccinated COVID-19 staff were not wearing N95 masks in resident care areas. Housekeeping Aide #75 was wearing a surgical mask and verified he should have been wearing a N95 mask because he was not vaccinated for COVID-19. Hospitality Aide #53 was wearing a surgical mask and verified she should have been wearing a N95 mask because she was not vaccinated for COVID-19. LPN #119 was wearing a surgical mask and verified she should have been wearing a N95 mask because she was not vaccinated for COVID-19. Observation on 08/14/22 at 8:15 A.M. revealed Diet Aide #105 opened entry door for surveyor with no mask and no goggles. Diet Aide #105 verified she should have been wearing goggles and a mask. Observation and interview on 08/14/22 from 8:17 A.M. through 8:20 A.M. revealed four staff were not wearing PPE in resident care areas. LPN # 109 was at the nurse station without a face shield, goggles or mask. LPN #109 verified she did not have on a face shield or mask. STNA #66 and #15 were observed providing care with Resident #38 with no face shield or goggles. STNA #66 and #15 verified they should have been wearing face shield or goggles. LPN #200 was in Unit 400 resident hallway passing medications and was not wearing face shield or goggles. LPN #200 verified she should have been wearing a face shield or goggles. Observation on 08/14/22 at 8:57 A.M. revealed family member of Resident #69 entered front door with an entry code without staff assistance. Family member of Resident #69 was greeted upon entry by STNA #15 who did not assist the family member to complete the sign in screening form. Family member of Resident #69 went to the resident room without screening for COVID-19. Interview on 08/14/22 at 9:00 A.M., family member of Resident #69 verified he had the facility front door entrance code, could enter the facility without staff assistance and does not always get screened by staff. The family member verified he had not been screened by staff on 08/14/22 at 9:00 A.M. Interviews on 08/14/22 from 9:00 A.M. through 9:30 A.M. STNA's #35, #107, and LPN #109 and #200 verified they did not screen for COVID-19 on 08/14/22 prior to beginning work in resident care areas. Interview on 08/14/22 at 9:45 A.M., Unit Manager Registered Nurse, (RN) #72 verified STNA's #35, #107, #111 and LPN #109 and #200 had not been screened for COVID-19 on 08/14/22 prior to beginning work in resident care areas. Review of facility policy titled Promedica Hillsboro COVID-19 Policy for Employee Screening , undated, revealed upon arrival, employees must be screened and record their exact temperature reading. Review of facility policy Patient Visitation Policy and Plan, dated 03/18/22 revealed upon arrival, visitors will report to the screening area to complete screening. If the visitor triggers any element of the screen, the visit will not occur. Review of facility policy Personal Protective Equipment Usage Guide, dated 08/10/22, revealed face shields are to be worn in counties with high transmission rates in patent care areas. Masks are to only be removed during scheduled breaks and outside of the patient care areas. This deficiency substantiates Master Complaint #OH 747 and Complaint #OH 539.

Based on medical record review, observations, resident, resident representative and staff interview and policy review, the facility failed to ensure meals were served at a temperature that was palatable and appetizing. This affected four (#8, #27, #30 and #64) out of four residents sampled for food palatability. This had the potential to affect 87 out of 90 residents who receive their meals from the kitchen, the facility identified three (#17, #60 and #61) residents who do not receive meals/food from the kitchen. Facility census was 90. Findings include: Review of the medical record for the Resident #8 revealed an admitted [DATE]. Diagnoses included heart failure, vitamin B 12 [CONDITION(S)], [CONDITION(S)], obesity, diabetes mellitus, and hypertension. Review of Resident #8's physician diet order included carbohydrate controlled low sodium diet cardiac diet and regular texture. Resident #8 had intact cognition and required setup only assistance for meal service and eating. Review of the medical record for the Resident #30 revealed an admitted [DATE]. Diagnoses included [CONDITION(S)], vitamin D deficiency, hypertension, and diabetes. Review of Resident #30's physician diet order included carbohydrate controlled low sodium diet cardiac regular diet and regular texture. Resident #30 had intact cognition and required setup only assistance for meal service and eating. Review of the medical record for the Resident #27 revealed an admitted [DATE]. Diagnoses included acute [CONDITION(S)] hypertension, [CONDITION(S)] disease, diabetes, chronic obstructive pulmonary disease and muscle weakness. Review of Resident #27 physician diet order included carbohydrate controlled and regular texture. Resident #27 had intact cognition and required setup only assistance for meal service and eating. Review of the medical record for the Resident #64 revealed an admitted [DATE]. Diagnosis included vitamin B deficiency, hypertension, diabetes, and heart failure. Review of Resident #64's physician diet order included carbohydrate controlled low sodium diet cardiac diet and regular texture. Resident #64 had intact cognition and required setup only assistance for meal service and eating. Interview on 03/22/22 at breakfast from 8:35 A.M. through 8:46 A.M. and at lunch from 12:15 P.M. through 1:10 P.M., Residents #8, #27, #30 and #64 revealed the breakfast and lunch meals were served cold on 03/22/22 and were cold at previous meals. Residents #8, #27, #30 and #64 revealed the noodles and meat sauce served at the lunch meal was cold to the taste. Resident #8 stated his coffee was so cold the [NAME] creamer would not dissolve into the coffee. Resident #8 family representative verified the resident has complained of the food temperature being cold to the staff. Residents #27 and #64 stated staff do not respond to their concerns regarding hot foods being cold. Observation on 03/22/22 at the lunch meal of the 200-unit tray line revealed the cart tray line started at 11:35 A.M. and the last tray was delivered to a resident on unit 200 at 12:05 P.M. There were 16 resident trays on the delivery cart. The plate base equipment and the plate warmer equipment were nonfunctioning. The insulated base and insulated cover were used on top and bottom of the plate. Cook #17 put plate bases into the insulated base without the use of an insulated mitt. Interview on 03/22/22 at 11:35 A.M. A.M. of Cook #17 revealed the plate base equipment used to serve trays/meals has not worked for over a month and did not work frequently. Cook #17 revealed the plate warmer equipment was also not functioning on 03/22/22 at the time of the survey and was not sure when it became nonfunctioning. Cook #17 stated the food was delivered in insulated plate bases and an insulted cover. Cook #17 reveal the Registered Dietitian, (RD) #116 had recommended on this date, 03/22/22 to heat the plate bases in the oven prior to lunch meal service. Cook #17 revealed she had not heated plate bases in the oven prior to this date, 03/22/22. Observation on 03/22/22 of lunch meal at 1:10 P.M. revealed Resident #8 coffee creamer did not dissolve in the coffee. Resident #30 ate zero percent of the noodles and meat sauce. Review of a sample tray on 03/22/22 at 12:07 P.M., after all room trays were served, revealed the hot food of noodles and meat sauce, was at a temperature of 124 degrees Fahrenheit (F) and was cool to the taste. The plate base was warm to the touch. This was verified by RD #116. Interview on 03/22/22 at 2:30 P.M. with RD #116 revealed she was aware the plate base equipment was nonfunctioning for over a month and reported to the Administrator and Diet Manager, (DM) #49. RD #116 stated she had recommended the cooks heat the plate bases in the oven prior to meal service several weeks ago. RD #166 stated she was unaware the plate warmer equipment was also nonfunctioning. Interview on 03/22/22 at 2:00 P.M. with DM #49 revealed the plate base equipment had been nonfunctioning for about a month and was awaiting replacement parts. DM #49 stated the plate warmer equipment had previously been repaired. DM #49 stated he was not aware of the plate warmer equipment was not functioning until this date, 03/22/22 and revealed it had been previously repaired multiple times. DM #49 stated he was unaware of any resident food temperature concerns. Interview on 03/22/22 at 4:05 P.M. with the Administrator revealed she was aware the plate base equipment has been nonfunctioning for about a month and had previous periods of nonfunctioning. The Administrator stated she was unaware the plate warmer equipment was also nonfunctioning. The facility confirmed 87 out of 90 residents receive their meals from the kitchen, the facility identified three (#17, #60 and #61) residents who do not receive meals/food from the kitchen. Review of facility policy titled Food Temperatures at Point of Service, dated November 2020, revealed the proper point of service food temperature, means both appetizing to the resident and minimizing the risk for scalding and [CONDITION(S)]. For temperatures at point of service, patient acceptance is used as a guide. A heat support system aide is used in maintaining hot temperatures during transport of trays. This deficiency substantiates Complaint Number OH 834.

Based on observation, staff interview, and review of facility policy/procedures, the facility failed to ensure that one of two shower rooms utilized by residents was kept clean and in good repair. This had the potential to affect 51 residents (#15 through #64) on the 300/400/units, out of a total facility census of 85. Findings include: Observation on 12/27/21 at 11:52 A.M. of the central shower room for the 300/400 units, with State tested Nurse Aide (STNA) #128 revealed the only shower stall in use was soiled and in disrepair. Upon examination there were several cracked tiles along the bottom inside wall near the floor, and a cracked tile along the bottom of the stall near the floor on the right. There was an accumulation of orange biofilm in the grout between the tiles from the floor up the tiles extending upwards for approximately nine tiles. There was also an accumulation of orange/pink debris adhering to tiles where the shower stall met the floor. In addition, the handle to the water valve was missing and staff was using a set of vice grips handing from the valve stem to turn the water on and off. STNA #128 affirmed the presence of the orange biofilm, and affirmed that staff had to use vice grips to turn the water on and off at the valve. STNA #128 stated that housekeeping/maintenance staff come and clean it but the orange biofilm comes right back. Interview on 12/27/21 at 12:16 P.M. with Director of Maintenance (DM) #101 revealed he was aware of the condition of the 300/400 shower room related to the broken tiles and missing valve handle but had not had a chance to make the repairs, that he was figuring out what all needed to be done. He shared he had been in the position for about a month. DM #101 stated that he had included repair of the valve handle when the new hot water heater is installed. However, he confirmed there was no date scheduled for the repairs. DM #101 communicated that the repairs to the shower room/stall would be the responsibility of maintenance staff, and that housekeeping would be responsible for cleaning the shower room. Interview on 12/27/21 at 1:22 P.M. with Housekeeping Aide (HA) #137, during observation of the 300/400 shower room, revealed that she was responsible for cleaning the shower room and stall. She stated housekeeping staff sprayed the shower stall with disinfectant and wiped it down. HA #137 affirmed the presence of the orange biofilm between the tiles and that the shower room appeared in need of a deep cleaning/scrubbing. She stated that she did not know who was responsible for deep cleaning/scrubbing the shower stall walls. During interview on 12/27/21 at 3:08 P.M. with Laundry and Housekeeping Supervisor (LHS) #144, while observing the 300/400 shower room, LHS #144 affirmed the shower stall had a build up of orange biofilm between the tiles. She agreed that it did not appear that the debris had been scrubbed from the walls for an extended period of time. LHS #144 then provided that Shower and Tub cleaning policy and procedure. Review of the procedure included steps for spraying the shower/tub and wall areas with disinfectant, and then damp wiping. LHS #144 affirmed the procedure did not include any mention of scrubbing the walls/floors or tile in the shower room to remove visible debris including mold/mildew. This deficiency substantiates Complaint Number OH 304.

Based on medical record review, observation, resident interview, staff interview, and review of facility policy, the facility failed to respect the rights of two residents (#47 and #178) of two observed wearing smoking aprons when they were not needed. The facility census was 81. Findings include: 1. Review of Resident #47's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #47's care plan dated 07/19/19 revealed the resident had a history of [REDACTED]. Interventions included to smoke safely in designated areas, offer smoking cessation options, staff to provide smoking materials and light cigarettes and not to leave resident unattended when smoking. Review of Resident #47's smoking assessment dated [DATE] revealed interventions included allowing the resident to smoke independently in designated areas, and the resident did not require a smoking apron or vest. Review of Resident #47's Minimum Data Set ((MDS) dated [DATE] revealed resident was cognitively intact. Observation of residents smoking on 09/23/19 at 10:03 [NAME]M. revealed State tested Nurse Aide (STNA) #520 placed a smoking apron on Resident #47. Interview with Resident # 47 on 09/24/19 at 8:51 [NAME]M. revealed the facility had never put smoking aprons on the residents in the past and wearing a smoking apron made him feel uncomfortable and embarrassed. 2. Review of Resident #178's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #178's care plan dated 9/22/19 revealed the resident had a history of [REDACTED]. Review of Resident #178 smoking assessment dated [DATE] revealed revealed interventions included allowing resident to smoke independently in designated areas and the resident was not required to wear a smoking apron or vest. Observation on 09/23/19 at 10:03 [NAME]M. revealed STNA #520 placed a smoking apron on Resident #178. Interview with STNA #520 on 09/23/19 at 3:16 P.M. revealed only one resident was deemed as needing a smoking apron on the smoking assessment, however she just puts them on the residents to be sure. STNA #520 confirmed Resident #47 and Resident #178 had a smoking apron on at the 10:03 [NAME]M. smoke break. Interview with Resident #178 on 09/26/19 at 10:27 [NAME]M. revealed he did not like wearing a smoking apron when he smoked and did not understand why he had to wear one. Review of the facility policy untitled dated 08/11/06 revealed the interdisciplinary team (IDT) will evaluate and make a decision if a resident is independent or an at risk smoker and if a patient is deemed at risk, the resident will be required to wear a smoking vest or apron.

Based on medical record review, observation, resident interview, staff interview, and facilities policy review, the facility failed to ensure two staff members were present with the use of a mechanical lift during transfers for safety. This affected one resident (#8) of six reveiwed for accidents. The facility census was 81 . Findings include: Review of the medical record for Resident #8 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 had no cognitive deficits and required a total assistance of two people for transfers. Review of the care plan revealed Resident #8 required assistance with transferring as evidence by weakness related to spinal stenosis and diabetes mellitus with [MEDICAL CONDITION]. Intervention included to utilize mechanical lift with large sling for transfers. Observation and interview on 09/24/19 at 10:00 [NAME]M. revealed State tested Nursing Assistant (STNA) #611 was getting Resident #8 up for the day and she was the only staff member in the room. STNA #611 confirmed she did lift the resident with mechanical lift by herself. She revealed the resident was a a total assist for transfers with mechanical lift and one person could lift him with the lift. Interview on 09/25/19 at 1:36 P.M. with the Director of Nursing (DON) revealed it was her expectation staff always used two staff members when using a mechanical lift for safety. Review of facilities Mechanical Lift Policy dated (MONTH) 2019 revealed the purpose was to move immobile or obese residents for whom manual transfer poses potential for staff or resident injury. Use of a mechanical lift requires a second caregiver.

Based on medical record review and staff interview, the facility failed to initiate a gradual dose reduction (GDR) attempt on residents taking [MEDICAL CONDITION] medications and also failed to provide proper [DIAGNOSES REDACTED]. This affected three residents (#43, #6 and #63) of five reviewed for unnecessary medications. The facility census was 81. Findings include: 1. Review of Resident #43's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #43's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43's cognition was intact. Review of Resident #43's current medications revealed [MEDICATION NAME] (anti-depressant) 10 milligrams (mg), one tablet by mouth two times per day related to depression and Duloxetine Capsule 30 mg, take one capsule by mouth one time in the afternoon related to depression, and [MEDICATION NAME] tablet 50 mg take one tablet by mouth at bedtime for [MEDICAL CONDITION]. Review of Resident #43's monthly pharmacy reviews revealed no irregularities were noted from (MONTH) 2019 through (MONTH) 2019. There was no evidence an attempts for a GDR was made with any of the resident's [MEDICAL CONDITION] medications. Interview on 09/26/19 at 2:32 P.M. with the Director of Nursing (DON) verified the facility had not attempted a GDR for Resident #43. 2. Review of Resident #6's medical record revealed the resident was admitted to the facility on [DATE] with the following diagnoses, [MEDICAL CONDITIONS], diabetes mellitus type II, depression, and anxiety. Review of the most recent MDS assessment dated [DATE] revealed the resident was cognitively intact. Review of Resident #6's current medications revealed Duloxetine 60 mg, one capsule daily for depression and Aripiprazole 2 mg, one tablet for depression Review of Resident #6's monthly pharmacy review with the last date of 09/18/19 revealed the resident had been taking the Duloxetine and Aripiprazole for a [DIAGNOSES REDACTED]. There was no evidence a GDR had been attempted. On 09/25/19 at 1:51 P.M., interview with the Director of Nursing (DON) verified a GDR had not been recommended by the pharmacy, and none have been attempted. 3. Review of Resident #63's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #63's physician order [REDACTED]. Review of Resident #63's Minimum Data Set ((MDS) dated [DATE] revealed the resident was cognitively impaired. Interview with the Director of Nursing (DON) and the Social Services Director on 09/26/19 at 11:04 [NAME]M. confirmed Resident #62 was on [MEDICATION NAME] for behavioral disturbances due to dementia. The DON further revealed the resident had not had any behaviors for the last 18 months.

Based on observation, staff interview, review of a dietary listing and policy review, the facility failed to ensure food was prepared and served under sanitary conditions. The facility identified four (#23, #42, #1 and #64) residents who were physician ordered to receive nothing by mouth (NPO) and that do not receive meals from the kitchen; therefore, this had the potential to affect 84 out of the 88 residents residing in the facility who receive food from the kitchen. Facility census was 88. Findings include: On 08/08/18 from 11:21 A.M. to 11:25 A.M. during observation of the preparation of meal trays, Dietary Staff #8 was observed to wipe her face with her hand after having a liquid splashed on her face, she did not wash her hands. Dietary Staff #8 also was observed touching the inside of two cups while picking them up to place them on the meal tray. Dietary Staff #8 stated she should not have touched the inside of the cups and should have washed her hands. During interview on 08/08/18 at 11:33 A.M. with Registered Dietician #16 she verified Dietary Staff #8 should not have touched the inside of the cups and should have washed her hands after touching her face. Review of a dietary listing revealed there were four (#23, #42, #1 and #64) residents who were physician ordered to receive NPO and that did not receive meals from the kitchen. The dietary listing revealed the 84 other residents residing in the facility received their meals from the kitchen. Review of facility's hand washing policy for safe food handling dated (MONTH) 2014 revealed hands were to be washed after touching skin.

Based on record review, observation, and staff interview, the facility failed to ensure privacy during incontinence care for one (#36) out of three sampled resident observed for incontinence care. The facility census was 90. Findings include: Review of the medical record for Resident #26 revealed she was originally admitted on [DATE] with the latest readmission date of [DATE]. Admitting [DIAGNOSES REDACTED]. Review of care plan progress note dated 06/25/18 revealed Resident #26 required minimal assist of one for transfers, dressing, toileting, bathing and the resident was incontinent of bowel and bladder. Observation on 06/26/18 at 3:13 P.M. revealed State tested Nurse Aide (STNA) #15 put on gloves and assisted Resident #26 to get up from her wheelchair and walk into the bathroom. STNA #15 pulled down Resident #26's pants and disposable brief and assisted her to sit on the toilet. STNA #15 did not shut the door to the bathroom while assisting Resident #26 with toileting and incontinence care and Resident #26 was in full view of her roommate. Interview on 06/26/18 at 3:21 P.M., STNA #15 verified she had not closed the door to the bathroom while assisting Resident #26 with toileting and incontinence care. STNA #15 stated she should have closed the door for privacy. This is an incidental citation discovered at the time of the investigation for Complaint Number OH 517.

Based on staff interview and record review, the facility failed to provide showers per the shower schedule for Iwo (#26 and #51) out of three residents reviewed for showers. The facility census was 90. Findings include: 1. Record review of Resident #26 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 03/30/18, revealed the resident was rarely understood and required extensive assistance from staff for bed mobility, transfer, walk in corridor, locomotion on unit, dressing, toilet use and personal hygiene. The resident required physical help of one person for bathing and was frequently incontinent of bladder and occasionally incontinent of bowel. Review of the shower documentation dated 05/01/18 to 06/25/18 revealed Resident #26 was supposed to get showers on Mondays, Wednesdays, and Saturdays. The shower documentation revealed Resident #26 did not receive showers on 05/19/18 ,05/26/18, 06/02/18, 06/09/18, and 06/16/18. Interview with Registered Nurse (RN) #20 on 06/26/18 at 4:24 P.M. verified Resident #26 did not get her showers as required on 05/19/18 ,05/26/18, 06/02/18, 06/09/18, and 06/16/18. 2. Record review of Resident #51 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the shower documentation dated 05/01/18 to 06/25/18 revealed Resident #51 was supposed to get showers on Mondays, Thursdays, and Saturdays. Resident #51 did not receive showers on 05/24/18, 05/26/18, 05/28/18, 06/04/18, 06/07/18, 06/09/18, 06/11/18, 06/14/18, and 06/16/18. Interview with RN #20 on 06/26/18 at 4:24 P.M. verified Resident #51 did not get showers as required on 05/24/18, 05/26/18, 05/28/18, 06/04/18, 06/07/18, 06/09/18, 06/11/18, 06/14/18, and 06/16/18. This deficiency substantiates Complaint Number OH 517.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to follow their infection control policy for posting signage identifying transmission based precautions for one (#10) out of one resident sampled with isolation precautions. The facility census was 90. Findings include: Review of the medical record for Resident #10 revealed she was admitted on [DATE]. [DIAGNOSES REDACTED]. Review of progress note, dated 06/17/18, revealed Resident #10 was being treated for [REDACTED]. Review of progress note, dated 06/25/18, revealed Resident #10 continued with contact precautions for [MEDICAL CONDITION]. Review of the physician's order dated 06/18/18 revealed contact isolation every shift for [MEDICAL CONDITION]. Observation on 06/26/18 at 09:16 A.M. revealed an isolation cart located outside Resident #10's room. There was no signage posted indicating isolation precautions were in effect and instructing all to see the nurse before entering the room. Interview on 06/26/18 at 09:18 A.M., Licensed Practical Nurse (LPN) #22 verified Resident #10 had isolation precautions in place and no signage indicating transmission based precautions was located on the door of Resident #10's room. Review of the facility policy titled Transmission Based Precautions, indicated to protect patient confidentiality and provide a safe and healthful environment a Stop, See Nurse for Instructions sign is posted on patient room door for transmission-based precautions. This is an incidental citation discovered at the time of the investigation for Complaint Number OH 517.

Based on staff interview and observation, the facility failed to post daily nursing staff information that included the census. This had the potential to affect all 90 Residents in the facility. Findings include: Observation on 06/26/18 at 9:15 A.M. revealed the posted daily nursing staff information was from the the previous day 06/25/18 and it did not include the census of the facility. Interview with Registered Nurse #20 on 06/26/18 at 9:17 A.M. verified that the nursing staff information was from the previous day and that it did not include the census of the facility. This is an incidental citation discovered at the time of the investigation for Complaint Number OH 517.

Based on review of the medical record and staff interview, the facility failed to notify the physician of an unintended significant weight loss. This affected one (#74) of four residents reviewed for significant weight loss. There were 20 residents who's weights were reviewed. Facility census was 95. Findings include: Review of the medical record for Resident #74 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the weights revealed on 03/24/17 a weight of 192 pounds, weight on 05/12/17 was 177 pounds and on 06/09/17 the weight was down to 170 pounds. The June 2017 physicians orders included an order for [REDACTED]. Interview with Registered Dietician #140 on 06/22/17 at 1:28 P.M. confirmed there was no evidence the physician was notified of Resident #74's weight loss. She stated she was filling in and was not the regular dietician. She stated the facility has a meeting to discuss weight loss for residents in the facility and provided a worksheet with residents on it and the nurse practitioner was present during the interview and agreed that this happens. It had listed resident names, interventions for the weight loss, orders they need to obtain for these interventions however there was nothing provided for Resident #74 that the physician was notified.

Based on review of the medical record, review of a self-reported incident (SRI), resident and staff interview and review of the facility abuse policy and procedure, the facility failed to thoroughly investigate an allegation of abuse. This affected one (#110) of one resident reviewed for abuse. There were 22 residents interviewed for abuse. Facility census was 95. Findings include: Review of Resident #110's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. On 06/19/17 at 2:08 P.M. Resident #110 stated he was abused while at the facility back on 02/17/17. He stated he had reported it to the nurse at the time. He stated the aide no longer works at the facility. He reported that a nursing assistant started picking on his roommate and then started picking on him. When asked for an example he stated the aide would come in and tell him he didn't have a right to be up this time of night and generally saying things that were not right. He did grab me and lead me to my bed and kind of tossed me down on my bed. I went to the office. At that time my walking ability was better than I am now. He stated that he was a former cop and I'm not letting anyone do that to my roommate. Interview on 06/20/17 at 1:16 P.M. with the administrator revealed she was not the administrator at the time of this investigation. Looking at the records of the investigation including the SRI, interviewable residents were questioned on the unit of the incident, non-interviewable residents were examined by staff for bruising/skin issues. No issues were found. The administrator stated none of the residents interviewed had any problems with the aide. When reviewing the statements, there was a resident, Resident #158, who stated the accused staff member was rough with him. The nursing assistant was suspended pending investigation. Nursing assistant was given a formal education on return. The administrator was asked to see the roommates statement. She began reading the statement to the surveyor. She was asked a second time to see the statement and again she began reading it to the surveyor. She was asked a third time to see the statement and did give it to the surveyor after she was told by the general manager #150 to let the surveyor review it. She had left out some pertinent information in the statement. She was asked why she left out this information and she had no answer. The roommate of the resident was interviewed and his statement closely aligned with Resident #110's statement. The administrator agreed on 06/20/17 at 2:06 P.M. there were no other staff interviews included in the investigation except the nurse the allegation was reported to and the accused staff member. She stated she didn't know how the other administrator came to the conclusion that the abuse was unsubstantiated with two resident statements and another resident who stated he was rough with him. She stated she was not sure because she was not working there at the time of the incident. The general manager #150 stated we should talk to the Director of Nursing (DON) since she was here at the time of the investigation. The DON on 06/20/17 2:11 P.M. agreed interviewable residents were interviewed regarding this allegation. She agreed she had one statement from Resident #158, who was asked if staff is caring and gentle with your care and the care of other patients, who stated no, he was rough helping me to roll over and get changed but he came back later and he was better. She stated she didn't know how the administrator decided this was unsubstantiated abuse. She agreed that there were no statements or interviews with other staff who were working at the time of the incident or other staff who may have worked with the accused aide. Review of the abuse policy and procedure dated 11/11 titled Patient Practice Guide revealed on page 10, once reported, the center conducts a timely, thorough and objective investigation of any allegations of abuse. Part of this investigation is the consideration of the indicators of possible abuse.