Every finding on record at Keystone Pointe Health and Rehabilitation

Based on observation and staff interview, the facility failed to maintain its garbage disposal area in a clean and sanitary condition. This had the potential to affect all 112 residents residing in the facility. Findings include: Observation and interview of the facility's garbage disposal area with Dietary Manager (DM) #400 and Registered Dietician (RD) #401 on 07/13/23 at 8:20 A.M. revealed significant food refuse and other trash all (used gloves, plastic utensils, dirt, leaves, and trash bags) around the dumpster area. DM #400 and RD #401 verified the above findings at the time of observation. RD #401 stated the condition of the dumpster area was the worst she had ever seen.

Based on observations, medical record review, and staff interviews, the facility failed to ensure the residents had access to a call light. This affected one (Resident #57) of four residents reviewed for call lights. The facility census was 111. Findings include: Review of Resident #57's medical record revealed an admitted to the facility occurred on 07/29/20. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #57's annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #57 eats independently. Observation and interview with Resident #57 on 09/12/22 at 7:54 A.M. revealed Resident #57 was verbal and able to identify her name, location, date of birth and children's names. Resident #57 was also observed with some confusion. The observation revealed her call light button was draped over the call light box located behind her bed at this time. Resident #57 was asked if she could reach the button and she confirmed she could not after attempting. Resident #57's head of bed was elevated at the time additionally making it impossible to reach the call light. Resident #57 revealed she can yell for someone if necessary, however her room was located at the end of the hallway. Resident #57 confirmed she stays in bed most all the time, per her choice. Resident #57 stated staff put the light away from me if I'm using it to much. Subsequent observations on 09/12/22 at 8:32 A.M. revealed Resident #57 was observed to receive her breakfast tray and the call light remained draped over the call light box located behind her bed. Observation on 09/12/22 at 10:09 A.M. of Resident #57 revealed Resident #57's call light remained in the same position draped over the box, located behind the bed. Observation and interview on 09/12/22 at 11:36 A.M. of Resident #57 with the Assistant Director of Nursing (ADON) #150 and State tested Nursing Assistant (STNA) #160) revealed the call light remained draped over the call light box located behind the bed. The observation and staff interview confirmed Resident #57 cannot access the call button if needed with it located on the wall. The staff interview confirmed Resident #57 does use the call light for assistance and was physically capable of using it. This deficiency substantiates Complaint Number OH 334.

Based on observations, medical record review, and staff interviews, the facility failed to ensure a resident received the correct thickened consistency of fluids per physician orders. This affected one (Resident #57) of four residents reviewed for diet orders. The facility identified four residents who receive thickened liquids. The facility census was 111. Findings include: Review of Resident #57's medical record revealed an admission to the facility occurred on 07/29/20. Diagnoses included stroke, [CONDITION(S)], anxiety, dysphasia and high blood pressure. Review of Resident #57's annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #57 eats independently. Review of Resident #57's medical record revealed she was hospitalized from 06/13/22 through 06/23/22 for aspiration pneumonia. The hospital records revealed Resident #57 was aspirating thin liquids at that time and a recommendation for NPO (nothing by mouth) with alternate nutrition was made. The records revealed Resident #57 had a short term naso-gastric tube feeding from 06/23/22 until 06/27/22, when the decision to resume oral feeding was made, following risk and benefits analysis. Resident #57 had a decline of recommended treatment form signed on 06/30/22 for NPO. The form revealed the risk and benefits were explained and a diet of regular with pureed consistency with honey thickened liquids. Review of the physician's order dated 06/27/22 revealed pureed regular diet with honey consistency liquids. Observation of Resident #57 receiving her breakfast meal occurred on 09/12/22 at 8:32 A.M. Resident #57 received oatmeal and nectar thickened coffee and red juice. Review of Resident #57's meal ticket, which was on the meal tray was observed with the nectar thickened liquids. Resident #57 was observed to consume the liquids without issues. Interview on 09/12/22 at 8:37 A.M. with Dietary Manager (DM) #120 revealed DM #120 provided the resident listing of residents on a thickened liquid diet, which contained four residents, including Resident #57. DM #120 confirmed the meal tickets were printed off and used to prepare meal trays including drinks. DM #120 confirmed the facility buys prepared liquids in nectar and honey consistencies; however milk, coffee and other liquids may need to be manually thickened. Observation of Resident #57 receiving her meal tray for lunch on 09/12/22 at 11:51 A.M. revealed the meal ticket was changed to reflect honey consistency liquids. State tested Nursing Assistant (STNA) #130 was observed to have used a thickener powder mix for Resident #57's coffee. STNA #130 confirmed she uses the residents' meal tickets to identify what type of diet and liquid consistencies residents were to receive. STNA #130 confirmed Resident #57 also received cranberry juice that was from a pre-mixed box of honey thickened. Interview on 09/12/22 at 12:38 A.M. with the Director of Nursing (DON) confirmed DM #120 had completed an audit of all residents diet orders following breakfast this morning. The audits found Resident #57's meal ticket was listed with 'nectar' thickened liquids, however her actual physician order was 'honey' thickened liquids. The DON confirmed the facility corrected the meal ticket following breakfast on 09/12/22, but was not sure how long Resident #57 was receiving the incorrect consistency. The DON confirmed the facility was looking into why the physician order did not match the meal ticket. The DON confirmed the electronic physician orders and the meal tickets come from two separate systems and new orders must be physically placed into the dietary system. This deficiency substantiates Complaint Number OH 334.

Based on observations, staff and resident interview, review of the pharmacy narcotic record and policy review the facility failed to ensure nursing staff followed medication administration procedures. This affected three residents (#10, #59 and #81) of seven reviewed for medication administration on the East 100/200 hallway. The facility census was 115. Findings include: 1. Observation and interview with Licensed Practical Nurse (LPN) #220 on 02/11/22 at 5:31 A.M., LPN #220 confirmed she usually started her medication pass at 4:00 A.M. LPN#220 confirmed she knows she should not give medications more than an hour earlier than ordered; however she does start early. Observation with LPN #220 on 02/11/22 at 5:41 A.M. administering medications for Resident #81. Interview on 02/11/22 at 5:41 A.M., Resident #81 revealed she was awake this morning to go to the bathroom and received medications however, said she was woken up at 4:00 A.M. yesterday. 2. Observation with LPN #200 occurred on 02/11/22 at 6:05 A.M. LPN #200 opened the medication cart drawer and Resident #10's medications were sitting already prepared in a cup. LPN #200 confirmed she pre-poured all of her morning medications and knows she is not supposed to do that but did it anyway's because she has trouble completing her medication pass timely. LPN #200 confirmed she administers medications for 15 residents in the morning. LPN#200 was asked when she starts her morning medication pass and she identified 4:00 A.M. LPN #200 confirmed she was aware she should pass medications one hour before or one hour after they are scheduled but starts early because she has issues getting medications passed. Interview with Assistant Director of Nursing occurred on 02/11/22 at 6:21 A.M. The interview confirmed nursing staff should not be pre-pouring any medications or waking residents at 4:00 A.M. to administer medications. 3. Observation of medication administration was completed with Licensed practical Nurse (LPN #230) on 02/11/22 at 7:50 A.M. The observation of the Medication Administration record (MAR) for Resident #59 identified he had three 6:00 A.M. medications ordered were not initialed as administered. LPN #230 identified Resident #59 had revealed, to her, that he had not received his morning medications. LPN #230 confirmed she received morning report from LPN #220, prior to her leaving and she had not mentioned Resident #59 had not received his medications. LPN #230 then obtained the narcotic records (which documents every pill removed with a complete count of the pills) for Resident #59 that verified no [MEDICATION(S)] ([MEDICATION(S)]) 15 mg had been administered to Resident #59 that morning. LPN #230 confirmed an omission of three of Resident #59's medication had occurred this morning for the scheduled 6:00 A.M. doses. LPN #230 confirmed the medications were; [MEDICATION(S)] 15 mg (Narcotic Pain Medication), Omeperzole (stomach medication) 20 mg, and Midorine 5 mg (used to treat low blood pressure). Review of the pharmacy narcotic record for resident #56's [MEDICATION(S)] identified a dose was administered on 02/10/22 at 10:00 P.M., as scheduled. The record confirmed no [MEDICATION(S)] had been signed out for the 02/11/22 6:00 A.M. dose and the narcotic count was correct. Review of the facility policy titled Medication Administration dated 07/08/12 revealed pre-pouring medication is NOT an acceptable or safe practice. This deficiency substantiated Complaint Number OH 876.

Based on medical record review, observation, resident and staff interviews and review of the pharmacy narcotic count record the failed to prevent a significant medication error for one resident (#59) of seven residents observed for medication administration. The facility census was 115. Findings include: Review of the medical record revealed Resident #59 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #59 had intact cognition. Resident #59 was on palliative care services for pain management. Observation of medication administration completed with Licensed practical Nurse (LPN #230) on 02/11/22 at 7:50 A.M. The observation of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M. medications ordered that had not be initialed as administered. LPN #230 identified Resident #59 had revealed, to her, that he had not received his morning medications. LPN #230 confirmed she received morning report from LPN #220, prior to her leaving and she had not mentioned Resident #59 had not received his medications. LPN #230 then obtained the narcotic records (which documents every pill removed with a complete count of the pills) for Resident #59 that verified no [MEDICATION(S)] ([MEDICATION(S)]) 15 milligram (mg) had been administered to Resident #59 that morning. LPN #230 confirmed an omission of three of Resident #59's medication had occurred this morning for scheduled 6:00 A.M. doses. LPN #230 confirmed the medications were; [MEDICATION(S)] 15 mg (Narcotic Pain Medication), Omeperzole (stomach medication) 20 mg, and Midorine 5 mg (used to treat low blood pressure). LPN #230 completed a pain assessment where Resident #59 identified his pain level as a seven out of 10 with 10 being the worst pain. Interview with Resident #59 on 02/11/22 at 8:01 A.M. confirmed he had not received his scheduled morning medications. Resident #59 confirmed his pain medication was scheduled for 6:00 A.M. and he was leaving in the ambulance as soon as he gets his medications. Review of the pharmacy narcotic count record for resident #59's [MEDICATION(S)] identified the previous dose was administered on 02/10/22 at 10:00 P.M., as scheduled. The record revealed no [MEDICATION(S)] had been signed out for the 02/11/22 6:00 A.M. dose and the count was correct. This deficiency substantiated Complaint Number OH 876.

Based on record review, staff interview and review of the facility policy, the facility failed to ensure one residents topical medication was applied as ordered by the physician. This affected one (#121) of three residents reviewed for topical medications. The facility census was 110. Findings Included: Review of the medical record for the Resident #121 revealed an admitted [DATE], and a discharge date of [DATE]. Diagnoses included [CONDITION(S)], [CONDITION(S)], and [CONDITION(S)]. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had intact cognition. The resident was extensive assistance of one staff for toileting and bed mobility. Review of the care plan dated 07/10/21, revealed alteration in skin integrity as evidenced by rash behind right knee and buttocks. Maintain pressure reducing mattress, dietary supplement as ordered, body check weekly, assess for pain, provide skin care as needed and notify physician and family of changes as needed. Review of the physician order dated 07/01/21, revealed to apply house barrier ointment to peri area, buttocks, and coccyx after incontinent episode and as needed every shift, and apply house moisture cream to heels for preventive skin care every shift. Review of the physician order dated 07/07/21, revealed [MEDICATION(S)]-[MEDICATION(S)] cream 1-0.05 % apply topically to right knee every shift for rash for 14 days, cleanse area with soap and water, pat dry, and apply cream. Review of the Treatment Administration Record (TAR) dated 07/14/21, 07/15/21, 07/17/21 and 07/28/21, revealed [MEDICATION(S)]-[MEDICATION(S)] cream 1-0.05 % was not administered as ordered. Review of the progress note dated 07/14/21, revealed Registered Nurse (RN) #151 called the pharmacy at 7:00 A.M., to reorder [MEDICATION(S)]-[MEDICATION(S)] cream to be delivered immediately (STAT) as the medication had not been delivered and the resident has missed doses of medication. Interview on 08/03/21 at 9:56 A.M., with RN #151, revealed the cream would run out faster than the amount pharmacy was sending and she called the pharmacy to make aware of the additional [MEDICATION(S)]-[MEDICATION(S)] cream needed. Review of the facility policy titled, Medication Administration, dated 06/21/17, revealed medications will be administered by legally authorized and trained persons in accordance with applicable State, Local and Federal laws and consistent with acceptable standards of practice. This deficiency substantiates Master Complaint Number OH 295 and Complaint Number 0.

Based on observations, interviews, and record reviews, the facility failed to have an effective Infection Prevention and Control Program (IPCP) to prevent the potential transmission of COVID-19 within the facility. The facility failed to ensure all staff and visitors were screened and that the absence of signs/symptoms of COVID-19 were documented. Additionally, the facility failed to ensure all staff followed proper Personal Protective Equipment (PPE) usage and completed proper hand hygiene for five of seven sampled residents (Resident (R) 1, R2, R3, R4, and R5). Both the facility's failures had the potential to affect all 91 residents who resided in the facility at the time of the survey. Findings include: 1. Review of the facility's policy titled, Novel Coronavirus Prevention and Response, revised 12/28/20, revealed .5. Interventions to prevent the introduction of COVID-19 into the facility: .e. Screen employees and essential visitors/vendors for fever, exposure, as well as, signs/symptoms of respiratory or flu like illness and prohibit entrance where symptoms or exposure risks exist .i. Assess visitors and healthcare personnel for symptoms of COVID-19 or exposure to others with suspected or confirmed COVID-19 infection. This can include but is not limited to i. Individual screening on arrival at the facility; ii. Implementation of an electronic monitoring system in which, prior to arrival at the facility, people report absence of fever and symptoms of COVID-19 . During an observation on 03/01/21 at 8:45 AM, the Receptionist who was located at the entrance of the building took this writers temperature. Continued observation revealed the receptionist taking another contract surveyor's temperature. During the screening process for entry to the facility the receptionist failed to screen either surveyor by asking about the presence or absence of signs and symptoms of COVID-19. Interview on 03/01/21 at 9:42 AM with the Receptionist revealed she forgot to ask the surveyors if they had any of the signs and symptoms of COVID-19. Review of the facility's (facility name) Daily Staffing Sheet, dated 02/27/21, revealed State tested Nurse Aide (STNA) 11 and STNA 12 were assigned to the East 100/200 unit. Review of the facility's COVID-19 Employee, Vendor, and Visitor Log, dated 02/27/21 revealed no documented evidence that STNA11 and STNA12 were screened for the absence of signs and symptoms of COVID-19; or that the STNAs' temperatures were taken prior to entering resident care areas on the East unit. Review of the facility's (facility name) Daily Staffing Sheet, dated 02/27/21, revealed Licensed Practical Nurse (LPN) 16, LPN19, STNA5, STNA9, and STNA10 were all assigned to the Pathways unit. Review of the facility's COVID-19 Employee, Vendor, and Visitor Log, dated 02/27/21 revealed no documented evidence that LPN16, LPN19, STNA5, STNA9, and STNA10 were screened for the absence of signs and symptoms of COVID-19 or that that the staff's temperatures were taken prior to entering resident care areas on their units. Review of the facility's (facility name) Daily Staffing Sheet, dated 02/27/21, revealed STNA6 and STNA8 were both assigned to the West 100/200 unit. Review of the facility's COVID-19 Employee, Vendor, and Visitor Log, dated 02/27/21 revealed no documented evidence that STNA6 and STNA8 were screened for the absence of signs and symptoms of COVID-19 or that the STNAs' temperatures were taken prior to entering resident care areas. Review of the facility's (facility name) Daily Staffing Sheet, dated 02/27/21, revealed STNA7 was assigned to the WEST 400 unit. Review of the facility's COVID-19 Employee, Vendor, and Visitor Log, dated 02/27/21 revealed no documented evidence that STNA7 was screened for the absence of signs and symptoms of COVID-19 or that that the STNA's temperature were taken prior to entering resident care areas. Review of the facility's (facility name) Daily Staffing Sheet, dated 02/28/21, revealed LPN16, STNA5, and STNA13 were assigned to the Pathways unit. Review of the facility's COVID-19 Employee, Vendor, and Visitor Log, dated 02/28/21 revealed no documented evidence that LPN16, STNA5, and STNA13 were screened for the absence of signs and symptoms of COVID-19 or that that their temperatures were taken prior to entering resident care areas. Review of the facility's (facility name) Daily Staffing Sheet, dated 02/28/21, revealed LPN20 was assigned to the West100/200 unit. Review of the facility's COVID-19 Employee, Vendor, and Visitor Log, dated 02/28/21 revealed no documented evidence that LPN20 was screened for the absence of signs and symptoms of COVID-19 or that that the LPN's temperature was taken prior to entering resident care areas. Review of the facility's (facility name) Daily Staffing Sheet, dated 02/28/21, revealed Registered Nurse (RN) 23 and RN24 were assigned to the West 400 unit. Review of the facility's COVID-19 Employee, Vendor, and Visitor Log, dated 02/28/21 revealed no documented evidence that RN23 and RN24 were screened for the absence of signs and symptoms of COVID-19 or that the RNs' temperatures were taken prior to entering resident care areas. An interview on 03/01/21 at 10:55 AM with the Staff Scheduler (SS) confirmed there was no documented evidence for 02/27/21 or 02/28/21 that facility staff were properly screened prior to entering resident care areas and potentially increasing exposure risks to the residents. The employees were not screened to rule out the presence of signs and symptoms of COVID 19 and/or elevated temperatures as they entered the building. The SS stated all staff were to have their temp taken and recorded every four hours when the facility was in outbreak testing. SS said staff should record their temperature at the beginning of their shift, and document it in the binders kept at the nurse's stations on each unit. The temperature log binders were reviewed with the SS during this interview and the SS confirmed the employees were already in resident care areas prior to being properly screened for potential COVID symptoms and/or exposures and/or elevated temperatures. Interview on 03/01/21 at 11:32 AM with STNA6 revealed that on 02/27/21 she did get screened by the employee at the receptionist desk upon her arrival to work; however, she did not remember which employee screened her. The STNA stated her temperature was not documented because she either forgot to record it or got busy and didn't take her temperature. Interview on 03/01/21 at 11:52 AM with RN23 revealed on 02/28/21 she did take her own temperature at the front desk when she arrived at work. RN23 stated she should have documented her temperature and the absence of signs and symptoms, but she may have forgotten. Interview on 03/02/21 at 5:07 PM with the Director of Nursing/Infection Preventionist (DON/IP) revealed it was her expectation that the facility was 100% compliant with all screening of staff and visitors. Continued interview revealed 100% compliance was important to prevent COVID-19 from entering the building. The DON/IP stated the reason for the noncompliance for 02/27/21 and 02/28/21 was due to the normal nursing supervisors who normally completed screenings were not on duty. Interview on 03/02/21 at 5:20 PM with the Administrator revealed it was his expectation all staff and visitors would have been properly screened to decrease the potential of COVID-19 coming into the building. Review of the Centers for Medicare and Medicaid guidance titled Nursing Home Visitation COVID-19 revised September 17, 2020, revealed, Core Principles of COVID-19 Infection Prevention .Screening of all who enter the facility for signs and symptoms of COVID-19 (e.g., temperature checks, questions or observations about signs or symptoms), and denial of entry of those with signs or symptoms .100% screening of all persons entering the building and for all staff at the beginning of the shift: - Temperature checks - Ensure all outside persons entering have a cloth face covering or facemask - Questionnaire about symptoms and potential exposures - Observation of any signs or symptoms . 2. Review of R1's undated Admission Record, located in R1's electronic medical record (EMR) under the profile tab, revealed R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of R1's Order Summary Report, located in the R1's EMR under the orders tab, revealed a physician's orders [REDACTED]. Observation on 03/01/21 at 10:01 AM revealed the Nurse Practitioner (NP) exited R1's room and did not doff her PPE gown. Continued observation revealed the NP walked down the hall passing one resident room, doffed the soiled gown, and placed the soiled gown in a trash can placed next to the storage room door on the west unit. R1's room had signage outside the door indicating droplet/contact precautions, what PPE was to be donned prior to entering the room; and there was a PPE disposal bin outside the door to R1's room. Interview on 03/01/21 10:04 AM with the NP revealed she was contracted and worked under R1's attending physician. The NP stated she should have doffed her gown prior to coming out of R1's room and that she should not have doffed outside in the hallway because of the possibility of spreading organisms. Review of R2's undated Admission Record, located in R2's EMR under the profile tab revealed R2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of R2's Order Summary Report, located in R2's EMR under the orders tab revealed R2 was ordered by his physician Contact + Droplet Precautions every shift for COVID-19 Precautions. Continued review of the order summary report also revealed R1 was ordered hospice services with the [DIAGNOSES REDACTED]. Observation on 03/01/21 at 10:14 AM revealed two family members in R2's room, at his bedside. They were wearing a gown, mask, and eye protection; however, the family members did not have gloves on. There was signage outside of R2's door which indicated R2 was on droplet/isolation precautions. Interview on 03/01/21 at 10:16 AM with LPN22 revealed the LPN confirmed R2's family did not have all of the proper PPE on while in R2's room. LPN22 stated both family members should have donned gloves prior to entering the room. Review of R3's undated Admission Record, located in R3's EMR under the profile tab, revealed R3 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of R3's Order Summary Report, located in R3's EMR under the orders tab, revealed R3 was ordered by his physician Contact + Droplet Precautions every shift for COVID-19 Admission Precautions for 14 Days . Observation on 03/01/21 at 10:17 AM revealed STNA3 in R3's room directly assisting R3 with a transfer from the bed to the chair in his room and the STNA was wearing full PPE. Continued observation revealed signage outside of R3's room which indicated droplet/contact precautions, the PPE required to enter the room, and a PPE bin stationed outside of the resident's room. Further observation revealed STNA3 correctly doffed her gloves and her gown prior to exiting R3's room; however, the STNA failed to perform hand hygiene and directly opened the PPE bin outside the room to retrieve a clean gown. The STNA contaminated the PPE bin, which was considered a clean area, by touching it with unwashed/unsanitized hands. Interview on 03/01/21 at 10:21 AM with STNA3 revealed the STNA confirmed that she forgot to perform hand hygiene prior to touching the PPE bin and a new gown. Review of R5's undated Admission Record, located in R5's EMR under the profile tab, revealed R5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of R5's Order Summary Report, located in R5's EMR under the orders tab, revealed R5 was ordered by her physician Contact + Droplet Precautions every shift for COVID-19 Admission Precautions for 14-days . Observation on 03/01/21 at 1:30 PM on the Pathways unit (the facility's secure/dementia unit) revealed R5 was independently ambulating on the hall. Continued observation revealed R5 to be confused and noncompliant with PPE use. STNA 4 offered R5 a mask and when the resident refused the STNA was attempting to redirect R5 back to her room. STNA 4 was wearing a gown, and reached out her ungloved, bare hand to R5. R5 took STNA4's hand and walked down the hall and entered R5's room. Observation of R5's room revealed signage which indicated R5 was on contact and droplet precautions with what PPE was to be worn in the room. Stationed outside R5's door was a PPE bin. STNA4 did not don gloves prior to entering R5's room. Continued observation on 03/01/21 at 1:34 PM revealed STNA4 and R5 exited R5's room with the same gown she had on when she entered the room. Interview on 03/01/21 at 1:35 PM with STNA4 revealed the STNA confirmed she assisted R5 to her room using her ungloved bare hands. STNA4 also confirmed she did not doff her gown prior to exiting R5's room. Continued interview revealed STNA4 had forgotten that R5 was on isolation precautions. Review of R4's undated Admission Record, located in R4's EMR under the profile tab, revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of R4's Order Summary Report, located in R4's EMR under the orders tab, revealed R4 was ordered by his physician Contact + Droplet Precaution. Observation on 03/02/21 at 9:40 AM revealed LPN24 in R4's room with full PPE on touching R4's enteral tube feeding pump. Continued observation on 03/02/21 at 9:41 AM revealed LPN24 entered R4's restroom and performed hand hygiene and then exited R4's room. LPN24 did not doff the PPE gown prior to exiting the room. R4's room had signage outside the room which indicated R4 was on contact and droplet precautions. Interview on 03/02/21 at 9:42 PM with LPN24 revealed she did have another gown on top of her current gown; however, the LPN stated she had a hot flash, and had to remove the top gown while in the room checking on R4's pump. Continued interview with LPN24 revealed she acknowledged she should have doffed her current gown prior to exiting R4's room because he was on contact and droplet precautions. Interview on 03/02/21 at 5:07 PM with the DON/IP revealed it was her expectation the facility would have been 100% in compliance with the proper PPE usage for all staff and visitors. Continued interview revealed it was also her expectation the family who was in the facility for end of life visitation would have had on full PPE including gloves. The DON stated it was important to prevent the spread of infections. Interview on 03/02/21 at 5:20 PM with the Administrator revealed it was his expectation that all staff should have had on all the proper PPE when in isolation rooms. The Administrator stated it was also his expectation that family members visiting the facility would have had on the proper PPE. The Administrator stated it was important to reduce the potential transmission of COVID-19 and potentially other organisms. Review of the facility's policy titled, Novel Coronavirus Prevention and Response, revised 12/28/20, revealed .6. Interventions to prevent the spread of COVID-19 within the facility: .h. Support hand hygiene and respiratory/cough etiquette by residents, visitors, and employees by making sure tissues, soap, paper towels, and alcohol-based hand rubs are available. i. Educate staff on proper use of personal protective equipment and application of standard, contact and droplet transmission precautions, including eye protection . Review of the facility's policy titled, Donning and Doffing PPE for COVID-19, revised 02/17/21, revealed This facility will implement the CDC (Centers for Disease Control and Prevention) guidelines for use of person protective equipment when caring for residents with confirmed or suspected COVID-19 .1. PPE will be donned before entering the resident care area (isolation room .) .PPE is doffed deliberately in a sequence that prevents self-contamination to the extent possible .exit isolation area/room. Perform hand hygiene . Review of the Centers for Disease Control (CDC) guidance titled Using Personal Protective Equipment (PPE) updated August 19, 2020 revealed, .How to Put On (Don) PPE Gear .Training and practice using your healthcare facility's procedure is critical .Identify and gather the proper PPE to don. Ensure choice of gown size is correct (based on training). 1. Perform hand hygiene using hand sanitizer. 2. Put on isolation gown. Tie all of the ties on the gown. Assistance may be needed by other healthcare personnel. 3. Put on NIOSH-approved N95 filtering facepiece respirator or higher (use a facemask if a respirator is not available). If the respirator has a nosepiece, it should be fitted to the nose with both hands, not bent or tented. Do not pinch the nosepiece with one hand. Respirator/facemask should be extended under chin. Both your mouth and nose should be protected. Do not wear respirator/facemask under your chin or store in scrubs pocket between patients. oRespirator: Respirator straps should be placed on crown of head (top strap) and base of neck (bottom strap). Perform a user seal check each time you put on the respirator. oFacemask: Mask ties should be secured on crown of head (top tie) and base of neck (bottom tie). If mask has loops, hook them appropriately around your ears. 4. Put on face shield or goggles. When wearing an N95 respirator or half facepiece [MEDICATION NAME] respirator, select the proper eye protection to ensure that the respirator does not interfere with the correct positioning of the eye protection, and the eye protection does not affect the fit or seal of the respirator. Face shields provide full face coverage. Goggles also provide excellent protection for eyes, but fogging is common. 5. Put on gloves. Gloves should cover the cuff (wrist) of gown. 6. Healthcare personnel may now enter patient room. How to Take Off (Doff) PPE Gear Training and practice using your healthcare facility's procedure is critical. Remove gloves. Ensure glove removal does not cause additional contamination of hands. Gloves can be removed using more than one technique (e.g., glove-in-glove or bird beak). 1. Remove gown. Untie all ties (or unsnap all buttons). Some gown ties can be broken rather than untied. Do so in gentle manner, avoiding a forceful movement. Reach up to the shoulders and carefully pull gown down and away from the body. Rolling the gown down is an acceptable approach. Dispose in trash receptacle. * 2. Healthcare personnel may now exit patient room. 3. Perform hand hygiene. 4. Remove face shield or goggles. Carefully remove face shield or goggles by grabbing the strap and pulling upwards and away from head. Do not touch the front of face shield or goggles. 5. Remove and discard respirator (or facemask if used instead of respirator). Do not touch the front of the respirator or facemask. oRespirator: Remove the bottom strap by touching only the strap and bring it carefully over the head. Grasp the top strap and bring it carefully over the head, and then pull the respirator away from the face without touching the front of the respirator. oFacemask: Carefully untie (or unhook from the ears) and pull away from face without touching the front. 6. Perform hand hygiene after removing the respirator/facemask and before putting it on again if your workplace is [MEDICATION NAME] reuse. Facilities implementing reuse or extended use of PPE will need to adjust their donning and doffing procedures to accommodate those practices.

Based on interview and record review, the facility failed to ensure residents were notified by 5:00 PM the following day after a new positive COVID-19 case was identified in the facility for one of one supplemental resident reviewed for timely notifications (Resident (R) 8). Findings include: Review of the facility's policy titled, COVID-19 Reporting, dated 05/08/21, revealed, .3. The facility will notify residents and representatives/families of any new confirmed or probable COVID-19 infections for residents or staff and any new onset of respiratory symptoms experienced by three or more residents of Staff .i. Initial Notification. All residents and the residents' representatives/family must be notified by 5 p.m. the next calendar day or within 24 hours of identification, whichever is earlier, of the first Confirmed COVID-19 or Probable COVID-19 case in the Facility by a resident or Staff member . Review of the facility's undated and untitled COVID-19-line listings revealed on 02/26/21 a resident in the facility (R10) tested positive for COVID-19. This was the most recent COVID-19 case. Review of R8's undated Admission Record, located in R8's electronic medical record (EMR) under the profile tab revealed R8 was admitted to the facility on [DATE]. Review of R8's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 01/28/21 revealed the facility assessed R8 to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R8 was fully cognitively intact. Interview on 03/02/21 at 11:55 AM with R8 revealed when asked if she was notified of staff or other residents testing positive for COVID-19, R8 stated, No, they called my family and my family told me. Continued interview with R8 revealed she wanted to know if someone at the facility did test positive for COVID-19. R8 stated she did not have access to the internet. Interview on 03/01/21 at 9:22 AM, during the entrance conference, the Administrator stated the facility's website informs families of new resident and staff COVID-19 cases. The Administrator further stated the facility designated different departments to speak with different residents weekly; however, the residents were not updated after each single COVID-19 case in the facility. Interview on 03/02/21 at 5:07 PM with the Director of Nursing/Infection Preventionist (DON/IP) revealed all residents with at BIMS of eight or higher should have been notified after each positive case identified in the facility. Review of the Centers for Medicare and Medicaid Services QSO (Quality Safety & Oversight) -20-29-NH (Nursing Home) dated 5/6/20 indicated, Covid-19 Reporting. Facilities must .Inform resident, their representatives, and families of those residing in facilities by 5 p.m. the next calendar day following the occurrence of either a single confirmed infection of COVID-19, or three or more residents or staff with new onset of respiratory symptoms occurring within 72 hours of each other .

Based on medical record review, observation, interviews, and review of facility policy, the facility failed to provide care and services to potentially prevent skin breakdown for one resident who was totally dependent on staff for care. This affected one Resident (#100) of four reviewed for skin breakdown. The facility census was 93. Findings include: Review of the medical record for Resident #100 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the care plan for Resident #100 dated 10/29/20 revealed the resident was at risk for alteration in skin integrity related [MEDICAL CONDITION], reduced mobility and bowel incontinence. Interventions included keeping linen dry and as wrinkle free as possible. Provide assistance with activities of daily living (ADLs) and positioning as needed. The care plan further revealed the resident was admitted with an alteration in skin integrity as evidenced by a pressure ulcer present on the coccyx. Interventions for this care planned concern keeping linen dry and wrinkle free. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #100, dated 11/15/20, revealed the resident had an altered level of consciousness, required extensive assistance with ADLs, required extensive assistance with bed mobility, was at risk for the development of pressure ulcers, and had one unstageable pressure injury that was present at admission. Review of the Braden Risk Assessment for predicting the development of pressure ulcers for SR #100 dated 12/06/20, revealed the resident was at risk to develop pressure ulcers. Observation on 12/10/20 at 10:30 A.M. of Resident #100 revealed the resident resting in bed. Beneath the resident the bed sheets were wet and stained yellow. The area of moisture began next to the residents' tube feeding port. At 11:55 A.M. the resident's sheets beneath her remained soiled and wet. A towel had been placed beneath the tube feeding port. At 1:48 P.M. the Resident's sheets beneath her were still soiled and wet. Interview on 12/10/20 at 1:51 P.M. with Registered Nurse (RN) #20 revealed she was caring for Resident #100. RN #20 revealed Resident #100 had a leaking tube feeding port and she had gone in and placed a towel beneath the port one to two hours ago. RN #20 stated she was unsure when the last time the resident had been checked or changed. Observation and interview on 12/10/20 at 1:58 P.M. of incontinence care provided to Resident #100 by RN #20 and State tested Nursing Assistant (STNA) #25 revealed the sheets beneath the resident were heavily soiled and required a full bed change. The mattress beneath the resident was also noted to be wet once the fitted sheet was removed from the bed. STNA #25 said it was al due to the tube feeding leaking. The STNA further revealed she was made aware the resident needed a bed change around noon, however was busy and had not gotten to it yet. Interview on 12/10/20 at 2:21 P.M. with Licensed Practical Nurse (LPN) #60 revealed she was the wound specialty nurse for the building and rounded with the Wound Care Nurse Practitioner weekly. LPN #60 revealed moisture contributes to the breakdown of skin and the development of wounds and she would expect a dependent resident be checked and changed at least every two hours to prevent any new or further skin damage. Review of the policy and procedure for skin dated 12/02/15 revealed the facility will consider factors placing the resident at risk for developing a pressure ulcer, including specific conditions, causes, needs and behaviors are assessed and interventions for preventing pressure ulcer development are defined and implemented in accordance with the resident's needs, goals and recognized standards of practice. This deficiency substantiates Complaint Number OH 702.

Based on personnel file review, observation, staff interview, and review of facility policy, the facility failed to ensure food was served in a sanitary manner when staff was observed not wearing appropriate hair coverings. This had the potential to affect the 24 residents (#3, #9, #10, #14, #17, #22,#28, #39, #43 #48, #50, #52, #63, #66, #69, #70, #85, #87, #90, #105, #410, #411, #412 and #413) who received food from the West 100/200 unit servery. The facility census was 112. Findings include: Review of the personnel file for Dietary Aide (DA) #995 revealed the DA signed a document during his orientation on 10/30/19 entitled Hand washing/Infection Control Guidelines indicating acknowledgement of a directive for staff to use hairnets and/or facial nets when handling food. Observation of the West 100/200 servery on 11/20/19 at 12:07 P.M., with Dietary Aide (DA) #995 revealed the DA was serving food with uncovered and noticeable facial hair. DA #995 verified his facility hair was not covered during the observation. Review of the facilities policy entitled Infection Control-Dietary/Food Handling dated 03/01/16 revealed hairnets or caps must be worn to effectively keep hair from contacting exposed food, clean equipment, utensils and linens.

Based on medical record review, staff interview, and facility policy review, the facility failed to update a resident's care plan to implement precautions for the [DIAGNOSES REDACTED]. This affected one resident (#35) of four reviewed for infection. The facility census was 112. Findings include: Review of Resident #35's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #35's quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had a low cognitive function. Review of Resident #35's wound care note dated 11/07/19 revealed the resident acquired a laceration to the left lower extremity while on an outing with family. Resident #35 acquired a skin tear measuring 3.5 centimeters (cm) x 2.6 cm x 0.1 cm on a running board of a pick up truck. Review of Resident #35's medical record revealed a physician's order dated 11/15/19 for [MEDICATION NAME]-[MEDICATION NAME] (antibiotic) 800-160 milligram (mg) tablet by mouth every 12 hours [MEDICAL CONDITION] to left lower leg wound for eight days. Review of Resident #35's most recent care plan revealed no evidence the care plan had been updated to include the recent [DIAGNOSES REDACTED]. Interview with Resident #35's State tested Nursing Aide (STNA) #400 on 11/20/19 at 2:58 P.M. confirmed the STNA was unaware Resident #35 had any infections. Interview with Resident #35's Licensed Practical Nurse (LPN) #300 on 11/20/19 at 3:01 P.M. revealed the nurse was unaware that Resident #35 had any infections. Interview on 11/21/19 at 10:51 [NAME]M. with the MDS Nurse verified the facility failed to update Resident #35's care plan timely after being diagnosed with [REDACTED]. Review of the facility policy titled Documentation: Care Plan dated 07/06 revealed the care plan was to be reviewed and revised at least quarterly with the MDS and on an as needed basis as changes occur in the resident's regimen.

Based on medical record review, review of facility agreement with the [MEDICAL TREATMENT] center, resident and staff interview, the facility failed to ensure there was documented evidence of collaboration of care and communication between the nursing facility and the [MEDICAL TREATMENT] provider. This affected one resident (#33) of one reviewed for [MEDICAL TREATMENT]. The facility census was 112. Findings include: Medical record review revealed Resident #33 admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The resident was receiving [MEDICAL TREATMENT] treatments every Tuesday, Thursday and Saturday. Review of Resident #33's most recent plan of care revealed the resident received [MEDICAL TREATMENT] treatments every Tuesday, Thursday and Saturday and was at risk for adverse effects of [MEDICAL TREATMENT] and/or infection of the [MEDICAL TREATMENT]. Interventions included to encourage Resident #33 to take the communication form to [MEDICAL TREATMENT] and return it to the nurse when she returned and for the facility to maintain communication with the [MEDICAL TREATMENT] center staff and physician. Review of the facility's Intra-Facility Communication Form revealed the facility was to provide the [MEDICAL TREATMENT] provider residents current mental status, weight history and vital signs, medications given the day of treatment, diet order, fluid limit, meal intakes over the past week, lung sounds, [MEDICAL TREATMENT] access dressing condition, assessment of the access site, if signs of infection were present and any pertinent comments or recent and/or impending surgeries for the resident. Review of Resident #33's Intra-Facility Communication Forms, from 10/01/19 through 11/19/19, revealed the facility failed to provide the requested information listed on the form to the [MEDICAL TREATMENT] center. Review of the forms dated 10/22/19, 10/31/19, 11/14/19 and 11/19/19 revealed only the resident's vital signs and that her morning medications were given was provided and on 10/26/19 only the resident's vital signs were provided. Further review revealed no documented evidence the facility provided any of the requested information on 10/01/19, 10/05/19, 10/08/19, 10/12/19, 10/15/19, 10/17/19, 10/24/19, 10/29/19, 11/05/19, 11/09/19, 11/12/19 and 11/16/19. Interview on 11/18/19 at 10:23 [NAME]M., with Resident #33 revealed staff sometimes gave her paperwork to take with her to her [MEDICAL TREATMENT] appointments. If they did, she was supposed to bring it back with her when she returned to the facility. Interview on 11/19/19 10:22 [NAME]M., Licensed Practical Nurse (LPN) #301 revealed nursing staff were supposed to fill out a new Intra-Facility Communication Form each time a resident went to a [MEDICAL TREATMENT] appointment and the form was sent with the resident to their appointment. The [MEDICAL TREATMENT] center was supposed to fill out their required portion of the form, pertaining to the resident's condition during the [MEDICAL TREATMENT] treatment, and return the form with the resident at the end of the appointment. If the resident did not return with the form, staff were supposed to call the [MEDICAL TREATMENT] center to obtain the form. If unsuccessful, attempts were to be documented in the residents medical record. Interview on 11/20/19 04:20 P.M., the Director of Nursing (DON) verified Resident #33's Intra-Facility Communication Forms for 10/22/19, 10/26/19, 10/31/19, 11/14/19 and 11/19/19 were not completed with all the requested information. The DON further verified there was no documented evidence the facility provided any of the requested information on 10/01/19, 10/05/19, 10/08/19, 10/12/19, 10/15/19, 10/17/19, 10/24/19, 10/29/19, 11/05/19, 11/09/19, 11/12/19 and 11/16/19. Review of an agreement between the facility and [MEDICAL TREATMENT] center titled, SNF Outpatient [MEDICAL TREATMENT] Services Agreement, dated 09/15/08, revealed the [MEDICAL TREATMENT] center would provide to the facility information on aspects of the management of a designated resident's care related to the provision of [MEDICAL TREATMENT] services. Further review revealed the facility was to ensure all appropriate medical and administrative information accompanied all residents at the time of transfer or referral to the [MEDICAL TREATMENT] unit. Appropriate information was supposed to include the resident's name, address, date of birth, social security number, name and telephone number of the resident's next of kin, insurance information, appropriate medical records including a history of the resident's illness and any laboratory and/or x-ray findings, treatment's presently being provided to the resident including medications. Further review revealed the nursing facility was to ensure that there was documented evidence of collaboration of care and communication between the nursing facility and the [MEDICAL TREATMENT] unit.

Based on medical record review, staff interview, and facility policy review, the facility failed to ensure staff were informed of a resident who was diagnosed with [REDACTED]. This affected one resident (#35) of four reviewed for infection. The facility census was 112. Findings include: Review of Resident #35's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #35's quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had a low cognitive function. Review of Resident #35's wound care note dated 11/07/19 revealed the resident acquired a laceration to the left lower extremity while on an outing with family. Resident #35 acquired a skin tear measuring 3.5 centimeters (cm) x 2.6 cm x 0.1 cm on a running board of a pick up truck. Review of Resident #35's physician's order dated 11/15/19 revealed an order for [REDACTED]. Review of Resident #35's most recent care plan revealed no evidence the care plan was updated regarding the recent [DIAGNOSES REDACTED]. Interview with Resident #35's State tested Nursing Aide (STNA) #400 on 11/20/19 at 2:58 P.M. confirmed she was unaware Resident #35 [MEDICAL CONDITION] and did not use any extra infection control precautions while caring for the resident. Interview with Resident #35's Licensed Practical Nurse (LPN) #300 on 11/20/19 at 3:01 P.M. confirmed she was unaware Resident #35 had been diagnosed with [REDACTED]. Interview with the Director of Nursing (DON) on 11/21/19 at 10:35 [NAME]M. confirmed STNA #400 should have been informed during shift reports Resident #35 [MEDICAL CONDITION] in the left lower leg. Review of the facility policy titled Infection Prevention and Control Program (IPCP) dated 08/18/10 revealed the RN's (registered nurses) and LPN's supervise direct care staff in daily activities to assure appropriate precautions and techniques are observed, assess the resident's isolation needs, initiate appropriate precautions and consult with Medical Director and/or the resident's attending physician.

Based on record review, review of video footage, review of facility policy and staff interview, the facility failed to ensure a resident was free from verbal abuse. This affected one (Resident #112) of three residents reviewed for abuse. The facility census was 111. Findings include: Closed record review for Resident #112 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. The resident discharged from the facility on 03/19/19. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 02/09/19, revealed the resident had impaired cognition. Review of the video footage revealed there were separate clips of videos. The first video clip was dated 03/05/19 from 10:56:04 (there was no indication of A.M. or P.M.) through 11:01:03. The video clip revealed State tested Nursing Assistant (STNA) #1 was providing incontinence care for Resident #112, alone. STNA #1 was repeatedly heard saying, in a firm voice, calling the resident by name and stating, move your hands, keep your hands up here, I don't need your hands down there, you're a mess. At 10:58:52, an unidentified STNA (#2) enters the resident's room and says to STNA #1, oh you got the same situation I got, you should see Resident #89, he was yelling, and I go in there and it is all up the front and over, a complete bed change. At 10:59:49, STNA #1 was observed standing near the door of the resident's bathroom talking to STNA #2 and stated, whoever this old lady is here, she's expletive about she wants to know where his inaudible is, I am like I don't know, I didn't take it. STNA #2 tells STNA #1, Let me finish (an unidentified resident) and I will be in and STNA #2 left the resident's room. At 10:59:49, STNA #1 was heard saying in a firm voice, god damn-it, keep your hands out of there, and repeatedly saying the resident's name telling him no, and to put his hands up here. At 11:00:10, STNA #1 was heard saying, there's expletive all over me now. The second video clip, dated 03/06/19 from 11:01:19 through 11:05:09, revealed at 11:01:40, STNA #1, in a firm voice, said, get your hands out of there god damn-it. At 11:02:30, STNA #1 moves to the resident's left side of the bed. A second later you see the resident's arm dangling over the side of the bed as he was now on his right side. STNA #1 was heard, in a very firm voice, saying, Resident #112, get out, then it appeared the resident was rolled over even further onto his right side as the resident's arm was extended and moving quickly off of the side of the bed; at this point, STNA #1 was heard firmly telling the resident, I ain't telling you again. At 11:03:08, STNA #1 was heard saying, keep your god-damn self over there. Interview on 06/26/19 at 11:37 A.M. with the Administrator and the Director of Nursing (DON), both confirmed they viewed the video and witnessed the above observations by STNA #1 and the unidentified STNA #2. They verified the STNA did not treat the resident appropriately. Review of the facility policy titled, Abuse, Neglect, Exploitation & Misappropriation of Resident Property, dated 11/21/16, revealed it was the facility's policy to investigate all alleged violations involving abuse, neglect, exploitation, mistreatment of [REDACTED]. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also included the deprivation by an individual, including a caretaker of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. This deficiency substantiates Complaint Number OH 953.

Based on record review, review of video footage and staff interview, the facility failed to implement the resident's care plan interventions when they failed to provide appropriate assistance during care. This affected one (Resident #112) of three residents reviewed for implementation of care planned interventions. The facility census was 111. Findings include: Review of the medical record for Resident #112 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. The resident discharged from the facility on 03/19/19. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 02/09/19, revealed the resident had impaired cognition. The resident was dependent and needed the assistance from two staff for toileting, transfers, and bed mobility. Further review revealed the resident was always incontinent of both bowel and bladder. Review of the resident's plan of care revealed a decline in activities of daily living (ADL) may be expected related to his medical conditions and because he required extensive to total assistance with all of his activities of daily living (ADLs). Interventions included two staff assistance for all aspects of care. Review of the video footage, dated 03/05/19 from 10:56:04 (there was no indication of A.M. or P.M.) through 11:01:03. The clip revealed State tested Nursing Assistant (STNA) #1 was providing incontinence care for Resident #112, alone. STNA #1 struggled to provide the needed care to the resident and was repeatedly heard telling the resident no, to move his hands, and to stop. A second video clip, dated 03/06/19 from 11:01:19 revealed at 11:02:30, STNA #1 moves to the resident's left side of the bed without any other staff assistance. A second later you see the resident's arm dangling over the side after being rolled over to his right side. The resident was rolled over even further onto his right side as the resident's arm was extended and moving quickly off of the side of the bed. At 11:03:32, the resident appears to be rolled even further onto his right side and the resident's arm quickly extends over the side of the bed then appears to be trying to find something to hold onto. At 11:05:55, an unidentified STNA was seen rushing into the room towards the resident's bed and said, oh god, just wait a minute before you roll him off the bed, I will help you. Interview on 06/26/19 at 11:37 A.M., the Director of Nursing (DON), confirmed Resident #112 required extensive assistance from two staff for all aspect's of care including incontinence care. The DON verified she watched the video footage and verified STNA #1 provided incontinence care for the resident with out the assistance from another staff member. This deficiency substantiates Complaint Number OH 953.

Based on observation and staff interview, the facility failed to ensure expired food items were discarded. This had the potential to affect all 108 resident receiving food from the facility kitchen. Resident #47, #62, #72 and #116 were identified to receive no oral food or fluids. The census was 112. Findings include: Observation of the facility kitchen on 07/10/17 at 8:50 A.M. revealed there were one open box of buttermilk biscuit mix and four unopened boxes of buttermilk biscuit mix. All five boxes were dated as received by the facility on 06/01/17. All five boxes of buttermilk biscuit mix had an expiration date of 03/13/17. Observation of the walk-in freezer revealed a plastic bag of golden crispy portioned chicken breast filets and a plastic bag of pork sausage links. Both bags of meat were not securely closed and the meat was exposed to the air. Further observation revealed a plastic bag of hotdogs that was also not securely closed and left the meat exposed to the air. There were ice crystals surrounding the hotdogs freezing them to each other. Interview on 07/10/17 at 8:50 A.M. with the Corporate Executive Chef verified there were five boxes of buttermilk biscuit mix with an expiration date of 03/13/17. The Corporate Executive Chef further verified there were open bags of chicken breast filets, pork sausage links, and hotdog's in the walk-in freezer.

Based on medical record review, family interview, policy review, and staff interviews, the facility failed to provide residents with care planning meetings on a quarterly basis. This affected three (#18, #62, and #83) of 23 residents reviewed on stage two and 68 additional residents (#1, #3, #6, #15, #16, #17, #21, #23, #24, #25, #27, #28, #36, #38, #39, #40, #41, #43, #44, #46, #47, #48, #50, #51, #52, #53, #57, #58, #59,#63, #67, #69, #71, #73, #74, #76, #77, #80, #81, #82, #84, #87, #88, #89, #91, #92, #94, #95, #97, #98, #99, #100, #104, #106, #107, #109, #113, #114, #119, #122, #123, #124, #125, #131, #143, #147, #152 and #156) identified by the facility to have had the last care conference more than 90 days prior to the survey. The facility census was 112. Findings include: 1. Review of Resident #83's medical record identified admission occurred 09/20/13. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 05/17/17, identified Resident #83 had intact cognition. Interview on 07/11/17 at 9:24 A.M., Resident #83 identified the facility only conducts care meetings once a year and its been a long time since she has had one. 2. Review of Resident #18's medical record identified admission occurred on 04/01/15. [DIAGNOSES REDACTED]. Review of the IDT care plan conference form, dated 01/11/16, revealed a meeting was held in which all staff members and family had signed acknowledging participation. The conference notes identified the covered issues such as discharge goals, dietary, nursing, plan of care and medication review. The record lacked any evidence of additional meetings following the 01/11/16 meeting. Interview on 07/12/17 at 2:45 P.M., Resident #18's Power of Attorney stated there are no scheduled care plan meetings occurring quarterly regarding Resident #18's care and medications. Resident #18's family confirmed they would in fact participate in quarterly meetings regarding Resident #18's care. 3. Review of Resident #62's medical record identified admission occurred on 12/16/16. [DIAGNOSES REDACTED]. Review of the IDT care planning conferences revealed meetings were held on 12/22/16, 01/24/17 and 02/15/17. The record was silent to any other care planning meetings occurring. Interview on 07/11/17 at 8:12 A.M., Resident #62's family stated the facility does not have quarterly care planning meetings. Interview with Licensed Social Worker (LSW) #310 on 07/11/17 at 1:45 P.M. identified all residents are scheduled a care planning meeting upon admission and then annually. The interview identified the facility had a sign posted throughout the facility that identified the facility offered family meetings with the interdisciplinary team (IDT) to discuss care, concerns and goals upon admission. The sign indicates after the initial meeting they are welcome to request additional meetings at anytime. LSW #310 confirmed the facility does not provide routine care meetings for residents and or families. The facility identified 68 residents (#1, #3, #6, #15, #16, #17, #21, #23, #24, #25, #27, #28, #36, #38, #39, #40, #41, #43, #44, #46, #47, #48, #50, #51, #52, #53, #57, #58, #59,#63, #67, #69, #71, #73, #74, #76, #77, #80, #81, #82, #84, #87, #88, #89, #91, #92, #94, #95, #97, #98, #99, #100, #104, #106, #107, #109, #113, #114, #119, #122, #123, #124, #125, #131, #143, #147, #152 and #156) to have had their last care conference more than 90 days ago. Review of the facility policy titled Resident/Family/Responsible Party Care Conference, dated August 8, 2006, identified upon admission, the resident and family/responsible party are offered an initial care conference meeting. They are also informed they may request a care conference at any time.

Based on medical record review and staff interview, the facility failed to ensure recommended follow up psychiatric services were provided for one (#74) of 20 residents reviewed on stage two of the survey The census was 112. Findings include: Medical record review revealed Resident #74 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #74's cognition was moderately impaired. Review of a progress note revealed Resident #74 was evaluated by a psychiatrist on 11/23/16. The progress note indicated the psychiatrist was treating the resident for depression and anxiety. The note indicated Resident #74 was to follow up with the psychiatrist in three months. There were no other progress notes from this psychiatrist found in Resident #74's medical record. Interview on 07/13/17 with the Director of Nursing revealed the facility was not able to find evidence Resident #74 followed up with a psychiatrist after 11/23/16.

Based on observations, medical record review, resident interview, and staff interviews, the facility failed to ensure a maintenance restorative program was provided for one (#67) of three residents reviewed for a decline in activities of daily living. The facility census was 112. Findings include: Review of Resident #67's medical record identified admission occurred on 09/08/16 following hospitalization from a [MEDICAL CONDITION]. The record identified prior to admission Resident #67 lived alone in the community. Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/24/17, identified Resident #67 to have moderate cognitive impairment. The assessment indicated Resident#67 had a decline in her ability to transfer and walk, requiring extensive assistance. The record identified a physical therapy evaluation and treatment was completed on 05/19/17 and continued through 06/28/17. Review of the 06/16/17 notification of discharge from therapy form revealed the therapist recommendations were to ambulate the resident with a front wheeled walker and shoe lift for 40 to 150 feet with minimal assistance and a gait belt, following the resident with a wheelchair. The form indicated the resident was being discharged to nursing on 06/28/17. Resident #67 was discharged from physical therapy on 06/28/17 with recommendations for a nursing restorative program. Interview on 07/12/17 at 9:01 A.M., Resident #67 identified she has not walked with staff since her therapy was completed. Resident #67 identified she would love to walk with the staff and would participate if asked. Observation at the time of the interview of Resident #67's room revealed the resident had a wheeled walker and a lift shoe for the left foot. Observations on 07/10/17, 07/11/17,or 07/12/17 revealed Resident #67 was not observed to be offered to ambulate. Interview on 07/12/17 at 9:45 A.M., Registered Nurse (RN) #300 stated when a resident was discharged from therapy the therapy staff provide a discharge notification form to the nursing staff. RN #300 confirmed when she receives this information she places it on the resident's plan of care. RN#300 confirmed there was no established program with evidence of any attempts to complete the post therapy discharge goals completed for residents. RN #300 confirmed Resident #67 could request to be walked but there was no current scheduled plan of treatment for [REDACTED].

Based on observation, staff interview, and review of facility policy, it was determined the facility failed to ensure medications were not kept unsecured at bedside for one (Resident #87) of 40 residents observed on stage one of the survey. The census was 112. Findings include: Medical record review for Resident #87 admitted [DATE]. [DIAGNOSES REDACTED]. Review of Medication Administration Record [REDACTED]. Observation on 07/10/17 at 3:18 P.M. revealed Resident #87 with plastic mediation cup sitting on night stand with five enteric coated pills in the cup. Interview on 07/10/17 at 3:18 P.M., Resident #87 stated she receives ASA EC 81 mg every day. The resident stated she has told staff she doesn't take the coated medications and they give it to her anyway. Interview on 07/10/17 at 7:4 A.M., Licensed Practical Nurse (LPN) #29 verified the five pills in the plastic medication cup were Aspirin Enteric-Coated 81 mg. LPN #29 stated the staff should be observing the resident taking medications. Review of facility policy titled Medication Procedure, dated 10/01/11, revealed if the resident refuses to take their medications prior to removal of the from the blister, place the meds back into the med pass bag, and place the bag in the resident's bin.