Every finding on record at Homestead II

Based on record review, interview, and self-reported incident (SRI) review, the facility failed to provide adequate supervision for a Resident #45 for an outside appointment. This affected one (Resident #45) of four residents reviewed for appointments. The facility census was 44. Findings include:Review of the closed medical record for Resident #45 revealed an admission date of 06/24/25. Diagnoses included gastrointestinal tumor, malignant neoplasm of the liver and bile duct, chronic obstructive pulmonary disease (COPD). There was no diagnosis of dementia. The resident was discharged home on [DATE]. Review of the plan of care dated 06/24/25 revealed Resident #45 required supervised leave of absence (LOA). Review of the 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #45 had intact cognition. Review of the baseline care plan report dated 07/01/25 and reviewed with Resident #45 and family revealed Resident #45's appointments on 07/03/25 and on 07/10/25 stated daughter to transport written beside the appointments. The appointment on 07/07/25 did not have anything written beside it. Review of the Director of Nursing (DON's) note dated 07/07/25 at 6:40 A.M. per charge nurse, Resident #45 left the facility via Lake [NAME] for his scheduled urology appointment. Review of facility SRI tracking number 262468 and investigation dated 07/07/25 revealed Resident #45 was admitted to the facility on [DATE] with multiple follow-up doctor appointments. The appointments were placed in Matrix, and transportation was set up with Lake [NAME] transportation services. A care plan meeting for short term residents (PATH meeting) was held with the resident and his daughter where she stated that she may be cancelling appointments. She was advised at that time to let the nursing staff know so the transportation could be cancelled and the order removed from our system. On 07/03/25 Resident#45 attended an appointment using Lake [NAME] services without incident. On 07/07/25 the resident had a scheduled urology appointment, Lake [NAME] transported him leaving the building around 6:40 A.M. Around 9:22 A.M. the facility received a call from the urology department that the resident had not been picked up. Resident #45's return trip was scheduled for 8:45 A.M. to 9:15 A.M. The building contacted Lake [NAME] for an estimated time of arrival (ETA) and it was reported Resident #45 was marked as will call. The facility informed Lake [NAME] that Resident #45 needed a return trip. Lake [NAME] stated that he would be picked up. Resident #45's daughter called the facility around 10:30 A.M. stating that the appointment had been cancelled and questioned why the resident had gone to the appointment. The resident's daughter was unable to state who she informed at the facility that she had cancelled the appointment. No nursing staff at the building were notified of the appointment being cancelled. The urology office was called by the facility to confirm that the appointment had been cancelled, and the scheduling department stated that it had been cancelled and rescheduled for 07/07/25. Resident #45's daughter drove to the appointment office and picked up Resident #45. She took the resident back to his assisted living apartment rather than returning to the facility. Interview on 09/05/25 at 8:54 A.M. the DON revealed the facility typically asks family to go on appointments with a resident. Depending on cognition, the facility will send a staff member with the resident. Transportation was usually arranged through Lake [NAME]. Pick up and return times are scheduled. Lake [NAME] had a 30-minute window. Interview on 09/05/25 at 10:58 A.M. with Receptionist/Human Resources (HR)/Payroll #203 revealed on 07/07/25 the facility received a phone call between 10:00 A.M. to 10:30 A.M. from a doctor's office saying Resident #45 was waiting to be picked up from his appointment. She called Lake [NAME] and was told pick up was marked as will call. Receptionist/HR/payroll #203 told them it couldn't be because the facility had a return time written down. Lake [NAME] informed her that they had already been there and left. With Lake [NAME] you call and wait on hold or have option for them to call you back. The facility was talking to the doctor's office, Lake [NAME], and the office again. The doctor's office also called the resident's daughter. Resident #45's daughter called and said she would pick the resident up, but she wasn't bringing him back here. Interview on 09/05/25 at 1:29 PM. With Resident #45's daughter said she didn't even know the facility was taking the resident to an appointment that day. She had cancelled the appointment. The facility didn't call her. At the last appointment she had come to the facility to go with her father to an appointment, and the facility had arranged for a staff member to go with him. When she picked up her father from the appointment 07/07/25, he was very upset and very hungry. He had not had anything to eat that day and it was almost noon. She could not believe the facility had sent him to the appointment unattended. Interview on 09/05/25 at 1:50 P.M. the DON verified Resident #45 had been sent to the appointment 07/07/25 unaccompanied by staff or family. This deficiency represents noncompliance investigated under Master Complaint Number 1392904 (OH00165517) and Complaint Number 1392903 (OH00167496).

Based on observation, interview, record review, and facility policy review, the facility failed to properly store labeled, non-expired insulin and Tuberculin testing solution inside refrigerators which were routinely defrosted and contained no food items. This affected one resident (#32) and had the potential to affect all 42 residents residing in the facility. The facility reported eight residents (#6, #11, #14, #23, #30, #32, #34 and #245) who received insulin. Findings include: Observation of medication storage on 12/31/24 at 8:20 A.M. with Licensed Practical Nurse (LPN) #526 revealed the 200-unit medication refrigerator had a large amount of ice buildup in the freezer area and three individual serving sized containers of ice cream stored for use. Within the same refrigerator, there was a Lantus insulin injectable pen stored not inside a labeled container and was without a prescription type label for proper identification. Instead, the pen had a last name written on it with a black marker but no first name to accurately identify a resident it belonged to. In addition, the refrigerator had one opened vial of Tuberculin testing solution stored inside which was undated. Interview at the time of the observation with Licensed Practical Nurse (LPN) #526 verified the findings. Observation of medication storage on 12/31/24 at 8:32 A.M. with the Director of Nursing (DON) revealed the 100-unit medication refrigerator had one opened vial of Tuberculin testing solution stored inside which was undated. In addition, the refrigerator had one opened vial of Lispro insulin for Resident #32 with an opened date of 11/05/24 written on it, which indicated the insulin was expired. Interview at the time of the observation with the DON verified the findings. Review of the medical record for Resident #32 revealed an admitted [DATE] and diagnosis of diabetes mellitus type two. There was no active order in the medical record for Lispro insulin injectable solution from a vial. Review of the facility policy, Storage and Expiration Dating of Medications and Biologicals, dated 12/01/07 revealed the facility should ensure food was not stored in the refrigerator/freezer where medications were stored, ensure expired medications were stored separately from other medications until destroyed or returned, ensure opened medications had a recorded opened date on the primary medication container, ensure medications were stored in the original containers in which received, and reorder medications with illegible, worn, makeshift, incomplete, damaged or missing labels.

Based on interview, record review, and facility policy review the facility failed to provide showers as scheduled. This affected two (Resident's #5 and #6) of three residents reviewed for showers. The facility census was 40. Findings include: 1. Review of the medical record for Resident #5 revealed and admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #5 had mild cognitive impairment. Resident #5 required extensive assistance of two staff for bed mobility, transfers, dressing, toileting, and personal hygiene; supervision with set-up help only for eating; and physical help of one staff for bathing. Resident #5 had an indwelling catheter for urine and was always continent of bowel. Review of the care plan dated 10/02/22 revealed Resident #5 had a self-care deficit related to diagnoses. Interventions included to assist with activities of daily living, dressing, grooming, toileting, feeding, and oral care. Review of the nursing assistant documentation revealed Resident #5 was scheduled for a shower every Monday and Thursday on the night shift. Review of the shower documentation from 09/13/22 to 10/12/22 revealed Resident #5 only received one shower on 10/11/22. Interview on 10/11/22 at 11:04 A.M. with Resident #5 revealed he had not had a shower in two weeks until this morning. Interview on 10/12/22 at 1:41 P.M. with the Director of Nursing (DON) verified there was no documented evidence of showers for Resident #5 from 09/13/22 through 10/12/22, except for 10/11/22. 2. Review of the medical record for Resident #6 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #6 had moderate cognitive impairment. Resident #6 required extensive one-staff physical assistance for bed mobility, transfers, dressing, and personal hygiene; supervision with set-up help only for eating; and extensive two-staff physical assistance for toilet use. Resident #6 required physical help of one staff for bathing. Resident #6 was occasionally incontinent of urine and always continent of bowel. Review of the care plan dated 10/04/22 revealed Resident #6 had an activities of daily living/self-care deficit related to his diagnoses. Interventions included to assist with dressing, grooming, toileting, feeding, and oral care. Review of the physician's order dated 10/07/22 for Resident #6 revealed he was to have a shower every Monday and Friday during the day shift. Review of the nursing assistant documentation from 09/13/22 to 10/12/22 revealed Resident #6 had refused a shower on 09/21/22 and only received showers on 09/25/22 and 10/07/22. Interview on 10/11/22 at 11:18 A.M. with Resident #6's wife revealed sometimes when she visited him, he was stinky, but the staff reports to her he is getting bathed as scheduled. Interview on 10/12/22 at 1:41 P.M. with the DON confirmed Resident #6 did not have documented evidence of showers as scheduled. Review of the facility policy on bathing/showering/ and scheduling policy, revised 09/09/22, revealed residents will be bathed or showered according to their preferences to maintain healthy hygiene and skin condition. When the shower or bath is complete the nursing assistant will document the activity on the shower sheet or in point of care section in the electronic record. If the bath/shower cannot be given or the resident refuses the nursing assistant will promptly report this to the charge nurse. The charge nurse will speak to the resident who refuses to ascertain why they are refusing and to determine if alternative arrangements that suit the resident can be made. If the resident continues to refuse the charge nurse will document the resident's refusal in the medical record.

Based on observation, interview, record review, and facility policy review the facility failed to administer medications to Resident #41 in a manner to prevent infection. This affected one (Resident #41) of three residents observed for medication administration. The facility census was 40. Findings include: Review of the medical record for Resident #41 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's order for Resident #41 dated 05/07/21 revealed an order to administer [MEDICATION(S)] (diabetic medication) 50 milligrams (mg) one time daily. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #41 had severe cognitive impairment. Resident #41 required supervision with set-up help only for bed mobility; supervision with one-staff assistance for transfers, eating, and toilet use; and extensive one-staff physical assistance for dressing and personal hygiene. Observation of medication administration on 10/13/22 at 8:43 A.M. with Licensed Practical Nurse (LPN) #523 for Resident #41 revealed while pushing out the [MEDICATION(S)] tablet from the medication packaging into the medication cup, the [MEDICATION(S)] tablet fell on top of the medication cart. LPN #523 then immediately picked up the [MEDICATION(S)] tablet with her bare hands and placed in the medication cup with Resident #41's other pills. LPN #523 then took the medication cup and administered the medications to Resident #41. Interview on 10/13/22 at 8:55 A.M. with LPN #523 confirmed she did drop the [MEDICATION(S)] tablet out of the medication packaging onto the surface of the medication cart. She also confirmed she had picked the [MEDICATION(S)] tablet up with her bare hands and placed it in the medication cup with Resident #41's other medications and administered it to her. LPN #523 reported since she had cleaned her medication cart that morning and was using hand sanitizer in between resident care she felt everything was clean. Review of the facility policy general dose preparation and medication administration, revised 01/01/22, revealed if medication which is not in a protective container is dropped, facility staff should discard it according to facility policy.

Based on interview, observation, record review and policy review, the facility failed to ensure State tested Nursing Assistant (STNA) #604 covered or changed her N95 masks or cleansed her goggles after exiting a room of Resident #7 on droplet isolation precautions. This affected one resident (Resident #7) of one resident on respiratory isolation droplet precautions and had the potential to affect all 37 residents residing in the facility. Findings include: Review of the medical record for Resident #7 revealed an admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of his immunization status revealed he was unvaccinated against Covid-19. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan dated 09/23/21 for Resident #7 revealed due to Covid-19 outbreak, the resident was at risk for infection related to potential virus exposure and resident's current health status. Interventions included implement transmission-based precautions as needed, monitor for cough, sore throat, shortness of breath, respiratory changes fever, and notify the physician of a change in condition. Observation of the lunch meal on 09/27/21 at 11:49 A.M. revealed STNA #604 went to pass Resident #7 his lunch tray into his room. Upon entrance into Resident #7's room there was signage indicating Resident #7 was on respiratory droplet precautions. STNA #604 donned a gown and gloves and wore the same N95 mask without covering the N95 mask and goggles that she had been previously wearing into his room to pass and assist with setting up his lunch tray. She proceeded to then doff her gloves and gown but continued to wear the same N95 mask and goggles out of the room. She proceeded down the hallway towards the kitchen. Interview on 09/27/21 at 11:56 A.M. with STNA #604 verified she did not change her N95 mask upon exiting Resident #7's room or have her N95 mask covered upon entering Resident #7's room. She verified she continued to wear the same goggles after exiting Resident #7's room and verified she did not sanitize her goggles upon exiting his room. She verified Resident #7 was on respiratory droplet precautions. She revealed she was not aware that she was to change her N95 mask and goggles or that she needed to sanitize her goggles after exiting Resident #7's room as she had never done that for any resident on respiratory droplet precautions. She stated she had always worn the same N95 mask and goggles after exiting their rooms. Interview on 09/27/21 at 12:04 P.M. with the Director of Nursing verified Resident #7 was on respiratory droplet precautions as he was a new admission, and he was not vaccinated. She verified STNA #604 should have changed her N95 mask and sanitized her goggles after exiting Resident #7's room as that was the facility policy. Review of undated facility policy labeled, Covid-19 Personal Protective Equipment: Doffing Step by Step revealed upon exiting a patient room on respiratory isolation perform hand hygiene for a minimum of 20 seconds or until hand sanitizer was dry and then don clean gloves to handle the disinfectant wipes safely. The policy then revealed use the disinfectant wipe to clean the surface of face shield or eye protection. The policy revealed to doff the N95 first remove the bottom strap with both hands and let dangle and then remove the top strap of the N95 mask with both hands and place gently the N95 mask into the trash. This deficiency substantiates Master Complaint Number OH 007 and Complaint Number OH 899.

Based on observation, interview, record review and policy review, the facility failed to ensure Resident #32's peripherally inserted central catheter (PICC) line dressing was changed as ordered. This affected one resident (Resident #32) of one resident reviewed for intravenous access. The facility census was 37. Findings include: Review of the medical record for Resident #32 revealed an admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medicare five-day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #32 had impaired cognition, and he required extensive assist of two staff with bed mobility and toileting. He was totally dependent of two staff with transfers. He was unable to ambulate. He received intravenous medications. Review of the care plan revised on 07/29/21 revealed Resident #32 had a potential and actual impairment to skin integrity related to intravenous site. Interventions included assess, document per routine and report abnormalities to the physician. There was nothing in the care plan regarding intravenous dressing changes to be completed. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The dressing was scheduled and documented as being changed on 09/03/21, 09/10/21, 09/17/21, and on 09/24/21. The dressing was signed off by Licensed Practical Nurse (LPN) #900 as being completed on 09/24/21. Observation on 09/27/21 at 1:48 P.M. of Registered Nurse (RN) #600 administered Resident #32's antibiotic intravenous medication of [MEDICATION(S)]- [MEDICATION(S)] solution reconstituted one gram per 50 milliliters. Observation revealed the PICC line transparent dressing to Resident #32's right arm was dated 09/17/21 as it last being changed. Observation revealed the site appeared without any signs of infection. RN #600 verified the PICC line dressing should have been changed prior as PICC line dressings were to be changed every seven days. Interview on 09/27/21 at 2:02 P.M. with Director of Nursing verified LPN #900 had signed that the PICC line transparent dressing change was completed on 09/24/21 but verified the dressing was not changed on this date as documented as his PICC line dressing to his right arm was dated 09/17/21. She verified per the facility policy all central line dressing changes including PICC line dressings were to be changed at least every seven days. Review of facility policy labeled, Central vascular Access device (CVAD) Dressing Changes dated 05/01/16 revealed central vascular access devices included PICC lines. The policy revealed the catheter insertion site was a potential entry site for bacteria that may cause a catheter related infection. The policy revealed a transparent dressing was the preferred dressing. The policy revealed the guidance was to complete a sterile dressing change using a transparent dressing and to change at least weekly. This deficiency substantiates Master Complaint Number OH 007.

Based on observation, interview, record review and policy review, the facility failed to ensure Resident #32's medical record contained accurate documentation. This affected one resident (Resident #32) of three residents reviewed for accuracy of documentation contained in the medical record. The facility census was 37. Findings include: Review of the medical record for Resident #32 revealed an admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medicare five-day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #32 had impaired cognition, and he required extensive assist of two staff with bed mobility and toileting. He was totally dependent of two staff with transfers. He was unable to ambulate. He received intravenous medications. Review of the care plan revised on 07/29/21 revealed Resident #32 had a potential and actual impairment to skin integrity related to intravenous site. Interventions included assess, document per routine and report abnormalities to the physician. There was nothing in the care plan regarding intravenous dressing changes to be completed. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The dressing was scheduled and documented as being changed on 09/03/21, 09/10/21, 09/17/21, and on 09/24/21. The dressing was signed off by Licensed Practical Nurse (LPN) #900 as being completed on 09/24/21. Observation on 09/27/21 at 1:48 P.M. of Registered Nurse (RN) #600 administered Resident #32's antibiotic intravenous medication of [MEDICATION(S)]- [MEDICATION(S)] solution reconstituted one gram per 50 milliliters. Observation revealed the PICC line transparent dressing to Resident #32's right arm was dated 09/17/21 as it last being changed. Observation revealed the site appeared without any signs of infection. RN #600 verified the PICC line dressing should have been changed prior as PICC line dressings were to be changed every seven days. Interview on 09/27/21 at 2:02 P.M. with Director of Nursing verified LPN #900 had signed that the PICC line transparent dressing change was completed on 09/24/21 but verified the dressing was not changed on this date as documented as his PICC line dressing to his right arm was dated for 09/17/21. She verified per the facility policy all central line dressing changes including PICC line dressings were to be changed at least every seven days. She verified the medical record documentation for Resident #32 was not accurate as LPN #900 had signed off that she had completed Resident #32's PICC line dressing on 09/24/21 but that she had not completed the dressing change. Interview on 09/28/21 at 12:55 P.M. with the Director of Nursing revealed the facility did not have a policy regarding ensuring accuracy of documentation as the facilities expectation was that all documentation was always accurate. Review of facility policy labeled, Central vascular Access device (CVAD) Dressing Changes dated 05/01/16 revealed central vascular access devices included PICC lines. The policy revealed the catheter insertion site was a potential entry site for bacteria that may cause a catheter related infection. The policy revealed a transparent dressing was the preferred dressing. The policy revealed the guidance was to complete a sterile dressing change using a transparent dressing and to change at least weekly. This deficiency substantiates Master Complaint Number OH 007.

Based on review of the facility self-reported incident (SRI), interview and policy review, the facility failed to prevent misappropriation of controlled medications. This affected seven residents (Resident #3, Resident #13, Resident #21, Resident #27, Resident #95, Resident #96 and Resident #97) of seven reviewed for misappropriation of medications. This had the potential to affect all residents residing in the facility. The facility census was #40. Findings include: Review of the SRI, tracking number 4 and the corresponding investigation completed on 10/04/19 revealed on 09/25/19 at 11:14 P.M. the Director of Nursing (DON) was notified the medication count was off by one medication card of narcotics and one narcotic count sheet. On 10/26/19 the DON reviewed all narcotic count sheets and the shift to shift narcotic count sheets for the month of 09/19. Several narcotic count sheets were noted to be missing. The facility checked the (MONTH) 2019 narcotic delivery report against the current medications in the cart and the completed narcotic count sheets. The DON noted there were multiple medication cards delivered and signed into the medication cart with no narcotic count sheet available. The DON listed the resident's and medications missing and noted a pattern of the same few residents, all with similar medications. Seven residents (Resident #3, Resident #13, Resident #21, Resident #27, Resident #95, Resident #96 and Resident #97) were identified as the residents without narcotic count sheets. [MEDICATION NAME] (narcotic pain medication), [MEDICATION NAME]-[MEDICATION NAME] (narcotic pain medication) and [MEDICATION NAME]-[MEDICATION NAME] (narcotic pain medication) were identified as the medications involved. The facility then launched a formal investigation. The police were called. An officer came to the facility and opened a police report (#19- ) and obtained a list of nurses in facility to begin the investigation. On Friday, 09/27/19, all nurses were contacted by the administrator to come into the facility and complete drug screening. All drug screens came back negative for illicit drugs. The DON went through the shift to shift sheets and cataloged which nurse had signed out the medication for which there were missing count sheets. 28 of 31 medications were signed out on the shift to shift sheets by Licensed Practical Nurse (LPN) #200. On 10/01/19 the decision was made to suspend LPN #200 pending investigation. On 10/02/19 the audit was completed. On 10/03/19 LPN #200's written statement was obtained with no new information noted. LPN #200 was officially terminated on 10/03/19. The facility was awaiting the police decision to charge the nurse or the pharmacy decision that nurse did in fact alter narcotic prescriptions to report nurse to The Ohio Board of Nursing. Interview on 11/24/19 at 10:38 [NAME]M. with the DON and Administrator revealed when they found out about the missing medications they investigated. They interviewed all of the facilities nurses and had all of them drug tested . The residents involved were interviewed and were not found to have been affected by the missing medications. The facility had contacted The Ohio Department of Health (ODH), submitted a SRI, contacted The Ohio Board of Nursing and the local police. Interview on 11/26/19 at 9:20 [NAME]M. with the DON and the Administrator revealed LPN #200 never admitted to taking the medications, but it was clear from the investigation. A total of 527 doses of medication had been found to be missing. LPN #200 was suspended during the investigation and then terminated on 10/03/19. Review of the Ohio Resident Abuse Policy, Section: Abuse, Neglect and Exploitation, dated 07/17, revealed the facility would not tolerate abuse, neglect, mistreatment, exploitation of resident and misappropriation of residents property by anyone. Misappropriation was defined as the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a residents belongings or money without the resident's consent.

Based on observation, taste test, interview and recipe review, the facility failed to serve pureed foods at a smooth consistency for safe swallowing. This affected six of six residents (#10, #11, #12, #16, #23 and #29) who were prescribed a pureed diet of 40 residents who took food by mouth. The facility census was 40. Findings include: Observation on 12/27/18 at 5:40 P.M. in the dining room revealed the pureed food did not appear to be smooth. A test tray was requested, the pureed peas were not smooth and not the proper texture. Dietary Manager #13 tasted the puree food and stated that it needed to be pureed more. Review of the pureed diet from the diet manual and recipe for pureed peas revealed peas should be prepared according to the regular recipe and blended until smooth. Review of resident diet list revealed Residents #10, #11, #12, #16, #23 and #29 received pureed diets. This was verified by Dietary Manager #13.

Based on interview and record review, the facility failed to ensure Resident #43 was given a 30 day notice prior to being discharged from the facility after she was sent out for a psychiatric hospital evaluation, and never returned to the facility. This affected one resident (Resident #43) of three residents reviewed for admission, transfer, and discharge rights. Findings include: Review of the closed medical record for Resident #43 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was discharged on [DATE] to another facility. The Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed she had little interest in doing things; a moderately impaired memory; trouble sleeping; trouble concentrating; delusions; and verbal behaviors one to three days in the assessment period. She was on antipsychotic and antidepressant medication. Review of the plan of care initiated on 07/05/16 for verbally aggressive behaviors, agitation, yelling out, and tearfulness was conducted. The goal was of this care plan was to reduce mood indicators with interventions including administering medications, reducing stressors, counsel resident, encourage family involvement, and positive reinforcement. On 07/26/16 at 9:40 A.M. an interview with Licensed Practical Nurse (LPN) #21 was conducted. She said she was familiar with Resident #43 She said the resident had mood changes and would yell out often. She did not want to be left alone and would say staff were being mean to her. She would tell us to quit laughing at her when we were not laughing. She said they checked lab work and for any other medical issues that may be related to her behaviors and said they were negative. She said Resident #43 was sent for a psychiatric evaluations more than once and had medication changes but continued to have verbal behaviors. She said Resident #43 was recently sent for another evaluation and the next thing she knew the resident was discharged and never came back. Review of the nurses progress notes dated May 2016 through July 2016 revealed staff were documenting that Resident #43 had frequent verbal behaviors that included asking staff for things repeatedly and yelling out for help. There was no indication that the resident was disruptive or or harmful to any other resident. Review of the nurses progress noted dated 06/08/16 at 9:59 P.M. revealed Resident #43 was transferred to a hospital medical center for psychiatric evaluation, and a message was left with her daughter regarding the transfer. The resident returned to the facility 06/15/16. Review of social service notes written by Social Worker (SW) #26, dated 06/20/16 at 12:40 P.M., revealed the Resident #43 was in a calm, pleasant mood, exhibiting no distress. No behaviors were noted that day with the social worker. Staff continued to anticipate and meet the resident's needs, and respond to requests for help. The resident stated, I'm doing better when the social worker asked how she was doing. The note written by SW #26 on 06/27/16 at 10:43 A.M. revealed Resident #43 was again in a calm, pleasant mood, exhibiting no distress. No behaviors were noted that day with the social worker. Staff continued to anticipate and meet the resident's needs, and respond to requests for help. Resident #43 stated, I'm fine in response to the social worker asking how she was doing. The resident had resumed normal activities of daily living, such as watching TV, and showed no decline in well-being at that time. On 06/30/16 at 10:50 A.M., SW #26 documented contacting the resident's daughter and providing contact information for a sitter to be with resident, which was recommended for the resident as behaviors have continued. However, there were no behaviors documented in this note to indicate why a sitter was recommended for the resident. Nursing progress notes written on 07/04/16 indicated the resident was anxious, calling out, and wanting someone to stay with her. On 07/05/16 the nurses note documented the resident was yelling out, with one-to-one response given with a positive effect. On 07/06/16, the nurse documented the resident was yelling out with one-to-one staff response provided, and the resident calmed. Review of the nurses progress noted dated 07/07/16 at 4:24 P.M. revealed Resident #43 was accepted at another psychiatric hospital for evaluation, and was transported to the emergency room for medical clearance as ordered by the physician before going to the behavioral unit. There was no indication in the note of the resident's behaviors that required a psychiatric hospitalization at this time. Review of the nurses progress note dated 07/07/16 at 5:30 P.M. revealed the residents daughter was notified her mother was sent to the psychiatric hospital for psychiatric evaluation. Resident #43's nurses notes documented on 07/13/16, an IDT meeting was held regarding the residents behaviors, transfer to the psychiatric hospital , and contacting the resident's daughter. This note also indicated the resident's behavior continued at the hospital, however, did not describe anything specific about the behaviors the resident was displaying at this time. On 07/27/16, the Director of Social Work from the psychiatric hospital, emailed a letter to this surveyor. The letter documented her conversations with Admissions Coordinator (AC) #24 from the facility. It said she had spoken with AC #24 prior to 07/13/16 regarding Resident #43. She said AC #24 stated the facility felt they could no longer manage the resident's behaviors or meet her needs. According to Admissions Coordinator #24 the resident's daughter had been told if she had to be sent out again for psychiatric reasons, they would likely not be able to accept patient back. AC #24 told the hospital Director of Social Work that she had sent a referral for Resident #43 to be considered for admission at two other facilities and had offered to place her at their other facility that was more equipped to handle her behaviors. The letter also acknowledged that Resident #43's daughter had asked the hospital Director of Social Work multiple times if it was legal for the facility to discharge her mother with so little notice. The letter stated Resident #43 was discharged on [DATE] from the psychiatric hospital and the nurses and aids there had notified the resident she was being discharged to another facility that day. Review of the facility Discharge Summary dated 07/14/16 revealed a note that said the facility was unable to meet Resident #43's needs at the current level of care. Resident discharged due to continued behaviors. However, there were no specific behaviors documented that indicated the resident was harmful or disruptive to any other residents. On 07/26/16 at 11:40 A.M. a phone interview with Admissions Coordinator #24 was conducted. She said she had many conversations with Resident #43's daughter regarding the resident's behaviors. She said they offered for the resident to be transferred to a related facility down the street where they could better work with her types of behaviors, but the resident's daughter had declined. She admitted to telling the Director of Social Work at the psychiatric hospital that Resident #43 was not appropriate for their facility due to her verbal behaviors. She said she helped the hospital arrange the resident's transfer to another facility. She verified that there was no documentation of her conversations with Resident #43 or her daughter regarding her appropriateness for the facility or that she may need to be discharged due to her behaviors, and there was no documentation of the arrangements she made for Resident #43's discharge. On 07/26/16 at 2:19 P.M. an interview was conducted with the Administrator. She said Resident #43 was sent out for psychiatric evaluation due to her verbal behaviors. She said Resident #43 was given a bed hold notice but was not appropriate to return to the facility because her behaviors had not improved and she was disruptive to other residents. When asked how she knew the resident's behaviors had not improved, (because the resident had never returned from the psychiatric hospital and had only been at the hospital for one week), she said it was because the staff at the hospital told them she had not improved. She said the resident did not want to come back to the facility anyway. When asked if the resident or a family member was given a 30 day discharge notice the Administrator verified Resident #43 nor her family had received notice of discharge. Review of Resident #43's medical record revealed no documented evidence from the facility staff, or from Resident #43's physician, stating why the resident was no longer appropriate for the facility; the specific behaviors that could not be managed by the facility staff; or that the resident did not want to return to the facility. There was also no documented evidence of notification in writing to the resident and/or family member of the reasons and specific behaviors that would warrant a discharge from the facility, the right to appeal the discharge decision, and the contact information for the Ombudsman. This deficiency substantiates Complaint Number OH 606.

Based on record review and interview the facility failed to thoroughly investigate an allegation of verbal abuse for Resident #39. This affected one of three residents reviewed for abuse. The facility census was 39. Findings include: Review of the facility's self reported incident (SRI) dated 04/20/16 revealed on 04/20/16 at 5:40 A.M. Resident #39 was in her room on the west wing of facility. At around 5:40 A.M. the resident put her call light on. The nurse responded and assisted the resident with putting on her compression hose. While the nurse on duty was assisting Resident #39 with her compression hose, the resident stated she did not like the aide that had been providing care to her during the shift. The nurse asked the resident what she meant by that. The resident stated that she thought she heard the aide call her a name under her breath. The resident stated the aide was assisting her in the bathroom. The resident stated the aide put her on the toilet sideways and as the aide was providing care, whispered the word [***] under her breath. The resident was asked what time this occurred and she stated it was around 4:30 A.M. The resident stated no other words were exchanged between herself and the aide. A head to toe assessment was completed with no concerns noted. The doctor, guardian, social worker and psychiatrist were notified. The new intervention was the resident would have two staff when giving her personal care. On 04/27/16 at 1:10 P.M. interview with the administrator revealed the director of nursing (DON) was notified by Licensed Practical Nurse (LPN) #6 of the incident. The state tested nurse aide (STNA) involved, STNA #7, had already left for the day when the resident made the allegation. The administrator said STNA #7 was suspended and did not return to work until Saturday 04/23/16. She said STNA #7 was asked to come to the facility on [DATE] to write a statement. The investigation was completed prior to STNA #7 returning to work. A statement was also provided by LPN #6. There were no other staff statements or interviews completed with the other staff on duty at the time of the alleged incident. On 04/27/16 at 2:45 P.M. interview with the DON verified LPN #11 and STNA #10 worked the night shift when the incident was alleged and neither staff member was interviewed or asked to provide a statement to ensure a thorough investigation. This deficiency substantiates control number OH 718.

Based on record review and interview, the facility failed to act on pharmacy recommendations. This affected three (Resident #7, #28 and #39) of five residents reviewed for unnecessary medications. The facility census was 47. Findings include: 1. Resident #7 was admitted on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) 3.0 assessment revealed the resident had moderate cognitive impairment and exhibited trouble concentrating, sleeping and was tired. The resident was assessed to have no verbal or physical behaviors. The resident required supervision or limited assistance to complete her daily needs. Review of the June 2015 monthly Physician order [REDACTED]. daily. Review of a pharmacy drug interaction notice dated 05/01/15 revealed a possible drug interaction between Abilify 2 mg. tablets and Bupropion HCL 75 mg. At the bottom of the page was an undated handwritten note to discontinue the Bupropion per the psychiatrist. A physician order [REDACTED]. On 06/11/15 at 11:27 A.M., an interview with the unit nurse, Licensed Practical Nurse (LPN) #1 regarding the pharmacy recommendation and drug interaction revealed when a pharmacy recommendation was received it was placed on a clipboard to ensure the physician received the information for review. LPN #1 stated she did not see the 05/01/15 recommendation until 06/10/15 and verified the pharmacy recommendation had not been acted on timely. She stated the resident had no seizure activity. Interview with the Director of Nursing (DON) on 06/11/15 at 11:45 A.M., revealed she was not sure why the recommendation had not been put on the clipboard on 05/01/15. 2. Resident #28 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) of 05/03/15 revealed the resident had severe cognitive impairment and required extensive to total assistance of staff to meet her daily needs. The resident's behaviors included hallucinations, delusions and verbal and physical behaviors. The resident was receiving Hospice services. Record review of the June 2015 physician's orders [REDACTED]. Record review of the Pharmacy Consultation Report of 05/28/15 revealed the resident had orders for labs to be drawn, but at the time of the review, they were no available in the resident record. The missing lab values included BMP (basic metabolic panel) and HgbA1C (blood sugar testing) that were ordered 04/20/15 to be drawn on 04/27/15. Interview with the Director of Nursing (DON) on 06/11/15 at 6:10 P.M. verified the pharmacy recommendation was not acted on and the lab work had not been completed on 04/27/15. 3. Review of the medical record for Resident #39 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] assessed Resident #39 as severely cognitively impaired and as having displayed behaviors. Review of the plan of care dated 03/27/14 for Resident #39 revealed a focus of the resident is at risk for adverse effects related to the use of psychoactive medication with an intervention including to assess for any side effects of medication. Review of a pharmacy recommendation dated 05/28/15 revealed Resident #39 received Seroquel ( an antipsychotic medication) and that this medication may cause involuntary movements. The pharmacist recommended monitoring for involuntary movements by using one the available scales. The form was signed by the Director of Nursing (DON) on 05/28/15 and stated that an Abnormal Involuntary Movement Scale (AIMS) test was completed on 03/23/15. Review of the medical record for Resident #39 revealed no AIMS test had been documented as completed. Interview with the DON on 06/11/15 at 5:27 P.M. verified there was no AIMS test documented as completed in the medical record.

Based on interview and document review, the facility failed to ensure shower preferences were honored. This affected one (Resident #47) of three residents reviewed for choices. The census was 47. Findings include: Review of Resident #47's record revealed he was admitted on [DATE] with [DIAGNOSES REDACTED]. His care plan for activities of daily living initiated 12/04/14 indicated to assist Resident #47 with bathing/showering in the evening per his preference. The resident's most recent quarterly assessment dated [DATE] revealed he had moderately impaired cognition and needed set up help only for bathing needs. Review of the Resident Care Card revealed the Resident #47 received showers two times weekly on second shift, on Sunday and Thursday. Review of the CNA (certified nursing assistant) - ADL (activities of daily living) Tracking and shower sheets revealed the resident received five showers in May, on 05/03, 05/07, 05/17, 05/21, and 5/31/15, and three in June, on 06/04, 06/07, and 06/08/15. During an interview on 06/09/15 at 4:00 P.M., Resident #47 indicated he would like three showers a day but one a day would be okay. The resident reported getting only two showers per week. During an interview on 06/11/15 at 9:41 A.M., the Administrator and Director of Nursing (DON) indicated the resident preference questionnaire was part of quality assurance (QA). The resident questionnaires are completed quarterly. Once completed, the QA committee meets, addresses resident needs, and fixes issues that are occurring. The Administrator revealed Resident #47 was interviewed on 05/08/15. The resident indicated he would like showers three times a day. On 06/11/15 at 5:30 P.M., the DON agreed the facility did not increase the frequency of Resident #47's showers to accommodate his preferences.

Based on observation and interview, the facility failed to ensure dietary staff's hair was covered to prevent possible physical contamination of food during meal service. This had the potential to affect 46 residents receiving food prepared in the kitchen. The facility census was 47. Findings include: On 06/10/15 from 4:48 P.M. to 5:23 P.M., a kitchen trayline observation was completed. Dietary aide (DA) #22 prepared drinks then placed them on the meal trays. He had a beard. The beard was not covered. At 4:56 P.M., Dietary Manager (DM) #21 confirmed DA #22's beard was not covered. The manager told the aide that he needed to cover his beard. DM #21 assisted with serving food from the steam table, heated soup on the stove, and did various other tasks in the kitchen area. A large section of her hair hung down out of the hair net on the left side. She made no attempts to reposition the hair net or don a new hair net. After completion of a test tray on 06/10/15 at 5:30 P.M., an interview with Dietary Manager #21 confirmed Dietary Aide #22's beard remained uncovered during the entire trayline observation. She confirmed a large section of her hair was hanging down out of the hair net.

Based on record review and interview, the facility failed to ensure state tested nurse aides received twelve inservice hours per year. This had the potential to affect all 47 residents residing in the facility. Findings include: On 06/11/15 at 5:45 P.M. a review of the state tested nurse aide (STNA) personnel files with the manager of Human Resources (HR) #4 revealed STNA #2 had a hire date of 09/01/12. Review of the Nurse Aide In-service Record revealed inservices had been recorded from 05/30/13 through 01/30/15. There were only two inservices that noted the number of hours the inservice was conducted. One on 08/21/13 a length of two hours was recorded and and the inservice on 10/29/13 was noted as a one hour inservice. All the remaining listed inservices did not denote the length of the inservice. Review of the personnel file of STNA #1 revealed a hire date of 09/01/12. Review of the In-service Record revealed inservices were recorded from 04/09/14 to 01/30/15, with no length of time recorded for any of the inservices. There was no documentation of the total year to date inservices for either STNA #1 or STNA #2. Interview with the HR manager on 06/11/15 at 6:10 P.M., verified the In-service Records did not track the length of the inservices to determine if the STNA's met the requirement of receiving twelve in-service hours per anniversary year. The HR director stated she thought each in-service was about two hours in duration. She stated the director of nursing provided the list of STNA's that attended the inservice, but she did not provide the length of the inservice. The HR director verified she also had no evidence of tracking the actual number of in-services attended by the STNA's.

Based on record review and interviews, the facility failed to act on resident concerns related to privacy issues. This affected six (Resident #10, Resident #20, Resident #36, Resident #53, Resident #66, and Resident #69) of 19 residents who resided on the 100 unit. The facility census was 41 residents. Findings include: On 02/25/14 between 10:32 A.M. and 12:02 P.M., multiple resident interviews were conducted with alert and oriented residents residing on the 100 unit. Each of the residents were asked if they had any concerns with their roommates or any other residents. Resident's #10, #36, #53, #66 and #69 all responded they had concerns regarding Resident #57 entering their rooms uninvited, closing their blinds and turning off their lights. Resident #10 and Resident #69 also stated Resident #57 was verbally abusive to them. Resident #36 stated Resident #57 touched her personal items and she stated that she did not like the resident to come into her private space. Resident #52 stated Resident #57 also turned off her television, and would not leave the room when asked. Resident #52 stated she would have to call for assistance to remove the resident. Resident #53 stated Resident #57 repeatedly entered his room and he was concerned about falsely accusing him of misdeeds. Resident #57 was in contact isolation. Review of the concern log revealed that on 12/30/13 a concern was recorded related to Resident #57. The name of the person filing the complaint was listed as "various residents" at the resident council meeting, with the concern of Resident #57 wandering into everyone's rooms. The concern was to be investigated by the director of nursing (DON), social service, and nursing. The date the person(s) filing was notified of the findings was listed as 01/09/14. The person completing the form noted that Resident #57 was counseled and noted the complaint was ongoing due to the resident's belief the facility was her house and every room belonged to her. Review of the resident council meeting minutes of 12/20/13 revealed no concerns related to Resident #57 were documented on the meeting notes. Interview with the activity director, Licensed Practical Nurse (LPN) #20, on 02/27/14 at 3:00 P.M., revealed Resident #10 and Resident #20 were among the residents who complained about Resident #57 wandering into their rooms. LPN #20 stated when the concern was verbalized at the 12/30/13 meeting, she did complete a resident /family concern form, but did not include the concern on the monthly resident council meeting notes. The DON and Licensed Social Worker (LSW) #21 were also present during the interview with LPN #20 on 02/27/14 at 3:00 P.M. The DON stated after the concern was noted they placed a stop sign on the doorway of Resident #10 and Resident #20, who were roommates. The DON also stated they talked about placing door alarms, but none had been placed. LPN #20 also stated that other residents had voiced concerns about Resident #57, including Resident #52. The DON stated that Resident #57 had been seen by the psychiatrist and her behaviors have been improving. Review of social service notes of 02/25/14, revealed LSW #20 noted she spoke with Resident #57 upon being informed that Resident #57 hit another resident in his arm the previous day. The LSW noted that "again" it was related to the fact that the resident believed the facility was her house and had the right to defend herself. She noted the one to one intervention had no positive effect. Review of the Resident Council meeting minutes of 01/28/14 revealed an old business note that stop signs were on door and looking into alarm for door. The note did not reflect who or what the stop sign was related to and if there was a resolution to the problem. LPN #20 stated she was not aware that she should have followed through with the concern at the meeting. The DON also verified other resident's had voiced concerns but the individual concerns were not documented.

Based on review of the self-reporting incidents and interviews with the administrator and director of nursing (DON), the facility failed to ensure that one resident (Resident #44) was protected from verbal abuse. This was found in one of four facility self-reported incidents reviewed. The facility census was 41 residents. Findings include: 1. The surveyor reviewed the facility self-reported incidents (SRI's) on 02/26/14 between 4:30 P.M. and 5:00 P.M. One incident, dated 12/03/13, described that on 12/03/13, Resident #54, who was alert and oriented to person, place, and time, reported to the administrator that STNA #30 was throwing things around his room directed toward his roommate, Resident #44. In addition, he related that the STNA was "yelling" at his roommate because the resident was [MEDICATION NAME] and talking, and had a bowel movement. Resident #54 stated that STNA #30 appeared angry. Resident #54 heard STNA #30 say "shut up" and "be quiet" a couple of times while he was providing incontinence care to Resident #44, whose [DIAGNOSES REDACTED]. According to the SRI, Resident #54 reported the incident immediately to the administrator. The administrator suspended STNA #30 until the investigation was completed. The investigation substantiated the allegation of verbal abuse, and STNA #30 was then terminated. During an interview with administrator and director of nursing (DON) on 02/26)14, at 5:00 P.M., they affirmed that the incident did occur, it was substantiated, and the employee was terminated,. The surveyor reviewed the in-services that were conducted related to abuse, neglect and misappropriation on 12/03/13, 12/04/13 & 12/05/13 for all shifts and all departments. Review of 15 personnel records revealed that everyone had a background check and they were hired based on the background check and reference checks. Review of the personnel record of STNA #30 revealed he had the appropriate screening and background check.

Based on record review and interview, the facility failed to ensure the Resident #52's health status was assessed upon return from [MEDICAL TREATMENT]. This affected the one resident (Resident #52) in the facility who received [MEDICAL TREATMENT] services offsite. The facility census was 41 residents. Findings include: Resident #52 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was receiving [MEDICAL TREATMENT] three times per week. Interview with Licensed Practical Nurse (LPN) #22 on 02/26/14 at 10:30 A.M. revealed when the resident returned from [MEDICAL TREATMENT], a full body check was completed. She stated that the body check was documented in the nursing notes. Record review of the nursing notes revealed no documented evidence of the post [MEDICAL TREATMENT] full body checks on 01/30/14, 02/04/14, 02/06/14, 02/08/14, 02/13/14, 02/15/14, 02/20/14, or 02/22/14. The LPN stated she did not take vital signs on the resident's return or specifically document the appearance of the [MEDICAL TREATMENT] site. Interview with the director of nursing (DON) on 02/27/14 at 12:30 P.M. verified there was no specific policy or procedure related to post-[MEDICAL TREATMENT] assessments. She stated that she instructed the staff to follow the leave of absence policy which stated that upon return to the facility, the nurse would complete the Skin Assessment. The DON stated she checked in medical records and found one Skin Assessment completed in February 2014 (dated 02/13/14). She verified no other documentation of post [MEDICAL TREATMENT] assessments were completed.

Based on observation, record review and interview, the facility failed to ensure Resident #67, who had a Stage III pressure ulcer, had his dressing in place as ordered by the physician and was provided incontinence care. The facility also failed to maintain complete and accurate pressure ulcer assessments. This affected the one resident (Resident #67) in the facility identified as having a pressure ulcer. The facility census was 41 residents. Findings include: Resident #67 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. His mother was granted guardianship on 02/06/14. The comprehensive Minimum Data Set Assessment, dated 01/13/14, indicated Resident #67 had short and long term memory impairment and was severely cognitively impaired. He required extensive assistance with one staff person for toileting and hygiene. The admission nursing assessment indicated Resident #67 had a reddened area on his coccyx. The pressure ulcer risk assessment dated [DATE] revealed a score of 13 for Resident #67, with a score of 13 to 14 indicating he was at moderate risk for pressure ulcer development. Resident #67 had an altered skin care plan initiated on 01/27/14 related to the reddened area present on his coccyx on admission. This plan of care was updated on 01/31/14 when the pressure ulcer opened. Interventions on this care plan included the provision of incontinence care as needed. On 02/25/14 at 10:02 A.M., interview with Resident #67's nurse, Licensed Practical Nurse (LPN) #13, revealed the resident had a Stage III pressure ulcer (a full thickness tissue loss in which subcutaneous fat may be visible but not bone, tendon or muscle and slough that does not obscure the depth of tissue loss may be present and the wound may include undermining or tunneling). The pressure ulcer was on his coccyx/left buttocks and had developed at the facility. The nurse's note on 01/31/14 at 5:30 A.M. indicated an open area was found on Resident #67's coccyx but no assessment or description was recorded. The physician was notified and a treatment order was obtained. The current treatment order, written on 02/23/14, was to clean the pressure ulcer with normal saline (NS), pat dry, apply [MEDICATION NAME] Ag with silver and cover with a dry dressing and Opsite, a clear occlusive dressing every 3 days and as needed. On 02/26/14 at 10:30 A.M., Licensed Practical Nurse (LPN) #10 and State tested Nursing Assistant (STNA) #11 were observed completing the dressing change for Resident #67. The nursing assistant removed his pants and socks and then the incontinence brief. STNA #11 verified there was blood and urine in the brief. She disposed of the brief and then removed his pants and socks per Resident #67's request. The nursing assistant prompted Resident #67 to turn on his right side towards her and he was able to on his own. Resident #67 indicated he can lay on his side but doesn't like to and prefers to lay on his back. When he turned, no dressing was covering his pressure ulcer. The open area was a circular area, approximately 2 to 2.5 centimeters (cm), at the coccyx area with a linear extension approximately 6 cm long and 1.5 cm wide ending on the left buttock in a circular area approximately 2 cm in diameter. There was a small amount slough present in the linear extension with whitish material in the center and then pinkish tissue. The nurse cleansed the pressure ulcer with normal saline, dried the area and applied the dressing as ordered. The nursing assistant put a new incontinence pull-up type brief on around Resident #67's ankles. The nurse and nursing assistant were at the sink and were asked to check the soiled brief for the old dressing. The nursing assistant obtained and unrolled the soiled brief and they both verified there was no dressing present inside. The nurse left the room and STNA #11 indicated she would finish dressing Resident #67 and get him up for lunch. STNA #11 put on his socks, sweat pants and shoes. She opened the door and indicated she was getting his chair. She got the Broda chair from the hall and moved it into the doorway of the room when the surveyor interrupted her so as not to allow her to get Resident #67 up and then have to put him right back to bed to provide the needed incontinence care they had not done. STNA #11 verified she had not provided any incontinence care to Resident #67 and would go back in and provide the care before getting him up for lunch. She indicated she had been helping the nurse but the assigned nursing assistant for Resident #67 for the shift was STNA #12. At 11:17 A.M., STNA #12 indicated she had toileted Resident #67 just before 8:00 A.M. but had not noticed if the dressing to his coccyx/left buttock was intact at that time. Review of the pressure ulcer tracking revealed the current pressure ulcer started as two areas, one on the coccyx/buttocks midline and one on the left buttock. On 01/31/14, the coccyx ulcer was 1.2 cm by 0.3 cm by less than 0.1 cm deep with pink tissue. No drainage was documented and no staging was listed. On 02/08/14, eight days later, the pressure ulcer was documented as 2 cm long by 0.7 wide by 0.1 deep without any drainage. There was no assessment of the wound bed documented and no staging was listed. The left buttocks pressure ulcer was first assessed on 01/31/14 as a 2 cm by 0.6 cm by 0.1 cm ulcer. There was no stage listed but it was described as pink for the wound bed with white margins. On 02/08/14, eight days later, the ulcer was 2 cm by .06 cm by 0.1 cm with white margins. There was no assessment of the wound bed, no stage listed and no drainage documented. The pressure ulcer tracking dated 02/14/14 indicated the two ulcers were now one large pressure ulcer measuring 10.5 cm by 7.0 cm by 0.1 cm deep. No staging or assessment of the wound bed was completed. This assessment indicated the wound margins were beefy red with the surrounding skin being tan/red and no drainage was present. The next assessment on 02/17/14 indicated the pressure ulcer was 7.5 cm by 5.5 cm by 0.2 cm and was now documented as a Stage III with 10% eschar (dead, blackened tissue) and 50% slough, dying tissue in the process of separating from the viable portions of the body and is usually light colored, soft, moist, and at times stringy. The wound margin was documented as slough and the surrounding tissue was macerated and red. No drainage was documented. The last assessment dated [DATE] indicated the pressure ulcer was a Stage III and was 7.3 cm by 5.4 cm by 0.2 cm and was 50% slough. The wound margin was red. No drainage was documented. These pressure ulcer assessments were reviewed with the DON on 02/26/14 at 2:50 P.M. and she verified that some entries lacked an assessment of the wound bed and a stage in order to closely monitor the pressure ulcer for changes and that the assessments should be completed at least weekly.

Based on observation, interview and review of facility policy, the facility failed to ensure that only licensed nursing staff provided care and handled Resident #67's gastrostomy tube and tube feeding equipment. This affected the one resident (Resident #67) residing in the facility who utilized with a gastrostomy tube for nutrition. The facility census was 41 residents. Findings include: Resident #67 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #67 had a pressure ulcer on his coccyx/left buttock and the wound and the dressing change procedure was observed on 02/26/14, at 10:30 A.M., with Licensed Practical Nurse (LPN) #10 and State tested Nursing Assistant (STNA) #11. The nurse had placed Resident #67's tube feeding via his GT on hold during his dressing change. After the treatment was completed the nurse left the room and STNA #11 indicated she would finish getting Resident #67 dressed, and get him up for lunch. STNA #11 put on his socks, sweat pants, and shoes. She was observed to turn off the tube feeding pump and unhook Resident #67's tube feeding tubing from his GT and drape it over the machine. leaving the end uncovered. She opened the door and indicated she was getting his chair. She got the Broda chair and moved it into the doorway of the room and the surveyor interrupted as the STNA verified she had not completed incontinence care and would do so now. Later in the day, on 02/26/14 at 1:20 P.M., STNA #11 verified that she had turned off Resident #67's tube feeding, unhooked the tube feeding line from Resident #67's gastrostomy tube and draped the end, without covering it, over the top of the tube feeding administration pump. STNA #11 indicated she was not aware that nursing assistants were not permitted to disconnect tube feedings and make changes to the tube feeding pump. LPN #10 indicated she did not remember what time she restarted the tube feeding as Resident #67 was up in a chair in the lounge now with the tube feeding running. On 02/26/14 at 1;27 P.M. the director of nursing (DON) was notified of these concerns and verified the nursing assistants were not permitted to do any functions related to GT's. At 1:35 P.M., the DON provided a GT care policy, effective 01/2011 and last reviewed January 2014. This policy indicated the licensed nurse will be the staff person to provide routine care for the gastrostomy tube.