Every finding on record at Home at Hearthstone, The

Based on observations, staff interview, review of the admission agreement, and record review, the facility failed to ensure residents were treated with dignity and respect during dining and incontinence care. This affected four (#6, #27, #38, and #55) of four residents reviewed for dignity. The facility census was 87. Findings include:1. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE]. Diagnoses included cerebral infarction.The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #6 had moderately impaired cognition and required substantial assistance with toileting.Observation in the 100-hallway on 12/17/25 from 9:03 A.M. to 9:05 A.M. revealed staff were performing incontinence care on Resident #6 without the door closed or privacy curtain pulled. From the hallway, staff were observed in Resident #6's room and rolled the resident on her side so that she was uncovered and no clothes from waist down. The staff rolled Resident #6 the other way still undressed. Licensed Practical Nurse (LPN) #22 closed Resident #6's door at 9:06 A.M. Interview on 12/17/25 at 9:06 A.M. with LPN #22 confirmed the door was open while staff were performing incontinence care.Observation and interview on 12/17/25 at 9:09 A.M. revealed Certified Nursing Assistant (CNA) #23 walking out of Resident #6's room with a bag of soiled items. CNA #23 confirmed the door was open during incontinence care for Resident #6.Interview on 12/17/25 at 2:42 P.M. with the Administrator and the Director of Nursing (DON) confirmed the privacy curtain should remain pulled and the door closed during incontinence care. Review of the facility's (undated) admission packet revealed the residents have the right to privacy during medical examination or treatment and in the care of personal or bodily needs.2. Review of the medical record revealed Resident #27 had diagnoses including Alzheimer's disease with early onset, delusional disorders, and dementia. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the Resident #27 had severely cognitive impairment, and required set up assistance for eating.Review of the medical record revealed Resident #38 had diagnoses including vascular dementia, dysphagia, and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. The MDS 3.0 assessment dated [DATE] revealed Resident #38 had moderately impaired cognition and was dependent on staff for eating.Review of the medical record revealed Resident #55 had diagnoses including dementia, dysphagia following cerebral infarction, aphasia, and type two diabetes mellitus. The MDS 3.0 assessment dated [DATE] revealed Resident #55 had severe cognitive impairment and required set up assistance for eating.Observation on 12/17/25 at 11:48 A.M. revealed Certified Nursing Assistant (CNA) #99 placed a clothing protector on Resident #55. Resident #55 was in wheelchair at the table in the dining room preparing to eat. CNA #99 then put the clothing protectors on Resident #27 and Resident #38.Interview on 12/17/25 at 11:50 A.M. with CNA #99 revealed clothing protectors were put on the residents in case the residents try to feed themselves, it will prevent food from getting on them. Interview on 12/17/25 at 12:07 P.M. with the Administrator revealed the clothing protectors were used if the residents were care planned for it, but not sure if there was a policy regarding the clothing protectors. At 12:15 P.M., the Administrator confirmed there was no policy for clothing protectors. The Administrator confirmed they wear the clothing protectors if residents request them. The Administrator was unable to answer if clothing protectors should be worn for residents who have severe cognitive impairment. Interview on 12/17/25 at 1:08 P.M. with CNA #76 confirmed they automatically put on clothing protectors to protect clothing, they do not ask residents, and no residents ask for the clothing protectors. Review of the facilities (undated) admission packet revealed the residents have the right to be treated at all times with courtesy, respect, and full recognition of dignity and individuality.This deficiency represents non-compliance investigated under Complaint Number 2645862.

Based on observation, interview, record review, and policy review, the facility failed to have physician orders for the use of supplemental oxygen. This affected one (Resident #57) of one resident reviewed for respiratory care. Findings included: Review of the admission record revealed Resident #57 was admitted on [DATE]. The resident had diagnoses including chronic obstructive pulmonary disease (COPD) and chronic respiratory failure with hypoxia. Review of the physician orders revealed no order for oxygen. Review of the admission Minimum Data Set (MDS) assessment, dated 07/12/24, revealed Resident #57 had moderate cognitive impairment. Resident #57 did not have oxygen therapy on admission or while a resident during the assessments 14-day lookback period. Review of Resident #57's care plan dated 07/15/24, documented the resident had altered health maintenance related to progressive physical and mental status and diagnoses of COPD and acute respiratory failure. Interventions directed staff to administer oxygen per the physician's orders. During an observation on 07/22/24 at 9:58 AM, Resident #57 was receiving oxygen at a flow rate of 4.5 liters per minute. During a concurrent interview Resident #57 stated they never touched the oxygen flow rate setting. During an observation on 07/23/24 at 3:00 PM, Resident #57 was sitting up on the side of their bed wearing a nasal cannula with oxygen set at a flow rate of 4.5 liters per minute. During an observation on 07/24/24 at 7:30 AM, Resident #57 was lying in their bed on their back wearing a nasal cannula with oxygen set at a flow rate of 4 liters per minute. During an observation and interview on 07/24/2024 at 1:33 PM, Registered Nurse (RN) #4 went to the dining room. Resident #57 at the dining room tables wearing supplemental oxygen set at 4 liters per minute via a portable oxygen tank. RN #4 said that the resident's oxygen was set at 4 liters per minute and stated that was what she thought the resident's order for oxygen was. She said that she thought that Assistant Director of Nursing (ADON) #5 had applied the resident's oxygen earlier that day. RN #4 reviewed Resident #57's orders and said she was unable to find an order for the resident's oxygen flow rate settings. She stated that she put Resident #57's oxygen on the previous day, before the resident left for dialysis, at a flow rate of 4 liters per minute. During an observation and interview on 07/24/2024 at 1:52 PM, ADON #5 checked Resident #57's oxygen flow rate and stated that it was set at 4 liters per minute. ADON #5 stated she thought the resident was supposed to receive oxygen at a flow rate of 2 liters per minute. ADON #5 stated Resident #57's supplemental oxygen was set at a flow rate of 4 liters per minute this morning when the resident was up in their wheelchair and the flow rate was adjusted to 2 liters per minute. ADON #5 stated that the resident was known to change their supplemental oxygen flow rate settings. During a concurrent interview Resident #57 stated they did not change their supplemental oxygen flow rate settings and that they did not know how to. ADON #5 reviewed Resident #57's orders and stated that there was no order for the resident's supplemental oxygen flow rate settings.

Based on observation, interview, record review, and policy review, the facility failed to ensure a urinary catheter bag was not left on the floor and failed to ensure contaminated incontinence care supplies were disposed of appropriately. This affected two (Residents #54 and #21). Findings include: 1. Review of the admission record revealed the facility admitted Resident #54 on 07/14/23. Diagnoses included obstructive and reflux uropathy. Review of the annual Minimum Data Set (MDS) assessment, dated 06/08/24, revealed Resident #54 had intact cognition. The resident had an indwelling catheter. During an observation on 07/22/24 at 10:37 AM, Resident #54 was sitting up on the side of their bed with the urinary catheter bag lying on the floor. During an observation on 07/22/24 at 10:40 AM , a State tested Nurse Aide (STNA) entered the room to answer the call light and exited the room without removing the catheter bag from the floor. The STNA returned at 10:42 AM and again left without taking the catheter bag off the floor. During observations 07/22/24 at 10:48 AM, 11:14 AM and 11:46 AM, Resident #54's urinary catheter bag remained on the floor. During an observation on 07/22/24 at 11:48 AM, STNA #20 entered Resident #54's room, washed her hands, told the resident she would be back, and exited the room without removing the urinary catheter bag from the floor. During an interview on 07/23/24 at 10:32 AM, STNA #20 stated that Resident #54's catheter bag should never be left on the floor due to the floor being dirty and possible cross contamination. 2. Review of the admission record revealed the facility admitted Resident #21 on 05/24/23. The resident had diagnoses including multiple sclerosis, hemiplegia and hemiparesis (muscle weakness on one side of the body) following cerebral infarction (stroke), and an overactive bladder. Review of the quarterly MDS, dated [DATE], revealed Resident #21 had intact cognition. Resident #21 required substantial to maximal assistance with toilet hygiene, was always incontinent of urine, and was frequently incontinent of bowel. Resident #21's care plan initiated on 05/25/23, documented the resident may require assistance with activities of daily living (ADL), was incontinent of bladder and bowel and required the assistance of two staff members for toileting. During an observation on 07/23/24 at 10:37 AM, a STNA #12 positioned Resident #21 in a sit-to-stand lift so that they could perform incontinence care. While providing care, STNA #12 discarded the soiled cloths directly on the floor with the resident's soiled brief. During an interview on 07/23/24 at 11:05 AM, STNA #12 stated she set the soiled brief and the soiled incontinence supplies on the floor and bagged them after completing Resident #21's incontinence care. STNA #12 stated that was not how she was trained, and she was trained to place the soiled supplies into a bag and not on the floor. Review of the policy titled Infection Prevention and Control Program (IPCP), revised 11/28/2017, revealed it is a policy of this facility to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Review of the facility policy titled Skin: Incontinence Care Protocol, revised 09/17, revealed the facility will provide incontinence care for the resident to assist in maintaining skin integrity, preventing skin breakdown, controlling odor and providing comfort and self-esteem for the resident. Dispose of soiled equipment and supplies in the appropriate receptacle.

Based on interview, record review, and policy review, the facility failed to report an alleged incident of resident to resident abuse. This affected two (Residents #25 and #65) of two residents reviewed for mood/behavior needs. Findings include: 1. Review of the admission record revealed the facility admitted Resident #65 on 11/23/19. The resident had diagnoses including dementia of unspecified severity with other behavioral disturbance, need for assistance with personal care, restlessness and agitation, delusional disorders, and hallucinations. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/22/24, revealed Resident #65 had short- and long-term memory problems and had severely impaired cognitive skills for daily decision making. The resident experienced hallucinations and delusions, exhibited physical, verbal, and other behavioral symptoms directed towards others, and wandered during one to three days of the assessment look-back period. Resident #65's care plan initiated on 02/26/20, stated the resident had altered cognitive function, dementia, and delusional disorder. The resident had a history of wandering into rooms and verbalizing delusional/unrelated comments. The resident was also known to pace the unit in their wheelchair, bumping into walls and other residents due to poor posture. 2. Review of the admission record revealed the facility admitted Resident #25 on 02/11/20. The resident had diagnoses including Parkinsonism, delusional disorders, post-traumatic stress disorder (PTSD), major depressive disorder, and dementia in other diseases classified elsewhere without mood disturbance. Review of the quarterly MDS dated [DATE], revealed Resident #25 had short- and long-term memory problems and had moderately impaired cognitive skills for daily decision making. The resident had delusions, exhibited verbal behavioral symptoms directed towards others during four to six days of the assessment look-back period, wandered during one to three days of the assessment look-back period, and rejected care daily during the assessment look-back period. Resident #25's care plan, initiated on 09/27/22, stated the resident experienced alterations in mood and/or behaviors as evidenced by having difficulty concentrating, resident has a diagnosis of depression, speaking or moving slowly or feeling fidgety/restless, lack of interest, appearing down, sleeping too much, tired, poor appetite, easily annoyed/short-tempered, displays agitation, physical behaviors, paces, hoarding, and yelling. 3. Review of the Resident #65's progress notes, dated 07/13/24 at 9:57 AM documented Resident #65 was being yelled at by another resident, who swung their left hand at Resident #65. After separating the residents, a slight scratch was noted on Resident #65's left cheek bone. Review of Resident #25's progress notes, dated 07/13/24 at 9:23 AM, stated Resident #25 was seated at a dining room table when another resident approached them. Resident #25 started yelling and hit the other resident with their left hand. Review of the document titled General Investigation of Incident, signed by the Director of Nursing (DON) on 07/15/24, revealed that on 07/13/24, a physical altercation occurred between Resident #25 and Resident #65. Resident #25 was sitting at a dining room table when Resident #65 bumped Resident #65's wheelchair. Resident #25 started yelling and hit Resident #65 on their left cheek. The physician and responsible parties were notified; however, there was no documentation to indicate the facility reported the incident to the state survey agency. During an interview on 07/23/24 at 3:15 PM, Licensed Practical Nurse (LPN) #6 stated the DON was notified of the incident involving Resident #25 and Resident #65 that occurred the week prior. During an interview on 07/25/24 at 12:51 PM, DON #3 stated any occurrence between residents should be reported immediately after ensuring the safety of the residents. She stated incidents resulting in serious injury, falls with hospitalization , anything fatal to a resident, any injury or medication error resulting in death, any allegation of abuse, or unknown injuries were all incidents that needed to be reported. She stated the incidents between Resident #25 and Resident #65 in July 2024 did not meet the reporting criteria because both residents had dementia and did not recall the incident afterwards, and no major injuries were sustained by either resident; although she stated she felt there was intent when Resident #25 hit Resident #65. DON #3 stated that the Administrator was responsible for submitting reports to the state survey agency. During an interview on 07/25/24 at 5:05 PM, the Administrator stated that per guidance from the state survey agency, any incident with police involvement, serious injury, injury of unknown origin, and resident-to-resident incidents that resulted in serious physical or psychosocial injury should be reported to the state survey agency. The Administrator stated the incident on 07/13/24 did not qualify for reporting, because there was no intent to harm between the residents. Per the Administrator, Resident #65 bumped into Resident #25, and in response, Resident #25 flailed to get them away. She stated that neither resident recalled the incident and neither had any decline in function. A facility policy titled, Abuse, Neglect, Exploitation & [and] Misappropriation of Resident Property, dated 11/21/2016, indicated, E. REPORT & INVESTIGATE l. All incident and allegations of Abuse, Neglect, Exploitation, Mistreatment of a resident, or Misappropriation of Resident Property and all Injuries of Unknown Source must be reported immediately to the Administrator or designee. 2. In response to allegations of abuse, neglect, exploitation or mistreatment, the facility must: a. Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation or [sic] resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the advents that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator or designee of the facility and to other officials, including the State Survey Agency, in accordance with State law.

Based on observation, medical record review, staff interview, and review of a facility policy, the facility failed to ensure interventions to prevent skin breakdown were in place as ordered by the physician and per the resident plan of care. This affected two (#18 and #60) of three residents reviewed for pressure ulcers. The facility census was 86. Finding include: 1. Review of the medical record for Resident #18 revealed an admitted [DATE] with diagnoses including Alzheimer's disease, chronic obstructive pulmonary disease (COPD), osteoporosis, and mitral valve insufficiency. Review of the Minimum Data Set (MDS) assessment for Resident #18 dated 03/13/23 revealed the resident was cognitively impaired and required extensive assistance of one staff with activities of daily living (ADLs). Further review of the MDS assessment for Resident #18 revealed the resident was assessed with a stage four pressure ulcer (full-thickness skin and tissue loss) which was present upon admission to the facility. Review of the pressure ulcer risk assessment for Resident #18 dated 03/06/23 revealed the resident was at risk for the development of pressure ulcers. Review of the care plan for Resident #18 dated 03/06/23 revealed the resident had an alteration in skin integrity as evidenced by a pressure ulcer was present at the sacrum. Interventions included to elevate heels in bed as tolerated and as needed, encourage and assist the resident to turn and reposition as needed, provide assistance with ADLs and positioning as needed, provide the resident and family education on skin impairment and potential complications as needed, provide skin care as needed, and provide treatments per physician orders. Review of the care plan for Resident #18 dated 03/14/23 revealed the resident was at risk for alteration in skin integrity related to blood disease, cognitive impairment, dementia, incontinence, mobility impairment, and existing pressure ulcer. Interventions included that staff should encourage and assist the resident to elevate heels when in bed as needed and as tolerated, and provide assistance with ADLs and positioning as needed. Review of Resident #18's May 2023 monthly physician orders revealed an order dated 03/06/23 to encourage and assist the resident to float heels every shift. Review of the May 2023 treatment administration record (TAR) for Resident #18 revealed the order to float heels was signed off as completed daily every shift. Review of the nursing progress notes for Resident #18 dated 05/01/23 to 05/15/23 revealed no documentation of Resident #18's refusal of interventions to prevent skin breakdown including floating of heels. Observation on 05/15/23 at 9:22 A.M. of Resident #18 revealed the resident was resting in bed and her heels were not floated or elevated. There were no open areas or redness noted to Resident #18's heels at that time. Interview on 05/15/23 at 9:22 A.M. with State tested Nurse Aide (STNA) #335 confirmed Resident #18's heels were not floated or elevated, and she was not aware of any orders to float or elevate the resident's heels. Observation on 05/16/23 at 6:55 A.M. of Resident #18 revealed resident was resting in her recliner and her heels were not floated or elevated. There were no open areas or redness noted to Resident #18's heels at that time. Interview on 05/16/23 at 6:55 A.M. with STNA #360 confirmed Resident #18's heels were not floated or elevated, and she was not aware of any orders to float or elevated the resident's heels. STNA #360 further confirmed she learned in report the night shift nurse aide got the resident up in her recliner about an hour prior to the observation. STNA #360 confirmed Resident #18's recliner did have a footrest which could be raised by staff if desired in order to elevate Resident #18's heels. Interview on 05/16/23 at 1:00 P.M. with the Administrator confirmed Resident #18 had a physician's order to float or elevate her heels every shift to prevent skin breakdown. 2. Review of the medical record for Resident #60 revealed an admitted [DATE] with diagnoses including spinal stenosis, hypertension (HTN), acute kidney failure (AKF), diabetes mellitus (DM), Down's syndrome, and seizure disorder. Review of the MDS assessment for Resident #60 dated 05/03/23 revealed the resident was cognitively impaired and required extensive assistance of one to two staff with ADLs. Review of the MDS assessment for Resident #60 revealed the resident was assessed with the presence of a stage four pressure ulcer that was not present on admission to the facility. Review of the pressure ulcer risk assessment for Resident #60 dated 01/30/22 revealed the resident was at risk for the development of pressure ulcers. Review of the care plan for Resident #60 dated 12/21/21 revealed the resident was at risk for alteration in skin integrity related to apathy and lack of concern, cognitive impairment, dementia, diabetes, incontinence, mobility impairment, and obesity. Interventions included to assess for pain and provide treatment per physician orders, encourage and assist the resident to elevate heels when in bed as needed and tolerated, encourage and assist the resident to turn and reposition as needed, offloading pressure boots as tolerated to the left foot every shift and check skin when donning and doffing, provide assistance with ADLs and positioning as needed, provide the resident and family education on maintaining skin integrity and potential complications as needed, and provide skin care as needed. Review of the care plan for Resident #60 dated 10/05/22 revealed the resident had an alteration in skin integrity as evidenced by a pressure ulcer was present to the sacrum. Interventions included to assess for pain and provide treatment per physician order, elevate heels in bed as tolerated and as needed, encourage and assist the resident to turn and reposition as needed, provide assistance with ADLs and positioning as needed, provide the resident and family education on skin impairment and potential complications as needed, provide skin care as needed, and provide treatments per physician orders. Review of May 2023 monthly physician orders for Resident #60 revealed an order dated 01/18/23 for staff to encourage and assist the resident to float heels off the bed as tolerated every shift, and an order to apply offloading pressure boots as tolerated with skin checks completed with donning and doffing as tolerated. Review of the May 2023 TAR for Resident #60 revealed the orders to float heels and provide offloading pressure boots were signed off as completed every shift. Review of the nursing progress notes for Resident #60 dated 05/01/23 to 05/15/23 revealed there was no documentation of the resident's refusal of interventions to prevent skin breakdown including floating heels and the application of bilateral pressure boots. Observation on 05/15/23 at 9:31 A.M. of Resident #60 revealed the resident had a pressure boot on her left foot; however, Resident #60's right heel was laying directly on the mattress and neither heel was elevated. Observation of the exposed right heel revealed no redness or skin breakdown. Interview on 05/15/23 at 9:31 A.M. with Registered Nurse (RN) #300 confirmed Resident #60 had orders to float her heels and to have offloading pressure boots applied as ordered. RN #300 confirmed Resident #60's heels were not floated or elevated at the time of the observation. Review of the facility policy titled, Skin Assessment, dated September 2017, revealed the facility would provide necessary treatment and services to promote healing, prevent infection, and prevent new ulcers from developing. The facility would ensure interventions for preventing pressure ulcer development were defined and implemented in accordance with the resident's needs, goals, and recognized standards of practice. This deficiency represents non-compliance investigated under Complaint Number OH00139522, Complaint Number OH00135816, and Complaint Number OH00135758.

Based on record review, observation, resident representative and staff interview, review of facility Self-Reported Incidents (SRI's), review of facility documents, and review of facility policy, the facility failed to report potential misappropriation of resident property to the Ohio Department of Health. (ODH). This affected one (#81) of three residents reviewed for misappropriation of property. The census was 88. Findings include: Review of the medical record for Resident #81 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) for Resident #81 dated 03/12/22 revealed resident was cognitively impaired and required extensive assistance of one to two staff with activities of daily living (ADL's.). Review of the activity progress note for Resident #81 dated 09/07/21 revealed resident's family shared resident preferred small group activities or activities in her own room. Resident #81 was particularly interested in watching television and had favorite shows she liked to watch regularly. Review of the care plan for Resident #81 dated 09/24/21 revealed resident had the potential for alterations in activities due to medical fluctuation and was unable to pursue her interests due to her physical and/or cognitive condition. Resident #81 was willing to interact with others and participate in activities. Watching television and movies was an important activity to resident. Interventions included the following: encourage and allow resident to rest so she may attend the activities per preference, give resident verbal reminders of activity before commencement of activity, invite, and encourage resident's family to attend activities. Review of the nurse progress note for Resident #81 dated 02/08/22 revealed the resident was moved from a room on the first floor to a room on the second floor. Review of the facility document titled Theft or Missing Item Report dated 02/16/22 completed by Social Service Designee (SSD) #770 revealed Resident #81's television set was reported missing on 02/16/22 and was last seen in her old room on the first floor prior to her room change. Further review of report revealed SSD #770 interviewed nurses and State tested Nursing Assistants (STNA's) and they confirmed resident had television in her room on the first floor. Facility staff were unable to find resident's television set. There was no inventory sheet on files for Resident #81's belongings. There was no documentation of an interview with the staff member who moved Resident #81's room. Resolution listed on form was Resident #81's representative purchased a new television for resident. Police were not notified. At the top of the form, it was noted that when there is an allegation of misappropriation of resident property a complete investigation would be completed, and the incident would be reported to ODH. Review of the facility SRI's dated 02/16/22 through 05/25/22 revealed there were no SRI's filed related to Resident #81's television set. Interview on 05/24/22 at 4:00 P.M. with Assistant Administrator (AA) #315 confirmed Resident #81's television was reported missing by one of the resident's representatives shortly after she moved from the first floor to the second floor. AA #315 confirmed the facility completed a missing item report but did not report the incident as an SRI because Resident #81's representative did not allege misappropriation and the resident representative purchased a new television set for resident the same day it was reported missing. AA #315 further confirmed there was no inventory sheet on files for Resident #81's belongings and there was no documentation of an interview with the staff member who moved Resident #81's room. Interview on 05/24/22 at 4:30 P.M. with SSD #770 confirmed she completed the missing item report for Resident #81's television set. SSD #770 confirmed staff reported Resident #81 had her television set in her room when she was on the first floor but once she got moved upstairs the television was not there. SSD #770 did not know which staff had facilitated the room move and did not interview them. SSD #770 confirmed the staff searched for the television but were unable to locate it. SSD #770 confirmed she considered the concern to be resolved because the resident representative had purchased a new television for Resident #81. Interview on 05/25/22 at 9:50 AM. with Resident #81's representative confirmed Resident #81's family brought in her television from home when she was admitted to the facility. Resident #81's representative further confirmed RR #800 discovered the television was missing when she visited Resident #81 in February 2022 after the resident moved from first floor to the second floor. Resident #81's representative confirmed she reported to the facility the television was missing and the facility never explained what happened to resident's television. Resident #81's representative further confirmed RR #800 purchased a new television for the resident the same day it was noted missing because she didn't want resident to be without a television because that was very important to resident. Interview on 05/25/22 at 3:18 P.M. with Resident #81's representative confirmed the resident family brought in her television from home when she was admitted to the facility and resident enjoyed watching television. Resident #81 representative confirmed she visited the resident shortly after she was moved from the first floor to the second floor and noted the television was gone. Resident #81's representative confirmed she purchased a replacement television for the resident that same day so the resident would not have to be without a television while the facility was searching for television family had brought in upon admission. Review of the facility policy titled Abuse, Neglect, and Misappropriation of Resident Property dated 11/21/16 revealed residents or interested family members could contact the facility at any time with concerns including concerns regarding misappropriation and the facility would report misappropriation to ODH. This deficiency substantiates Complaint Number OH 661.

Based on record review, observation, resident representative interview, staff interview, review of facility Self-Reported Incidents (SRI's), review of facility documents, and review of facility policy, the facility failed to thoroughly investigate potential misappropriation of resident property. This affected one (#81) of three residents reviewed for misappropriation of property. The census was 88. Findings include: Review of the medical record for Resident #81 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) for Resident #81 dated 03/12/22 revealed resident was cognitively impaired and required extensive assistance of one to two staff with activities of daily living (ADL's.). Review of the activity progress note for Resident #81 dated 09/07/21 revealed resident's family shared resident preferred small group activities or activities in her own room. Resident #81 was particularly interested in watching television and had favorite shows she liked to watch regularly. Review of the care plan for Resident #81 dated 09/24/21 revealed resident had the potential for alterations in activities due to medical fluctuation and was unable to pursue her interests due to her physical and/or cognitive condition. Resident #81 was willing to interact with others and participate in activities. Watching television and movies was an important activity to resident. Interventions included the following: encourage and allow resident to rest so she may attend the activities per preference, give resident verbal reminders of activity before commencement of activity, invite, and encourage resident's family to attend activities. Review of the nurse progress note for Resident #81 dated 02/08/22 revealed the resident was moved from a room on the first floor to a room on the second floor. Review of the facility document titled Theft or Missing Item Report dated 02/16/22 completed by Social Service Designee (SSD) #770 revealed Resident #81's television set was reported missing on 02/16/22 and was last seen in her old room on the first floor prior to her room change. Further review of report revealed SSD #770 interviewed nurses and State tested Nursing Assistants (STNA's) and they confirmed resident had television in her room on the first floor. Facility staff were unable to find resident's television set. There was no inventory sheet on files for Resident #81's belongings. There was no documentation of an interview with the staff member who moved Resident #81's room. Resolution listed on form was Resident #81's representative purchased a new television for resident. Police were not notified. At the top of the form, it was noted that when there is an allegation of misappropriation of resident property a complete investigation would be completed, and the incident would be reported to ODH. Review of the facility SRI's dated 02/16/22 through 05/25/22 revealed there were no SRI's filed related to Resident #81's television set. Interview on 05/24/22 at 4:00 P.M. with Assistant Administrator (AA) #315 confirmed Resident #81's television was reported missing by one of the resident's representatives shortly after she moved from the first floor to the second floor. AA #315 confirmed the facility completed a missing item report but did not report the incident as an SRI because Resident #81's representative did not allege misappropriation and the resident representative purchased a new television set for resident the same day it was reported missing. AA #315 further confirmed there was no inventory sheet on files for Resident #81's belongings and there was no documentation of an interview with the staff member who moved Resident #81's room. Interview on 05/24/22 at 4:30 P.M. with SSD #770 confirmed she completed the missing item report for Resident #81's television set. SSD #770 confirmed staff reported Resident #81 had her television set in her room when she was on the first floor but once she got moved upstairs the television was not there. SSD #770 did not know which staff had facilitated the room move and did not interview them. SSD #770 confirmed the staff searched for the television but were unable to locate it. SSD #770 confirmed she considered the concern to be resolved because the resident representative had purchased a new television for Resident #81. Interview on 05/25/22 at 9:50 AM. with Resident #81's representative confirmed Resident #81's family brought in her television from home when she was admitted to the facility. Resident #81's representative further confirmed RR #800 discovered the television was missing when she visited Resident #81 in February 2022 after the resident moved from first floor to the second floor. Resident #81's representative confirmed she reported to the facility the television was missing and the facility never explained what happened to resident's television. Resident #81's representative further confirmed RR #800 purchased a new television for the resident the same day it was noted missing because she didn't want resident to be without a television because that was very important to resident. Interview on 05/25/22 at 3:18 P.M. with Resident #81's representative confirmed the resident family brought in her television from home when she was admitted to the facility and resident enjoyed watching television. Resident #81 representative confirmed she visited the resident shortly after she was moved from the first floor to the second floor and noted the television was gone. Resident #81's representative confirmed she purchased a replacement television for the resident that same day so the resident would not have to be without a television while the facility was searching for television family had brought in upon admission. Review of the facility policy titled Abuse, Neglect, and Misappropriation of Resident Property dated 11/21/16 revealed residents or interested family members could contact the facility at any time with concerns including concerns regarding misappropriation and the facility would report misappropriation to ODH. This deficiency substantiates Complaint Number OH 661.

Based on record review, observation, staff interview, and review of the policy, the facility failed to assess and treat a resident displaying physical and verbal signs of pain, and ensure physicain ordered pain medcaitions were available for admintstration to treat pain. This affected one (#23) of three residents observed for pain management. The facility census was 82. Findings include: Review of the medical record for Resident #23 revealed a readmitted [DATE], with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment for Resident #23 revealed the resident was cognitively impaired and required extensive assistance of staff with activities of daily living. Review of the care plan for Resident #23 dated 03/01/22, revealed resident is at risk for alteration in comfort, back, disease process/condition, generalized pain. Resident received as needed pain medication for complaints of pain and asked for it when needed and stated that pain medications were effective when administered. Goal of care was: complaints/signs of discomfort would be reduced or resolved following intervention. Interventions included the following: decrease residents' pain to an acceptable level for the resident which allows participation in ADL's, activities, therapy, treatment, etc.; acknowledge presence of pain and discomfort; listen to resident's concerns; administer medications as ordered; monitor for effectiveness of interventions; monitor for increased levels of pain and notify physician; and use pain scale as reported by resident, offer non-pharmacological interventions (quiet environment, repositioning, back rub, diversion activities). Review of the nurse's progress note for Resident #23, dated 04/20/22, revealed the resident's order for [MEDICATION(S)] was discontinued and the physician gave a new order for [MEDICATION(S)] twice daily as needed for pain. Review of the 04/20/22 physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the April Medication Administration Record (MAR) for Resident #23 revealed the last assessment of resident's pain recorded was conducted on 04/19/22 at 5:19 P.M., prior to administration of [MEDICATION(S)] (before the medication was discontinued). Resident #23's pain level was documented as 7 out of 10 (scale of 1 to 10 with 10 being the absolute worst pain). The nurse noted the medication was not effective. Further review of the MAR revealed the pain assessment section of the MAR was not completed on 04/21/22 or 04/22/22. Review of the MAR and nurse's notes revealed no documentation of attempted non-pharmacological interventions for pain prior to medication administration. Observation on 04/22/22 at 10:05 A.M., revealed Resident #23 had a moderate amount of emesis after Licensed Practical Nurse (LPN) #200 administered morning medications. Further observation revealed Resident #23 exhibited the following nonverbal signs of pain: facial grimacing, clenched fists, crying. Resident #23 verbalized complaints of abdominal and back pain. The nurse was observed not to assess the resident or question the resident regarding her pain level. Resident #23 also was observed to moan and cry out regarding her pain. Interview on 04/22/22 at 10:30 A.M., with LPN #200 confirmed Resident #23 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #200 stated the pain medication [MEDICATION(S)] was not available from pharmacy and could not be pulled from the emergency supply. LPN #200 confirmed Resident #23 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #200 further confirmed Resident #23's pain level should be assessed every shift and she did not conduct a pain assessment of the resident during medication administration. Observation on 04/22/22 at 10:55 A.M., revealed LPN #200 administered Tylenol per gastronomy tube to Resident #23. Resident #23 was crying and rated her pain for the nurse as 10 out of 10. Resident #23 verbalized she thought the vomiting had made her abdominal pain worse than usual. Observation on 04/22 at 11:57 A.M., revealed LPN #200 asked Resident #20 if the Tylenol was effective and resident said it was not effective and Resident #20 rated her pain as 10 out of 10. Review of the policy titled Pain Assessment and Management dated 03/31/16, revealed assessments, adequate management, and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficiency substantiates Complaint Number OH 177.

Based on record review, observation, staff interview, and review of facility policy the facility failed to ensure staff stored handheld nebulizer masks and tubing in a sanitary manner and ensure nebulizer masks and tubing were changed regularly. This affected one (#23) of three residents observed for medication administration. The census was 82. Findings include: Review of the medical record for Resident #23 revealed a readmitted [DATE], with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment for Resident #23 revealed resident was cognitively impaired and required extensive assistance of staff with activities of daily living. Review of the April 2022, physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no orders indicating how often the nebulizer mask and tubing should be changed. Review of the April 2022, Medication Administration Record (MAR) for Resident #23 revealed the resident received budesonide via HHN twice daily. Review of the April 2022 MAR and April 2022 Treatment Administration Record (TAR) for Resident #23 revealed there were no orders to change the nebulizer mask and tubing. Review of the nurse's progress notes, dated 04/01/22 through 04/22/22, revealed notes were silent regarding changing of nebulizer mask and tubing. Observation on 04/22/22 at 10:01 A.M., revealed the nebulizer mask and tubing for Resident #23 was undated and was found to be resting directly on the resident's windowsill. Intervention on 04/22/22 at 10:01 A.M., with Licensed Practical Nurse (LPN) #200 confirmed Resident #23's nebulizer mask and tubing was undated and was resting directly on the resident's windowsill. LPN #200 further confirmed she was unsure when the mask and tubing was last changed. Interview on 04/22/22 at 4:00 P.M. with Assistant Administrator (AA) #100 confirmed the facility staff should change nebulizer masks and tubing at least once weekly. AA #100 further confirmed the facility had no documentation regarding nebulizer mask and tubing change for Resident #23. Review of the policy titled Small Volume HHN dated 11/24/15, revealed to reduce the incidence of pneumonia and other respiratory tract infections staff should discard remaining contents of solution in nebulizer and place equipment in plastic equipment bag following treatments.

Based on record review and staff interview, the facility failed to ensure a resident was provided with the required beneficiary notice in writing and in advance of discontinuing skilled Medicare part A services. This affected one (#74) of three residents reviewed for beneficiary protection notification. The facility census was 84. Findings include: Review of the Resident #74's chart revealed Resident #74 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #74's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to be moderately cognitively impaired and Resident #74 required supervision with bed mobility, transfers, eating, toileting, and personal hygiene. Resident #74 required limited assistance with dressing. Review of Resident #74's chart revealed Resident #74 was admitted to the facility on [DATE] under Medicare Part A services. Resident #74's last covered day of Medicare Part A services was 01/13/22. Review of Resident #74's Notice of Medicare Non Coverage (NOMNC) dated 01/12/22 revealed Resident #74's Medicare Part A services would end on 01/13/22. Further review of the NOMNC revealed verbal consent was received on 01/12/22 and the NOMNC was completed by Social Services #65 and witnessed by Registered Nurse (RN) #18. The form did not include the name of the person that provided the verbal consent. Review of Resident #74's Skilled Nursing Facility Advanced Beneficiary Notice of Non Coverage (SNFABN) dated 01/12/22 revealed Resident #74 may have to pay out of pocket for skilled services beginning on 01/13/22. Further review of the SNFABN revealed verbal consent was received on 01/12/22 and the SNFABN was completed by Social Services #65 and witnessed by Registered Nurse (RN) #18. The form did not include the name of the person that provided the verbal consent. Interview on 02/01/22 at 2:00 P.M. with Manager of Clinical Services #300 verified Resident #74's NOMNC and SNFABN was only provided one day prior to Resident #74's discharge from Medicare Part A skilled services. Telephone interview with Manager of Clinical Services #300 on 02/03/22 at 10:56 A.M. revealed the facility did not have a policy on beneficiary notices.

Based on interview and record review, the facility failed to provide a resident with their possessions after a room change. This affected one resident (#14) out of 84 residents residing at the facility. The facility census was 84. Findings include: Review of the Resident #14's chart revealed Resident #14 admitted to the facility on [DATE] with diagnoses including other injury of unspecified body region, presence of left artificial knee joint, arthritis due to other bacteria, [CONDITION(S)] of left lower limb, essential hypertension, pain in left leg, retinal artery branch occlusion, low tension [CONDITION(S)], unqualified visual loss both eyes, myopia, [CONDITION(S)] and carpal tunnel syndrome right upper limb. Review of Resident #14's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to be severely cognitively impaired and Resident #14 required extensive with transfers, bed mobility, dressing, toileting, and personal hygiene. Resident #14 also required supervision with eating and Resident #14 had adequate vision with no devices. Review of Resident #14's census sheet revealed Resident #14 moved from the sycamore to the willow unit on 01/03/22. Review of Resident #14's progress note dated 01/03/22 revealed Resident #14 and Resident #14's family was notified of a room change. Interview with Resident #14 on 01/31/22 at 9:45 A.M. revealed she moved rooms approximately five to six weeks ago due to the facility making a coronavirus (COVID-19) unit and she still had not received all her belongings. Interview on 02/02/22 at 1:47 P.M. with Licensed Practical Nurse (LPN) #93 revealed residents that were moved from their rooms when the facility made the COVID-19 unit had their belongings locked up in storage. LPN #93 verified resident belongings remained in storage. Email correspondence with Assistant Administrator #117 on 02/03/22 at 12:56 P.M. revealed the facility did not have policy on moving resident belongings.

Based on observation, record review and staff interview, the facility failed to ensure privacy curtains were clean and free of stains and substances. This affected two (#17 and #09) of 24 residents reviewed for privacy curtains. The facility census was 84. Findings include: 1. Review of the Resident #9's chart revealed Resident #09 admitted to the facility on [DATE] with diagnoses including [CONDITION(S)], [CONDITION(S)] disease, shortness of breath, [CONDITION(S)], [CONDITION(S)], other irritable bowel syndrome, other muscle spasms and unspecified abdominal pain. Review of Resident #09's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to be moderately cognitively impaired and Resident #9 required extensive with bed mobility, transfers, dressing, toileting, and personal hygiene. Resident #09 required supervision assistance with eating. Interview with Resident #09 on 01/31/22 at 1:40 P.M. revealed Resident #09 was concerned that the facility did not change his privacy curtain. Observation of Resident #09's privacy curtain on 01/31/22 at 1:40 P.M. revealed Resident #09's privacy curtain had multiple brown splatters and a smeared brown substance on the curtain. Observation of Resident #09's privacy curtain on 02/02/22 at 1:36 P.M. revealed Resident #09's privacy curtain had multiple brown splatters and a smeared brown substance on the curtain. Interview with the Director of Nursing (DON) on 02/02/22 at 1:36 P.M. verified Resident #09's privacy curtain had multiple brown splatters and a smeared brown substance on the curtain. 2. Review of the Resident #17's chart revealed Resident #17 admitted to the facility on [DATE] with diagnoses including hypertension, [CONDITION(S)], constipation, muscle weakness, [CONDITION(S)], and abnormal posture. Review of Resident #17's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to be severely cognitively impaired and Resident #17 required extensive assistance with bed mobility, eating, and toileting. Resident #17 required total dependence with transfers, dressing, and personal hygiene. Observation of Resident #17's privacy curtain on 01/31/22 at 12:53 P.M. revealed Resident #17's privacy curtain had multiple brown splatters and a smeared brown substance on the curtain. Observation of Resident #17's privacy curtain on 02/02/22 at 1:36 P.M. revealed Resident #17's privacy curtain had multiple brown splatters and a smeared brown substance on the curtain. Interview with the Director of Nursing (DON) on 02/02/22 at 1:36 P.M. verified Resident #17's privacy curtain had multiple brown splatters and a smeared brown substance on the curtain. Email correspondence with Assistant Administrator #117 on 02/03/22 at 12:56 P.M. revealed the facility did not have policy on cleaning privacy curtains. This certification deficiency substantiates OH 101.

Based on interview and record review, the facility failed to ensure vision and hearing impairment was accurately coded on the Minimum Data Set (MDS) assessment. This affected two resident (#14 and #22) out of 19 residents reviewed for accuracy of assessments. The facility census was 84. Findings include: 1. Review of the Resident #14's chart revealed Resident #14 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #14's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to be severely cognitively impaired and Resident #14 required extensive with transfers, bed mobility, dressing, toileting, and personal hygiene. Resident #14 also required supervision with eating and Resident #14 had adequate vision with no devices. Review of Resident #14's vision care plan dated 08/21/19 revealed Resident #14 had impaired vision related to [CONDITION(S)] and wearing glasses. Review of Resident #14's optometry vision dated 08/21/21 revealed Resident #14 had [CONDITION(S)] in both eyes. Resident #14 was to follow up with ophthalmology. Review of Resident #14's ophthalmology clinic note dated 12/20/21 revealed Resident #14 had intraocular pressure. Interview with Resident #14 on 01/31/22 at 9:47 A.M. revealed she had issues with vision with an upcoming vision surgery that was supposed to be schedule. Interview with Licensed Practical Nurse (LPN) #93 on 02/02/22 11:04 A.M. verified Resident #14's impaired vision was not coded accurately on the MDS. 2. Review of the Resident #22's chart revealed Resident #22 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #22's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to be moderately cognitively impaired and Resident #22 required extensive assistance with bed mobility and dressing. Resident #22 required supervision with transfers, eating, and toileting and limited assistance with personal hygiene. Resident #22 had adequate hearing with no hearing aid or hearing appliances used. Review of Resident #22's care plan revealed Resident #22 did not have a care plan for hearing. Review of Resident #22's audiology visit dated 09/21/20 revealed resident complained of hearing loss. Resident #22 was interested in trialing hearing aids and hearing aids were recommended in the ear. Resident #22 had mild to severe sensorineural hearing loss in the right ear and a moderate to severe sensorineural hearing loss in the left ear. Interview with Licensed Practical Nurse (LPN) #93 on 02/02/22 11:04 A.M. verified Resident #22's impaired hearing was not coded accurately on the MDS. Telephone interview with Manager of Clinical Services #300 on 02/03/22 at 10:56 A.M. revealed the facility did not have a policy on coding the MDS.

Based on interview and record review, the facility failed to develop a care plan to address a resident's hearing impairment and seizures. This affected two resident (#22 and #83) out of 19 residents reviewed for accuracy of care planning. The facility census was 84. Findings include: 1. Review of the Resident #22's chart revealed Resident #22 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #22's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to be moderately cognitively impaired and Resident #22 required extensive assistance with bed mobility and dressing. Resident #22 required supervision with transfers, eating, and toileting and limited assistance with personal hygiene. Resident #22 had adequate hearing with no hearing aid or hearing appliances used. Review of Resident #22's care plan revealed Resident #22 did not have a care plan for hearing. Review of Resident #22's audiology visit dated 09/21/20 revealed resident complained of hearing loss. Resident #22 was interested in trialing hearing aids and hearing aids were recommended in the ear. Resident #22 had mild to severe sensorineural hearing loss in the right ear and a moderate to severe sensorineural hearing loss in the left ear. Interview with Licensed Practical Nurse (LPN) #93 on 02/02/22 11:04 A.M. verified Resident #22's impaired hearing was addressed on Resident #22's care plan. Telephone interview with Manager of Clinical Services #300 on 02/03/22 at 10:56 A.M. revealed the facility did not have a policy on care planning. 2. Resident #83 was admitted to the facility originally on 03/26/21 and readmitted on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She had a quarterly Minimum Data Set (MDS) assessment completed on 01/20/22. She was assessed as having memory problems. She needed limited assist of one staff for bed mobility, and transfer. She did not walk. She needed extensive assist of one staff for locomotion, dressing, toilet use, personal hygiene, and bathing. She was frequently incontinent of bowel and bladder. She had a significant weight gain and was on a physician-prescribed weight-gain regimen. She was at risk for pressure ulcers and had no unhealed pressure ulcers. Review of the clinical record revealed she was ordered [MEDICATION(S)] 500 milligrams (mg) by mouth daily for seizures. Further review revealed she was hospitalized on [DATE] and 12/31/21 after having a [CONDITION(S)]. Review of Resident #83's care plans revealed she did not have a care plan for [CONDITION(S)] activity. An interview was conducted with the MDS Nurse #93 on 02/02/22 at 2:15 P.M. She verified Resident #83 did not have a care plan for seizures.

Based on observation, record review and staff interview, the facility failed to a resident's smoking care plan was revised. This affected one (#09) of 19 residents reviewed for privacy care plans. The facility census was 84. Findings include: Review of the Resident #09's chart revealed Resident #9 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #09's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to be moderately cognitively impaired and Resident #09 required extensive with bed mobility, transfers, dressing, toileting, and personal hygiene. Resident #09 required supervision assistance with eating. Review of Resident #09's smoking assessment dated [DATE] revealed Resident #09 needed a smoking holder attached to this wheelchair. Review of Resident #09's smoking assessment dated [DATE] revealed Resident #09 needed a smoking holder attached to this wheelchair. Review of Resident #09's smoking care plan dated 11/21/17 revealed resident was at risk for health risks due to smoking. Interventions included a smoking apron to be worn when smoking. Further review of Resident #09's smoking care plan revealed resident's smoking holder to his wheelchair was not listed on the care plan. Observation of Resident #09 smoking on 02/01/22 at 1:38 P.M. revealed Resident #09 was not wearing a smoking apron but Resident #09 was using a smoking holder that was attached to his wheelchair. Interview on 02/01/22 at 2:00 P.M. with Manager of Clinical Services #300 verified Resident #09's care plan was not revised to reflect Resident #09's updated smoking assessment that did not require a smoking apron. Manager of Clinical Services #300 also verified Resident #09's smoking care plan was not revised to address Resident #09's smoking holder. Telephone interview with Manager of Clinical Services #300 on 02/03/22 at 10:56 A.M. revealed the facility did not have a policy on care planning.

Based on interview and record review, the facility failed to address a resident's drug regimen review timely. This affected one resident (#22) out of five residents reviewed for unnecessary medications. The facility census was 84. Findings include: Review of the Resident #22's chart revealed Resident #22 admitted to the facility on [DATE] with diagnoses including [CONDITION(S)], [CONDITION(S)] with behavioral disturbance, transient cerebral ischemic attack, pain in right knee, major depressive disorder, muscle weakness, [CONDITION(S)], and tremors. Review of Resident #22's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to be moderately cognitively impaired and Resident #22 required extensive assistance with bed mobility and dressing. Resident #22 required supervision with transfers, eating, and toileting and limited assistance with personal hygiene. Resident #22 received antidepressant, anticoagulant, diuretic and opioids during the MDS review period. Review of Resident #22's consultant pharmacist recommendation dated 10/08/21 revealed Resident #22 was receiving antidepressant therapy with [MEDICATION(S)] 175 milligrams (mgs) daily. A dose reduction was recommended. Resident #22's physician provided a response that stated Resident #22 was tolerating the medication well and a dose reduction would worsen symptoms on 11/03/21. Interview on 02/22/22 at 1:58 P.M. with Manager of Clinical Services #300 verified Resident #22's pharmacy recommendation was made on 10/08/21 and it was not addressed by the physician until 11/03/21. Review of the facility's medication regimen review dated 11/28/17 revealed the facility designee or physician will respond to the recommendations in a timely manner upon the completion of the monthly regimen review.

Based on medical record review, observation and staff and wound clinic staff interviews, the facility failed to ensure a resident nails were trimmed in order to prevent and/or reduce the risk of skin breakdown. This affected one (#25) of three residents sampled. The census was 83. Findings include: Review of the medical record for Resident #25 revealed an admission date of [DATE] with a [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment for Resident #25 dated 03/13/21 revealed resident was cognitively impaired and required extensive assistance of one to two staff with activities of daily living (ADL's). Review of physician progress notes [REDACTED]. Review physician order [REDACTED]. Review of December 2020, January 2021, February 2021, and March 2021 Treatment Administration Records (TAR) for Resident #25 revealed the record contained no documentation regarding physician's orders [REDACTED]. Review of nurse progress notes for Resident #25 dated 12/23/20 through 03/23/21 revealed notes contained no documentation regarding the resident's fourth and fifth fingernails to the left hand being cut. Review of physician orders [REDACTED]. Review of physician orders [REDACTED]. OT to treat three times weekly for four weeks. Review of OT evaluation for Resident #25 dated 02/10/21 revealed resident had a contracture to his left hand and the skin integrity to the left hand was compromised, resident had an abnormal fifth digit to the left hand with reddened areas to the hand. Goals of therapy included to improve hand hygiene and prevent further decline and skin breakdown. Review of nurse progress note for Resident #25 dated 02/12/21 revealed resident was out of the facility at the vascular access clinic for an appointment. Review of the note from the vascular access clinic for Resident #25 dated 02/12/21 revealed the nurse practitioner at clinic noted the fingernail to resident's left fifth digit was grossly overgrown with wounds to underside of ring finger and palm with the left hand contracted but fingers are easily manipulated. Further review of note revealed the nurse wrapped resident's hand with Kerlix gauze to prevent rubbing from nail as nurse was unable to trim the nail in a clinic setting. Review of note revealed nurse referred to clinic social worker regarding resident concerns. Review of OT progress note for Resident #25 dated 02/14/21 revealed resident tolerated left palm protector application to prevent skin breakdown and decrease further contracture, but resident's fifth digit to the left hand with abnormal nail growth made concerns for digging in skin when palm protector not on. Review of late entry wound note per certified wound nurse practitioner for Resident #25 originally dated 02/24/21 revealed note was updated on 03/24/21 and indicated resident had an elongated [DIAGNOSES REDACTED] fingernail to his left hand that was not able to be cut by the facility and nurse trimmed the nail. Review of OT note for Resident #25 dated 03/01/21 revealed resident's left hand fifth digit had been trimmed and was now out of the and no longer digging into resident's palm. Review of OT discharge summary for Resident #25 dated 03/09/21 revealed resident was discharged from therapy with recommendations to wear bilateral hand rolls during the day for six to eight hours as tolerated and to doff hand rolls at night. Review of summary revealed resident's left hand fifth digit nail was in good condition and had been trimmed and out of way for digging into palm. Further review of summary revealed a referral form was provided for staff information on caring for Resident #25's contracted left hand. Review of Splinting Referral Form for Resident #25 dated 03/09/21 revealed if resident's pinky nail to the left hand becomes too long refer to nursing to trim nail to avoid risk of puncturing the skin. Interview on 03/23/21 at 12:03 P.M. with Social Worker (SW) #350 with the vascular access clinic revealed she called the facility on 02/12/21 or 02/13/21 and spoke to a nurse regarding concerns that the nails on Resident #25's left hand were abnormally long and were digging into his skin. SW #350 confirmed nurse told her the facility would address the concern. Observation on 03/24/21 at 1:45 P.M. of Resident #25 with State tested Nursing Assistant (STNA) #225 revealed resident's fingernails were trimmed to an appropriate length. Interview on 03/24/21 at 1:45 P.M. with STNA #225 confirmed only nurses could trim Resident #25's nails because he was diabetic. Interview on 03/24/21 at 1:50 P.M. with Licensed Practical Nurse (LPN) #275 confirmed nurses trimmed Resident #25's nails because he was diabetic but if nails were very thick the facility wound nurse would trim them. LPN #275 further confirmed she thought the outside wound nurse for the facility had trimmed the resident's nails, but she was unsure when this had occurred. Interview on 03/25/21 at 7:30 A.M. with LPN #325 confirmed someone from the vascular access clinic had called the facility and spoken to her with concerns that Resident #25's fingernails to his left hand were too long and needed to be trimmed. LPN #325 confirmed she looked at resident's hands but didn't think the nails looked too long. Interview on 03/25/21 at 9:00 A.M. with OT #300 confirmed Resident #25 had contracture's to both hands and the fourth and fifth fingers on the left hand were more severely contracted. OT #300 confirmed she evaluated Resident #25 on 02/10/21 for contracture management and resident was treated from 02/10/21 until 03/09/21 when he was discharged from therapy. OT #300 confirmed therapy recommendations were for Resident #25 to wear bilateral hand rolls with foam between the fourth and fifth finger on the left hand for six to eight hours during the day as tolerated and to doff at night. OT #300 further confirmed hand rolls for Resident #25 were in his room and she had completed a Splint Referral Form for nursing when resident was discharged from therapy on 03/09/21. OT #300 confirmed she did not think the facility had received a copy of the Splint Referral Form. Interview on 03/25/21 at 11:25 A.M. with the Administrator confirmed the facility wound nurse had trimmed Resident #25's fingernails on 02/24/21 by the facility wound nurse, and the facility had no record of the thickened nails to resident's left hand being trimmed prior to that time. This deficiency substantiates Complaint Number OH 680.

Based on record review, observation and staff interview, the facility failed to implement occupational therapy (OT) recommendations to manage contracture's. This affected one (#25) of three residents sampled. The census was 83. Findings include: Review of the medical record for Resident #25 revealed an admission date of [DATE] with a [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment for Resident #25 dated 03/13/21 revealed resident was cognitively impaired and required extensive assistance of one to two staff with activities of daily living (ADL's). Review of physician orders [REDACTED]. Review of physician orders [REDACTED]. OT to treat three times weekly for four weeks. Review of OT eval for Resident #25 dated 01/25/21 revealed resident had contracture's to his hands and an orthotic for left hand was recommended to reduce further or worsening contracture's. Review of OT note for Resident #25 dated 01/29/21 revealed resident was discharged from therapy due to hospitalization . Review of nurse progress notes for Resident #25 dated 02/02/21 through 02/05/21 revealed resident was out of the facility at the hospital due to mental status change from 02/02/21 through 02/05/21. Review of physician orders [REDACTED]. Review of physician orders [REDACTED]. OT to treat three times weekly for four weeks. Review of OT evaluation for Resident #25 dated 02/10/21 revealed the resident had bilateral hand contracture's with limited ability to open and close palm and would benefit from skilled OT services to address contracture's through splinting and orthotic's. Review of OT discharge summary for Resident #25 dated 03/09/21 revealed resident was discharged from therapy with recommendations to wear bilateral hand rolls during the day for six to eight hours as tolerated and to doff hand rolls at night. Further review of summary revealed a referral form was provided for staff knowledge on regarding wear times of bilateral hand rolls. Review of Splinting Referral Form for Resident #25 dated 03/09/21 revealed was discharged from therapy with recommendations to wear bilateral hand rolls with foam between 4th and 5th left finger during the day for six to eight hours as tolerated and to doff hand rolls at night for prevention of contracture's. Further review of form revealed it included a picture of the hand roll to be used for Resident #25. Review of the nurse progress notes for Resident #25 dated 03/09/21 through 03/22/21 revealed the notes contained no documentation regarding bilateral hand rolls for the resident. Review of March 2021 physician orders [REDACTED].#25 revealed there were no orders for bilateral hand rolls for resident. Observation on 03/24/21 at 1:45 P.M. of Resident #25 with State tested Nursing Assistant (STNA) #225 revealed the resident was resting in bed, his hands were visibly contracted, and he was not wearing hand rolls. Resident #25 was not interviewable. Interview on 03/24/21 at 1:45 P.M. with STNA #225 confirmed Resident #25 was not wearing hand rolls and she was not aware if he was supposed to wear any devices to his hands. Observation on 03/24/21 at 1:50 P.M. of Resident #25 with Licensed Practical Nurse (LPN) #275 confirmed resident's hands were visibly contracted and he was not wearing hand rolls. Interview on 03/24/21 at 1:50 P.M. with LPN #275 confirmed resident's hands were visibly contracted and he was not wearing hand rolls. LPN #275 confirmed she thought therapy had been working with Resident #25 because of his bilateral hand contracture's but resident did not have any orders for hand rolls, splints, or devices to his hands currently. Interview on 03/25/21 at 9:00 A.M. with OT #300 confirmed Resident #25 had contracture's to both hands and the fourth and fifth fingers on the left hand were more severely contracted. OT #300 confirmed she evaluated Resident #25 on 02/10/21 for contracture management and resident was treated from 02/10/21 until 03/09/21 when he was discharged from therapy. OT #300 confirmed therapy recommendations were for Resident #25 to wear bilateral hand rolls with foam between the fourth and fifth finger on the left hand for six to eight hours during the day as tolerated and to doff at night. OT #300 further confirmed hand rolls for Resident #25 were in his room and she had completed a Splint Referral Form for nursing when resident was discharged from therapy on 03/09/21. OT #300 confirmed she did not think the facility had received a copy of the Splint Referral Form. Interview on 03/25/21 at 11:25 A.M. with the Administrator confirmed the facility had not implemented the therapy recommendations for Resident #25 made on 03/09/21 upon resident's discharge from therapy. Administrator further confirmed the nursing department had not received a copy of the Splint Referral Form with recommendations to manage Resident #25's contracture's.

Based on record review, review of facility self-reported incidents (SRI's), staff interview, and review of online medication resources from Medscape, the facility failed to ensure a resident was free from unnecessary medications regarding having an adequate indication for use regarding the use of an antipsychotic medication. This affected one (#62) of two residents reviewed for SRI's. The census was 83. Findings include: Review of the medical record for Resident #62 revealed an admission date of [DATE] with a [DIAGNOSES REDACTED]. Review of Minimum Data Set (MDS) assessment for Resident #62 dated 02/28/21 revealed resident was cognitively impaired and required supervision with activities of daily living (ADL's), was coded negative for behavioral symptoms affecting others, was coded negative for the use of antipsychotic medications, and did not have [DIAGNOSES REDACTED]. Review of the nurse progress note for Resident #62 dated 02/28/21 revealed the resident struck another resident in the eye and the attending physician was notified. Further review of the note revealed the nurse practitioner on call for the physician gave a one time order for an injection of [MEDICATION NAME] an antipsychotic to be given for aggressive behavior. Review of the February 2021 Medication Administration Record [REDACTED]. Review of SRI initiated 02/28/21 revealed Resident #62 struck another resident in the eye, the facility did not substantiated abuse. Further review of March 2021 physician orders [REDACTED]. Review of the March 2021 physician orders [REDACTED]. Review of the medical record for Resident #62 dated 02/28/21 through 03/22/21 revealed it did not include documentation in the clinical record from the attending physician or nurse practitioner regarding a clinical rationale to justify the use of [MEDICATION NAME] and [MEDICATION NAME] for the resident. Interview on 03/25/21 at 11:25 A.M. with the Administrator confirmed Resident #62's record did not include documentation from the attending physician or nurse practitioner regarding clinical rationale for the use of antipsychotic medication for the resident. Review of an online resource Medscape revealed the United States Food and Drug Administration (FDA) had issued a black box warning for the use of [MEDICATION NAME] and [MEDICATION NAME] and indicated the medications were not approved for use for elderly dementia patients. Further review revealed patients with dementia-related [MEDICAL CONDITION] who were treated with antipsychotic drugs were at an increased risk for death.

Based on medical record review, observation, staff interview, review of facility policy, and review of online resources per the Centers for Disease Control (CDC), the facility failed to ensure personnel working directly with residents wore proper personal protective equipment (PPE) to potentially prevent the spread of Coronavirus Disease 2019 (COVID-19). This had the potential to affect one (#65) of three residents sampled for infection control. The census was 83. Findings include: Review of the medical record for Resident #65 revealed an admission date of [DATE] with a [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) for Resident #65 dated 01/07/21 revealed resident was cognitively impaired and required extensive assistance of one staff with activities of daily living (ADL's). Observation on 03/23/21 at 11:13 A.M. of the facility beauty salon revealed Beautician #150 was washing Resident #65's hair and was wearing a cloth mask. Interview on 03/23/21 at 11:13 A.M. with Beautician #150 confirmed she was wearing a cloth mask she had brought from home while washing Resident #65's hair. Review of the facility policy titled Novel Coronavirus Prevention and Response updated 03/19/21 revealed the facility would educate staff and visitors on proper use of personal protective equipment and would implement staff wearing face masks in accordance with regulatory requirements. Review of an online resource from the CDC at https://www.cdc.gov/Coronavirus/2019-ncov/hcp/long-term-care-strategies.html revealed the following guidance regarding facemask's: ensure all healthcare care personnel (HCP) wear a facemask while in the facility. Cloth face coverings are not considered personal protective equipment (PPE) because their capability to protect HCP is unknown.

Based on observation, record review and staff interview, the facility did not ensure for one resident, with a history of [MEDICAL CONDITION] requiring anti-[MEDICAL CONDITION] medications, the medications were administered.. The resident did not receive the medications as ordered and was admitted to the hospital with [REDACTED]. One resident with a history of recent multiple [MEDICAL CONDITION] did not receive her medications timely. This affected two (#92, #66) of three sampled residents with [MEDICAL CONDITION]. The facility identified nine residents that required anti-[MEDICAL CONDITION] medications. Findings include: 1. Record review revealed Resident #92 had [DIAGNOSES REDACTED]. Review of hospital physician progress notes [REDACTED]. The resident was loaded with an anti-[MEDICAL CONDITION] medication, [MEDICATION NAME], a drug he is often non-compliant with taking. He was also given an anti-[MEDICAL CONDITION] medication, [MEDICATION NAME], and Versed as well and [MEDICATION NAME] to finally abate the [MEDICAL CONDITION] which were tonic clonic in nature. The resident required intubation and placement on the vent secondary to [MEDICAL CONDITION] and aspiration and was aggressively treated with antibiotics. Resident #92 was admitted to the facility 05/24/12, with the first nurse's notes for vitals signs taken at 3:24 P.M. Review of admitting physician orders [REDACTED]. Review of admitting physician orders [REDACTED].M. and 6:00 P.M.. The orders indicated a second anti-[MEDICAL CONDITION] medication, [MEDICATION NAME] 750 milligrams to be given 12 hours at 6:00 A.M. and 6:00 P.M. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M., 05/25/12 at 6:00 A.M. or 6:00 P.M., and on 05/26/12 at 6:00 A.M. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. medications were given at 12:45 P.M. when the pharmacy delivered them to the facility. Nurse's notes dated 05/26/12 at 5:32 P.M. noted at approximately 5:10 P.M. the nurse brought the resident's 6:00 P.M. medications to the room and the resident was having a [MEDICAL CONDITION]. The nurse stayed by the resident's side. The resident did not wake from the [MEDICAL CONDITION] and 911 was called. Review of nurses notes dated 05/27/12 at 2:22 A.M. revealed the hospital called and Resident #92 was admitted with [DIAGNOSES REDACTED]. Interview with the Director of Nursing on 10/18/12 at 10:54 A.M., reviewed of the medical record, confirmed the medications were not given until 05/26/12 at 12:45 P.M.. She confirmed the physician was not notified the medications were not given and the resident was admitted to the hospital with [REDACTED]. 2. Record review revealed Resident #92 had [DIAGNOSES REDACTED]. Review of hospital physician progress notes [REDACTED]. The resident was loaded with an anti-[MEDICAL CONDITION] medication, [MEDICATION NAME], a drug he is often non-compliant with taking. He was also given an anti-[MEDICAL CONDITION] medication, [MEDICATION NAME], and Versed as well and [MEDICATION NAME] to finally abate the [MEDICAL CONDITION] which were tonic clonic in nature. The resident required intubation and placement on the vent secondary to [MEDICAL CONDITION] and aspiration and was aggressively treated with antibiotics. The resident was admitted to the facility 05/24/12 with the first nurse's notes for vitals signs taken at 3:24 P.M. Review of admitting physician orders [REDACTED]. Review of admitting physician orders [REDACTED].M. Review of computerized documentation of vital signs noted upon admission on 05/24/12 at 3:20 P.M. revealed Resident #92' s temperature was 98 degrees Fahrenheit. At 11:09 P.M. his temperature was 98.7 degrees Fahrenheit. At 11:57 P.M. his temperature was 98.7 degrees Fahrenheit. On 05/25/12 at 11:17 P.M. the resident's temperature was 101.5 degrees Fahrenheit and on 05/26/12 at 3:05 A.M. it was 101.5 degrees Fahrenheit. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M. The MAR indicated [REDACTED]. medications were given at 12:45 P.M. when the pharmacy delivered them to the facility. Nurse's notes dated 05/26/12 at 5:32 P.M. noted at approximately 5:10 P.M. the nurse brought the resident's 6:00 P.M. medications to the room and the resident was having a [MEDICAL CONDITION]. The nurse stayed by the resident's side. The resident did not wake from the [MEDICAL CONDITION] and 911 was called. Review of nurse's notes dated 05/27/12 at 2:22 A.M. the hospital called and Resident #92 was admitted with [DIAGNOSES REDACTED]. Interview with the Director of Nursing on 10/18/12 at 10:54 A.M. reviewed the medical record and confirmed the medications were not given until 05/26/12 at 12:45 P.M.. She confirmed the physician was not notified the medications were not given and the resident was admitted with [MEDICAL CONDITION]. She confirmed the resident's temperature of 101.5 and the Bactrim was not given. The DON stated the Bactrim was in the emergency box (E-box) at the facility and could have been given. 3. Record review of the [DIAGNOSES REDACTED]. Review of the minimum data set assessment dated [DATE] noted the resident had long and short term memory loss and resists care daily. The resident requires extensive assistance for all functional tasks. Review of current physician orders [REDACTED].M. and 9:00 P.M. Review of nurse's notes dated 09/21/12 at 11:22 A.M. Resident #66 stated she was not feeling well. The resident has a history of [MEDICAL CONDITION] and was placed in bed in the lowest position. The resident is in a sleepy state but arouse's to name being called. Nurse notes dated 10/05/12 at 10:44 A.M. noted at 9:50 A.M. the resident was sitting in the wheel chair in the common area. The resident called to the nurse and the nurse went over to the resident just as the resident was about to fall out of her wheel chair. The resident was taken back to her room and laid down in bed. The resident seemed to be having a [MEDICAL CONDITION]. The physician was notified. Nurse's notes dated 10/06/12 at 11:35 A.M. the resident was noted laying in supine position on the fall mat to the right side of the bed. The resident was noted to be in a postictal state. At 1:30 P.M. the physician was aware of the fall. The resident was unable to follow commands due to she was having a [MEDICAL CONDITION] at the time of the fall. Nurse's notes dated 10/07/12 at 11:33 A.M. another resident noted Resident #66 with [MEDICAL CONDITION] activity and the other resident put Resident #66 to bed. Nurse's notes dated 10/08/12 at 8:05 A.M. noted the resident as lying on the floor in the dining room at her assigned dining room table in a [MEDICAL CONDITION]. The resident sustained [REDACTED]. The bleeding stopped after a few minutes. 911 was call and the resident went to a local hospital for evaluation. Nurse's notes dated 10/09/12 at 3:08 P.M. revealed at 9:45 A.M. the resident was in her Geri-chair at the nurses station and started to have a [MEDICAL CONDITION]. The resident was observed in a drowsy state and aroused when named was called. Nurse's notes dated 10/11/12 at 12:27 P.M. revealed an order was obtained for the resident to be sent to the hospital for evaluation. The resident was unresponsive to verbal and sternal stimuli. The resident's arms and head were moving side to side tearful at times. At 6:54 A.M. the staff at the hospital notified the facility and the resident was being admitted for [MEDICAL CONDITION] and a change in mental status. The resident returned to the facility on [DATE]. Nurse's notes dated 10/14/12 at 10:36 A.M. noted the nurse gave the resident morning medications at 8:15 A.M. At 8:30 A.M. the resident had a [MEDICAL CONDITION], sitting in the Geri chair in the common area in front of the TV. After the [MEDICAL CONDITION], the resident went into a drowsy state but aroused when named called. Nurse's notes dated 10/17/12 at 11:24 P.M. revealed the resident had [MEDICAL CONDITION] activity around 8:45 P.M. [MEDICATION NAME] approximately three minutes. Observation on 10/18/12 at 10:40 A.M. revealed the [MEDICATION NAME] and [MEDICATION NAME] scheduled for 9:00 A.M. was not signed off in the MAR indicated [REDACTED] Interview with Register Nurse (RN) #4 on 10/18/12 at 10:40 A.M. confirmed the resident's medications were not given due to when she first went to the resident's room the resident was being changed so she proceeded with administration of medications to other residents and left this resident until last. She called the physician and obtained an order to give the resident's medication at 10:00 A.M. for one time only. RN #4 confirmed the medications were not given as of yet. RN #4 was asked regarding the anti-[MEDICAL CONDITION] medications and she said the resident has had uncontrollable [MEDICAL CONDITION] for the last few weeks. The [MEDICATION NAME] and [MEDICATION NAME] were administered at 10:50 A.M. Interview with the Director of Nursing on 10/18/12 at 10:54 A.M. confirmed the resident had multiple [MEDICAL CONDITION] recently and requires to receive her medication as close to the time scheduled as possible. If the physician had given permission for the medications at 10:00 A.M., they should have been given at 10:00 A.M. This citation substantiated Complaint Control Number OH 527.