Every finding on record at Minerva Rehabilitation and Nursing Center

Based on record review and interview, the facility failed to ensure pre-employment tuberculosis (TB) testing was completed timely for all new staff and new residents received TB testing on admission. This affected one resident (Resident #7) out of three residents reviewed for TB control with the potential to affect all 15 residents residing in the facility. Findings include:1. Review of the employee file of Housekeeper (HK) #202 revealed she had a hire date of 03/27/26. HK #202's employee file revealed she had not received TB testing before working at the facility. Interview on 04/14/26 at 8:43 A.M. with HK #202 revealed she had worked at the facility a little over two weeks. She stated she had not had her TB testing completed since she was hired. Interview on 04/14/26 at 10:29 A.M. with Registered Nurse (RN) #200 verified HK #202 had not received her tuberculin skin test on hire. Interview on 04/14/26 at 11:01 A.M. with Human Resources Director (HR) #211 verified the process for new hires receiving TB testing. She stated when a new staff member was hired she would provide a sheet to nursing to complete both steps of the TB testing. She stated the nursing staff would then return it to her completed. HR #211 stated due to the high turnover of staff recently she had not had time to audit her employee files to ensure staff received the testing required. Review of the facility policy titled, Tuberculosis Control Plan, undated, revealed it was the policy of the facility to screen newly admitted residents and new employees for tuberculosis infections. All newly admitted residents would receive a two-step tuberculin skin test, with the first step administered upon admission. All new employees would receive their first step prior to beginning employment. 2. Review of the medical record for Resident #7 revealed an admission date of 03/19/26 with diagnoses including heart failure, acute respiratory failure, hypertension and difficulty walking. Review of the Medication Administration Record (MAR) for March and April 2026 revealed Resident #7 was scheduled to have Tubersol Solution (tuberculin skin test) administered on admission on [DATE]. However, nursing staff had documented code nine, which meant to review the nursing progress notes. There was no further documentation or orders in the MAR that revealed Resident #7 received his tuberculin skin test from 03/20/26 through 04/14/26. Review of the nursing progress note dated 03/20/26 at 5:50 A.M. revealed nursing staff had documented the Tubersol Solution was unavailable and they were awaiting pharmacy. The physician was made aware. There was no further documentation in the nursing progress notes that Resident #7 had received his tuberculin skin test from 03/20/26 through 04/14/26. Review of the nursing progress note dated 04/14/26 at 10:52 A.M. by Licensed Practical Nurse (LPN) #209 revealed Resident #7's physician was updated that he had missed his initial admission tuberculin skin test on 03/19/26. The physician ordered for the facility to administer his skin test on 04/14/26. Interview on 04/14/26 at 10:10 A.M. with Registered Nurse (RN) #200 verified Resident #7 had not had his tuberculin skin test administered on admission and there was no follow-up to ensure the facility received the Tubersol Solution from the pharmacy. Review of the facility policy titled, Tuberculosis Control Plan, undated, revealed it was the policy of the facility to screen newly admitted residents and new employees for tuberculosis infections. All newly admitted residents would receive a two-step tuberculin skin test, with the first step administered upon admission. All new employees would receive their first step prior to beginning employment. This deficiency represents non-compliance investigated under Complaint Number 2973174.

Based on record review, staff interview and facility policy review, the facility failed to ensure comprehensive care plans were developed timely for Residents #4, #7, #16, #18, and #24. This affected five residents (#4, #7, #16, #18, and #24) of 15 residents reviewed for care plans. The facility census was 16.Findings include:1. Record review for Resident #7 revealed an admission date of 11/20/25 with diagnoses of Alzheimer's disease, senile degeneration of the brain, anxiety disorder, major depressive disorder, and unspecified psychosis. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #7 was cognitively impaired and was receiving hospice services. Review of Resident #7's interim care plan assessment, dated 11/20/25, revealed hospice/end of life care provided. Review of Resident #7's comprehensive care plan, dated 11/20/25, revealed no hospice care plan. Interview on 01/20/26 at 4:23 P.M. with Licensed Practice Nurse (LPN) #211 revealed hospice residents had a hospice order and care plan in their chart. LPN #211 indicated the hospice order and care plan would have to be verified as they couldn't be located. Interview on 01/21/26 at 12:10 P.M. with the Director of Nursing (DON) confirmed Resident #7 did not have a hospice care plan. The DON revealed the hospice care plan was added to Resident #7's comprehensive care plan on 01/20/26 as a care plan audit was completed. Review of facility's policy titled Care Planning-Interdisciplinary Team, revised 09/13, a comprehensive care plan for each resident is developed within seven days of completion of the resident assessment (MDS). The care plan is based on the resident's comprehensive assessment and is developed by an interdisciplinary team. 2. Record review for Resident #18 revealed an admission date of 10/07/25 with diagnoses of cerebral infarction, chronic obstructive pulmonary disease, type I diabetes, and anxiety. Review of the interim care plan assessment, dated 10/07/25, revealed Resident #18 was not a current smoker. Review of Resident #18's comprehensive care plan, dated 10/07/25, revealed no smoking care plan. Review of the admission MDS 3.0 assessment dated [DATE] revealed Resident #7 was cognitively impaired, and no tobacco use was listed. Review of the smoking assessment, dated 11/04/25, revealed Resident #18 was safe to smoke with supervision. Interview on 01/21/26 at 10:34 A.M. with the Administrator revealed Resident #18 had a history of smoking but was not smoking until after she was admitted when a family member was smoking. Interview on 01/21/26 at 12:10 P.M. with the DON confirmed Resident #18 did not have a smoking care plan. The DON revealed the smoking care plan was added to Resident #18's comprehensive care plan on 01/21/26 as a care plan audit was completed. Review of the undated Smoking policy revealed any smoking-related privileges, restrictions, and concerns shall be noted on the care plan, and all personnel caring for the resident shall be alerted to these issues. Review of facility's policy titled Care Planning-Interdisciplinary Team, revised 09/13, a comprehensive care plan for each resident is developed within seven days of completion of the resident assessment (MDS). The care plan is based on the resident's comprehensive assessment and is developed by an interdisciplinary team. 3. Review of the medical record for Resident #4 revealed an admission date of 10/30/25 with diagnoses that included urinary tract infection, stroke, cognitive communication deficit, insomnia, and anxiety. Review of the MDS 3.0 admission assessment dated [DATE] revealed Resident #4 was moderately cognitively impaired, did not reject care, and needed maximal assistance with activities of daily living. Review of the elopement assessment dated [DATE] revealed Resident #4 was a high risk for elopement due to ambulatory status, intermittent confusion, and having resided in the facility for 30-120 days. Review of the care plan dated 12/14/25 revealed the absence of elopement interventions. Review of the physician orders for Resident #4 revealed an order for elopement precautions to monitor for wandering and exit seeking behaviors, and no unsupervised leave of absence's due to being an elopement risk. The orders were dated 12/14/25. An interview on 01/22/26 at 10:05 A.M. with LPN #208 verified Resident #4 was categorized as high risk for elopement related to the assessment, and the care plan was absent of elopement interventions. Review of facility's policy titled Care Planning-Interdisciplinary Team, revised 09/13, a comprehensive care plan for each resident is developed within seven days of completion of the resident assessment (MDS). The care plan is based on the resident's comprehensive assessment and is developed by an interdisciplinary team. 4. Review of the medical record for Resident #24 revealed an admission date of 01/14/26 with diagnoses that included pneumonia, urinary tract infection, heart failure, bacteremia (bacteria in the blood), and respiratory failure. Review of the interim care plan dated 01/15/26 revealed Resident #24 needed assistance with activities of daily living. Review of the Brief Interview for Mental Status (BIMS) dated 01/16/26 revealed Resident #24 was moderately cognitively impaired. Review of the physician orders revealed Resident #24 had an order to change PICC dressing per protocol, measure the external length of the peripherally inserted central catheter (PICC), an intravenous catheter that extends from a vein in the arm into the large vein just before the heart often used for long term antibiotic administration, in centimeters (cm), and measure the upper arm circumference in cm at the insertion site. All orders were dated 01/16/26. An observation on 01/21/26 at 10:22 A.M. revealed Resident #24 had a PICC line. Review of current the care plan for Resident #24 revealed the absence of PICC-related interventions. An interview on 01/22/26 at 10:19 A.M. with LPN #208 verified the absence of PICC-related interventions in the care plan. Review of facility's policy titled Care Planning-Interdisciplinary Team, revised 09/13, a comprehensive care plan for each resident is developed within seven days of completion of the resident assessment (MDS). The care plan is based on the resident's comprehensive assessment and is developed by an interdisciplinary team. 5. Review of the medical record for Resident #16 revealed an admission date of 12/24/25. Diagnoses included cellulitis of left lower limb, type II diabetes mellitus, morbid obesity due to excess calories, difficulty in walking, lack of coordination, unspecified injury of kidney, atherosclerotic heart disease of native coronary artery without angina pectoris, acute diastolic heart failure, chronic embolism and thrombosis, obstructive sleep apnea, benign prostatic hyperplasia without lower urinary tract symptoms, essential hypertension, chronic pain syndrome, anemia, and cannabis abuse. Review of a care plan dated 12/24/25 for Resident #16 failed to reveal a focus of care for central line or peripherally inserted central catheter (PICC). Review of the medical record for Resident #16 revealed a MDS 3.0 assessment dated [DATE] revealed BIMS score of 15 on a 0-15 scale, indicating the resident was cognitively intact. The resident required some assistance with activities of daily living. On 01/20/26 at 10:20 A.M., an observation of Resident #16 revealed a central line catheter, which he called a PICC line to his right upper chest. The line was not accessed. He reported he had been getting intravenous antibiotics through the line; however, now it was just being flushed daily, and he got dressing changes to it weekly. An interview with the DON on 01/22/26 at 1:13 P.M. revealed there was no focus of care for a PICC line for Resident #16. She further confirmed the resident had orders for PICC line care and interventions. Review of facility's policy titled Care Planning-Interdisciplinary Team, revised 09/13, a comprehensive care plan for each resident is developed within seven days of completion of the resident assessment (MDS). The care plan is based on the resident's comprehensive assessment and is developed by an interdisciplinary team.

Based on record reviews, observations, interviews and reviews of facility policies, the facility failed to follow proper infection control processes during incontinence care and blood glucose testing for Resident #3 and wound care for Resident #25. This affected two (Residents #25 and #3) of four residents reviewed for infection control. The facility census was 16.Findings include:1. Review of the medical record for Resident #25 revealed an admission date of 01/14/26. Diagnoses included chronic obstructive pulmonary disease, acute respiratory failure with hypoxia, pneumonia, essential hypertension, anxiety disorder and major depressive disorder. Review of the Minimum Data Set (MDS) 3.0 assessment for Resident #25, dated 01/15/26, revealed a Brief Interview for Mental Status (BIMS) score of 13 on a 0-15 scale. A BIMS score of 13 indicated intact cognitive functioning, or normal thinking and memory. On 01/22/26 at 2:35 P.M., an observation of wound care for Resident #25 revealed Licensed Practical Nurse (LPN) #202 did not perform appropriate hand hygiene throughout the dressing change. LPN #202 performed hand hygiene, applied clean gloves, and then lowered the head of the bed, positioned resident, adjusted her clothing to reveal the dressing, then removed the soiled dressing without first performing hand hygiene and changing her gloves. She then cleansed the wound and applied the new dressing without performing hand hygiene or changing her gloves. On 01/22/26 at 3:00 P.M., an interview with LPN #202 confirmed she should have adjusted bed and resident clothing, then performed hand hygiene and donned gloves prior to performing wound care. She also acknowledged hand hygiene should have again been performed after removing the soiled dressing, and new gloves should have been applied prior to wound care being performed and new dressing being applied. Review of a facility policy titled Handwashing/Hand Hygiene, dated 2001, revealed the facility considered hand hygiene the primary means to prevent the spread of infection. The policy indicated personnel should use an alcohol-based hand rub containing at least 62% alcohol or soap and water after contact with a resident's intact skin, after handling used dressings, after contact with objects in the immediate vicinity of the resident, and after removing and disposing of personal protective equipment. Review of a facility policy titled Dressings, Dry/Clean, dated 2001, revealed guidelines for the application of dry, clean dressings. The policy provided the staff was to position the resident, including clothing to provide access to affected area, wash hands thoroughly, apply clean gloves, remove soiled dressing, discard gloves, wash hands thoroughly, open dressings and label with date, time and initials, then using clean technique open any other necessary products. The care provider should then wash hands, apply clean gloves, assess wound, and cleanse with ordered cleanser. Next apply the ordered dressing and secure. 2. Review of the medical record for Resident #3 revealed an admission date of 03/04/25. Diagnoses included chronic obstructive pulmonary disease, muscle wasting, unsteadiness, dysphagia, history of urinary tract infection, depression, metabolic encephalopathy, and malignant neoplasm of the prostate. Review of the MDS 3.0 assessment, dated 12/31/25, revealed Resident #3 has a BIMS score of 10 on a 0-15 scale. A BIMS score of 10 would indicate moderate problems with thinking and memory. The resident had a Foley catheter for urinary elimination. On 01/20/25 at 9:30 A.M., and observation of the entry to Resident #3 revealed signage indicating the resident was on Enhanced Barrier Precautions (EBP). The signage indicated staff was to don gowns and gloves when performing any personal care for a resident with an indwelling medical device. On 01/20/26 at 10:15 A.M., an observation of LPN #211 revealed she donned gloves only and performed bowel incontinence care for Resident #3. On 01/20/26 at 11:00 A.M., an interview with LPN #211 confirmed EBP signage was placed on doors for residents who have wounds, or any type of intravenous access or urinary catheters. She was aware Resident #3 was on EBP. She confirmed she did not wear a gown when providing incontinence care for Resident #3. Review of a facility policy titled Enhanced Barrier Precautions, dated 04/01/24, revealed the facility would follow state and federal guidelines to minimize the spread of Multidrug Resistant Organisms (MDROs) by implementing effective Personal Protective Equipment (PPE) usage. EBP was an infection control intervention designed to reduce transmission of resistant organisms which employed targeted gown and glove usage during high contact resident care activities. These activities included wounds and indwelling medical devices even when the resident did not have an identified infection. High contact care included dressing, bathing, transferring, providing hygiene, changing briefs or assisting with toileting, device care and any wound care. 3. An observation on 01/21/26 at 4:04 P.M. with LPN #202 of blood glucose testing for Resident #3 revealed the following: LPN #202 applied gloves, wiped down the top of the medication cart with a disinfectant wipe, placed paper towels on top of the medication cart, removed her gloves, and then immediately applied new gloves without hand hygiene being performed; LPN #202 then removed two glucometer's (devices that measure blood glucose (sugar)) from the medication cart, removed alcohol pads from the medication cart, removed a container of blood glucose test strips (a strip where blood is placed in a designated section and then inserted into a glucometer to measure blood glucose levels) from the medication cart, cleaned a glucometer with a disinfecting wipe, placed the glucometer on a paper towel, removed gloves, and then immediately applied new gloves without hand hygiene being performed; LPN #202 then cleaned the next glucometer, placed it on a paper towel, removed her gloves without hand hygiene being performed, picked up a glove from the ground and disposed of it into the trash, removed a finger stick lancet from the medication cart, entered Resident #3's room and explained the procedure, moved the bedside table near the resident, and then applied gloves; the rest of the blood glucose testing procedure was performed. An interview on 01/21/26 at 4:21 P.M. with LPN #202 verified hand hygiene was not performed after removing old gloves before new gloves were applied. LPN #202 verified Resident #3 was in EBP, and a gown was not worn during blood glucose testing a high contact care activity. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses that included cellulitis (a skin infection) of the left lower limb, type II diabetes, coronary artery disease, and high blood pressures. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #3 required set up or moderate assistance for activities of daily living, did not reject care, and was cognitively intact. Review of Resident #3's current Treatment Administration Record (TAR) from 01/01/26 to 01/21/26 revealed the resident was in EBP related to wounds and a peripherally inserted central catheter (PICC) (an intravenous catheter that extends from a vein in the arm into the large vein just before the heart that is often used for long term antibiotic administration). Review of the facility policy titled Handwashing/Hand Hygiene, dated 08/2015, revealed hand hygiene is the primary method to prevent the spread of infections, all personal shall follow the handwashing/hand hygiene procedures, hand hygiene should be performed after removing gloves, and hand hygiene should be performed after entering isolation precaution settings. Review of the facility policy titled Enhanced Barrier Precautions (EBP) Policy and Procedure, dated 04/01/24, revealed Enhanced Barrier Precautions is used to minimize the spread of Multidrug Resistant Organisms (MRDO's) by effective Personal Protective Equipment (PPE) usage, gown and gloves are to be used during high contact resident care activities, EBP is indicated anytime a resident has wounds or indwelling medical devices such as a PICC line, and a high contact activity included care where there is a skin opening.

Based on record reviews, observations, interviews and facility policy review, the facility failed to respect the dignity of residents by failing to empty a urinal in full view of the hallway or cover a urinary catheter drainage bag. This affected two (Resident #16 and Resident #3) of two residents reviewed for dignity and respect. The facility census was 16.Findings include:1. Review of the medical record for Resident #16 revealed an admission date of 12/24/25. Diagnoses included cellulitis of left lower limb, type two diabetes mellitus, morbid obesity due to excess calories, difficulty walking, lack of coordination, unspecified injury of the kidney, atherosclerotic heart disease of native coronary artery without angina pectoris, acute diastolic heart failure, chronic embolism and thrombosis, obstructive sleep apnea, benign prostatic hyperplasia without lower urinary tract symptoms, essential hypertension, chronic pain syndrome, anemia, and cannabis abuse. Review of the medical record for Resident #16 revealed a Minimal Data Set (MDS) 3.0 assessment, dated 01/05/26, revealed a Brief Interview of Mental Status (BIMS) score of 15 on a 0-15 scale. A score of 15 indicated Resident #16 was cognitively intact. The resident required some assistance with activities of daily living.On 01/20/26 at 9:20 A.M., an observation of Resident #16's room revealed a urinal which was half full of urine. The urinal was on the over-the-bed table, in full view of the hallway.On 01/20/26 at 10:14 A.M., an observation of Licensed Practical Nurse (LPN) #211 revealed she passed by the urinal to care for another resident. After care of the other resident, she walked out of the room and did not remove or empty the urinal. This was confirmed by LPN #211 on 01/20/26 at 11:00 A.M.On 01/20/2026 at 10:18 A.M., an observation and interview with Resident #16 confirmed a urinal, half full, sitting on the over-the-bed table in full view of the hallway, had been there for several hours. This was confirmed by LPN #211 on 01/20/26 at 11:00 A.M.On 01/20/26 at 11:00 A.M., an interview with LPN #211 confirmed the half full urinal could be seen from the hallway for Resident #16. She further confirmed she had entered and exited the room, passing the urinal each time, and had not emptied it.2. Review of the medical record for Resident #3 revealed an admission date of 03/04/25. Diagnoses included chronic obstructive pulmonary disease, muscle wasting, unsteadiness, dysphagia, history of urinary tract infection, depression, metabolic encephalopathy, and malignant neoplasm of the prostate. Review of the MDS 3.0 assessment, dated 12/31/25, revealed a BIMS score of 10 on a 0-15 scale, indicating Resident #3 had moderate cognitive impairment. The resident had a Foley catheter for urinary elimination.On 01/20/2026 10:55 P.M., an observation of Resident #3 revealed a Foley catheter. The catheter bag was half full and uncovered, exposed to the rest of the room. This was confirmed by LPN #211 at the time of the observation.On 01/20/26 at 11:40 A.M., an interview with LPN #211, revealed Resident #3 had a Foley catheter. She confirmed it was uncovered and exposed to the room. She further indicated she had since covered it.On 01/20/26 at 2:15 P.M., an interview with the Director of Nursing (DON) revealed urinals should not be left in view of the hallway and should be emptied as soon as the staff notice the urinal has urine in it. She further confirmed all Foley catheter drainage bags should be covered at all times to protect the resident's dignity.Review of a facility policy titled Quality of Life-Dignity, dated 2001, revealed each resident would be cared for in a manner which promoted and enhanced quality of life, dignity, respect and individuality. The policy explained demeaning practice and standards of care which compromised dignity were prohibited. Such practices included keeping urinary bags covered and responding to residents' requests for toileting assistance.

Based on record review and interview, the facility failed to provide a complete and accurate baseline care plan for Resident #25. This affect one resident (#25) of 15 residents reviewed for care plans. The facility census was 16.Findings include:Review of the medical record for Resident #25 revealed an admission date of 01/14/26. Diagnoses included chronic obstructive pulmonary disease, acute respiratory failure with hypoxia, pneumonia, essential hypertension, anxiety disorder and major depressive disorder. Review of progress notes for Resident #25 revealed an admission note, dated 01/14/26, which indicated the resident had a boney prominence to sacrum which was reddened, but not open, and applied house zinc to the area.Review of a care plan for Resident #25, dated 01/14/26, failed to reveal any evidence of oxygen care planning or interventions. Further, the care plan failed to reveal any evidence of wound care planning or interventions.Review of orders for January 2026 for Resident #25 revealed no oxygen or wound care orders on admission. Review of the Minimum Data Set (MDS) version 3.0 for Resident #25, dated 01/15/26, revealed a Brief Interview for Mental Status (BIMS) score of 13 on a 0-15 scale. A BIMS score of 13 indicated intact cognitive functioning, or normal thinking and memory. The MDS failed to review any wound care needs. The resident needed stand-by assistance for bed mobility and was not able to ambulate without assistance.Review of vital sign documentation for Resident 25 revealed oxygen levels taken daily from 01/14/26 through 01/21/26. The resident was wearing oxygen when the vital signs were taken on all days except 01/14/26 and 01/15/26.On 01/21/26 at 12:24 P.M., an interview with Licensed Practical Nurse (LPN) #211 revealed the care plan for Resident #25 did not contain interventions for wound care or oxygen. She confirmed the resident used oxygen and required care for a pressure ulcer. She further confirmed the admission orders for Resident #25 did not contain orders for oxygen or wound care.

Based on record review, observations, interview and facility policy review, the facility failed to ensure a peripherally inserted central catheter (PICC) line (a long, thin, flexible tube inserted into a vein and threaded into a large vein near the heart) dressing was changed as ordered by the physician for Resident #24. This affected one resident (#24) of five residents reviewed for medication administration. The facility census was 16.Findings include:Review of the medical record for Resident #24 revealed an admission date of 01/14/26 with diagnoses including pneumonia, urinary tract infection, heart failure, bacteremia (bacteria in the blood), and respiratory failure.Review of the interim care plan dated 01/15/26 revealed Resident #24 needed assistance with activities of daily living.Review of the care plan dated 01/15/26 revealed the absence of central line focus and associated interventions.Review of the Brief Interview for Mental Status (BIMS) dated 01/16/26 revealed Resident #24 was moderately cognitively impaired. Review of the physician orders revealed an order dated 01/16/26 to change PICC dressing and caps per protocol.Review of the TAR from 01/14/26 to 01/21/26 revealed absence of documentation the PICC dressing was changed.An observation on 01/21/26 at 10:22 A.M. revealed Resident #24's PICC line dressing was dated as changed on 01/13/26.An observation on 01/21/26 at 2:42 P.M. of antibiotic administration for Resident #24 revealed the same PICC dressing dated 01/13/26.An observation on 01/21/26 at 4:33 P.M. of antibiotic discontinuation for Resident #24 revealed the same PICC dressing dated 01/13/26.An interview on 01/21/26 at 4:39 P.M. with the Covering Director of Nursing (DON) #295 verified PICC dressings should be changed every seven days, and the dressing should have been changed on 01/20/26.Review of the facility policy titled Central Venous Catheter Dressing Changes, dated 04/2016, revealed the purpose of dressing changes are to prevent catheter-related infections and the dressing should be changed every five to seven days.

Based on record review, observation and interview, the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program for Resident #25. This affected one (Resident #25) of one resident reviewed for pressure ulcers. The facility census was 16.Findings include:Review of the medical record for Resident #25 revealed an admission date of 01/14/26. Diagnoses included chronic obstructive pulmonary disease, acute respiratory failure with hypoxia, pneumonia, essential hypertension, anxiety disorder and major depressive disorder. Review of progress notes for Resident #25 revealed an admission note, dated 01/14/26, which indicated the resident had a boney prominence to the sacrum, which was reddened, but not open, and applied house zinc to the area. Review of the admission physician's orders dated 01/14/26 revealed no wound care orders for Resident #25.Review of a care plan for Resident #25, dated 01/14/26, revealed the resident was to have enhanced barrier precautions (EBP) related to chronic wounds, initiated 01/20/26. The goal was for Resident #25 to remain infection free. Interventions were EBP signage on the door, gloves and gowns for high contact resident care. The care plan failed to reveal any evidence of wound care planning or interventions. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 on a 0-15 scale, indicating Resident #25 was cognitively intact. The MDS was still in progress. Review of progress notes for Resident #25, dated 01/15/26 at 12:07 A.M., revealed a second assessment which indicated her coccyx was red and blanchable and the plan was to continue with house barrier cream and to encourage the resident to turn and reposition. Review of medical record for Resident #25 revealed skilled nursing charting dated 01/16/26, 01/17/26, 01/18/26, which indicated the resident had no open areas on skin. Review of a nursing progress note, dated 01/18/26 at 6:30 P.M., revealed the nurse observed a suspected deep tissue injury (SDTI) to the left buttocks, coccyx, and right buttocks, which had a small amount of bloody drainage noted. A SDTI is a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. The note further read the surrounding skin was pink. No signs and symptoms of infection. Resident #25 spends a majority of her time sitting upright in bed. Resident #25 was noted to be sitting on a cushion while in bed. This nurse encouraged the resident and educated the resident on not sitting on that cushion while in bed and to turn side to side to get off her buttocks. Resident #25 stated that the cushion helps it feel better, and she was not taking it out from under her, and she can't lay side to side due to her breathing issues. The nurse cleansed the area to right buttocks and coccyx with normal saline solution (NSS) and applied dry dressing. The physician was notified and was aware of resident sitting on cushion while in bed. Review of the medical record for Resident #25 revealed a Braden Scale for predicting pressure ulcers, dated 01/18/26, four days after admission. The score of the assessment was 16 on a 0-18 scale. A score of 16 on a Braden scale would indicate the resident was at risk of developing a pressure ulcer. Review of a weekly wound assessment, dated 01/18/26, revealed Resident #25 had a Stage II pressure ulcer. This was documented as Wound #1. A Stage II pressure ulcer is a partial thickness loss of dermis presenting as a shallow open ulcer with a red, pink wound bed, without slough. It may also present as an intact or open/ruptured serum-filled blister. The assessment indicated the wound was on the resident's coccyx and was acquired 01/18/26. Measurements of 1.0 centimeter (cm) in length by 1.0 cm in width with no depth was documented, with a pink peri-wound and well-defined edges. Per the assessment, treatment was to cleanse coccyx with NSS and apply Calazime (zinc oxide paste) ointment and cover with dry dressing three days a week. This was noted to be the first wound assessment with measurements and staging.Review of a weekly wound assessment, dated 01/18/26, revealed Resident #25 had a SDTI. This was documented as Wound #3. The assessment indicated the wound was on the resident's left buttocks and acquired on 01/18/26. Measurements of 1.0 cm in length by 1.0 cm in width with no depth was documented, with a pink peri-wound. Per the assessment, treatment was to apply Calazime ointment and cover with a protective dressing. No cleansing treatment was noted. This was noted to be the first wound assessment with measurements and staging.Review of a weekly wound assessment, dated 01/19/26, revealed Resident #25 had a Stage II pressure ulcer on her right buttocks. This was documented as Wound #2. It indicated the wound was acquired on 01/18/26. The wound measured 2.0 cm in length by 2.0 cm in width and had no depth. The peri-wound was described as pink with well-defined edges. Treatment for this wound was to be cleansed with NSS, applying Calazime and dry dressing three days a week. This was noted to be the first wound assessment with measurements and staging.Review of Resident #25's medical record revealed a History and Physical (H&P) dated 01/20/25. The H&P failed to identify or address the resident's skin condition. The H&P further failed to identify any need for prevention or treatment of pressure ulcers. On 1/20/26 at 11:38 A.M., an interview with Resident #25 revealed she had a facility acquired pressure ulcer. During interview she explained it burned and was very uncomfortable. She believed the staff was applying some cream and some padding to it. No pressure relieving mattress or other specialty mattress noted at that time.On 01/21/2026 from 9:15 to 11:15 A.M., Resident #25 was observed to be lying in bed. She was flat on her back with the head of the bed elevated. She was on a standard mattress. No intervention or attempts by staff to encourage her to turn on her side to relieve pressure to her coccyx and buttocks were made during the entire observation period. On 01/21/26 at 12:24 P.M., an interview with Licensed Practical Nurse (LPN) #211 revealed an admission note, dated 01/14/26, which indicated the resident had a boney prominence to sacrum which was reddened, but not open, and applied house zinc to the area. No wound care orders were noted on admission. The baseline care plan for Resident #25 did not contain interventions for wound care. LPN #211 revealed a second assessment was completed on 01/15/26 at 12:07 A.M. which indicated her coccyx was red and blanchable and the plan was to continue with barrier cream and to encourage the resident to turn and reposition; however, no orders were written, and there was no documented evidence the interventions were implemented. The skilled nursing charting dated 01/16/26, 01/17/26, 01/18/26, indicated the resident had no open areas on skin and there were no orders for wound care on the record until 01/19/26. She confirmed Resident #25 required care for a pressure ulcer which had developed since admission to the facility. LPN #211 indicated Braden scales were to be completed on residents upon admission.On 01/22/26 at 1:13 P.M., an interview with the DON confirmed Resident #25 did not have interventions in place, including a pressure relieving mattress, until after the ulcers had declined. The pressure relieving mattress was not implemented until 01/21/26. She reported wounds at the facility were addressed weekly by a wound care nurse, who would come to the facility every Monday. She verified the H&P dated 01/20/26 failed to identify or address the resident's skin condition. The H&P further failed to identify any need for prevention or treatment of pressure ulcers. Resident #25 had not been seen by the wound care nurse on the Monday after her wound was identified, and the staff had notified the wound care nurse on 01/22/26 of the need to see the resident.On 01/22/26 at 2:35 P.M., an observation of wound care for Resident #25 completed by LPN #202 revealed Resident #25 had three areas of skin concern. The resident had a Stage II pressure ulcer on both her right and left buttocks located in the gluteal cleft. There were no other open areas noted. The resident did have a light red, blanchable area on her coccyx. These observations were confirmed by LPN #202 at the time of observation.

Based on observation, record review and interview, the facility failed to ensure orders were obtained for residents requiring oxygen administration. This affected two (Resident #5 and Resident #25) of three residents reviewed for oxygen use. The facility census was 16.Findings include:1. Review of the medical record for Resident #5 revealed an admission date of 11/20/23. Diagnoses included diverticulitis of intestine, asthma, muscle weakness, unsteadiness on feet, assistance with personal care, wedge compression fracture of the third vertebra; depression, parkinsonism, rheumatoid arthritis, and muscle wasting.Review of a Minimum Data Set (MDS) 3.0 assessment, dated 12/31/25, revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 15 on a 0-15 scale. A score of 15 would indicate the resident had intact cognitive function, or normal thinking and memory. The MDS also indicated the resident was dependent in all activities of daily living.Review of a care plan for Resident #5, dated 01/04/26, revealed a focus of care for oxygen therapy related to ineffective gas exchange. The goal was for no signs or symptoms of poor gas exchange and included an intervention of oxygen from one to four Liters (L) per minute per nasal cannula.On 01/20/2026 at 11:00 A.M., an observation revealed Resident #5 had oxygen via nasal cannula at a flow rate of 2.5 Liters (L). She reported she was to be on 3L of oxygen. The flow rate of 2.5L was confirmed by Licensed Practical Nurse (LPN) #211 on 01/20/26.Review of the current medication administration record for Resident #5 failed to reveal orders for oxygen administration or flow rate.On 01/20/26 at 11:10 A.M., an interview with LPN #211 confirmed Resident #5 had oxygen at 2.5L via nasal cannula. She reported the resident should have been on a flow rate of 3L. During the interview, the LPN #211 checked the orders for Resident #5's oxygen, and found the resident did not have any orders to be on oxygen.2. Review of the medical record for Resident #25 revealed an admission date of 01/14/26. Diagnoses included chronic obstructive pulmonary disease, acute respiratory failure with hypoxia, pneumonia, essential hypertension, anxiety disorder and major depressive disorder. Review of the MDS 3.0 assessment, dated 01/15/26, revealed a BIMS score of 13 on a 0-15 scale, indicating Resident #25 had intact cognitive functioning, or normal thinking and memory. On 01/20/26 at 11:38 A.M., interview and observation of Resident #25 revealed she had been on oxygen for some time. She was noted to be on 1.5 L of oxygen per minute via nasal cannula. This was confirmed by LPN #211 at the time of the observation.Review of vital signs documentation for Resident 25 revealed oxygen levels taken daily from 01/14/26 through 01/21/26. The resident was wearing oxygen when the vital signs were taken on all days except 01/14/26 and 01/15/26.Review of medical record for Resident #25 revealed skilled nursing charting dated 01/16/26, 01/17/26, 01/18/26, which indicated the resident was wearing oxygen.Review of a care plan for Resident #25, dated 01/14/26, failed to reveal any evidence of oxygen care planning or interventions.Review of the medical record for Resident #25 failed to reveal any orders for oxygen use. This was confirmed by LPN #211 on 01/21/26 at 12:26 P.M.Review of a facility policy titled Oxygen Administration, dated 2010, revealed the facility would provide safe oxygen administration. The policy indicated the staff should verify there was a physician order for oxygen and review the resident care plan for any specific or special needs for the resident prior to applying oxygen.

Based on record review and interview, the facility failed to ensure Resident #27's Gabapentin medication was not administered to Resident #21. This finding affected two (Residents #21 and #27) of six residents reviewed for medication administration. Findings include: Review of Resident #21's medical record revealed the resident was admitted on [DATE] and discharged on [DATE] with diagnoses including encounter for orthopedic aftercare, cerebral palsy and anxiety disorder. Review of Resident #21's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #21's physician orders revealed an order dated [DATE] for Gabapentin oral tablet 800 mg (milligrams) give one tablet by mouth four times a day for 120 days due at 12:00 A.M., 6:00 A.M., 12:00 P.M. and 6:00 P.M.; and an order dated [DATE] to give Gabapentin 600 mg one time only for nerve pain for one day. Review of Resident #21's progress note dated [DATE] at 3:03 P.M. authored by Licensed Practical Nurse (LPN) #809 revealed it was okay to give a one-time dose of 600 mg of Gabapentin as ordered by the physician. Review of Resident #21's progress note dated [DATE] at 3:13 P.M. authored by LPN #809 revealed the Gabapentin oral tablet 800 mg due at 12:00 P.M. was held and a one-time only dose of 600 mg was administered to the resident. The physician was aware. Review of Resident #21's medication administration records (MARS) from [DATE] to [DATE] revealed the medications were administered as ordered. Review of Resident #27's medical record revealed the resident was admitted on [DATE] and expired in the facility on [DATE] with diagnoses including hemiplegia, chronic obstructive pulmonary disease and bipolar disorder. Review of Resident #27's physician orders revealed an order dated [DATE] (discontinued [DATE]) for Gabapentin 600 mg give one tablet by mouth three times a day; and an order dated [DATE] for Gabapentin 600 mg give one tablet by mouth four times a day. Interview on [DATE] at 9:16 A.M. with Licensed Practical Nurse (LPN) #809 revealed she administered 600 mg of Gabapentin to Resident #21 on [DATE] at 12:00 P.M. and the dose should have been 800 mg. LPN #809 confirmed she called the physician and obtained a one-time order for the 600 mg of Gabapentin for the resident's nerve pain. A second interview on [DATE] at 10:16 A.M. with Director of Nursing (DON) #830 and LPN #809 confirmed LPN #809 administered Resident #27's Gabapentin to Resident #21 on [DATE]. The nurse stated this was done in error. This violation represents non-compliance investigated under Complaint Number OH00164228.

Based on review of personnel files, staff interview, and review of the job description and performance standards for the Administrator, the facility's Administrator failed to provide adequate oversight of hiring and promotion of facility staff to ensure minimum qualifications were met for their assigned duties in providing activities to meet resident needs/preferences This had the potential to affect all 23 residents in the facility. Findings include: Review of resident council meeting minutes from January 2024 to June 2024 revealed on 02/15/24 residents reported they would like more movie nights and exercise activities. The 04/18/24 meeting notes revealed notes that the facility would be doing movie night around 3 P.M. instead of later in the evening. (The July 2024 activity calendar had Exercise Saturday and walking Wednesday scheduled each week no movie nights.) Review of the personnel file for Activities Director #112, who also served as the facility's Social Services Designee, revealed a hire date of 10/29/22. There was no evidence of completion of a certification or training program for leading activities programs in long term care centers. On 07/22/24 at 9:22 A.M. Resident #77 stated he was not at all interested in participating in activities. He was admitted for short term therapy and administration of intravenous medications. On 07/22/24 at 9:37 A.M., Resident #10 stated the only activities the facility offered was bingo. However, she was not interested in participating in any activities and had no suggestions as to activities she might be interested in if offered. 07/22/24 2:12 P.M. Resident #19's daughter reported Resident #19 had difficulty hearing even with hearing aids and difficulty seeing even with glasses. Attempts to participate in group activities increased anxiety and overwhelmed Resident #19 who preferred not to participate On 07/23/24 at 2:17 P.M., an interview with Human Resources Director #114 stated Activities Director #112 began her role as the facility's Activities Director on 02/15/24 and she was unsure what training was provided. The Administrator, who was standing nearby, stated Activities Director #112 was trained by the staff member who previously filled that role. On 07/23/24 at 3:08 P.M., an interview with the Administrator stated Activities Director #112 had not yet been enrolled in a activities professional training program because the facility was looking for the cheapest option for completing the training. On 07/23/24 at 3:34 P.M., an interview with the Administrator stated she was unaware that Activities Director #112 was hired with the contingency that oversight would be provided by a qualified activities professional until Activities Director #112 had completed the required trainings. The Administrator further stated the reason she was unaware of this contingency was because she only worked part-time as the Administrator for this facility. She verified Activities Director #112 had not received the required oversight for the activities programs at the facility. On 07/24/24 starting at 9:53 A.M., the July 2024 activity calendar was reviewed with Activity Director #112. The activity calendar indicated three to four activities were scheduled each day with bingo scheduled at 2:00 P.M. every Monday, Wednesday and Friday. Some of the activities scheduled included one on one visits, leisure time, puzzles and activity packets. Activity Director #112 stated she started her position at the end of February 2024 and followed the activity patterns from the previous calendars. Activity Director #112 stated one person had requested movie nights but she was the only one who participated and one resident had requested an open therapy gym. No other residents had made suggestions. When asked about the puzzles on the activity calendar, Activity Director #112 stated there were two residents with puzzle tables in their rooms and once in a while a few residents would gather and work on the puzzles. Activity Director #112 stated the leisure time on the activity calendar was for residents to obtain papers which she left up front on a bulletin board and do independently. The brain teasers activity was also papers available up front and can be obtained for residents to do individually. The board games activity was also a resident generated activity. There were board games in the activity room which residents could use. Exercise Saturday was supposed to be provided by nursing. Activity Director #112 indicated she did was not aware what the activity consisted of and was not 100% sure it was provided. The Walking Wednesdays activity was provided by a person from psychiatric services who did laps around the facility with residents. The music hour activity consisted of a radio in the dining room which sometimes would be turned on but one of the residents did not care for it so it was not consistent. Group activities that were included in the calendar were bingo, resident council meetings and snacks/treats. During a meeting between a state surveyor and resident council on 07/24/24 at 1:29 P.M., three (Residents #3, #14, and #21) indicated they would like to have more activities offered but did not wish to pursue the matter because it would take away from Activity Director #112's other duties. Resident #17, who also attended, indicated she preferred individual activities. On 07/24/24 at 2:01 P.M., Therapeutic Behavioral Support (TBS) Specialist #200 (identified as the person from the psychiatric services who provided the Walking Wednesday activity) stated she worked with 15 residents at the facility to provide coping skills and mental health services. TBS Specialist #200 stated she only ambulated around the facility with Resident #14 because walking was one of her coping skills and helped promote body self image for her. TBS Specialist #200 stated while she visited she would try to engage residents in activities to help with coping skills. TBS Specialist #200 stated Activity Director #112 did not always have time to do both social service responsibilities and activities and the facility's budget did not really allow for more activities or staff. TBS Specialist #200 stated she did believe residents could benefit from more activities. Review of the facility's Activity Programs policy (revised August 2006) indicated the activity programs were designed to encourage maximum individual participation and were geared to the individual resident's needs. The activity programs consisted of individual and small and large group activities that were designed to meet the needs and interests of each resident and include, at a minimum: 1. activities that stimulated the cardiovascular system and assisted with range of motion offered five to seven times a week 2. intellectual activities that were mentally stimulating five to seven times a week 3. weather permitting, at least one activity a month is head away from the facility 4. weather permitting, outdoor activities were held on a regular basis 5. At least one evening activity was offered per week depending on population needs 6. spiritual programming was scheduled to meet the religious needs of the residents 7. at least two group activities per day were to be offered on Saturday, Sunday and holidays 8. At least four group activities were offered per day Monday through Friday 9. Creative and expressive activities, such as arts and crafts, ceramics, painting, drama, creative writing, poetry and music were available on a regular basis to meet the needs of residents 10. Social activities were scheduled to increase self esteem, to stimulate interest and friendships and to provide fun and enjoyment. Activities, included, but were not limited to, daily coffee social, birthday and holiday parties, entertainment, candlelight dinner, country breakfast, cultural and theme events) 11. Participation in community groups and religious organizations were encouraged based on the needs of the resident population. The activity programs policy further explained activities were not necessarily limited to formal activities being provided only by activities staff. Other facility staff, volunteers, visitors, residents and family members could also provide the activities. Activity schedules were posted on the resident bulletin board and provided individually to residents who could not access the bulletin board. Individual and group activities were provided that reflected the schedules, choices and rights of the residents, were offered at hours convenient to the residents (including evenings, holidays and weekends), reflect the cultural and religious interests, hobbies, life experiences and personal preferences of the residents and appeal to men and women as well as those of various age groups residing in the facility. On 07/25/24 at 11:22 A.M., Activity Director #112 stated she had never read and was not sure she had access to the activity program policy.

Based on record review and interview, the facility failed to conduct an annual review of the facility assessment between January 2023 and July 2024. This had the potential to affect all 23 residents in the facility. Findings include: Review of the facility assessment revealed it was last reviewed on 01/26/23, indicating it had not been reviewed in 18 months. In addition, the facility assessment indicated the facility's social worker would be licensed by the State of Ohio. On 07/24/24 at 9:45 A.M., an interview with the Administrator verified the facility assessment had not been reviewed since 01/26/23 and stated she was working on the new format for the 2024 facility assessment. She also verified that the list of people responsible for reviewing the assessment annually was inaccurate because the listed Administrator, Director of Nursing (DON), Minimum Data Set (MDS) Coordinator, and resident representative were no longer at the facility.

Based on record review, observations, interviews, and review of facility policies, the facility failed to record tuberculin skin test results for all new employees upon hire, ensure staff perform hand hygiene during medication administration, and to have signage indicating Resident #23 required reverse isolation protocol. This had the potential to affect all 23 residents residing in the facility. Findings include: 1. Review of the personnel file for State tested Nurse Aide (STNA) #101 revealed a hire date of 07/02/24. Review of the Tuberculin Skin Test Record Form, dated 07/02/24, indicated a skin test was administered to STNA #101 on 07/02/24 at 6:50 A.M. and there were no results documented on the form. Review of the Tuberculin Skin Test Record Form, dated 07/09/24, indicated a skin test was administered to STNA #101 on 07/09/24 at 8:00 A.M. and there were no results documented on the form. On 07/25/24 at 10:30 A.M., an interview with Licensed Practical Nurse (LPN) #115 verified the tuberculin skin tests were administered to STNA #101 on 07/02/24 and 07/09/24 and the results of the skin tests were not recorded. Review of the facility policy titled Guidelines for Skin Testing for Potential New Employees, not dated, revealed all new employees would be screened for tuberculosis, new employees who did not have results of a two-step tuberculin skin test completed within the past one year would undergo the first step skin test before beginning employment and a second step seven to 10 days after the first step was administered, and a written report of test results would be maintained in the employee file. 2. Review of the personnel file for State tested Nurse Aide (STNA) #118 revealed a hire date of 06/24/24. Review of the Tuberculin Skin Test Record Form, dated 06/25/24, indicated a skin test was administered to STNA #118 on 06/25/24 at an unspecified time and there were no results documented on the form. Review of the Tuberculin Skin Test Record Form, dated 07/02/24, indicated a skin test was administered to STNA #118 on 07/02/24 at 8:00 A.M. and there were no results documented on the form. On 07/25/24 at 10:30 A.M., an interview with LPN #115 verified the tuberculin skin tests were administered to STNA #118 on 06/25/24 and 07/02/24 and the results of the skin tests were not recorded. Review of the facility policy titled Guidelines for Skin Testing for Potential New Employees, not dated, revealed all new employees would be screened for tuberculosis, new employees who did not have results of a two-step tuberculin skin test completed within the past one year would undergo the first step skin test before beginning employment and a second step seven to 10 days after the first step was administered, and a written report of test results would be maintained in the employee file. 3. Review of the personnel file for State tested Nurse Aide (STNA) #126 revealed a hire date of 07/08/24. Review of the Tuberculin Skin Test Record Form, dated 07/09/24, indicated a skin test was administered to STNA #126 on 07/09/24 at an unspecified time and there were no results documented on the form. Review of the Tuberculin Skin Test Record Form, dated 07/16/24, indicated a skin test was administered to STNA #126 on 07/16/24 at 8:10 A.M. and there were no results documented on the form. On 07/25/24 at 10:30 A.M., an interview with LPN #115 verified the tuberculin skin tests were administered to STNA #126 on 07/09/24 and 07/16/24 and the results of the skin tests were not recorded. Review of the facility policy titled Guidelines for Skin Testing for Potential New Employees, not dated, revealed all new employees would be screened for tuberculosis, new employees who did not have results of a two-step tuberculin skin test completed within the past one year would undergo the first step skin test before beginning employment and a second step seven to 10 days after the first step was administered, and a written report of test results would be maintained in the employee file. 4. Review of the personnel file for STNA #128 revealed a hire date of 07/09/24. Review of the Tuberculin Skin Test Record Form, dated 07/09/24, indicated a skin test was administered to STNA #128 on 07/09/24 at 2:25 P.M. and there were no results documented on the form. Review of the Tuberculin Skin Test Record Form, dated 07/16/24, indicated a skin test was administered to STNA #128 on 07/16/24 at 8:00 A.M. and there were no results documented on the form. On 07/25/24 at 8:39 A.M., an interview with the Director of Nursing (DON) verified the tuberculin skin tests were administered to STNA #128 on 07/09/24 and 07/16/24 and the results of the skin tests were not recorded. On 07/25/24 at 8:45 A.M., an interview with LPN #115 stated she administered the skin tests for STNA #128 and she read the results two days later. She stated she forgot to document the results of the skin tests on the forms. Review of the facility policy titled Guidelines for Skin Testing for Potential New Employees, not dated, revealed all new employees would be screened for tuberculosis, new employees who did not have results of a two-step tuberculin skin test completed within the past one year would undergo the first step skin test before beginning employment and a second step seven to 10 days after the first step was administered, and a written report of test results would be maintained in the employee file. 22653 5. On 07/24/24 at 7:43 A.M., LPN #131 was observed administering medication to Resident #7. During the medication administration, LPN #131 was observed touching items in the environment such as the over bed table. LPN #131 returned to the medication cart and obtained a medication cup to prepare medication for Resident #10 without performing hand hygiene. LPN #131 verified she had not performed hand hygiene but continued to prepare and administer medication to Resident #10 including an inhaler and medications by mouth prior to washing her hands. Review of the facility's Administering Medications policy (revised December 2012) revealed staff were required to follow established facility infection control procedures (e.g. handwashing, antiseptic technique, gloves, isolation precautions, etc) for the administration of medications. Review of the facility's Handwashing/Hand Hygiene policy (revised August 2015) revealed all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors. Staff were instructed to use an alcohol-based hand rub containing at least 62% alcohol, or, alternatively, soap and water for situations such as before and after direct contact with resident and after contact with objects in the immediate vicinity of the resident. 49774 6. Review of Resident #23's active physician orders revealed the resident was on protective isolation starting 02/09/24 related to chronic lymphocytic leukemia of B-cell type not having achieved remission. Observation on 07/22/24 at 9:41 A.M. revealed there was a three-drawer plastic bin of personal protective equipment (PPE) inside Resident #23's room upon entering however there was no signage indicating Resident #23 was on enhance barrier precautions (EBP). Interview on 07/22/24 at 9:58 A.M. with LPN #110 revealed that residents only have the three-drawer plastic bins of PPE in their room when they are on EBP or isolation precautions. LPN #110 explained that Resident #23 was on protective isolation, also known as reverse isolation, because he was immunocompromised due to receiving chemotherapy. Anyone entering Resident #23's room was required to wear a mask, gloves, and a gown to protect him. LPN #110 stated Resident #23 should have a sign on his door that instructed visitors and staff what his precautions were. Upon notification that Resident #23 did not have any door signage LPN revealed she was unaware the resident didn't have signage on the door. She provided the surveyor a copy of the sign that should have been hanging on his door that said please stop at the nurse's station before entering. Thank you and then was observed hanging the sign on the door.

Based on review of personnel files and staff interview, the facility failed to ensure Activities Director #112 was qualified to direct the facility activities program. This had the potential to affect all 23 residents in the facility. Findings include: Review of the personnel file for Activities Director #112, who also served as the facility's Social Services Designee, revealed a hire date of 10/29/22. There was no evidence of completion of a certification or training program for leading activities programs in long term care centers. On 07/23/24 at 1:20 P.M., an interview with the Administrator stated Activities Director #112 was the only activities staff for the facility. On 07/23/24 at 2:17 P.M., an interview with Human Resources Director #114 stated Activities Director #112 began her role as the facility's Activities Director on 02/15/24 and she was unsure what training was provided. The Administrator, who was standing nearby, stated Activities Director #112 was trained by the former staff member who previously filled that role. On 07/23/24 at 2:37 P.M., an interview with the Administrator stated the only training Activities Director #112 had prior to taking over the role of Activities Director was a one week training led by the former staff member who previously filled that role. On 07/23/24 at 3:08 P.M., an interview with the Administrator stated Activities Director #112 had not yet been enrolled in a activities professional training program because the facility was looking for the cheapest option for completing the training. On 07/23/24 at 3:34 P.M., an interview with the Administrator stated she was unaware that Activities Director #112 was hired with the contingency that oversight would be provided by a qualified activities professional until Activities Director #112 had completed the required trainings. She verified Activities Director #112 had not received the required oversight for the activities programs at the facility.

Based on medical record review, policy review, observations, and interviews, the facility failed to ensure activities were provided in accordance with resident preferences. This affected one (Resident #21) of 15 residents interviewed and/or observed for activity participation. This also had the potential to affect 20 of 23 residents who resided at the facility when scheduled activities were known to be of no interests to any of the residents and/or were placed on the activity schedule with the knowledge the activity was an individual and not group based activity. (Residents #10, family of Resident #19 and Resident #77 indicated they were not interested in group activities regardless of what might be offered. Findings include: 1. Review of Resident #21's medical record revealed diagnoses including chronic obstructive pulmonary disease, severe protein-calorie malnutrition, generalized muscle weakness, hypertension, anxiety disorder, and major depressive disorder. An annual Minimum Data Set Assessment (MDS) dated [DATE] revealed Resident #21 was able to make herself understood, was able to understand others and was cognitively intact. The activities portion of the MDS indicated it was somewhat important for Resident #21 to be around animals such as pets. It was very important for Resident #21 to do things with groups of people, do her favorite activities, and go outside to get fresh air when the weather was good. Review of Resident #21's activities annual participation review dated 06/06/24 indicated Resident #21 enjoyed both independent and group activities. Resident #21 enjoyed playing bingo, watching television, spending time with family and friends, socializing with other residents, having special treats, sitting outside and doing puzzles. The review indicated activity-related focuses remained appropriate. Review of Resident #21's activity participation log for May 2024 revealed active participation in bingo up to three times a week, two visits with family/friends, watching television and socializing, participation with treats/eating activities five times and passive participation in a sing along once. Review of Resident #21's June activity participation log revealed participation in bingo three times a week, going to the beauty shop once, two family/friend visits, attending resident council, watching television and socializing every day, participating in yard games once and treats three times. During an interview on 07/22/24 at 8:51 A.M., Resident #21 stated she participated in bingo which was offered three times a week but that was the only group activities the facility had scheduled. Once in while she would go outside and sit on the patio. Resident #21 stated she believed the facility was trying to find someone to do activities. Resident #21 stated she would like more activities offered. Resident #21 was observed actively participating in bingo on 07/22/24 at 2:57 P.M. playing bingo with three other residents and on 07/24/24 at 2:15 P.M. Observations on 07/23/24 at 7:55 A.M. and 07/24/24 at 7:36 A.M., 10:46 A.M., and 12:37 P.M. revealed Resident #21 was in her room with the television on but sometimes watching the hallway. No facility initiated activities were observed during those times. On 07/25/24 at 7:43 A.M., Resident #21 was noted sitting in her bed feeding herself. Her face became more animated while talking about playing bingo the previous day. During an interview on 07/24/24 beginning at 9:53 A.M., Activity Director #112 reviewed Resident #21's activity preferences from the MDS, activity calendars and activity participation logs with the surveyor. Activity Director #112 acknowledged Resident #21 had reported it was somewhat important for her to be around animals such as pets. Activity Director #112 stated there had been on animal related activities since April when somebody had taken pet pigs to the facility to visit residents. When discussing that Resident #21 had indicated it was very important to do things with groups of people, Activity Director #112 reviewed the activity calendar and verified multiple activities were either not pertinent because no residents had expressed interest, pertained to only one or two residents, or were available for residents to do as individual activities. Activity Director #112 stated Resident #21's favorite activity was bingo. Activity Director #112 stated although there was only documentation of activity of yard games once in the past three months (July activity participation logs were requested but not provided because they were not filled out) Resident #21 would sit outside on the patio at times. 2. Review of resident council meeting minutes from January 2024 to June 2024 revealed on 02/15/24 residents reported they would like more movie nights and exercise activities. The 04/18/24 meeting notes revealed notes that the facility would be doing movie night around 3 P.M. instead of later in the evening. (The July 2024 activity calendar had Exercise Saturday and walking Wednesday scheduled each week no movie nights.) On 07/22/24 at 9:22 A.M. Resident #77 stated he was not at all interested in participating in activities. He was admitted for short term therapy and administration of intravenous medications. On 07/22/24 at 9:37 A.M., Resident #10 stated the only activities the facility offered was bingo. However, she was not interested in participating in any activities and had no suggestions as to activities she might be interested in if offered. 07/22/24 2:12 P.M. Resident #19's daughter reported Resident #19 had difficulty hearing even with hearing aids and difficulty seeing even with glasses. Attempts to participate in group activities increased anxiety and overwhelmed Resident #19 who preferred not to participate On 07/24/24 starting at 9:53 A.M., the July 2024 activity calendar was reviewed with Activity Director #112. The activity calendar indicated three to four activities were scheduled each day with bingo scheduled at 2:00 P.M. every Monday, Wednesday and Friday. Some of the activities scheduled included one on one visits, leisure time, puzzles and activity packets. Activity Director #112 stated she started her position at the end of February 2024 and followed the activity patterns from the previous calendars. Activity Director #112 stated one person had requested movie nights but she was the only one who participated and one resident had requested an open therapy gym. No other residents had made suggestions. When asked about the puzzles on the activity calendar, Activity Director #112 stated there were two residents with puzzle tables in their rooms and once in a while a few residents would gather and work on the puzzles. Activity Director #112 stated the leisure time on the activity calendar was for residents to obtain papers which she left up front on a bulletin board and do independently. The brain teasers activity was also papers available up front and can be obtained for residents to do individually. The board games activity was also a resident generated activity. There were board games in the activity room which residents could use. Exercise Saturday was supposed to be provided by nursing. Activity Director #112 indicated she did was not aware what the activity consisted of and was not 100% sure it was provided. The Walking Wednesdays activity was provided by a person from psychiatric services who did laps around the facility with residents. The music hour activity consisted of a radio in the dining room which sometimes would be turned on but one of the residents did not care for it so it was not consistent. Group activities that were included in the calendar were bingo, resident council meetings and snacks/treats. During a meeting between a state surveyor and resident council on 07/24/24 at 1:29 P.M., three (Residents #3, #14, and #21) indicated they would like to have more activities offered but did not wish to pursue the matter because it would take away from Activity Director #112's other duties. Resident #17, who also attended, indicated she preferred individual activities. On 07/24/24 at 2:01 P.M., Therapeutic Behavioral Support (TBS) Specialist #200 (identified as the person from the psychiatric services who provided the Walking Wednesday activity) stated she worked with 15 residents at the facility to provide coping skills and mental health services. TBS Specialist #200 stated she only ambulated around the facility with Resident #14 because walking was one of her coping skills and helped promote body self image for her. TBS Specialist #200 stated while she visited she would try to engage residents in activities to help with coping skills. TBS Specialist #200 stated Activity Director #112 did not always have time to do both social service responsibilities and activities and the facility's budget did not really allow for more activities or staff. TBS Specialist #200 stated she did believe residents could benefit from more activities. Review of the facility's Activity Programs policy (revised August 2006) indicated the activity programs were designed to encourage maximum individual participation and were geared to the individual resident's needs. The activity programs consisted of individual and small and large group activities that were designed to meet the needs and interests of each resident and include, at a minimum: 1. activities that stimulated the cardiovascular system and assisted with range of motion offered five to seven times a week 2. intellectual activities that were mentally stimulating five to seven times a week 3. weather permitting, at least one activity a month is head away from the facility 4. weather permitting, outdoor activities were held on a regular basis 5. At least one evening activity was offered per week depending on population needs 6. spiritual programming was scheduled to meet the religious needs of the residents 7. at least two group activities per day were to be offered on Saturday, Sunday and holidays 8. At least four group activities were offered per day Monday through Friday 9. Creative and expressive activities, such as arts and crafts, ceramics, painting, drama, creative writing, poetry and music were available on a regular basis to meet the needs of residents 10. Social activities were scheduled to increase self esteem, to stimulate interest and friendships and to provide fun and enjoyment. Activities, included, but were not limited to, daily coffee social, birthday and holiday parties, entertainment, candlelight dinner, country breakfast, cultural and theme events) 11. Participation in community groups and religious organizations were encouraged based on the needs of the resident population. The activity programs policy further explained activities were not necessarily limited to formal activities being provided only by activities staff. Other facility staff, volunteers, visitors, residents and family members could also provide the activities. Activity schedules were posted on the resident bulletin board and provided individually to residents who could not access the bulletin board. Individual and group activities were provided that reflected the schedules, choices and rights of the residents, were offered at hours convenient to the residents (including evenings, holidays and weekends), reflect the cultural and religious interests, hobbies, life experiences and personal preferences of the residents and appeal to men and women as well as those of various age groups residing in the facility. On 07/25/24 at 11:22 A.M., Activity Director #112 stated she had never read and was not sure she had access to the activity program policy.

Based on observations, review of physician orders/medication administration records, policy review, and interview, the facility failed to ensure a medication rate of less than 5 percent (%). Two errors were identified out of 25 opportunities for error resulting in a 8% medication error rate. This affected one resident (Resident #7) of six residents observed for medication administration Findings include: On 07/24/24 at 7:43 A.M., Licensed Practical Nurse (LPN) #131 was observed administering medication to Resident #7. Among medications administered were two tablets of Senna (laxative-stimulant) 8.6 milligrams (mg). No Glycolax (laxative) was administered. However, it was signed off as administered. Review of physician orders and the Medication Administration Record (MAR) revealed among medications ordered for administration at 8:00 A.M. were two tablets of Senna docusate (used to treat constipation) 8.6/50 mg and Glycolax powder 17 grams. On 07/24/24 at 8:33 A.M., LPN #131 verified she administered Senna instead of Senna docusate and she had not administered Glycolax. Review of the facility's Administering Medications policy (revised December 2012) revealed medications must be administered in accordance with the orders. The individual administering the medication must check the label three times to verify the right resident, right medication, right dosage, right time and right route of administration before giving the medication. The individual administering the medication must initial the resident's MAR on the appropriate line after giving each medication and before administering the next ones.

Based on review of personnel files, review of the facility new hire list, review of the facility abuse policy and staff interview the facility failed to ensure all new staff hires were checked against the Nurse Aide Registry (NAR) prior to employment to ensure the employee did not have a finding entered into the State Nurse Aide Registry concerning abuse, neglect, exploitation, mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of the Bureau of Criminal Identification and Investigation log, dated 2021 to 2022 and review of employee personnel files revealed the following employees had been hired within this time period: Licensed Social Worker/Activity Director #203, Housekeeping Supervisor #220, Housekeeper #222, Maintenance Director #221, Licensed Practical Nurse #225 and Cook #223. Licensed Social Worker/Activity Director #203 had a date of hire of 07/05/21 Housekeeping Supervisor #220 had a date of hire of 07/19/21 Housekeeper #222 had a date of hire of 07/14/21 Maintenance Director #221 had a date of hire of 07/21/21 Licensed Practical Nurse #225 had a date of hire of 07/26/21 Cook #223 had a date of hire of 03/31/22 Record review revealed no evidence any of these employees had been checked against the NAR to ensure none of the employees had a finding entered into the NAR concerning abuse, neglect, exploitation, mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 04/07/22 at 3:55 P.M. interview with the Administrator verified Licensed Social Worker/Activity Director #203, Housekeeping Supervisor #220, Housekeeper #222, Maintenance Director #221, LPN #225 and Cook #223 had not been checked against the NAR prior to hire. Review of the undated facility policy titled Abuse, Neglect, Exploitation and Misappropriation of Resident Property revealed it was the facility policy to undertake background checks of all employees and to retain on file prior to hiring a new employee of the Ohio Nurse Assistant Registry and any other nurse assistant registries the facility had reason to believe contain information on an individual prior to using the individual as a nurse assistant.

Based on review of the facility assessment and interview the facility failed to ensure the development of an accurate assessment to determine what resources were necessary to care for its residents competently during both day-to-day operations and emergencies. This had the potential to affect all 20 residents. Findings include: Review of the facility assessment, dated 2022 revealed the following: a. A minimum of five times the assessment referred to a facility by another name when determining its capabilities and needs. On 04/06/22 at 4:25 P.M. interview with the Director of Nursing (DON) verified the facility assessment did refer to the names of other facilities which were used as a template for this facility's assessment. b. The facility assessment indicated the number of residents licensed for the facility by another name was 91. On 04/06/22 at 4:25 P.M. interview with the DON verified the capacity was not 91. This facility's capacity was 34. c. One area of the assessment indicated employment of a full time Administrator and another area indicated a part time Administrator was required. d. The facility assessment indicated a separate social service worker, activity director and two activity assistants were employed. On 04/06/22 at 4:25 P.M. interview with the DON verified the facility employed one person to work as the social worker/activity director and had no activity assistants which differed from information in the facility assessment. e. The facility assessment indicated the Minimum Data Set (MDS) nurse ran a census and condition report each morning and provided it to the DON so she could assess staffing needs. On 04/06/22 at 4:25 P.M. interview with the DON revealed the MDS nurse did not run a census and condition report each morning and provide it to her. f. The assessment indicated the Dietary Manager's licensure/certification requirements was a high school diploma or equivalent and was silent to requirements for the Activity Director. On 04/06/22 at 4:25 P.M. interview with the DON verified the facility assessment was silent as to the qualifications of the Activity Director and that the Dietary Manager was required to have training in food safety and management.

Based on observation, record review and interview the facility failed to ensure Minimum Data Set (MDS) 3.0 assessments were accurate for Resident #9 related to oral/teeth status, Resident #12 related to pre-admission screening and resident review (PASARR), Resident #13 related to Hospice, Resident #16 related to medications, Resident #17 related to nutrition and Resident #19 related to pressure ulcers. This affected six residents (#9, #12, #13, #16, #17 and #19) of 20 residents whose MDS 3.0 assessments were reviewed. Findings include: 1. Review of the medical record for Resident #9 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 01/05/22 and the comprehensive MDS 3.0 assessment, dated 11/03/22 for Resident #9 revealed the resident did not have his natural teeth. On 04/06/22 at 8:00 A.M. observation and interview with Resident #9 revealed the resident had his own teeth. On 04/06/22 at 4:00 P.M. interview with Registered Nurse (RN) #214 confirmed both MDS 3.0 assessments reviewed above were coded incorrectly as Resident #9 did have his own teeth. 2. Review of the medical record for Resident #16 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .M. and as needed every four hours between scheduled and as needed doses. The resident had no orders for any medication(s) in the drug classification of an anti-anxiety. Review of the MDS 3.0 assessment, dated 01/29/22 revealed Resident #16 received an anti-anxiety medication during the assessment reference period. Review of the drug classification for [MEDICATION(S)] according to Medscape revealed it was an antihistamine (relief for allergies) and antiemetic (relief for nausea). On 04/06/22 at 4:00 P.M. interview with RN #214 confirmed the MDS 3.0 assessment, dated 01/29/22 was coded incorrectly as staff had coded the [MEDICATION(S)] as an anti-anxiety medication however, it was an antihistamine and antiemetic and not an antianxiety medication. 3. Review of the medical record for Resident #19 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS 3.0 assessment, dated 02/09/22 for Resident #19 revealed the resident had a pressure ulcer, scar over a bony protrusion or a non removable dressing or device. Review of progress notes, assessments and orders from 02/09/22 revealed no evidence of any skin related issues for Resident #19. On 04/06/22 at 4:00 P.M. interview with RN #214 confirmed the MDS 3.0 assessment, dated 02/09/22 was coded incorrectly as Resident #19 did not have any skin related issues at the time of assessment. 4. Review of Resident #12's medical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Preadmission Screening/Resident Review (PASARR) Identification Screen, signed 02/20/18 indicated Resident #12 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review results indicated Resident #12 had indications of a developmental disability and referral to the local Developmental Board evaluation for Level II evaluation had been received. An in-person assessment was performed. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 01/16/22 indicated Resident #12 was not considered by the State Level II PASARR process to have serious mental illness and/or intellectual disability. On 04/07/22 at 10:55 A.M. interview with RN #214 verified the MDS 3.0 assessment, dated 01/16/22 was inaccurate regarding PASARR information and intellectual disabilities. 5. Review of Resident #17's medical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the December 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission MDS 3.0 assessment, assessment dated [DATE] indicated Resident #17 ate once or twice. Review of the January 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 01/16/22 a weight of 312 pounds was recorded. On 01/25/22 a weight of 295 pounds was recorded. Review of the quarterly MDS 3.0 assessment, dated 01/25/22 revealed Resident #17 only ate once or twice and had no significant weight change. On 04/07/22 at 10:55 A.M. interview with RN #214 verified the MDS assessments dated 12/11/21 and 01/25/22 were coded incorrectly for eating as Resident #17 had received enteral (tube) feeding only during those time frames. RN #214 also verified the MDS 3.0 assessment, dated 01/25/22 should have reflected Resident #17 had a significant loss. 6. Review of the medical record for Resident #13 revealed an admitted [DATE]. Resident #13 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the quarterly MDS 3.0 assessment, dated 03/20/22 for Resident #13 revealed no evidence the resident was receiving Hospice services. On 04/06/22 at 12:11 P.M. interview with RN #214 verified the quarterly MDS 3.0 assessment dated [DATE] was inaccurate as it should have coded Resident #13 received Hospice services.

Based on record review and interview the facility failed to ensure a discharge Minimum Data Set (MDS) 3.0 assessment was completed for Resident #1. This affected one resident (#1) of 20 residents whose MDS assessments were reviewed. Findings include: Review of the medical record for Resident #1 revealed an admitted [DATE] and a discharge date of [DATE]. Review of the list of Minimum Data Set (MDS) 3.0 assessments completed for Resident #1 revealed no discharge MDS 3.0 assessment was completed. On 04/07/22 at 9:18 A.M. interview with Registered Nurse (RN) #214 verified no discharge MDS 3.0 assessment was completed for Resident #1. Review of the Long Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual dated October 2019 revealed a discharge assessment should have been completed within 14 days of discharge.

Based on record review and interview the facility failed to develop an individualized and comprehensive care plan related to Resident #16's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of the medical record revealed Resident #16 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .M. and as needed (PRN) every four hours between scheduled and as needed doses for anxiety. [MEDICATION(S)] is classified as an antiemetic and antihistamine medication and not an anti-anxiety medication. The resident was not ordered any medications that were in the anti-anxiety drug classification. Review of the resident's care plans revealed a plan of care related to monitoring side effects of anti-anxiety medication. However, there was no individualized or comprehensive plan of care to address the resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no goal developed specific to anxiety and no interventions to resolve/address situations of anxiety including the use of any appropriate non-pharmacological interventions or situations when PRN [MEDICATION(S)] should be administered. On 04/06/22 at 4:00 P.M. interview with Registered Nurse (RN) #214 verified the facility had not developed an individualized and comprehensive plan of care related to the resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on interview and record review, the facility failed to institute a restorative bladder training program when a decline in bladder function was identified by the facility. In addition, the facility failed to implement an incontinence program to ensure a resident was at her highest practicable level in regard to continence. This affected two of two residents reviewed for incontinence of 18 residents identified by the facility as being incontinent (Residents #14 and #23). The census was 31. Harm occurred when Resident #23 declined from continent to frequently incontinent of urine. Findings Include: 1. Record review revealed Resident #23 was admitted to the facility on [DATE] following a hospital stay for surgical repair of a closed [MEDICAL CONDITION] section of the femur (broken hip). Resident #23 had history of closed fracture of trochanteric section of femur, dementia, hypertension (high blood pressure), [MEDICAL CONDITION] and [MEDICAL CONDITION]. Review of the admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #23 was always continent of urine. Review of admission Bowel and Bladder Evaluation dated 03/01/13 indicated Resident #23 was always continent of urine and was aware of the need to void. Resident #23 was assessed as a 10. A score of 6-11 indicated a moderate restorative potential. The record did not identify any restorative program was initiated. Review of the Bowel and Bladder assessment dated [DATE] revealed Resident #23 was occasionally incontinent which indicated less than seven episodes of incontinence in the last seven days. Review of the 90 day MDS dated [DATE] revealed Resident #23 was frequently incontinent of urine. Frequently incontinent indicated Resident #23 had seven or more episodes of urinary incontinence, but at least one episode of continent voiding. On 08/14/13 at 4:54 P.M., interview with the Director of Nursing (DON) verified Resident #23 had a decline in bladder function. She confirmed Resident #23 was a candidate for a restorative bladder program and confirmed no program had been initiated in response to Resident #23's decline in bladder function. 2. Resident #14 was admitted the facility on 03/14/05. The resident's current [DIAGNOSES REDACTED]. The resident's most recent MDS dated [DATE] indicated the resident was severely cognitively impaired and was frequently incontinent of urine. The activities of daily living, (ADL) care plan updated through October 2013, indicated the resident had functional incontinence and was on a check and change program. (Check the resident to see if they were incontinent, then change the soiled undergarment if incontinent). The Bowel and Bladder Continence Evaluations dated 04/08/13 and 07/03/13 stated the resident was occasionally incontinent (less than seven incontinent episodes in the past seven days) and had moderate restorative potential for either habit training or prompted voiding. Review of the medical record revealed there was no evidence of any evaluation by restorative nursing to determine which of the two types of suggested restorative incontinence programs was most appropriate for the resident. Interview with State tested Nurse Aide (STNA) #3 on 08/14/13 at 8:47 A.M., revealed the resident was usually continent and would tell them when she had to use the restroom. Interview with the Assistant Director of Nursing,( ADON) on 08/14/13 at 9:41 A.M. verified the bowel and bladder evaluations indicated the resident had moderate restorative potential for a restorative incontinence program. The ADON stated the resident was currently supposed to be toileted upon rising, before and after meals and as needed. The ADON stated the resident was not continent. The ADON verified there had been no assessment regarding the resident's ability to participate in a restorative continence program based on the bowel and bladder evaluations completed 04/08/13 and 07/03/13.

Based on observation, record review and interview, the facility failed to provide the necessary services to Resident #33 to maintain functional ability and prevent a decline in activities of daily living (ADL) and locomotion. This affected one resident (Resident #33) of three residents reviewed related to declines in ADL and/or locomotion. Findings include: Resident #33 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review revealed a plan of care initiated on 03/23/11 related to ADL performance. The plan of care indicated the resident had an inability to perform all ADL tasks independently related to dementia and muscle weakness. The care plan indicated the resident ambulated independently, but this was crossed off and marked that the resident had an inability to ambulate independently. This change was not dated. The care plan indicated the resident had an unsteady gait related to weakness. The care plan did not include any other problems related to ADL's. Interventions listed on the care plan included to use a walker and wheelchair and the use of of a sensor pad alarm to the resident's bed and chair. The care plan indicated physical and occupational therapy (PT/OT) were to be provided as indicated. None of the interventions were dated as to when they were initiated for the resident. There were no interventions related to toileting, dressing, transferring, bed mobility or ambulation ability for the resident. A physical therapy (PT) discharge note dated 11/27/11, revealed Resident #33 was to continue with a restorative nursing program to maintain her current level of functioning. She required minimum assistance to transfer out of the recliner in room, had progressed with her gait to walking to two to three meals consistently, required contact guard assistance for bed mobility and transferred with minimum assistance. Review of restorative documentation for Resident #33 revealed she was provided a restorative ambulation program and active range of motion services from November 2011 through January 2012. The documentation from January 2012 revealed the resident was ambulating to meals three times per day and refused to do exercises on 01/01/12, 01/04/12, 01/05/12, 01/08/12 and 01/10/12. There was no evaluation or review during this time period of the resident's status or condition related to her functional mobility and ADL status. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #33 required supervision and set up with eating and limited assistance from one staff for bed mobility, transferring, ambulation in the room and corridor, toilet use and locomotion. Review of the MDS assessment dated [DATE] revealed Resident #33 was totally dependent on one staff for locomotion on and off the unit, required extensive assistance from two staff for dressing, extensive assistance from one staff for eating and was totally dependent on two staff for bed mobility and transferring, one staff for toileting and two staff for hygiene. The assessment revealed the resident was non-ambulatory in the corridor and used a wheelchair for locomotion. Record review reveal no re-assessment or therapy interventions were initiated following the decline in ADL/locomotion status determined during the April 2012, MDS assessment. Resident #33 was observed sitting in either a wheelchair, chair, or in bed in her room on 05/29/12 at 2:13 P.M., 3:31 P.M., and 4:30 P.M. The resident was observed on 05/30/12 at 7:03 A.M., 8:25 A.M., 9:35 A.M. and 11:15 A.M., in her room in bed. The curtain was partially drawn around the resident's bed. At 11:22 A.M., staff assisted the resident out of bed and then assisted her, via wheelchair, to the dining area for lunch. At 12:25 P.M., the resident had been returned to her room by staff and sat in the chair in her room. On 05/30/12 at 1:08 P.M., 1:30 P.M., 2:38 P.M., 2:55 P.M., 3:21 P.M., 4:00 P.M. and 4:31 P.M., Resident #33 was sitting in a chair in her room. Interview with the DON and the regional Quality Assurance Registered Nurse on 05/31/12 at 1:21 P.M., verified Resident #33, who was assessed to have experienced a decline in ADL function and locomotion between February 2012 and April 2012, had not received restorative nursing services from February 2012 through May 2012. The DON verified the resident had been ambulatory in February and currently required staff to propel her in a wheelchair. No changes to the resident's plan of care had been completed. No assessment or evaluation to detect the decline or to implement an individualized plan of care had been completed.