Every finding on record at Logan Acres

Based on observation, medical record review and family and staff interview, the facility failed to ensure residents had physician ordered eyeglasses available for use. This affected one (#97) of one resident reviewed for vision care. The facility census was 104. Findings include: Review of the medical record for Resident #97 revealed an admission date of 01/03/22. Diagnoses included glaucoma and major depressive disorder.Review of the Minimum Data Set (MDS) assessment, dated 05/08/25, revealed Resident #97 had severe cognitive impairment. Further review of the MDS revealed Resident #97's vision was highly impaired and the resident utilized corrective lenses.Review of the care plan, dated 11/19/24, revealed Resident #97 had adequate vision but was at risk for impaired vision related to a diagnosis of glaucoma. Staff were to assist with cleaning and applying glasses as needed.Further review of the medical record revealed on 05/22/25, Resident #97 was seen by the facility's vision provider for evaluation of glaucoma in the right and left eye, and a prescription for new eyeglasses was obtained. Additional review revealed an invoice, dated 05/31/25, for prescription eyeglasses. Observation on 07/28/25 at 3:02 P.M. revealed Resident #97 was sitting in the [NAME] Creek Hall dining room with no eyeglasses on. Additional observations on 07/29/25 at 12:55 P.M. and 07/31/25 at 10:57 A.M. of Resident #97 revealed the resident was sitting in the Will Creek Hall dining room and did not have eyeglasses on. Interview on 07/28/25 at 3:02 P.M. with Resident #97's son revealed the resident previously resided on the facility's memory care unit and moved to the [NAME] Creek Hall in August 2024. Resident #97's son stated the resident's eyeglasses were misplaced and had not had eyeglasses since that time. Interview on 07/29/25 at 12:55 P.M. with Licensed Practical Nurse (LPN) #365 revealed she spoke with Resident #97's son yesterday and the resident's eyeglasses had been missing since the resident moved from the memory care unit. Interview on 07/29/25 at 12:59 P.M. with Social Service Assistant (SSA) #940 revealed Resident #97 was supposed to get new eyeglasses at the end of May 2025. SSA #940 stated she contacted the vision provider on 07/28/25, after it was brought to her attention that the resident did not have her eyeglasses, and was told the eyeglasses must have been lost in the mail. SSA #940 was unsure of how long Resident #97 had been without her eyeglasses. Interview on 07/30/25 at 1:30 P.M. with the Administrator revealed it was not reported that Resident #97 did not have her physician ordered eyeglasses and confirmed they were misplaced during her move from the memory care unit to the [NAME] Creek Hall in August 2024.

Based on medical record review, observation, staff interview, and policy review, the facility failed to follow Enhanced Barrier Precautions (EBP) and further failed to use proper hand hygiene during wound care. This affected one (#04) of one resident reviewed for pressure ulcers. The facility census was 104. Findings include:Review of the medical record for Resident #04 revealed an admission date of 10/04/24 with medical diagnoses of chronic right heart failure, Stage III pressure ulcer to right heel, anemia, diabetes mellitus, and peripheral vascular disease. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/11/25, revealed Resident #04 was cognitively intact and required partial/moderate staff assistance for bed mobility and transfers, was dependent upon staff for toilet hygiene, and required set-up assistance with eating. Further review revealed Resident #04 had a Stage III pressure ulcer, which was not present upon admission. Review of the physician orders revealed an order dated 05/06/25 for EBP and an order dated 07/31/25 to cleanse proximal right heel wound and distal right heel wound with antibacterial soap and water, rinse, pat dry, apply loPlex (foam dressing with slow-release iodine) to wound bed, and cover/secure with bordered foam dressing every shift.Review of a skin issue assessment dated [DATE] revealed Resident #04 had a Stage III pressure ulcer to the right proximal heel, which measured 1.5 centimeters (cm) by 2.0 cm by 0.2 cm, a Stage III pressure ulcer to right distal heel, which measured 0.4 cm by 0.4 cm by 0.1 cm, and an abrasion to the right foot second toe, which measured 0.2 cm by 0.2 cm.Observation on 07/31/25 at 10:37 A.M. of Resident #04's wound care revealed Licensed Practical Nurse (LPN) #670 explained the wound care to Resident #04, prepared the bedside table with wound care supplies, and applied gloves. LPN #670 was observed to remove the old dressing from Resident #04's right heel. Continued observation revealed two pressure ulcers to the right heel, no drainage was noted, and the old dressing was discarded. LPN #670 removed the glove from her right hand only, applied a new glove, and then proceeded to cleanse the pressure ulcers with soap and water and patted dry. LPN #670 then removed both gloves, applied new gloves, and applied loPlex and dressing to the wounds as ordered. LPN #670 was observed to reorganize the resident's bedside table and then removed her gloves. Interview on 07/31/25 at 10:49 A.M. with LPN #670 confirmed Resident #04 was under EBP and she did not don a gown during wound care. LPN #670 also confirmed she did not perform hand hygiene between glove changes. Review of the facility policy titled, EBP, dated 11/12/24, revealed the purpose was to help the facility prevent and control the spread of possible infections. The policy stated residents should be placed in EBP if they have a wound or indwelling medical device, and secretions or excretions that were unable to be covered or contained and were not known to be infected or colonized with any Multidrug Resistant Organism (MDRO). Further review revealed residents were to be placed in EBP for hands on care for chronic wound care (pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers). The policy stated personal protective equipment (PPE) that may be worn included gloves and gown.Review of the facility policy titled, Hand Hygiene, revised 03/19/20, revealed the purpose was to prevent the transmission of infection and that handwashing should be performed after removing gloves or apron, after handling soiled residents care items, dressing, and equipment.

Based on observation, medical record review and staff interview, the facility failed to ensure residents were assessed for safe use of bed rails and further failed to ensure informed consent was received prior to the installation of bed rails. This affected three (#05, #07, and #83) of three residents reviewed for bed rails. The facility census was 104.Findings include: 1. Review of Resident #83's medical record revealed an admission date of 07/17/24. Diagnoses included traumatic subdural hemorrhage, dementia, hypertension, aphasia, altered mental status, major depressive disorder, and anxiety. Review of the annual Minimum Data Set (MDS) assessment, dated 07/17/25, revealed Resident #83 had severe cognitive impairment. Review of the physician orders revealed an order dated 07/17/24 for bilateral top half bed rails up while in bed to aid in bed mobility, transfers, and increase independence. Further review of Resident #83's medical record revealed no evidence an assessment was completed before, or after, the incident on 07/08/25. Additional review of the medical record revealed no evidence informed consent had been obtained prior to the implementation of bed rails for Resident #83. Observation of Resident #83's bed on 07/30/25 at 7:26 A.M. revealed bilateral upper bed rails with blue pads were in place. Interview on 07/30/25 at 9:53 A.M. with the DON verified bed rail assessments were not completed for residents to ensure safe use and further confirmed the facility did not obtain informed consent for the use of bed rails. 2. Review of the medical record for Resident #05 revealed an admission date of 09/26/22 with medical diagnoses of dementia with other behavioral disturbances, unspecified psychosis, hypertension, severe protein calorie malnutrition, and diabetes mellitus. Review of the quarterly MDS assessment, dated 04/06/25, revealed Resident #05 was cognitively intact and required set-up assistance for eating, substantial/maximum assistance for showers/bathing, bed mobility, transfers and was dependent upon staff for toilet hygiene. Further review of the MDS revealed no bed rail use was identified. Review of the physician orders revealed an order dated 09/17/22 for bilateral top half bed rails up while in bed to aid in bed mobility, transfers, and increase independence. Further review of Resident #05's medical record revealed no evidence an assessment had been completed to ensure safe use of bed rails. Observation on 07/28/24 at 10:38 A.M. revealed Resident #05 was lying in bed with bilateral top half bed rails in place. Observation on 07/30/25 at 11:50 A.M. revealed Resident #05 lying in bed with bilateral top half bed rails up. Concurrent interview with Resident #05 revealed the bed rail on the top of her bed was always up and that she used it at times for turning in bed with cares. Resident #05 stated she was not able to lower the bed rail independently. Interview on 07/30/25 at 2:00 P.M. with Resident Care Manager (RCM) #350 confirmed Resident #05 had bilateral top half bed rails up. RCM #350 verified the facility did not complete assessments to determine safe use of bed rails. 3. Review of the medical record for Resident #07 revealed an admission date of 12/15/23 with medical diagnoses of Alzheimer's disease, chronic kidney disease Stage III, dementia, and hypothyroidism. Review of the quarterly MDS assessment, dated 06/24/25, revealed Resident #07 had severely impaired cognition and required set-up assistance for eating, substantial/maximum assistance for bed mobility, and was dependent upon staff for toilet hygiene, transfers, and showers/baths. Review of the MDS revealed no documentation to support the use of bed rails. Review of a physician order dated 12/14/23 revealed Resident #07 had bilateral top half bed rails up while in bed to aid in bed mobility, transfers, and increased independence. Further review of Resident #07's medical record revealed no evidence and assessment had been completed to ensure safe use of bed rails. Observation on 07/28/25 at 2:38 P.M. revealed Resident #07 was sleeping in bed with padded bilateral top half bed rails up. Observation on 07/30/25 at 10:21 A.M revealed Resident #07 was sleeping in bed with padded bilateral top half bed rails up. Interview on 07/30/25 at 2:00 P.M. with RCM #350 confirmed Resident #07 had bilateral top half bed rails up. RCM #350 verified the facility did not complete assessments to determine safe use of bed rails.

Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure skin assessments were completed per facility policy and further failed to ensure treatments for identified skin conditions were implemented timely. This affected two (#72 and #05) of three residents reviewed for non-pressure ulcer skin conditions. The facility census was 104.Findings include: 1. Review of the medical record for Resident #72 revealed an admission date of 08/16/21. Diagnoses included unspecified dementia with behaviors, Alzheimer's disease, essential thrombocythemia, depression and anxiety. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/20/25, revealed Resident #72) had severely impaired cognition. She required maximum (staff) assistance with eating, bed mobility, transfers and toileting. Review of the current plan of care revealed Resident #72 had behaviors related to dementia with agitation and restlessness. Interventions included to administer medications as ordered and to monitor behaviors. Further review of the plan of care revealed Resident #72 was at risk for bleeding and bruised easily related to medications. Interventions included to monitor for unexplainable or increased bruising and document and report if it occurred. Review of a physician order dated 02/07/25 revealed to monitor all bruising for abnormal development and report to the physician. Review of the late entry progress note, dated 05/14/25 and created on 07/30/25, revealed the Certified Nurse Assistant (CNA) noted bruising to Resident #72's right shoulder during a shower. The note also documented the resident was known to roll into the bedrails. Review of the skin condition report, dated 05/14/25, revealed a diagram of a person with the right shoulder circled with the word bruise above it. Further review of Resident #72's medical record revealed a skin assessment for 05/14/25 was not completed until 07/30/25, which documented bruising to the resident's right shoulder measuring five centimeters 9cm) by (x) three cm. Review of the progress note dated 05/21/25 revealed the CNA had reported a bruise to Resident #72's right shoulder, the bruise had been reported on 05/14/25 and the area was noted to be fading and looked like a new bruise was developing on top of the old bruise. Treatment in place to monitor the bruise and padding placed on resident side. Additional review of Resident #72's medical record revealed no measurements were completed on 05/21/25, no skin assessment was completed on 05/21/25 and no further documentation regarding the bruise was present in the chart. Review of the May 2025 Treatment Administration Record (TAR) revealed staff documented monitoring or Resident #72 for bruising, as ordered. Interview on 07/30/25 at 8:22 A.M. with Resident Care Manager (RCM) #545 revealed if a skin condition, such as a bruise, was found by a CNA during a shower or cares, the expectation was that the CNA would notify the nurse. The nurse would then do a skin assessment in the electronic medical record (EMR) and initiate an investigation if warranted. RCM #545 verified there was no skin assessment in Resident #72's EMR for 05/14/25, following the identification of a bruise on the resident, and further stated she would investigate the incident. A follow-up interview on 07/30/25 at 9:17 A.M. with RCM #545 revealed she contacted the nurse who cared for Resident #72 on 05/14/25, who confirmed she failed to complete a skin assessment for the bruise discovered on 05/14/25. RCM #545 explained the nurse had measurements of the bruise on a paper record and was able to complete the skin assessment as a late entry. RCM #545 also verified there was no further skin assessment of the bruise. She stated staff had documented they had monitored the bruise on the TAR but acknowledged without documentation of measurements or description of the bruise, staff would not be able to determine if the bruise had improved or worsened. 2. Review of Resident #05's medical record revealed an admission date of 09/26/22. Diagnoses included unspecified dementia, unspecified psychosis not due to a substance or known physiological condition, Type II diabetes mellitus, and atherosclerotic heart disease of native coronary artery without angina pectoris. Review of the quarterly MDS assessment, dated 04/06/25, revealed Resident #05 was cognitively intact and required set-up assistance for eating, substantial/maximum (staff) assistance for showers/bathing, bed mobility, transfers and was dependent upon staff for toilet hygiene. Further review of the MDS revealed no skin issues were identified for Resident #05. Review of a skin assessment, dated 02/12/25, revealed Resident #05 had an open area/scabbed area to the left lower extremity (LLE), which measured 5 cm x 2 cm. The assessment noted two small areas of white drainage came out while cleaning, no bleeding, redness, or swelling. The assessment stated the area was covered with dry sterile dressing (DSD), to monitor and cleanse every day and as needed with normal saline and cover with DSD. Review of a physician order dated 02/19/25 revealed to apply betadine, non-adherent and kerlix daily to the LLE open area. Additional review of the physician orders revealed no evidence of a treatment being initiated on 02/12/25, when the skin concern was initially identified. Further review of Resident #05's medical record revealed no evidence of another skin assessment being completed until 02/26/25 (14 days after the skin concern was identified on 02/12/25), which stated Resident #05 had an open area to the LLE and measured 4 cm x 1.5 cm with no drainage. The assessment stated small areas of scabbing were noted and no swelling. Treatment included to swab area with betadine and apply Telfa (non-adherent wound dressing designed to protect and promote healing of wounds). Additionally review of a skin issue assessment dated [DATE] revealed Resident #05 had a skin tear to the LLE, which measured 0.9 cm by 0.9 cm with no drainage and was 100% scabbed. Interview on 07/31/25 at 11:21 A.M. with the Director of Nursing (DON) verified a treatment for Resident #05's skin issue was not ordered on 02/12/25, when initially identified, and further confirmed a weekly skin assessment was not completed on 02/19/25 to assess the area. The DON confirmed Resident #05 continued with the skin issue to the LLE, but stated the area had slowly improved. Review of the facility policy titled, Skin/Wound, revised April 2023, revealed any resident who had, or developed, skin issues should receive treatment/interventions to promote healing and to prevent further injury from occurring. The policy stated skin assessments should be done at the time of admission, weekly if a skin condition was noted, and as needed.

Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure resident care plans addressed the use of psychotropic medications. This affected three (#11, #56, and #83) of five residents reviewed for unnecessary medications. The facility census was 104. Findings include:1.Review of Resident #83's medical record revealed an admission date of 07/17/24. Diagnoses included dementia, hypertension, aphasia, altered mental status, major depressive disorder, and anxiety. Review of an annual Minimum Data Set (MDS) assessment, dated 07/17/25, revealed Resident #83 had severe cognitive impairment. Further review revealed Resident #83 used antianxiety, antipsychotic, and antidepressant medications. Review of the current physician orders revealed Resident #83 had the following orders: trazodone oral tablet 50 milligrams (mg), give one tablet at bedtime for depression/insomnia; quetiapine fumarate (anti-psychotic medication) 25 mg; give 12.5 mg at bedtime; Ativan oral tablet, give one tablet two times daily for anxiety/aggression; and Ativan oral tablet 0.5 mg, give one tablet every 24 hours as needed for anxiety/aggression. Review of Resident #83's care plan, initiated 10/07/24 and revised on 07/23/25, revealed no focus area, goals, or interventions related to the use of psychotropic medications (antianxiety, antipsychotic, and antidepressant). Interview on 07/31/25 at 9:38 A.M. with MDS Coordinator (MDSC) #920 verified there was no plan of care related to the use of psychotropic medications for Resident #83. 2. Review of Resident #56's medical record revealed an admission date of 06/03/24. Diagnoses included dementia, hypertension, heart failure, diabetes mellitus, anxiety, and major depressive disorder. Review of the quarterly MDS assessment, dated 04/29/25, revealed Resident #56 had moderate cognitive impairment. Further review revealed Resident #56 used antianxiety, antipsychotic, hypnotic, and antidepressant medications. Review of the current physician orders revealed Resident #56 had the following orders: Rexulti oral tablet, three mg, give one tablet three times daily for Bipolar disorder; lorazepam one mg, give one tablet three times daily for anxiety/agitation; lorazepam one mg, give one tablet daily, as needed, for anxiety/agitation; galantamine hydrobromide oral tablet 12 m, give one tablet two times daily for Bipolar disorder; doxepin 10 mg, give one capsule at bedtime; citalopram hydrobromide 20 mg, give one tablet daily for depression; and buspirone 10 mg, give one tablet three times daily for anxiety. Review of Resident #56's care plan, initiated 10/07/24 and revised on 07/23/25, revealed no focus area, goals, or interventions related to the use of psychotropic medications (antianxiety, antipsychotic, hypnotic, and antidepressant). Interview on 07/31/25 at 9:38 A.M. with MDSC #920 verified there was no plan of care related to the use of psychotropic medications for Resident #56. 3. Review of medical record for Resident #11 revealed admission date of 06/22/25. The resident was admitted with diagnoses including dementia with anxiety and psychotic disturbances and Alzheimer's disease. Review of the quarterly MDS assessment, dated 06/15/25, revealed Resident #11 had a Brief Interview Mental Status (BIMS) score of 07, indicating severe cognitive impairment. Resident #11 was independent with eating, toileting, bed mobility and transfers. Further review revealed no behaviors were documented and wandering occurred daily for the seven-day look back period. Review of the current physician orders revealed Resident #11 had orders for hydroxyzine (antianxiety) 25 mg every evening, Seroquel (anti-psychotic) 25 mg at bedtime and Buspar (antianxiety) 5 mg three times daily. Review of Resident #11's care plan, initiated 06/30/25 and revised on 06/24/25, revealed no focus area, goals, or interventions related to the use of psychotropic medications (antianxiety, antipsychotic, hypnotic, and antidepressant). Interview on 07/31/25 at 9:38 A.M. with MDSC #920 verified there was no plan of care related to Resident #11's psychotropic medication use. Review of the facility policy titled, Plan of Care, dated 01/26/23, revealed each resident would have an individualized interdisciplinary plan of care in place. The Interdisciplinary Team (IDT) Would continue to develop the comprehensive care plan in conjunction with the MDS. The care plan would address resident's goals, actual and potential problems, needs, strengths , and individual preferences of the resident.

Based on observation, medical record review, staff interview and review of facility policy, the facility failed to investigate bruising of unknown origin. This affected one (#72) of three residents reviewed for skin conditions. The facility census was 104. Findings include: Review of the medical record for Resident #72 revealed admission date of 08/16/21. Diagnoses included unspecified dementia with behaviors, Alzheimer's Disease, essential thrombocythemia, depression and anxiety. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/20/25, revealed Resident #72 had severely impaired cognition and required maximum (staff) assistance with eating, bed mobility, transfers and toileting.Review of the current care plan revealed Resident #72 had behaviors related to dementia with agitation and restlessness. Interventions included to administer medications as ordered and to monitor behaviors. An additional care plan area revealed she bruised easily related to medications and to monitor for unexplained bruising or increased bruising and to document and report if it occurred.Interview on 07/30/25 at 9:17 A.M. with Resident Care Manager (RCM) #545 verified no skin assessments had been completed for Resident #72 since 05/14/25, when a five centimeter (cm) by three cm bruise was documented to her right shoulder.Observation on 07/30/25 at 10:25 A.M. of Resident #72's right shoulder revealed a light blue circular area, approximately five cm by 2.5 cm in size. Also observed were three small circular bruised areas on her right inner forearm. The three circular bruises were light purple surrounded by a faded yellow tone. Concurrent interview with RCM #545 verified the bruises resembled fingerprints. RCM #545 added Resident #72 would cross her arms and place her fisted hands into her chest area and stiffen during cares, but was unaware if the behaviors had been documented. Interview on 07/30/25 at 10:33 A.M. with Certified Nursing Assistant (CNA) #408 revealed she cared for Resident #72 the day prior and had seen the bruises while providing care. She stated she did not report the bruises to the nurse because they appeared old. CNA #408 stated she was unsure when the bruises had occurred and added she had returned after two weeks off of work.A follow-up interview on 07/30/25 at 2:30 P.M. with RCM #545 confirmed there was no documentation in the electronic medical record (EMR) or the skin condition reports for the areas of bruising on Resident #72. RCM #545 contacted Resident #72's daughter and physician to provide an update. She explained staff should be educated that a skin condition should be reported immediately and be documented. Staff should also be educated on the fragility of the resident's skin and the propensity for bruising, and to inform the nurse of any combative behavior with care so it may be tracked.Interview on 07/31/25 at 9:18 A.M. with the Administrator verified an investigation was not completed for the bruises to Resident #72's right inner arm. She stated Resident #72 would cross her arms, ball her hand into a fist and tighten them across her chest. The Administrator verified this behavior had not been documented and there was no documentation of when or how the bruises occurred.Review of the undated facility policy titled, [NAME] Acres Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property revealed it was the facility's policy to investigate all alleged violations involving abuse, neglect, misappropriation of resident property, exploitation or mistreatment, including injuries of unknown source. An injury was classified as an injury of unknown source when the following were met: the source of the injury was not observed by any person, the source of the injury could not be explained by the resident, and the injury was suspicious because of the extent, location, number of injuries observed at one time or over time.

Based on medical record review, staff interview and policy review, the facility failed to ensure the preadmission screening and resident review (PASARR) were accurately completed and updated. This affected four residents (#02, #21, #23, and #61) out of four residents reviewed. The facility census was 88. Findings include 1. Review of the medical record for the Resident #61 revealed an admitted [DATE]. Diagnoses included heart failure, diabetes, chronic obstructive pulmonary disease, dysphagia, dementia, bipolar disorder, and depression. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #61 was cognitively impaired and required extensive assistance of one staff members for transfers and mobility. Review of the plan of care dated 01/04/23 revealed Resident #61 had impaired cognition with interventions for medications, clip call light with bright colors, establish a routine for resident and provide cueing and prompting to resident. The care plan also revealed the resident had diagnosis of depression, bipolar disorder, and anxiety with interventions including acknowledge resident moods, provide medication as ordered, encourage group activities and encourage family visits. Review of the physician orders dated 10/17/20 revealed an order for citalopram hydrobromide tablet 20 milligram (mg) for depression, buspirone tablet five mg for anxiety, and donepezil tablet 10 mg for dementia. An order dated 03/21/22 for hydroxyzine tablet 25 mg for anxiety. Review of the PASARR document dated 03/25/19 revealed Resident #61 had no dementia diagnosis listed. The resident also had no mental health diagnosis listed under section D of the PASARR. 2. Review of the medical record for the Resident #23 revealed an admitted [DATE]. Diagnoses included pulmonary embolism, heart failure, edema, peripheral vascular disease, anxiety, schizophrenia, and depression. Review of the MDS assessment dated [DATE] revealed Resident #23 was cognitively intact and was independent with transfers and mobility. Review of the plan of care dated 01/24/23 revealed Resident #23 had diagnosis of schizophrenia, anxiety and depression with interventions to see the social worker for one-on-one visits, use diversional activities as appropriate, provided medications as ordered and refer to psychiatric services as needed. Review of the physician orders dated 09/21/17 identified orders for escitalopram oxalate tablet 20 mg for depression. An order dated 11/15/21 for risperidone tablet four mg for schizophrenia. An order dated 03/21/22 for hydroxzine tablet 25 mg for anxiety. Review of the PASARR document dated 07/13/16 revealed Resident #23 had dementia and schizophrenia listed under the mental health diagnosis. Anxiety and depression were not documented on the PASARR. Further review of the medical record found no record of dementia documented as one of Resident #23's medical diagnoses. Interview on 01/24/23 at 2:35 P.M., with the Social Service designee (SSD) #118 revealed admissions completed PASARR's upon admissions and after a hospital exemption expires. She revealed she had completed updated PASARRs for changes in condition or diagnosis but does not regularly do them. The SSD #118 revealed she was unsure if admissions staff were also responsible for updating the PASARRs for already admitted residents. The SSD #118 revealed the facility staff had not updated her with changes in diagnosis, only changes in medications and if psychotropic medications were started. The SSD #118 verified the PASARR information for Resident #23 and #61 were not updated with changes in diagnosis. Review of the facility policy titled Admission Manual: Universal Preadmission review, undated revealed the facility would follow all state and federal preadmission review regulations. The policy revealed copies of the screens would be kept in a consistent place on the medical record. The policy did not address how often the PASARRs would be updated. 34290 3. Review of the medical record for Resident #21 revealed he was admitted to the facility on [DATE] with a diagnosis of schizoaffective disorder, bipolar type, sprain ligaments of the cervical and lumbar spine, hypertension, suicidal ideation, post traumatic stress disorder, chronic obstructive pulmonary disease, anxiety, and morbid obesity. Review of the quarterly MDS dated [DATE] revealed Resident #21 was cognitively intact. His functional status is listed as independent set up only. Review of the PASARR dated 06/21/19 revealed Resident #21 had no indications of serious mental illness nor a developmental disability. The resident had not qualified for a PASARR II at that time. Review of Resident #21's diagnosis revealed chronic post-traumatic stress disorder, schizoaffective disorder bipolar type, on his diagnosis list dated 06/14/19. Review of the physician orders dated 01/13/22 revealed aripiprazole tablet 20 mg, give one tablet by mouth, one time a day related to schizoaffective disorder, bipolar type, give with 5 mg tablet to equal 25 mg. Fluoxetine capsule 40 mg, give one capsule by mouth one time a day related to schizoaffective disorder bipolar type and anxiety disorder. Interview with the Social Services Designee #118 on 01/24/23 at 2:35 P.M., verified the PASARR was not completed properly. 34742 4. Review of the Medical record for Resident #02 revealed admitted [DATE]. Diagnoses included dementia, acute and chronic respiratory failure, chronic pain, emphysema, bipolar disorder, anxiety disorder, hallucinations, psychosis not due to a substance or known physiological condition, and major depressive disorder. Review of the PASARR dated 02/13/12 revealed Resident #02 did not have a documented diagnosis of dementia and had no diagnosis of mental disorders. Interview on 01/24/23 at 2:29 P.M., the SSD #118 stated the admissions staff took care of the PASARR. She stated she had helped with them, but admissions usually completed them. She stated the PASARR should be updated with change of diagnosis or status. She stated she usually was not informed when there was a change in diagnosis, or updates. She stated she usually received notification of a drug change, but not a diagnosis. She stated if she were aware of changes the PASARR would have been updated.

Based on medical record review, staff interview, and policy review, the facility failed to develop a comprehensive care plan for contracture's. This affected one resident (#33) out of one resident reviewed for position and mobility. The facility identified three additional residents (#18, #55, and #14) with contracture's. The facility census was 88. Findings include: Medical record review for Resident #33 revealed admitted [DATE]. Diagnoses included hemiplegia and hemiparesis, congestive heart failure, history of transient ischemic attack, and cerebral infarction without residual deficits. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had intact cognition. Resident #33 required extensive assistance of two plus persons physical assistance for bed mobility, dressing, and personal hygiene. The resident required total dependence of two plus persons for transfers. The resident had functional limitations in range of motion (ROM) in the upper and the lower extremities on both sides. The resident received Occupational Therapy (OT) services from 06/07/22 to 09/15/22. Review of the plan of care dated 10/24/22 revealed Resident #33 was independent with eating, needs extensive assist with bed mobility, transfers, dressing, toilet use and personal hygiene. The resident was dependent on staff for locomotion on and off the unit, bathing. The goal was maintain current level of independence. Interventions include encourage resident to participate in activities of daily living (ADL) and praise effort to do so. Offer ROM with morning and bedtime care. Educate on risks and benefits if the resident refused. Review of Occupational Therapy Recertification Progress Report and Updated Therapy Plan dated 06/07/22 revealed hemiplegia and hemiparesis following other cerebrovascular disease affecting the right dominant side. Treatment for contracture, unspecified joint. Interview on 01/24/23 at 2:42 P.M., the Occupational Therapist (OT) #160 stated Resident #33 was on the case load from 06/07/22 to 09/15/22 with goals for transfers with staff, a custom wheelchair, for pressure relief, passive range of motion goals for the right hand and arm. She stated the resident had a contracture of the right hand, with additional medical events, and then a goal for a resting hand splint. She stated the resident was showing swan neck deformity. She stated they discontinued the hand splint and trialed oval eight (8) splints (a type of splint for the fingers), morning to afternoon, one for each digit. She stated the resident hated them and did not wish to continue. She stated last week the nursing staff mentioned the resident's hand contracture was worse. She stated they have to get preauthorization and try to pick up the resident for additional therapy. She stated they planned to try a palm protector. Interview on 01/26/23 at 1:51 P.M., Registered Nurse (RN) #150 stated Resident #33 did not have an individualized comprehensive care plan for contractures. She stated the requested list of residents with contractures did not include Resident #33, but he would be added. Review of facility policy titled Advance Care Planning, dated 01/01/12 revealed it is the policy of [NAME] Acres to give the residents the opportunity to discuss their goals for care including their preferences for advance care planning. The problems, goals and interventions are discussed and documented during the care planning session and documented in the medical record of the resident. Results of the care planning session are communicated to the care team by oral, written, or telecommunication methods.

Based on medical record review, review of the Fall/Incident Statement, staff interview, and policy review, the facility failed to ensure care plans were timely updated. This affected one resident (#14) out of two residents (#12 and #14) reviewed for falls. The facility census was 88. Findings include: Medical Record Review for Resident #14 revealed admitted [DATE]. Diagnoses included congestive heart failure (CHF), headache, macular degeneration, stiffness of the right hip, cardiomegaly, history of falling, and protein-calorie malnutrition. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 had intact cognition. The Resident required extensive two plus person assistance for bed mobility and transfers. The resident required extensive one person assistance for dressing, toilet use, and personal hygiene. The resident was frequently incontinent of bladder and always continent bowel. The resident assessment revealed no falls since admission/entry or reentry. Review of the plan of care dated 11/16/22 revealed Resident #14 was at risk for injuries from falls related to impaired balance, use of psychoactive/narcotic/cardiovascular medications, diagnoses bradycardia, and anemia. The goal will be free of injuries from falls. Interventions included appropriate nonskid footwear when out of bed or dressed for the day. Call light within reach at all times. Keep room free of obstacles, clutter, and debris which may cause injury. Mat beside the bed when in it. Medications as ordered. Personal items within reach at all times. Soft touch call light. When non-compliant with need for assistance, re-educate on risks/benefits and document. Toilet in advance of need initiated 12/02/22 this intervention created date was 01/25/23 by Registered Nurse (RN) #146. Review of the Fall/Incident Statement dated 12/02/22 revealed Resident #14 had an unwitnessed fall. The last fall was dated 07/19/21. The resident was found on the floor in front of her recliner. Resident #14 stated, I was trying to go to the bathroom. No injuries found. Action Plan: Resident educated on call light use. Conclusions/Summary/Interventions included toilet in advance of need. Interview on 01/26/23 at 9:53 A.M., the RN #146 stated the care plan was updated on 01/25/23 to include toilet in advance of need. She stated the intervention was overlooked and not added to the plan of care. Review of facility policy titled Advance Care Planning, dated 01/01/12 revealed any situations that need investigation and/or follow up are conducted timely and reported to the resident, responsible party, and interdisciplinary team (IDT) as soon as possible. The problems, goals and interventions are discussed and documented during the care planning session and documented in the medical record of the resident. Results of the care planning session are communicated to the care team by oral, written, or telecommunication methods.

Based on observation, staff interview, and policy review the facility failed to ensure proper hand hygiene was performed during a wound/dressing treatment to promote healing and prevent infection. This affected one resident (#76) out of one resident reviewed for pressure ulcers. The facility identified four residents (#53, #71, #76, and #82) with pressure ulcers. The facility census was 88. Review of the medical record for Resident #76 revealed she was admitted to the facility on [DATE] with a diagnosis of Alzheimer's Disease, diabetes type II, hypertension, rheumatic tricuspid valve insufficiency, nonrheumatic aortic valve stenosis, nonrheumatic mitral valve insufficiency. Review of the Minimal Data Set (MDS) dated [DATE] revealed Resident #76 had extensive cognitive impairment. Her functional status was listed as extensive two person assist for all activities of daily living. The assessment also revealed Resident #76 had a stage III pressure ulcer. Observation of the wound/dressing change on 01/24/23 at 1:35 P.M. with License Practical Nurse (LPN) #67 revealed she used hand sanitizer upon entering Resident #76's room. She placed gloves on her hands and removed the old dressing from the wound and placed it in the trash can along with her gloves. The LPN #67 donned new gloves and started to clean and redress the resident's wound when the surveyor stopped her and asked her if she used sanitizer or washed her hands after removing the old dressing. The LPN #67 then stopped removed the gloves, used the sanitizer to clean her hands, donned new gloves, and continued to complete the dressing change. Interview with the LPN #67 on 01/24/23 at 1:50 P.M., verified she failed to wash her hands between removing the old and cleaning and redressing Resident #76's wound. Review of the facility policy titled Dressing-Clean, dated 11/1919 revealed to perform hand hygiene, apply clean gloves, remove soiled dressing, place soiled dressing and gloves in plastic bag, complete hand hygiene, apply clean gloves, follow treatment order for application of topical medication, and apply absorbent dressing , remove gloves and discard in plastic bag. Wash hands.

Based on medical record review, review of the pharmacy recommendations, staff interview, and policy review, the facility failed to ensure a pharmacy recommendation were timely reviewed by the physician and included an appropriate reasoning for continuing the medication. This affected one resident (#59) out of five residents reviewed for pharmacy recommendations. The facility census was 88. Finding include Review of the medical record for the Resident #59 revealed an admitted [DATE]. Diagnoses included Parkinson's disease, cognitive communication deficit, dysphagia, dementia, urine retention, tremors, psychotic disorder with delusions, neurocognitive disorder with lewy bodies, aphasia, hemiplegia, and urgency of urination. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #59 was cognitively impaired and required extensive assistance of one staff member for transfers and mobility. The MDS also revealed the resident had a urinary catheter. Review of the plan of care dated 01/11/23 revealed Resident #59 had a suprapubic catheter due to urinary obstruction and lower urinary symptoms with interventions for medication as ordered (oxybutynin), refer to the urologist, provide catheter care and complete bladder scans each shift. Review of the physician orders dated 09/04/22 identified orders for oxybutynin chloride tablet five milligram (mg) with instructions to give one tablet by mouth twice daily for bladder spasms. Review of Resident #59's pharmacy recommendation form dated 09/15/22 revealed a concern of resident receiving oxybutynin five mg twice daily for bladder spasms ordered 09/04/22. The pharmacist recommendation revealed this medication was contraindicated for geriatric residents due to side effects of urine retention, hallucinations confusions and increased risk of falls. Request was documented to have the medication changed to bethanechol or another urinary antispasm agent. The recommendation was reviewed by the physician on 10/27/22 and did not mark a decision but left a comment of urologist prescribed. Review of the progress notes dated 09/2022 to 01/23/23 revealed no mention of the urologist being informed of the pharmacy recommendation from 09/15/22. The progress note dated 01/24/23 revealed a message was left with the urology office regarding a pharmacy review recommendation related to the oxybutynin medication. No determination was noted from the call. Interview on 01/24/23 at 12:40 P.M., with the Director of Nursing (DON) and Infection Preventionist (IP) #150 revealed the pharmacy recommendations were printed off and provided to the physician on the next scheduled visit. The DON revealed the physician comes in every two weeks. The DON revealed being unaware of staff or the physician contacted the urologist regarding Resident #59's pharmacy recommendation. Interview on 01/26/23 at 11:26 A.M., with the Physician #160 revealed he was at the facility two days every other week. He revealed he reviews pharmacy recommendations during those visits and they should be responded to within two weeks of the facility receiving the recommendation. The Physician #160 revealed he has made changes to urology medications in the past if residents had been on multiple medications for the same thing without reasoning. He revealed no memory of speaking with the urologist specifically related to the 09/15/22 recommendation and denied a system was in place to refer the pharmacy recommendations related to a specialist prescribed medication to that specialist. The Physician #160 revealed he does not typically make changes to a resident's medications prescribed by a specialty physician. Review of facility policy titled Pharmacist consulting services, dated 06/08/18 revealed each resident would be reviewed monthly by a pharmacist for any medication concerns or irregularities and provide a written recommendation. The policy does not address how the facility was to follow up on the recommendations made by the consulted pharmacist.

Based on medical record review, staff interview and policy review, the facility failed to ensure a significant weight loss was timely notified to the Dietician and the resident family. This affected one resident (#71) out of four residents reviewed for nutrition. The facility census was 88. Findings include: Review of the medical record for the Resident #71 revealed an admitted [DATE]. Diagnoses included pneumonia, dementia, dehydration, unsteadiness, syncope and collapse. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #71 was cognitively impaired and required extensive assistance of two staff members for mobility and transfers. Review of the baseline care plan dated 12/22/22 revealed Resident #71 was at risk for alteration in nutrition. Review of the physician orders dated 12/22/22 revealed an order for Resident #71 weights daily for seven days then weekly for three weeks then monthly. An order dated 01/07/22 revealed an order for registered dietician (RD) consult for a 9.33 pound weight loss since arrival. An order dated 01/22/22 revealed an order for RD consult due to weight loss. Review of Resident #71's weights revealed an admission weight on 12/22/22 of 107.8 pounds (lbs), a weight on 12/31/22 of 112.5 lbs, a weight on 01/07/22 of 98.6 lbs, and a weight on 01/22/23 of 96 lbs. On 01/07/23 the resident had a significant weight loss of 8.53 percent since admission on 12/22/22. On 01/22/23 resident had a significant weight loss of 10.95 percent since admission 12/22/22. Review of the physician note dated 01/04/22 revealed Resident #71 had low food intake and was refusing medications and food and the medical team was discussing concerns with the family with the possibility of initiating palliative care. Review of the progress note dated 01/24/23 revealed the dietician was informed of the weight loss on 01/22/23. The dietician reviewed Resident #71's dietary needs and revealed he had increased intake over the previous week and felt he had stabilized and had not recommend additional supplements at that time. Their was no mention in the progress notes related to the dietician or family being informed of a significant weight loss on 01/07/23. Interview on 01/25/23 at 3:05 P.M., with the State tested Nursing Assistant (STNA) #62 revealed the nurses would inform the aides of which residents had scheduled weights for a given shift and would report the weight back to the nurse upon completion for documentation and follow up. Interview on 01/25/23 at 3:20 P.M., with the Dietician #162 revealed she assessed residents upon admission and with significant changes in weights. The Dietician #162 revealed she was informed of Resident #71's weight loss on 01/22/23 and assessed the resident on 01/24/23. Interview on 01/26/23 at 11:18 A.M., with the Infection Preventionist (IP) #150 revealed the nurse checked the daily notes that Resident #71's family was contacted on 01/07/22 about the significant weight loss, but confirmed no note was made related to informing the family or the dietician of the weight loss, or related to any follow-up from the dietician related to the weight loss. A follow-up interview on 01/26/23 at 11:27 A.M., with the Dietician #162 revealed when a resident had weight loss staff would put a note in her mailbox to see the next time she was at the facility. The Dietician #162 revealed she worked onsite at the facility on Tuesdays each week. The Dietician #162 revealed she was not informed of the weight loss on 01/07/23 and revealed she was not aware of the order put in on 01/07/23 related to assessing the resident for weight loss. Review of facility policy titled Weights, dated 08/2021 revealed significant weight loss would be reported to the responsible party or family member and the dietician.

Based on record review, staff, family, and resident representative interview, and policy review, the facility failed to ensure residents and representatives participated in care conference meetings. This affected one resident (#59) out of two residents reviewed for care conferences. The facility census was 88. Finding include: Review of the medical record for the Resident #59 revealed an admitted [DATE]. Diagnoses included Parkinson's disease, cognitive communication deficit, dysphasia, dementia, urine retention, tremors, psychotic disorder with delusions, neurocognitive disorder with lewy bodies, aphasia, hemiplegia, and urgency of urination. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #59 was cognitively impaired and required extensive assistance of one staff member for transfers and mobility. Review of the care conferences dated 12/27/21, 03/15/22, 06/21/22, 09/20/22, and 12/01/22 revealed care conferences had no evidence of the resident or the resident representative was invited or attended. Review of the progress notes dated 12/2021 to 12/2022 revealed no documentation of the resident or the resident representative invited or attending care conferences. Interview on 01/23/23 at 11:07 A.M., with Resident #59's representative revealed she had never been invited to attend any multidisciplinary care conferences. She revealed she would have interest in attending had she been invited. Interview on 01/23/23 at 1:30 P.M., with Resident #73's family revealed they typically received the letter after the care conference had occurred. Interview on 01/24/23 at 2:35 P.M., with Social Services designee (SSD) #118 revealed the facility held care conferences for each resident quarterly and revealed they were typically held in the residents room. She revealed she tried to invite family to the meetings about one week to 10 days ahead of time either through phone call or through a mailed letter. The SSD #118 said residents do not sign the sheet when they attend the meeting and families do not always sign the attendance form. No families were informed of care conferences on 01/24/23 due to the SSD #118 being off, and revealed she informed resident's families today for meetings on 01/26/23. The SSD #118 revealed Resident #59's power of attorney (POA) was his girlfriend and could not remember if resident's POA had been been invited to attend any care conferences. The SSD #118 said she had not documented in the medical record about who was invited to attend the care conferences. Review of the facility policy titled Care Conferences, dated 08/23/18 revealed the facility failed to implement the policy regarding the allegation. The policy revealed the care conference are a time when staff resident and family/POA/guardian can discuss concerns. The care conference should include resident, family/POA/Guardian if able to participate and staff including State tested Nurse Aide (STNA), nurse, dietary, activities, and social services. The procedure included to make sure the resident and family are aware of the date and time of the care conference. All attendees would sign the bottom of the care conference summary form used during the meeting.

Based on medical record review, staff interview and review of standing house orders, the facility failed to monitor Resident #23's bowel status and implement their standing house orders as directed. This resulted in Actual Harm when Resident #23 did not have a bowel movement for six days and the resident was subsequently hospitalized for [REDACTED]. This affected one (#23) of two residents reviewed for hospitalization . Facility census was 91. Findings include: Review of the medical record revealed Resident #23 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the admission minimum data set (MDS) assessment, dated 06/29/18, revealed the residents brief interview for mental status was not assessed due to being rarely or never understood. Further review revealed the resident was frequently incontinent of bowel and required extensive staff assist with toileting. Review of the care plan, initiated 07/05/18, revealed Resident #23 was prone to constipation, had decreased mobility, and a history of constipation. The goal was for Resident #23 to have a bowel movement every one to three days. Care plan interventions instructed staff to monitor for a bowel movement every shift. Review of physician orders [REDACTED].#23. Further review of orders, dated 06/22/18, revealed Resident #23 was to receive [MEDICATION NAME] (pain medicine that can cause constipation) 50 milligrams (mg) three times daily. Review of a report titled Look Back Report regarding Resident #23's bowel movement history revealed the resident had a medium bowel movement documented on 07/26/18 at 4:16 A.M. Further review of the report revealed the resident did not have a bowel movement documented on 07/27/18, 07/28/18, 07/29/18, 07/30/18 or 07/31/18. Review of progress notes dated 08/01/18 at 6:20 A.M. (late entry) revealed Resident #23 had large emesis (vomiting). The resident's abdomen was slightly distended, was passing gas, and had three small bowel movements while turning and repositioning. Review of progress notes, dated 08/01/18 at 2:30 P.M., revealed Resident #23 had nausea with periodic emesis since the morning. The resident had a large bowel movement, however the nausea and vomiting continued. The resident's abdomen was distended and firm. After suppositories (for constipation) were given and an abdominal x-ray was obtained the resident was sent to the emergency room for evaluation at 11:30 P.M. Review of the hospital history and physical, dated 08/02/18, revealed Resident #23 was admitted with an acute large bowel obstruction, gastrointestinal hemorrhage, and acute kidney failure. The resident had nausea, vomiting, and abdominal distention likely due to large bowel obstructions from fecal impaction. The plan was to aggressively treat constipation with stool softeners and a daily enema. The resident was hospitalized for [REDACTED]. Interview on 08/27/18 at 4:02 P.M. with the Director of Nursing (DON) confirmed Resident #23 had no bowel movement times for a period of six days (07/26/18 to 08/01/18). Further interview confirmed the facility did not assess the resident after not having a bowel movement after three days and did not follow standing house orders for constipation. The DON confirmed Resident #23 was admitted to the hospital for an acute large bowel obstruction. Review of standing house orders, physician approved 07/03/18, revealed if the resident does not have a bowel movement for three days to assess their bowel sounds and document in nurses' notes, administer 120 milliliters (ml) of prune juice with breakfast, and assess manually for stool after each meal removing if present. If prune juice is ineffective and no stool present upon manual assessment, administer milk of magnesia (for constipation) 30 milliliter (ml) by mouth before the end of first shift. Further review revealed if the resident does not have a bowel movement for four days the facility is to assess bowel sounds and document in nurse's notes and assess manually for stool after each meal. If no stool present, administer [MEDICATION NAME] (for constipation) 10 milligram (mg) suppository rectally times one by 6:00 A.M. unless contraindicated. If no results from [MEDICATION NAME] within eight hours, administer Fleets enema times one at 2:00 P.M. If no results from Fleets enema within one hour, administer soapsuds enema. If no results from soap suds enema contact physician immediately.

Based on observation, staff interview, review of a dietary listing and review of policy, the facility failed to ensure pans were appropriately dried to maintain proper sanitation. In addition, the facility failed to store ready to use icing in the refrigerator per label to prevent contamination. This had to the potential to affect all residents residing in the facility. The census was 91. Findings include: 1. Observation on 08/26/18 at 9:00 A.M. during the initial tour of the kitchen revealed seven stacks of various sized metal storage pans on the shelf. Further observation of Dietary Aide #34 remove pans from each stack revealed condensation on the inside. Two stacks had visible water dripping off the edges. Interview on 08/26/18 at 9:00 A.M. with Dietary Aide #34 confirmed seven stacks of various sized metal storage pans were not dried prior to stacking on the shelves. Further interview revealed the pans were washed and put away the night before. Review of the undated facility policy titled Cleaning Procedure - Pots and Pans revealed to remove the pans from the sanitizing sink and invert on drain board. Let air dry. Do not wipe. 2. Observation on 08/26/18 at 9:00 A.M. during the initial tour of the kitchen revealed one opened container of ready to serve cream cheese icing in the dry storage room. The icing was opened on 08/15/18. Further review of the label read once icing container has been opened, the icing can be stored covered at room temperature for one week. After this time period, store covered in the cooler. Interview on 08/26/18 at 9:00 A.M. with Dietary Aide #34 confirmed the icing was opened on 08/15/18 and had not been stored properly in the cooler. Review of the dietary list revealed all 91 residents receive food from the kitchen.

Based on observation, staff interview, list provided by the facility and review of policy and procedures, the facility failed to appropriately clean a glucometer after checking a resident's blood sugar. This affected one (#283) out of one resident observed having their blood sugar checked during medication administration and had the potential to affect five (#2, #16,#32, #41 and #282) additional residents identified by the facility as using the same glucometer for blood sugar monitoring. Facility census was 91. Findings include: Review of list provided by the facility identified six (#2, #16, #32, #41, #282 and #283) Residents as using the same glucometer for blood sugar monitoring. On 08/26/18 at 11:36 A.M. an observation was made of Resident #283 blood sugar check with a glucometer device. At this time Registered Nurse (RN) #100 nurse checked the Resident's blood sugar. When she was completed with the blood sugar check she cleaned the glucometer device with an alcohol prep pad and placed it back in the medication cart drawer. On 08/26/18 at 11:38 A.M. an interview with RN #100 verified she cleaned the glucometer with an alcohol prep pad. She stated she isn't sure but she did have the proper sanitizing wipes available in her cart. She revealed she is not sure if the facility is out so it had to be cleaned with something. She verified there are six (#2, #16, #32, #41, #282 and #283) residents all together who use the same glucometer machine for the unit. Review of policy titled glucometer-infection control/disinfecting dated 11/29/17 documented the glucometer must be cleaned with super sani-cloth germicidal disposable wipes after each resident use. The glucometer is to be wiped down. The glucometer is to be wet for two full minutes and be left out to air dry for each use.

Based on observation, review of dietary spreadsheets, and staff interview the facility failed to serve bread per the dietician approved spreadsheet to residents receiving puree diets. This affected eight (#6, #8, #17, #43, #49, #61, #64, and #66) of eight residents receiving pureed diets. The census was 91. Findings include: Observation during lunch on 08/27/18 at 11:25 A.M. revealed bread was not served to residents receiving pureed diets. Review of the dietician approved spreadsheet revealed residents receiving pureed diets were to receive a pureed wheat roll for lunch on 08/27/18. Interview on 08/27/18 at 11:35 A.M. with Dietary Manager #109 confirmed bread was not served to residents receiving pureed diets. Further interview revealed the facility stopped serving pureed bread items approximately one year ago due to residents dislike. Interview on 08/28/18 at 11:39 A.M. with Registered Dietician #144 revealed she was aware residents were not receiving pureed bread, but was not aware it was still on the spreadsheet. The facility confirmed eight (#6, #8, #17, #43, #49, #61, #64, and #66) residents receive pureed diets.

Based on medical record review, resident and staff interview, review of facility self-reported incidents (SRI's) and review of facility policy, the facility failed to implement their abuse policy to ensure allegations of abuse were immediately reported and thoroughly investigated. This affected two (#69 and #73) of two residents reviewed for abuse. The census was 91. Findings include: 1. Review of the medical record revealed Resident #69 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was hospitalized from [DATE] through 08/19/18 for a right hip sustained after a fall in the facility. Review of the minimum data set (MDS) assessment, dated 07/07/18, revealed a brief interview for mental status (BIMS) of 14. Interview on 08/26/18 at 2:41 P.M. with Resident #69 revealed State tested Nurse Aide (STNA) #64 was loud and rough when providing care. The resident stated she fought with me, she yelled and screamed at me, I wasn't sitting right, I wasn't walking right, I wasn't doing anything right, it was horrible. Further interview revealed allegations that STNA #64 drug her (with assist of an unnamed STNA) to the bathroom in the middle of the night. The resident reported being a nervous wreck ever since STNA #64 worked with her. Interview on 08/28/18 at 11:51 A.M. with Registered Nurse (RN) Unit Manager #29 revealed she was aware that STNA #64 had upset Resident #69 by saying you need to try, you are weight bearing as tolerated. Further interview revealed RN #29 had not interviewed the resident and/or other residents on the unit regarding care provided by STNA #64. Interview on 08/28/18 at 12:15 P.M. with STNA #39 revealed Resident #69 had complained about care provided by STNA #64. She stated STNA #64 was too rough with putting her to bed and assisting her to the bathroom. Interview on 08/28/18 at 12:24 P.M. with Licensed Practical Nurse (LPN) #85 revealed Resident #69 reported allegations that STNA #64 was rough and told her she should be doing more for herself. Further interview revealed she reported the allegations to LPN #59 on 08/25/18 at 7:00 P.M. during shift change. Interview on 08/28/18 at 12:08 P.M. with the Director of Nursing (DON) revealed she was notified on 08/25/18 at 7:42 P.M. by LPN #59 via text messages of the allegations. The text message read there was a complaint from the resident on STNA #64. LPN #59 assumed all direct care for Resident #69 the remainder of the shift. STNA #64 continued to work the shift taking care of other residents. Further interview confirmed Resident #69 and/or other residents had not been interviewed regarding allegations of abuse. Interview on 08/28/18 at 5:00 P.M. with the Administrator confirmed an investigation had not been initiated regarding the allegation of abuse from Resident #69. Further interview confirmed the facility did not report an allegation of abuse to the required officials per policy. 2. Review of the medical record revealed Resident #73 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS assessment, dated 08/01/18, revealed a BIMS of 15. Further review revealed the resident required extensive staff assist with transfers and toileting. Interview on 08/28/18 at 12:34 P.M. with Activities Assistant #13 revealed Resident #73 complained about care provided by STNA #64 on 06/25/18. Resident #73 had asked for assistance with going to the bathroom. The resident reported that STNA #64 told her to go in her diaper. Further interview revealed Activities Assistant #13 gave a written statement regarding the allegation to the Assistant Director of Nursing (ADON). Interview on 08/28/18 at 12:44 P.M. with the Assistant DON (ADON) revealed she was aware Resident #73 reported an allegation that STNA #64 would not let her use the bed pan. Further interview revealed no further investigation was done by the ADON. Interview on 08/28/18 at 4:05 P.M. with Resident #73 revealed an STNA told her to pee in her diaper because they were not putting her on the bedpan. Interview on 08/28/18 at 5:00 P.M. with the Administrator confirmed an investigation had not been initiated regarding the allegation of abuse from Resident #73. Further interview confirmed the facility did not report an allegation of abuse to the required officials per policy. Review of the facilities SRI's revealed no incident/investigations regarding Resident #69 or #73's allegations. Review of the undated facility policy titled Abuse, Mistreatment, Neglect, Exploitation, and Misappropriation of Resident Property revealed abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Review of section, initial report, revealed the Administrator or designee will notify the Ohio Department of Health (ODH) of all alleged violations involving mistreatment, neglect, and abuse 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. If the event that caused the allegation involves an allegation of abuse or serious bodily injury, it should be reported to ODH immediately, but not later than two hours after the allegation is made. Review of section, investigate, revealed once the Administrator and ODH are notified, an investigation of the allegation violation will be conducted. The investigation must be completed within five working days unless there are special circumstances. If a staff member is accused or suspected of abuse or neglect the facility should immediately remove that staff member from the facility and the schedule pending the outcome of the investigation.

Based on medical record review, resident and staff interview, review of facility self-reported incidents (SRI's) and review of facility policy, the facility failed to report allegations of abuse to the state agency. This affected two (#69 and #73) of two residents reviewed for abuse. The census was 91. Findings include: 1. Review of the medical record revealed Resident #69 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was hospitalized from [DATE] through 08/19/18 for a right hip sustained after a fall in the facility. Review of the minimum data set (MDS) assessment, dated 07/07/18, revealed a brief interview for mental status (BIMS) of 14. Interview on 08/26/18 at 2:41 P.M. with Resident #69 revealed State tested Nurse Aide (STNA) #64 was loud and rough when providing care. The resident stated she fought with me, she yelled and screamed at me, I wasn't sitting right, I wasn't walking right, I wasn't doing anything right, it was horrible. Further interview revealed allegations that STNA #64 drug her (with assist of an unnamed STNA) to the bathroom in the middle of the night. The resident reported being a nervous wreck ever since STNA #64 worked with her. Interview on 08/28/18 at 11:51 A.M. with Registered Nurse (RN) Unit Manager #29 revealed she was aware that STNA #64 had upset Resident #69 by saying you need to try, you are weight bearing as tolerated. Further interview revealed RN #29 had not interviewed the resident and/or other residents on the unit regarding care provided by STNA #64. Interview on 08/28/18 at 12:15 P.M. with STNA #39 revealed Resident #69 had complained about care provided by STNA #64. She stated STNA #64 was too rough with putting her to bed and assisting her to the bathroom. Interview on 08/28/18 at 12:24 P.M. with Licensed Practical Nurse (LPN) #85 revealed Resident #69 reported allegations that STNA #64 was rough and told her she should be doing more for herself. Further interview revealed she reported the allegations to LPN #59 on 08/25/18 at 7:00 P.M. during shift change. Interview on 08/28/18 at 12:08 P.M. with the Director of Nursing (DON) revealed she was notified on 08/25/18 at 7:42 P.M. by LPN #59 via text messages of the allegations. The text message read there was a complaint from the resident on STNA #64. LPN #59 assumed all direct care for Resident #69 the remainder of the shift. STNA #64 continued to work the shift taking care of other residents. Further interview confirmed Resident #69 and/or other residents had not been interviewed regarding allegations of abuse. Interview on 08/28/18 at 5:00 P.M. with the Administrator confirmed an investigation had not been initiated regarding the allegation of abuse from Resident #69. Further interview confirmed the facility did not report an allegation of abuse to the required officials per policy. 2. Review of the medical record revealed Resident #73 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS assessment, dated 08/01/18, revealed a BIMS of 15. Further review revealed the resident required extensive staff assist with transfers and toileting. Interview on 08/28/18 at 12:34 P.M. with Activities Assistant #13 revealed Resident #73 complained about care provided by STNA #64 on 06/25/18. Resident #73 had asked for assistance with going to the bathroom. The resident reported that STNA #64 told her to go in her diaper. Further interview revealed Activities Assistant #13 gave a written statement regarding the allegation to the Assistant Director of Nursing (ADON). Interview on 08/28/18 at 12:44 P.M. with the Assistant DON (ADON) revealed she was aware Resident #73 reported an allegation that STNA #64 would not let her use the bed pan. Further interview revealed no further investigation was done by the ADON. Interview on 08/28/18 at 4:05 P.M. with Resident #73 revealed an STNA told her to pee in her diaper because they were not putting her on the bedpan. Interview on 08/28/18 at 5:00 P.M. with the Administrator confirmed an investigation had not been initiated regarding the allegation of abuse from Resident #73. Further interview confirmed the facility did not report an allegation of abuse to the required officials per policy. Review of the facilities SRI's revealed no incident/investigations regarding Resident #69 or #73's allegations. Review of the undated facility policy titled Abuse, Mistreatment, Neglect, Exploitation, and Misappropriation of Resident Property revealed abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Review of section, initial report, revealed the Administrator or designee will notify the Ohio Department of Health (ODH) of all alleged violations involving mistreatment, neglect, and abuse 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. If the event that caused the allegation involves an allegation of abuse or serious bodily injury, it should be reported to ODH immediately, but not later than two hours after the allegation is made.

Based on medical record review, resident and staff interview, review of facility self-reported incidents (SRI's) and review of facility policy, the facility failed to thoroughly investigate allegations of abuse. This affected two (#69 and #73) of two residents reviewed for abuse. The census was 91. Findings include: 1. Review of the medical record revealed Resident #69 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was hospitalized from [DATE] through 08/19/18 for a right hip sustained after a fall in the facility. Review of the minimum data set (MDS) assessment, dated 07/07/18, revealed a brief interview for mental status (BIMS) of 14. Interview on 08/26/18 at 2:41 P.M. with Resident #69 revealed State tested Nurse Aide (STNA) #64 was loud and rough when providing care. The resident stated she fought with me, she yelled and screamed at me, I wasn't sitting right, I wasn't walking right, I wasn't doing anything right, it was horrible. Further interview revealed allegations that STNA #64 drug her (with assist of an unnamed STNA) to the bathroom in the middle of the night. The resident reported being a nervous wreck ever since STNA #64 worked with her. Interview on 08/28/18 at 11:51 A.M. with Registered Nurse (RN) Unit Manager #29 revealed she was aware that STNA #64 had upset Resident #69 by saying you need to try, you are weight bearing as tolerated. Further interview revealed RN #29 had not interviewed the resident and/or other residents on the unit regarding care provided by STNA #64. Interview on 08/28/18 at 12:15 P.M. with STNA #39 revealed Resident #69 had complained about care provided by STNA #64. She stated STNA #64 was too rough with putting her to bed and assisting her to the bathroom. Interview on 08/28/18 at 12:24 P.M. with Licensed Practical Nurse (LPN) #85 revealed Resident #69 reported allegations that STNA #64 was rough and told her she should be doing more for herself. Further interview revealed she reported the allegations to LPN #59 on 08/25/18 at 7:00 P.M. during shift change. Interview on 08/28/18 at 12:08 P.M. with the Director of Nursing (DON) revealed she was notified on 08/25/18 at 7:42 P.M. by LPN #59 via text messages of the allegations. The text message read there was a complaint from the resident on STNA #64. LPN #59 assumed all direct care for Resident #69 the remainder of the shift. STNA #64 continued to work the shift taking care of other residents. Further interview confirmed Resident #69 and/or other residents had not been interviewed regarding allegations of abuse. Interview on 08/28/18 at 5:00 P.M. with the Administrator confirmed an investigation had not been initiated regarding the allegation of abuse from Resident #69. Further interview confirmed the facility did not report an allegation of abuse to the required officials per policy. 2. Review of the medical record revealed Resident #73 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS assessment, dated 08/01/18, revealed a BIMS of 15. Further review revealed the resident required extensive staff assist with transfers and toileting. Interview on 08/28/18 at 12:34 P.M. with Activities Assistant #13 revealed Resident #73 complained about care provided by STNA #64 on 06/25/18. Resident #73 had asked for assistance with going to the bathroom. The resident reported that STNA #64 told her to go in her diaper. Further interview revealed Activities Assistant #13 gave a written statement regarding the allegation to the Assistant Director of Nursing (ADON). Interview on 08/28/18 at 12:44 P.M. with the Assistant DON (ADON) revealed she was aware Resident #73 reported an allegation that STNA #64 would not let her use the bed pan. Further interview revealed no further investigation was done by the ADON. Interview on 08/28/18 at 4:05 P.M. with Resident #73 revealed an STNA told her to pee in her diaper because they were not putting her on the bedpan. Interview on 08/28/18 at 5:00 P.M. with the Administrator confirmed an investigation had not been initiated regarding the allegation of abuse from Resident #73. Further interview confirmed the facility did not report an allegation of abuse to the required officials per policy. Review of the facilities SRI's revealed no incident/investigations regarding Resident #69 or #73's allegations. Review of the undated facility policy titled Abuse, Mistreatment, Neglect, Exploitation, and Misappropriation of Resident Property revealed abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Review of section, initial report, revealed the Administrator or designee will notify the Ohio Department of Health (ODH) of all alleged violations involving mistreatment, neglect, and abuse 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. If the event that caused the allegation involves an allegation of abuse or serious bodily injury, it should be reported to ODH immediately, but not later than two hours after the allegation is made.

Based on medical record review, surveyor observations, resident and staff interview, the facility failed to ensure fall interventions were implemented for Resident #79. This resulted in actual harm when Resident #79 experienced an avoidable fall resulting in a cervical spine (C2) compression fracture. Additionally, the facility failed to have fall interventions in place regarding having the residents rolling walker within Resident #79's reach during observations on the survey. This affected one (#79) of four residents reviewed for accidents. The facility census was 88. Findings include: Review of Resident #79 medical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Review of Resident #79's fall assessment dated [DATE], the resident scored an 18 indicating that she was at high risk for falls. Review of the admission minimum data set (MDS) assessment, dated 05/27/13, documented that the resident required limited assistance of one person for walking in the room, the resident was unsteady with balance and was only able to stabilize herself with staff assistance. The admission MDS fall care area assessment further documented Resident #79 is at risk for injuries from falls related to impaired balance, incontinence, [DIAGNOSES REDACTED]. Review of a facility form entitled "Ambulation Data" dated 07/29/13, revealed that Resident #79 ambulates with supervision and a rolling walker, her posture is poor and has swollen feet. Resident #79's comprehensive care plan 06/09/13 entitled "Prone to Edema" documented Resident #79 used ace wraps from the feet to the knees due to lower extremity swelling and history of legs weeping. Review of a second care plan dated 06/09/13 entitled "Resident is at risk for falls" documented to follow the Interdisciplinary Master Intervention Plan. Review of the Interdisciplinary Master Intervention Plan documented Resident #79 was to have non-slip foot wear and to have personal items within her reach to increase safety and decrease risk of injury. Review of nursing progress notes documented on 07/30/13 at 6:14 A.M., the resident was sitting in her recliner and was provided her medications. On 07/30/13 at 7:35 A.M., nursing progress notes documented the nurse was in the hallway outside Resident #79's room, when the nurse heard a loud noise and went to assess. The nurse entered Resident #79's room to find the resident laying on her right side hold her neck and head, complaining of pain in the neck/ head and the resident was immobilized. Further review of the progress notes documented that Resident #79 stated she was attempting to spit into the trash can and fell on to her head. Resident #79 had ace wraps on her bilateral lower extremities at the time of the incident with no socks or shoes in place. Resident #79 was sent to the emergency room and found to have a C2 compression fracture. Per the nursing documentation Resident #79 was readmitted to the facility from the hospital on [DATE] with a [DIAGNOSES REDACTED]. Review of the facility incident report entitled "Fall/ Incident Statement" dated 07/30/13 regarding Resident #79's incident was reviewed. According to the incident report Resident #79 was toileted at 7:15 A.M., the resident was then seated back into her recliner. The incident report further documented that the resident was attempting to spit in the trash bin and fell . Per the incident report Resident #79 was in need of non-skid socks and further interventions included providing dycem to the chair and a spit basin at the bedside. Further review of the incident report revealed the facility failed to determine the location of Resident #79's walker at the time of the incident or the position of the recliner regarding if the recliner was reclined or in an upright seated position. On 08/15/13 at 9:25 A.M., Resident #79 was observed seated in an electric recliner with her legs elevated on an ottoman due to swelling of the lower legs. Resident #79 had ace wraps on the bilateral lower extremities with non-skid foot wear on. Resident #79 was noted to be wearing a neck brace. During the observation, Resident #79's walker was noted to be on the opposite side of the room near the widow/foot of the bed. On 08/15/13 at 10:00 A.M., during a second observation Resident #79 continued to be seated in her recliner with her legs elevated. Resident #79's walker remained near the window/foot of the bed. Interview with Licensed Practical Nurse (LPN) #200 on 08/14/13 at 2:00 P.M., revealed on 07/30/13 at around 7:35 A.M. she was outside Resident #79's room, she heard a "thud" and she went to investigate and found the resident on the floor complaining of head/ neck pain. LPN #200 stated that prior to the incident Resident #79 had a period of being restless and was started on antipsychotic medications which seemed to help. LPN #200 stated the resident told her she was attempting to spit in the trash bin and fell on to the floor. LPN #200 confirmed that upon her arrival to the room the resident was wearing ace wraps however she was not wearing any non-skid foot wear. LPN #200 stated she cannot recall the location of the resident's walker at the time of the incident however her recliner was in the standard upright position. LPN #200 stated the resident was then sent to the emergency room , was admitted to the hospital related to a C2 compression fracture and now requires a neck collar at this time. Interview with the Director of Nursing (DON) on 08/15/13 at 8:45 A.M., revealed Resident #79 was taken to the bathroom on 07/30/13 at 7:15 A.M. and that she was then seated back in her electric recliner in a reclined position. The DON stated on 07/30/13 at 7:35 A.M., the nurse on duty heard a loud noise; the nurse investigated the noise and found Resident #79 on the floor in front of the recliner area with the recliner in an upright position. The DON verified that upon the nurse's arrival Resident #79 was wearing her ace wraps due to leg edema and that she was without appropriate non-skid foot wear. The DON further confirmed that the resident stated she was attempting to spit into the trash bin and fell . The DON stated that the resident's trash bin was located directly to the left of the recliner and the resident was found on her right side which would be consistent with her attempting to self-ambulate. The DON confirmed that Resident #79's recliner was in the upright position, she was not wearing non-skid foot wear as per her care plan and that the facility is unable to determine the location of the walker at the time of the incident. Interview with Resident #79 on 08/15/13 at 9:25 A.M., revealed she broke her neck and the neck brace bothers her and she does experience pain in the neck area. Resident #79 stated that she was attempting to spit into a trash can and fell which resulted in her breaking her neck. Resident #79 stated she can't remember exactly what happened when she fell because everything happened so quickly. Resident #79 stated that she can ambulate by herself but that she has to be really careful so she doesn't fall. Interview with Registered Nurse (RN) #5 on 08/15/13 at 9:29 A.M., revealed she was one of the nurses who assisted with the initial treatment of [REDACTED]. RN #5 explained the set-up of Resident #79's room at the time of the incident. RN #5 stated the resident's bed is near the window, there is a night stand between the bed/recliner, then there is a recliner, there is a trash bin located to the left of the recliner and the resident also has a movable bedside table. RN #5 stated upon her arrival to the resident's room the residents head was near the bed with her head being almost under the bed. RN #79 stated she was unable to recall if the resident was wearing appropriate foot wear or the location of her walker as this was an emergency situation and a lot occurred at once. Interview with the DON on 08/15/13 at 10:05 A.M., verified that Resident #79's walker was not in reach. The DON further verified that Resident #79's walker should be within her reach and that the staff will place it within reach. The DON stated they would prefer that the resident not self-ambulate; however, if she is going to do so they want to make it as safe as possible. On 08/15/13 at 12:40 P.M., an interview with the DON revealed that the facility does not have a policy and procedure to ensure that interventions are followed regarding interventions found on the Interdisciplinary Master Plan. The DON stated that the only policy the facility has is if the interventions on the care plan are physician ordered. In the case of Resident #79's fall care plan intervention they were only on the Interdisciplinary Master Plan and that the facility is working on how to resolve this issue.