Every finding on record at Marion Pointe

Based on observation, staff interview, and policy review, the facility failed to properly store, label, and date food in the kitchen. Furthermore, the facility failed to ensure the kitchen was maintained in a sanitary manner. This had the potential to affect all residents. The facility census was 38. Observation on 12/08/25 at 8:01 A.M. of the dry storage revealed a bag of oats and honey granola that was opened and undated, a bag of pasta noodles that was opened and undated, and a loaf of bread that was opened and undated. Interview on 12/08/25 at 8:03 A.M. with Dietary Manager (DM) #242 verified the granola, pasta, and bread had been opened and was not dated. Observation on 12/08/25 at 8:04 A.M. of reach in refrigerator #1 revealed the inside of the refrigerator was coated in unidentifiable liquids and food crumbs. Inside of refrigerator #1 was a bottle of barbeque sauce that was opened and undated, a bag of mozzarella that was opened and undated, a bottle of cranberry juice that was opened and undated, and a bottle of thickened apple and orange juice that were both opened and undated. Concurrent interview with DM #242 verified the refrigerator was dirty and these items were opened and undated. Observation on 12/08/25 at 8:09 A.M. of reach in freezer #1 revealed a bag of breaded pork patties that were opened, unlabeled, and undated, a bag of chicken breasts that were opened, unlabeled, and undated, and a bag of sausage links that were opened, unlabeled, and undated. Concurrent interview with Dietary Aide (DA) #243 verified these items were opened, unlabeled, and undated. Observation on 12/09/25 at 9:00 A.M. of the kitchen revealed dust and debris coating the wall and metal support for overhead piping above two coffee pots and near the food preparation area. Interview on 12/09/25 at 9:06 A.M. with DM #242 verified the dust and debris on the wall and on the overhead metal piping support. Review of the facility policy with a last revised date of February 2018 titled JAG- Food Receiving and Storage revealed food storage areas should always be clean. Furthermore, opened food should be labeled and dated.

Based on medical record review, staff interview, and policy review the facility failed to comprehensively treat residents after a fall. This deficient practice affected one (Resident #27) of three resident reviewed for accidents. The facility census was 38.Review of Resident #27 medical record revealed an admission date of 5/21/25 and medical diagnosis of Alzheimer's disease with late onset, unspecified protein-calorie malnutrition, dementia with moderate mood disturbance and agitation, anxiety, psychotic disorder with delusions, glaucoma, hypertension, muscle weakness, abnormal gait and mobility, repeated falls, and personal injury in unspecified motor-vehicle accident.Review of Resident #27 Minimum Date Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and was at risk for falls. Review of Resident #27 care plan last updated 12/9/25 revealed a risk for fall related to confusion related to the dementia process, impaired balance, impaired mobility, non-compliance with mobility aide, poor coordination, unsteady gait, use of psychotropic medications and poor safety awareness related to the dementia resident non-compliant with fall interventions, continued falls with non-compliance, and ambulates herself without use of call light. Interventions included for a floor mat to be placed next to bed at all times, to provide safer bed boundaries, reinforce need to call for assistance, and have commonly used articles within easy reach. Further review of the care plan revealed Resident #27 had an actual and was identified for a potential alteration in skin integrity related to incontinence, poor oral intake, and non-compliance with interventions.Review of Resident # 27 progress notes dated 12/05/25 at 9:05 P.M. revealed staff heard a cry for help, went to the resident's room and found Resident # 27 on the floor next to the bed, between the bed and wheelchair. The resident was apparently trying to walk to the bathroom and did not see the wheelchair obstructing their pathway. Resident #27 sustained an abrasion above the right eye, denied a headache or head pain, and denied any vision changes. Resident #27 was assisted to the bathroom by a Certified Nursing Assistant (CNA) and walked back to bed with supervision. The resident's emergency contact and the provider were notified of the fall at 10:28 P.M. on 12/05/25.Further review of progress notes dated 12/06/25 at 8:52 A.M. revealed the resident was on neurological checks and had sustained a skin tear above the right eye and had no complaints of pain or discomfort. Review of Resident #27 skin assessments revealed no skin assessment was completed documenting the skin tear to the right eyebrow.Attempted interview with Resident #27 on 12/19/25 at 9:00 A.M. was unsuccessful due to the residents cognitive status.Interview on 12/11/2025 at 3:34 P.M. with the Interim Director of Nursing confirmed the facility did not have a treatment plan regarding Resident #27 fall and injury above the right eye. Further interview confirmed the expectation for residents that have fallen is to have follow up care including the nurses documenting any wounds or injuries sustained as a result of a fall in a skin assessment and in a nurses note, with ongoing skin scheduled skin assessments for continued monitoring of the skin alteration. Review of facility policy, Fall- Clinical Protocol last revised march 2018 revealed the nurses shall assess and document recent injury, especially fracture or head injury. Further review revealed the staff, with the physician's guidance, will follow up on any fall with associated injury.

Based on record review, observation, staff interview, resident interview, and policy review, the facility failed to ensure a clear advanced directive, and failed to ensure the advanced directive in the electronic medical record (EMR) and in the paper chart matched. This affected one Resident (#41) of 38 residents reviewed for advanced directives. The facility census was 38. Review of Resident #41's medical record revealed an admission date of 09/25/24. Diagnoses included cerebrovascular disease, hypertensive heart disease without heart failure, major depressive disorder, and vascular dementia. Review of Resident #41's annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #41 had severe cognitive impairment. Review of Resident #41's care plan with a last revision date of 09/04/25 revealed Resident #41 and or the responsible party had chosen for Resident #41 to be a full code with interventions including to call emergency services for emergency help, if needed, offer information and discuss the advanced directive and code status with the resident and family quarterly and as needed. Observation on 12/08/25 at 3:02 P.M. of the paper chart for Resident #41 revealed the first document under the advanced directives tab was a Do Not Resuscitate (DNR) order signed by the physician on 06/06/24. Further review of the paper chart revealed a document titled full code signed by Resident #41 on 07/16/25. Resident #41 was identified as a full code status the EMR.Interview on 12/09/25 at 8:54 A.M. with Licensed Practical Nurse (LPN) #260 revealed in the event of a resident needing Cardiopulmonary Resuscitation, she would first check the residents code status. Concurrently, LPN #260 verified Resident #41 had a DNR order as the first document behind the advanced directives tab in the paper chart and was a full code in the EMR. Interview on 12/10/25 at 8:20 A.M. with Social Services (SS) #208 revealed when a residents code status changes, she will update the EMR and the paper chart. SS #208 revealed she would remove the previous code status paperwork from the paper chart and update it with the new code status paperwork. Interview on 12/10/25 at 10:12 A.M. with Resident #41 revealed Resident #41 wanted to be a full code.Review of the facility policy last revised in September of 2022 titled Advanced Directives revealed advanced directives would be placed in the residents medical record and should be readily available for staff.

Based on observation, record review, resident interview, staff interview, and policy review, the facility failed to ensure the temperature inside of the facility remained between 71 and 81 degrees Fahrenheit (DF). This affected three residents (#9, #10, and #33) of seven residents reviewed for facility temperature. The facility census was 38. Observation on 12/10/25 at 2:32 P.M. of the 200 hallway revealed it felt cold in the facility.Review of the medical record for Resident #9 revealed an admission date of 08/10/23. Diagnoses included epilepsy, dementia with mood disturbances, major depressive disorder, and anxiety disorder. Review of Resident #9's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 had moderately impaired cognition. Furthermore, Resident #9 was dependent for toilet hygiene, personal hygiene, and shower hygiene.Interview on 12/10/25 at 2:40 P.M. with Resident #9 revealed he felt it was cold in his bedroom. Concurrent interview with Maintenance Assistant (MA) #214 verified Resident #9's room felt cool. MA #214 further verified the temperature in the room was 69.4 degrees Fahrenheit (F).Review of the medical record for Resident #10 revealed an admission date of 06/26/19. Diagnoses included hyperlipidemia, quadriplegia, apraxia, major depressive disorder, and obstructive sleep apnea.Review of Resident #10's annual MDS assessment dated [DATE] revealed Resident #10 had moderately impaired cognition. Furthermore, Resident #10 was dependent for personal hygiene, toilet hygiene, and all mobility.Interview on 12/10/25 at 2:41 P.M. with Resident #10 revealed he felt it was cold in his bedroom. Concurrent interview with MA #214 verified Resident #10's room felt cool. MA #214 further verified the temperature in the room was 69.7 degrees Fahrenheit (F).Review of Resident #33's medical record revealed an admission date of 12/21/24. Diagnoses included Alzheimer's, hyperlipidemia, hypertension, and type two diabetes mellitus.Review of Resident #33's annual MDS assessment dated [DATE] revealed Resident #33 had intact cognition. Furthermore, Resident #33 was independent for mobility.Interview on 12/10/25 at 10:09 A.M. with Resident #33 revealed it is cold in his room, and he had reported this to the facility. He stated he had to wear multiple layers of clothes because it was so cold.Interview on 12/10/25 at 2:43 P.M. with MA #214 verified it was 69.8 degrees F in Resident #33's room. MA #24 verified building temperature should be between 71 and 81 degrees F. Review of the undated facility policy titled Maintenance of Building Temperatures / Provisions for Extreme Heat or Cold revealed the building temperature in all resident areas will be maintained between 71 and 81 degrees F.

Based on observation, medical record review, staff interview, and review of the facility policy, the facility failed to properly store medication in a safe manor. This affected one (#15) resident reviewed for medication storage. The facility census was 38. Review of the medical record for Resident #15 revealed an admission on [DATE] with a readmission on [DATE]. Diagnoses included displaced intertrochanteric fracture of left femur, chronic kidney disease, and dementia.Review of the quarterly Minimum Data Set (MDS) on 09/25/25 revealed Resident #15 had impaired cognition. Resident #15 required moderate assistance with activities of daily living (ADLs).Review of the care plan dated 07/21/25 revealed Resident #15 prefers to provide his own personal care and is resistant to staff assistance and refuses assistance when offered. Interventions included assisting with functional abilities as requested. Review of the Self Medication Program Assessment of Skills dated 09/30/25 revealed Resident #15 presents a danger to himself or others while self -administering medication and was not a candidate to participate in the self-medication program.Review of the physician orders dated 02/28/25 for Resident #15 revealed an order for Nystatin External Cream 100,000 units/gram, apply to red areas topically every 12 hours as needed for red areas.Review of the Treatment Administration Record (TAR) for 12/2025 revealed Resident #15 had not received Nystatin External Cream.Observation on 02/09/25 at 7:46 A.M. revealed Resident #15 sitting in recliner chair. On the bed was a medication cup with an unknown substance mixed with water.Interview on 02/09/25 at 7:46 A.M. with Resident #15 revealed the substance in the cup was his fungus cream. Resident #15 stated they give him the cream every day.Interview on 02/09/25 at 7:48 A.M. with Licensed Practical Nurse (LPN) #253 revealed the substance in the medication cup was Resident #15's Nystatin cream. LPN #253 further stated that Resident #15 was allowed to self-administer the medication per the doctor. LPN #253 confirmed there were no orders for Resident #15 to self-administer.Interview on 02/09/25 at 7:52 A.M. with Director of Nursing (DON) #779 confirmed Resident #15 did not have an order to self-administer and further confirmed the Nystatin cream had not been signed out in the TAR.Review of the facility policy titled Administering Medications dated April 2025, revealed residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they can do so safely.

Based on record review, observation, staff interview, and policy review, the facility failed to ensure residents received the correct portions during meal service and further failed to ensure liquids were thickened per the physician's orders. This affected three (#37, #38 and #18) of three residents revealed for diets to meet the resident needs. The facility census was 38. 1. Review of Resident #37 ' s medical record revealed an admission date of 04/12/17. Diagnoses included esophageal varices without bleeding, muscle wasting and atrophy, dysphagia, and functional dyspepsia. Review of Resident #37 ' s physician orders revealed a diet order for a regular diet, pureed texture, with thin liquids. Review of Resident #37 ' s quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #37 required a mechanically altered diet. Review of Resident #37 ' s care plan dated 10/10/25 revealed Resident #37 had an altered nutritional status as evidenced by the need for a mechanically altered diet with interventions that included to provide a diet per the Registered Dieticians recommendations and the physicians orders and to honor meal preferences. 2. Review of Resident #38 ' s medical record revealed an admission date of 03/16/16. Diagnoses included paranoid schizophrenia, muscular dystrophy, dental caries, and dysphagia oropharyngeal phase. Review of Resident #38 ' s physician orders revealed a diet order for a regular diet, pureed texture, with thin liquids. Review of Resident #38 ' s quarterly MDS assessment dated [DATE] revealed Resident #38 required a mechanically altered diet. Review of Resident #38 ' s care plan with a last revision date of 12/10/25 revealed Resident #38 had an altered nutritional status as evidenced by the need for a mechanically altered diet with interventions that included to provide a diet per the Registered Dieticians recommendations and the physicians orders and to honor meal preferences. Review of the week two menus and spreadsheets revealed residents on a pureed diet were to have three ounces of pureed sliced turkey with gravy, four ounces of mashed potatoes, four ounces of pureed green beans, two ounces of pureed dinner roll, two ounces pureed brownie, eight ounces of coffee/tea, and one packet of margarine for the lunch meal on 12/08/25. Observation on 12/08/25 at 11:35 A.M. of the meal preparation revealed Dietary Aide (DA) #246 placed two four ounce scoops of green beans into the blender with an unmeasured amount of water to puree the green beans. DA #246 poured the green beans into two separate bowls and placed the covered bowls into the warmer. DA #246 sent the blender and its parts through the dishwasher and then pureed six hot slices of deli turkey with an unmeasured amount of water. Interview on 12/08/25 at 12:04 P.M. with DA #246 verified she used an unmeasured amount of water to puree the green beans and an unmeasured amount of gravy to puree the deli turkey. DA #246 stated she knew how much liquid to add based on what the food looked like. Interview with Dietary Manager (DM) #242 on 12/08/25 at 12:04 P.M. verified the previously pureed green beans measured out to slightly more than half of a half cup. Furthermore, DM #242 verified the pureed turkey did not completely fill the one third cup. Observation on 12/08/25 at 12:15 P.M. revealed the dietary staff served Resident #37 and Resident #38 the food they pureed. Interview on 12/11/25 at 10:57 A.M. with Dietician #207 revealed the facility should be following the menu and serving sizes. She stated there are the same nutritional components before and after pureeing food. Dietician #207 stated best practice would be to puree more food so that the food appears in decent volumes and appetizing. She stated if residents are not receiving the correct portion sizes, they may experience weight loss, it could delay wound healing, and could affect overall health. 3. Review of the medical record for Resident #18 revealed an admission on [DATE]. Diagnoses included Huntington's Disease, anorexia, and dysphagia. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #18 had severe cognitive impairment. Resident #18 was dependent for activities of daily living (ADL) and required a mechanically altered diet. Review of the care plan dated 05/24/23 revealed Resident #18 had an ADL self-care performance deficit related to Huntington's disease, impaired balance, limited mobility, functional quadriplegia, and muscle spasms. Interventions included partial to moderate assistance with eating. Further review of the care plan revealed Resident #18 had a potential for episodes of nutritional problems, abdominal pain, indigestion, nausea and vomiting, diarrhea, constipation, and dysphagia, related to constipation, nausea, and dysphagia. Interventions included following diet per Registered Dietitian recommendation and physician order and encouraging fluid intake at and between meals. Additional review of the care plan revealed Resident #18 had altered nutritional status as evidence by Huntington ' s disease, and need for mechanically altered diet and thickened liquids. Interventions included monitoring and recording by mouth intake, encouraging adequate fluid intake during and between meals, and giving diet per Registered Dietician recommendations and physician order. Review of the physician ' s order dated 06/03/23 revealed Resident #18 was on a mechanical soft diet with nectar thickened liquids. Resident #18 was to have strict supervision with all by mouth intake. Review of the speech therapy evaluation and treatment plan dated 11/11/25 revealed Resident #18 had dysphagia due to Huntington ' s Disease and required a mechanical soft diet with nectar thick liquids. Observation on 12/09/25 at 2:27 P.M. of Resident #18 ' s room revealed a water pitcher on bed side table that was half full of water. Interview on 12/09/25 at 2:31 P.M. with Certified Nursing Assistant (CNA) #271 confirmed the liquid in Resident #18 ' s room was not nectar thick. CNA #271 further confirmed Resident #18 was to be supervised with all oral intake. Interview on 12/09/25 at 3:33 P.M. with Director of Nursing (DON) #779 revealed Resident #18 was able to hold a water pitcher independently. DON further confirmed Resident #18 was to receive nectar thickened liquids, with total supervision due to the potential for aspiration. Review of the facility policy titled Therapeutic Diets dated 10/2017 revealed, a therapeutic diet is considered a diet ordered by a physician, practitioner, or dietitian as part of treatment for a disease or clinical condition and should match what the residents are receiving.

Based on observation, record review, staff interview, and review of the facility policy, the facility failed to ensure medications were documented in the Treatment Administration Record (TAR). This affected one (#15) of four residents reviewed for medication administration. The facility census was 38. Review of the medical record for Resident #15 revealed an admission on [DATE] with a readmission on [DATE]. Diagnoses included displaced intertrochanteric fracture of left femur, chronic kidney disease, and dementia.Review of the quarterly Minimum Data Set (MDS) on 09/25/25 revealed Resident #15 had impaired cognition. Resident #15 required moderate assistance with activities of daily living (ADLs)Review of the care plan dated 07/21/25 revealed Resident #15 prefers to provide his own personal care and is resistant to staff assistance and refuses assistance when offered. Interventions included assisting with functional abilities as requested. Review of the Self Medication Program Assessment of Skills dated 09/30/25 revealed Resident #15 presents a danger to himself or others while self -administering medication and was not a candidate to participate in the self-medication program.Review of the physician orders dated 02/28/25 for Resident #15 revealed an order for Nystatin External Cream 100,000 units/gram, apply to red areas topically every 12 hours as needed for red areas.Review of the Treatment Administration Record (TAR) for 12/2025 revealed Resident #15 had not received Nystatin External Cream.Observation on 02/09/25 at 7:46 A.M. revealed Resident #15 sitting in recliner chair. On the bed was a medication cup with an unknown substance mixed with water.Interview on 02/09/25 at 7:46 A.M. with Resident #15 revealed the substance in the cup was his fungus cream. Resident #15 stated they give him the cream every day.Interview on 02/09/25 at 7:48 A.M. with Licensed Practical Nurse (LPN) #253 revealed the substance in the medication cup was Resident #15's Nystatin cream. LPN #253 further stated that Resident #15 was allowed to self-administer the medication per the doctor. LPN #253 confirmed there were no orders for Resident #15 to self-administer.Interview on 02/09/25 at 7:52 A.M. with Director of Nursing (DON) #779 confirmed Resident #15 did not have an order to self-administer and further confirmed the Nystatin cream had not been signed out in the TAR.Review of the facility policy titled Administering Medications dated April 2025, revealed topical medications used in treatments are recorded on the residents TAR.

Based on observation, staff interview, and policy review, the facility failed to ensure food was stored in a sanitary manner. This had the potential to affect all 40 residents who receive food from the facility. The facility census was 40.Findings include:Observation on 09/03/25 from 8:45 A.M. to 8:50 P.M. of the kitchen dry storage area revealed one case of fudge rounds stored on the floor and four plastic grocery bags containing fruit-flavored cereal on the floor. Observation of the reach-in freezer revealed seven bags of unidentified product open and not dated.Interview on 09/03/25 at 8:47 A.M. with Dietary Staff (DS) #242 revealed the unidentified products in the reach-in freezer were fried chicken, chicken patties, chicken cordon bleu, sausage patties, hamburger patties, diced chicken, and vegetables. DS #242 verified the bags were not labeled or dated when opened and verified the case of fudge rounds and the four bags of cereal were on the floor.Review of the undated policy titled, Food Receiving and Storage, revealed food in designated dry storage areas are raised off the floor unless packaged for case lot handling, for example dollies, pallets, racks and skids, and clear of sprinkler heads, sewage/waste disposal pipes, and vents. All foods stored in the refrigerator or freezer are covered, labeled, and dated use by date.This deficiency represents an incidental finding investigated under Complaint Number OH00166601 (1366364).

Based on observation, resident and staff interview, and medical record review, the facility failed to ensure residents were provided activities per their interests. This affected one (#38) of one residents reviewed for activities. The facility census was 40.Findings include:Review of the medical record for Resident #38 revealed an admission date of 08/26/24 with diagnoses including but not limited to senile degeneration of the brain, type two diabetes, other symptoms and signs involving cognitive functions and awareness, visual hallucinations, major depressive disorder, muscle wasting and atrophy, difficulty walking, abnormal posture, schizoaffective disorder, mixed obsessional thoughts and acts, and anxiety disorder. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38 had moderate cognitive impairment. Further review revealed the resident's activity preferences included it was very important to the resident to have books, newspapers, and magazines to read, be around animals such as pets, and participate in religious services or practices. It was somewhat important to listen to music she liked and keep up with the news. Resident #38 was dependent on staff for activities of daily living except for eating and was dependent on staff for wheelchair mobility. Review of Resident #38's comprehensive care plan dated 06/03/25 revealed there was no care plan for activities or indications why the resident could not get out of bed.Interview and observation on 09/03/25 at 9:50 A.M. with Resident #38 revealed she did not get out of bed because her legs were weak and she could not stand. Resident #38 stated she would like to get out of bed and stated the facility only uses a mechanical (Hoyer) lift to weigh her. Resident #38 stated the facility does not bring her anything to do while she is bedbound. Observation during the interview revealed Resident #38 did not have any books, magazines, or newspapers, and the television in the room was not on. Interview on 09/04/25 at 9:41 A.M. with the Administrator revealed she did not know why Resident #38 could not get out of bed or why she was in bed all the time. The Administrator verified there was no documentation regarding activities or the reason Resident #38 was in bed all the time. The Administrator verified there was no documentation Resident #38 refusing to get out of bed. The Administrator verified there was no documentation why Resident #38 did not have books, magazines, or newspapers for activities that were assessed as very important to the resident in the MDS assessment. Follow-up interview on 09/04/25 at 1:05 P.M. with Resident #38 revealed the resident would be scared to get up in her wheelchair but she would do it. Resident #38 stated she would like to do something besides lay in bed all day. Resident #38 stated she would like to have some books and magazines for activities.This deficiency represents an incidental finding discovered under Master Complaint Number OH00167412 (1366365).

Based on observation, medical record review, resident and staff interview, and policy review, the facility failed to provide timely incontinence care for a dependent resident. This affected one (#11) of four residents reviewed for bowel and bladder incontinence. The facility census was 40.Findings include:Review of medical record for Resident #11 revealed an admission date of 09/25/24 with diagnoses including but not limited to cerebrovascular disease, psychotic disorder with delusions, vascular dementia, and major depressive disorder. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 had moderate cognitive impairment and was assessed as frequently incontinent of bowel and bladder. Review of Resident #11's current care plan revealed a focus area for alteration in urinary elimination related to urinary incontinence. Interventions included to check the resident every two hours and assist with toileting as needed. Observation on 09/04/25 from 3:10 P.M. to 4:15 P.M. revealed Resident #11 was visibly incontinent. Resident #11 was wearing gray sweatpants which were visibly wet in the front and the resident was sitting in his wheelchair in his room. Second shift nurse aides were observed sitting with the first shift nurse aides and no room-to-room report was observed to be done. Continued observation revealed at 3:26 P.M. Resident #11 remained in his room with the door closed. Resident #11 remained in the same gray sweatpants that were wet in the front and the room had a slight musty smell. Social Services (SS) #212 entered Resident #11 room at 3:42 P.M. and exited the room at 3:50 P.M. The Surveyor entered Resident #11's room after SS #212 left the room and the resident remained in the same gray sweatpants that were wet and the room continued to have a musty smell. No nurse aides were observed on the 100 hall at that time. Resident #11 was checked by staff at 4:16 P.M. after the Surveyor brought it to the Director of Nursing's (DON) attention that Resident #11 had been sitting in a wet brief for an extended period of time with no staff intervention. Interview on 09/04/25 at 12:59 P.M. with Resident #11 stated second shift staff would sometimes leave him lay in a wet bed and/or brief for an extended period. Resident #11 stated it could be up to an hour or more before any staff come to change him. Interview on 04/09/25 at 4:15 P.M. with the DON confirmed Resident #11 was up in his wheelchair and his pants were wet in the front. The DON verified the room had a musty smell.Review of the undated policy titled, Activities of Daily Living (ADLs), Supporting, revealed residents who are unable to carry out activities of daily living independently receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.This deficiency represents non-compliance investigated under Master Complaint Number OH00167412 (1366365).

Based on observation, interview, and policy review, the facility failed to ensure a clean and sanitary environment in the dry storage room in the kitchen. This had the potential to affect all residents who receive food from the kitchen. The facility census was 37. Findings include: Observation on 03/26/25 from 8:36 A.M. to 9:07 A.M. of the dry storage area in the kitchen revealed mouse droppings and urine in a box of thickened orange juice. Mouse droppings observed in the following: silverware container holding packets of ketchup, mustard, and A1 sauce with several packets of ketchup chewed into, on top of box with lasagna noodles, on several unopened boxes, on the top of three peanut butter tubs, on the bottom of soda cans, a bag of chocolate sprinkles, in a box of unopened lime gelatin packets (urine as well as droppings), and all over the storage area. One bag of French-fried onions was observed to be chewed through. Two bags of macaroni noodles, one bag of regular noodles, box of lasagna noodles, large box of shell noodles, and one bag of chocolate sprinkles were opened and not dated. Interview on 03/26/25 at 8:53 A.M. with Dietary Staff #135 and #134 revealed the facility has been actively working on getting rid of the mice. Dietary Staff #135 stated if a mouse would chew through any food products, they would throw it out. Dietary Staff #135 verified the mouse droppings and urine throughout the dry storage area and on the food products. Dietary Staff #135 verified the French-fried onions were chewed through. Dietary Staff #135 stated they are in the process of putting all small single packed items in clear plastic containers with lids so the mice can't get to them. Interview on 03/26/25 at 8:59 A.M. with Dietary Supervisor #136 revealed he verified the mouse droppings and urine throughout the storage area. Dietary Supervisor #136 stated they clean rack to rack to try and clean up the droppings and urine, but it had only been a few days and it is all back again. Dietary Supervisor #136 stated that they have been treating for mice for two months. Interview on 03/26/25 at 10:25 A.M. with the Administrator revealed she was upset with the response from the dietary staff. Administrator stated the dietary staff was aware of the cleanliness issue but did not relay that to the appropriate staff. Administrator stated they have an awesome housekeeping staff that could have cleaned the storage area daily. Review of policy titled, Sanitation-Dietary Services, not dated revealed all kitchens, kitchen areas, and dining areas are kept clean, free from garbage and debris, and protected from rodents and insects. Review of policy titled, Food Receiving and Storage, not dated revealed non-refrigerated foods, disposable dishware and napkins are stored in a designated dry storage unit which is temperature and humidity controlled and kept clean. Dry food and goods are handled and stored in a manner that maintains the integrity of the packaging until they are ready to use. This deficiency represents non-compliance investigated under Complaint Number OH00163794.

Based on record review and staff interview, the facility failed to ensure residents Pre-Admission Screening and Resident Review (PASARRs) were completed accurately and updated when a new diagnosis was identified. This affected four (#01, #13, #31 and #35) of the five residents reviewed for PASARRs. The facility census was 36. Findings include: 1) Review of the medical record for Resident #01 revealed an admitted [DATE]. Diagnoses included schizoaffective disorder, paranoid schizophrenia, personality disorder, depression, and anxiety. Review of the PASARR dated 12/12/22 for Resident #01, revealed mood disorder, and schizophrenia were listed for the resident. Personality disorder was not documented. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #01 was cognitively intact with a Brief Interview for Mental Status (BIMS) of 15. 2) Review of the medical record for Resident #13 revealed an admitted [DATE]. Diagnoses included depression, chronic pulmonary disease, dementia, schizoaffective disorder bipolar type, anxiety, suicidal ideations, and cognitive impairments. Review of the PASARR dated 03/17/21 for Resident #13, revealed mood disorder, panic disorder and alcohol abuse were listed. Schizophrenia or other psychotic disorders were not documented for the resident's diagnosis of schizoaffective disorder. Review of the MDS assessment dated [DATE] revealed Resident #13 was cognitively intact with a BIMS of 15. 3) Review of the medical record for Resident #31 revealed an admitted [DATE]. Diagnoses included dementia, bipolar disorder, spinal stenosis, unspecified psychosis, and chronic obstructive pulmonary disease. Review of the PASARR completed 07/23/23 for Resident #31 revealed the resident was documented to have schizophrenia and a mood disorder. Other psychotic disorders were not marked. Review of the MDS assessment dated [DATE] revealed Resident #31 was cognitively intact with a BIMS of 15. 4) Review of the medical record for Resident #35 revealed an admitted [DATE]. Diagnoses included unspecified dementia, schizotypal disorder, depressive disorder, lack of coordination and altered mental status. Review of the PASARR dated 03/17/21 for Resident #35, revealed no dementia or mental disorders were listed. The Dementia section was marked no, and mental disorders were not selected. Review of the MDS assessment dated [DATE] revealed Resident #35 was cognitively impaired with a BIMS of 12. Interview on 03/20/24 at 11:03 A.M. with Social Services Director (SSD) #201 confirmed the facility staff discuss changes in diagnoses and discuss when a new PASARR was needed. SSD #201 confirmed the PASARR for Resident #01 did not have personality disorder documented, Resident #13 had diagnosis of Schizoaffective disorder and confirmed the diagnosis was not included on the PASARR, Resident #31 did not have a diagnosis of schizophrenia but had it marked on the PASARR and also had a diagnosis of unspecified psychosis which was not identified on the PASARR under other psychotic disorder and Resident #35 had a diagnosis of dementia which was not identified on the PASARR and a diagnosis of schizotypal disorder and depression which were not identified on the PASARR. Review of facility policy titled, PASRR Completion Policy undated, revealed the Administrator would designate a staff member to ensure PASARR was done on all potential residents. The policy did not state a process for ensuring documentation was updated from a change in diagnosis or to ensure accuracy.

Based on observations, staff interview, review of portion size documents and review of the facility policy, the facility failed to ensure the recipes for pureed foods were followed to ensure nutritional value. This had the potential to affect four (#01, #07, #10, #20) of the four residents who received pureed diets. The facility census was 54. Findings include: Observation of Cook # 220 preparing puree meals on 03/20/24 at 11:15 A.M. revealed Cook #225 added water and bread to make the pureed chicken patty and did not add any chicken base. Interview with Cook #220 at the same time verified she always used water to put in the pureed foods and does not follow a recipe. Interview with Dietary Manager (DM)#285 on 03/20/24 at 11:20 A.M. verified they always use water to do their pureed foods. DM #285 reported the facility did not follow a specific recipe for pureed foods and this was the way she had been trained. Interview with Registered Dietitian Nutritionist, Licensed Dietitian #400 on 03/20/24 at 3:45 P.M. verified the DM#285 and the cook should be following the recipes for all meals. Review of the facility documents for sandwich chicken breaded pureed, revealed the portion size to be one each chicken breast fritter, a chicken base, hot water, food thickener and pureed bread. Review of the facility policy titled Nutrient Retention of Foods dated 04/07 revealed the facility will endeavor to prepare and serve foods in such a manner as to conserve the nutritive value of foods. Supervisors will instruct the cooks to prepare food in accordance with guidelines to minimize nutrient loss.

Based on observation, record review, facility staff interview, policy review and manufacturer instruction review, the facility failed to accurately complete insulin pen administration which resulted in a significant medication error. This affected one (#04) of the two residents observed for insulin administration. The facility identified nine (#03, #05, #18, #25, #26, #32, #33, and #35) residents who received insulin pen injections. The total facility census was 36. Findings Include: Review of Resident #04's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included type two diabetes mellitus, pure hyperglycemia, and schizoaffective disorder. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #04, revealed the resident was cognitively intact and the resident received injections and insulin on seven days of the review period. Review of the physician's orders dated 01/22/24 for Resident #04, revealed the resident was ordered to receive Basaglar KwikPen injector (long-acting insulin) 100 units/milliliter (mL), inject 20 units subcutaneously in the morning and 40 units subcutaneously at bedtime for diabetes. Observation of the medication administration on 03/18/24 at 6:39 P.M. for Resident #04 and performed by Registered Nurse (RN) #258 revealed, RN #258 obtained the Basaglar KwikPen from the medication cart, placed the disposable needle on the pen, and dialed the dose to 40 units. RN #258 was observed to administer the medication to Resident #04 in the resident's abdomen as per standard. Observation revealed RN #258 did not prime the insulin pen prior to the administration. During an interview with RN #258 on 03/18/24 at 6:50 P.M., the Surveyor questioned if RN #258 did anything to the Basaglar KwikPen after putting the disposable needle on the pen and prior to dialing up the ordered 40-unit dose and RN #258 replied no, you just have to dial up the dose and administer it to the resident. RN #258 verified she did not prime the Basaglar KwikPen prior to administering the insulin. Review of the September 2014 facility policy titled Insulin Administration revealed the purpose was to provide guidelines for the safe administration of insulin to residents with diabetes. The instructions included the nursing staff will have access to specific instructions (from the manufacturer if appropriate) on all forms of insulin delivery system(s) prior to their use. Review of manufacturer Basaglar KwikPen instructions for use revealed in step six included Priming the KwikPen. Prime the KwikPen before each injection. Priming means removing the air from the needle and cartridge that may collect during normal use. It is important to prime your pen before each injection so that it will work correctly. If you do not prime before each injection, you may get too much or too little insulin. To prime your Pen, turn the dose knob to select two units. Hold your pen with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top. Continue holding your pen with the needle pointing up. Push the dose knob in until it stops, and 0 is seen in the dose window. Hold the dose knob in and count to five slowly. You should see insulin at the tip of the needle. If you do not see insulin, repeat the priming steps six to eight, but not more than four times. If you still do not see insulin, change the needle, and repeat the priming steps six to eight.

Based on observation, staff interview, medical record review, facility policy review and manufacturer instructions review, the facility failed to discard the disposable needle off an insulin pen in a safe and sanitary manner. This affected one (#4) of two residents observed for insulin administration. The facility also failed to prepare an insulin pen injection in a sanitary manner. This affected one (#05) of two residents observed for insulin administration. The facility identified nine (#03, #18, #25, #26, #32, #33, and #35) residents who received insulin injections. The facility census was 36. Findings Include: 1) Review of Resident #04's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included type two diabetes mellitus, pure hyperglycemia, and schizoaffective disorder. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #04, revealed the resident was cognitively intact and the resident received injections and insulin on seven days of the review period. Review of the physician's orders dated 01/22/24 for Resident #04, revealed the resident was ordered to receive Basaglar KwikPen pen-injector (long-acting insulin) 100 units/milliliter (mL), inject 20 units subcutaneously in the morning and 40 units subcutaneously at bedtime for diabetes. Observation of medication administration on 03/18/24 at 6:39 P.M. for Resident #04 and performed by Registered Nurse (RN) #258, revealed RN #258 retrieved the Basaglar KwikPen from the medication cart, placed the disposable needle on the pen, and dialed the dose to 40 units. RN #258 was observed to administer the medication to Resident #04 in her abdomen as per standard. RN #258 was observed to remove the disposable needle off the insulin pen and place it in her soiled gloves and discard the gloves and the disposable needle in the trash can next to Resident #04's bed. As the nurse and Surveyor were exiting the resident's room, RN #258 reported the needle retracts after the injection so it could be disposed of in a regular trash can. Interview with RN #258 on 03/18/24 at 6:50 P.M., verified the used insulin pen disposable needle was discarded in the regular trash can and not placed in a sharp's container. Review of the policy titled Sharps Disposal revised January 2012, revealed the facility shall discard contaminated sharps into designated containers. Staff will discard them immediately or as soon as feasible into designated containers. Review of the Basaglar KwikPen manufacturer instructions revealed when disposing of the pens and needles, put the used needles in a Food and Drug Administration (FDA) cleared sharps disposal container right away after use and do not throw away (dispose of) loose needles in a house hold trash. 2) Review of Resident #05's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included type two diabetes mellitus with diabetic neuropathy, anxiety, and retention of urine. Review of the quarterly MDS assessment dated [DATE] for Resident #05, revealed the resident was cognitively intact and the resident received injections and insulin seven days of the review period. Review of the physician's orders dated 11/13/23 for Resident #05, revealed the resident was ordered to receive Insulin Glargine /Lantus (long-acting insulin) 100 units/mL to inject 30 unit subcutaneously at bedtime for diabetes. Observation of medication administration for Resident #05 on 03/18/24 at 8:34 P.M. by Licensed Practical Nurse (LPN) #215 revealed the nurse retrieved the insulin pen from the medication cart, removed the pen cap, placed a disposable needle on the pen, primed the pen with two units of insulin, and then dialed up the 30-unit dose for the Resident. LPN #215 was observed to administer the dose to the resident as per standard and discarded her disposable needle in the sharp's container on her medication cart after removing her gloves and performing hand hygiene. Observation revealed LPN #215 did not cleanse the rubber seal on the insulin pen prior to attaching the disposable needle. Interview with LPN #215 on 03/18/24 at 8:38 P.M. verified she did not cleanse the rubber seal on the insulin pen prior to placing the disposable needle. LPN #215 reported she did not need to clean the rubber seal because the pen had a cover over it as it was being stored in the medication cart. Review of the September 2014 facility policy titled Insulin Administration revealed the purpose was to provide guidelines for the safe administration of insulin to residents with diabetes. The instructions and steps in the procedures included disinfecting the top of the insulin container with an alcohol prep. Review of the insulin Glargine (Lantus Solostar pen) manufacturer instructions revealed wipe the pen tip (rubber seal) with an alcohol swab then remove the protective seal from the new needle, line the needle up straight with the pen, and screw the needle on the to pen.

Based on resident and staff interviews and record review, the facility failed to ensure a resident was offered and assisted with showers per the resident's preference and according to the shower schedule. This affected one (#31) resident of two residents reviewed for activities of daily living (ADL) care. The facility census was 36. Findings include: Review of the medical record for Resident #31 revealed an admitted [DATE]. Diagnoses included dementia, bipolar disorder, spinal stenosis, unspecified psychosis, and chronic obstructive pulmonary disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 was cognitively intact with a Brief Interview for Mental Status (BIMS) of 15 and required set up and clean up assistance with bathing. Review of the paper shower sheets from 02/01/24 to 03/20/24 for Resident #31 revealed there was only documented evidence of a shower/bathing being provided on 02/02/24, 02/27/24, 03/12/24 and 03/19/24. Review of the shower schedule for Resident #31, revealed showers should have been offered/provided included Tuesdays and Fridays on 02/02/24, 02/06/24, 02/09/24, 02/13/24, 02/16/24, 02/20/24, 02/23/24, 02/27/24, 03/01/24, 03/05/24, 03/08/24, 03/12/24, 03/15/24, and 03/19/24. Review of the bathing tasks section in the electronic medical record for Resident #31 revealed from 02/19/24 to 03/20/24, baths/showers were only documented as being provided on 03/05/24, 03/08/24 and 03/12/24. It was documented supervision assistance with oversite help only was provided. Review of the plan of care dated 03/07/24 for Resident #31 revealed the resident had an ADL care performance deficit and required set up and clean-up assistance with showering. Interview on 03/19/24 at 8:58 A.M. with Resident #31 revealed she was not receiving showers per her preference and on her scheduled dates. Resident #31 revealed she regularly missed showers and revealed it would get so late in the day, and her showers got missed due to staff being busy. Resident #31 reported she would prefer them earlier in the day during the first shift. Resident #31 reported she typically misses about one shower weekly. Interview on 03/21/24 at 9:00 A.M. with State tested Nurses Assistants (STNAs) #207 and #208 revealed shower sheets were to be filled out for every shower including if/when a resident refused. STNA's #207 and #208 revealed shower sheets were placed into a binder and then collected almost daily by the medical records staff. Interview on 03/21/24 at 12:50 P.M. with Director of Nursing (DON) confirmed Resident #31 only had documented showers on 02/02/24, 02/27/24, 03/12/24 and 03/19/24. The DON reported the facility had a process to audit the shower sheets weekly and revealed no knowledge of the missing 10 shower sheets for Resident #31. Interview on 03/21/24 at 1:15 P.M. with the Administrator and DON confirmed they only had four shower sheets to provide for February and March 2024 and also confirmed there were three documented showers in the tasks section of the electronic medical record with one documented on both the electronic record and on the shower sheet for 03/12/24. Review of facility policy titled, Bath, Shower undated, revealed the purpose was to promote cleanliness, promote comfort and observe resident skin. The documentation required for showers includes date and time shower was provided, names of staff who assisted, supervisor shall be notified if resident refuses a shower.

Based on medical record review, staff interview, review of the hospital records, and policy review, the facility failed to ensure a baseline care plan was completed for a newly admitted resident. This affected one resident (#40) out of three residents reviewed for diabetes. The facility census was 38. Findings include Review of the medical record for Resident #40 revealed an admitted [DATE] and discharge date [DATE]. Diagnoses included pneumonitis due to inhalation of food and vomit, sepsis from pneumonitis, metabolic encephalon, respiratory failure, type two diabetes, kidney disease and Alzheimer's disease. Review of the hospital history and physical dated 03/16/22 revealed residents blood sugar upon admission was 352 milligram per deciliter (mg/dL). Review of the hospital progress note dated 03/17/22 by the attending hospitalist revealed Resident #40 had uncontrolled diabetes with recommendation to start sliding scale insulin (SSI). The note reported resident's blood sugars had been variable but poor food intake with recommendation to continue SSI and hold the metformin (an oral blood sugar reducing medication). Review of the hospital continuity of care form dated 03/18/22 revealed Resident #40 had physician orders for insulin lispro (admeLOG, HumaLOG) injection zero to 30 units with instructions to be given three times daily before meals and to use the normal sensitivity scale. Resident #40 also had physician orders for insulin lispro (admeLOG, HumaLOG) injection zero to 15 units with instructions to be given nightly for corrective use only for blood sugars over 300 mg/dL. No doses were given within 24 hours of hospital discharge. Review of the hospital discharge instructions and summary dated 03/18/22 revealed Resident #40 should stop taking metformin 500 MG tablet and was admitted to the hospital with uncontrolled diabetes with a hemoglobin A1C of 7.6 percent. Review of the baseline care plan dated 03/18/22 revealed Resident #40's plan had not mentioned the resident was diabetic and included no interventions to maintain a healthy status with his diabetes. Review of the physician order dated 03/18/22 identified an order for linagliptin tablet 5 MG with instructions to provide one tablet by mouth in the evening for diabetes. Review of the physician order dated 03/21/22 identified an order for metformin Hcl Tablet 500 MG with instructions to provide one tablet in the morning and one tablet in the evening for diabetes. Review of the physician order dated 03/22/22 identified an order for Novalog solution pen injector of 100 unit solution with instructions for sliding scale insulin: to be provided subcutaneously before meals and at bedtime for blood glucose readings: (0-150 mg/dL give zero units; 151-200 mg/dL give 2 units; 201-250 mg/dL give four units; 251-300 mg/dL give six units; 301-350 mg/dL give eight units; and 351-400 mg/dL give 10 units.) Review of the progress notes dated 03/19/22 revealed nursing spoke with nurse practitioner regarding medication at the family's request. The family had requested Resident #40 be on metformin. Nurse Practitioner reported she would need to review labs next time she was at the facility to see if he should be on metformin. Progress note dated 03/21/22 revealed nurse practitioner was at facility and nurse informed them of resident's loose stools. Resident was on antibiotics. At that time, nurse also informed nurse practitioner of family request regarding restarting metformin for twice daily. Nurse Practitioner reported metformin would start once loose stools were better and antibiotic was completed due to side effects. Progress note dated 03/22/22 revealed resident was not responding as normal and was clammy. The nurse assessed Resident and took his blood glucose reading which was documented as high. The nurse notified the nurse practitioner and was instructed to give 20 units of Novalog and retake the blood sugar reading after 30 minutes. If the blood sugar reading was still high, the resident should be sent out to the emergency room . Progress note dated 03/22/22 revealed the retesting of Resident #40's blood sugar was 589 mg/dL. The resident's family requested the resident be transferred to the hospital. The nurse contacted the ambulance and the nurse practitioner regarding the hospital transfer. Review of the discharge summary dated 03/22/22 from the nursing facility revealed resident was discharged due to hyperglycemia. Review of the hospital admission paperwork dated 03/22/22 revealed resident was admitted with sepsis. Interview on 12/08/22 at 4:56 P.M., with the Director of Nursing (DON) verified the diagnosis of diabetes, monitoring, and treatment were not marked on the baseline care plan and were blank. The DON revealed Resident #40's diabetes was monitored by nursing and the nurse practitioner regardless of it not being on the baseline care plan. Review of the facility policy titled Care plans - baseline, dated 02/2018 revealed the interdisciplinary team would review the orders and implement a baseline care plan to meet the resident's care needs. This deficiency represents non-compliance investigated under Complaint Number OH00137878.

Based on medical record review, staff interview and policy review, the facility failed to ensure an elopement care plan was completed related to resident's at risk for elopement. This affected one resident (#29) out of three reviewed for elopement. The facility census was 38. Findings include Review of the medical record for the Resident #29 revealed an admitted [DATE]. Diagnoses included encephalon, urinary tract infection (UTI), vascular dementia, heart disease, and depression. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #29 had mild cognitive impairment and required extensive assistance of one staff members for transfers and ambulation. Review of the quarterly assessments for elopement risk with most recent assessments dated 02/20/22 scored a four, 05/14/22 scored a four, and 10/28/22 scored a seven. Review of the 10/28/22 assessment revealed Resident #29 upon admission had a diagnosis of dementia or mental illness and exhibited a high level of frustration. Resident #29 was to be placed on elopement protocols. Resident #29 had a combined score of three triggers including the physical ability to leave, he became easily agitated, confused, and disoriented. Scores of three or more triggers reveal the possible elopement risk. The risk assessments dated 02/20/22, 05/14/22, and 10/28/22 revealed resident was At risk for elopement with risk protocol was indicated and a care plan for risk behavior was to be completed. Review of the progress notes dated 11/09/22 revealed resident was found outside by staff with another resident sitting on the front yard grassy area. Resident was asked about why he left and resident stated he was going for a walk with a friend. Resident was assessed by the nurse and educated to get staff assistance to go outside. Review of the plan of care dated 11/10/22 revealed Resident #29 was independently mobile and expressed a desire to leave the facility unattended. Resident was at risk for elopement and injury with interventions including a wander guard to be placed on the resident and monitored for function, escort the resident when outside, divert attention if possible when the resident insists on leaving, and create elopement assessments quarterly and as needed. Resident #29 had no elopement mentioned in his care plan at the time of the elopement. Interview on 12/08/22 at 4:56 P.M., with the Director of Nursing (DON) verified Resident #29's care plan had wandering and elopement added to it after the incident occurred and would look into what was being done prior to the elopement as Resident #29 was listed as being high risk for elopement in several prior elopement assessments. The DON verified Resident #29 should have had a care plan for wondering and elopement due to his risk assessment determination. A follow-up interview on 12/12/22 at 3:15 P.M., with the DON revealed resident #29 was listed as high risk for elopement according to his behaviors and had never had exit seeking behaviors. The DON revealed Resident #29 had elopement risk in the care plan dated 10/2021, but when reviewing the care plan history, the elopement risk was resolved 12/13/21 and was not put back on the care plan until after the resident eloped on 11/09/22. Review of facility policy titled Care plans - baseline, dated 02/2018 revealed revealed the interdisciplinary team would review the orders and implement a care plan to meet the resident's care needs. This deficiency represents non-compliance investigated under Complaint Control Number OH00137529.

Based on observation, staff interview and policy review, the facility failed to safety store food in dry storage area and in the refrigerator. This affected 40 of 40 residents (except #24) who eats food from the kitchen. The facility census was 41. Findings include: Observation on [DATE] at 6:34 P.M., revealed a six pound can of country sausage gravy with a large fist sized dent. A tied bag of Oreo's and a tied bag of coconut were found to be undated. Review of the refrigerator revealed a turkey sandwich wrapped in foil with no date and four cups of apple juice that expired in [DATE]. Interview on [DATE] at 6:45 P.M., with Cook #162 confirmed the can had a large dent and revealed the facility would serve food from a dented can if it could be opened with the can opener. Cook #162 confirmed the Oreo's and coconut was not dated. Cook #162 confirmed the turkey was not dated and the four apple juice containers were expired. Observation on [DATE] at 9:38 A.M., revealed the can of country sausage gravy remained on the shelf but was placed behind a another can without a dent. Two cups of apple juice remained in the refrigerator and had expired [DATE]. Interview on [DATE] at 9:38 A.M., with Kitchen Manager (KM) #177 revealed any cans found with dents should be marked refused and returned to the supplier. KM #177 confirmed the can of country sausage remained on the shelf and had a large dent. KM #177 confirmed the apple juice in the fridge expired [DATE] and should not be served. Review of the policy titled, Food Receiving and Storage, dated February 2018, revealed when food was delivered it would be inspected for safe transport and quality before being accepted. All food in the refrigerator would be dated with a use by date. The policy did not specify what facility would do with dented cans and open food should be cover/sealed and dated.

Based on observations, staff interviews and policy review, the facility failed to ensure medications were stored appropriately. This had the potential to affect six (#2, #6, #15, #22, #23, and #25) of 41 residents in the facility. The facility census was 41. Findings include: 1. Observation of the 200 hall medication cart on [DATE] at 8:00 A.M., with Licensed Practical Nurse (LPN) #128 revealed three [MEDICATION(S)] 5 milligram (mg) tablets loose in the top drawer of the cart and one bottle of Aspirin 325 mg that expired in February 2022. Interview on [DATE] at 8:00 A.M., with LPN #128 confirmed the above findings. 2. Observation of the 300 hall medication cart on [DATE] at 8:40 A.M., with LPN #126 revealed a bottle of [MEDICATION(S)] tablets that expired in [DATE]. Interview on [DATE] at 8:40 A.M., with LPN #126 confirmed the above findings. 3. Observation of the medication room on [DATE] at 10:00 A.M., with LPN #152 revealed a bottle of [MEDICATION(S)] 80 milligrams (mg) that expired in February 2021 and four containers of Benecal 330 calorie supplement that expired on [DATE]. Interview on [DATE] at 10:00 A.M., with LPN #152 confirmed the above findings. Interview on [DATE] at 2:50 P.M., with the Administrator revealed there were no residents receiving Benecal or [MEDICATION(S)]. She provided information stating Resident #15 was the only resident receiving Aspirin 325 mg, two Residents (#2 and #23) were receiving [MEDICATION(S)], and three Residents (#6, #22, and #25) were receiving [MEDICATION(S)] 5 mg tablets. Review of the policy titled, Storage of Medications, dated February 2018, revealed the facility shall not use discontinued, outdated, or deteriorated drugs or biological's and such drugs shall be returned to the dispensing pharmacy or destroyed. It further stated that all nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manager. The policy revealed that drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems.

Based on observations, review of fall investigation reports, review of Incident/Accident Reports, hospital discharge records, and staff interviews and written reports, the facility failed to ensure one resident (Resident #22) received adequate supervision to prevent elopement and injury. This affected one of five sampled residents reviewed. The facility identified five residents who were assessed at risk of elopement (Residents #17, #20, #21, #30 and #90). The facility census was 36. Harm occurred to Resident #22 when she eloped from the facility through the front door; went down an exterior set of concrete stairs and sustained a laceration which required 22 sutures. Findings include: Review of Resident #22's closed medical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was identified as being at high risk for elopement. Review of Resident #22's minimum data set (MDS) assessment dated [DATE] revealed the resident was identified as a daily wanderer which placed the resident at risk for danger. Review of the Elopement Risk assessment dated [DATE] identified the resident was at high risk of elopement. A Leave of Absence assessment dated [DATE] identified Resident #22 required supervision. Review of the resident's plan of care (dated 10/10/12) with a target date of 01/10/13 revealed the resident had exhibited exit seeking behaviors and was at risk for elopement and injury. The plan of care identified the resident wandered with no discernable rational purpose, wandered into other residents rooms disturbing their belongings. Interventions included: wander prevention device; ensure placement and function every shift, respond promptly to alarms and ensure resident's safety/whereabouts, attempt to redirect resident, attempt to find causative factors preceding resident's attempts to leave, eliminate/reduce if possible, if appropriate escort resident on walks outside or within facility, divert attention if possible when a resident becomes insistent on leaving, do not agitate, provide activities of interest to the resident, elopement assessment upon admission, quarterly, and as needed, identify and remove from the environment any stimuli that precipitates elopement from the facility, alert staff of potential elopement. Goals included the resident's whereabouts would be monitored every shift for safety and the resident would be free from harm and that staff would be aware of resident's whereabouts at all times and resident would not wander from the unit. There was no physician's order for the resident to wear a Wanderguard device. Review of nurses notes identified the resident had a Wanderguard alarm in place that would alarm if the resident got close to the alarmed doors. All doors in the facility were designed to alarm when a resident with a Wanderguard in place approached them. Review of Resident #22's medical record revealed on 12/25/12 at 2:00 A.M., the resident had to be medicated with an intramuscularly injection of Haldol (anti-psychotic medication), for wandering into other residents rooms. The nurses notes documented on 12/25/12 at 9:30 A.M., Resident #22 was wandering in and out of other resident rooms and was easily redirected. Nurses notes revealed at 3:15 P.M. the staff heard an alarm sounding at the facility front door. The staff went to the front door and found Resident #22 outside laying at the bottom of four concrete stairs with her wheelchair on top of her. The nursing notes evidenced Resident #22 had a large gash to her forehead with "blood running down the sidewalk". The nursing notes evidenced 911 was called and Resident #22 was taken to the hospital. Nursing notes revealed Resident #22 returned from the hospital on [DATE] at 7:30 PM with 22 stitches to the forehead. The resident had abrasions to the right and left shin that were bandaged. Additional multiple entries for 12/25/12 identified the resident complained of her head hurting and she was medicated with Tylenol. Review of the hospital emergency department report revealed Resident #22 arrived at the hospital at 3:48 P.M. on 12/25/12. The hospital assessment evidenced Resident #22 arrived with a "hematoma to left forehead, with large full thickness laceration which was irregular shaped and 6 centimeters in size". A CAT scan was completed and was negative for fractures, subdural hematoma, concussion, and intercranial hemorrhage. The hospital was noted to discharge Resident #22 back to the facility on [DATE] at 6:03 P.M. Review of the facility's Incident /Accident Report dated 12/25/12 at 3:15 P.M. revealed staff heard the door alarm sounding. Both nurses got up to see where it was and found the resident on the bottom of the steps on her head with her wheelchair on top of her. The resident's head was open and blood was running down the sidewalk. The resident's level of consciousness was alert with confusion. Review of the Fall Investigation dated 12/25/12 corroborated the same information as the Incident/Accident Report with the exception of a new intervention which identified Resident #22 was to be in eyesight of staff at all times. Observation of the facility exit doors located throughout the building on 12/31/12 at 8:00 A.M., with the director of nursing (DON). The observation revealed all of the facility exit doors are equipped with a Secure-Care system, which alarmed when a resident wearing a Wanderguard alarm went near the door. The door then activates and sends an alarm signal to the nursing station. On 12/31/12 at 8:15 A.M. all the facility's exit doors were tested . The front door (main entrance) and the side door on the 100 Hall did not alarm when tested with two Wanderguard alarm bracelets. The two identified doors did not activate when two separate bands were used to test the doors. The DON confirmed the doors were not working properly and did not alarm when tested . Further observation revealed those same two Wanderguard bracelets activated the additional exit door alarms located in the building. Observation of the exit doors on 01/15/13 at 10:30 A.M. with facility Maintenance Person #900 and Environmental Director #920 was completed. The observations revealed the front door would not go into alarm mode when tested with two separate different Wanderguard bands were used. The doors were identified not to alarm when the bands were taken out through the door. All additional exits were tested and determined to be functioning properly. Interview with Maintenance Person #900 at the time of the observation confirmed the front door was noted functioning properly. Review of the facility's maintenance records for December 2012 evidenced weekly checks were being documented for proper functioning of the exit doors. The doors were documented as last being checked by Maintenance Person #100 on 12/18/12. Maintenance Person #100 confirmed during an interview on 12/31/12 at 10:00 A.M. the doors were functioning properly on 12/18/12. Interview with Facility Ombudsman #150 on 12/31/12 at 10:17 A.M. revealed she was at the facility on 12/27/12 and all the exit doors worked properly at that time, when they were tested . Telephone interview with Licensed Practical Nurse (LPN) #500 on 01/15/13 at 11:00 A.M. in regard to the incident with Resident #22 on 12/25/12 revealed she had just observed Resident #22 five minutes prior to entering report with the other nurse. While in report, she heard the alarm sounding and State tested Nurse Aide (STNA) #700 came running in and said there was a bad fall. The other nurse, LPN #400, provided first aid to the resident. Someone outside the building called 911. LPN #500 revealed Resident #22 had attempted to get out of the facility before. She used to walk and she would go to the employee entrance doors, the alarm would sound and she would back away. LPN #500 identified she thought the resident had gotten outside the doors once. LPN #500's written statement of the incident dated 12/27/12 identified Resident #22 was found with "large amounts of blood found running down the sidewalk and large gash was noted on the left side of her forehead". Telephone interview with STNA #800 on 01/15/13 at 11:11 A.M. in regard to the incident with Resident #22 on 12/25/12 revealed she was working in another resident room with the door closed and the alarm was not audible in that room with the door closed. When she left that room she heard the alarm and took off running. STNA #800 identified she knew it was the front door. When she arrived, STNA #600 was already with the resident. STNA #800 ran into the report area and told LPN #400 she was needed immediately. STNA #800 stated people who had driven by and observed the resident had already called 911. When asked if Resident #22 had ever tried to exit the facility before, she replied "yes, all the time". STNA #800 revealed that normally when Resident #22 pushed the doors open and heard the alarm she would shut the door and back away. STNA #800's written statement dated 12/27/12 identified Resident #22 "laying there with blood everywhere". Interview with STNA #600 (assigned to work the 300 Hall where Resident #22 resided) on 01/15/13 at 12:20 P.M. revealed that at approximately 3:10 P.M. she went to the end of the 300 Hall to start her assignment. Approximately halfway down the hall, she heard the alarm sounding. STNA #600 stated no one responded and she could not tell the location of the alarm. STNA #600 then went to the box where the location of the alarm is identified. The alarm location was the main entrance. STNA #600 identified someone from the public came running in and said that someone was hurt. STNA #600 followed him out the door and was the first one to see the resident. She saw Resident #22 lying face down. STNA #600 identified there were many people around and cars were stopped in the road. STNA #600 ran back inside to get the nurse. STNA #600 also identified the alarm cannot be heard at the end of the 300 hall and toward the middle of the hall or with a resident room door closed. STNA #600 identified Resident #22 would often try and get out but would stop when she heard the alarm. Interview with STNA #700 on 01/15/13 at 2:20 P.M. revealed she was running late to work that day and did not clock in until 3:05 P.M. The interview revealed when she arrived at work she saw nothing out front and has to pass the door to get in. STNA #700 revealed she heard an alarm as she was walking past the nursing station close to where the kitchen is located. The STNA revealed the door alarm cannot be heard in multiple locations in the facility. When she heard the alarm sounding she went to the box, (near the nursing station) and determined the alarm was for the "main door". STNA #700 confirmed she did not know which door that was in reference to. STNA #700 then revealed about that same time another STNA stated it was the front door and they headed in that direction. The interview revealed a community person was coming in the door to report a person was outside badly injured. STNA #700 confirmed Resident #22 was outside down the stairs with a laceration to her head that was bleeding. The STNA then confirmed the staff went to get the licensed nurses who were already on their way down the hall. This deficiency substantiates Complaint OH 482.

Based on surveyor observation, resident interview and staff interview, and review of the AHCPR (Agency for Health Care Policy and Research) Supported Guide and Guidelines, it was determined the facility failed to follow physician orders [REDACTED]. This resulted in actual harm for Resident #4 who developed two avoidable Stage II pressure ulcers on the coccyx and two avoidable Stage I pressure ulcers on the right foot. This affected two (#4 and #14) of three residents reviewed for pressure ulcers. The facility identified only one resident with a current pressure ulcer. The facility census was 44. Findings include: 1. Review of Resident #4's medical record revealed the resident was originally admitted to the facility on [DATE] with a most recent readmission date of [DATE]. [DIAGNOSES REDACTED]. Review of the facility skin risk assessment completed on [DATE] revealed the resident scored a 15 placing her at low risk for pressure ulcer development. The resident, however, was observed by the surveyor to be morbidly obese and to remain immobile in bed due to a previous knee injury and surgical procedure. Observation of Resident #4 at 9:05 A.M. during the initial tour of the facility on [DATE] revealed her sleeping on her back with the head of the bed elevated. A [DEVICE] on the right leg surgical wound was noted to be present and functioning at the bedside, as well as a low air loss mattress on the bed which was turned on and inflated. Observations at 12:50 P.M., 1:50 P.M., and 3:50 P.M. failed to show any changes in the resident's positioning of her body or the use of devices to elevate the heels. Observations on [DATE] at 10:50 A.M., 12:30 P.M., 2:40 P.M., 4:00 P.M. and 6:00 P.M. continued to find Resident #4 positioned on her back with her heels resting on the mattress. At 8:30 P.M. on [DATE], a skin inspection of the lower extremities was performed by Assistant Director of Nursing (ADON) #1 in the presence of the surveyor due to observations noting no change in positioning as well as difficulty in following documentation of the foot and leg wounds. No open areas were noted to be present. However, the tissue on the right ankle was noted to have a reddened area measuring 1.0 centimeter by 0.75 centimeter and appearing fragile with two small areas showing evidence of previous tissue injury. The outer aspect of the right upper foot was reddened at the joint and measured 2.0 centimeters in length and 1.0 centimeter in width with an additional bright red, non-blanchable area noted on the plantar surface of the right foot measuring 1.0 centimeter in diameter. These findings were verified with ADON #1 at the time of discovery. Further observation of Resident #4 on [DATE] at 1:00 P.M., after her utilization of the bedpan, revealed the presence of two Stage II pressure ulcers on the left buttock. The upper wound measured 0.5 centimeters long by 0.2 centimeters in width by less than 0.1 centimeters in depth and the lower wound measured 1.0 centimeter in diameter by 0.1 centimeter in depth. This finding was verified during interview with ADON #1 at the time of discovery. During interview with Resident #4 at 11:00 A.M. on [DATE], she stated the staff had started putting her feet up on pillows and turning her during the night ([DATE]). Review of the plan of care, "Actual/Potential Alteration in Skin Integrity," revealed facility staff interventions were to include repositioning the resident every two hours; floating her heels on a pillow; utilizing an air mattress; performance of a weekly skin assessment observing for skin irritation, redness, bruises, scratches, open areas and providing treatment as directed by the physician; and documenting wound status weekly and as necessary. According the AHCPR Supported Guide and Guidelines - Rockville (MD): Agency for Health Care Policy and Research (US) <http://www.ahrq.gov/>; ,[DATE], revealed written repositioning schedules should be developed even when patients are using a pressure-reducing support surface. There are numerous reports that patients develop pressure ulcers while using pressure-reducing support surfaces, regardless of the type of surface. Also under the title "Tissue Load Management", the goal of load management is to create an environment that enhances soft tissue viability and promotes healing of the pressure ulcer (s). The vigilant use of proper positioning and support surfaces are important. Avoid positioning patients on a pressure ulcer. Use devices like pillows or foam to keep the heels off the bed, keep knees and ankles from touching. Maintain the head of the bed at the lowest degree medically necessary. No evidence to show that any one support surface consistently performs better than another. A patient should avoid sitting if he/she has an ulcer on a sitting surface. Move a sitting patient at least once an hour. 2. Review of Resident #14's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the history and physical dated [DATE] revealed the resident had a history of [REDACTED]. Review of the Braden Scale assessment to determine the risk for pressure sore development completed on [DATE] indicated the resident was at high risk with a score of 10. Despite this finding, observations failed to show evidence of aggressive preventative measures. At 12:45 P.M. on [DATE], Resident #14 was observed resting in bed, positioned on her back and looking to her left. The low air loss mattress was turned on and functional. Pillows were noted to be placed between her arms and her chest. No hand rolls or splints were observed. Observation at 1:50 P.M. and 3:50 P.M. on [DATE] noted no changes in the resident's position. At 10:50 A.M. on [DATE] the resident was observed to be resting on her back in bed with the head of her bed elevated. Pillows were again noted between her arms and chest and hand rolls were present in her hands bilaterally. Observations at 12:30 P.M., 2:40 P.M., 4:00 P.M., 6:00 P.M., and 8:00 P.M. revealed no changes in position. A skin inspection of her heels performed during transfer and incontinence care observation at 10:30 A.M. on [DATE] revealed a reddened but blanchable area to be present on the left ankle. Discolored areas were noted on the heels bilaterally, but the tissue was firm and intact. The skin tissues to the coccyx and buttocks was noted to be intact. The state tested nurse aides were observed to lotion her feet and elevate the heels on pillows. Review of the medical record revealed the presence of monthly physician orders, last updated [DATE], directing Resident #14 be turned side to side every two hours. This was verified with ADON #1 during interview on [DATE] at 2:00 P.M.