Every finding on record at Loveland Care Center

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, review of outside provider office notes, review of hospital records, and staff interview, the facility failed to ensure wound care treatments were implemented for a resident. This resulted in Actual Harm on 08/08/25 when the facility failed to implement the orthopedic surgeon's orders for treatment to Resident #2's left ankle surgical wound. Subsequently, Resident #2 was admitted to the hospital for an infection to the left ankle surgical wound, which was treated with debridement, placement of a wound vac, and intravenous (IV) antibiotics. This affected one (Resident #2) of three residents reviewed for surgical wounds. The facility census was 75 residents. Findings include: Review of the medical record for Resident #2 revealed an admission date of 06/16/25 with diagnoses including open reduction and internal fixation of bimalleolar left ankle fracture, chronic kidney disease, and diastolic congestive heart failure. Resident #2 was discharged to the hospital from the orthopedic surgeon's office on 08/08/25 and did not return to the facility. Review of the Minimum Data Set (MDS) assessment for Resident #2 dated 06/20/25 revealed the resident was cognitively intact and required staff assistance with activities of daily living. (ADL.) Review of the orthopedic surgeon's progress notes revealed the resident was seen post operatively at the surgeon's office for follow-up to surgery to the left ankle on 06/27/25, 07/03/25, 07/11/25 and 07/25/25 with an appointment scheduled for 08/08/25. Review of the office visit report for Resident #2 dated 07/25/25 revealed a physician's order for the resident to be referred to for wound care and for the facility's wound care practitioner to evaluate and treat the surgical wound to the resident's left ankle. Review of the physician's orders for Resident #2 in the electronic medical record for July and August 2025 revealed there were no orders for a referral to wound care nor were there any treatment orders for the left ankle surgical wound. Review of the office visit report for Resident #2 dated 08/08/25 revealed the resident's left ankle surgical wound presented with signs of infection. The dressing to the wound had foul-smelling drainage and the wound itself had a large opening with a full-thickness skin defect directly over the ankle and redness around the perimeter of the wound. Resident #2 reported to the surgeon that despite the referral to wound care no one at the facility had changed the dressing to his ankle or evaluated the wound. Due to concern for surgical wound infection the orthopedic surgeon sent Resident #2 to the hospital for a direct admission to for the treatment of the infected surgical wound to include debridement, placement of wound vac, and IV antibiotics. Review of the hospital notes for Resident #2 dated 08/08/25 revealed the resident was admitted to the hospital from the orthopedic surgeon's office with an infection to the left ankle surgical wound. The dressing to the wound had not been changed, and Resident #2 underwent debridement of the wound, and a wound vac was placed. Resident #2 was also started Daptomycin, an IV antibiotic, for the wound infection. During an interview on 05/05/26 at 10:00 A.M., the Director of Nursing (DON) stated Resident #2 had an appointment on 07/25/25 at the orthopedic surgeon's office at which the surgeon gave an order for Resident #2 to be evaluated by the facility's wound care practitioner and to obtain treatment orders to the left ankle surgical wound. The DON confirmed the nurses failed to transcribe the order for wound care referral and the facility's wound care practitioner did not examine the resident nor did she provide orders for treatment of the resident's left ankle surgical wound. The DON verified the facility nurses provided no treatment to Resident #2's wound during the time frame of 07/25/25 to 08/08/25. The DON stated Resident #2 was sent to the hospital directly from the orthopedic surgeon's office on 08/08/25, was admitted , and did not return to the facility. The deficiency was corrected on 02/16/26 when the facility implemented the following corrective action: On 02/16/26, nurses were in-serviced on the importance of transcribing and implementing orders from appointments with outside physicians. On 02/16/26, Unit Managers completed an audit of December 2025 and January 2026 physician orders to ensure no orders were missed on current in-house residents. Monthly audits of physician orders were completed in February 2026, March 2026 and April 2026, and will continue on an ongoing basis. This deficiency represents noncompliance investigated under Complaint Number 2748554.

Based on observations, staff interviews, and policy review, the facility failed to properly label and store food as well as ensure expired products were disposed of. The facility also failed to maintain clean equipment. This had the potential to affect all 73 residents who receive food from the kitchen. The facility census was 73. Findings include: 1. Observations on [DATE] from 8:00 A.M. to 8:15 A.M., in the kitchen, revealed a shallow pan with croutons, covered not dated and a pan with rolls covered with plastic wrap not dated. Observation of the ice machine outside of the kitchen had a scoop in an attached container. The container holding the scoop had a yellow sludge on the bottom with stagnant water. The container had no holes for drainage. Interview on [DATE] at 8:20 A.M., with Dietary Staff #106 confirmed the undated food and condition of the ice scoop. 51520 2. Observation of the kitchen on [DATE] at 8:55 A.M., with the Dietary Director (DD) #18 revealed there were 11 undated chocolate cakes, 1 undated pitcher of iced tea, 2 undated pitchers of lemonade, and 1 stick of butter with a substance on its wrapper in the walk-in refrigerator. Interview on [DATE] at 8: 59 A.M., with DD #18 confirmed there were 11 undated chocolate cakes, 1 undated pitcher of iced tea, 2 undated lemonade pitchers, and 1 stick of butter with a substance on its wrapper in the walk-in refrigerator. Observation of the kitchen on [DATE] at 9:00 A.M., with the DD #18 revealed the steam tables had a build up of grime and debris. Interview on [DATE] at 9:01 A.M., with the DD #18 revealed the steam tables had a build up of grime and debris. Review of the policy titled ,Food Storage, dated on [DATE], stated all food will be covered, dated, and labeled. Review of the undated policy titled, Basic Cleaning Equipment, stated all equipment will be washed and sanitized after every use.

Based on observation, staff interview, and review of policy, the facility failed to ensure the garbage cans in the kitchen food preparation area garbage receptacles were covered to prevent cross contamination and pest control. This had the potential to affect all 73 residents who receive food from the kitchen. The facility census was 73 residents. Findings include: Observation on 04/16/25 at 9:05 A.M., revealed the kitchen garbage receptacle by the primary handwashing sink and the garbage receptacle on the opposite side of the dishwashing sink next to a prep-area counter were not covered. Interview on 04/16/25 at 9:06 A.M., with Dietary Director #18 confirmed the garbage receptacles in the kitchen food preparation areas were not covered with lids. Review of the undated policy titled, Garbage Cans stated the facility should cover the garbage cans when not in use.

Based on observation, interview, record review, and policy review, the facility failed to ensure staff treated residents with dignity and respect when providing feeding assistance. This affected one (Resident #20) of four residents sampled for feeding assistance. The facility census was 74. Findings include: Review of the medical record revealed Resident #20 was admitted to the facility on [DATE]. Diagnoses included unspecified cerebral infarction, chronic obstructive pulmonary disease, schizoaffective disorder-bipolar type, unspecified anxiety disorder, and unspecified protein calorie malnutrition. Review of the most recent minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #20 had moderately impaired cognition, had verbal behaviors, did not wander, and did not reject care. Resident #20 was impaired on one side and required partial, moderate assistance with eating. Review of the care plan dated 01/21/20 revealed Resident #20 had and activities of daily living (ADL) self-care deficit. Interventions included one-staff extensive assistance with meals to be spoon-fed and drinks in sippy cups. Observation on 11/07/24 at 11:58 A.M. revealed Licensed Practical Nurse (LPN) #117 was seated at a table in the main dining room with Resident #20. LPN #117 fed a spoonful of food to Resident #20, seated in a wheelchair to her right, then turned back to the table and began scrolling through her cell phone on the table. During an interview on 11/07/2024 at 12:06 P.M. LPN #117 verified she was scrolling through her cell phone while feeding Resident #20. LPN #117 stated she had texted the Nurse Practitioner earlier and was checking to see if she had responded. LPN #117 stated she was unaware of any rules restricting cell phone use while feeding patients. Review of policy titled Policy and Procedure for Resident Rights, Advance Directives, and Advance Care Planning dated 11/2023 revealed residents had the right to a dignified existence and the right to be treated in a manner and environment that promoted maintenance or enhancement of his or her quality of life. This deficiency represents noncompliance investigated under Complaint number OH00159395 and OH00158863.

Based on observation, interview, record review, and policy review, the facility failed to ensure staff treated residents with dignity and respect when providing feeding assistance. This affected one (Resident #20) of four residents sampled for feeding assistance. The facility census was 74. Findings include: Review of the medical record revealed Resident #20 was admitted to the facility on [DATE]. Diagnoses included unspecified cerebral infarction, chronic obstructive pulmonary disease, schizoaffective disorder-bipolar type, unspecified anxiety disorder, and unspecified protein calorie malnutrition. Review of the most recent minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #20 had moderately impaired cognition, had verbal behaviors, did not wander, and did not reject care. Resident #20 was impaired on one side and required partial, moderate assistance with eating. Review of the care plan dated 01/21/20 revealed Resident #20 had and activities of daily living (ADL) self-care deficit. Interventions included one-staff extensive assistance with meals to be spoon-fed and drinks in sippy cups. Observation on 11/07/24 at 11:58 A.M. revealed Licensed Practical Nurse (LPN) #117 was seated at a table in the main dining room with Resident #20. LPN #117 fed a spoonful of food to Resident #20, seated in a wheelchair to her right, then turned back to the table and began scrolling through her cell phone on the table. During an interview on 11/07/2024 at 12:06 P.M. LPN #117 verified she was scrolling through her cell phone while feeding Resident #20. LPN #117 stated she had texted the Nurse Practitioner earlier and was checking to see if she had responded. LPN #117 stated she was unaware of any rules restricting cell phone use while feeding patients. Review of policy titled Policy and Procedure for Resident Rights, Advance Directives, and Advance Care Planning dated 11/2023 revealed residents had the right to a dignified existence and the right to be treated in a manner and environment that promoted maintenance or enhancement of his or her quality of life. This deficiency represents noncompliance investigated under Complaint number OH00159395 and OH00158863.

Based on observations, interview, medical record review, and policy review, the facility failed to ensure residents were bathed according to personal preference. This affected one (Resident #10) of five residents sampled for bathing. The facility census was 74. Findings include: Review of the medical record revealed Resident #10 was admitted to the facility on [DATE]. Diagnoses included unspecified hepatic failure, unspecified staphylococcus disease, type II diabetes, unspecified protein calorie malnutrition, unspecified depression, acute on chronic diastolic congestive heart failure, unspecified psoriasis, unspecified chronic kidney disease, alcoholic cirrhosis of the liver with ascites, and unspecified homelessness. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact, had no behaviors, did not reject care, and did not wander. Resident #10 required set up assistance with oral hygiene, and substantial/maximum assistance with bathing. Review of care plan dated 10/16/24 revealed Resident #10 had a self-care deficit related to balance deficit, disease process, and weakness. Interventions included assistance with activities of daily living (ADL)s as needed, encourage participation in ADLs, and showers twice weekly on Monday and Thursday nights. Review of progress note dated 10/30/24 at 3:33 P.M. LPN #164 documented Resident #10 was demanding a bed bath. LPN #164 .explained to (the) resident he only will be getting shower/bed bath on Monday/Thursday nights. Resident was vocal about not getting the care he deserves at nighttime and was cursing about the night workers. Review of the medical record revealed Resident #10 was hospitalized and was not present in the facility on 10/18/24, 10/19/24, 10/20/24, and 10/29/24. Review of shower sheets revealed Resident #10 received bed baths on 10/25/24, 10/31/24, 11/04/24, and 11/06/24. During an interview on 11/06/24 at 9:33 A.M. Resident #10 stated he was itchy because he had not had a shower or bed bath in a while. He was supposed to get baths at night and for the previous two nights staff had refused to bathe him. During an observation on 11/06/24 at 9:43 A.M. Resident #10 stated to LPN #164 the night shift nurse had refused to give him a bed bath or change his bed linens. LPN #164 stated to Resident #10 residents only received two baths per week and his were scheduled on Mondays and Thursdays during the night shift. During an interview on 11/06/24 at 9:45 A.M. LPN #164 verified she had stated to Resident #10 residents only received two baths per week. LPN #164 stated residents could not be bathed every day. Residents were bathed on scheduled shower days and as needed if they looked dirty, and they tried to accommodate preferences for bathing times. Review of policy titled Policy and Procedure for Resident Rights, Advance Directives, and Advance Care Planning dated 11/2023 revealed residents had the right to self-determination and choices for care were incorporated into the plan of care. Review of policy titled ADL Care dated 11/2023 revealed ADL assistance was provided on a schedule that was in accordance with the preferences of the resident. This deficiency represents noncompliance investigated under Complaint number OH00159395.

Based on record review, interview, and policy review, the facility failed to ensure resident care plans were comprehensive and reflected all resident care needs. This affected one (Resident #10) of nine residents sampled for care plans. The facility census was 74. Findings include: Review of the medical record revealed Resident #10 was admitted to the facility on [DATE]. Diagnoses included unspecified hepatic failure, unspecified staphylococcus disease, type II diabetes, unspecified protein calorie malnutrition, unspecified depression, acute on chronic diastolic congestive heart failure, unspecified psoriasis, unspecified chronic kidney disease, alcoholic cirrhosis of the liver with ascites, and unspecified homelessness. Review of care plan dated 10/16/24 revealed Resident #10 had no care plan for psoriasis or discomfort related to itching. During an interview on 11/06/24 at 9:47 A.M. Resident #10 stated he felt like he needed help with his psoriasis. It was all over his body. The resident stated he had an order for Triamcinolone (corticosteriod) topical cream and took Hydroxyzine (antihistamine) for itching. The resident stated staff were applying non-medicated lotions, too, that were helpful but not as effective as the Triamcinolone cream. The patient stated he wanted to see a dermatologist. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact, had no behaviors, did not reject care, and did not wander. Resident #10 required set up assistance with oral hygiene, and substantial/maximum assistance with bathing. Review of care plan dated 10/16/24 revealed Resident #10 had no care plan for psoriasis or discomfort related to itching. During an interview on 11/07/2024 at 12:17 P.M. LPN Unit Manager #132 verified Resident #10 had no care plan for psoriasis or itching. Review of policy titled Care Planning/Interdisciplinary Team dated 11/2023 revealed the Interdisciplinary Team was responsible for the development of an individualized comprehensive care plan for each resident.

Based on interview, record review, and policy review, the facility failed to ensure residents were given assistance with or access to daily oral care. This affected one (Resident #10 ) of five residents sampled for activities of daily living (ADL) assistance. The facility census was 74. Findings include: Review of the medical record revealed Resident #10 was admitted to the facility on [DATE]. Diagnoses included unspecified hepatic failure, unspecified staphylococcus disease, type II diabetes, unspecified protein calorie malnutrition, unspecified depression, acute on chronic diastolic congestive heart failure, unspecified psoriasis, unspecified chronic kidney disease, alcoholic cirrhosis of the liver with ascites, and unspecified homelessness. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact, had no behaviors, did not reject care, and did not wander. Resident #10 required set up assistance with oral hygiene, and substantial/maximum assistance with bathing. Review of care plan dated 10/16/24 revealed Resident #10 had altered dental status and required assistance with dental hygiene. Interventions included assistance with oral care as needed, brushing and flossing teeth daily. Review of the medical record revealed Resident #10 had no documentation related to daily assistance with oral care. During an interview on 11/06/24 at 9:47 A.M. Resident #10 stated he had only brushed his teeth once during his stay and staff were not offering assistance with oral care. During an interview on 11/06/24 at 10:01 A.M. Certified Nursing Assistant (CNA) #173 stated she completed rounds for morning care after breakfast each day and did not offer oral care unless the resident specifically asked for assistance. CNA #173 stated she did not have time for oral care. CNA #173 stated when resident #10 first admitted , she set him up for oral care when he asked for assistance. CNA #173 stated she had not provided setup assistance for oral care in a few weeks because Resident #10 did not ask for it. CNA #173 stated there was no place in the medical record for aides to document oral care, so there was no documentation of oral care being offered, provide, or refused in the record. During an interview on 11/07/24 at 2:02 P.M. Licensed Practical Nurse (LPN) Unit Supervisor #132 verified there was no documentation available for oral care, but it should be offered daily. Review of policy titled ADL Care dated 11/2023 revealed all residents received necessary services to maintain good nutrition, grooming, and personal and oral care. This deficiency represents noncompliance identified under Complaint number OH00159395.

Based on observations, interview, record review, and policy review, the facility failed to ensure residents assessed for fall risk had fall preventions interventions in place according to the care plan. This affected one (Resident #62) of six residents sampled for falls. The facility census was 74. Findings include: Review of the medical record revealed Resident #62 revealed the resident was admitted to the facility on [DATE]. Diagnoses included unspecified anxiety disorder, major depressive disorder, and unspecified malignant neoplasm. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had moderately impaired cognition, had no behaviors, did not reject care, and did not wander. Review of the care plan dated 10/22/21 revealed Resident #62 had potential for injuries related to falls. Interventions included anti-rollbacks to wheelchair, assist in positioning for comfort as needed, Dycem to wheelchair when in use, encourage non-skid footwear, instruct on use of adaptive equipment, observe/report unsafe conditions, therapy evaluations as needed, toileting every two to three hours, and a raised toilet seat. Observations made on 11/07/24 at 9:19 A.M. revealed Resident #62 did not have the anti-rollback device installed on her wheelchair as indicated in her care plan. During an interview on 11/07/24 at 9:53 A.M. Assistant Director of Nursing (ADON) #113 verified Resident #62's wheelchair located in her bathroom did not have an anti-rollback device installed on it and verified her care plan stated the wheelchair would have anti-rollbacks. Resident #62 was present during this interview and stated to ADON #113 about one week prior, maintenance had taken the wheelchair she had been using prior to the fall, which had the anti-roll back device, with the current, smaller wheelchair that did not have the anti-rollback device because she had trouble maneuvering the former, wider wheelchair through the narrow bathroom doorway. Review of policy titled Fall Prevention Policy and Procedure dated 02/2024 revealed the facility identified residents who were at risk for falls and implemented a plan of care to address risk factors and protect from injury. This deficiency represents noncompliance identified under complaint number OH00159423 and OH00158863.

Based on observation, interview, and policy review, the facility failed to ensure staff sanitized hands when providing feeding assistance to multiple residents. This affected two Residents #65 and #72 of four residents sampled for feeding assistance. The facility census was 74. Findings include: 1. Review of most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #72 was cognitively intact, had no behaviors, did not wander, and did not reject care. Resident #72 required set-up assistance for eating. Review of care plan dated 04/30/22 revealed Resident #72 had an activities of daily living (ADL) self-care deficit. Interventions included supervision assistance with eating with set up help only in the Geri-chair. If the resident was eating in bed, then staff must assist. 2. Review of the medical record revealed Resident #65 was admitted to the facility on [DATE]. Diagnoses included unspecified Alzheimer's disease, unspecified protein calorie malnutrition, and major depressive disorder. Review of the most recent MDS assessment dated [DATE] revealed Resident #65 had severely impaired cognition, had no behaviors, did not wander, and did not reject care. Resident #65 was dependent for eating. Review of care plan dated 02/01/22 revealed Resident #65 had and ADL self-care deficit. Interventions included total assistance per one staff member with eating. Observation on 11/07/24 at 12:02 P.M. revealed Certified Nursing Assistant (CNA) #156 was seated between Residents #65 and #72 and was using both hands interchangeably to feed residents at the same time without sanitizing hands between residents. CNA#156 used the fork in her right hand to feed Resident #72 a bite of salad. CNA #156 switched the fork to her left hand, loaded the fork with salad, switched the fork from the left to the right hand, and fed Resident #72 another bite of salad. Next CNA #156 took Resident #65's spoon in her left hand, scooped a spoonful of pureed strawberry angel food cake and fed Resident #65 with the spoon in her left hand. CNA #156 set the placed the spoon in the dish containing Resident #65's dessert, placed the fork in Resident #72's salad bowl, used both hands to remove the cover from Resident #72's container of apple juice, and placed the juice container on the table. Then CNA #156 loaded Resident #65's spoon with pureed cake using her left hand and fed the resident a bite of cake. CNA#156 used the fork in her right hand to feed Resident #72 a bite of salad. CNA #156 switched the fork to her left hand, held the salad bowl in her right hand, Scraped the sides of the bowl, loaded the fork with salad, switched the fork from the left to the right hand, and fed Resident #72 another bite of salad. Next, CNA #156 picked up Resident #65's milk carton with her right hand and assisted Resident #65 to take a sip of milk through the straw. CNA #156 did not sanitize her hands at any point during the observation. During an interview on 11/07/2024 at 12:08 P.M. CNA #156 stated she had been trained to use only one hand per resident when feeding multiple residents at the same time and verified she had been using her hands interchangeably when feeding Residents #65 and #72 and did not sanitize her hands between feeding residents. Review of policy titled General Infection Control dated 11/2023 revealed all staff followed proper infection control measures to prevent the spread of infection.

Based on observation, medical record review, staff interview and policy review the facility failed to ensure enhance barrier precautions (EBP) were initiated for incontinence and wound care for a resident who had an open wound. This affected one (#13) of three residents reviewed for incontinence care and wound care. The census was 74. Findings included: Medical record review for Resident #13 revealed an admitted [DATE]. Medical diagnoses included progressive neurological disorder, dementia, and Alzheimer's. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #13 was severely cognitively impaired. Functional status was supervision or touching for eating, dependent for toileting, bed mobility, and transfers. She was always incontinent for bladder and had a colostomy. Review of the progress notes dated 08/10/24 revealed a reoccurring open area to the coccyx identified as a stage two was discovered and a treatment was put into place. Review of the physician orders from 08/10/24 through 08/26/24 revealed there wasn't any order for EBP for the resident. Observation of wound care and incontinence care for Resident #13 on 08/26/24 at 8:00 A.M. revealed there wasn't a sign on the door for EBP and no cart for the Personal Protective Equipment (PPE). The Licensed Practical Nurse (LPN) #128 provided the wound care and didn't have a gown on. The State tested Nursing Aide (STNA) #139 provided the incontinence care and didn't have on a gown. Interview with the LPN #128 and STNA #139 on 08/26/24 at 8:30 A.M. revealed they didn't know the resident should be in EBP. They admitted they didn't wear a gown for the treatment or the incontinence care. They confirmed there wasn't a sign on the door and there was no order for EBP's for Resident #13. The nurse revealed she thought since the resident didn't have an infection or her wound wasn't chronic she didn't have to be in EBP. Review of the policy entitled Enhanced Barrier Precautions not dated revealed to implement EBP in the following situations: a) Residents with infection or colonization with a novel or targeted Multidrug Resistant Organisms (MRDO) when Contact Precautions do not apply. b) All residents with chronic wounds, indwelling medical devices (I.e., central line, urinary catheter, feeding tube, trach) regardless of MDRO colonization status. Place sign on resident's room door. (Optional: Placement of signage may be better located in the resident room near the resident's bed especially for shared rooms - choose location that most appropriate to make staff and visitors aware of precautions.)* Gown and gloves will be placed immediately outside of the resident room (Optional: Supplies may be placed in an area inside of the room.) Gown and gloves use will be used, in addition to standard precautions, in the following activities: a) Dressing b) Bathing/showering c) Transferring d) Providing hygiene e) Changing linens f) Changing briefs or assisting with toileting g) Device care or use (central line, urinary catheter, feeding tube, tracheostomy) h) Wound care/any skin opening requiring a dressing. Review of the Quality, Safety and Oversight (QSO) 24-08-NH dated 03/20/24 revealed EBP are indicated for residents with any of the following: Infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply; Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. Wounds generally include chronic wounds, not shorter-lasting wounds, such as skin breaks or skin tears covered with an adhesive bandage (e.g., Band-Aid(R)) or similar dressing. Examples of chronic wounds include, but are not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers. This deficiency represents non-compliance investigated under Complaint Number OH0015287.

Based on record review, observation, staff interview and policy review the facility failed to ensure a homelike environment was provided for the residents. This affected three (#13, #32 and #75) of three residents reviewed for environment. The facility also failed to ensure a room was cleaned on a regular basis. This affected one (#75) of one reviewed for cleansing of the room. The census was 74. Findings included: Observation of Resident #13's room on 08/20/24 at 9:18 A.M. revealed cobwebs in the window sills and thick black substance, scuff marks on the walls, and holes where pictures used to hang, and holes with nails sticking out of the wall. The bathroom floor was sticky, and room walls have black marks on them. The curtains in the room on the windows were dusty and wrinkled. On the inside bathroom door there is a substance that ran down the door that had dried. Observation of Resident #32's room on 08/20/24 at 9:50 A.M. revealed throughout the room there were holes in the walls with nails sticking out of the walls. The walls had black marks on them. The bathroom had a dusty vent in the ceiling, black marks on the walls, floors were stained and the door going into the bathroom looked like it had some kind of substance running down both sides that had dried. Observation of Resident #75's room on 08/20/24 at 11:02 A.M. revealed there were black marks on the walls throughout the room. In the bathroom it was dirty by the handrails, and coming into the room there was molding coming off the wall. A tour and interview of the above mentioned rooms with Housekeeping Supervisor on 08/20/24 at 2:30 P.M. confirmed all of these areas needed to be cleaned. 2. Medical record review for Resident #75 revealed an admitted [DATE]. Medical diagnoses included fracture to the right femur. She was discharged on [DATE]. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #75 was cognitively intact. Her functional status was setup or clean-up assistance for eating, dependent for toileting, bed mobility was independent, and transfers were partial/ moderate assistance. She was frequently incontinent for bladder and occasionally incontinent for bowel. She didn't have any pressure ulcers on this assessment. Review of the daily housekeeping documents revealed there was an empty space for cleaning on 07/10/24, 07/11/24, 07/14/24, 07/16/24, 07/19/24, 07/22/24, and 07/23/24 for Resident #75. Further review of the document revealed on 07/17/24, 07/21/24, and 07/25/24 it was blank for a check mark as being cleaned. Interview with Housekeeping Aide (HSKG) #151 on 08/26/24 at 11:25 A.M. revealed on the days she didn't clean FSR's room she did work. She stated there wasn't enough staff in the facility and she had to clean other halls. She stated she was off on 07/17/24, 07/21/24, and 07/25/24 and the room didn't get cleaned on those days either. She stated the rooms were to be cleaned everyday. Review of the policy entitled Environmental Services undated revealed housekeeping will keep resident areas clean and will be assigned specific areas of the facility to ensure that all areas are cleaned. Cleaning of resident rooms, bathrooms, and all public areas will be maintained on a routine basis. This deficiency represents non-compliance investigated under Complaint Number OH00156287.

Based on observation, staff interview, and review of facility policy, the facility failed to ensure supplies used in the kitchen were clean. This had the potential to affect 60 residents who received food from the kitchen and utilized kitchen dishes. The facility census was 62. Findings include: Tour of the kitchen on 04/19/22 at 8:20 A.M. revealed an orange industrial floor fan was observed to have a brown like substance build up located on the inside blades and the exterior grill face of the fan. The fan was on and blowing air directly onto clean dishes. On 04/19/22 at 8:25 A.M. interview with Dietary Manager #25 revealed the fan was on daily because the kitchen got extremely hot while washing the dishes. Additionally, Dietary Manager #25 verified the brown build up on the fan and verified the fan was turned on and blowing air directly onto clean dishes. Review of the policy, Sanitation dated January 2022, all equipment in the kitchen shall be kept clean and maintained in good repair.

Based on medical record review, observations, staff interview, review of facility policy, and review of Centers for Disease Prevention and Control (CDC) guidance, the facility failed to ensure staff utilized proper Personal Protective Equipment (PPE) when interacting with a resident (Resident #367) on droplet isolation. This affected one resident (#367) out of four residents reviewed for infection control and had the potential to affect eight additional residents (#16, #39, #58, #62, #167, #168, #169, and #171) being cared for by the same staff members. The facility census was 61. Findings Included: Medical record review for Resident #367 revealed an admitted [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Minimum Data Set (MDS) assessment dated [DATE] for Resident #367, revealed the assessment was not completed in its entirety and a Brief Interview of Mental Status (BIMS) score (cognition level) was not established. Review of physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Full PPE including an N95 mask was required. All services were to be provided in Resident #367's room every day and night shift for 10 days. Further review of Resident #367's medical record revealed an immunization for [CONDITION(S)] only. There was no evidence the resident received any COVID-19 vaccines. Observation on 04/21/22 at 1:10 P.M. revealed State tested Nurse Aide (STNA) #68 assisting Resident #367 out of the restroom and proceeded to provide care. STNA #68 was observed wearing a gown, gloves, and surgical mask while interacting with Resident #367. STNA #68 was not wearing an N95 mask. Interview on 04/21/22 at 1:15 P.M. STNA #68 verified she was wearing a surgical mask when interacting with Resident #367 and she did not wear an N95 mask. STNA #68 reported she only had to wear the surgical mask. Interview on 04/21/22 at 1:18 P.M. with Licensed Practical Nurse (LPN) #67 revealed she was only wearing a surgical mask for the newly admitted Resident #367 per facility protocol. LPN #67 verified Resident #367 was in quarantine for being a new admission. Interview on 04/21/22 at 1:25 P.M. the Director of Nursing (DON) stated new admits would be quarantined if the resident did not have COVID-19 vaccination or partial vaccination. All employees whether vaccinated or not, were required to wear all required PPE in quarantined resident's room. Interview on 04/21/22 at 2:00 P.M. the Assistant Director of Nursing (ADON) reported new admits would be on droplet precautions if the resident did not have COVID-19 vaccination or partial vaccination. The ADON verified regardless of vaccination status, staff were to wear PPE, including an N95 mask when interacting with residents on droplet precautions. Surgical masks were not to be used. Interview on 04/21/22 at 2:45 P.M. the Administrator verified eight residents (#16, #39, #58, #62, #167, #168, #169, and #171) resided on the same hallway as Resident #367 and were cared for by STNA #68 and LPN #67. Review of facility policy titled, Covid-19 Policy and Procedure, revised 02/2022, revealed new admission and readmission residents who leave the facility for 24 hours or more would be quarantined. Residents not up to date on COVID-19 vaccinations, who were new admissions or readmissions or who had been out of the facility for 24 hours or greater: would be placed in a quarantine for 10 days or seven days if asymptomatic and negative test result. New admissions or readmissions would be tested immediately upon admission or return and would be retested in five to seven days. New admissions and residents who had been out of the facility for 24 hours or more required quarantine only when they were not up to date with COVID-19 vaccinations. However, residents who were up to date still required testing as outlined above. Health care providers caring for residents in quarantine should use full personal PPE, including a gown, gloves, eye protection, and N95 or higher-level respirator. Review of CDC Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes updated 02/02/22 revealed in general, all residents who were not up to date with all recommended COVID-19 vaccine doses and were new admissions and readmissions should be placed in quarantine, even if they have a negative test upon admission. Facilities located in counties with low community transmission might elect to use a risk-based approach for determining which of these residents require quarantine upon admission. Decisions should be based on whether the resident had close contact with someone with [CONDITION(S)]-CoV-2 infection while outside the facility and if there was consistent adherence to infection prevention practices in healthcare settings, during transportation, or in the community prior to admission. Guidance addressing duration and recommended PPE when caring for residents in quarantine was described in Section: Manage Residents who had Close Contact with Someone with [CONDITION(S)]-CoV-2 Infection: Health Care Personnel (HCP) should utilize full PPE, including an N95 mask, when caring for residents who had close contact with someone with [CONDITION(S)]-CoV-2 and were not up to date with vaccination.

Based on medical record review, staff interview, and observations the facility failed to ensure a resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This affected one Resident (#65) of three residents reviewed for care plans. The facility census was 61. Findings include: Medical record review for Resident #65 revealed an admission of 10/22/22 with a diagnosis [CONDITION(S)]. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] for Resident #65 revealed the assessment was silent for diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the plan of care dated 10/21/22 for Resident #65 revealed the plan of care was silent for [CONDITION(S)]. Review of active physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .M. revealed a routine visit and verification Resident #65 had [CONDITION(S)] with treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 04/19/22 at 11:35 A.M. of Resident #65 revealed a well-groomed alert and oriented resident sitting in her wheelchair in her room without signs and symptoms of distress or discomfort. Interview on 04/19/22 at 11:38 A.M. Resident #65 verified she had [CONDITION(S)] and received treatment, but she did not remember when her last treatment dose of medication was. Interview on 04/20/22 at 11:01 A.M. the MDS Licensed Practical Nurse (LPN) #26 verified [CONDITION(S)] was not included in Resident #65's plan of care. LPN #26 verified [CONDITION(S)] and treatment should have been included in Resident #65's plan of care.

Based on record review and staff interview, the facility failed to ensure residents were provided Skilled Nursing Facility Advance Beneficiary Notice of Non Coverage (SNF ABN) notices to inform residents of potential liability for a non-covered stay. This affected two residents (#56 and #62) out of three residents reviewed for beneficiary notices. The facility census was 61. Findings include: 1. Review of medical record for Resident #56 reveled an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #56's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to be cognitively intact. Resident #56 required extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. Resident #56 also required supervision with eating. Review of Resident #56's Notice of Medicare Non Coverage (NOMNC) dated 04/11/22 revealed Resident #56 discharged from Medicare Part A services on 04/11/22. Resident #56 signed the NOMNC on 04/06/22. Review of Resident #56's chart revealed Resident #56 did not receive a Skilled Nursing Facility Advance Beneficiary Notice of Non Coverage (SNF ABN) notice to inform the resident of the potential liability for a non-covered stay. Interview with Social Services Director #12 on 04/21/22 at 1:17 P.M. verified Resident #56 was discharged from Medicare Part A services on 04/11/22 and Resident #56 was not provided a SNF ABN to inform the resident of the potential liability for a non-covered stay. Social Services Director #12 verified Resident #56 remained in the facility and was private pay after being discharged from Medicare Part A skilled services. 2. Review of the Resident #62's chart revealed Resident #62 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #62's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to be severely cognitively impaired and Resident #62 required extensive assistance with bed mobility, transfers, dressing, eating, toileting, and personal hygiene. Review of Resident #62's Notice of Medicare Non Coverage (NOMNC) dated 03/24/22 revealed Resident #62 discharged from Medicare Part A services on 03/24/22. Resident #62 signed the NOMNC on 03/22/22. Review of Resident #62's chart revealed Resident #62 did receive a Skilled Nursing Facility Advance Beneficiary Notice of Non Coverage (SNF ABN) notice to inform the resident of the potential liability for a non-covered stay. Interview with Social Services Director #12 on 04/21/22 at 1:17 P.M. verified Resident #62 was discharged from Medicare Part A services on 03/24/22 and Resident #62 was not provided a SNF ABN to inform the resident of the potential liability for a non-covered stay. Social Services Director #12 verified Resident #62 remained in the facility after being discharged from Medicare Part A skilled services.

Based on record review and staff interview, the facility failed to provide a bed hold notice to a resident within 24 hours of transferring to the hospital. This affected one (#03) resident out of five residents reviewed for hospitalization s. The facility census was 61. Findings include: Review of Resident #03's medical record revealed Resident #03 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #03's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to be severely cognitively impaired. Resident #03 required extensive assistance with bed mobility, transfers, dressing, toileting, eating and personal hygiene. Resident #03 also had adequate vision with corrective lenses. Review of Resident #03's progress note dated 10/02/21 revealed Resident #03 was gagging and making a coughing sound. Resident #03's eyes were rolling back in his head. The nurse practitioner was called, and a new order was put in place to send the resident to the emergency department. Review of Resident #03's census sheet revealed Resident #03 readmitted to the facility from the hospital on 10/06/21. Review of Resident #03's bed hold notice dated 10/08/21 verified Resident #03 discharged to the hospital on 10/02/21. The bed hold notice also stated Resident #03 readmitted to the facility on [DATE] and he used four bed hold days. Interview with the Administrator on 04/20/22 at 12:36 P.M. verified Resident #03 transferred to the hospital on 10/02/21 and was not provided a bed hold notice until 10/08/21. Review of the facility's undated bed hold and leave of absence notifications policy, revealed residents should be provided notice prior to transfer to the hospital.

Based on record review and staff interview, the facility failed to complete and transmit resident discharge Minimum Data Set (MDS) assessments. This affected two residents (#01 and #02) out of 16 residents reviewed for assessments. The facility census was 61. Findings include: 1. Review of Resident #01's medical record revealed Resident #01 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #01 discharged from the facility on 11/20/21. Review of Resident #01's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required extensive assistance with bed mobility, transfers, and toileting. Resident #01 required limited assistance with dressing, eating, and personal hygiene. Review of Resident #01's progress note dated 11/20/21 revealed Resident #01 discharged from the facility on 11/20/21. Review of Resident #01's medical record revealed Resident #01 did not have a completed or transmitted discharge MDS assessment. Interview on 04/20/22 at 8:57 A.M. with Licensed Practical Nurse (LPN) #26 verified Resident #01's discharge MDS assessment was not completed. 2. Review of Resident #02's medical record revealed Resident #02 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #02 discharged from the facility on 12/27/21. Review of Resident #02's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to be moderately cognitively impaired and required extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. Resident #02 required limited assistance with eating. Review of Resident #02's progress note dated 12/27/21 revealed Resident #02 discharged home with her daughter. Review of Resident #02's medical record revealed Resident #02 did not have a completed or transmitted discharge Minimum Data Set (MDS) assessment. Interview on 04/20/22 at 8:57 A.M. with LPN #26 verified Resident #02's discharge MDS assessment was not completed. Review of the facility's resident assessment instrument policy dated November 2021 revealed the facility would complete and transmit MDS assessments within federal and state guidelines.

Based on medical record review, resident interview, and staff interview the facility failed to ensure residents care plans were updated to reflect current health status. This affected two residents (#30 and #65) of three reviewed for care plans. The facility census was 61. Findings included: 1. Medical record for Resident #30 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #30 had intact cognition. Resident #30 required supervision for bed mobility, transfers, eating and limited assist with toileting. Resident was coded with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #30 was receiving antipsychotic, antianxiety, and antidepressant medications during the assessment period. Review of the care plan for Resident #30 dated 06/22/16 with revisions on 05/09/17 and 01/07/21 revealed, Resident #30 received [CONDITION(S)] medication for [CONDITION(S)] disorder. Interventions included, administer medication as ordered, monitor for side effects to the medication and provide notifications per facility protocol, follow up as ordered, educate caregivers about risks, benefits and the side effects and/or toxic symptoms of [MEDICATION(S)] and [MEDICATION(S)], monitor and re-evaluate quarterly for continued need for this medication and initiate medication reduction if appropriate. Review of discontinued physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 04/19/22 at 3:20 P.M. Resident #30 stated she did not remember taking [MEDICATION(S)] or [MEDICATION(S)]. Interview on 04/21/22 at 1:14 P.M. the Assistant Director of Nursing (ADON) verified the care plan contained [MEDICATION(S)] and [MEDICATION(S)] and should not have. 2. Medical record review for Resident #65 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #65 revealed intact cognition. Resident #65 required extensive assistance for bed mobility, transfer, and toileting. Resident #65 required supervision for eating. Resident #65 was coded as receiving an application of non surgical dressings. Resident #65 received antidepressant, anticoagulant and antibiotic medications daily during the assessment period. Review of care plan dated 10/22/21 for Resident #65 revealed the resident was at potential risk for infection, fluid overload related to intravenous antibiotic via left upper extremity midline peripheral inserted central catheter (PICC). Interventions included, change PICC line dressing weekly and as needed, change PICC line tubing every 24 hours, flush PICC after antibiotic with 10 cubic centimeter (cc) with normal saline followed by 5 milliliters (ml) of [MEDICATION(S)], flush PICC per facility policy, and flush PICC prior to antibiotic administration with five ml of normal saline using a 10 cc syringe. Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 04/20/22 on 11:01 A.M. with the MDS Licensed Practical Nurse (LPN) #25 verified the PICC was discontinued and should have been taken off the plan of care.

Based on medical record review, staff interview, observations, and review of facility policy, the facility failed to monitor for adverse side effects for [CONDITION(S)] medications. This affected two resident (#30 and #65) reviewed for monitoring for adverse side effects for [CONDITION(S)] medications. The facility census was 61. Findings include: 1. Medical record for Resident #30 revealed an admitted [DATE] with diagnoses including stroke, [CONDITION(S)] disorder, arthropathy, altered mental status, type II diabetes, sleeplessness, and anxiety. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #30 had intact cognition. Resident #30 required supervision for bed mobility, transfers, eating and limited assistance with toileting. Resident #30 was coded with diagnoses including anxiety, depression, [CONDITION(S)] disorder, psychotic disorder, and [CONDITION(S)]. Resident #30 was receiving antipsychotic, antianxiety and antidepressant medications during the assessment period. Review of the care plan for Resident #30 initiated on 05/09/17 with revisions, revealed the resident used antianxiety medications related to anxiety disorder. Interventions included educate the resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms of (anti-anxiety medication drugs being given), give anti-anxiety medications ordered by physician, and monitor/document side effects and effectiveness. Further review of the care plan revealed the resident received [CONDITION(S)] medication related to [CONDITION(S)] disorder. Interventions included administer medication as ordered and monitor for adverse side effects to the medication and provide notifications per facility protocol. Review of physician orders for Resident #30 revealed an order dated 04/18/22 for [MEDICATION(S)] 200 milligrams (mg) one tablet daily for sleeplessness, an order for Haloperidon tablet 5 mg give one tablet daily at bedtime dated 04/14/22, an order for [MEDICATION(S)] 50 mg, give one table by mouth daily for major depressive disorder dated 04/12/22 and an order for [MEDICATION(S)] 0.5 mg give one table by mouth two times a day for anxiety. Review of discontinued physician order for Resident #30 revealed an order for [MEDICATION(S)] 25 mg give one tablet one time a day for [CONDITION(S)] disorder dated 02/08/22 and discontinued on 04/12/22, an order for [MEDICATION(S)] 5mg give one tablet daily for [CONDITION(S)] disorder dated 02/08/22 and discontinued on 04/12/22, an order for [MEDICATION(S)] 150 mg give one tablet daily by mouth at night for sleeplessness and an order for [MEDICATION(S)] 25 mg give one tablet daily for [CONDITION(S)] disorder dated 02/08/22 and discontinued on 04/12/22. Review of Resident #30's Medication Administration Record (MAR) from 01/01/22 to 04/21/22 revealed the MARs were silent for monitoring for adverse side effects of [CONDITION(S)] medications. Review of Resident #30's Treatment Administration Record (TAR) from 01/01/22 to 04/21/22 revealed the TARs were silent for monitoring for adverse side effects of [CONDITION(S)] medications. Review of progress notes for Resident #30 from 01/01/22 to 04/21/22 revealed progress notes were silent for for monitoring for adverse side effects of [CONDITION(S)] medications. Observation on 04/19/22 at 3:19 P.M. of Resident #30 revealed the resident was resting in bed, awakened easily with verbal stimulation. Resident was well groomed and in appropriate clothing. Interview on 04/21/22 at 10:25 A.M. Licensed Practical Nurse (LPN) #25 verified the facility was not monitoring for specific side effects related to [CONDITION(S)] medications. LPN #25 stated she was unaware of any monitoring tools used by the facility. Interview on 04/21/22 at 1:07 P.M. with Assistant Director of Nursing (ADON) #25 verified the facility is not monitoring for adverse side effects and they should have. Further stated the last monitoring of adverse side effects was documented in 2018. 2. Review of the medical record for Resident #26 revealed an admitted [DATE] with diagnoses including [CONDITION(S)] disorder [CONDITION(S)] type, cerebral infarction, COVID-19, personality disorder, depression, involuntary movements, type II diabetes and [CONDITION(S)]. Review of quarterly Minimum Data Assessment (MDS) assessment dated [DATE] revealed Resident #26 had intact cognition. Resident #26 displayed behaviors including physical symptoms directed at others, verbal behaviors directed at others, other behavioral symptoms not directed towards others, and rejected care. Resident #26 required extensive assistance for bed mobility, transfers, eating, and toileting. Review of the care plan for Resident #26 revealed the resident had potential for or alteration in psychosocial well being and or moods behaviors related to [CONDITION(S)] disorder, thoughts of being better off dead, self harm, wandering, depression and anxiety. Interventions included administer medication as ordered and monitor and document for side effects and effectiveness, behavioral consults as needed, monitor and record mood to determine if problems seem to be related to external causes. Further review of the care plan revealed the need to monitor for altered behavior patterns, disruptive interactions, disruptive verbally, resistive to care, violence/anger related to manipulative behavior, history of suicidal ideation's, attention seeking behaviors, feeling depressed, placing self on floor from wheelchair and/or bed. Interventions included administer prescribed medications, observe for side effects and monitor for effectiveness, and allow resident to pace where he or she can be observed. Review of the active physician orders for Resident #26 revealed an order for [MEDICATION(S)] level every three months, dated 4/4/22, an order for [MEDICATION(S)] [MEDICATION(S)] ER Tablet Extended Release 450 mg, give 1 tablet by mouth one time a day for [CONDITION(S)] disorder dated 04/04/22, [MEDICATION(S)] tablet 200 mg give one tablet by mouth at bedtime for [CONDITION(S)] dated 03/21/22, [MEDICATION(S)] tablet, give 150 mg by mouth two times a day for [CONDITION(S)] dated 03/21/22, [MEDICATION(S)] Solution 1 mg/ml inject 1 mg intramuscularly every 12 hours as needed for extrapyramidal signs and symptoms dated 03/11/22, and [MEDICATION(S)] tablet (antidepressant), give 15 mg by mouth at bedtime for schizo affective disorder dated 03/11/22. Review of progress notes for Resident #26 from 01/01/22 through 04/21/22 revealed progress notes were silent for monitoring for adverse side effects. Review of Resident #26's Medication Administration Record (MAR) from 01/01/22 to 04/21/22 revealed the MARs were silent for monitoring for adverse side effects of psychotrophic medications. Review of Resident #26's Treatment Administration Record (TAR) from 01/01/22 to 04/21/22 revealed the TARs were silent for monitoring for adverse side effects of [CONDITION(S)] medications. Interview on 04/21/22 at 10:25 A.M. Licensed Practical Nurse (LPN) #25 verified the facility was not monitoring for specific side effects related to [CONDITION(S)] medications. LPN #25 stated she was unaware of any monitoring tools used by the facility. Interview on 04/21/22 at 1:07 P.M. with Assistant Director of Nursing (ADON) #25 verified the facility is not monitoring for adverse side effects and they should have. Further stated the last monitoring of adverse side effects was documented in 2018. Review of facility policy titled, [CONDITION(S)] Medications, undated, revealed residents would be monitored for adverse side effects.