Every finding on record at Larchwood Care

Based on interviews. record review, and facility policy, the facility failed to ensure proper wound care assessments, treatment and skin monitoring was in place for Resident #70. This affected one resident (#70) of three reviewed for skin impairments. The facility census was 59.Findings include:Review of the closed medical record for Resident #70 revealed an admission date of 12/19/25 and a discharge date of 04/25/26. Resident #70's diagnoses included but were not limited to cerebral infarction due to unspecified occlusion or stenosis of left middle cerebral artery, respiratory failure, type 2 diabetes mellitus with hyperglycemia, hemiplegia and hemiparesis, nontraumatic subarachnoid and intracerebral hemorrhage, cognitive communication deficit, tracheostomy, gastrostomy, and obstructive sleep apnea.Review of hospital after visit summary dated 12/19/26 revealed Resident #70 had a wound pressure injury to coccyx posterior with treatment to include cleanse with wound cleanser, apply calmoseptine and foam dressing. There was no evidence this was ordered upon admission.Review of the admission Nursing assessment dated [DATE] revealed under the skin assessment Resident #70 had a skin tear to coccyx area which measured 3 centimeters (CM) by (X) 2 cm. The assessment did accurately identify the skin impairment as a pressure ulcer.Review of Resident #70's care plan dated 12/19/25 revealed the care plan did not properly identify the resident had a pressure ulcer. The care plan was incomplete indicated (specify) pressure ulcer (specify location) or potential for pressure ulcer development related to mobility. No pressure ulcer noted on admission or type. Interventions included administer medications and treatments as ordered and monitor for effectiveness.Review of the physician orders revealed no wound treatment was ordered until 12/26/26. On 12/26/26, Resident #70 was ordered a treatment to coccyx, cleanse area with normal saline (NS), pat dry, apply triad cream and foam dressing, change daily and as needed (PRN). Review of the Wound Physician Note dated 12/26/26 revealed Resident #70 had a stage two pressure injury to the coccyx with measurements of 1.0 cm x 0.5 cm x 0.1 cm. The wound had moderate serous drainage, with no signs of infection noted. Treatment included hydrocolloid paste (triad) apply once daily and as needed (PRN). Apply foam with border once daily and PRN. Review of the facility weekly skin observations revealed the first skin observation was completed on 12/28/25. Additional weekly skin observations were completed 01/22/26 and 02/03/26.Review of the quarterly Minimum Data Set (MDS) assessment, dated 03/26/26 revealed Resident #70 had severely impaired cognition with both short-term and long-term memory problem. Resident #70 was dependent for all activities of daily living. Resident #70 was always incontinent of bladder and bowel.Interview on 04/29/26 at 1:33 P.M. with MDS Coordinator Registered Nurse (MDS RN) #170 confirmed Resident #70's care plan was not comprehensive and individualized. MDS RN #170 reported she doesn't know what happened and it must have been an oversight. Interview on 05/04/26 at 11:11 A.M. with Wound Licensed Practical Nurse (LPN)/Assistant Director of Nursing (ADON) #105 confirmed the weekly skin observations were not completed timely and weekly. Wound LPN/ADON #105 confirmed on 12/19/25 the Nursing admission Assessment did not accurately reflect the resident's pressure ulcer. Wound LPN/ADON #105 confirmed Resident #70 admitted to facility with pressure injury to coccyx. Wound LPN/ADON #105 confirmed wound treatment for Resident #70 was started on 12/26/26, seven days after admission. Review of facility policy, Pressure Injury Prevention and Management, revised 01/01/2026, revealed the facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. Further states, Licensed nurses will conduct a full body skin assessment on all resident upon admission/re-admission, weekly and after any newly identified pressure injury. This deficiency represents non-compliance investigated under Complaint Number 299631.

Based on interviews, record reviews, and review of video recordings, the facility failed to monitor for changes in condition by not engaging with Resident #70 during care provided to ensure timely treatment related to a change in the resident's condition. This affected one resident (Resident #70) out of three residents reviewed for change in condition. The facility census was 59.Findings include: Review of the closed medical record for Resident #70 revealed an admission date of [DATE] and a discharge date of [DATE]. Resident #70's diagnoses included but were not limited to cerebral infarction due to unspecified occlusion or stenosis of left middle cerebral artery, respiratory failure, type two diabetes mellitus with hyperglycemia, hemiplegia and hemiparesis, nontraumatic subarachnoid and intracerebral hemorrhage, cognitive communication deficit, tracheostomy, gastrostomy, and obstructive sleep apnea.Review of the care plan dated [DATE] for Resident #70 revealed a care plan that was incomplete, indicating the resident is (SPECIFY) independent/dependent on staff etc.) for meeting emotional, intellectual, physical, and social needs related to (if depended) cognitive deficits, physical Limitations. Interventions included all staff to converse with resident while providing care.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #70 had severely impaired cognition with both short-term and long-term memory problem. Resident #70 was dependent on staff for all activities of daily living. Resident #70 was always incontinent of bladder and bowel.Review of the video recording dated [DATE] at 11:00 P.M. revealed Certified Nursing Assistant (CNA) #262 entered Resident #70's room. The video shows Resident #70 opening her mouth to take a breath and moving her eyes/head. CNA #262 announced turning on light when she entered the room. At no point CNA #262 attempted to arouse the resident to perform care or communicate what care was being provided.Review of the video recording dated [DATE] at 11:02 P.M. revealed Resident #70 no longer was opening her mouth to take a breath or moving her head. CNA #262 continued to provide care to Resident #70. At no point CNA #262 attempted to arouse the resident to perform care or communicate what care was being provided.Review of the video recording dated [DATE] at 11:04 P.M. revealed Resident #70 was not visibly moving. At no point CNA #262 attempted to arouse the resident to perform care or communicate what care was being provided.Review of the video recording dated [DATE] at 11:07 P.M. revealed Resident #70 was not visibly moving. At no point CNA #262 attempted to arouse the resident to perform care or communicate what care was being provided.Review of the video recording dated [DATE] at 11:08 P.M. revealed Resident #70 was not visibly moving. At no point CNA #262 attempted to arouse the resident to perform care or communicate what care was being provided.Review of the video recording dated [DATE] at 11:09 P.M. revealed Resident #70 was not visibly moving. At no point CNA #262 attempted to arouse the resident to perform care or communicate what care was being provided. CNA #262 can be seen moving the resident's head of bed up and lowering bed.Review of the video recording dated [DATE] at 11:10 P.M. revealed Resident #70 was not visibly moving. At no point CNA #262 attempted to arouse the resident to perform care or communicate what care was being provided. CNA #262 can be seen adjusting the resident's pillows.Review of the video recording dated [DATE] at 11:11 P.M. to 11:12 P.M. revealed CNA #262 was seen finishing up care and left the room. Resident #70 was not visibly moving. At no point CNA #262 attempted to arouse the resident to perform care or communicate what care was being provided. There was no video evidence staff entered the resident's room again until 11:53 P.M.Review of the progress note dated [DATE] at 12:45 A.M. authored by Licensed Practical Nurse (LPN) #160 revealed she was alerted by RN #196 around 11:55 P.M. Resident #70 was unresponsive. Upon assessment Resident #70 had no pulse, no respirations, and no response to verbal or tactile stimuli. Code status verified as full code. Cardiopulmonary Resuscitation (CPR) initiated immediately and 911 called. CPR continued until Emergency Medical Services (EMS) arrived. Upon EMS arrival, cardiac monitor applied with no pulse detected. EMS evaluated resident and pronounced deceased on scene on [DATE] at 12:05 A.M. Interview on [DATE] at 10:32 A.M. with Resident #70's family revealed on [DATE] at 11:02 P.M. while CNA #262 was providing the resident care, Resident #70 took her last breath and her head goes down, and CNA #262 left the room at 11:11 P.M. Resident #70's family revealed at approximately 11:53 P.M. Registered Nurse (RN) #196 entered Resident #70's room looked at her and checked her pulse, she had no pulse, starred at Resident #70 and then left the room. Resident #70's family member reported on [DATE] at approximately 11:55 P.M. everybody rushed into her room, to include two nurses and two other staff. Staff put on automatic external defibrillator (AED) and staff tried for approximately five minutes of cardiopulmonary resuscitation (CPR). Resident #70's family reported they could tell Resident #70 was already gone.Interview on [DATE] at 10:03 A.M. with Certified Nursing Assistant (CNA) #262 confirmed she provided care to Resident #70 and reported she was alive. CNA #262 confirmed when she entered the room she said she was turning on the light but did not have a conversation with Resident #70 while providing care.Interview on [DATE] at 7:15 A.M. with RN #197 revealed he worked on [DATE] when Resident #70 coded. RN #197 revealed when responding to the code Resident #197 had a grayish/blue look to her skin.Interview on [DATE] at 8:06 A.M. with Administrator after showing video recordings sent in by Resident #70's family with consent, confirmed she did not see the resident move in the video footage after 11:04 P.M. on [DATE].Interview on [DATE] at 9:18 A.M. with Respiratory Therapy Director (RT Director) #206 after showing video recordings sent in by Resident #70's family with consent, confirmed Resident #70 had movement of head and eyes, and breathing on the [DATE] 11:00 P.M. video recordings and RT Director #206 confirmed Resident #70's the breathing was not her normal breathing. RT Director #206 confirmed there was no movement for Resident #70 in the video recording dated [DATE] at 11:07 P.M.Interview on [DATE] at 11:38 A.M. via phone with RN #196 confirmed on [DATE] he was finishing up his rounds and went he entered Resident #70's room to check on her and she had no pulse, was apneic, and was cold to touch. RN #196 reported he left the room to notify staff and got the crash cart. RN #196 reported 911 was called and they initiated CPR to Resident #70. RN #196 reported EMS arrived, applied their machine, did CPR and then pronounced her dead.Interview on [DATE] at 2:16 P.M. with Director of Nursing (DON) after showing video recordings sent in by Resident #70's family with consent, confirmed Resident #70's breathing didn't appear to be normal on the [DATE] at 11:00 P.M. video. DON confirmed change in breathing from first video to the other videos that followed. DON confirmed she would consider this a change in Resident #70's breathing.Interview on [DATE] at 2:48 P.M. with RT Director #206 after showing video recordings sent in by Resident #70's family with consent, confirmed Resident #70 mouth opening isn't normal breathing, more of an accentuated breathing, did not know what it could be but was showing something abnormal in her breathing. Interview on [DATE] at 7:38 A.M and 7:41 A.M. with RN #202 and Licensed Practical Nurse (LPN) #153, who took care of Resident #70, confirmed Resident #70 normally did not open her mouth to breathe. Interview on [DATE] at 12:07 P.M. with Nurse Practitioner (NP) # 305, after showing the [DATE] video recording at 11:00 P.M., revealed she had not seen Resident #70's breathing like that before. NP #305 confirmed the [DATE] at 11:02 P.M. video recording there was a difference in Resident #70's breathing.Interview on [DATE] at 2:12 P.M. with DON confirmed for Resident #70 it would be difficult to say whether CNA #262 would recognize a difference in Resident #70's breathing pattern.This deficiency represents non-compliance investigated under Complaint Number 2996310.

Based on observation, record review, interview, and facility policy review, the facility failed to provide adequate staff assistance to prevent a fall with injury. Actual Harm occurred on 07/26/25 at 10:20 A.M. when Resident #7, who was dependent on staff for bed mobility, transfers, and toileting, fell during incontinence care when assisted by only one Certified Nursing Assistant (CNA), resulting in an intracerebral contusion (closed head injury) and a dislodged jejunostomy tube (feeding tube). Resident #7 was transferred to the hospital and admitted for additional care and monitoring before returning to the facility on [DATE]. This affected one resident (#7) of three residents reviewed for accidents. The facility census was 67. Findings include:Review of the medical record for Resident #7 revealed an admission date of 04/12/24. Diagnoses included chronic respiratory failure, protein-calorie malnutrition, intercranial hemorrhage, Alzheimer's disease, and gastrostomy.Review of Resident #7's care plan initiated 04/17/24 revealed the resident was at risk for falls related to weakness, impaired cognition, use of assistive devices, medication side effects, impaired mobility, and history of falls. Listed interventions included to anticipate and meet the resident's needs and follow the facility's fall protocol. Continued review of Resident #7's care plan dated 04/17/24 revealed the resident had an activity of living (ADL) self-care performance deficit related to underlying disease and impaired physical mobility. Listed interventions included to transfer Resident #7 using a mechanical (Hoyer) lift and two staff assist and encourage the resident to participate to the fullest extent possible. On 07/30/25, an intervention was added to reflect Resident #7 was totally dependent on two staff for repositioning and turning in bed. Review of Resident #7's physician's orders revealed an order dated 06/21/24 for an air mattress with bolsters to the bed. Review of Resident #7's fall risk assessment dated [DATE] revealed Resident #7 was at low risk for falls.Review of the Minimum Data Set (MDS) quarterly assessment, dated 07/17/25 revealed Resident #7 had severely impaired cognition. The resident was dependent for bed mobility, transfers, toileting hygiene and ambulation. Resident #7 was always incontinent of bowel and bladder. Resident #7 was noted to have a feeding tube and a tracheostomy. Review of the Change in Condition Report dated 07/26/25 at 10:20 A.M. revealed Resident #7 had experienced a fall. At the time of evaluation, Resident #7 had no mental status change, but the resident was noted to have pain. The physician was notified and recommended calling nine-one-one (911) to summon emergency medical services.Review of the Health Status Note dated 07/26/25 at 10:49 A.M. revealed CNA #963 reported to the charge nurse that Resident #7 was on the floor. Upon entering the room, the resident was found lying on her back, face up, with her arms and legs contracted per her baseline. Blood was noted on the floor under resident's head. Resident #7's pupils were equal and reactive. Resident #7's vital signs were taken and at baseline. Facility staff called 911 and Resident #7 was transported to the hospital.Review of the facility fall investigation dated 07/26/25 revealed at 10:20 A.M. Resident #7 had a witnessed fall, sustaining a one-centimeter (1cm) laceration behind her right ear. Resident #7 was sent to the emergency room (ER) for evaluation. Per ER note the resident had no acute fractures or dislocations. The Computed Tomography (CT) scan showed no midline shift or brain herniation. The investigation noted CNA #963 was changing the resident without a second staff member at bedside when the resident's leg slid, resulting in the resident sliding onto the floor. The resident was sent to ER for evaluation. The resident's J-Tube had become dislodged during the fall and was replaced while in the hospital. Resident #7 remained a two-assist for care with a perimeter air mattress in place. Resident #7 was not on blood thinners. The resident was transported to a local ER for evaluation. Resident #7 returned to the facility on [DATE].Review of the Hospital Report dated 07/27/25 at 9:30 A.M. revealed Resident #7 was seen by the hospital trauma team upon arrival to the ER. The resident was at baseline, which was nonverbal and contracted. The resident had a small laceration behind her right ear, a dislodged jejunostomy tube, a hematoma of the left thigh, and a right parietal hemorrhagic contusion (bleeding into the brain tissue of the right parietal lobe of the brain) with no loss of consciousness. Interventional Radiology was consulted and replaced Resident #7's jejunostomy tube, and neurosurgery was consulted for monitoring and non-operative management of Resident #7's intracranial contusion, including every four hour neurological assessments and repeat imaging tests. Resident #7 returned to the facility on [DATE]. Observation on 09/04/25 at 11:38 A.M. revealed Resident #7 in bed on an air mattress with a touch pad call light beside her. The resident had her eye closed. Interview on 09/04/25 at 12:08 P.M. with Licensed Practical Nurse (LPN) #884 revealed she was Resident #7's nurse at the time of the recent fall. LPN #884 revealed when they were assessing the resident post-fall, they saw her tracheostomy was still in place, but the resident's feeding tube was dislodged. LPN #884 saw a laceration to the resident's head and some blood on the ground near her head. Resident #7 had no other visible bruises or lacerations. LPN #884 reported Resident #7 was nonverbal. The staff did not feel Resident #7 was safe to move, so staff stayed with her and called 911. LPN #884 further stated a CNA had transferred the resident by herself and verified a resident on an air mattress always needed two people to assist. LPN #884 stated the CNA should have known.Interview on 09/04/25 at 1:05 P.M. with the Director of Nursing (DON) verified Resident #7 sustained a fall with injury when CNA #963 was providing care without a second staff member assisting. The DON revealed a resident on an air mattress always required two-person assist with turning and changing.Review of the policy Fall Prevention Program dated 2024 revealed each resident would be assessed for fall risk and would receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls.

Based on observation, record review, interview, and facility policy review, the facility failed to ensure medications were not left unattended during medication administration. This affected one resident (#12) of three residents reviewed for safe storage of medications. The facility census was 67. Findings include: Review of the medical record for Resident #12 revealed she was admitted on [DATE] and had diagnoses including diabetes, mild cognitive impairment, and major depressive disorder. Review of Resident #12's self-medication administration assessment dated [DATE] revealed the resident did not wish to self-administer medications. Resident #12 was identified on the assessment to not be a candidate for self-administration of medications. Review of Resident #12's physician's orders revealed the resident had no physician order to self-administer medications. Observation of Resident #12 on 09/02/25 at 9:36 A.M. revealed she had several unknown pills mixed in with applesauce in a medication cup on her bedside table. No staff was in the room or observing from the doorway. Resident #12 had a tracheostomy and ventilator and could not be understood, but appeared to shake her head 'no' when asked if she had concerns. Interview with Registered Nurse (RN) #848 on 09/02/25 at 9:39 A.M. revealed Resident #12 took a long time to swallow her medications. During the medication administration for Resident #12, RN #848 stated she got distracted with another resident and left the remainder of medications at Resident #12's bedside. RN #848 confirmed the medications were still at the bedside and that Resident #12 had no order for self-administration of medications. Review of the policy Medication Administration dated 03/01/25 revealed part of the medication administration process was to observe resident consumption of medications.

Based on observations, medical record review, resident interview, staff interviews, and facility policy review, the facility failed to ensure a resident's request for assistance was responded to in a timely manner. This affected one resident (#5) of one reviewed for timely care and assistance. The facility census was 67.Findings include: Review of the medical record for Resident #5 revealed she was admitted to the facility on [DATE] with diagnoses that included acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, and attention to tracheostomy (a surgically-created artificial airway).Review of the care plan dated 06/27/25 revealed Resident #5 had an ADL self-care performance deficit related disease process and generalized weakness with interventions that included assistance with ADLs and dressing.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 14 that indicated she was alert and oriented to person, place, and time. Resident #5 had impairments to both lower extremities and was dependent on staff for activities of daily living (ADLs). Observation and interview on 09/02/25 at 3:02 P.M. revealed Resident #5 was lying in bed with her call light activated. Resident #5 had a white washcloth covering her upper chest and cleavage area and a white sheet covering her stomach and lower extremities. Resident #5 appeared visibly upset and stated she had been waiting for 2 hours for someone to assist her with getting dressed. Resident #5 revealed she received a bed bath and was awaiting assistance with her dressing change so she could finish getting dressed. At the time of Resident #5's interview, Certified Nurse Assistant (CNA) #837 entered the room and informed Resident #5 that Licensed Practical Nurse (LPN) #883 told her to let Resident #5 know she would be in soon. CNA #837 revealed LPN #883 was passing medications to other residents and she did not know how much longer she would be waiting. CNA #837 apologized to Resident #5 for the long wait and stated, I know you're waiting to get dressed and don't want to put the shirt on due to the dressing change.Observation and interview on 09/02/25 at 3:14 P.M. revealed LPN #883 passing medications. LPN #883, upon seeing the state surveyor approaching, stated I'm already aware that Resident #5 is waiting for her tube feed tube to be replaced and dressing change. She doesn't like getting dressed until after her dressing change so that she doesn't have to keep getting dressed and undressed. Resident #5 will have to wait until I finish passing medications. She has only been waiting 40 minutes, and I still have 3 residents to go. I will get to her when I am done with the medication pass. Her tube came out during her bed bath, and she doesn't want to get dressed until the tube is replaced. LPN #883 confirmed and verified Resident #5 needed assistance and she had been waiting at least 40 minutes. Observation and interview on 09/03/25 at 7:45 A.M. revealed Resident #5's call light was activated. Registered Nurse (RN) #845 was observed near Resident #5 room with the medication cart. RN #845 began to push the medication cart in the opposite direction of Resident #5 room to continue medication pass and did not answer the call light. The state surveyor entered Resident #5's room and Resident #5 stated she wanted something to drink. Upon state surveyor exiting Resident #5 room, RN #845 asked state surveyor What does she want?! I'll go in there in a minute. RN #845 confirmed and verified she did not answer Resident #5 call light, and all staff were responsible to answer call lights once activated. Interview on 09/03/25 at 3:45 P.M. with the Director of Nursing (DON) revealed all facility staff were to answer call lights and assist residents as needed. DON revealed Resident #5's bed bath and dressing change should have been scheduled concurrently to ensure Resident #5's preference in wanting to be dressed and not waiting long period of times in between bed bath and dressing change were honored. The DON revealed there were 5 CNA's, 3 nurses, and a unit manager on the unit that could have assisted Resident #5 to ensure timely care and assistance was provided. Review of the facility document titled Call Lights: Accessibility and Timely Response undated, revealed the facility had a policy in place that indicated all staff members were responsible for responding to call lights if they see or hear an activated call light. Review of the document revealed the facility did not implement the policy. This deficiency represents noncompliance investigated under Complaint Number 2584278.

Based on resident record review, staff interview, facility Self-Reported Incident (SRI) review, and facility policy review, the facility failed to ensure Resident #67 was not inappropriately restrained during resident care tasks. This affected one resident (#67) of one reviewed for physical restraints. The facility census was 67.Findings include: Review of the medical record for Resident #67 revealed he was admitted to the facility on [DATE] with diagnoses that included diffuse traumatic brain injury with loss of consciousness, carrier of carbapenem-resistant Acinetobacter baumannii (a multi-drug resistant organism), and chronic respiratory failure with hypoxia. Review of the care plan initiated 09/17/24 revealed Resident #67's daughter was his guardian. Resident #67 had an electronic monitoring device in use in his room, and required assistance from staff with interventions that included to assist as needed, approach the resident in a calm and gentle state, and ensure a safe environment. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #67 had a short- and long-term memory problem, severely impaired cognition regarding tasks of daily life, impairment to both upper and lower bilateral extremities, and was dependent on staff for activities of daily living (ADLs).Review of the physician orders dated 11/26/24 revealed an order to suction oropharyngeal and tracheal as needed and every shift.Review of the progress note dated 01/31/25 at 11:53 A.M. revealed Resident #67 was combative throughout the shift with care. Review of the progress note revealed tracheostomy care was provided. Review of the progress note dated 02/02/25 at 4:37 P.M. revealed Resident #67 was somewhat combative during tracheostomy care. Review of the progress note dated 02/18/25 at 5:47 P.M. revealed Resident #67 tolerated suctioning and routine respiratory care well but was very combative. Review of the progress note dated 02/21/25 at 9:33 A.M. revealed Resident #67 tracheostomy tube was changed and replaced without any distress. Resident #67 was fighting but Resident #67 daughter held and calmed him down. Review of the progress note dated 02/24/25 at 1:55 P.M. revealed Resident #67 was very combative during suctioning. Review of the progress note dated 02/26/25 at 11:36 A.M. revealed Resident #67 was very combative during tracheostomy care and suctioning, and tracheostomy gauze was unable to be placed.Review of the progress note dated 02/27/25 at 3:49 P.M. revealed Resident #67 was extremely combative with care. Resident #67's daughter was in the room trying to hold him down, but he kept grabbing at the tubing for suction and swinging at Respiratory Therapist (RT).Review of the progress note dated 02/27/25 at 9:00 P.M. revealed Resident #67 had a head-to-toe skin assessment, and a bruise was noted to the back of his left hand related to recent blood draw. Review of the progress note dated 02/28/25 at 2:03 A.M. revealed Resident #67 was combative and a second RT came in to assist with respiratory care. Review of the progress note dated 02/28/25 at 3:56 P.M. revealed Social Service Designee (SSD) #850, the Administrator, and the Director of Nursing (DON) met with Resident #67's daughter related to an incident with a staff member regarding Resident #67 receiving inappropriate care. Review of the progress note revealed the incident was reviewed and Resident #67's daughter was given time to process and vent her frustrations. Review of the SRI #257691 revealed on 02/27/25 at 9:00 P.M., the Administrator received a report of abuse occurring on the night shift during shift change and that resulted in Resident #67 being immediately assessed. Continued review of the SRI revealed a head-to-toe assessment was completed resulting in a bruise noted to the back of Resident #67 left hand that was ruled out as being caused by a recent blood draw. Resident #67 had no signs of pain and/or discomfort to her hand. Resident #67's daughter was at the bedside during the incident. Review of the SRI revealed RT #500 was placed on suspension pending investigation, abuse educations in-services were initiated for all staff, and additional head-to-toe assessments were completed for additional residents. Review of the SRI revealed Resident #67's daughter was contacted and stated she was at the bedside at the time RT #500 entered the room without knocking or identifying herself before providing care. Resident #67 became combative by swinging his arms towards RT #500, when RT #500 abruptly used her knee to hold down Resident #67 hand. Resident #67's daughter revealed she offered to assist RT #500 during tracheostomy care and RT #500 knee was immediately removed and care was provided. Review of the witness statement written by RT #854 dated 02/27/25 revealed during report RT #500 stated Resident #67 was combative during tracheostomy care and she had to place her knee on his arm to restrain it, and while suctioning, Resident #67 grabbed the suction catheter. RT #500 then stated she had to bend Resident #67 finger back to get him to release it. RT #500 then stated Resident #67 daughter was at the bedside and asked RT #500 please don't bend my father's finger back and to not place her knee on her father's arm. RT #500 reported Resident #67's daughter was willing to assist RT #500 in holding Resident #67's arm. RT #500 then told Resident #67's daughter that she had a job to do and she wasn't going to get hit. Review of the witness statement written by RT #856 dated 02/27/25 revealed during 7:00 P.M. report, RT #500 stated she was at Resident #67's bedside to suction him and Resident #67's daughter was also in the room. RT #500 stated Resident #67 became combative and she placed her knee on his arm to hold it down when Resident #67's daughter told her not to do that and offered to help her hold him down. RT #500 then told Resident #67 daughter she was not going to get hit and she was doing her job. R T #500 then stated Resident #67 daughter was not holding Resident #67 arm and he grabbed the suction catheter when RT #500 bent Resident #67's finger back to get him to release his grip. Resident #67's daughter told RT #500 to not bend Resident #67's finger back, when RT #500 stated she was doing her job, Resident #67 was always like that, and she would do what she had to do. Review of the witness statement written by SSD #850 dated 02/27/25 revealed SSD #850 was notified by RT #854 and RT #856 that during the night shift report, RT #500 revealed she held down Resident #67 and pulled his finger back while suctioning him. SSD #850 immediately alerted the Administrator, the Director of Nursing (DON) and the Assistant DON #894. SSD #850, who previously worked as a Registered Nurse (RN), assessed and interviewed Resident #67 and multiple additional residents with no issues noted to any body part. Review of the personnel file for RT #500 revealed a notice and termination given on 02/28/25 for being discharged for unsafe work conduct, procedures, habits, practices and/or methods. Review of RT #500 Department of Unemployment Insurance Operations document titled Request to Employer for Separation Information revealed RT #500 was discharged from work for an allegation of abuse by physically restraining patient on 02/27/25 due to zero tolerance of abuse or physical restraints. Interview on 09/03/25 at 4:27 P.M. with the Administrator revealed RT #500 held Resident #67 down with her knee while performing care due to him being combative. The Administrator revealed all abuse policies and protocols were initiated immediately with RT #500 being suspended pending investigation, staff educated, and like-residents interviewed and assessed. The Administrator revealed Resident #67 daughter was upset, crying, and in a state of disbelief. The Administrator revealed RT #500 was subsequently terminated as a result of the incident. Review of the facility document titled Restraint Free Environment, undated, revealed the facility had a policy in place that each resident shall attain and maintain a practical well-being in an environment that prohibits the use of physical restraints for discipline or convenience such as holding down a resident in response to a behavioral symptom or during the provision of care if the resident is resistive or refusing care.

Based on observation, resident record review, staff interview, and family interview, the facility failed to ensure mouth care was provided for a dependent resident. This affected one resident (#21) of one reviewed for mouth care. The facility census was 67. Findings include: Review of the medical record for Resident #21 revealed he was admitted to the facility on [DATE] with diagnoses that included anoxic brain damage, chronic respiratory failure with hypoxia, and cerebral infarction. Review of the medical record revealed Resident #21 had a guardian in place. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had a short- and long-term memory problem, severely impaired regarding tasks of daily life, impaired on both side upper and lower extremities, and was dependent on staff for activities of daily living (ADLs). Review of the care plan dated 08/06/25 revealed Resident #21 had an electronic monitoring device in use in his room and required assistance from staff for ADLs. Interventions included encouraging ongoing family support and providing assistance with ADLs. Observation on 09/02/25 at 8:53 A.M. Resident #21 laying in bed with dry, cracked, and peeling lips. Interview on 09/02/25 at 10:22 A.M. with Resident #21's guardian revealed Resident #21's lips were always dry, and she had to constantly tell facility staff to keep his lips moisturized. Resident #21's guardian revealed dry, cracked, and peeling lips would hurt if it built up. Observation on 09/02/25 at 3:08 P.M. revealed Resident #21 was in his room, up in a chair, and his lips appeared dry, cracked, and peeling. Interview on 09/02/25 at 3:12 P.M. with Certified Nurse Assistant (CNA) #837 revealed Resident #21 was assigned to another staff member and was not aware of the last time he received mouth care. CNA #837 revealed Resident #21 moved his head from side to side but that did not interfere with providing mouth care. CNA #837 confirmed and verified Resident #21's dry, cracked, and peeling lips.

Based on observations, resident record review, staff interviews, family interview, and facility policy review, the facility failed to ensure orders for splints were obtained per guardian preference for Resident #21, who was known to have bilateral upper extremity contractures. This affected one resident (#21) of one reviewed for positioning and mobility. The facility census was 67. Findings include: Review of the medical record for Resident #21 revealed he was admitted to the facility on [DATE] with diagnoses that included anoxic brain damage, chronic respiratory failure with hypoxia, and cerebral infarction. Review of the medical record revealed Resident #21 had a guardian in place.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had a short- and long-term memory problem, severely impaired regarding tasks of daily life, impaired on both side upper and lower extremities, and was dependent on staff for activities of daily living (ADLs).Review of the care plan dated 08/06/25 revealed Resident #21 had an electronic monitoring device in use in his room, had the potential for pain related to contractures with interventions that included, but not limited to, required assistance from staff for ADLs and encourage ongoing family support.Review of the physician orders revealed an order initiated on 12/23/23 and discontinued on 05/08/24 for Resident #21 to wear bilateral dorsiflexion assist splints up to 6 hours as tolerated and remove for hygiene.Review of the physician orders revealed an order initiated on 09/18/24 and discontinued on 01/06/25 for Resident #21 to admit to restorative services for splinting bilateral hands, Pressure Relief Ankle Foot Orthosis (PRAFO) boots (used to relieve pressure on the heel and aid in positioning) and bilateral and range of motion (ROM). Resident #21 had an additional order initiated on 01/09/25 for a referral to restorative services for ROM and splinting which was discontinued on 02/27/25. Review of Resident #21's current physician orders revealed no active orders for splints.Review of the assessment titled Skilled Note dated 09/01/25 and 09/02/25 revealed Resident #21 required bilateral upper extremity splinting.Observation on 09/02/25 at 8:53 A.M. revealed Resident #21 lying in bed with both hands contracted. Resident #21 had a white cloth rolled up in the palm of his left hand. Observation revealed, on the wall adjacent to the foot of the bed, a sign that read Resting hand roll splint on bilateral hands for 6 hours per day, fit 2 fingers between strap and arm/hand, skin check and hand hygiene before donning and after doffing, and left upper extremity in neutral and keep in sight (not under blankets) while wearing splint.Interview on 09/02/25 at 8:55 A.M. with Licensed Practical Nurse (LPN) #873 revealed the therapy department was responsible for maintaining ROM and splinting for Resident #21. LPN #873 revealed the therapy department placed splints on residents and was not sure why Resident #21 had one towel in his left hand. LPN #873 revealed staff were to follow instructions based on the sign on his wall. LPN #873 confirmed and verified Resident #21 was lying in bed without splints in place.Interview and observation on 09/02/25 at 9:05 A.M. with Therapy Director (TD) #890 revealed a white cloth/towel rolled up in Resident #21's left hand. TD #890 revealed the cloth/towel was possibly placed in Resident #21 hand due to staff cleaning him up and soaking up moisture in his hand. Follow-up interview on 09/02/25 at 9:28 A.M. with TD #890 revealed the signs posted in Resident #21 room were signs provided by Resident #21's guardian. TD #890 revealed the signs were not provided by the facility and not followed by facility staff. TD #890 confirmed and verified Resident #21 had bilateral contractures in his hands, the resident's guardian had preferences for splints to be applied per the sign on the wall, and that Resident #21 previously had orders for splints.Interview on 09/02/25 at 10:22 A.M. with Resident #21's guardian revealed there was a camera in the room that she utilized for monitoring to ensure Resident #21 received adequate care. Resident #21's guardian revealed Resident #21 had contractures in both his left and right hands and splints were supposed to be in place. Resident #21's guardian stated Regardless of Resident #21's current state, mentally and physically, he should still be properly cared for. Resident #21's guardian revealed every time she visited or checked the camera's; the bilateral hand splints were not in place as she wished and preferred, to prevent Resident #21 hands from contracting further. Interview on 09/02/25 at 3:12 P.M. with Certified Nurse Assistant (CNA) #837 revealed Resident #21 was not alert and oriented and was dependent on staff for all his care. CNA #837 revealed Resident #21 was contracted in both hands and the therapy department was responsible for putting splints in place. CNA #837 revealed she was aware of Resident #21's guardian request for splints via the sign on the wall, but she had never seen the splints in place. CNA #837 revealed the cloth in Resident #21 hand was not for moisture because if that were the case, both hands would have the cloths in place. CNA #837 confirmed and verified Resident #21's bilateral contractures of the hand, sign requesting splints, and splints not in place. Follow-up interview on 09/02/25 at 4:08 P.M. with TD #890 revealed the facility followed physician orders when it came to residents requiring splints. TD #890 revealed Resident #21 was not currently wearing any splints and he was not sure why. TD #890 revealed the sign on wall were Resident #21 guardian's preference. TD #890 revealed there were no current orders in place. TD #890 also revealed Resident #21's guardian could visit the facility and put the splints on Resident #21, but the facility would remove them and not put them back on. TD #890 revealed the facility purchased the splints and kept them in a bin in resident rooms and whether it was a preference or not, the facility removed them if there weren't any orders in place.Interview on 09/03/25 at 3:45 P.M. with the Director of Nursing (DON) confirmed and verified Resident #21 did not have an order for splints and staff were not putting splints on per guardian's request.Review of the facility document titled Care Planning-Resident Participation undated, revealed the facility had a policy in place that the facility would encourage and assist the resident and/or resident representative to participate in choosing care and treatment options including initial decisions about treatment, decisions about changes and the right to refuse treatment. Review of the document revealed the facility did not implement the policy.

Based on observation, interview and policy review the facility failed to ensure staff performed hand hygiene and followed infection control practices when handling soiled linen to prevent cross contamination of germs during Resident #23's tracheostomy care and suctioning procedure. This affected one out of three residents reviewed for tracheostomy care. The facility census was 58. Findings include: Clinical record review revealed Resident #23 was admitted on [DATE] with diagnoses including traumatic brain injury , stroke, high blood pressure, anemia, gastroesophageal reflux disease, kidney disease, hyperlipidemia, depression, and respiratory failure with a tracheostomy. An observation on 03/05/24 at 9:50 A.M. of Respiratory Therapist (RT) #70 perform Resident #23's tracheostomy care and suctioning revealed a concern with performing hand hygiene and following infection control practices. RT #70 gathered the supplies for suctioning the secretions from Resident #23's tracheostomy tube. RT #70 opened the suctioning kit and donned a pair of sterile gloves and proceeded to use the suction catheter to suction Resident #23's secretions via her tracheostomy tube. When RT #70 completed the suctioning task, he wrapped the soiled suction catheter inside his glove and discarded the glove with the catheter in the waste receptacle. RT #70 removed the glove from his other hand and discarded the glove in the waste receptacle. RT #70 did not perform hand hygiene and donned a pair of disposable gloves and then removed them. RT #70 did not perform hand hygiene. RT #70 then exited the room to obtain supplies needed to perform Resident #23's tracheostomy care from the supply cart located in the hallway. RT #70 entered Resident #23's room and donned another pair of gloves and proceeded to perform Resident #23's tracheotomy care. During the tracheostomy care RT #70 noted a wound was present under Resident #23's tracheostomy collar. RT #70 removed the wound dressing (calcium alginate) and obtained a pair of scissors from his shirt pocket and cut the calcium alginate dressing and then placed the scissors back in his shirt pocket without sanitizing/disinfecting the scissors before or after he used the scissors. RT #70 proceeded to apply the calcium alginate to the wound and covered the wound with a split gauze dressing. RT #70 removed the inner tracheostomy cannula and discarded the cannula. RT #70 removed an inner cannula from the packaging and placed the inner cannula inside Resident #23's tracheostomy tube. RT #70 reapplied Resident #23's oxygen mask covering the tracheostomy. RT #70 then removed a towel located under Resident #23's tracheostomy collar soiled with secretions and placed the soiled towel on the floor by the doorway to Resident #23's room. RT #70 used the same gloved hands and touched his cellular phone, pulse oxygenation probe, and television. RT #70 removed his soiled gloves and did not perform hand hygiene and exited Resident #23's room. RT #70 documented Resident #23's tracheostomy care and suctioning procedure in Resident #23's electronic record. RT #70 then gathered supplies to administer Resident #6's respiratory treatment via her tracheostomy tube. RT #70 entered Resident #6's room and donned a pair of disposable gloves. RT #70 was stopped and asked to perform hand hygiene before proceeding to administer Resident #6's respiratory treatment. An interview with RT #70 on 03/05/24 at 10:20 A.M. verified the above findings and confirmed he failed to maintain infection control practices during Resident #23's tracheostomy care and suctioning procedure. Review of the facility policy titled Hand Hygiene dated 2023 indicated staff would perform hand hygiene procedures to prevent the spread of infections to other personnel, residents and visitors. Hand hygiene was a general term for cleaning hands by handwashing using soap and water or the use of an antiseptic hand rub (alcohol-based hand rub). The facility policy titled Tracheostomy Care dated 2023 indicated the procedure with use of a disposable inner cannula. The procedure included: - Verify the inner cannula is disposable, Verify the correct size. - Explain the procedure to the resident and screen for privacy. - Perform hand hygiene and put on a clean gloves. - Slowly remove the inner cannula from the tracheostomy tube by squeezing the tabs on the connector until both snaps clear the ridged lock on the outer cannula. - Dispose the removed cannula. - Pick up the new inner cannula, touching only the outer locking portion. Insert the and lock the inner cannula into position. - Change the tracheostomy ties/tube holder when soiled or wet. Replace dressing using manufactured split dressing with flaps pointing upward. - Discard gloves and perform hand hygiene. - Make sue oxygen is administered as ordered. - Document the procedure and report any signs/symptoms of infection to the physician. This deficiency represents non-compliance investigated under Complaint Number OH00150890.

Based on record review and interview the facility failed to ensure a plan of care meeting was provided quarterly for Resident #25 and Resident #16. This affected two out of three residents reviewed for participation in their plan of care. The facility census wa 58. Findings include: Clinical record review revealed Resident #25 was admitted on [DATE] with diagnoses including traumatic brain injury, chronic respiratory failure with hypoxia, tracheostomy, intracranial abscess, cerebral infarction, occlusion/stenosis of right middle cerebral artery, epilepsy, encephalopathy, disorder of autonomic nervous system, hearing loss, dementia with agitation, mood disorder, depression, contracture of the right knee and left hand, cognitive communication deficit, and gastronomy tube with tube feedings. Further review of Resident #25's clinical record revealed one plan of care meeting was provided on 04/23/23 during the last 12 months. There was no documentation a plan of care meeting was provided during the first, third and fourth quarter of 2023. Clinical record review revealed Resident #16 was admitted on [DATE] with diagnoses including Parkinson's disease, morbid obesity, left artificial knee joint, high blood pressure, hypothyroidism, anxiety, psychotic disorder with hallucinations, depression, blepharitis (inflammation of the eyelids), lymphedema, sleep disorder, vitamin D deficiency, gastroesophageal disorder, abnormal posture, and osteoporosis. Further review of Resident #16's clinical record revealed the facility had not provided a plan of care meeting during the first, third and fourth quarter of 2023. Resident #16's clinical record indicated a plan of care meeting was held on 04/18/23 and 02/06/24 during the last 12 months. An interview with Licensed Social Worker #73 on 03/05/24 at 11:24 A.M. verified the plan of care meetings were not provided as required.

Based on record review and interview the facility failed to accurately document an incident of maggots in Resident #42's tracheostomy in the medical record. This affected one resident (#42) out of three residents reviewed for tracheostomy care. The facility census was 58. Findings include: Review of the medical record for the Resident #42 revealed an admitted [DATE] and a readmitted [DATE]. Diagnoses included end stage renal disease, dependence on respirator, epilepsy, major depressive disorder, glomerular disease in systemic lupus, dependence on renal dialysis, and cerebral infarction. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 had moderately impaired cognition. The resident required extensive assistance with two staff for mobility, total dependence of two staff for transfers, extensive assistance of one staff for personal hygiene, and supervision with set-up help only for eating. Review of the physician's order for August 2023 revealed Resident #42 had an order for tracheostomy care every shift. Interview on 08/21/23 at 9:34 A.M. with the Director of Nursing (DON) revealed that on 07/27/23 at 6:30 P.M. she received a call from Licensed Practical Nurse (LPN) #212 said there was a maggot on Resident #42's tracheostomy and one on the bedside table. LPN #212 got Respiratory Therapist (RT) #209 to provide tracheostomy care. Resident #42 would only let RT #209 change out her split sponge and briefly suction. LPN #212 contacted the Nurse Practitioner and Respiratory Pulmonary Nurse Practitioner (RPNP) #210. RPNP #210 stated that she would be in the next day and change out the tracheostomy. On the morning of 07/28/23, Wound Doctor #213 came in and stated that he saw no maggots. The DON stated that she did a soft file on the maggots; there was no documentation regarding the maggots in Resident #42's medical record. RPNP #210 came in the next day, changed the tracheostomy and there were no signs of maggots. RPNP #210 did education with Resident #42 and attempted to call the resident's mother and mother hung up on RPNP #210. The DON stated that there were no issues with maggots since. Phone interview on 08/21/23 at 3:07 P.M. with RT #209 revealed that she was an as needed (PRN) RT and earlier that day Resident #42 refused to be suctioned and would only let her change the split pad. If she remembers correctly, Resident #42 was combative, and there was a bug on the tray table, but she could not identify it. Phone interview on 08/21/23 at 3:25 P.M. with RPNP #210 revealed that she did not see maggots. She changed the tracheostomy and spoke to LPN #212 about the maggots. Review of the medical record revealed it was silent to the concerns of maggots in Resident #42's tracheostomy. This deficiency is an incidental finding discovered during the investigation of Complaint Number OH00145628.

Based on observation, interview, record review and review of facility policy, the facility failed to maintain appropriate hand hygiene during the tracheostomy care for Resident #42. This affected one resident (#42) out of three residents reviewed for tracheostomy care. This had to potential to affect 18 additional residents (#2, #7, #9, #10, #12, #14, #15, #20, #23, #24, #25, #26, #29, #39, #40, #43, #59, and #60) who had tracheostomies residing in the facility. The facility census was 58. Findings include: Review of the medical record for the Resident #42 revealed an admitted [DATE] and a readmitted [DATE]. Diagnoses included end stage renal disease, dependence on respirator, epilepsy, major depressive disorder, glomerular disease in systemic lupus, dependence on renal dialysis, and cerebral infarction. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 had moderately impaired cognition. The resident required extensive assistance with two staff for mobility, total dependence of two staff for transfers, extensive assistance of one staff for personal hygiene, and supervision with set-up help only for eating. Review of the physician's order for August 2023 revealed Resident #42 had an order for tracheostomy care every shift. Observation of tracheostomy care on 08/21/23 at 12:00 P.M. with Respiratory Therapist (RT) #201 revealed RT #201 had to get a bedside table from across the hall. RT #201 wiped it down and washed his hands and brought the bedside table to Resident #42's room. RT #201 pulled a set of gloves out of his pocket, donned the gloves, and proceeded to put on a barrier on the table. He took out the old disposable cannula from Resident #42's tracheostomy and washed the area with the items provided in the kit. RT #201 then put the gloves that were in the kit over the same soiled gloves that he took the old cannula out and proceeded to put the new cannula in and applying a new split sponge around the tracheostomy. RT #201 did not need to suction Resident #42. RT #201 verified that he did not take off the soiled gloves that he removed the old cannula with and did not perform hand hygiene or prior to donning new gloves. He stated it was practice to just put on the new gloves over the first pair of soiled gloves. Review of the undated facility policy titled Hand Hygiene revealed that if a task requires gloves, perform hand hygiene prior to donning gloves. This deficiency was an incidental finding discovered during the investigation of Complaint Number OH00145628.

Based on record review and staff interview, the facility failed to check all potential new hires against the State Nurse Aide Registry (NAR) to ensure no employee had a finding entered into the State NAR concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property. This affected all non-STNA (state tested nursing aide) staff who were hired by the facility in the past year, including: seven registered nurses, 11 licensed practical nurses (LPN), 10 dietary workers, six housekeeping staff, two administration workers, one social services staff member and one activities professional. This had the potential to affect all 64 residents admitted to the facility at the time of the survey. Findings include: Interview with Human Resources Director #901 on 09/05/19 at 10:53 A.M. revealed the facility only checked newly hired nursing aides in the State NAR. Other staff members did not receive NAR checks. Review of a list of new hires in the past year (since 08/16/18) revealed the facility hired seven registered nurses, 11 licensed practical nurses, 10 dietary workers, six housekeeping staff, two administration workers, one social services staff member and one activities professional within the past year. Record review of seven employee files (State Tested Nurse Aides (STNA) #401, #402, #403, LPNs #404, #405, Administrator, and Social Service Director #407) revealed no evidence non-STNA staff were checked in the State NAR for concerns related to abuse or other mistreatment of residents.

Based on record review and staff interview, the facility failed to check all potential new hires against the State Nurse Aide Registry (NAR) to ensure no employee had a finding entered into the State NAR concerning abuse, neglect, exploitation, mistreatment of [REDACTED]. This affected all non-STNA (state tested nursing aide) staff who were hired by the facility in the past year, including: seven registered nurses, 11 licensed practical nurses (LPN), 10 dietary workers, six housekeeping staff, two administration workers, one social services staff member and one activities professional. This had the potential to affect all 64 residents admitted to the facility at the time of the survey. Findings include: Interview with Human Resources Director #901 on 09/05/19 at 10:53 [NAME]M. revealed the facility only checked newly hired nursing aides in the State NAR. Other staff members did not receive NAR checks. Review of a list of new hires in the past year (since 08/16/18) revealed the facility hired seven registered nurses, 11 licensed practical nurses, 10 dietary workers, six housekeeping staff, two administration workers, one social services staff member and one activities professional within the past year. Record review of seven employee files (State tested Nurse Aides (STNA) #401, #402, #403, LPNs #404, #405, Administrator, and Social Service Director #407) revealed no evidence non-STNA staff were checked in the State NAR for concerns related to abuse or other mistreatment of [REDACTED].

Based on observation, record review and interview, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner, and food products were covered properly and dated when opened. This had the potential to affect 64 out of 64 residents who ate meals prepared in the facility's kitchen. Findings include: Observations during the initial tour of the kitchen on 09/03/19 from 8:12 [NAME]M. through 8:49 [NAME]M. with Dietary Manager (DM) #44 revealed food residue and crumbs located on the bottom of the steamer and bottom shelf of the steamtable, crab cakes and hamburgers were not labeled and dated in the walk-in freezer, sliced salami and shredded cheese was not labeled or dated in the walk-in refrigerator and dried grease drippings were on the steamtable near the knobs. Interview with DM #10 on 09/04/19 at 9:003 [NAME]M. verified the observations above and he said has been employed at the facility for two weeks, the kitchen could be cleaner, but he has been working on training the staff. Review of posted work cleaning schedules revealed that all work surfaces would be cleaned daily.

Based on interview and record review, the facility failed to ensure that resident food preferences were honored. This affected five residents (#7, #13, #15, #53, and #56) of 64 residents that take food by mouth. Findings include: 1. Review of resident's medical record revealed Resident #7 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident # 7's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was moderately cognitively impaired and required extensive assistance with two people for most Activities of Daily Living (ADLs) except eating is supervision with set up only. Further review of Resident #7's medical record revealed that she had a weight loss and was receiving nutritional supplements to promote extra calories which resulted in a weight gain. Her body mass index (BMI) was 17.5 which indicates underweight for her height and weight. 2. Review of resident's medical record revealed Resident #15 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident # 15's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was moderately cognitively impaired and required extensive assistance with one person for most Activities of Daily Living (ADLs) except eating is limited assistance with one person. Further review of Resident #15's medical record revealed that he had a weight loss and was receiving nutritional supplements to promote extra calories which resulted in a weight gain. 3. Review of resident's medical record revealed Resident #56 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident # 56's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition and required supervision without set up for most Activities of Daily Living (ADLs) except eating is supervision with set up. Further review of Resident #56's medical record revealed that he had a weight loss and was receiving nutritional supplements to promote extra calories which resulted in a weight gain. Interviews on 09/03/19 between 9:36 [NAME]M. through 4:39 P.M. with Residents #7, #13, #15, #53 and #56 revealed the facility did not honor food preferences. Residents #7, #15 and #56 stated that they do not get enough food to eat. Phone interview with Registered Dietitian (RD) #99 with Dietary Manager (DM) #44 and Administrator #101 present on 09/05/19 at 9:32 [NAME]M. revealed Dietary Manager (DM) #44 usually obtains food preferences and the RD #99 only speaks to residents upon admission. The software program got changed recently and lost all the residents food preferences but started obtaining preferences last week and still need to be put in the system. Review of the undated policy and procedure titled liberalized geriatric diet indicated personal food preferences would be addressed on an individualized basis and assessment however, there was no evidence resident food preferences were obtained on the quarterly or annual nutritional assessments.

Based on observation and interview the facility failed to maintain the environment in a clean and sanitary manner. This affected Residents #20, #7, #39, #23, #13, #22, #37, #64 and #4. The facility census was 64. Findings include: 1. Observations during the initial tour of the facility and screening of residents for the annual survey on 09/02/19 from 8:17 [NAME]M. to 11:37 [NAME]M. revealed the following: Resident #20's ceiling had mold on the bathroom ceiling and paint was peeling on the wall in his room. This was verified at the time of observation on 09/02/19 at 9:31 [NAME]M. by Maintenance Assistant #85. Resident #7's carpet was stained and near the window, there was dried food stain on the carpet. This was verified at the time of observation by Housekeeper #54 on 09/02/19 at 9:35 [NAME]M. Resident #39's ceiling had mold on the bathroom ceiling. This was verified at the time of observation on 09/02/19 at 9:36 [NAME]M. by Director of Nursing #100. Resident #23's ceiling paint was peeling and holes in the wall in his room. This was verified at the time of observation on 09/02/19 at 11:04 [NAME]M. by Director of Nursing #100. Interview on 09/03/19 at 2:30 P.M. with the Director of Maintenance and Housekeeping # 84 revealed the facility has plans to change the carpeting in residents' rooms. They started with assisted living and the dining room on the first floor. Resident rooms are cleaned daily Review of policy entitled, Routine Cleaning dated (YEAR) revealed that rooms should be cleaned routinely. 2. Observation on 09/03/19 between 9:00 [NAME]M. and 11:30 [NAME]M. revealed the second-floor hallway had large, black stains in the carpeting throughout the hall. Resident ' s #13, #22, #37 and #64 had light beige carpeting with large black stains throughout. Resident #4 had a hole that broke through the drywall approximately 5 long and 4 inches wide. Interview on 09/03/19 with Resident #4 and Resident's #4's family member at 11:37 [NAME] M. revealed the hole in the wall had been there for several months. Interview on 09/04/19 with Licensed Practical Nurse (LPN) #78 at 4:15 P.M. verified the findings. 3. The second floor dining room was observed on 09/03/19 at 12:05 P.M. State tested Nurse Aide #14 verified the windows were covered with a moderate amount of debris making it difficult to look outside. The two portable air-conditioning units vents and extending hose were heavily soiled with dust, lint and food debris. The Speech Therapist #103 was observed to move a chair out of service saying it was too wobbly and chose another chair to sit on. The steam table was observed to be soiled with dried food drips and food debris on the sides and heavier at the bottom. The castors were heavily soiled with dirt, debris and gunk. Dietary Aide #49 was observed pulling out a tray to set a plate on and the tray was soiled with loose dried food debris. Interview with State tested Nurse Aide #14 on 09/03/19 at 12:29 P.M. verified the condition of the above items.

Based on observation, record review and interview, the facility failed to ensure a dignified dining experience for residents that ate in the first and second floor dining rooms by serving dessert in a sandwich bag instead of on a plate. In addition State tested Nursing Assistants (STNAs) served meals to the residents by trays switching from table to table with not all residents served by table. This affected 22 residents that ate in the dining rooms (Resident's #12, #14, #16, #19, #24, #27, #36, #39, #44, #52, #56 and #60 were in the first floor dining room; Resident's #1, #3, #5, #9, #10, #32, #37, #42, #50 and #65 were in the second floor dining room). Findings include: 1. Observations during meal service for lunch on 09/03/19 from 12:00 P.M. through 12:30 P.M. revealed that Resident's #12, #14, #16, #19, #24, #27, #36, #39, #44, #52, #56 and #60 were served cake portioned out into sandwich bags instead of a china plate. This was verified by the Director of Nursing #100 at 12:16 P.M. Interview on 09/03/19 at 12:35 P.M. with the Administrator #101 and Dining Manager #44 revealed the diet aide did plain cake instead of strawberry shortcake because the strawberries were bad. She should not have put the cake into a sandwich bag. Observations during the meal service for lunch on 09/03/19 beginning at 12:16 P.M. revealed Resident's #1, #3, #5, #9, #10, #32, #37, #42, #50 and #65 were served cake portioned out into sandwich bags instead of a china plate. Interview with State tested Nurse Aide #14 on 09/03/19 at 12:29 P.M. verified the residents were served a plain piece of cake in a plastic sandwich bag instead of on a plate. 2. Observations during meal service for dinner in the first floor dining room on 09/03/19 from 5:37 P.M. through 6:00 P.M. revealed that residents were served by STNA #16 switching from table to table with not all residents served by table. This was verified by STNA #16 at 5:50 P.M. Interview on 09/03/19 at 5:50 P.M. with STNA #16 revealed that she did not know the residents that well and when she mistakenly gave Resident #12's tray to Resident #60, the rest of the dining room was not in order. Review of Resident #12 and Resident #60's tray tickets revealed that both were on regular consistency diets. Interview with Administrator on 09/03/19 at 6:20 P.M. revealed that STNA #16 did not know the residents well and verified that STNA should have asked the residents their name and served the residents table by table.

Based on observation, record review, interview and policy review, the facility failed to ensure oxygen concentrators were maintained in a clean and sanitary condition. This affected two residents (Residents #21 and #53) of four residents identified with oxygen concentrators in the facility. Findings include: Review of the medical record revealed Resident #21 was admitted to the facility on [DATE] with diagnoses including acute and chronic respiratory failure, pneumonia and congestive heart failure. Review of the comprehensive assessment (MDS 3.0) dated 06/08/19 indicated he used oxygen. Review of the plan of care indicated he had oxygen therapy related to respiratory failure and congestive heart failure. On 09/03/19 at 11:50 A.M. Resident #21 was observed seated in his wheelchair using oxygen via a concentrator and nasal cannula. The back of the oxygen concentrator had a black removable filter that was thick with white dust. On 09/04/19 at 11:55 A.M., during interview, State Tested Nurse Aide (STNA) #17 verified the condition of the filter as dirty. On 09/04/19 at 1:37 P.M. Licensed Practical Nurse (LPN) #74 verified Resident #21's filter was dirty. She was not aware of who was responsible for cleaning the vents or filters. 2. On 09/04/19 at 2:11 P.M., with the director of nursing observation and interview revealed the vent on Resident #53's oxygen concentrator was observed to have thick brown dust. Interview with the director of nursing on 09/04/19 at 2:11 P.M. said it was the responsibility of the Hospice company or the oxygen company to clean them. Review of oxygen administration policy dated 07/01/18 indicated staff should perform hand hygiene and don gloves when administering oxygen or when in contact with oxygen equipment. Follow manufacturer recommendations for the frequency and cleaning equipment filters. Cleaning and care of equipment shall be in accordance with the facility policies for such equipment.

Based on observation, interviews and review of menus, the facility failed to provide meals that met daily nutritional needs. This affected 10 (#1, #3, #5, #9, #10, #32, #37, #42, #50 and #65) of 12 residents observed during the lunch meal on 09/03/19 beginning at 12:05 P.M. on the second floor dining room and Resident's #11, #18, #20, #41 and #56 who voiced concerns at the resident group meeting. The facility census was 64. Findings include: The menu posted for the lunch meal on 09/03/19 included beefsteak, buttery seasoned rice, glazed carrots, strawberry shortcake and a beverage of choice. At 12:16 P.M. the steam table arrived in the second floor dining room. Residents #1, #3, #5, #9, #10, #32, #37, #42, #50 and #65 received regular or ground meals. None of the 10 residents received a vegetable. An unfrosted piece of cake in a plastic baggy was given to the 10 residents. Interview with State tested Nurse Aide #14 on 09/03/19 at 12:29 P.M. verified the residents who received pureed meals received a green vegetable identified as zucchini, she verified the residents who were provided regular and ground diets did not receive a vegetable and verified the residents received a plain piece of cake. Interview with Dietary Aide #49 on 09/03/19 at 12:35 P.M. verified she forgot to bring up a pan of vegetables for the regular and ground diets. She said the pureed vegetable was zucchini. She verified residents just got plain cake and not strawberry shortcake as posted on the menu. Interview with the Dietary Manager #44 on 09/03/19 at 12:40 P.M. said the strawberries were spoiled and had to be thrown out. He did verify the facility did have canned strawberry that could have been substituted but was not. He said he also changed the menu to glazed carrots because he did not know they had zucchini in the walk-in refrigerator. During a group interview conducted on 09/04/19 at 10:13 [NAME]M., with Resident's #11, #18, #20, #41 and #56 present, reported not receiving a vegetable at the lunch meal on 09/03/19. They reported the menu was not always followed.

Based on observation, record review and interview, the facility failed to provide pressure ulcer prevention interventions for Resident #29. This resulted in Actual Harm when Resident #29's Stage Two pressure ulcer declined to a Stage Three pressure ulcer in the facility. This affected one resident (Resident #29) of three residents reviewed for pressure ulcer prevention. Findings Include: Review of the medical record for Resident #29 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the plan of care for Resident #29 dated 01/12/15 revealed the resident was at risk for impaired skin integrity with an intervention including to encourage implementation of pressure-relieving devices commensurate with degree of risk for skin. Review of an Minimum Data Set (MDS) 3.0 assessment dated [DATE] assessed Resident #29 as being at risk for developing pressure ulcers, and not having an pressure ulcers. The MDS 3.0 assessment dated [DATE] identified that skin treatments for Resident #29 included a turning and repositioning program. Review of an MDS 3.0 assessment dated [DATE] identified Resident #29 as being at risk for developing pressure ulcers and as having one Stage Two pressure ulcer. The MDS 3.0 assessment dated [DATE] identified skin treatments as a pressure reducing device for the chair and a turning and repositioning program, and assesed Resident #29 as requiring total dependence upon staff for bed mobility and transferring. Review of the plan of care for Resident #29 revealed the plan did not include to turn and reposition the resident every two hours. Review of progress notes and treatment records did not reveal documentation that the resident was turned and repositioned every two hours. Review of a skin/wound care management document dated 03/31/15, identified Resident #29 as having a Stage Two pressure ulcer to the sacrum measuring 2.2 centimeters (cm) long by 2.4 cm wide by 0.2 cm deep. The document identified current treatment as a pressure reducing device for the chair and a turning and repositioning program. Review of a skin/wound care management document dated 04/28/15 identified Resident #29 as having a Stage Three pressure ulcer to the sacral area measuring 2 cm long by 2.2 cm wide and 0.1 cm deep. Observation of Resident #29 on 05/06/15 at 6:20 A.M. revealed the resident was lying on his back in bed with the head of the bed elevated and knees raised. Observation of Resident #29 on 05/06/15 at 7:57 A.M. and at 8:31 A.M. revealed the resident was lying in the same position as previously observed with the resident lying on the back with the head of the bed elevated and knees raised. Interview with Licensed Practical Nurse (LPN) #104 on 05/06/15 at 8:35 A.M. stated she was assigned to Resident #29 that day. The nurse stated she came on shift at 7:00 A.M. and was told by the State tested Nurse Aide (STNA) that worked the previous shift, that the resident had just been provided with care but could not state if that included turning and repositioning. Interview with STNA #105 on 05/06/15 at 8:36 A.M. stated Resident #29 was assigned to the STNA and she arrived on her shift at approximately 7:45 A.M. She denied having turned and repositioned the resident since her arrival. Interview with Registered Nurse (RN) #106 on 05/06/15 at 8:40 A.M. stated Resident #29 was assigned to her for the previous shift. RN #106 stated the last time the nurse observed Resident #29 being turned and repositioned was at 4:00 A.M. Observation of Resident #29 with RN #106 at that time revealed the nurse agreed that the resident appeared to be in the same position as the resident was in at 6:20 A.M. Interview with the Director of Nursing (DON) on 05/06/15 at 9:39 A.M. verified that the plan of care for Resident #29 did not include turn and reposition every two hours and verified that there was no documentation of the resident being turned and repositioned every two hours. Observation of Resident #29 on 05/06/15 at 10:19 A.M. revealed the resident was seated in a reclining geri-chair in the room. There was no pressure reducing cushion observed on the chair. Resident #29's wound was not observed during the complaint investigation because it was scheduled to be changed on night shift on Tuesday, Thursday and Saturday and did not need to be changed between the scheduled treatments. Interview with the DON on 05/06/15 at 10:20 A.M. verfied there was no pressure reducing cushion on Resident #29's chair. Interview with the DON on 05/06/15 at 10:26 A.M. and observation of resident room at that time verified no pressure reducing cushion in the resident's room. This deficiency substantiates Complaint Number OH 852.