Every finding on record at Kensington at Anna Maria

Based on record review, observation, interviews, review of the manufacturer's instruction for insulin flex pens and facility policy, the facility failed to ensure a medication error rate of less than 5 percent (%). There were four errors observed of 34 opportunities, resulting in an 8.82 % total error rate. This affected one Resident (#21) out of three residents observed for medication administration. The facility census was 88.Findings include:Review of the medical record for Resident #21 revealed an admission date of 04/28/25 with diagnoses of spinal stenosis, type two diabetes, chronic kidney disease, gastro-esophageal reflux disease, overactive bladder, atrial fibrillation, adult failure to thrive, and hyperlipidemia.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of eight out of 15 which indicated severe cognitive decline. The functional assessment revealed Resident #21 needed supervised assistance with grooming and maximum assistance with toileting, transferring, and mobility via wheelchair.Review of the physician orders for Resident #21 revealed the resident was to receive 52 units of Humulin 70/30 Insulin subcutaneously in the morning via KwikPen Subcutaneous Suspension Insulin Pen-injector (100 units per milliliter). Resident #21 was also to receive Lispro Insulin (100 units per milliliter) per sliding scale insulin coverage.On 12/16/25 at 7:40 A.M. Resident #21's glucose Accu-Chek revealed a glucose level of 209. The sliding scale order for result of 209 was to administer 4 units of Lispro Insulin subcutaneously before meals (breakfast). Observation on 12/16/25 at 7:53 A.M. of medication administration to Resident #21 by Licensed Practical Nurse (LPN) #544 revealed the LPN attached the needle to the Humulin 70/30 insulin and dialed in 30 units. (There was not enough medication in the Humulin 70/30 insulin to give the full 54-unit dose and had to be divided with another insulin pen.). LPN #544 then applied the needle tip to the second Humulin 70/30 KwikPen and dialed in 24 units. LPN # 544 then applied a needle tip to the Lispro KwikPen insulin syringe and dialed in 4 units. LPN #544 then proceeded to administer all three insulin dosages per KwikPens but did not prime any of the three KwikPens prior to administration. Additionally, LPN #544 was observed to omit the morning dose of Midodrine 5 milligrams which the ordered parameter was to hold the medication if the systolic blood pressure was greater than 130. LPN #544 checked Resident #21's blood pressure which was 127/84. All other morning medications were observed given.Interview with LPN #544 on 12/16/25 at 7:58 A.M. verified that she did not prime the pens prior to dialing insulin dosage and administering to Resident #21. LPN #544 stated she forgot and knows to prime the pens. When asked what the resident's blood pressure was, LPN #544 stated Resident #21's blood pressure was 127/84 and his heart rate was 78.Interview with Director of Nursing (DON) on 12/16/25 at 12:10 P.M. verified that all insulin pens should be primed prior to dialing in dosage and administering to any resident. DON also confirmed that LPN #544 should have administered the Midodrine 5 milligram morning dose as the ordered parameter to hold the medication was a blood pressure greater than 130 systolic and the resident's blood pressure was lower than 130 systolic.Review of the undated facility policy titled, Multidose Pens of Injectable Medications revealed after placing needle hub onto injectable pen, prime the pen per manufacturer's guidelines which include: turning dose selector to 2 units, hold pen with needle pointing up, tap the pen cartridge gently a few times so air bubble rise to the top of the cartridge, and press the injector button to check that insulin comes out of the needle. If the insulin does not come out, then try again. If still no insulin, attach a new needle and repeat. If after 6 trials and you still do not get insulin, discard the pen and use another pen.Review of the facility policy titled, General Guidelines for Medication Administration, dated 04/01/23, revealed to check the physician's order for correct dosage schedule. If a dose is withheld, an explanatory note is entered in the record.Review of the undated Manufacturer Instructions of KwikPen Insulin Pens revealed before each injection small amounts of air could collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing turn the dose selector to select two units. Hold the Tresiba insulin pen with the needle pointing up. Turn the dose selector to dial in two units. Press and hold the dose button until the dose counter shows 0. Make sure a drop appears. Turn the dose selector to select the number of units you need to inject. Wipe the skin with an alcohol swab and let it dry before you inject your dose. Press and hold the dose button.

Based on record review, interview, observation, and review of witness statements, facility investigation, mechanical lift policy and fall policy and procedure the facility failed to ensure Resident #27 was safely transferred with a Hoyer (mechanical) lift to prevent a fall with injury and failed to ensure a physician ordered fall intervention was implemented for Resident #48. This affected two residents (#27 and #48) of three residents reviewed for falls. The facility census was 95. Actual Harm occurred on 10/30/23 at 7:45 P.M. when State tested Nurse Aide (STNA) #520 attempted to transfer Resident #27 without another staff member from her wheelchair to her bed using a Hoyer lift with the Hoyer pad in the incorrect position. This resulted in Resident #27 sliding through the lift pad and falling onto the floor with subsequent transfer to emergency room for evaluation where Resident #27 was diagnosed with a closed non-displaced fracture of her left clavicle and a hematoma to her left ear. Findings include: 1. Review of the medical record for Resident #27 revealed an admitted [DATE] with diagnoses including heart failure, mild cognitive impairment, muscle weakness and non-displaced fracture of the left clavicle (10/30/23). Review of Resident #27's care plan dated 10/15/21 revealed Resident #27 had a self-care deficit related to heart failure with complications, hypertension, anxiety, depression, insomnia, and malnutrition and needed assist with most activities of daily living. An intervention dated 11/01/22 revealed Resident #27 required a mechanical lift for transfers using a full body sling Hoyer pad. Review of the physician's orders for Resident #27 revealed an order dated 05/16/23 for mechanical lift for transfers and an order dated 11/02/23 to use a full sling Hoyer pad for transfers. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #27 had intact cognition and was dependent on staff for transfers from the chair to the bed. Review of the fall risk assessment dated [DATE] revealed Resident #27 had intermittent confusion and was at high risk for falls. Review of the nursing progress note dated 10/30/23 timed 7:45 P.M. authored by Licensed Practical Nurse (LPN) #560 revealed LPN #560 was called to Resident #27's room by a STNA. The STNA stated Resident #27 had fallen out of the Hoyer pad onto the floor. Resident #27 was assessed, and a new order was obtained to send her to the emergency room for evaluation. There was no mention Resident #27 was being transferred using the Hoyer lift by only one staff member. Review of LPN #560's witness statement dated 10/30/23 revealed STNA #520 reported to her Resident #27 had fallen to the floor from the Hoyer lift. There was no mention Resident #27 was being transferred using the Hoyer lift by only one staff member. Review of LPN #624's witness statement dated 10/30/23 revealed STNA #520 came out to the hallway yelling for LPN #560 because Resident #27 had fallen and was on the floor. LPN #624 indicated Resident #27 was observed on the floor and complained of back and left ear pain. The statement indicated Resident #27 was a Hoyer lift and STNA #520 stated the lift had malfunctioned. There was no mention Resident #27 was being transferred using the Hoyer lift by only one staff member. Review of STNA #520's witness statement dated 10/30/23 revealed STNA #520 had witnessed the incident. STNA #520 indicated he was transferring Resident #27 from the wheelchair to the bed with the Hoyer lift. While transferring, Resident #27 slipped through the Hoyer pad and landed on the floor. STNA #520 indicated the Hoyer straps let loose from the machine. STNA #520 did not mention he was transferring Resident #27 using the Hoyer lift by himself. Review of the fall investigation for the incident which occurred on 10/30/23, signed by the Director of Nursing (DON) dated 11/02/23, revealed Resident #27 was dependent for transfers and mobility. On 10/30/23 during a transfer, Resident #27 was being transferred from her wheelchair to her bed. The green sling (Hoyer pad) was attached to the mechanical lift while in the wheelchair. The back straps and leg straps were crossed between the resident's legs. As Resident #27 was being lifted from her wheelchair toward the bed, the Hoyer pad slid from under her buttocks, and she slipped through the lift pad. Resident #27 landed on the floor on her bottom and rolled to her left side. The resident was assessed, and a new order was obtained to send her to the emergency room for evaluation. At the emergency room , it was noted Resident #27 had a closed non-displaced fracture of her clavicle and a hematoma to her left ear. Upon Resident #27's return to the facility an order was obtained to use a full sling for transferring Resident #27. During the DON's investigation, it was noted if the resident was sitting in the sling and it was placed too high on her, it provided enough room for her to slide through the straps due to Resident #27 having little lower body control. Resident #27's sling was changed to a full body sling and the staff were re-educated on the use and placement of the sling and educated on mechanical lift transfers. The root cause of the incident was that Resident #27 had minimal control of her lower body and her legs lifted up enough for her to slide out of the sling. There was no mention of STNA #520 transferring Resident #27 with the Hoyer lift by himself in the investigation. Review of the hospital emergency department documentation dated 10/30/23 revealed Resident #27 had an x-ray of her left shoulder. The impression indicated suspected non-displaced distal clavicular fracture. Review of the nursing progress note date 10/31/23 timed 12:30 A.M. revealed Resident #27 returned from the emergency room and was noted to have a closed non-displaced fracture of the left clavicle and hematoma to her left ear. Review of STNA #520's employee file revealed a disciplinary action dated 10/31/23 due to a new or ongoing deficiency in his conduct or performance. The notification indicated during transfer it was the facility's policy to have two people present. STNA #520 was suspended for two days. Also, in STNA #520's employee file was his job description signed and dated 08/05/20. Under the section of special skills and requirements it indicated STNA #520 would perform, and complete resident care as outlined on the care needs sheet including lifting residents as determined as a one-person, two-person or Hoyer lift as well as follow safety policies including following proper transfer techniques. Interview on 04/03/24 at 7:58 A.M. with the DON verified STNA #520 had transferred Resident #27 by himself with the Hoyer lift on 10/30/23 when Resident #27 slid out of the Hoyer pad and landed on the floor. Interview on 04/03/24 at 9:30 A.M. with STNA #520 verified he transferred Resident #27 with the Hoyer lift on 10/30/23 by himself. He stated the strap came loose and she slid through the Hoyer pad onto the floor. He stated he had been educated on hire that two staff were required to utilize the Hoyer lift. STNA #520 stated he had been in a hurry to transfer her and did not wait on another staff member because Resident #27 was visibly upset and crying and wanted to go to bed. Interview on 04/03/24 at 10:07 A.M. with STNA #552 revealed staff were trained by the facility on Hoyer lifts on hire. She stated two staff were always required when using the lift. Review of the facility policy titled, Lifting Machine, Using a Portable, revised March 2004, revealed the portable lift could be used by one nursing assistant if the resident could participate in the lifting procedures. If not, two nursing assistants were required to perform the procedure. 39969 2. Review of the medical record for Resident #48 revealed an admitted [DATE]. Diagnoses included anxiety disorder, falls, subdural hemorrhage with unknown loss of consciousness, muscle weakness, difficulty walking, need for assistance with personal care, and orthostatic hypotension. Review of the care plan dated 09/21/23 revealed Resident #48 was at risk for falls related to multiple recent falls, decreased balance, mobility, and safety awareness and use of antidepressant and antianxiety medications. Resident had a history of removing and hiding alarms from staff, so they did not sound. Resident #48 had a history of a fall resulting in a subdural hemorrhage. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #48 had impaired cognition, required partial and moderate assistance with sit to stand, chair/bed to chair transfer, and toilet transfer, and had falls. Interventions included Dycem (non-slip mat) above and below wheelchair cushion. Review of the fall risk evaluation dated 03/18/24 revealed Resident #48 was a high fall risk. Review of the physician orders for April 2024 revealed active orders for Dycem above and below wheelchair cushion with a start date of 01/02/24. Observation on 04/02/24 at 8:17 A.M. revealed Resident #48 was sitting in her wheelchair in the hall. Further observation revealed a blue Dycem in Resident #48' room sitting on the nightstand near her bed. Interview on 04/02/24 at 8:23 A.M. with Licensed Practical Nurse (LPN) #572 revealed therapy got Resident #48 a new cushion for her wheelchair. Observation with LPN #572 confirmed the blue Dycem on the nightstand in Resident #48's room. LPN #572 stated she did not know what the blue thing was. Interview on 04/02/24 at 8:26 A.M. with Resident #48 who sitting in her wheelchair in the common area revealed there was not a blue Dycem on her wheelchair cushion. Resident #48 stated the Dycem helped to keep her from sliding and it was her fault the Dycem was not in the cushion because she did not put it on the cushion before transferring to the wheelchair. Resident #48 stated she could not transfer herself into the wheelchair, State tested Nurse Aide (STNA) #536 helped her into her chair. Interview on 04/02/24 at 8:29 A.M. with STNA #536 revealed she had not been to work in the past three days but knew they were waiting on a larger Dycem for Resident #48. STNA #536 stated Resident #48 received a new cushion for wheelchair and she would check to see if a Dycem was on Resident #48's wheelchair cushion. Observation revealed STNA #536 wheeling Resident #48 to a handrail, locking the wheelchair, and assisting Resident #48 to a standing position as Resident #48 held onto the handrail. There was not a Dycem on the wheelchair cushion. STNA #536 lifted up the wheelchair cushion and there was a blue Dycem under the cushion. STNA #536 verified there was not a Dycem on top of the resident's wheelchair cushion and assisted Resident #48 to sit back down in the wheelchair. Further observation revealed another staff member giving STNA #536 a large blue Dycem. STNA #536 then pushed Resident #48 to her room. Upon entering Resident #48's room, STNA #536 verified the blue Dycem sitting on the nightstand and stated it was a smaller Dycem but it should had been in the resident's wheelchair because Resident #48 slid in forward while in the wheelchair and was a high fall risk. Review of the facility policy titled Falls Policy and Procedure, revised 09/06/19 revealed the facility strived to reduce the risk of falls and injuries by implementing the falls policy and procedure. Residents were assessed for fall risk factors. The interdisciplinary team worked with the resident and family to identify and implement appropriate interventions to prevent falls or injuries while maximizing dignity and independence.

Based on observation, interview, and record, and review of the sample room test tray evaluations, the facility failed to ensure food was served at palatable temperatures. This had the potential to affect all residents except one resident (#65) who received nothing by mouth. Facility census was 95. Findings include: Interviews on 04/01/24 from 9:41 A.M. to 11:00 A.M. with Resident #12, #28, #29, #66, and #147 revealed the food was often served cold and tasted bland. Observation of tray line service on 04/02/24 at 12:12 P.M. revealed the food was served on plates that were then placed on a food tray and covered with a thermal lid. The food tray was then placed in a metal, enclosed food cart. Completion of a test tray on 04/02/24 at 1:57 P.M. with Certified Dietary Manager (CDM) #591, after the last meal tray was served, revealed the pureed lasagna was 113 degrees Fahrenheit (F) and pureed vegetable was 107.6 degrees F. All food items were flavorful, well-seasoned but were lukewarm. CDM #591 also tasted the pureed lasagna and verified the findings. CDM #591 stated she had heard food complaints from residents that resided on the short term unit. CDM #591 stated they ordered thermal plate bottoms that coordinated with the thermal lids but did not have heated transportation units that would help keep the food warm during hall tray pass. Review of the facility's most recent Room Test Tray Evaluation form dated 03/04/24 indicated acceptable delivery temperatures were 40 to 55 degrees F for cold foods and 135 to 160 degrees F for hot foods. Review of the Consistency Census Report dated 04/02/24 revealed there was one residents (#65) who received nothing by mouth.

Based on observation and interview, the facility failed to ensure all meals were served in a sanitary manner. This affected one (#63) of one resident who received the alternate meal selection. The facility census was 95. Findings included: Observation of tray line meal service on 04/02/24 at 12:17 P.M. revealed Dietary Cook (DC) #609 opening the steamer with gloved hands, removing a cooked hamburger patty and setting the hamburger patty onto the steamtable. DC #609 closed the steamer door and obtained a knife and cut the hamburger into bite sized pieces. DC #609 obtained a plate, scooped the cut up hamburger patty with gloved hands and placed the hamburger on the plate. At 12:19 P.M., DC #609 changed her gloves and continued serving. Further observation revealed the meal tray with the cut up hamburger was taken to the dining room by staff. Interview on 04/02/24 at 12:24 P.M. with DC #609 verified the observation and stated she knew when she grabbed the hamburger with her hands she should not have. DC #609 stated that tray was for Resident #63.

Based on observation, record review and interview, the facility did not ensure appropriate personal protection equipment (PPE) was implemented for Resident #189 while the resident was on isolation precautions. This finding affected one resident (Resident #189) receiving therapy services and had the potential to affect six additional residents currently receiving occupational therapy (Residents #3, #15, #71, #77, #87 and #140) and ten additional residents currently receiving speech therapy (Residents #10, #15, #26, #27, #85, #139, #140, #141, #191 and #289) of 87 residents residing in the facility. Findings include: Review of Resident #189's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #189's physician orders [REDACTED]. Observation on 02/10/20 at 9:37 [NAME]M. revealed Speech Therapist (ST) #801 was in Resident #189's room assisting the resident to drink fluids. ST #801 donned gloves and was observed touching the resident's overbed table and the resident to assist the resident to drink fluids. ST #801 did not have a yellow protective gown over her clothing to prevent possible cross contamination of her clothing during care of the resident. Observation on 02/12/20 at 9:30 [NAME]M. with ST #801 revealed Occupational Therapist (OT) #802 and student OT #803 were in Resident #189's room. Student OT #803 was observed leaning on Resident #189's chair with her hands on the back of the chair. Both staff members indicated they were going to provide care to the resident, both donned gloves and no isolation gown was implemented over their clothing to prevent possible cross contamination during the resident's care. Interview on 02/12/20 at 10:15 [NAME]M. with Registered Nurse (RN) #804 confirmed the facility policy indicated the standards for contact precautions included to use universal precautions including gloves and handwashing. RN #804 also confirmed staff were required to wear a disposable gown for tasks that involve contact with the resident or potentially contaminated areas of the room including the bed, resident chair and overbed table. Interview on 02/13/20 at 12:58 P.M. with Physical Therapy Assistant (PTA) #805 confirmed seven residents resided in the facility who were receiving occupational therapy with OT #802 including Residents #3, #15, #71, #77, #87, #140 and #189 and eleven residents resided in the facility who were receiving speech therapy with ST #801 including Residents #10, #15, #26, #27, #85, #139, #140, #141, #189, #191 and #289. Review of the undated Isolation-Categories of Transmission-Based Precautions policy revealed in addition to wearing gloves, wear a disposable gown for tasks that involve contact with the resident or potentially contaminated areas of the room, such as giving care to the resident, changing bed linens, repositioning the resident in a chair, or cleaning in the room.

Based on record review and interview, the facility failed to ensure coordination of hospice services for Resident #47's advance directives. This finding affected one (Resident #47) of two residents reviewed for hospice. Findings include: Review of Resident #47's medical record revealed the resident was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #47's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment. Review of Resident #47's undated Ohio DNR (do not resuscitate) Identification Form indicated the resident's code status was DNRCC-Arrest (DNR comfort care arrest or DNRCCA). Review of Resident #47's physician order [REDACTED]. Review of Resident #47's hospice documentation signed on 01/29/20 revealed the resident's code status was identified as DNRCC (DNR comfort care). Interview on 02/12/20 at 3:01 P.M. with the Director of Nursing (DON) confirmed Resident #47's medical record and physician orders [REDACTED]. Review of the Ohio DNR form confirmed DNRCC code status included not to administer chest compressions, insert an artificial air way, administer resuscitative drugs, defibrillate or cardiovert, provide respiratory emergency assistance and initiate cardiac monitoring. The form also indicated the DNRCCA code status was implemented only in the event of a [MEDICAL CONDITION] or a respiratory arrest.

Based on observation, interview and record review, the facility failed to ensure adequate fluids were given to Resident #67 to prevent dehydration. This affected one of one resident (Resident #67) reviewed for hydration. Findings include: Review of the medical record for Resident #67 revealed an admission date of [DATE] with medical [DIAGNOSES REDACTED]. Review of the Minimum Data Set (3.0) assessment revealed Resident #67 had severe cognitive impairment. Review of progress notes nutrition note dated 06/26/19 revealed estimated fluid needs were 2200 to 2400 milliliters (ml) per day. Review of physician's orders [REDACTED]. Review of physician's orders [REDACTED]. Review of the electronic record for Resident #67 dated 01/14/20 through 02/06/20 revealed documentation of fluids taken in by mouth including nutritional supplements of 600 ml per day to 1560 ml per day. Further review of the electronic record noted fluid amounts were written in for each day, but were not added up at the end of the day and documented in the record. Review of Resident #67's progress notes dated 02/05/20 revealed Certified Nurse Practitioner (CNP) #815 was notified that the resident was complaining of dizziness and a low blood pressure of 75/42. CNP #815 instructed staff to have resident drink more fluids, and she would come to the facility later in the day to assess Resident #67. Review of Resident #67's progress notes dated 02/06/20 revealed bloodwork showed Resident #67 had an acute kidney injury (most common cause is dehydration) including a BUN (blood urea nitrogen) of 146 (normal range is 7-20, a high BUN can be due to low blood flow to the kidneys caused by dehydration). CNP #815 instructed facility staff to send Resident #67 to the hospital for reasons including administration of intravenous (IV) fluids and discontinued his diuretic. Further review of the progress notes revealed Resident #67 refused to go to the hospital, and CNP #815 gave orders to start IV fluids. Review of the Medication Administration Record [REDACTED]. Interview on 02/12/20 with Director of Nursing (DON) and Licensed Practical Nurse (LPN) #810 confirmed that Resident #67 had acute kidney injury caused by dehydration. Observation on 02/13/20 at 12:18 P.M. of Resident #67 sitting in his wheelchair in the dining room being served lunch by the facility staff revealed staff offered him drinks which he willingly took and began drinking immediately. The cup and glasses in front of Resident #67 were not graduated and did not have marks for measuring fluids on them. Interview on 02/13/20 at 12:31 P.M. with Dietary Aide (DA) #812 stated that glasses and cups used to serve fluids to residents did not have have marks for measuring the fluids on them. DA #812 further stated that no measuring items were used to pour fluids into any of the cups and glasses used by residents residing in the facility. Interview on 02/13/20 at 12:37 P.M. with State tested Nursing Assistant (STNA) #814 indicated she was responsible for writing down the fluids Resident #67 consumed on his meal ticket when he had finished eating. Resident #67 had a large empty glass, a small glass turned upside down, and an insulated cup with some light brown liquid in it. STNA #814 stated when there was fluid left in a glass or cup she estimated how much was left, and did not use any measuring device. Interview on 02/13/20 at 12:53 P.M. with the DON revealed when a physician wrote an order for [REDACTED]. Phone interview on 02/13/20 at 3:56 P.M. with CNP #815 revealed on 02/05/20 Resident #67 complained of dizziness and was not drinking enough fluids and needed to have intravenous fluids for hydration. CNP #815 further stated that Resident #67's acute kidney injury was most likely caused by dehydration.

Based on interview and record review, the facility failed to ensure residents fund account were kept private and unavailable to the public. This effected 14 Residents (#44, #59, #93, #97, #98, #99, #100, #101, #102, #103, #104, #105, #106, and #107's) of 93 residents residing in the facility. Findings include: Review of Resident #29's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #29's social service notes dated 04/23/19 at 4:53 P.M. documented as a late entry, revealed the resident was seen by audiology services Nurse Practitioner (NP) #300 through 360 care on 04/23/19. On 05/23/19 Resident #29's family member requested a statement for the removal of the charge for the audiology visit on 04/23/19 and was sent a statement including 14 other residents (# 44, #59, #93, #97, #98, #99, #100, #101, #102, #103, #104, #105, #106, and #107) financial statements, amounts owed to the facility and dates of discharge. Review of an email sent to the facility by Resident #29's family to the Administrator of the facility on 05/23/19 revealed the family member was upset she was sent Resident #29's financial statement as well as Residents #44, #59, #93, #97, #98, #99, #101, #102, #103, #104, #105, #106, and #107's financial statements. This information also contained date of discharge, full names of the residents and the residents financial status with the facility. The Administrator responded to the email on 05/23/19, acknowledged the error was a clerical error and requested the information be returned to the facility. Interview with Billing Director (BD) #200 on 07/10/19 at 1:00 P.M. verified she hit the wrong button on the computer and sent other residents' dates of discharge and financial information to Resident #29's family member. Interview with the Director of Nursing (DON) on 07/10/19 at 1:30 P.M. verified the 14 residents' personal financial information was sent to Resident #29's family member by mistake. This violation substantiates Complaint Number OH 246.

Based on observation, menu review and interview the facility failed to ensure kitchen staff followed the menu spreadsheets during meal service. This affected all 15 residents identified by the facility as receiving a pureed diet (Resident #6, #11, #12, #23, #31, #34, #45, #48, #55, #59, #60, #62, #69, #73, #88). Findings include: Review of the facility menu spreadsheet for Day 10 which correlated to 12/11/18 revealed residents on a pureed diet were to receive a #8-scoop of pureed crispy baked chicken, a #10-scoop of pureed corn, a #20-scoop of pureed bread and a #10-scoop of pureed spinach. Observation of the lunch trayline on 12/11/18 from 12:01 P.M. until 12:43 P.M. revealed a blue #16-scoop used to serve the pureed chicken and a gray #8-scoop used to serve the pureed corn and the pureed spinach. Additionally, no pureed bread was available for service until the surveyor questioned Cook #300 and Food Service Director (FSD) #301 at 12:28 P.M. about the missing bread and the portion sizes of the pureed foods. When pureed bread was added to the trayline at 12:41 P.M., there was a red #24-scoop used for service. The menu spreadsheets were not observed to be available for review during the trayline observation. Interviews with Cook #300 on 12/11/18 at 12:10 P.M. and 12:28 P.M. revealed all residents on a pureed diet received 4-ounce portions. Cook #300 verified the blue #16-scoop was not the correct scoop for the pureed chicken and also verified bread purees had not been prepared. Interview with FSD #301 at 1:20 P.M. verified Cook #300 did not use the correct utensils to serve the pureed vegetables, chicken and bread. FSD #301 and the surveyor reviewed the supplier equipment guide to verify scoop sizes, colors and portions. FSD #301 revealed an ivory #10-scoop was the appropriate utensil to serve the pureed corn and spinach, a gray #8-scoop should have been used to serve the pureed chicken and a yellow-#20 scoop should have been used to serve the pureed bread.

Based on observation, interview and record review, the facility failed to ensure a resident was assisted and encouraged to eat as care planned during observed meal service. This affected one of three residents reviewed for nutrition (Resident #6). Findings include: Review of the record revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of her most recent quarterly minimum data set assessment dated [DATE] revealed she was severely cognitively impaired and rejected care one to three days a week. She required the extensive assistance of one to two staff for her activities of daily living and required the supervision of a staff member to eat. Review of her care plans dated 05/17/17 revealed she had a history of [REDACTED]. A care plan dated 04/08/16 revealed the resident had a history of [REDACTED]. A care plan dated 10/16/17 revealed the resident would often refuse assistance for eating, eat with her hands and had been noted to throw food during meals. Interventions included to approach the resident in a calm manner when attempting to feed her, continue to provide cues during meals and provide assistance as needed and refer to therapy as needed. Another care plan dated 12/03/18 revealed the resident had resistive behaviors such as refusing her ordered food supplements and throwing food, with interventions to allow resident to make decisions regarding treatment, educate her and family as to outcomes of not complying with treatment, encourage interactions and participation by the resident during care and give a clear explanation of all care activities prior to each contact. Observation of the lunch meal on 12/10/18 at 12:50 P.M. in the assist dining room revealed Resident #6 sitting at a table with three other residents. A state tested nursing assistant, (STNA) # 404, was sitting between two residents and started feeding them when they received their food. Another resident received her tray and started eating. Resident #6 was the last resident to receive her tray at 12:54 P.M. A staff member set her food, which was all in bowls, in front of her and walked away. Resident #6 looked around the dining room for several minutes and then looked at her food. Around 12:59 P.M., she picked up a cup of orange juice sitting on the table and dumped it on the floor. She set the empty cup on the table and put her hands in her lap. As STNA #404, who had noticed her actions, looked around for another staff member, Resident #6 picked up a bowl with mashed potatoes and gravy, with her fingers in the bowl and dumped the mashed potatoes on the floor as well. Another staff member walked by and STNA #404 indicated the resident had dropped her food. A staff member brought her a new bowl of mashed potatoes and covered the food on the floor with a towel. At 1:03 P.M., STNA #404 stood up and came over to Resident #6. She put a spoon in a bowl and stated the Resident #6 should eat her pudding. She had not spoken to the resident or encouraged her to eat prior to this time. Resident #6 eventually took about 4 bites of pudding. She also put her spoon in a bowl of another food, but then put the spoon of food in the pudding. She did not eat anymore food or drink any of the three cups of liquids near her bowls. At 1:11 P.M., STNA # 403 walked by and asked what had happened on the floor. STNA #404 stated Resident #6 had dumped her food on the floor. STNA #403 laughed and walked by. Resident #6 did not eat anymore food. She pulled at the clothing and blanket of the resident sitting next to her, smiled and blew kisses at the surveyor sitting behind her and sat with her hand in her lap. She did not receive any other encouragement to eat or drink. At 1:17 P.M. , STNA # 403 walked up behind Resident #6 and asked (Resident name), are you all done? The resident did not answer. STNA #403 took off the clothing protector that was around her neck and wheeled the resident out of the dining room. At 1:24 P.M., STNA #403 returned to the dining room and knelt down to pick up the towel on the floor, covering the food that Resident #6 had dropped on the floor. She then started to remove the bowls of food that were on the table. The surveyor approached to check the amount of food taken and STNA #403 confirmed the resident had not eaten much of her food. She started walking to the kitchen and asked for a bowl of mashed potatoes. STNA #403 stated she was going to give the resident more potatoes and help her eat at a table on the unit, since she had dropped hers on the floor. The surveyor pointed out that another serving had been given to the resident soon after she dropped them but she had not eaten them. STNA #403 verified that she did not come back to the kitchen to get food for the resident, but first went to clean the floor. She also verified she had not checked how much food the resident ate or asked STNA #404 about how the resident was eating prior to removing her from the dining room. An interview with STNA #404, with STNA #403 present during the interview, on 12/11/18 at 2:30 P.M. revealed Resident #6 generally was able to eat with only cues. She stated cues would include telling the resident to take the spoon, take a bite, try other foods. She stated she was concerned with feeding the two residents that she was working with and verified she did not provide encouragement to Resident #6 to eat or try other foods. She stated the resident had dumped food on the floor in the past but verified the resident was not removed from the dining room for the behavior, but instead was given more food, however, was not encouraged to eat or provided with directions. She stated the resident would at times become agitated with staff intervention, but verified there had been no attempts to intervene to encourage the resident to eat. An interview with the director of nursing on 12/13/18 at 3:45 P.M. confirmed that Resident #6 had behaviors at times, but should receive encouragement to eat and may need increased assistance at times if she were agitated, distracted or restless.

Based on observation, interview and record review, the facility failed to ensure dressings were in place as ordered for a resident who had a pressure ulcer. This affected one of one residents reviewed for pressure ulcers (Resident #48). Findings include: Review of the record of Resident #48 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident developed an area of moisture associated skin damage in (MONTH) of (YEAR) and from there an open area developed into a pressure area by 4/30/18. Review of an assessment by the wound nurse care physician on 12/10/18 revealed the wound was a Stage 4 pressure area (full thickness tissue loss with exposed bone, tendon or muscle) that measured 1.4 centimeter (cm) by 2.4 cm by 0.5 cm deep. Review of the treatment order dated 12/11/18 revealed the area was to be cleansed with normal saline, patted dry and Medi-honey (a treatment that helps to liquefy necrotic wound tissue) was to be applied to the wound. The wound was to then have a layer of AG (silver based dressing that cover wounds that are excreting pus or fluids) covered by a foam dressing. The dressing was to be changed twice a day and as needed. Licensed Practical Nurse (LPN) #400 approached the surveyor on 12/12/18 at 2:30 P.M. and stated he could perform the dressing change at any time as the resident was in her bed. He stated he was just looking for another staff person to assist him in the dressing change, so arrangements were made to meet for the dressing change at 2:45 P.M. The surveyor arrived on the unit at 2:40 P.M. and LPN #400 was checking supplies for the treatment on the cart and after a couple minutes, took the cart down the hall towards the resident's room. The observation of dressing change was completed with LPN #400 and LPN #401 on 12/12/18 at 2:45 P.M. After LPN #400 cleansed the top of the table, he laid out a waterproof cloth and all the dressing supplies on the top of the cloth. He washed his hands, applied gloves and with the assistance of LPN #401 rolled Resident #48 to her left side and unsecured her incontinence brief. The brief was dry but the wound was noted with no dressing in place. A small amount of pink tinged drainage was noted on the incontinence brief. LPN #400 verified the dressing was not in place and stated he had not been told the dressing was off. He was unsure how long it had been off. An interview with state tested nursing assistant (STNA) # 402 on 12/12/18 at 3:05 P.M. confirmed that she had laid the resident in her bed about 1:40 P.M. and performed incontinence care. She stated the resident had been incontinent and the dressing had fallen off. She stated she knew the nurse was going to change the dressing, so she did not tell the nurse the dressing had fallen off. She verified she should have told the nurse the dressing was off, as the wound was not protected from further incontinent episodes. An interview with the director of nursing (DON) on 12/12/18 at 3:45 P.M. confirmed the STNA should have told the nurse the dressing was not in place to ensure the wound was covered and free from possible infection. She verified the dressing had been changed early in the morning for the night shift, and as it was scheduled twice a day, it would not have been changed until later in the day or evening, except for the request of the surveyor to watch the procedure.

Based on observation, interview and record review, the facility failed to ensure interventions were in place to prevent falls for a resident #141. This affected one of six residents (Resident #141) reviewed for falls. Findings include: Review of the record revealed Resident #141 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Her minimum data set assessment had not yet been completed but a nursing note dated 12/05/18 at 3:14 A.M. revealed the resident was slightly confused on admission. She was indicated in her admission assessment to be a fall risk due to a history of falls and had orders for a low bed and alarms to her bed and chair. Review of her nursing notes dated 12/06/18 at 2:00 A.M. revealed she was found on the floor by her bed after staff heard her alarm sounding. She had a skin tear to her right arm. Non-skid strips were applied to the floor by her bed, as she was attempting to get up on her own. Review of a nursing note dated 12/06/18 at 2:55 P.M. revealed she was sitting in a recliner in the lounge area when staff were alerted to an alarm and found the resident on the floor in front of the recliner. She indicated she had pain to her neck and shoulder but had negative results from x-rays. A short string clip alarm was ordered to more effectively signal staff that she was attempting to self transfer. On 12/12/18 at 3:10 P.M. , the surveyor was on the unit, talking with Licensed Practical Nurse (LPN) #400 after a dressing change observation, when he ran past the surveyor to help Resident #141, who had been seated in a recliner behind the surveyor. Resident #141 was standing in front of the recliner. No alarm was sounding. LPN #400 helped Resident #141 sit down in the chair and after speaking with her, told her he would call her family. As he returned to the computer near the surveyor, the surveyor questioned if the resident had an alarm in place. LPN #400 checked the computer and stated that she should have a clip alarm in place and looking to where she was seated, noted a clip alarm on her wheelchair that was parked next to her recliner. He stated the resident was new to him and he was not sure of all of her orders, but verified the clip alarm should have been in place from the wheelchair when she was transferred to the recliner. The staff who transferred the resident to the wheelchair had not been identified prior to them leaving at the end of their shift. The above findings were confirmed with the director of nursing on 12/12/18 at 4:15 P.M., who verified the clip alarm should have been in place to prevent falls for Resident #141.

Based on observation, interview and policy review, the facility failed to ensure medications were disposed of as required after expiration. This had the potential to affect all 93 residents residing in the facility and specifically affected Resident #62. Findings include: Observation of West Hall Medication cart with Licensed Practical Nurse (LPN) #405 on [DATE] at 8:45 A.M. revealed a bottle of Latanoprost, eye drops to treat [MEDICAL CONDITION], dated [DATE] as the date it was opened. The Latanoprost was issued to Resident #62, who received the medication daily at 9:00 P.M Observation of the East/West Medication room with LPN #405 on [DATE] at 8:50 A.M. revealed one bottle of [MEDICATION NAME] in the medication refrigerator, which was marked as opened on [DATE]. During interview, the director of nursing verified on [DATE] at 8:55 A.M. that the [MEDICATION NAME] should have been discarded 30 days after it was opened. Observation of the North/West Medication room with LPN #406 on [DATE] at 9:00 A.M. revealed one bottle of [MEDICATION NAME] in the medication refrigerator, which was marked as opened on [DATE]. The director of nursing verified on [DATE] at 10:00 A.M. that the [MEDICATION NAME] should have been discarded 30 days after it was opened. The secured unit refrigerator did not have any [MEDICATION NAME] in it when observed with LPN #407 on [DATE] at 9:10 A.M. She stated she would obtain [MEDICATION NAME] from either the East/West or North/West medication rooms if needed. Review of the facility policy on Medication storage, dated [DATE], revealed medications should be monitored on a monthly basis and discarded based on expiration dates. Review of the expiration dates of medications, undated, provided by the facility, revealed the Latanoprost expired 6 weeks after opening and the [MEDICATION NAME] expired 30 days after opening. The director of nursing verified on [DATE] at 10:00 A.M. the Latanoprost and the [MEDICATION NAME] should have been discarded. She further verified the only two bottles of [MEDICATION NAME] were noted in the three medication room refrigerators and both should have been discarded. She stated the facility would have to obtain more [MEDICATION NAME] for testing.

Based on observation, interview and record review, the facility failed to ensure infection control standards were followed during a dressing change for a resident and during medication pass for a resident. This affected one of one residents observed for a dressing change (Resident #48) and two of six residents (Residents #20 and #60) observed for medication pass. Findings include: 1. Review of the record of Resident #48 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident developed an area of moisture associated skin damage in (MONTH) of (YEAR) and from there an open area developed into a pressure area by 4/30/18. Review of an assessment by the wound nurse care physician on 12/10/18 revealed the wound was a Stage 4 pressure area (full thickness tissue loss with exposed bone, tendon or muscle) that measured 1.4 centimeter (cm) by 2.4 cm by 0.5 cm deep. Review of the treatment order dated 12/11/18 revealed the area was to be cleansed with normal saline, patted dry and Medi-honey (a treatment that helps to liquefy necrotic wound tissue) was to be applied to the wound. The wound was to then have a layer of AG (silver based dressing that cover wounds that are excreting pus or fluids) covered by a foam dressing. The dressing was to be changed twice a day and as needed. Licensed Practical Nurse LPN #400 approached the surveyor on 12/12/18 at 2:30 P.M. and stated he could perform the dressing change at any time, as the resident was in her bed. He stated he was just looking for another staff person to assist him in the dressing change, so arrangements were made to meet for the dressing change at 2:45 P.M. The surveyor arrived on the unit at 2:40 P.M. and LPN #400 was checking supplies for the treatment on the cart and after a couple minutes, took the cart down the hall towards the resident's room. The observation of dressing change was completed with LPN #400 and LPN #401 on 12/12/18 at 2:45 P.M. After LPN #400 cleansed the top of the table, he laid out a waterproof cloth and all the dressing supplies on the top of the cloth. He washed his hands and applied gloves. After cleaning and measuring the wound, LPN #400 used hand sanitizer and applied clean gloves. He opened packages of a foam dressing and of the silver dressing. He removed the silver dressing from the packet and using a clean scissors, he cut a small rectangle of the silver dressing. He then picked up a tube of Medi-honey, opened it and removed the foil covering the end of the tube. Opening a package of wooden applicators, he squeezed medi-honey onto the end of the applicator and applied it to the wound. He then picked up the silver dressing, and noting it was too large, cut it to size and put it on the top of the wound. He then covered the wound with the foam dressing. An interview with LPN #400 after the dressing change was completed, on 12/12/18 at 3:07 P.M., confirmed he had touched the outside of all the packages and the tube of Medi-honey with the same gloved hands that he then held and cut the piece of silver dressing to apply to the wound. He verified he could not ensure the cleanliness of the outside of the packaging to ensure the dressing change was completed in a clean manner. Review of the facility policy for Clean Dressing Change, revised (MONTH) (YEAR), revealed the clean supplies should be opened when setting up the clean field, including preparing ointments. The policy also indicated clean gloves should be applied prior to the application of medications and dressings to the wound. 2. During an observation on 12/11/18 at 11:40 A.M., LPN #566 lined a plastic basket with paper towel then placed a glucometer, alcohol pads, and supplies inside the basket. The nurse carried the plastic basket into Resident #60's room. At first, she placed the bin on the bedside table then on top of Resident #60's bedspread. Once she completed the blood sugar monitoring, LPN #566 removed the basket with supplies and placed it on the top of the treatment cart. The nurse documented the blood sugar in Resident #60's Medication Administration Record [REDACTED] On 12/11/18 at 11:48 A.M., LPN #566 cleansed her hands and prepared insulin for Resident #20. The nurse placed a paper towel in the same plastic basket used previously then placed a [MEDICATION NAME] and alcohol pads inside the basket. LPN #566 entered Resident #20's room and placed the basket on Resident#20's bedside table. After the procedure, LPN #566 placed the plastic basket on top of the treatment cart. The nurse did not cleanse the bottom of the plastic basket after leaving Resident #60's room prior to placing it on the top surface of the treatment cart, prior to taking it into Resident #20's room, or after leaving Resident #20's room. During an interview on 12/11/18 at 12:09 P.M., LPN #566 verified she took the same plastic basket into two resident rooms. She confirmed she did not cleanse the bottom of the basket between rooms or prior to placing it on the top of the treatment cart. Review of the facility's Medication Administration - General Information Policy (effective 04/01/13) indicated the charge nurse should ensure equipment and supplies related to medication storage and use are clean and orderly.

THE FOLLOWING CITATION REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, self-reported incident review, policy review, in-services review, audit reviews and staff interview, the facility failed to implement the facility policy and procedure for reporting an injury of unknown origin immediately. This affected one (#80) of one residents reviewed for injuries of unknown origin. The facility census was 78. Findings include: Review of the closed record for Resident #80 revealed she was admitted on [DATE]. She had [DIAGNOSES REDACTED]. Review of the self-reported incident (SRI) dated 03/04/18, reveled a statement from Licensed Practical Nurse (LPN) #170 dated 03/04/18. The statement indicated on 03/04/18 at approximately 6:00 A.M., the State tested Nurse Aide (STNA) #117 notified her of a small lump to the right eyebrow of Resident #80. LPN #170 went in to assess the resident and noted a fluid filled area on the right eyebrow, slightly bigger than a nickel, with a pale blue discoloration in the middle. The surrounding skin was normal color. The area was not present when LPN #170 administered eye drops at bedtime to the resident on 03/03/18. Resident #80 said she did not know what happened. The resident denied falling. Review of a statement dated 03/04/18 from STNA#117 indicated she came to work at 7:00 P.M. on 03/03/18 and did walking rounds with STNA #162. Resident #80 was in bed. STNA #162 told STNA #117 the resident put herself to bed. On 03/03/18 at 9:00 P.M., STNA #117 assisted Resident #80 to the toilet with her walker. STNA #117 noticed a light colored bruise to the corner of the resident's right eyebrow. The resident said she did not know what happened. STNA #117 assisted the resident back to bed on her right side. Her bed was lowered and the alarm was on. STNA #117 checked on the resident three to four times during the night. Resident #80 slept all night and got up in the A.M. STNA #117 assisted the resident to change and put on her clothes. The resident then went back to bed. STNA #117 saw the the charge nurse on the way out of the room and reported the bruise to the resident's eyebrow area. The LPN #170 and STNA #117 went into the room to check the resident. The resident said the bruise hurt a little. The resident denied falling. The resident said she hit her eyebrow on the walker a couple times, but it was weeks ago. STNA #117 then left the resident's room. Review of the statement from the previous Director of Nursing (DON) Registered Nurse (RN) #238, dated 03/04/18 indicated she was in the facility and was notified by LPN #171 that Resident #80 had a change in status, when the staff had noted a fluid filled area to the right eyebrow. They were sending the resident to the hospital for evaluation. The ambulance arrived to transport the resident. RN #238 notified the Administrator, notified the state agency and the resident's daughter. RN #238 began an investigation and asked for statements from all staff who worked 03/03/18 and 03/04/18 on the dementia unit. No staff had knowledge of how the resident sustained [REDACTED]. Interview on 04/04/18 at 6:00 A.M. with the Administrator verified STNA #117 did not report the observation of the bruise to the resident's eyebrow when it was discovered on 03/03/18 at 9:00 P.M. She did not report the discovery of the area until 03/04/18 at 6:00 A.M., approximately nine hours later. The Administrator verified this was not the facility policy, the incident should have been reported. Review of the facility's undated policy titled Abuse, Neglect, Misappropriation, of Resident Property, Exploitation and Mistreatment indicated if the resident is injured the staff shall report all incidents immediately to the Administrator or the Administrator's designee. Review of the facility's corrective action revealed the following were implemented by 03/16/18, prior to this complaint survey. · Nursing staff completed full skin assessments of all residents on the dementia unit to ensure all skin issues were documented and treatments in place. · All nursing staff were re-educated on the importance of reporting change of condition and injuries of unknown origin. The education was provided on 03/0518 - 03/09/18 to all nursing staff members by RN #238. · A continuous quality improvement action plan was initiated regarding timely notification of discovery of an incident. · Eighty incident reports were reviewed from 12/01/17 to 03/16/18. · New procedures were implemented to review the post-incident packet the next business day to ensure the report and witness statements are complete and to check for timely notification and follow up from discovery to intervention, to be reviewed by Administrative staff. · The facility will audit time frames for all incidents for the next three months. · Audits were completed for all incidents beginning 03/10/18 until present, however there were no further injuries of unknown origin identified since 03/04/18. This deficiency substantiates Complaint Number OH 982.

THE FOLLOWING CITATION REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, self-reported incident review, policy review, in-services review, audit reviews and staff interview, the facility failed to report an injury of unknown origin immediately. This affected one (#80) of one residents reviewed for injuries of unknown origin. The facility census was 78. Findings include: Review of the closed record for Resident #80 revealed she was admitted on [DATE]. She had [DIAGNOSES REDACTED]. Review of the self-reported incident (SRI) dated 03/04/18, reveled a statement from Licensed Practical Nurse (LPN) #170 dated 03/04/18. The statement indicated on 03/04/18 at approximately 6:00 A.M., the State tested Nurse Aide (STNA) #117 notified her of a small lump to the right eyebrow of Resident #80. LPN #170 went in to assess the resident and noted a fluid filled area on the right eyebrow, slightly bigger than a nickel, with a pale blue discoloration in the middle. The surrounding skin was normal color. The area was not present when LPN #170 administered eye drops at bedtime to the resident on 03/03/18. Resident #80 said she did not know what happened. The resident denied falling. Review of a statement dated 03/04/18 from STNA#117 indicated she came to work at 7:00 P.M. on 03/03/18 and did walking rounds with STNA #162. Resident #80 was in bed. STNA #162 told STNA #117 the resident put herself to bed. On 03/03/18 at 9:00 P.M., STNA #117 assisted Resident #80 to the toilet with her walker. STNA #117 noticed a light colored bruise to the corner of the resident's right eyebrow. The resident said she did not know what happened. STNA #117 assisted the resident back to bed on her right side. Her bed was lowered and the alarm was on. STNA #117 checked on the resident three to four times during the night. Resident #80 slept all night and got up in the A.M. STNA #117 assisted the resident to change and put on her clothes. The resident then went back to bed. STNA #117 saw the the charge nurse on the way out of the room and reported the bruise to the resident's eyebrow area. The LPN #170 and STNA #117 went into the room to check the resident. The resident said the bruise hurt a little. The resident denied falling. The resident said she hit her eyebrow on the walker a couple times, but it was weeks ago. STNA #117 then left the resident's room. Review of the statement from the previous Director of Nursing (DON) Registered Nurse (RN) #238, dated 03/04/18 indicated she was in the facility and was notified by LPN #171 that Resident #80 had a change in status, when the staff had noted a fluid filled area to the right eyebrow. They were sending the resident to the hospital for evaluation. The ambulance arrived to transport the resident. RN #238 notified the Administrator, notified the state agency and the resident's daughter. RN #238 began an investigation and asked for statements from all staff who worked 03/03/18 and 03/04/18 on the dementia unit. No staff had knowledge of how the resident sustained [REDACTED]. Interview on 04/04/18 at 6:00 A.M. with the Administrator verified STNA #117 did not report the observation of the bruise to the resident's eyebrow when it was discovered on 03/03/18 at 9:00 P.M. She did not report the discovery of the area until 03/04/18 at 6:00 A.M., approximately nine hours later. Review of the facility's undated policy titled Abuse, Neglect, Misappropriation, of Resident Property, Exploitation and Mistreatment indicated if the resident is injured the staff shall report all incidents immediately to the Administrator or the Administrator's designee. Review of the facility's corrective action revealed the following were implemented by 03/16/18, prior to this complaint survey. Nursing staff completed full skin assessments of all residents on the dementia unit to ensure all skin issues were documented and treatments in place. All nursing staff were re-educated on the importance of reporting change of condition and injuries of unknown origin. The education was provided on 03/0518 - 03/09/18 to all nursing staff members by RN #238. A continuous quality improvement action plan was initiated regarding timely notification of discovery of an incident. Eighty incident reports were reviewed from 12/01/17 to 03/16/18. New procedures were implemented to review the post-incident packet the next business day to ensure the report and witness statements are complete and to check for timely notification and follow up from discovery to intervention, to be reviewed by Administrative staff. The facility will audit time frames for all incidents for the next three months. Audits were completed for all incidents beginning 03/10/18 until present, however there were no further injuries of unknown origin identified since 03/04/18. This deficiency substantiates Complaint Number OH 982.

Based on record review and interview the facility failed to thoroughly assess a resident for a possible head injury in a timely manner after a head injury was discovered. This affected one (#80) of one residents reviewed for injuries of unknown origin. The facility census was 78. Finding include: Review of the closed medical record for Resident #80 revealed she was admitted on [DATE]. She had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment indicated the resident had severe cognitive impairment. The resident resided on the secured dementia unit. Review of nurse's notes dated 03/04/18 at 6:45 A.M. indicated when Licensed Practical nurse (LPN) #170 came to the unit to pass morning medications, the State tested Nurse Aide (STNA) #117 said Resident #80 had a lump above her right eyebrow. LPN #170 went in to assess the resident and noted a fluid filled area on the right eyebrow, slightly bigger than a nickel, with a pale blue discoloration in the middle. The surrounding skin was normal color. The area was not present when LPN #170 administered eye drops at bedtime on 03/03/18 to the resident. Resident #80 said she did not know what happened. She denied falling. When asked if she bumped her head, Resident #80 indicated she bumped it on the walker a few times, but it was weeks ago. The note said the resident was alert to normal status and had just gotten up to get dressed, with no issues. The note indicated there were no evidence to LPN #170 that the resident had fallen and the resident would not have been able to get up by herself if she had. The alarms were on and functioning. It looked to LPN #170, that because the resident sleeps on her right side, the eyebrow area was slightly swollen due to being the dependent area. The observation was passed on to the day shift nurse, LPN #171 was to monitor the resident. Interview on 04/04/18 at 9:40 A.M. with the Administrator and the Director of Nursing verified there was no evidence in the medical record of LPN #170 completed a thorough assessment of Resident #80, including neurological checks (pulse, respirations, blood pressure, pupil size and reactivity, equality of hand grip strength) to determine possible head trauma. The record documented LPN #171 was the first to complete a neurological checks and oxygen saturation levels for Resident #80 on 03/04/18 at approximately 9:15 A.M. due to a change in condition. Resident #80 was transferred to the hospital for evaluation on 03/04/18 at approximately 10:30 A.M. This deficiency is an incidental finding during the investigation for Complaint Number OH 982

Based on observation, interview and record review the facility failed to ensure privacy curtains provided full visual privacy for Resident #9, #43, #60, #90, #91 and #111). This affected six residents (Resident #9, #43, #60, #90, #91 and #111) of 42 residents residing on the East and West units. Findings include: On 10/18/17 at 2:45 P.M. Licensed Practical Nurse (LPN) #2 was observed to prepare to complete a dressing change for Resident #60. LPN #2 pulled the privacy curtain between Resident #60 and his roommate, Resident #24. The privacy curtain extended to the foot of the bed but not around the foot of the bed. LPN #2 positioned Resident #60 on his side, exposed his buttocks and completed the dressing change to the wound on the resident's coccyx. Resident #60 was not interviewable. An interview was completed with LPN #2 following the dressing change. LPN #2 verified the curtain track did not have the pull chain to allow the curtain to be pulled around each resident, as needed. An environmental tour of the East and West units was completed with Maintenance Worker (MW) #108 on 10/18/17 beginning at approximately 3:15 P.M. MW #108 verified six resident rooms with two residents in each room, did not have a pull chain to change the direction of the track, as needed. Visual privacy was provided for one of the two residents in each room, depending on the direction of the track. MW #108 verified full visual privacy could not be provided for Resident #9, #43, #60, #90, #91 and #111. Review of the facility Policy Statement on Quality of Life - Homelike Environment, revised 04/2014 revealed the facility would provide privacy to each resident.

Based on observation and staff interview the facility failed to maintain resident care equipment in a clean and sanitary manner. This affected four residents (Resident #6, #13, #55 and #66) of 26 residents identified to require a fall mat and and two residents (Resident #28 and #90) of four residents who were identified to require intravenous (IV) medication. Findings Include: During a tour of resident rooms conducted on 10/17/17 between 2:10 P.M. and 2:19 P.M. with the Director Nursing (DON) the following concerns were identified: The fall mats beside the bed of Resident #6, #13, #55 and #66 were observed with multiple stained areas and torn areas over various areas of the mats. The IV poles hooked up to Resident #28 and #90 revealed the poles contained caked on debris and significant scuffing. The above findings were verified at the time of the observation with the DON.

Based on interview and record review, the facility failed to ensure Minimum Data Set (MDS) 3.0 assessments were accurate regarding refusal of care for Resident #33 and for falls for Resident #16. This affected two residents (Resident #33 and #16) of eight residents reviewed for medications and falls. Findings include: 1. Review of the record revealed Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the nursing notes revealed Resident #16 had a fall on 08/27/17, when she was found on the floor in her room. She was found with a bruise and abrasion to her forehead. Review of the quarterly MDS 3.0 assessment, dated 08/30/17 did not reveal the resident had had a recent fall. An interview with Licensed Practical Nurse (LPN) #103 on 10/19/17 at 10:15 A.M. verified the resident had a fall with an injury and the fall should have been coded on the 08/30/17 assessment. 2. Review of the record revealed Resident #33 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of her nursing progress notes, dated 09/26/17 at 5:54 P.M. revealed the resident refused medications and finger stick blood sugar checks. Review of a progress note dated 09/28/17 at 5:05 P.M. revealed the resident refused a blood sugar check. Review of the medication and treatment administration records for September and October 2017 revealed the resident refused medications on 09/26/17 and 09/30/17 and refused blood sugar checks on 09/26/17, 09/27/17, 09/28/17 and 09/30/17. Review of the quarterly MDS 3.0 assessment, dated 10/02/17 did not reveal the resident rejected or refused care. She was assessed to be severely cognitively impaired. An interview with the LPN #103, the assessment nurse on 10/19/17 verified the behaviors had occurred in the 7 day look-back period before the assessment reference period but the rejection of care had not been documented on the quarterly assessment.

Based on observation, interview and record review the facility failed to ensure Resident #34 had interventions implemented to alleviate as much pain as possible during a dressing change on 08/03/16. Actual harm occurred when Resident #34 experienced intense incident pain during a dressing change when the pressure ulcer was cleansed and the treatment was applied. Resident #38 yelled and expressed pain during this observation. This affected one resident of three residents reviewed for pressure wounds. Findings include: Resident #34's medical record revealed an admission date of [DATE] and a [DIAGNOSES REDACTED].#34 had a Stage 4 (a full-thickness skin and tissue loss with exposed or directly visible muscle, tendon, ligament, cartilage or bone and may contain tunneling or undermining) pressure wound to the right ischium. Review of the Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #34 was severely cognitively impaired. Review of Resident #34's plan of care dated 06/02/15 revealed Resident #34 had occasional pain related to a history of a [MEDICAL CONDITIONS], and a pressure ulcer to the ischium. Review of the interventions included staff to monitor, record, and report to the nurse any signs and symptoms of non-verbal pain including vocalizations (grunting, moans, yelling out, and silence) and administer [MEDICATION NAME]/pain medication as ordered. Review of the current physician orders [REDACTED]. Review of the Medication Administration Record [REDACTED].M. Review of the physician orders [REDACTED]. The [MEDICATION NAME] was not documented as administered on the MAR. Review of the most recent wound documentation dated 07/29/16 revealed Resident #34 had a Stage 4 pressure ulcer on her right ischium measuring 2.0 centimeters (cm) in length, 2.0 cm in width, and 3.0 cm in depth. An interview was attempted with Resident #34 on 08/01/16 at 11:36 A.M. but she did not respond to questions. Observation was, made of the dressing change to Resident #34's right ischium on 08/03/16 at 2:10 P.M. by Registered Nurse (RN) #7 and RN #8. RN #8 prepared the supplies and entered the room. After preparing the area to complete the treatment, RN #8 began to cleanse Resident #34's right ischium wound while RN #7 aided with positioning Resident #34 on her left side. The [MEDICATION NAME] was not observed on Resident #34. Resident #34 stated prior to the dressing change she did not want her butt touched. RN #8 discussed with the resident her dressing change needed completed and Resident #34 did not reply. When RN #8 cleansed the wound with the wound cleanser using gauze squares, Resident #34 yelled, AHH, AHH, that hurts, I can't stand it and then continued to yell, Please help me. At this time RN #8 indicated Resident #34 was medicated for pain prior to the procedure (in the last hour) with the [MEDICATION NAME]. RN #8 continued to complete the dressing change while RN #7 was observed rubbing Resident #34's hand. When RN #8 applied the Santyl ointment to Resident #34's wound, she yelled, That is enough I don't want anymore and then stated I love you, but that hurts so bad, why did you let them hurt me so bad, directed towards RN #7. RN #7 stated they didn't mean to. RN #8 told Resident #34 two more minutes and she would be done. RN #8 began to pack the wound with Maxsorb Alginate dressing. Resident #34 stated this is terrible and I can't stand it. The wound was then packed with Maxsorb foam as Resident #34 stated, I'm crying. RN #7 stated let's turn you on your side a bit and Resident #34 yelled, No it's not fine all together. The foam was applied and the resident continued to yell AH and stiffen when the foam was applied. Resident #34 was not noted to say or yell any AH's or moaning when touched in other areas including when RN #7 repositioned the resident. After the dressing was completed RN #8 and RN #7 cleansed their hands and began to clean up the dressing preparation area. After RN #8 completed the cleanup and before leaving the resident's room, Resident #34 stated my bottom hurts bad. RN #8 told her it probably will hurt for a few more minutes since she just completed the dressing change and told the resident you're going to take a nap now. Interview on 08/03/16 at 2:30 P.M., at the conclusion of the wound care observation with RN #8, confirmed Resident #34 was actively having pain during the dressing change and was yelling out. RN #8 stated Resident #34's pain is better now than it was before. RN #8 stated prior to the order for the as needed [MEDICATION NAME], the resident would thrash around in pain during the dressing change. RN #8 stated that once she begins to change the dressing for Resident #34 she thinks it is better to just keep going even if the resident is displaying symptoms of pain rather than subjecting her to that experience again at a later time. RN #8 confirmed Resident #34 was ordered a [MEDICATION NAME] on 08/02/16 to aide in pain relief and it was not applied to Resident #34 during the observation or since it was ordered. RN #8 stated the [MEDICATION NAME] had not been received from pharmacy. Review of the Pain Assessment and Pain Monitoring Flow Sheet policy dated 06/30/11 revealed the purpose was to ensure that the resident has his/her pain assessed and controlled on a regular basis.

Based on observation, record review and interviews, the facility failed to ensure adequate pain management was provided for Resident #43 and Resident #90, who were experiencing severe unrelieved pain. This affected two of four residents reviewed for pain. The facility census was 87 residents. Findings include: 1. Resident #43 was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. The comprehensive assessment dated [DATE] indicated the resident had no short or long term memory impairment or cognitive impairment for decision making. physician's orders [REDACTED]. Nurses note dated 6/22/10 at 5:00 A.M., indicated Resident #43's right hand was extremely swollen and painful to touch. The physician was notified and a new order was received to send the resident to the emergency room . She was admitted to the hospital. The re-admission nursing assessment dated [DATE] revealed the resident returned to the facility on [DATE] at 5:30 P.M. Re-admission physician's orders [REDACTED]. Nurses note dated 6/28/10 at 2:00 A.M. indicated that Resident #43 had been medicated at 12:00 A.M. for complaint of pain to the back and knees. The nurse wrote that the resident had called for pain medication three times since. The nurse explained the pain medication was ordered four times a day only. There was no indication in the nurses notes that the physician had been notified of the resident's increased complaints of pain. During an interview on 06/29/10 at 9:27 A.M., Resident #43 reported that she had "arthritis throughout my whole body." The resident explained that she also had falls and damage to the bones in her hips and knees, causing chronic pain. She reported that "something happened and there is a steady pain touching a nerve in my back." Resident #43 explained that prior to her recent hospitalization she was getting [MEDICATION NAME] every four hours. Resident #43 indicated that the [MEDICATION NAME] every four hours had been effective. Resident #43 indicated that she was unsure why the dose was changed, she stated, "I think it was the doctor's decision. They're trying to cut it back." Resident #43 reported that she was having "real bad pain right now and I can't have my medicine until noon." Resident #43 indicated that the dosing change had just been made a few days earlier and stated, "I just have to live with it." During the interview with Resident #43, Licensed Practical Nurse (LPN) #13 entered the room with a small plastic cup containing medications. Resident #43 questioned, "What meds are you giving me?" LPN #13 responded, "Oh, I don't know there are a whole lot of them." Resident #43 reported to the nurse that she was in pain and asked if she could have her [MEDICATION NAME]. LPN #13 responded that she had received [MEDICATION NAME] at 6:00 A.M., and she could not have it again until 12:00 P.M. LPN #13 told Resident #43 that she would check and see if the resident had anything else ordered for breakthrough pain. LPN #13 returned and told Resident #43 that she had nothing ordered, but that she would call her doctor and see if he would order something for her breakthrough pain. Resident #43 thanked the nurse. Nurses notes from 6/29/10 contained no notation of notification of Resident #43's physician of the breakthrough pain. On 6/30/10 at 10:20 A.M. Resident #43 was observed lying in bed, on top of the covers. Resident #43 reported that her pain was still there. During an interview on 6/30/10 at 11:17 A.M., Resident #43 indicated that she was in pain all the time. She stated that the pain was okay when she lies there perfectly still. She explained that if she moved at all, "It really hurts bad." Resident #43 indicated that she avoided movement as much as possible to prevent the pain. She stated, "I don't know what I'm gonna do." Resident #43 said "ouch" out loud when she moved and grabbed her left hip. The resident was tearful and stated, "I'm just so tired." During an interview on 6/30/10 at 11:25 A.M., LPN #13 verified that Resident #43 reported unrelieved pain on 6/29/10 when she entered the room to administer medications. She indicated that she checked Resident #43's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. LPN #13 verified that she told the resident she would telephone the doctor and report her breakthrough pain, and indicated that she never made the call. She explained that, "It's a constant behavior of hers for her to push you to give her her meds earlier." LPN #13 explained that she did not call the physician, because of the conversation with the outgoing nurse earlier that morning. She indicated the night shift nurse told her that Resident #43 always "pushes" to get her meds earlier. During an interview on 6/30/10 at 11:34 A.M., the director of nursing (DON) verified that Resident #43 needed something for breakthrough pain. The DON indicated the expectation would have been for LPN #13 to have notified the physician when Resident #43 reported unrelieved, breakthrough pain. 2. Resident #90 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. This resident received services from Hospice for pain management and end of life care and services. Review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. These medications included [MEDICATION NAME] 100 micrograms/hour, apply every 3 days ordered on [DATE] and 05/06/10; and [MEDICATION NAME] 5-325 milligrams (mg), one tablet every four hours PRN for pain, and two tablets every four hours PRN for severe pain ordered on [DATE]. The pain documentation form in Resident #90's record for May 2010 documented an increase in the administration of the PRN pain medication for increased indication of severe pain, rated as an 8 to a 10 on the following days: 05/01/10, 05/2/10, 05/03/10, 05/06/10, 05/07/10, 05/08/10, 05/09/10, 05/11/10, 05/12/10, 05/13/10, 05/18/10, 05/19/10, 05/22/10, 05/24/10, 05/26/10, and 05/30/10. In June 2010, the resident received PRN pain medication for severe pain rated as an 8 to a 10 on 06/05/10, 06/08/10, 06/12/10, 06/15/10, 06/16/10, 06/17/10, 06/19/10, 06/20/10, 06/21/10, 06/22/10, 06/23/10, 06/25/10, 06/26/10, 06/27/10, 06/28/10, 06/29/10, and 06/30/10. On each of these days, Resident #90 was medicated with two [MEDICATION NAME] tablets and repositioned. The pain documentation form indicated this was effective one hour after the medication was administered. The pain assessment completed on 05/21/10 documented Resident #90 described his pain as "8 or 9, very severe, aching, all over; medications and repositioning relieve pain per resident." There was no evidence in the medical record that during May and June 2010, Resident #90's expressions of severe pain and related medication administration were communicated to Hospice, or a reassessment of his pain and a revised plan to manage the resident's pain was completed. Review of Resident #90's medical record revealed the pain plan of care was developed on 04/29/08 and last updated on 05/25/10. There was no evidence of a reassessment of Resident #90's pain medications relative to type, dosage, and intervals administered since 04/28/10 to determine if the pain medications ordered were still appropriate to relieve his pain. The plan of care also did not include interventions with measurable objectives for the use of PRN medications for pain. The plan of care indicated to medicate the resident with narcotic [MEDICATION NAME] when needed, and that the resident took pain medications routinely. The plan of care did not identify the method and frequency of how nursing staff would monitor the resident's pain and use of PRN medications. On 06/28/10 at 10:15 A.M. Resident #90 was observed yelling from his room requesting pain medication. On 06/29/10 at 9:10 A.M. Resident #90 stated that his left leg was in pain and he wanted pain medication. Interview with Resident #90 on 06/30/10 at 11:25 A.M. revealed he had pain across his back and shoulders. The resident also said that when he was in bed, the pain was relieved until he was in bed for too long. Interview with State tested Nurse Aide (STNA) #20 on 06/29/10 at 2:30 P.M. revealed Resident #90 was "consistently in pain." She said he was usually in less pain when he was in bed, and the chair was sometimes ok for him, but when he was in pain they laid him down. She said she told the nurse when he asked for pain meds or when he yelled out in pain, and usually the [MEDICATION NAME] worked but sometimes it didn't relieve his pain. She said the only time she talked to Hospice about his pain was on 06/28/10) when they said they were going to try and get him something more for pain as this doesn't seem to be working. Interview with RN #30 on 06/30/10 at 2:10 P.M. revealed she gave Resident #90 two [MEDICATION NAME] tablets on 06/30/10 at 9:00 A.M. after he said his pain was a "10." She said she didn't tell anyone else because "he always says it is a 9 or 10." She said she had never talked to anyone from Hospice regarding his pain. She said he usually asked for pain medication around 9:00 A.M. every day, and was then ok for the rest of the shift after staff lay him down and she administered the PRN [MEDICATION NAME] medication. Interview with the DON on 06/30/10 at 2:40 PM revealed staff were to notify Hospice when there was any change in Resident #90's condition and pain. Interview with Resident #90 on 07/01/10 at 8:50 A.M. revealed staff put him in bed when he asked, and he felt better when in bed but the pain came back when in bed for too long. The nurses ask him about his pain, it doesn't take a long time to get his pain pills, and the pain pills work. On 07/01/10 at 9:04 A.M., Resident #90 was observed calling out for nurse, who responded and returned to his room with pain medication at 9:11 A.M. On 07/01/10 at 9:22 A.M. interview with the Hospice nurse revealed when the Hospice nurses came to the facility on e to three times a week in the afternoon, Resident #90 was usually in bed and comfortable. She was aware of his chronic pain in his left shoulder and his left leg, and she said she was thinking of asking the doctor for an increase in the [MEDICATION NAME] order, or make the [MEDICATION NAME] a straight order. She said she thought the resident was not aware of how to rate his pain appropriately, however, she also said they have not provided any other means for the resident to rate his pain. She said she spoke directly to the facility nurse and nurse aide regarding patient care and and pain needs. Hospice put their care plans in the chart directly and the assessment nurse reviews them when needed. She said it was up to the facility to communicate with the rest of the staff.