Every finding on record at Lima Convalescent Home

Based on review of personnel files, staff interviews, and review of facility policy the facility failed to ensure Certified Nursing Assistants (CNA) had documented competency in skills and techniques to meet the residents' needs. This had the potential to affect all residents. The facility census was 65.Findings include:Review of Certified Nursing Assistant (CNA) #201's personnel file revealed a hire date of 05/28/26. The contents of the personnel file was absent of a CNA checklist demonstrating competency in skills and techniques. Review of CNA #202's personnel file revealed a hire date of 01/28/26. The contents of the personnel file was absent of a CNA checklist demonstrating competency in skills and techniques. Review of CNA #203's personnel file revealed a hire date of 01/23/26. The contents of the personnel file was absent of a CNA checklist demonstrating competency in skills and techniques. Review of CNA #205's personnel file revealed a hire date of 05/28/26. The contents of the personnel file was absent of a CNA checklist demonstrating competency in skills and techniques. Interview on 07/30/26 at 10:45 A.M. with Human Resources (HR) #253 revealed nursing completed the competency checklist for the CNAs and the checklists were then filed in the employee's personnel record. HR #253 verified CNA #201, CNA #202, CNA #203 and CNA #205 did not have a competency skills checklist completed. Interview on 07/30/26 at 11:25 A.M. with the Director of Nursing (DON) revealed that due to staffing changes, there was a timeframe approximately a month ago when CNA competency checklists were not maintained. Review of the the facility policy titled, Orientation, dated 01/01/26, revealed departmental orientation would continue until the staff demonstrated competency in all the skills necessary for performing his/her role and to meet resident needs. This deficiency represents non-compliance investigated under Complaint Number 3031978.

Based on observation, staff interview, review of facility Legionella control measures, and policy review, the facility failed to follow facility control measures for Legionella. This had to potential to affect all resident residing in the facility. Additionally, the facility failed to follow infection prevention procedures during wound care observation. This affected one resident (#8) of two residents observed for wound care dressing change. The facility census was 66. Findings include: 1. Review of the facility's Legionella control measures revealed the facility would obtain resident room water temperatures. Further review of the facility's control measures revealed no empty resident rooms or shower room water flushes if a room is unoccupied. Review of the facility's Legionella log revealed no water temperatures for the resident's rooms and no unoccupied rooms water flushing. Interview on 04/24/25 at 11:05 A.M. with Maintenance Director (MD) #185 stated he does not keep a log of empty resident rooms and does not flush empty resident rooms no matter how long the rooms are empty and verified he does not test residents water temperatures any longer. Concurrent interview with MD #185 revealed the facility does not have a Legionella policy other than the facility control measures. Review of the facility policy titled Infection Prevention and Control Program, revised 02/25 revealed a water management program has been established as part of the overall infection prevention and control program. Control measure and testing protocols are in place to address potential hazards associated with the facility's water systems. 44076 2. Review of medical record for Resident #8 revealed admitted [DATE] with diagnoses including diabetes mellitus, dehydration, depression, non-pressure chronic ulcer of lower leg, and chronic osteomyelitis of her right ankle and foot. The quarterly Minimum Data Set (MDS) dated [DATE] revealed she had intact cognition and required extensive one person assistance for bed mobility, transfers, limited assistance with toileting and supervision for eating. Observation on 04/22/25 at 12:54 P.M. of Licensed Practical Nurse (LPN) #124 completing the dressing change to right heel revealed LPN #124 removed the stocking of right leg of Resident #8. LPN #124 proceeded to remove the dressing from her right heel. She then disposed of the dressing into the trash can. Without removing her gloves, LPN #124 retrieved a bottle of saline with her right hand and a four by four with her left. She placed she held the four by four in her left hand under the heel and used her right hand to pour the saline over the wound to wash it. She then put the saline bottle back onto the table and removed her gloves, without performing hand hygiene she put on a second set of gloves and proceeded to dress the wound. Interview on 04/22/25 at 1:07 P.M. directly following the dressing change, LPN #125 acknowledged she did not remove her gloves after removing the soiled dressing, and when she did remove her gloves after cleansing the wound she did not wash her hands prior to putting on another pair of gloves. Review of the facility policy, Clean Dressing Change, date 02/17/25 documented after removing the dressing to remove gloves, pulling inside out over the dressing, discard, wash hands and put on clean gloves.

Based on observation, staff interview, and facility policy review, the facility failed to ensure food preparation and storage was maintained. This had the potential to affect all residents. The facility census was 66. Findings include: Observation during initial kitchen tour on 04/21/25 between 8:20 A.M. to 8:40 A.M. revealed the stand-up freezer had one bag of French fries and one bag of chicken that were opened, unsealed, unlabeled, and undated, the walk-in freezer had two stacks of boxes sitting on the floor of the freezer. The two stacks contained the following food: four boxes were [NAME] frozen cakes and one box of wild caught cod. Concurrent observation revealed [NAME] #201 who prepared and served breakfast was not wearing a hat or hairnet, or hairnet covering his full beard. Interview during initial tour with Assistant Dietary Manager (ADM) #197 verified the boxes on the floor in the walk-in freezer, [NAME] #197 not wearing hairnet, and the opened, unsealed, undated, and unlabeled food in the stand-up freezer. Observations on 04/22/25 between 11:55 A.M. to 12:20 P.M. during tray line revealed [NAME] #200 was serving tacos for lunch and while making the tacos the [NAME] #200 did not use any tongs to add the cheese, lettuce, tomato, or onion to the tacos, she used her gloved hand. Concurrent observations of [NAME] #200 revealed the cook prepared alternate menu options for resident's to include chicken tenders, hamburger, hotdog, and fish filet and during the serving did not use tongs to retrieve any of the items and used her gloved hand and did not change gloves or perform hand hygiene. Additional observations during tray line revealed Maintenance Worker (MW) #196 and Food Service Director (FSD) #224 of which both are males with full beards, entered the kitchen and walked all around the kitchen, including the tray line, during tray line without wearing hairnet covers on their full beards and MW #196 did not wear a hairnet or hat on his head. Interview on 04/22/25 at 12:20 P.M. following tray line with [NAME] #200 verified she did not use tongs for the toppings for the tacos, and verified she did not use tongs to grab a hamburger on three occasions, a hotdog, three chicken strips, and one filet of fish. [NAME] #200 verified she used her gloved hand that she had touched other surfaces with to include the fryer handle, spoon handle for the taco meats, the suction cup handle to retrieve the hot plates and the dishes. Review of the facility policy titled, Maintaining a Sanitary Tray Line, dated 07/24 revealed the facility prioritizes tray assembly to ensure foods are handled safely to prevent the spread of bacteria. During tray line assembly staff shall use utensils such as tongs, serving spoons to handle food as much as possible. Review of the facility policy titled, Date Marking for Food Safety, dated 04/25 revealed food shall be clearly marked to indicate date or day by which the food shall be consumed or discarded. Review of the facility policy titled, Food Safety Requirements, dated 01/25 revealed food will be stored, prepared, distributed, and served in accordance with professional standards for food service safety.

Based on record review, staff interviews, and facility policy, the facility failed to ensure care plans were accurate. This affected four (#8, #9, #26, #54) of 23 residents reviewed for care planning. The facility census was 66. Findings include: 1. Review of medical record for Resident #8 revealed admitted [DATE] with diagnoses including diabetes mellitus, dehydration, depression, non-pressure chronic ulcer of lower leg, and chronic osteomyelitis of her right ankle and foot. The quarterly Minimum Data Set (MDS) dated [DATE] revealed she had intact cognition and required extensive one person assistance for bed mobility, transfers, limited assistance with toileting and supervision for eating. Record review revealed there was no plan of care for a pressure ulcer. Review of the 04/01/25 wound center documentation revealed a stage three pressure injury to her right heel. Interview on 04/24/25 at 9:43 A.M. with MDS Nurse #200 verified there was no pressure wound care plan. 2. Review of medical record for Resident #9 revealed admitted [DATE] with diagnoses including diabetes mellitus, stroke, depression and Parkinson's disease. The MDS dated [DATE] revealed she had impaired cognition and required extensive two-person assistance for bed mobility, transfers, toileting and supervision for eating. Record review revealed there was no plan of care for a pressure ulcer. A record review of the 02/24/25 wound note revealed a stage three pressure wound to the left gluteal fold. Interview on 04/24/25 at 9:43 A.M. with MDS Nurse #200 verified there was no pressure wound care plan. 3. Review of medical record for Resident #26 revealed admitted [DATE] with diagnoses including pulmonary hypertension, unspecified dementia without behaviors, peripheral vascular disease and chronic respiratory failure. The MDS dated [DATE] revealed she was cognitively intact and she required set up assistance for eating, dependent for toileting hygiene, substantial assistance for and maximum assistance for transfers. Record review revealed there was no plan of care for a pressure ulcer. Review of the 03/12/25 podiatry notes revealed an unstageable wound to right second toe. Interview on 04/24/25 at 9:43 A.M. with MDS Nurse #200 verified there was no pressure wound care plan until 04/23/25 when the wound was discussed during survey. 4. Review of medical record for Resident #54 revealed admitted [DATE]. The resident was admitted with diagnoses including dementia. The MDS dated [DATE] revealed the resident had severe cognitive impairment. The resident was on hospice. Review of the physician's orders revealed the resident was admitted to hospice with diagnosis of senile degeneration of the brain. Review of the care plan revealed no goals or interventions in place for hospice. Interview with MDS #200 on 04/24/25 at 10:22 P.M. verified Resident #54 did not have a care plan for hospice. Review of the facility policy, Comprehensive Care Plans, dated 02/10/25 documented it is the policy of the facility to develop and implement a comprehensive person centered care plan for each resident to meet that includes measurable objectives and time frames to meet the residents medical needs.

Based on observation, staff interview, and facility policy, the facility failed to ensure a resident's dignity was maintained. This affected one resident (#47) of one resident reviewed for dignity. The facility census was 66. Findings include: Review of the medical record for Resident #47 revealed she was admitted on [DATE] with diagnoses of hypertension and osteoarthritis. Review of the quarterly Minimum Data Set (MDS) dated [DATE] for Resident #47 revealed she was cognitively intact and required supervision assistance for showering and personal hygiene. Review of the care plan revised 04/25 for Resident #47 revealed she was care planned for self-care deficit related to decreased activities of daily living (ADL), activity intolerance, and arthritis with interventions of one to two assist for care, ADLs, and monitor the five P's (pain, potty, position, proximity of items, and personal needs) during rounding Observation on 04/21/25 at 11:48 A.M. of Resident #47 revealed chin hair at least one quarter of an inch long, and along her chin (greater than 10 hairs.) Concurrent interview with Resident #47 stated the staff assist with removing her chin hair and Resident #47 then stated I don't want to look masculine, I want to look feminine. Observation on 04/22/25 08:47 A.M. of Resident #47 revealed she was sitting at the dining room table eating breakfast and the hair on her chin remained. Interview on 04/22/25 08:49 A.M. with Licensed Practical Nurse (LPN) #124 verified the presence of chin hairs on Resident #47. Review of the facility policy titled, Promoting/Maintaining Resident Dignity, dated 12/24 revealed it is the practice of the facility to protect and promote residents' rights and treat each resident with respect and dignity. Residents should be assisted to be groomed and dressed according to their preference.

Based on resident interview, staff interview, review of the nursing schedule, and facility policy, the facility failed to ensure sufficient staffing to complete resident's activities of daily living. This affected one resident (#34) of 24 reviewed for sufficient staffing. The facility census was 66. Findings include: Review of the medical record for Resident #34 revealed an admitted [DATE] with diagnoses of congestive heart failure, diabetes mellitus, chronic obstructive pulmonary disease (COPD), and cerebral vascular accident (CVA) (stroke). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #34 revealed she was cognitively intact and was dependent for showering. Review of the current physician orders for 04/25 for Resident #34 revealed she had ordered showers on Tuesday and Friday on night shift. Review of the care plan revised 02/25 for Resident #34 revealed she was care planned for self-care deficit related to decreased activities of daily living (ADL) function and activity intolerance with intervention for one to two assist with ADL care. Interview on 04/21/25 at 10:01 A.M. with Resident #34 stated she does not get her showers when the staffing is short. Resident #34 stated when there is only one Certified Nursing Assistant (CNA) to both houses (house pods each house had the capacity to hold 12 residents) the aides do not have time to give her a shower. Resident #34 stated her preference for showers was early in the morning to be done for the day. Review of the physician orders and shower schedule for Resident #34 revealed she should have had a shower on 04/11/25 and 04/18/25 on third shift. Review of the CNA documentation for showers for Resident #34 for the past 30 days revealed on 04/11/25 there was no documentation for Resident #34 getting her shower and on 04/18/25 the documentation indicated not applicable. Interview on 04/24/25 at 12:33 P.M. with the Director of Nursing (DON) verified no documentation to account for a shower for Resident #34 for 04/11/25. The DON further stated if no documentation, then the shower was not completed. Further interview with the DON stated the documentation by the CNA on 04/19/25 at 1:19 A.M. verified the documentation showed the shower as not applicable and she would assume the CNA documented that to reflect the shower was not given. The DON further stated if the shower was refused by Resident #34 the CNA would have documented the refusal. Review of the nursing schedule provided by the DON for 04/18/25 revealed one CNA called for third shift on 04/18/25 leaving one CNA to cover both of the houses that shift. Concurrent interview with the DON verified the nursing schedule for 04/18/25 that reflected one CNA assigned to both of the houses for that shift. Review of the facility assessment dated ,d+[DATE] revealed the facilities average daily census was 68 residents. The facility assessment also revealed bathing preferences: a shower schedule for routine showers is maintained at the facility and resident preferences are considered into the schedule. Further review of the facility assessment revealed staffing requirements for third shift are the facility needs five CNAs. Further review of the nursing schedule for 04/18/25 revealed for third shift there were four CNAs that worked and three nurses scheduled. Review of the facility policy titled, Resident Showers, dated 09/24 revealed is it the practice of the facility to assist residents with bathing to maintain proper hygiene, stimulate circulation, and help prevent skin issues.

Based on observations, staff interviews, record reviews, and facility policy, the facility failed to accurately assess wounds and failed to complete treatments as ordered. This affected one (Resident #8) of three residents reviewed for pressure ulcers. The facility census was 66. Findings include: Review of the medical record for Resident #8 revealed an admitted [DATE] with diagnoses including diabetes mellitus, dehydration, depression, non-pressure chronic ulcer of lower leg, and chronic osteomyelitis of her right ankle and foot. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she had intact cognition and required extensive one person assistance for bed mobility, transfers, limited assistance with toileting, and supervision for eating. Review of the care plan revealed no current plan of care for a pressure wound. Review of the 03/01/25 skin and wound assessment revealed documentation of type of wound as other and measuring three centimeters (cm) in diameter, scab to the back of the right heel. Scab was intact with scant serous drainage. Review of the 03/04/25 After Visit Summary of the wound care center documented debridement of the right heel. There was no description of the wound, dressing orders were given with a follow up in four weeks. Review of the 03/29/25 skin and wound assessment revealed documentation of type of wound as other and measuring one cm by (x) one cm to right heel. Additional information described a small area from previous surgical procedure, with no drainage or pain. Review of the 04/06/25 skin and wound assessment revealed documentation of type of wound as other and measuring one centimeter (cm) by (x) one cm to right heel. Additional information described a small area from previous surgical procedure, with no drainage or pain. Review of the 04/12/25 skin and wound assessment revealed documentation of type of wound as other and measuring one centimeter (cm) by (x) one cm to right heel. Additional information described a small area from previous surgical procedure, with no drainage or pain. Interview on 04/23/25 at 2:37 P.M. with Wound Registered Nurse #201 revealed Resident #8 had chosen to go to an outside wound clinic for her wounds. She acknowledged the facility wound assessments did not accurately describe the type of heal wound. She acknowledged the current documentation from the wound clinic did not specify the description of the heel wound. WRN #201 acknowledged the facility should obtain information on the type of wound. Review of the wound care center progress note which was obtained by the facility on 04/24/25, revealed Resident #8 was seen on 04/01/25 for a previous ulceration to the posterior aspect of the calcaneus previous wound which had healed. Physical exam revealed a stage three pressure ulcer measuring 0.4 cm x 0.7 cm x 1 cm on the posterior aspect of the calcareous with some slough (yellow/white accumulation of dead cells) and some debris around the margin which was removed and derided. Observation on 04/22/25 at 12:54 P.M. with Licensed Practical Nurse (LPN) #124 of dressing change revealed the dressing removed from Resident #8's right heel was dated 04/17/25. Observation of the dressing revealed an approximately two cm in diameter yellow/green drainage. Interview on 04/22/25 with LPN #124 directly following wound care verified the right heel dressing was dated 04/17/24 and was ordered to be changed three times weekly. Review of the progress note dated 04/22/25 revealed observation of yellowish green drainage on the old dressing to the right heel during the dressing change. Review of the physician orders revealed an order to apply collagen to right heel wound, moisten with normal saline and cover with silicone foam border dressing at bedtime every Tuesday, Thursday and Saturday for wound healing. Review of the facility policy, Wound Treatment Management, dated 02/03/25 documented wound treatments to be completed in accordance with physician orders, including the cleansing method, type of dressing and frequency if dressing change. Treatment changes will be based on the etiology of the wound. Pressure ulcers will be differentiated from non-pressure ulcers.

Based on observations, record review, staff and resident interview, and facility policy the facility failed to follow physician orders for wound care. This affected one resident (#8) of three reviewed for wounds. The facility census was 66. Findings include: Review of medical record for Resident #8 revealed admitted [DATE] with diagnoses including diabetes mellitus, dehydration, depression, non-pressure chronic ulcer of lower leg, and chronic osteomyelitis of her right ankle and foot. The quarterly Minimum Data Set (MDS) dated [DATE] revealed she had intact cognition and required extensive one person assistance for bed mobility, transfers, limited assistance with toileting and supervision for eating. Review of the physician orders revealed an order for left forearm to keep steri-strips (skin closure) in place until healed. Cover the wound with dressing (Island) once daily and discontinue when healed with a start date of 04/13/25. Observation on 04/22/25 at 12:54 P.M. with Licensed Practical Nurse (LPN) #124 of dressing change revealed the dressing on Resident #8's left forearm was dated 04/15/25. Interview on 04/22/25 with LPN #124 directly following wound care verified the left forearm dressing was dated 04/15/24 and was ordered to be changed daily. Further review of the physician orders revealed an order for bilateral compression pumps twice daily and every evening shift for circulation with a start date of 03/17/25. Observation and interview on 04/22/25 at 1:00 P.M. with both LPN #124 and Resident #124 revealed no bilateral compression pumps were present in the room, and each denied placement of the compression pumps. Review of the facility policy, Wound Treatment Management dated 02/03/25 documented wound treatments to be completed in accordance with physician orders, including the cleansing method, type of dressing and frequency if dressing change.

Based on medical record review, review of self-reported incidents (SRI's), staff interviews, and review of facility policy, the facility failed to ensure staff timely reported allegations of verbal abuse to the Administrator or designee. Additionally, the facility failed to report allegations of verbal abuse to the State Agency. This affected two (#14 and #73) of three residents reviewed for abuse. The facility census was 70. Findings include: 1. Review of the medical record revealed Resident #14 was admitted on [DATE]. Diagnoses include other fracture of shaft of right fibula subsequent encounter for closed fracture with routine healing, essential (primary) hypertension, unspecified atrial fibrillation, obesity, mixed hyperlipidemia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Review of the care plan dated November 2022 revealed the resident was at risk for disturbed body image due to obesity, biophysical/psychosocial factors such as patient's view of self, family subculture encouragement of overeating and control issues. Review of Therapy Staff #207's witness statement dated 11/30/22 revealed on 11/28/22 she was in the therapy room working with Resident #14 and had walked to the sink approximately five feet from Resident #14. Activities Staff #211 approached Therapy Staff #207 with his back to Resident #14, and whispered loudly, When the [explicit term] are you getting her out of here, motioning towards Resident #14. Therapy Staff #207 wrote she had replied, 'not for a while,' and Activities Staff #211 replied, Because I am tired of taking her fat [explicit term] to appointments, and She just sits there and stares at you like a slug. Therapy Staff #207 wrote he made a strange face following the comment and then stated, She won't even attempt to move her fat [explicit term] legs. Interview on 12/16/22 at 12:10 P.M. with Therapy Staff #207 revealed on 11/28/22 Resident #14 was in the therapy room. Activities Staff #211 came in the therapy room and was standing with his back to Resident #14 approximately three to five feet from the resident. It was reported Activities Staff #211 stated something similar to, When are we getting her the [explicit term] out of here because I am tired of taking her to appointments. She just sits there like a slug and does not move her fat [explicit term] legs. Therapy Staff #207 stated she did not know if Resident #14 heard the incident and stated the resident did not appear affected. Therapy Staff #207 stated she reported the allegation to the Administrator. Interview on 12/16/22 at 1:40 P.M. with the Administrator revealed she was aware of the incident on 11/28/22 and had asked Activities Staff #211 about the situation and found that he had inquired about Resident #14 returning home and denied using derogatory terms. It was reported Therapy Staff #207 wavered about what was said. The Administrator also had reason to believe false allegations were made against Activities Staff #211. The Administrator reported Resident #14 was approximately ten feet from the conversation and stated the resident did not hear the conversation, however the Administrator verified she did not interview the resident or other residents to ensure they did not have concerns regarding verbal abuse and did not report the allegation to the State Agency. Interview on 12/16/22 at approximately 3:00 P.M. with the Administrator revealed she had observed the therapy room and Activities Staff #211 was approximately ten feet from Resident #14 when talking to Therapy Staff #207. Interview on 12/16/22 at 3:40 P.M. with Therapy Staff #207 revealed she was mistaken and Activities Staff #211 was approximately 10 feet from Resident #14 during the incident. Therapy Staff #207 verified not reporting the allegation of verbal abuse until the following day when the Administrator approached her regarding the incident. 2. Review of the medical record revealed Resident #73 was admitted on [DATE]. Diagnoses included cystoid macular degeneration, insomnia, essential primary hypertension, hyperlipidemia, functional urinary incontinence, major depressive disorder, generalized anxiety disorder, dementia in other disease classified elsewhere. Review of the MDS assessment dated [DATE] revealed the resident was cognitively impaired. Review of witness statement, dated 11/18/22, written by Housekeeping #208 revealed she was doing Resident #73 hair when she noticed her scalp was bleeding due to dryness and took her to the window to show Licensed Practical Nurse (LPN) #210. Housekeeping #208 wrote they were talking about activities for the day and could not see the television so she had told her (Resident #73) to ask Activities #211 because he was next to LPN #210 talking about appointments. When Resident #73 asked what it was (activities), Activities #211 said what you can't read! Housekeeping #208 wrote she was so offended by the way he said it that it had irritated her. Housekeeping #208 wrote that after it was said she (Resident #73) hung her head down and put her had (hand) on her head. Review of witness statement, dated 11/18/22, from State tested Nursing Assistant (STNA) #213 revealed she was at the nurses station when Resident #73 finished getting her hair done and Activities #211 was there. STNA #213 wrote Activities #211 never had a conversation with Resident #73. STNA #213 wrote Resident #73 does not communicate with us well and does not ask questions like what is stating was asked. Interview on 12/16/22 at 12:18 P.M. with Housekeeping Staff #208 revealed on an unknown date, she and Resident #73 were at the nurse's station when Resident #41, who was in the dining room, asked what activities were scheduled for the day. Housekeeping Staff #208 stated she could not see the schedule for the day and asked Resident #73 to ask Activities Staff #211 what activities were scheduled. Upon Resident #73 asking, Activities Staff #211 allegedly responded, What, you can't read? and did not further respond to the inquiry. Housekeeping Staff #208 stated Resident #73 heard Activities Staff #211 and put her head down. Housekeeping Staff #208 stated Resident #41 was too far to hear the remark. Interview on 12/16/22 at 3:14 P.M. with the Director of Nursing (DON) verified Housekeeping Staff #208 and her supervisor came to her the following day on 11/18/22 to report the alleged incident. The DON stated she did her due diligence and interviewed Licensed Practical Nurse (LPN) #210 who was in the area completing charting and stated she heard people talking but did not hear the conversation. The DON reported she was contacted by State tested Nursing Assistant (STNA) #213 who reported she was nearby and stated there was no conversation or communication between Activities Staff #211 and Resident #73. The DON stated she had a written statement from Housekeeping Staff #208 and text messages from STNA #213 but no other written statements or investigation. The DON stated she intended to receive a statement from Activities Staff #211 but did not. The DON reported Resident #73 was not alert and oriented and confirmed she did not interview Resident #73 as she may nod her head but cannot have a conversation. The DON verified a SRI was not completed. Review of the facility's SRI history from August 2022 to current revealed no SRI's completed for these two instances involving Resident #14 and #73, indicating a thorough investigation was not completed. Review of facility policy, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, dated 2017, verified all incidents and allegations of abuse, neglect, exploitation, mistreatment, and misappropriation of resident property and all injuries of unknown source must be reported immediately to the Administrator or designee. The Administrator or designee will notify the State Agency of all alleged violations involving mistreatment, neglect, abuse, exploitation, misappropriation of resident property and injuries of unknown source as soon as possible, but in no event later than 24 hours from the time of the incident/allegation was made known to the staff member. Once the Administrator and the State Agency are notified, an investigation of the allegation violation will be conducted. The investigation will be completed within five working days unless there are special circumstances. Generally the investigation should include interview of the resident, the accused, and all witnesses. Statements from the resident, if possible, the accused, and each witness. Review of the resident's record and review of the accused employees employment records. This deficiency represents non-compliance investigated under Complaint Number OH00138171.

Based on medical record review, review of facility self-reported incidents (SRI's), staff interviews, and review of facility policy, the facility failed to thoroughly investigate allegations of verbal abuse. This affected two (#14 and #73) of three residents reviewed for abuse. The facility census was 70. Findings include: 1. Review of the medical record revealed Resident #14 was admitted on [DATE]. Diagnoses include other fracture of shaft of right fibula subsequent encounter for closed fracture with routine healing, essential (primary) hypertension, unspecified atrial fibrillation, obesity, mixed hyperlipidemia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Review of the care plan dated November 2022 revealed the resident was at risk for disturbed body image due to obesity, biophysical/psychosocial factors such as patient's view of self, family subculture encouragement of overeating and control issues. Review of Therapy Staff #207's witness statement dated 11/30/22 revealed on 11/28/22 she was in the therapy room working with Resident #14 and had walked to the sink approximately five feet from Resident #14. Activities Staff #211 approached Therapy Staff #207 with his back to Resident #14, and whispered loudly, When the [explicit term] are you getting her out of here, motioning towards Resident #14. Therapy Staff #207 wrote she had replied, 'not for a while,' and Activities Staff #211 replied, Because I am tired of taking her fat [explicit term] to appointments, and She just sits there and stares at you like a slug. Therapy Staff #207 wrote he made a strange face following the comment and then stated, She won't even attempt to move her fat [explicit term] legs. Interview on 12/16/22 at 12:10 P.M. with Therapy Staff #207 revealed on 11/28/22 Resident #14 was in the therapy room. Activities Staff #211 came in the therapy room and was standing with his back to Resident #14 approximately three to five feet from the resident. It was reported Activities Staff #211 stated something similar to, When are we getting her the [explicit term] out of here because I am tired of taking her to appointments. She just sits there like a slug and does not move her fat [explicit term] legs. Therapy Staff #207 stated she did not know if Resident #14 heard the incident and stated the resident did not appear affected. Therapy Staff #207 stated she reported the allegation to the Administrator. Interview on 12/16/22 at 1:40 P.M. with the Administrator revealed she was aware of the incident on 11/28/22 and had asked Activities Staff #211 about the situation and found that he had inquired about Resident #14 returning home and denied using derogatory terms. It was reported Therapy Staff #207 wavered about what was said. The Administrator also had reason to believe false allegations were made against Activities Staff #211. The Administrator reported Resident #14 was approximately ten feet from the conversation and stated the resident did not hear the conversation, however the Administrator verified she did not interview the resident or other residents to ensure they did not have concerns regarding verbal abuse and did not report the allegation to the State Agency. Interview on 12/16/22 at approximately 3:00 P.M. with the Administrator revealed she had observed the therapy room and Activities Staff #211 was approximately ten feet from Resident #14 when talking to Therapy Staff #207. Interview on 12/16/22 at 3:40 P.M. with Therapy Staff #207 revealed she was mistaken and Activities Staff #211 was approximately 10 feet from Resident #14 during the incident. Therapy Staff #207 verified not reporting the allegation of verbal abuse until the following day when the Administrator approached her regarding the incident. 2. Review of the medical record revealed Resident #73 was admitted on [DATE]. Diagnoses included cystoid macular degeneration, insomnia, essential primary hypertension, hyperlipidemia, functional urinary incontinence, major depressive disorder, generalized anxiety disorder, dementia in other disease classified elsewhere. Review of the MDS assessment dated [DATE] revealed the resident was cognitively impaired. Review of witness statement, dated 11/18/22, written by Housekeeping #208 revealed she was doing Resident #73 hair when she noticed her scalp was bleeding due to dryness and took her to the window to show Licensed Practical Nurse (LPN) #210. Housekeeping #208 wrote they were talking about activities for the day and could not see the television so she had told her (Resident #73) to ask Activities #211 because he was next to LPN #210 talking about appointments. When Resident #73 asked what it was (activities), Activities #211 said what you can't read! Housekeeping #208 wrote she was so offended by the way he said it that it had irritated her. Housekeeping #208 wrote that after it was said she (Resident #73) hung her head down and put her had (hand) on her head. Review of witness statement, dated 11/18/22, from State tested Nursing Assistant (STNA) #213 revealed she was at the nurses station when Resident #73 finished getting her hair done and Activities #211 was there. STNA #213 wrote Activities #211 never had a conversation with Resident #73. STNA #213 wrote Resident #73 does not communicate with us well and does not ask questions like what is stating was asked. Interview on 12/16/22 at 12:18 P.M. with Housekeeping Staff #208 revealed on an unknown date, she and Resident #73 were at the nurse's station when Resident #41, who was in the dining room, asked what activities were scheduled for the day. Housekeeping Staff #208 stated she could not see the schedule for the day and asked Resident #73 to ask Activities Staff #211 what activities were scheduled. Upon Resident #73 asking, Activities Staff #211 allegedly responded, What, you can't read? and did not further respond to the inquiry. Housekeeping Staff #208 stated Resident #73 heard Activities Staff #211 and put her head down. Housekeeping Staff #208 stated Resident #41 was too far to hear the remark. Interview on 12/16/22 at 3:14 P.M. with the Director of Nursing (DON) verified Housekeeping Staff #208 and her supervisor came to her the following day on 11/18/22 to report the alleged incident. The DON stated she did her due diligence and interviewed Licensed Practical Nurse (LPN) #210 who was in the area completing charting and stated she heard people talking but did not hear the conversation. The DON reported she was contacted by State tested Nursing Assistant (STNA) #213 who reported she was nearby and stated there was no conversation or communication between Activities Staff #211 and Resident #73. The DON stated she had a written statement from Housekeeping Staff #208 and text messages from STNA #213 but no other written statements or investigation. The DON stated she intended to receive a statement from Activities Staff #211 but did not. The DON reported Resident #73 was not alert and oriented and confirmed she did not interview Resident #73 as she may nod her head but cannot have a conversation. The DON verified a SRI was not completed. Review of the facility's SRI history from August 2022 to current revealed no SRI's completed for these two instances involving Resident #14 and #73, indicating a thorough investigation was not completed. Review of facility policy, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, dated 2017, verified all incidents and allegations of abuse, neglect, exploitation, mistreatment, and misappropriation of resident property and all injuries of unknown source must be reported immediately to the Administrator or designee. The Administrator or designee will notify the State Agency of all alleged violations involving mistreatment, neglect, abuse, exploitation, misappropriation of resident property and injuries of unknown source as soon as possible, but in no event later than 24 hours from the time of the incident/allegation was made known to the staff member. Once the Administrator and the State Agency are notified, an investigation of the allegation violation will be conducted. The investigation will be completed within five working days unless there are special circumstances. Generally the investigation should include interview of the resident, the accused, and all witnesses. Statements from the resident, if possible, the accused, and each witness. Review of the resident's record and review of the accused employees employment records. This deficiency represents non-compliance investigated under Complaint Number OH00138171.

Based on observations, resident and staff interviews and policy review, the facility failed to accommodate resident needs by ensuring the resident's call lights were within reach. This affected four (#24, #30, #34, and #122) out five residents sampled for accessibility of call lights. Facility census was 71. Findings include: Observation on 08/08/22 at 4:55 P.M. revealed Resident #122 was sitting up in bed with her dinner tray in front of her. Resident #122 stated she did not like what they served her for dinner. When asked if she had told staff she stated she couldn't tell staff due to no being able to reach her call light. Resident #122's call light was on the bottom bar of the enabler side rail with the button pointing to the floor out of the reach of the resident. On 08/08/22 at 5:00 P.M. an interview with State tested Nursing Assistant (STNA) #224 verified Resident #122 could not reach her call light. On 08/09/22 at 2:10 P.M. observations revealed Resident #30 was lying in bed. Resident #30 stated she had a wet depends on that she couldn't get rid of. When asked if her depends needed changed she stated yes. The soft touch call light was hanging off the bed on the bottom bar of her right enabler side rail out of the reach of the resident. Interview with STNA #234 on 08/09/22 at 2:15 P.M. verified Resident #30 was not able to reach her call light. On 08/10/22 at 7:15 A.M. observation of Resident #24, #30, #34, and #122 revealed call lights were draped around the bottom bar on the enabler side rails hanging down towards the floor out of the reach of the residents. On 08/12/22 at 7:25 A.M. an interview with Licensed Practical Nurse (LPN) #240 verified Resident #24, #30, #34 and #122 call lights were out of reach. LPN #240 stated the call lights needed to be clipped to the resident's clothing as this is their direct line to access staff. Review of an undated policy titled Call Light revealed staff should keep nurses' call system within easy reach of the resident.

Based on medical record review, observations, resident and staff interviews and policy review, the facility failed to ensure hand splints were applied as recommended by therapy and/or ordered by the physician. This affected two (#29 and #30) two residents reviewed for limited range of motion. The facility census was 71. Findings include: 1. Review of Resident #29's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #29's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of six revealing he has a severe cognitive deficits. Resident #29 displayed physical behaviors toward others on one to three days of the assessment. Resident #29 is totally dependent for all activities of daily living except eating which he requires supervision of one person. Resident #29 is non ambulatory. Resident #29 has functional limitation in range of motion to his upper extremities on one side. Review of the plan of care updated 06/07/22 stated Resident #29 is at risk for alteration in comfort and pain related to [CONDITION(S)] of his left hand and history of a stroke with left [CONDITION(S)]. Resident #29 has had [MEDICATION(S)] in his left hand in the past. Interventions included a left hand splint at bedtime as tolerated per order and monitor skin for breakdown with application and removal of the splint. Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The splint is to be taken off during morning care, applied at lunch, taken off at dinner and applied at bedtime. The order stated to contact occupational therapy with any concerns. Review of the Occupational Therapy Discharge Summary, dated 06/14/22, revealed the OT recommendation was for Resident #29 to have a left hand splint (hand roll) placed eight hours a day per wearing schedule. Observation on 08/09/22 at 2:10 P.M. revealed Resident #29 was in reclining chair at the dining room table with another resident drinking strawberry lemonade. Resident #29's left hand was in a fist with his left arm flaccid lying on his left leg. Resident #29 stated they do not work with his left hand or put a splint on it. Resident #29 stated the only one who does anything with his hand is his son. Observation of Resident #29's room on 08/09/22 at 2:14 P.M. revealed a hand roll splint over the faucet in the sink. Interview with State tested Nursing Assistant (STNA) #212 on 08/09/22 at 2:15 P.M. verified Resident #29 had a splint for his left hand contracture. STNA #212 stated it had become soiled and she had to wash the splint and let it air dry. STNA #212 verified there was nothing currently in Resident #29's left hand. Interview with Licensed Practical Nurse (LPN) #195 on 08/09/22 at 2:20 P.M. verified Resident #29 was to have a soft hand splint on his left hand placed on after lunch until dinner. The splint is to be off at dinner and on at bedtime then off for morning care. LPN #195 verified Resident #29 did not have anything in his left hand at the time. LPN #195 verified there was no extra splints to use while the original hand splint was drying. F Interview with Certified Occupational Therapy Assistant (COTA) #600 on 08/10/22 at 2:00 P.M. verified Resident #29 was to wear a splint in his left hand to protect the skin on the palm of his hand and prevent the contracture of his left hand from contracting further. COTA #600 verified the splint was a hand roll and should be worn eight hours a day per splint schedule. COTA #600 stated the splint schedule is in the STNA's tasks for instructions and documentation. 2. Review of Resident #30's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #30's quarterly MDS assessment dated [DATE] revealed the resident scored an eight on the BIMS indicating moderate cognition deficits. Resident #30 displayed physical behaviors one to three days a week during the assessment. Resident #30 requires extensive assistance of two staff for bed mobility, transfers and personal hygiene. Resident #30 is non ambulatory and has limited range of motion on one side of upper extremities. Review of plan of care dated 06/10/22 revealed Resident #30 is at risk for knowledge deficits for use of hand splint for contracture . The interventions included treatment as ordered and keep hand splint clean and dry, and monitor skin under hand splint. Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no directions for use. Review of Occupational Therapy Discharge Summary, dated 05/10/22, revealed the recommendations indicated Resident #30 was to wear a left hand splint (hand roll) eight hours a day per wearing schedule. Observation on 08/10/22 at 2:00 P.M. revealed Resident #30 was in bed with her left hand lying on the mattress with her hand in a fist. There was no splint on Resident #30's left hand. Interview with STNA #234 on 08/10/22 at 2:10 P.M. verified Resident #30 was to have a splint to her left hand after lunch off at dinner and back on at bedtime. STNA #234 verified Resident #30 did not have a splint on her left hand at the present time and stated she was unable to find the splint. Interview with COTA 600 on 08/10/22 at 2:00 P.M. verified Resident #30 was to wear a splint in her left hand to protect the skin on the palm of her hand and prevent the contracture of her left hand from contracting further. COTA #600 verified Resident #30's splint was a hand roll and should be worn eight hours a day per splint schedule. COTA #600 stated Resident #30's splint schedule is in the STNA's tasks for instructions and documentation. Review of undated policy titled Contracture Management indicated nursing staff is to follow suggested physician interventions to manage changes in baseline limb movement and prevent further decline.

Based on medical record review, staff interview and review the facility policy, the facility failed to provide adequate supervision to ensure a cognitively impaired resident did not elope from the locked unit. This affected one (#41) out of three residents reviewed for elopement. The facility census was 71. Findings include: Review of Resident #41's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses include [CONDITION(S)], diabetes, falls, maxillary fracture, [CONDITION(S)], heart failure, tremors, dementia without behaviors. Review of Resident #41's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition and was a one-person assist for Activities of Daily (ADL). Review of the admission wandering risk assessment dated [DATE] revealed Resident #41 was assessed as being a low risk for wandering. Review of Resident #41's progress notes revealed on 06/09/22 the resident's family had concerns for Resident #41's wandering so they requested a Wanderguard. Per the note the physician agreed. Review of the care plans dated 06/08/22 revealed a focus for wandering from facility unattended due to dementia, depression, and anxiety. Interventions include allow the resident to wander in appropriate areas but remove from area if annoying peers, check alarm system to ensure safety, encourage to walk with a buddy to activities, frequent checks, medications per order, redirect attention, one-on-one (1:1) interactions, take on walks, take to common areas if wandering. Review of Resident #41's progress notes dated 07/21/22 revealed at 12:45 P.M. the nurse was notified by the aide that Resident #41 had left the gated patio area she was in with her Assisted Living (AL) visitor. Per the note, the AL visitor was aware he did not have permission to leave the locked unit with Resident #41. Per the note the nurse called the AL unit and the staff had located the resident in the AL. The nurse notified the Licensed Social Worker (LSW) #152, the Administrator, the physician and the resident's family representative. Interview on 08/09/22 at 3:15 P.M. with Licensed Practical Nurse (LPN) #157 revealed Resident #41 does not exhibit exit seeking behaviors by herself. Per LPN #157 she has a friend from the AL she had a relationship with while she was residing on the AL unit that comes to visit her. LPN #157 showed the surveyor the gated patio area Resident #41 and her visitor were visiting when the incident on 07/21/22 occurred. Per LPN #157, the gate has a locking mechanism on the outside that can be reached and unlocked by reaching through the gate and using force to lift the lock and push the gate open. LPN #157 stated Resident #41 was not capable of opening the locked gate by herself due to her condition. LPN #157 verified the resident's AL visitor could open the gate and leave with the resident if the staff did not supervise the visitation. LPN #157 stated the AL visitor did not have permission from the facility or the family of Resident #41 to leave the locked unit with the resident. LPN #157 stated the AL visitor visited Resident #41 on a daily basis but was to be supervised by staff. LPN #157 stated she assessed Resident #41 after the incident on her shift and found the resident to have no injuries and did not appear to be any distress after the incident. Interview on 08/09/22 at 4:26 P.M. with Licensed Social Worker (LSW) #152 and the Administrator revealed on 07/21/22 around 12:30 P.M. Resident #41 and a visitor, a resident from AL unit were visiting and staff let the resident and her visitor out to the gated patio connected to the locked dementia unit. Per the Administrator Resident #41 had a previous relationship with the AL resident who was visiting her in the locked unit and did so on a daily basis. The Administrator stated staff went to check on Resident #41 and the AL resident around 12:45 P.M. when they noticed the resident and the visitor were no longer in the gated patio area. The Administrator stated the aide immediately notified the nurse who began the missing person procedure. The aide was instructed to go to the AL unit to search for Resident #41 as she had been a previous resident on the AL unit and may have been going back to the AL unit with her visitor. Per the Administrator the nurse notified staff on the AL unit and the staff began to search for Resident #41. The Administrator and LSW #152 stated they had been notified by the nurse of the resident leaving the patio area with her AL visitor. Per the Administrator the resident had been gone for less than 10 minutes from the patio before being found in the AL unit. The LSW stated the nurses assessed the resident and found her to have no injuries and to be in no distress. LSW #152 verified the AL visitor was not given permission from the facility or Resident #41's family to take the resident out of the SNF unit to the AL unit. The Administrator verified the staff were to supervise visitations with Resident #41 and her AL visitor. Review of the facility policy titled, 'Missing Person', dated 08/2018 revealed staff are to monitor residents at risk for wandering and elopement, precautions are to be taken to prevent the residents from eloping. This deficiency substantiates Complaint Number OH 650.

Based on record review, staff interview and review of facility policy, the facility failed to ensure the physician responded to the pharmacist's recommendations for a gradual dose reduction and a end date for an as needed medication. This affected one (#2) out of five residents reviewed for unnecessary medications. The facility census was 71. Findings include: Review of Resident #2's medical record revealed the resident was admitted to the hospital on 12/21/18. Diagnoses include anxiety, [CONDITION(S)], [CONDITION(S)], mood affective disorder, dementia with behaviors, depression and falls. Review of Resident #2's Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed the resident had impaired cognition and was receiving anticoagulant, antipsychotic, anti-anxiety, and opioid medications for seven days. Review of care plans for Resident #2 dated 12/2018 revealed a focus for potential for adverse effect related to anti-psychotic, antidepressant, anti-anxiety, and medications that stabilize her mood. Interventions include medication increased due to increased behavior, administer antipsychotic medications, assure medications are swallowed, monitor effected of medications and update physician if having behaviors, monitor for side effects of medications, pharmacist/physician to review medications routinely to assure lowest effective dose. Review of Resident #2's physician prescribed medications revealed on 01/31/21, the resident was receiving [MEDICATION(S)] 0.5 milligrams (mg) every two hours as needed for anxiety. On 04/09/21 the resident was to receive [MEDICATION(S)] 0.25 mg two times a day for behaviors and mood disorder. Review of the pharmacy reviews revealed on 01/19/21 the pharmacist recommended the physician re-evaluate the medication for need and provide a stop date for the as needed medication. No documentation of a physician response to the recommendation was noted in the resident's record. Review of the pharmacy reviews revealed on 09/17/21 the pharmacist sent a recommendation to the physician to review the [MEDICATION(S)] 0.25 mg twice a day for mood disorder for a possible gradual dose reduction. Further medical record review revealed there was no documented physician response was noted in the resident's record. Interview on 08/11/22 at 8:30 A.M. with the Director of Nursing (DON) verified there were no documented physician responses to the pharmacist's recommendations on 01/19/21 and 09/17/21 for the [MEDICATION(S)] and the [MEDICATION(S)]. Review of the facility policy titled 'Antipsychotic Medication Use', dated 12/2016 revealed all antipsychotic medications are to be prescribed at the lowest dose for the shortest period of time and are subject to gradual dose reduction and re-review. The physician shall respond appropriately by changing the medications or by clearly documenting the rationale for continued use of the medication.

Based on medical record review, staff interview, and review of facility policy, the facility failed ensure a resident was free from unnecessary [CONDITION(S)] medication usage when the facility failed to have an adequate indication for use for an antipsychotic medication. This affected one (#32) of five residents reviewed for unnecessary medications. The facility census was 71. Findings Include: Review of Resident #32's medical record revealed an admitted d of 05/14/21 and a readmitted [DATE]. Diagnoses included history of heart failure, rapid heart rate, dementia with Lewy bodies, [CONDITION(S)], dysphagia, major depressive disorder, and cognitive communication deficit. Review of Resident #32's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating Resident #32 was cognitively intact. Resident #32 required extensive assistance with transfer, dressing, toilet use, and personal hygiene. Resident #32 required physical help in part of the bathing activity. Resident #32 displayed no behaviors during the review period. Resident #32 had depression and no psychotic disorder at the time of the review. Review of Resident #32's care plan revised 07/27/22 revealed supports and interventions for use of antidepressant medications related to major depressive disorder and risk for potential side effects related to [CONDITION(S)] medication use. It was noted Resident #32 received antipsychotic medications to stabilize her mood. Review of Resident #32's physician orders revealed an order dated 04/13/22 and discontinued 06/22/22 for [MEDICATION(S)] (antipsychotic medication) 25 milligrams (mg)-give 0.5 mg tablet by mouth at bedtime for cognitive communication deficit. An order dated 06/28/22 for [MEDICATION(S)] 25 mg-give 0.5 mg tablet by mouth at bedtime for cognitive communication deficit. Review of Resident #32's Psychiatric Reviews dated 06/09/22 and 07/06/22 revealed Resident #32 was receiving [MEDICATION(S)] 12.5 mg at bedtime for cognitive communication deficit. Interview on 08/11/22 at 8:12 A.M. with the Director of Nursing (DON) verified cognitive communication deficit was not an appropriate diagnosis for the use of the antipsychotic medication [MEDICATION(S)]. Review of the facility policy titled, Antipsychotic Medication Use, revised December 2016 revealed residents would only receive antipsychotic medications when necessary to treat a specific condition for which they were indicated and effective. Antipsychotic medication shall generally be used only for the following diagnoses as documented in the record, consistent with the definitions in the Diagnostic and Statistical Manual of Mental Disorders: [CONDITION(S)], [CONDITION(S)] disorder, delusional disorder, mood disorders, [CONDITION(S)] in the absence of dementia, medical illness with psychotic symptoms and or treatment related [CONDITION(S)] or [CONDITION(S)], [CONDITION(S)] disorder, [CONDITION(S)], hiccups, or nausea and vomiting associated with cancer or [CONDITION(S)]. Antipsychotic medications will not be used if they only symptoms were one or more of the following: wandering, poor self-care, restlessness, impaired memory, mild anxiety, [CONDITION(S)], inattention or indifference to surroundings, sadness or crying that is not related to depression or other psychiatric disorders, fidgeting, nervousness or uncooperativeness.

Based on medical record review, observations, resident and staff interview and review of facility policy, the facility failed to ensure residents with indwelling catheters had their catheters managed in a dignified manner. This affected two (#222 and #54) of the three residents reviewed for dignity. The facility census was 71. Findings Include: 1. Review of Resident #222's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #222's Minimum Data Set (MDS) revealed an Admission MDS was in progress. Review of Resident #222's Admission assessment dated [DATE] revealed Resident #222 was admitted to the facility from the hospital following a fall at home. Resident #222 had an indwelling catheter. Resident #222 used a manual wheelchair for mobility. Interview on 08/08/22 at 9:56 A.M. with Resident #222 revealed she had a catheter. Coinciding observation of her catheter bag found it attached under her wheelchair and the bag was not covered. The bag was observed to be partially full of dark yellow/light brown urine. Resident #222 stated she didn't know it wasn't covered as she was not able to manage her catheter bag herself and could not see it under her. Observation on 08/08/22 at 11:16 A.M. of Resident #222 found her out in the common area of the home working with physical therapy. Resident #222's catheter bag was uncovered and her urine was visible to other residents, staff and visitors. Interview on 08/08/22 at 11:18 A.M. with State tested Nursing Assistant (STNA) #174 verified Resident #222's catheter bag was not covered. STNA #174 reported Resident #222 did not have dignity bag and she was not sure where they could get one. 2. Review of Resident #54's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #54's MDS dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. Resident #54 required one person physical assistance with toilet use. Resident #54 had an indwelling catheter at the time of the review. Resident #54 displayed no behaviors during the review period. Review of Resident #54's care plan revised 07/15/22 revealed supports and interventions for risk for infection related to suprapubic catheter and risk for complications related to use of suprapubic catheter due to retention of urine and obstructive [CONDITION(S)]. Interview on 08/08/22 11:18 A.M. with STNA #174 revealed Resident #54 had a catheter bag which had no cover and he was currently out of the facility at an appointment. STNA #174 reported they didn't have catheter dignity bags for Resident #54 and she didn't know where to get them. Observation on 08/08/22 at 11:32 A.M. of Resident #54 found him propelling himself in his motorized wheelchair back into the home. Coinciding interview with Resident #54 verified he was returning home from a medical appointment. Resident #54's catheter bag was uncovered and lying on the footrest of his motorized wheelchair. Resident #54 stated he didn't have a cover for his catheter bag that he knew of. STNA #174 verified Resident #54's catheter bag was not covered and he had been out in public outside the facility. Review of the facility policy titled, Dignity, revised February 2021 revealed staff were to promote, maintain, and protect resident privacy. Urinary drainage bags must be covered.

Based on observation, staff interview and policy review, the facility failed to follow the menu spreadsheet to ensure residents' received adequate amounts of nutrition for their meals. This affected one of two kitchens and had the potential to affect all 50 residents that received food from the main kitchen. The facility identified 21 residents (#01, #02, #03, #04, #05, #06, #07, #08, #09, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20 and #21) who received meals from the Green House kitchen. The facility census was 71. Findings include: Observation on 03/10/22 at 11:52 A.M. revealed Cook #101 prepared pureed chicken breast. Cook #100 used a spatula to scrape the chicken into bowls and did not measure the chicken to be sure the proper amount was placed into each bowl. In addition, there were scoops on the steam table ready for use to serve the lunch meal. There was a gray and blue scoop and a black ladle. Staff interview on 03/10/22 at 12:15 P.M. with Cook #100 revealed he did not have a spread sheet for the lunch menu. Cook #100 was asked how he knows how much to serve and he stated usually they get four ounces of vegetables and potatoes and three ounces of meat. Cook #100 verified he had not measured the pureed chicken to ensure they receive the proper amount. Cook #100 verified he was not sure how much each scoop measured, as there was no numbers on the scoops or ladle he used to determine the amount he was serving. Review of the policy titled Food Preparation Area, revised 06/2003, revealed the facility will maintain a clean, sanitary, and safe food preparation area. This deficiency substantiates Complaint Number OH 686.

Based on observation, staff interview and facility policy review, the facility failed to store, prepare and distribute food in a sanitary manner from the kitchen. This affected one of two kitchens and had the potential to affect all 50 residents that received food from the main kitchen. The facility identified 21 residents (#01, #02, #03, #04, #05, #06, #07, #08, #09, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20 and #21) who received meals from the Green House kitchen. The facility census was 71. Findings include: Observation on 03/10/22 at 10:57 A.M. revealed the kitchen had dirty dishes and pans sitting in various areas of the kitchen. There were dirty dishes sitting in the three compartment sink with soap and water sitting in the dishes. However the three compartment sink was not filled with soap and water, water, and sanitizing solution. There were two carts on wheels that had crumbs and greasy grime on the shelves. Cook #101 checked the soap dispenser for the dishwasher and found the soap dispenser was empty. Cook #101 checked the kitchen and they had no more soap and she then went to the Assisted Living Kitchen to check for soap and they did not have any soap for them to use. The Assisted Living had a new dishwasher installed and they used different soap now. Cook #101 and Dietary Aide #102 did not have a hairnet on in the kitchen area. Staff Interview on 03/10/22 at 11:03 A.M. with Cook #101 revealed the kitchen staff were responsible to check the soap for the dishwasher. Cook #101 verified that there was no soap in the soap dispenser for the dishwasher and she had not checked to see if there was soap in the dispenser this morning prior to running the dishwasher. Staff Interview on 03/10/22 at 11:07 A.M. with Dietary Aide #102 and Cook #101 verified they were not wearing a hairnet in the kitchen area. Observation on 03/10/22 at 11:10 A.M. revealed a tray of salads, a tray of cherry desserts, and a tray of drinks in cups that were not dated. There was a pitcher of some juice not labeled or dated and a container of sliced tomatoes and onions not dated. There was a container of cheese slices with a sticker dated 2/27/22 and a throw out date of 03/04/22. A garbage can lid was lying on the floor not covering the garbage can that was filled with trash and scraps of food that had been scraped off of plates, before placing in the dishwasher. There was shelving holding cutting boards and metal pans that had dried crusted build up and a cart that holds trays were dirty with grease and grime. Staff interview on 03/10/22 at 11:20 A.M. with Cook #100 verified that the kitchen is not the cleanest, but they had just taken over the kitchen recently as they had got rid of the company that had been there and they had taken everything from the kitchen with them. Cook #100 verified there were trays of salads, drinks, and cherry dessert not dated and a pitcher of juice and a container of sliced tomatoes and onions not dated. There was also a container of cheese that was outdated. Observation on 03/10/22 at 11:52 A.M. revealed Cook #101 prepared a puree diet of cherry cobbler with a food processor and then Cook #100 washed the food processor with soapy water and rinsed it with water. Cook #100 did not sanitize the food processor and used the food processor to puree chicken breast. Observation on 03/10/22 at 12:03 P.M. revealed Cook #100 had a wash cloth and wiped down the counter in front of the steam table prior to serving lunch. There was no bucket with sanitizing solution in the kitchen. Cook #100 layed serving utensils on the counter where he had wiped with the wash cloth. Staff interview on 03/10/22 at 12:15 P.M. with Cook #100 revealed he had not sanitized the food processor after washing with soap and water and rinsing with water prior to using the food processor to puree the chicken. Cook #100 verified he did not have a bucket of sanitizing solution to use for his wash cloth he used to wipe down the counters in the kitchen area. Cook #100 verified it was soap and water he had on the dish cloth. Review of the policy titled Food Preparation Area, revised 06/2003, revealed the facility will maintain a clean, sanitary, and safe food preparation area. Review of the policy titled Food Storage, revised 06/2003, revealed food storage areas shall be maintained in a clean, safe, and sanitary manner. Review of the policy titled Sanitation, revised 06/2003, revealed the food service area shall be maintained in a clean and sanitary manner. All kitchens, kitchen areas, and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects. All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks, and chipped areas. Kitchen wastes that are not disposed of by mechanical means shall be kept in clean, leakproof, nonabsorbent, tightly closed containers and shall be disposed of daily. Review of the policy titled Sanitation of Dishwashing Area , revised 06/2003, revealed to ensure effective dishwashing, all equipment must be functioning. Mechanical Dishwashing; Ready the machine by filling with water and turning on according to the manufacturer's instructions. Charge the machine with detergent as recommended by the detergent supplier. This deficiency substantiates Complaint Number OH 686.

Based on observation, staff interview, review of facility handout for alcohol-based hand rub (ABHR) and Centers for Disease Control and Prevention (CDC) website, the facility failed to ensure hand hygiene was performed correctly. This had the potential to affect 25 (#49, #50, #51, #52, #53, #54, #55, #56, #71, #72, #73, #74, #75, #76, #77, #78, #79, #80, #81, #82, #83, #84, #85, #86, and #87) of 25 residents residing in the west wing. The facility census was 71. Findings include: Observation on 02/28/22 at 9:04 A.M., Licensed Practical Nurse (LPN) #120 revealed she took Resident #49's water bottle from him with her bare hands. LPN #120 used an ice scoop to fill the bottle with ice from an insulated ice chest and then handed the bottle back to Resident #49. LPN #120 went back to a medication cart and obtained medications and a glass of water and proceeded into Resident #71's room without performing any hand hygiene. Interview with LPN #120 at the time of the observation verified the lack of hand hygiene. LPN #120 was then observed to apply a small amount of alcohol-based hand rub (ABHR) and rubbed her hands together for approximately five seconds (maximum). LPN #120 stated she should use the ABHR between residents and for at least 30 seconds, but it normally dries before that. LPN #120 verified she only used a small amount of the ABHR, and it dries too quickly. Review of the facility undated handout, located at hand hygiene station at staff time clock, revealed The amount of product used matters. Use enough ABHR to cover all surfaces of your hands. Rub hands together until dry, for around 20 seconds, if the correct amount was used. Review of the Centers for Disease Control and Prevention website at www.cdc.gov/handwashing/hand-sanitizer-use.html revealed hands should be rubbed for a minimum of 20 seconds when using the ABHR. This deficiency substantiates Complaint Number OH 362.

Based on medical record review, staff interview and policy review, the facility failed to inform resident representative of changes in resident condition and treatments. This affected two (#58 and #61) of three residents reviewed for notification. The facility census was 71. Findings include: 1. Review of the medical record of Resident #58 revealed an admitted [DATE], with numerous stays at hospital and the most recent admission documented as 01/01/22. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #58 was cognitively intact. She exhibited no behaviors and scored as minimally depressed. Review of the progress notes entry on 02/15/22 at 10:28 P.M., revealed Licensed Practical Nurse (LPN) #140 documented Resident #58 kicked by peer in shin. No injuries noted. Review of the progress notes for Resident #58 revealed no documentation the family had been notified of the incident documented on 02/15/22 at 10:28 P.M. 2. Review of the medical record of Resident #61 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual (MDS) assessment dated [DATE] revealed Resident #61 was severely cognitively impaired. Review of the progress notes documented on Resident #61 revealed an entry dated 02/21/22 at 4:37 P.M., revealed she had been started on [MEDICATION(S)], an antianxiety medication, for anxiety and increased behaviors this afternoon. The entry indicated the physician would be notified of increased behaviors and would be requested to increase the [MEDICATION(S)] as well as [MEDICATION(S)], an antianxiety medication. No documentation was located related to family having been notified of new medication. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .M., for [MEDICATION(S)] Sprinkles 125 micrograms (mcg) to be given my mouth twice daily for increased behaviors. An order at 2:00 P.M. for [MEDICATION(S)] 0.25 milligrams (mg) to be given by mouth once daily at 2:00 P.M. for increased behaviors. Interview on 03/01/22 at 3:250 P.M., with Director of Nursing verified the documentation was absent for family notification and stated the family would typically be notified of changes. Review of the policy titled Change in a Resident's Condition or Status dated March 2001, revealed the facility shall notify the resident or representative of changes in the medical or mental condition. This deficiency substantiates Complaint Number OH 360.