Every finding on record at Montgomery Care Center

Based on observations, interview, and policy review, the facility failed to ensure showers were properly maintained. This affected 12 residents (#6, #8, #10, #11, #13, #14, #20, #21, #23, #26, #30, and #33) identified by the facility that utilized the shower room. The facility census was 64.Findings include:Observations on 08/11/25 at 8:42 A.M. of the shower room on the east unit revealed there were two shower areas. One of the showers had a leaking shower head that sprayed water in various directions when the water was turned on, and the shower handle in the other shower was loose and not secured to the wall.Interview on 08/11/25 at 8:44 A.M. with Maintenance Director (MD) #112 verified the findings at the time of the observations.Review of the facility policy titled, Quality of Life - Homelike Environment, revised 05/2017, revealed residents would be provided with a safe, clean, comfortable and homelike environment.This deficiency represents non-compliance investigated under Complaint Number 2566252 and Complaint Number 2565845.

Based on review of the medical record, observation, interviews, and policy review, the facility failed to ensure eye drops were labeled with open date. This affected two (#06 and #19) of the 14 residents with ordered eye drops. The facility also failed to timely dispose of narcotics for residents who were no longer in the facility. This affected two (#213 and #214) residents of the nine residents with narcotics. The facility census was 60. Findings include: 1) Review of the medical record for Resident #06 revealed an admitted [DATE]. Diagnoses included glaucoma, Alzheimer's disease, and type two diabetes mellitus (DM II). Review of the physician order dated 02/24/22 revealed Resident #06 was ordered Brimonidine Tartrate 0.2 percent solution, instill one drop in both eyes three times a day related to glaucoma. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #06 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of five. Observation of the medication cart on 12/19/24 at 10:39 A.M., revealed Resident #06's Brimonidine eye drops were opened without a date. Interview on 12/19/24 at 10:40 A.M. with Licensed Practical Nurse (LPN) #400 verified Resident #06's eye drops were opened and not labeled with open date. 2) Review of the medical record for Resident #19 revealed an admitted [DATE]. Diagnoses included glaucoma, major depressive disorder, heart failure, and type two diabetes mellitus (DM II). Review of the physician order dated 03/17/22 revealed Resident #19 was ordered Dorzolamide-HCl-Timolol Mal Solution 22.3-6.8 milligrams (mg) per milliliter (ml), instill one drop in both eyes two times a day related to glaucoma. Review of the MDS assessment dated [DATE] revealed Resident #19 had intact cognition as evidenced by a BIMS score of 15. Observation of the medication cart on 12/19/24 at 10:06 A.M. revealed Dorzolamide-HCl-Timolol Mal Solution 22.3-6.8 mg/ml did not have an open date on the bottle. Interview on 12/19/24 at 10:07 A.M. with Registered Nurse (RN) #185 verified there was no open date on Resident #19's eye drops Dorzolamide-HCl-Timolol Mal Solution 22.3-6.8 mg/ml. 3) Review of the medical record for Resident #213 revealed an admitted [DATE] with a discharge date of [DATE]. Diagnoses included major depressive disorder, alcohol abuse with intoxication, insomnia, chronic obstructive pulmonary disease (COPD), and acute kidney failure. Review of the physician order dated 07/19/24 with a discontinue date of 07/19/24 revealed Resident #213 was ordered Restoril 30 mg, give one capsule by mouth at bedtime related to insomnia. Review of the MDS assessment dated [DATE] revealed Resident #213 had intact cognition as evidenced by a BIMS score of 15. Observation of the medication cart on 12/19/24 at 10:12 A.M. revealed Resident #213's Restoril 15 mg was in the narcotic box inside the medication cart. Interview on 12/19/24 at 10:13 A.M. with RN #185 verified Resident #213 was not a current resident in the facility and the resident's Restoril was still being stored in the medication cart. 4) Review of the medical record for Resident #214 revealed an admitted [DATE] with a discharge date of [DATE]. Diagnoses included traumatic subdural hemorrhage, type two diabetes mellitus (DM II), and major depressive disorder. Review of the physician order dated 12/11/24 revealed Resident #214 was ordered Lorazepam 0.5 mg, give 0.5 mg by mouth every four hours as needed (PRN) for anxiety. Review of the physician order dated 12/13/24 revealed Resident #214 was ordered Lorazepam 0.5 mg, give one mg by mouth every two hours PRN for anxiety. Review of the physician order dated 12/13/24 revealed Resident #214 was ordered Morphine Sulfate oral solution 100 mg / five ml, give 0.5 ml by mouth every two hours PRN for severe pain. Observation of the medication cart on 12/19/24 at 10:16 A.M. revealed Resident #214 had Lorazepam 0.5 mg, Lorazepam 1 mg, and Morphine sulfate in the narcotic box inside the medication cart. Interview on 12/19/24 at 10:18 A.M. with RN #185 verified Resident #214 was not a current resident in the facility. Interview on 12/19/24 at 12:14 P.M. with the Director of Nursing (DON) verified nurses should be notifying the unit manager when residents discharge from the facility to dispose of narcotics. Review of the facility policy titled, Discarding and Destroying Medication, dated 2001 revealed all unused controlled substances were retained in a securely locked area with restricted access until disposed of. Schedule two, three, and four controlled substances were disposed of in accordance with state regulations and federal guidelines regarding disposition of non-hazardous medications.

Based on observation, record review, and staff and resident interviews, the facility failed to ensure residents received routine podiatry care. This affected four (Residents #20, #21, #2 and #14) of the four residents reviewed for podiatry services. The facility census was 60. Findings include: 1) Review of the medical record revealed Resident #20 was admitted to the facility on [DATE] with diagnoses of cerebral infarction with dominant left side hemiplegia and hemiparesis, vascular dementia and chronic kidney disease. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #20 had moderately impaired cognition, range of motion impairment on left upper and lower extremities and was frequently incontinent of bowel and bladder. Review of Resident #20's Activities of Daily Living (ADL) care plan dated 12/12/24 revealed Resident #20 had a self-care performance deficit. Interventions included total assistance with personal hygiene daily and as needed. Observation of wound treatment for Resident #20 on 12/17/24 at 2:15 P.M. with Licensed Practical Nurse (LPN) #400 revealed all ten of Resident #20's toenails were grossly overgrown with some curling back under the toes. Interview with LPN #400 at time of observation verified Resident #20's toenails needed to be cut. LPN #400 stated Resident #20 would be placed on the podiatry list. Interview on 12/18/24 at 2:40 P.M. with Resident #20 verified he would like his toenails to be cut. Interview on 12/18/24 at 2:50 P.M. with the Director of Nursing (DON) verified Resident #20's toenails needed cut and the resident is not diabetic. The DON revealed she was not aware of the condition of the resident's toenails and the facility staff should have provided the ADL care. Follow up interview with the DON revealed the facility does not have the equipment needed to cut the resident's toenails in their current condition and that it would have to be completed by a podiatrist. 2) Review of the medical record revealed Resident #21 was admitted to the facility on [DATE] with diagnoses of multiple sclerosis, dysphagia, epilepsy, neurogenic bladder, paraplegia and unspecified dementia. Review of the MDS quarterly assessment dated [DATE] revealed Resident #21 had moderate cognitive impairment. Review of Resident #21's ADL care plan dated 12/07/24 revealed Resident #21 had a self-care performance deficit. Interventions included total assistance with personal hygiene daily and as needed. Observation of Resident #21 on 12/18/24 at 4:18 P.M. revealed the resident was alert and able to respond with appropriate answers to questions. The resident had contractures in both lower extremities and the toenails on both feet were grossly overgrown, jagged and in need of nail care. Interview with Resident #21 at the same time, revealed he would like his toenails cut. Interview on 12/18/24 at 4:33 P.M. with the DON verified Resident #21's toenails were grossly overgrown, jagged and in need of nail care. 44412 3) Review of the medical record for Resident #02 revealed an admitted [DATE]. Diagnoses included multiple sclerosis (MS), neuromuscular dysfunction of bladder, and major depressive disorder. Review of the care plan dated 01/15/24 revealed Resident #02 had an ADL self-care performance deficit related to multiple sclerosis and pain. Interventions included substantial assistance with hygiene and bathing, skin inspection with care, and explain all procedures and tasks before starting. Review of the MDS assessment dated [DATE] revealed Resident #02 had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 15. Observation on 12/18/24 at 3:19 P.M. revealed Resident #02's toenails on the right foot were overgrown, about a quarter of an inch in length and big toenail on left foot was about a quarter of an inch and jagged. Interview on 12/18/24 at 3:21 P.M. with DON verified Resident #02's toenails were overgrown and needed cut. 4) Review of the medical record for Resident #14 revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), major depressive disorder, and type two diabetes. Review of the podiatry notes dated 08/04/23 revealed Resident #14 was to be seen again by podiatry in two to three months. Review of the care plan dated 03/13/24 revealed Resident #14 had an activity of daily living (ADL) self-care performance deficit related to asthma, COPD, CHF, and history of falls. Interventions included partial assistance with hygiene, explain all procedures or tasks before starting, and physical therapy and occupational therapy evaluation and treatment per physician orders. Review of the MDS assessment dated [DATE] revealed Resident #14 had intact cognition as evidenced by a BIMS score of 15. Review of the medical record revealed no current records of podiatry notes. Observation on 12/17/24 at 2:39 P.M. revealed Resident #14's toenails were overgrown about a quarter of an inch and jagged. Skin on feet was extremely dry and flaking. Interview on 12/17/24 at 2:40 P.M. with Resident #14 revealed her toenails got caught on her socks and caused her discomfort. Interview on 12/17/24 at 2:50 P.M. with Licensed Practical Nurse (LPN) #451 verified toenails were overgrown and jagged for Resident #14. LPN #451 also verified the resident's feet had dry skin. Review of the facility policy titled, Care of Fingernails/Toenails, dated 02/18, revealed the purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infection. General guidelines stated nail care included daily cleaning and regular trimming and unless otherwise permitted, do not trim the nails of diabetic residents or residents with circulatory impairments and stop and report to the nurse supervisor if there is evidence of ingrown nails, infections, pain, or if nails are too hard or too thick to cut with ease.

Based on review of the medical record, observations, interviews, and policy review, the facility failed to timely change oxygen tubing per physician orders. This affected one (#14) resident of six residents with oxygen therapy. The facility census was 60. Findings include: Review of the medical record for Resident #14 revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), major depressive disorder, and type two diabetes. Review of the care plan dated 11/01/22, revealed Resident #14 had oxygen therapy related to asthma, COPD, and shortness of breath (SOB). Interventions included check oxygen saturation as needed for SOB, encourage or assist with ambulation as indicated, and give medications as ordered by physician. Review of the physician order dated 06/27/24, revealed Resident #14 was ordered may use supplemental oxygen as needed (PRN) two liters per minute (LPM) via nasal cannula every shift for maintaining oxygen saturation greater than 90 percent (%) as tolerated. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #14 had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 15. Review of the physician order dated 11/07/24, revealed Resident #14 was ordered to change and date oxygen and nebulizer tubing weekly on Tuesday night shift. Observation on 12/16/24 at 10:04 A.M., revealed Resident #14's oxygen tubing was dated 11/13/24 and appeared dirty in appearance. Observation on 12/17/24 at 2:43 P.M., revealed Resident #14's oxygen tubing was dated 11/13/24 and appeared dirty in appearance. Interview on 12/17/24 at 2:45 P.M. with Licensed Practical Nurse (LPN) #251, verified oxygen tubing was dated 11/13/24 and appeared dirty in appearance. Review of the facility policy titled, Oxygen Administration, dated 2001 revealed the purpose of the procedure was to provide guidelines for safe oxygen administration. Staff verified there was a physician's order for the procedure and review the physician's orders for facility protocol for oxygen administration. Staff to assemble the equipment and supplies as needed.

Based on record review, staff and resident interviews, and policy review, the facility failed to timely arrange for audiology services. This affected one (#03) of the one resident reviewed for communication. The facility census was 60. Findings include: Review of the medical record for Resident #03 revealed an admitted [DATE]. Diagnoses included unspecified sequelae of unspecified cerebrovascular disease, cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery, hypothyroidism, spastic hemiplegia affecting unspecified side, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting unspecified side, major depressive disorder, localized edema, rhabdomyolysis, syncope and collapse, acute kidney failure, neuromuscular dysfunction of bladder, pure hypercholesterolemia, hypertension, and dysphagia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #03 was cognitively intact. The assessment also indicated Resident #03 had minimal difficulty with hearing and used hearing aids. Review of the assessment titled Care Conference Quarterly, for Resident #03 dated 02/05/24, revealed the resident needed to be seen by the audiologist. Review of the assessment titled Care Conference Quarterly, for Resident #03 dated 07/09/24, revealed the resident's power of attorney (POA) wanted the resident added to the audiology list. Review of the facility document titled Not Seen Visit Report dated 07/30/24 revealed Resident #03 was listed as a no show to the treatment area to see the audiologist. Review of an electronic mail communication dated 12/04/24 revealed Resident #03's brother sent a request for Resident #03 to be assessed for hearing aids. Interview on 12/17/24 at 8:56 A.M. with Resident #03 revealed he had difficulty hearing and reported he was waiting on hearing aids. Resident #03 was observed to have trouble with hearing during the interview. Interview on 12/19/24 at 11:50 A.M. with Social Service Designee (SSD) #105 revealed the audiologist was last at the facility on 08/29/24. SSD #105 verified Resident #03 has not been seen by the audiologist and stated the audiologist was unable to see every resident on the list and another visit was supposed to be scheduled soon after. SSD #105 reported the next audiology visit was scheduled for January 2025. Review of the policy titled Specialized Rehabilitation Services, revised 12/2009, revealed the facility provided specialized rehabilitative services by qualified professionals, including audiology.

Based on review of the medical record, staff interviews, and policy review, the facility failed to ensure care conferences were completed quarterly for residents. This affected two (#14 and #20) of three residents reviewed for care conferences. The facility census was 60. Findings include: 1) Review of the medical record revealed Resident #20 was admitted to the facility on [DATE]. Diagnoses include cerebral infarction with dominant left side hemiplegia and hemiparesis, vascular dementia and chronic kidney disease. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE], revealed Resident #20 had moderately impaired cognition. Review of the documentation provided by the Administrator revealed Resident #20 was offered care conferences in the first quarter (January, February and March 2024) and second quarter (April, May and June 2024) of 2024; however, the resident declined the need. A care conference was conducted for Resident #20 in the fourth quarter (October, November and December 2024) on 10/10/24 with Social Services Designee (SSD) #105 and Licensed Practical Nurse (LPN) #400. There was no documented evidence a care conference was offered or completed with the resident for the third quarter (July, August or September 2024). The Administrator verified Resident #20 did not have or was offered a care conference for the third quarter. Interview on 12/19/24 at 2:41 P.M. with SSD #105 verified the documentation provided by the Administrator was accurate and that the facility had not offered or conducted a care conference for Resident #20 in the third quarter of 2024. 44412 2) Review of the medical record for Resident #14 revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), major depressive disorder, and type two diabetes. Review of the most recent MDS assessment dated [DATE], revealed Resident #14 had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 15. Review of the medical record revealed Resident #14 received a care conference on 10/12/23, 04/24/24, and 11/29/24. Review of the progress note dated 07/12/24 at 2:25 P.M. revealed Resident #14 declined the need for care conference at this time. Interview on 12/18/24 at 2:50 P.M. with SSD #105 verified Resident #14 did not receive a care conference in the first quarter of 2024. Review of the facility policy titled, Care Conference Procedure, dated 02/01/18 revealed the facility would meet with residents and/or their legal representative for a care conference to discuss resident care at designated times through resident's stay. A care conference shall be held at the earliest convenient time for residents and/or their legal representative after admission to facility, quarterly, prior to discharge, and as requested by facility, resident, and/or their legal representative.

Based on record review, staff interview, and policy review, the facility failed to ensure accuracy of assessments related to hearing. This affected one (#03) of one resident reviewed for communication. The facility census was 60. Findings include: Review of the medical record for Resident #03 revealed an admitted [DATE]. Diagnoses included unspecified sequelae of unspecified cerebrovascular disease, cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery, hypothyroidism, spastic hemiplegia affecting unspecified side, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting unspecified side, major depressive disorder, localized edema, rhabdomyolysis, syncope and collapse, acute kidney failure, neuromuscular dysfunction of bladder, pure hypercholesterolemia, hypertension, and dysphagia. Review of the Minimum Data Set (MDS) assessments dated 01/30/24, 05/01/24 and 11/01/24, revealed Resident #03 was cognitively intact, had minimal difficulty with hearing and used hearing aids. Interview on 12/17/24 at 8:56 A.M. with Resident #03 revealed he had difficulty hearing and reported he was waiting on hearing aids. Resident #03 was observed to have trouble with hearing during the interview. Interview on 12/19/24 at 11:50 A.M. with Social Service Designee (SSD) #105 revealed Resident #03 had not utilized hearing aids while at the facility. Interview on 12/19/24 at 1:48 P.M. with MDS Coordinator/ Registered Nurse (RN) #175 revealed it was noted in Resident #03's record that he used hearing aids, which transferred over to the MDS and continued to populate on additional assessments. Review of the policy titled Certifying Accuracy of the Resident Assessment, revised 11/2019, revealed the information captured on the assessment reflects the status of the resident during the observation or look-back period for that assessment.

Based on record review, staff interview, and policy review, the facility failed to obtain authorization to manage resident funds. This affected two (#23 and #34) out of five residents reviewed for resident funds. The facility census was 60. Findings include: 1) Review of the medical record for Resident #23 revealed an admitted [DATE]. Diagnoses included flaccid hemiplegia affecting left non-dominant side, chronic obstructive pulmonary disease, type two diabetes mellitus without complications, hemiplegia and hemiparesis following cerebral infarction affecting unspecified side, anemia, major depressive disorder, atherosclerotic heart disease of native coronary artery with other forms of angina pectoris, hyperlipidemia, anxiety disorder, vascular dementia, chronic kidney disease stage three, atrial fibrillation, congestive heart failure, iron deficiency, fibromyalgia, cerebral edema, and vitamin d deficiency. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 was cognitively intact. Review of the resident funds records for Resident #23 revealed no authorization signed by the resident or the resident's representative for the facility to manage their personal funds. 2) Review of the medical record for Resident #34 revealed an admitted [DATE]. Diagnoses included dysphagia following cerebral infarction, hemiplegia unspecified affecting right dominant side, vitamin deficiency, anemia, mixed hyperlipidemia, congestive heart failure, major depressive disorder, and sleep apnea. Review of the quarterly MDS assessment dated [DATE] revealed Resident #34 was cognitively intact. Review of the resident funds records for Resident #34 revealed no authorization signed by the resident or the resident's representative for the facility to manage their personal funds. Interview on 12/18/24 at 3:09 P.M. with the Administrator verified no signed authorizations to manage resident funds for Residents #23 and #34. The Administrator stated the facility was the representative payee for both residents and had not obtained authorization from the residents or their representatives. Review of the policy titled Deposit of Residents' Personal Funds, revised 03/2021, revealed a copy of the resident's or representative's authorization designating the facility as the agency to manage the resident's funds is filed in the resident's financial record.

Based on medical record review, observation, resident and staff interview, and review of the facility policy, the facility failed to keep a resident's room clean and sanitary. This affected one (Resident #12) of three residents reviewed for environment. The facility census was 57. Findings include: Review of the medical record for Resident #12 revealed an admitted [DATE]. Diagnosis included anxiety disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 was cognitively intact. Interview on 06/20/24 at 10:35 A.M. with Resident #12 stated the housekeeping staff does not wipe down the furniture in her room. Resident #12 stated they do not sweep under her bed, or corners in the room. Resident #12 stated she took out her own trash from her room because it does not get taken care of. Resident #12 stated her toilet was disgusting, dirty, smells, and had urine ring around the toilet. Observation on 06/20/24 at 10:40 A.M. with Resident #12's room revealed all three of her bedroom walls, and around her air conditioner wall unit was dirty with an unknown black substance, dirt, food particles, and hair balls. Resident #12's bathroom floor was dirty with dirt particles and unknown particles on the floor. Resident #12 had a urine ring around her toilet base. The bathroom trash can had dirt and spots under and around the trash can. Resident #12's floor had scattered unknown black spots on her floor. Observations on 06/20/24 from 11:58 A.M. through 12:10 P.M. with Housekeeping Aide (HKA) #289 revealed she was cleaning Resident #12's room with blinds closed and lights out. HKA #289 opened the blinds at the window and cleaned Resident #12's end table around personal items, and half the bedside table which was part with no personal items. At 12:09 P.M., HKA #289 stated she was almost done cleaning Resident #12's room. Interview on 06/20/24 at 12:09 P.M. with HKA #289 verified she was mopping Resident #12's room a second time. HKA #289 verified she only mopped the main areas and pathways to the room. HKA #289 stated she did not mop under the walker, trash can, or bed. HKA #289 stated she did miss the areas that had dirt and food particles that were against the walls, under the bed, around the air conditioner wall unit, around the end table, around at the bedside table, or in the bathroom. HKA #289 confirmed there was dirt pile (in a pile of dirt that was approximately six inch in diameter in room when sweeping). HKA #289 also confirmed the hairball, urine ring around the toilet, and dirt and spots in the bathroom. HKA #289 stated she did not do the best job on Resident #12's room and could have done better. HKA #289 verified that she only wiped down half the bedside table, and around the personal items, and the end table around the personal items. HKA #289 stated Resident #12 was particular and did not want her to touch her personal items. HKA #289 verified on the bedside table there was dust, dirt, and unclean on the side with her personal items. Interview on 06/20/24 at 12:50 P.M. with Floor Technician (FT) #242 stated he also cleaned the resident rooms. FT #242 stated he would move the small items off the bed side table, and end table to perform a better job in wiping down residents most used items. FT #242 stated the unknown black substance around the air conditioner wall unit had glue that was covered in dirt that was hard to get off the floor. FT #242 stated there was black scuff marks all over Resident #12's room possibly from Resident #12's wheelchair. FT #242 stated Resident #12 was not that particular, to move her personal items to clean areas in the room. FT #242 stated he moved trash cans, walkers, and sweep under resident's beds and furniture to do light cleaning. Review of the facility's undated policy titled Cleaning and Disinfection of Environmental Surfaces revealed non-critical surfaces included bed rails, some food utensils, bedside tables, furniture, and floors. Environmental surfaces will be disinfected (or cleaned) on a regular basis (daily, three times a week, and when surfaces are visibly soiled. Horizontal surfaces will be dusted regularly using clean clothes moistened with an Environmental Protection Agency (EPA)-registered disinfectant (or detergent). Review of the facility policy titled Standard Precautions, dated December 2007, revealed staff should ensure that environmental surfaces, beds, bedside equipment, and other frequently touched surfaces are appropriately cleaned. This deficiency represents non-compliance investigated under Complaint Number OH00154206.

Based on observation, staff interview and review of facility policy, the facility failed to provide toileting for a resident in a dignified manner which enhanced their quality of life and with dignity and respect. This affected one Resident (#5) of the three residents reviewed. The facility census was 70. Findings included: Review of medical record for Resident #5 revealed resident was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent minimum data set (MDS) dated [DATE] indicated resident had moderately impaired cognition, had verbal behaviors, did not reject care, and required extensive assistance for toileting and other activities of daily living (ADLs). Review of 10/26/19 plan of care for Resident #5 indicated resident had bowel and bladder incontinence relate to impaired mobility and required extensive assistance of one staff for toileting and resident had an ADL self-care deficit and required extensive assistance of one staff. During medication administration observation on 03/10/22 beginning at 9:15 A.M. with Licensed Practical Nurse (LPN) # 30 revealed LPN #30 prepared medications for Resident #5. Observation at 9:42 A.M. revealed LPN #30 and surveyor approached resident's room and door was halfway open and resident was standing near the left side of wall holding on to grab bars with his pants down and exposed. Continued observation revealed State tested Nurse's Aide (STNA) #43 placed a shower chair under [NAME] resident and resident was assisted to shower chair. STNA #43 was observed placing a lined trash can under resident and STNA stated resident needed to be toileted. Observation revealed LPN #30 administered medications while resident was sitting on the shower chair and with pants down. Observation revealed the door to residents' room was still open as LPN #30 washed his hands, exited the room, and secured the door. Interview with LPN #30 on 03/10/22 at 9:44 A.M. indicated the door should have been shut when STNA started to provide personal care. LPN #30 verified resident was exposed and stated his expectations were for resident to have privacy during toileting. Review of 09/01/18 facility policy titled Quality of Life - Dignity revealed each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. This is an incident finding discovered during the course of complaint Number OH 554 investigation and is an example of continued noncompliance from the survey dated 03/02/22.

Based on medical record review, staff interviews, review of pharmacy records, review of Cubex (emergency pharmacy distribution system) records, and review of facility policy, the facility failed to ensure medical records on each resident were accurately documented. This affected one Resident (#05) of the two residents reviewed for medication administration. The facility census was 70. Findings included. Review of medical record for Resident #05 revealed resident was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent minimum data set (MDS) dated [DATE] indicated Resident #05 had moderately impaired cognition, had verbal behaviors, did not reject care, and required extensive assist or supervision for activities of daily living (ADLS). Review of plan of care for Resident #05 indicated resident had [CONDITION(S)]. Interventions included give anti-hypertensives as ordered, monitor /record medication side effects and report to physician as necessary. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of March 2022 medication administration records (MAR) for Resident #05 indicated the following: a. On 03/10/22 at 10:00 P.M. [MEDICATION(S)] 200 mg was marked as being administered by Agency Licensed Practical Nurse (LPN) #37. b. On 03/11/22 at 2:00 P.M. indicated [MEDICATION(S)] 200 mg was marked as being administered by LPN #30. c. On 03/12/22 at 2:00 P.M. indicated [MEDICATION(S)] 200 mg was marked as being administered by LPN #39. d. On 03/12/22 at 10:00 P.M. indicated [MEDICATION(S)] 200 mg was marked as being administered by agency LPN #37. Interview with LPN #36 on 03/13/22 at 9:26 A.M. indicated the pharmacy delivered Resident #05's [MEDICATION(S)] medications and LPN #37 signed for them on 03/13/22 sometime after midnight. Review of Cubex list of stocked/inventoried medications revealed [MEDICATION(S)] 200 mg was available to be pulled and administered to Resident #05 if/when he was out. Review of Cubex log sheets for Resident #05 from 03/09/22 through 03/13/22 at 10:00 P.M. reviewed [MEDICATION(S)] was removed once on 03/10/22 at 1:20 P.M. by LPN #30. Cubex system log sheets were silent for any indication [MEDICATION(S)] was removed and administered to Resident #05 on 03/10/22 at 10:00 P.M., 03/11/22 at 2:00 P.M., 03/12/22 at 2:00 P.M., and 03/12/22 at 10:00 P.M. Review of pharmacy delivery sheets dated 02/15/22 at 2:00 P.M. indicated 42 tablets (14-day supply) of [MEDICATION(S)] was sent out for delivery and delivered to the facility on [DATE] at 11:41 P.M. Review of pharmacy delivery sheets dated 03/12/22 at 5:30 P.M. indicated 42 tablets of [MEDICATION(S)] was sent out for delivery to facility and delivered to facility on 03/13/22 at 1:48 A.M. During phone interview with LPN #30 on 03/15/22 at 4:15 P.M. indicated Resident #05 had been out of his [MEDICATION(S)]. LPN stated he thought he pulled out [MEDICATION(S)] from the Cubex system for Resident #05 on 3/10/22 and 3/11/22. During review of Cubex log sheets with LPN #30, he verified he didn't pull the [MEDICATION(S)] on 3/11/22 at 2:00 P.M. and verified he documented as administered. LPN #30 stated he must have accidentally documented he administered the medications. During email correspondence with Director of Nursing (DON) on 03/16/22 at 6:40 A.M. indicated agency staff did not have access to the Cubex system and [MEDICATION(S)] was a medication stocked in the Cubex system. Phone interview with RN #37 on 03/16/22 at 11:15 A.M. indicated he worked on 03/10/22 and 03/12/22 from 7:00 P.M. to 7:00 A.M. and was tasked with caring and administering medications for Resident #05. RN #37 verified Resident #05's [MEDICATION(S)] was out of stock when he worked on 3/10/22 and 03/12/22. RN #37 stated agency staff did not have access to the emergency medications system (Cubex). RN #37 additionally stated he accidentally documented the [MEDICATION(S)] was administered on 03/10/22 at 10:00 P.M. and 03/12/22 at 10:00 P.M. Interview with Director of Nursing (DON) on 03/16/22 at 11:42 A.M. verified [MEDICATION(S)] doses for Resident #05 were recorded as being administered on 03/10/22 at 10:00 P.M., 03/11/22 at 2:00 P.M., 03/12/22 at 2:00 P.M., and 03/12/22 at 10:00 P.M. DON further verified medications were not pulled from the Cubex system and not in stock. DON stated there were no other residents on the medication cart who took [MEDICATION(S)]. DON stated she had spoken to the pharmacy on numerous occasions and the facility was not able to get medications delivered timely due to national supply chain issues. Review of 08/01/21 facility policy titled Documentation of Medication Administration revealed the facility shall maintain a Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . This is an incident finding discovered during the course of complaint Number OH 554 investigation.

Based on medical record review, staff interviews, review of pharmacy records, review of Cubex (emergency pharmacy distribution system) records, and review of facility policy, the facility failed to ensure residents were free of any significant medication errors. This affected one Resident (#05) of the three residents reviewed for medication administration. Facility census was 70. Findings included. Review of medical record for Resident #05 revealed resident was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent minimum data set (MDS) dated [DATE] indicated resident had moderately impaired cognition, had verbal behaviors, did not reject care, and required extensive assist or supervision for activities of daily living (ADLS). Review of plan of care indicated resident had [CONDITION(S)]. Interventions included give anti-hypertensives as ordered, monitor /record medication side effects and report to physician as necessary. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of nurse's progress notes for Resident #05 dated 03/09/22 at 9:47 P.M. by Registered Nurse (RN) #20 indicated [MEDICATION(S)] 200 mg was not administered and would be given when received from pharmacy. Nurse's progress notes dated 03/10/22 at 5:59 A.M. by RN #20 indicated [MEDICATION(S)] 200 mg was not administered and would be given when received from pharmacy. Nurse's progress notes dated 03/11/22 at 7:04 A.M. by agency RN #37 indicated [MEDICATION(S)] 200 mg was unavailable to be administered and was on order. Nurse's progress notes dated 3/12/22 at 12:29 A.M. by agency RN #37 indicated [MEDICATION(S)] 200 mg was unavailable to be administered. Nurses Progress notes dated 03/12/22 at 7:19 A.M. by Agency Licensed Practical Nurse (LPN) #38 indicated [MEDICATION(S)] 200 mg was not available to be administered. Nurse notes dated 03/13/22 were silent for any indication the physician was contacted for resident being out of his ordered [MEDICATION(S)]. Review of March 2022 medication administration records (MAR) for Resident #05 indicated the following: a. On 03/09/22 at 10:00 P.M. MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] #20 recorded a 9 (see other /nurses notes). b. On 03/10/22 at 6:00 A.M. indicated [MEDICATION(S)] 200 mg was not administered and RN #20 recorded with a 9. c. On 03/10/22 at 10:00 P.M. [MEDICATION(S)] 200 mg was marked as being administered by Agency LPN #37. d. On 03/11/22 at 6:00 AM indicated [MEDICATION(S)] 200 mg was not administered and LPN #37 recorded a 9. e. On 03/11/22 at 10:00 P.M. indicated [MEDICATION(S)] 200 mg was not administered and LPN #38 recorded a 9. f. On 03/11/22 at 2:00 P.M. indicated [MEDICATION(S)] 200 mg was marked as being administered by LPN #30. g. On 03/12/22 at 6:00 A.M. indicated [MEDICATION(S)] 200 mg indicated [MEDICATION(S)] 200 mg was not administered and LPN #38 recorded a 9. h. On 03/12/22 at 2:00 P.M. [MEDICATION(S)] 200 mg was marked as being administered by LPN #39. i. On 03/12/22 at 10:00 P.M. [MEDICATION(S)] 200 mg was marked as being administered by LPN #37. Interview with LPN #36 on 03/13/22 at 8:00 A.M. indicated resident received his [MEDICATION(S)] 220 mg on this date at 6:00 A.M. per report from night shift nurse /RN #37. LPN #36 stated she would search for the pharmacy delivery sheets and call surveyor back. Subsequent interview with LPN #36 on 03/13/22 at 9:26 A.M. indicated the pharmacy delivered Resident #05's [MEDICATION(S)] medications and RN #37 signed for them on 03/13/22 sometime after midnight. Review of Cubex list of stocked/inventoried medications revealed [MEDICATION(S)] 200 mg was available to be pulled and administered when Resident #05 was out. Review of Cubex log sheets of medications pulled for Resident #05 from 03/09/22 through 03/13/22 at 10:00 P.M. reviewed [MEDICATION(S)] was removed once on 03/10/22 at 1:20 P.M. by LPN #30. Cubex system log sheets were silent for any indication [MEDICATION(S)] had been removed for resident on 03/10/22 at 10:00 P.M., 03/11/22 at 2:00 P.M., 03/12/22 at 2:00 P.M., and 03/12/22 at 10:00 P.M. Review of pharmacy delivery sheets dated 02/15/22 at 2:00 P.M. indicated 42 tablets of [MEDICATION(S)] was sent out for delivery and delivered to the facility on [DATE] at 11:41 P.M. Review of pharmacy delivery sheets dated 03/12/22 at 5:30 P.M. indicated 42 tablets of [MEDICATION(S)] was sent out for delivery to facility and delivered to facility on 03/13/22 at 1:48 A.M. Phone Interview with Nurse Practitioner (NP) #12 on 03/15/22 at 3:24 P.M. indicated she was not aware resident did not get the 10 doses of [MEDICATION(S)] 200 mg and NP #12 stated the omitted doses did not contribute to any negative effects. Interview with LPN #30 on 03/15/22 at 4:15 P.M. indicated Resident #05 had been out of his Labetolol. LPN #30 stated he pulled out [MEDICATION(S)] 200 mg from the Cubex system for Resident #05 on 3/10/22 and 03/11/22. During review of Cubex log sheets with LPN #30, he verified he didn't pull the [MEDICATION(S)] on 3/11/22 at 2:00 P.M. and verified he documented as administered. LPN #30 stated he must have accidentally documented he administered the medications. During email correspondence with Director of Nursing (DON) on 03/16/22 at 6:40 A.M. indicated agency staff did not have access to the Cubex system and [MEDICATION(S)] was a medication stocked in the Cubex system. Phone interview with RN #37 on 03/16/22 at 11:15 A.M. indicated he worked on 03/10/22 and 03/12/22 from 7:00 P.M. to 7:00 A.M. and was tasked with caring and administering medications for Resident #05. RN #37 verified Resident #5's [MEDICATION(S)] was out of stock when he worked on 3/10/22 and 03/12/22. RN #37 verified the pharmacy delivered the medications to the facility on [DATE] at 1:48 A.M. and verified Resident #05's [MEDICATION(S)] was delivered because he put the medications in the cart. RN #37 stated agency staff did not have access to the emergency medications system (Cubex). RN #37 additionally stated he accidentally documented the [MEDICATION(S)] 200 mg was administered on 03/10/22 at 10:00 P.M. and 03/12/22 at 10:00 P.M. Interview with DON on 03/16/22 at 11:42 A.M. verified [MEDICATION(S)] doses for Resident #5 were recorded as being administered on 03/10/22 at 10:00 P.M., 03/11/22 at 2:00 P.M., 03/12/22 at 2:00 P.M., and 03/12/22 at 10:00 P.M. DON further verified medications were not pulled from the Cubex system and not in stock. DON stated she had spoken to the pharmacy on numerous occasions and the facility was not able to get some medications delivered timely due to national supply chain issues. Review of facility policy titled Administering Medications dated 04/01/19 revealed medications were to be administered in a safe and timely manner and as prescribed. This deficiency substantiates complaint number OH 504.

Based on observations, staff interviews, review of online resources, and review facility policy, the facility failed to ensure their medication error rate was less than five percent (%). The medication error rate was 6.25 %. This affected one Resident #5 of two resident observed for medication administration. The facility census was 70. Findings included: Review of medical record for Resident #05 revealed resident was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent minimum data set (MDS) dated [DATE] indicated resident had moderately impaired cognition, had verbal behaviors, did not reject care, and required extensive assistance or supervision for activities of daily living (ADLS). Review of 10/26/19 plan of care for Resident #05 indicated resident had [CONDITION(S)] and was risk for shortness of breath (SOB), had altered respiratory status and dyspnea related to [CONDITION(S)]. Interventions included administer medications and bronchodilators as ordered, monitor/document any side effects and effectiveness and use an incentive spirometer. Review of care plan was silent for indication resident refused or non-complaint with rinsing mouth or education about rinsing mouth after steroid inhaler use. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During medication administration observation on 03/10/22 beginning at 9:15 A.M. with Licensed Practical Nurse (LPN) # 30 revealed LPN #30 prepared medications for Resident #05. During preparations of medications, LPN #30 indicated resident was out of [MEDICATION(S)] (cholesterol) 40 mg, [MEDICATION(S)] inhaler (allergies) and there was no Vitamin-C 250 mg over the counter (OTC) in the cart for resident. LPN #30 stated running out of medications were common issues with the pharmacy. LPN #30 stated both medications had been reordered on the 03/09/22 but not delivered and he had to go stock room to look for OTC Vitamin-C. Observation at 9:42 A.M. revealed LPN #30 administered numerous other medications and administered Breo Elliptal. LPN #30 stated he needed to go the pyxis machine to get [MEDICATION(S)] for resident to finish the medication administration. Observation at 9:50 A.M. revealed LPN #30 and Registered Nurse (RN) #11 were in the medication room and RN #11 removed [MEDICATION(S)] 20 mg (two) from the pyxis and provided medication to LPN #30. Continued observation at 10:16 A.M. indicated LPN #30 administered resident his [MEDICATION(S)] 40 mg and Vitamin-C 250 mg. Interview with LPN #30 immediately afterwards, verified resident was not administered his ordered [MEDICATION(S)] inhaler due to not having it in stock. LPN #30 also verified he never instructed resident to rinse his mouth after being administered the Breo Elliptal inhaler. LPN #30 stated resident often refused to rinse mouth out and stated he forgot to remind resident. LPN #30 indicated resident #30 was dependent on staff for all medications and treatments. Review of March 2022 medication administration records (MAR) for Resident #05 indicated on 03/10/22 at 9:00 A.M. [MEDICATION(S)] 220 mcg was not administered, and MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, review of MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M. indicated Breo Elliptal was administered. Review of nurses notes for Resident #05 dated 03/10/22 were silent for any documentation related to the missed dose of [MEDICATION(S)]. Review of online resources from Breo Elliptal website, titled instructions for using your [MEDICATION(S)] Inhaler (https://www.breztrihcp.com/resources.html) updated 01/22, indicated Breo could cause serious side effects, including a fungal infection in your mouth or throat (thrush). Instructions indicated patients /residents were to rinse mouth with water without swallowing after using Breo to help reduce your chance of getting thrush. Review of online resources from Medscape titled Vilanterol/[MEDICATION(S)] furoate inhaled (https://reference.medscape.com/drug/breo-ellipta-vilanterol-[MEDICATION(S)]-furoate-inhaled- 7#11) indicated after inhalation, rinse mouth with water and expectorate to help reduce the risk of oropharyngeal candidiasis (fungal /thrush). Review of facility policy titled Administering Medications dated 04/01/19 revealed medications were to be administered in a safe and timely manner and as prescribed. This deficiency substantiates complaint number OH 504.

Based on observation, staff interviews, record review, and review of the facility policies, the facility failed to ensure that food was stored, prepared, and served in accordance with professional standards for food service safety. This had the potential to affect 69 of 70 residents residing in the facility, excluding Resident #50 who received enteral feedings and nothing by mouth. Findings include: 1. An initial tour of the kitchen was conducted on 02/14/22 at 9:45 A.M. with Cook #22. While touring the kitchen, the following was observed: 1a. The free-standing walk-in freezer located outside of the building with Cook #22 felt very warm and observation revealed a non-functioning thermometer sitting on the shelf. Continued observation revealed the ice cream was completely liquefied, the tater tots, French fries and all vegetables were very soft to touch. Cook #22 stated she last got something from the freezer at 5:45 A.M. and everything seemed to be working normally. Cook #22 verified the freezer was not working, non-functioning thermometer and numerous food items were thawed and liquefied. 1b. The common ice machine located in the common area and directly outside the kitchen and available for any resident to retrieve ice had a significant amount of mold accumulation on the upper inside area of the hopper where the ice was dispensed into reservoir. Cook #22 verified the presence of the mold and Cook #22 stated she was not sure who was responsible for cleaning the machine and when the last cleaning was completed. 1c. The facility was equipped with a high temperature dish machine with manufacturer's minimum wash recommendations at 150 degrees Fahrenheit (F) and rinse operating temperatures of 180 degrees F. The dishwasher log for February 2022 was blank for any dishwasher temperatures being recorded. Cook #22 verified there were no recorded temperatures for dishwasher and stated she was not sure who tested the dishwasher temperatures. 1d. The kitchen had three empty buckets used for sanitizing food preparation and contact surfaces which were stacked inside each other and on a shelf. Cook #22 stated the facility did not use the sanitizer buckets and kitchen used a spray bottle of mixed bleach to clean. Cook #22 stated she did not know how the kitchen tested the solution. 2. A follow-up tour of the central kitchen was conducted on 02/15/22 at 3:10 P.M. While touring the kitchen the following was observed: 2a. The three-sink cleaning/disinfecting system revealed the sanitized section was filled with a clear liquid. Interview with Dietary Aid (DA) #21 indicated the kitchen staff used the sanitized section of the sink to clean items not able be run through the dishwasher. DA #21 stated the kitchen did not have any testing strips to test the chemical in the three-sink cleaning/disinfecting system. Further observations of the form hanging above the sink titled Sanitizer Log -2022 revealed the last date recorded on the form was 02/06/22 and completed by DA #21. DA #21 stated the facility was out of sanitizer to put in the sink so he filled the sink with plain water to rinse the dishes. DA #21 verified the kitchen had been out of sanitizer since 02/06/22 and verified the log was absent for testing the sanitizer levels since 02/06/22. 2b. The kitchen had one sanitizer bucket sitting on a shelf with clear liquids and DA #21 stated Dietary Manager (DM) #23 had made up the sanitizer bucket earlier in morning. DA #21 stated the sanitizer bucket was made up with bleach and water. DA #21 stated the kitchen used spray bottles of bleach to clean the kitchen. DA #21 stated the facility had no way of testing the bleach mixture solution and followed no formula for making up the solutions. DA #21 stated he just added some bleach and water to bottle. Observation at the same time with DA #21 revealed the solution in spray bottles and bucket had no odor of bleach. When asked to observe the bleach he used, DA #21 stated he did not have any bleach in the kitchen. Interview with DM #23 at same time indicated she made up the bucket with bleach and water when she arrived around 6:00 A.M. DM #23 confirmed the facility still had no sanitizer solution for sinks or the sanitizer buckets. DM #23 stated the Sanitizer solution was still on order and should be delivered on 02/16/22. During an interview with the Administrator on 02/15/22 at 3:30 P.M. indicated she was not aware the kitchen did not have any sanitizer. Interview with Infection Preventionist (IP) /Licensed Practical Nurse (LPN) #30 on 02/15/22 at 4:00 P.M. indicated she was never instructed the kitchen was out of sanitizer. LPN #30 stated her expectations indicated being notified if/when the kitchen was out of sanitizer to monitor for any gastrointestinal issues (GI) related to food borne illness. LPN #30 denied any knowledge of GI related issues in the facility. Subsequent interview with DM #23 on 02/16/22 at 10:00 A.M. indicated the facility had not received the shipment of sanitizer. DM #23 further stated she had not notified the Administrator, Director of Nursing (DON) and/or or the IP/ LPN #30 when the kitchen ran out of sanitizer. DM #23 stated she only instructed the Maintenance Director so he could order more. DM #23 stated she was not aware she had to notify the nursing staff and stated she did not understand why she needed to notify them. Subsequent interview with the Administrator on 02/16/22 at 10:30 A.M. indicated she did not address the kitchen not having sanitizer but would address it immediately. 3. A follow-up tour of the kitchen was conducted on 02/16/22 at 11:28 A.M. While touring the kitchen, the following was observed: 3a. There continued to be no sanitizer solution for the kitchen and the kitchen was still using bleach and water solution with no way to test the solution and/or a formula for mixing the solution in a spray bottle and sanitizer buckets. Interview with DM #23 at same time verified the facility had not received the shipment for the sanitizer solution. 3b. Observation of meal preparation, service, and tray assembly on 02/16/21 beginning at 11:45 A.M. revealed food temperature logs for 02/10/22 through 02/14/22 were blank. Cook #22 verified there were no recorded temperature checks for the foods being served. 3c. During preparation of delivery of trays, DA #18 was putting the food trays with drinks inside an open rolling cart and once completed, DA #18 pushed the cart from the kitchen and when the door to the kitchen opened, the air/pressure pushed numerous meal tickets off the resident's food trays and on to the floor. DA #18 and Registered Dietitian (RD) #101 started sorting and putting the meal tickets back on the food trays by lifting the plates and putting the tickets under the plates. Once completed with sorting out the meal tickets, DA #18 stated the trays were ready for delivery. DA #18 exited the kitchen and pushed the food cart to the East section of the facility. RD #101 walked to the East section of the facility and when DA #18 delivered trays. Directly before staff started pulling the trays from the cart, the surveyor intervened due to the infection control issue from the meal tickets falling on the floor, RD #101 confirmed it was an infection control issue from the meal tickets falling on the floor. RD #101 instructed DA #18 to return the trays to the kitchen. RD #101 and DA #18 verified the infection control issue. DA #18 stated the facility had clear plastic covers to put over the open cart during delivery but forgot due to being in a hurry. 4. Continued observation of kitchen on 02/16/22 at 12:30 P.M. reveled numerous new bottles of food service grade industrial cleaner bottles. Interview with DM #23 at the same time indicated the Administrator purchased the pre-mixed cleaning solutions until the bulk sanitizer was delivered. Interview with DM #23 on 02/16/22 at 1:05 P.M. revealed her expectations were for the dishwasher temperature logs be completed and food should be checked for appropriate temperatures at every meal service and recorded. Surveyor asked DM #23 for copies of food temperature logs from 02/10/22 through 02/14/22. At 1:09 P.M., the surveyor entered the kitchen to ask DM #23 a question and observed DA #21 and Cook #22 standing with the temperature log book and DA #21 holding a pen and writing on the log dated 02/11/22. DA #21 stated he was just looking at them but when the surveyor reviewed the logs, 02/10/22 and 02/11/22 had been filled in with temperatures. Surveyor questioned DA #21 if he had filled in the logs and DA #21 stated he did not despite observing him writing on the 02/11/22 log and already having the blank logs verified by the staff. Interview with DM #23 at same time indicated she only instructed Cook #22 to make a copy of the logs since it was her responsibility. Interview with RD #101 on 02/16/22 at 1:10 P.M. indicated food temperatures should be completed and logged at each meal service. Review of the facility's list of residents who were nothing by mouth (NPO) revealed Resident #50 was NPO. Review of the facility's policy titled Sanitization, dated 10/01/08, revealed the food service area shall be maintained in a clean and sanitary manner. All equipment, food contact surfaces and utensil shall be washed to remove or completely loosen soils by using the manual or mechanical mean necessary and sanitized using hot water and/or chemical sanitizing solutions. Sanitizing of environmental surfaces must be performed with on the following solutions: 50-100 parts per million (ppm) of chlorine solution, 150-200 ppm quaternary ammonium compound (QAC) or 12.5 ppm iodine solution. Ice machines will be drained, cleaned, and sanitized per manufacturers instructions. Food service staff would be responsible for cleanliness of the kitchen. Review of the facility's policy titled Preventing Foodborne Illness - Food Handling, dated 07/01/14, revealed food would be stored, prepared handled and served so that the risk of foodborne illness was minimized. All food service equipment and utensils will be sanitized according to the current guidelines and manufactures recommendations. Review of the facility's policy titled Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices, dated 10/01/17, revealed food and nutrition employee would follow appropriate hygiene and sanitary procedures to prevent he spread of foodborne illness.

Based on observations, resident and staff interviews, review of the facilities policy, the facility failed to provide a safe, clean comfortable and homelike environment. This affected five (Residents #05, #38, #41, #422, and #423) of 18 residents reviewed for a homelike environment. The facility census was 70. Findings include: During interview with Residents #05 and #41 on 02/15/22 at 4:01 P.M. revealed the long wall where the resident's dressers and televisions were located revealed there were large areas of the drywall damaged. Observations also revealed the wall where the window was located had numerous damaged areas of drywall and the wall behind the resident's bed had large areas of damaged drywall. Resident #41 stated the walls had been in disrepair for long time. During observation of Residents #422 and #423's room on 02/15/22 at 4:30 P.M. revealed large areas of mold on the window blinds and the toilet was unsecured from the flange and moved side to side. The window blinds were directly over the heating air condition (HVAC) unit in the wall. Both residents were ambulatory and independent with toileting. During observation of Residents #38's room on 02/15/22 at 4:40 P.M. revealed the toilet was unsecured from the flange and moved side to side. Resident was independently mobile with toileting. During an interview with Maintenance Director #71 on 02/17/22 at 3:50 P.M. verified the above observations in Resident #05, #41, #422, #423, and #38's rooms. Maintenance Director #71 stated he was not aware of the areas in disrepair. Review of the facility's policy titled Maintenance Service, dated 12/01/09, revealed maintenance services shall be provided to all areas of the building, grounds and equipment. Functions of maintenance personnel included ensuring the building was in compliance with current federal, state and local laws regulations and guidelines and maintaining the building in good repair and free from hazards. This deficiency substantiates Complaint Numbers OH 652, OH 126, OH 809, OH 354, OH 586 and OH 693.

Based on observation, staff interviews, record review, and review of the facility's policy, the facility failed to provide food that was served at a safe and appetizing temperature. This had the potential to affect the two residents (#18 and #426) who were on a pureed diet. The facility census was 70. Findings included: During observations of the lunch pre-service food temperatures on 02/16/22 at 11:28 A.M. revealed Cook #22 checked the puree chicken and recorded a holding temperature of 108 degrees Fahrenheit (F) on the Daily Food Temp Log. Review of the completed temperature log with Cook #22, immediately as she completed temperature checks, Cook #22 confirmed she received and recorded the temperature of 108 degrees F for the puree chicken. Cook #22 stated Residents #18 and #426 were only two residents on a puree diet. During continued observations of the kitchen and follow-up interview with Cook #22 on 02/16/22 at 12:20 P.M. and review of the lunch temperature logs, the log appeared to have been changed to show the chicken was 188 degrees F. Cook #22 again confirmed the puree chicken was 108 degrees F when she checked it at 11:28 A.M. and did not change the log. During an observation of food service on 02/16/22 at 12:22 P.M. revealed the food cart with Resident #18's tray had exited the kitchen. Dietary Manager (DM) #23 and Registered Dietitian (RD) #101 walked with the trays as they were being delivered. RD #101 indicated at minimum, the holding temperature should have been 135 degrees F. Observation of the puree chicken directly before the meal was going to be delivered to Resident #18 with DM #23 revealed the puree chicken was 110 degrees F. Surveyor mentioned the recorded 108-degree temperature F in the kitchen by Cook #22, and RD #101 indicated that was not appropriate. DM #23 removed the tray for Resident #18 and returned to the kitchen to reheat the food. During an interview with RD #101 on 02/16/22 at 12:45 P.M. indicated Cook #22 should have addressed the 108 temperatures F before allowing the puree chicken to leave the kitchen. RD #101 verified the puree chicken was under the appropriate temperatures to be served. Review of the facility's policy titled Preventing Foodborne Illness-Food Handling, dated 07/01/14, revealed food will be stored, handled and served so that the risk of Foodborne illness is minimalized. This deficiency substantiates Complaint Numbers OH 809, OH 354, OH 126, and OH 244.

Based on medical record review, staff interview, and review of the facility's policy, the facility failed to ensure medications were administered as ordered. This affected two (#53 and #324) of five residents reviewed for unnecessary medications. The facility census was 70. Findings include: 1. Record review for Resident #324 revealed an admitted [DATE]. His diagnoses included diabetes mellitus II, local infection of the skin and subcutaneous tissue, gangrene, cutaneous abscess of right foot, [CONDITION(S)] susceptible staphylococcus aureus, and major depressive disorder. Review of the Minimum Data Set (MDS) assessment, dated 02/03/22, revealed Resident #324 had intact cognition. Review of the Medication Administration Review (MAR) dated February 2022 revealed the following information regarding missed dosages of medication for Resident #324: · [MEDICATION(S)] solution reconstituted (antibiotic) two gram intravenously one time a day related to cutaneous abscess of right foot until 02/17/22. One dose was missed on 02/11/22. A note was written in the progress notes that [MEDICATION(S)] solution was unable to be administered due to medication was exhausted from the e-box and despite several attempts to refill it from the pharmacy. The pharmacy is not sending the medication to the facility. · [MEDICATION(S)] capsule delayed release sprinkle 60 milligrams (mg) one capsule by mouth one time a day for depression. It was not administered three times on 02/02/22, 02/04/22, and 2/07/22. · Flush intravenous (IV) catheter after antibiotic with 10 milliliter (ml) syringe of normal saline (NS) followed by five ml of [MEDICATION(S)] Flush (used to flush out IV catheter, which helps prevent blockage in the tube after an IV infusion) every day. It was not administered on three days on 02/06/22, 02/09/22, and 02/11/22. It was marked at unavailable. · [MEDICATION(S)] Solution Pen-injector 0.75 mg/ 0.5 ml inject 0.5 ml subcutaneously one time a day every Thursday related to Type II diabetes mellitus with diabetic polyneuropathy. It was not administered on 02/03/22. Interview on 02/15/22 at 04:00 P.M. with the Unit Manager Nurse (UMN) #29 confirmed if a nurse did not write a progress note in Resident #324's chart regarding a missed medication then they nurse must have gotten busy and forgot to administer the medication. UMN #29 confirmed there was no note or information regarding Resident #324 missing medications of [MEDICATION(S)], [MEDICATION(S)] Flush or [MEDICATION(S)]. UMN #29 stated the facility continues to have ongoing issues with pharmacy. UMN #29 stated the facility ordered Resident #324's antibiotic however the pharmacy did not deliver it. UMN #29 stated the facility exhausted their supply of the medication. UMN #29 stated the facility nurses should have documented notifying the physician and family regarding the missed doses of medications. UMN #29 confirmed Resident t #324 did not receive the antibiotic as physician ordered. 2. Record review for Resident #53 revealed an admitted [DATE]. Diagnoses included [CONDITION(S)], peripheral vascular disease, contracture of left wrist, and chronic pain syndrome. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/11/22, revealed Resident #53 had moderately impaired cognition. Review of the current physician orders revealed an order for [MEDICATION(S)] HCI tablet 50 milligrams that indicated one tablet was to be given by mouth four times a day related to chronic pain. Review of the Medication Administration Record (MAR) for 02/2022 revealed on 02/19/22 for the 9:00 P.M. dose, the MAR indicated other/see nurse notes. Review of the nursing progress notes dated 02/19/22 revealed the medication was unavailable. Registered Nurse (RN) #150 received an authorization code to obtain the medication from the automated medication dispensing system at the facility but there was not another nurse with access to the system, so the medication was unable to be pulled. Interview on 02/24/22 at 2:15 P.M. with RN #150 verified Resident #53 did not receive the [MEDICATION(S)] as ordered. She stated she had access to the system, but two nurses with access were required to verify a narcotic. She reported no other nurses were working at the time to access to the system. Review of the facility's policy titled Documentation of Medication Administration, dated 07/01/2019, revealed the facility shall maintain administration record to document all medications administered. Section F of the policy stated, Reason(s) why a medication was withheld, not administered, or refused (as applicable). This deficiency substantiates Complaint Numbers OH 487, OH 244, and OH 693.

Based on medical record review, review of the facility's policy, and staff interview, the facility failed to complete a discharge care plan for a resident. This affected one (Resident #324) of three residents reviewed for discharge care planning. The facility census was 70. Findings Include: Record review for Resident #324 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) assessment, dated 02/03/22, revealed Resident #324 had intact cognition. Review of the Resident #324's care plans revealed he did not have a care plan in place regarding discharge planning. Interview on 02/15/22 at 2:55 P.M. with MDS Nurse #26 confirmed Resident #324 did not have a discharge care plan in place. MDS Nurse #26 confirmed the discharge planning begins upon admission and was usually completed. Interview on 02/15/22 at 3:01 P.M. with the Social Worker (SW) #01 confirmed Resident #324 did not have a discharge care plan in place. SW #01 confirmed the discharge planning should be completed upon admission. Review of the facility's policy titled Care Plans, Comprehensive Person- Centered, dated December 2016, revealed, it will contain information regarding discharge planning. It stated it should include the resident's stated preference and potential for future discharge, including his or her desire to return to the community and any referrals to local agencies or other entities to support such desire.

Based on medical record review, staff interview, and policy review, the facility failed to ensure advance directives were accurate. This affected two (#53 and #325) of 18 residents reviewed for advance directives. The facility census was 70. Findings include: 1. Review of the medical record for Resident #53 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/11/22, revealed Resident #53 had moderately impaired cognition. Review of the current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the plan of care, revised 06/09/21, revealed the resident had a code status of DNRCC. Review of the resident's paper health record revealed a do not resuscitate form that indicated the resident had a code status of DNRCC that was not signed by a physician. The form had the words 'Full Code' written on it as well. Interview on 02/17/22 at 9:05 A.M. with the Administrator confirmed the discrepancy regarding the code status for Resident #53. Review of the facility's policy titled Advance Directives, revised 12/2016, revealed the plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive. 2. Review of medical record revealed Resident #325 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician order, dated 02/09/22, revealed Resident #325 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the paper form for the advance directives for Resident #323 revealed the form was not completed by the attending physician with the residents' consent at the time of admission. Interview on 02/17/22 at 9:48 A.M. with Licensed Practical Nurse (LPN) #49 confirmed the form should be completed when the resident was admitted to the facility. Review of the facility's policy titled Advance Directives, dated 12/2016, revealed upon admission information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record.

Based on record review, observation, staff interview and review of the facility's policy, the facility failed to treat residents with respect and dignity. This affected two (Resident #29 and #34) of 18 residents reviewed for dignity and respect. The facility census was 70. Findings include: 1. Review of the medical record for Resident #29, revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment, dated 12/21/21, revealed Resident #29 was cognitively intact and required extensive or limited assistance with activities of daily livings (ADLs). Review of the activities interview for daily and activity preferences dated 05/27/20 revealed Resident #29 noted doing things in groups of people was very important to him. Observation of the group activities on 02/16/22 at 3:15 P.M. revealed 11 residents were in a group activity located in the West common area. During the observation, Activities Director (AD) #06 very loudly stated you don't talk to me that way to Resident #29. AD #06 was standing at the back/side of Resident #29 who was seated in a wheelchair. AD #06 abruptly grabbed the rear handles on Resident #29's wheelchair and pushed the resident from activities and down the hallway of the west front area. Observation immediately afterwards revealed AD #06 returned the common group activity without Resident #29. Observation at 3:29 P.M. revealed AD #06 exited the group activity and assisted Resident #29 back in the group activity area. Interview with AD #06 on 02/16/22 at 3:30 P.M. initially indicated she had removed Resident #29 because he was arguing with another resident. AD #06 did not state the other's resident name and indicated Resident #29 had told her (AD #05) To go to expletive so she removed him from the activity. AD #06 indicated Resident #29 had verbal behaviors. AD #06 verified the above observation and stated Resident #29 should not have been removed from the activities and she should not have said the comment to Resident #29. 2. Review of Resident #34's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment, dated 12/31/21, revealed Resident #34 had mild impaired cognition and required limited one-person assistance for toileting and dressing. The resident was always continent of bowel and bladder. Review of Resident #34's plan of care dated 02/16/22 revealed the plan was silent for goals or interventions related to assistance with activities of daily living. Observation on 02/17/22 at 8:37 A.M. revealed Resident #34 was propelling himself in his wheelchair in the hallway going toward the administrative offices. The resident was wearing light grey jogging pants and the pants appeared saturated from his knees to his waist. Observation and interview on 02/17/22 at 9:35 A.M. revealed Resident #34 was sitting in his wheelchair in the hallway by his room with signs of incontinence. The resident's light grey jogging pants remained saturated from below the knee up to urine stains on his pink, button-up shirt. Interview with the Resident #34 revealed he had wet himself this morning and was not able to change because he did not have any clothes. Continued observation from 9:35 A.M. until 10:13 A.M. of Resident #34's room revealed the resident's entry door was open and the resident's bathroom door was open and Resident #34 could be seen from the hallway through the bathroom door standing at the sink without any clothes on. There were no staff observed assisting the resident or checking on the resident. Observation on 02/17/22 at 10:13 A.M. revealed Resident #34 put on his bathroom call light. Observation revealed at 10:14 A.M., State tested Nursing Assistant (STNA) #50 entered the room. STNA #50 left the resident's room and returned to the room with gloves and bags. Interview on 02/17/22 at 10:25 A.M. with STNA #66 confirmed she was aware of Resident #34's incontinence earlier in the morning. STNA #66 stated she spoke to Resident #34 around 7:30 A.M. and encouraged him to return to his room and to change his clothes. STNA #66 stated Resident #34 told her he did not have any clothes to change into. STNA #66 confirmed she had not looked for any clothing for Resident #34. Interview and observation at 10:35 A.M. with Resident #34 revealed he had on clean dry clothing. The resident's wet and soiled clothing remained on the floor of the bathroom and on the floor in front of his bed. When the resident was asked if the STNA had assisted him, the resident replied, he cleaned himself up. The resident confirmed the STNA #50 found a pair of pants and a shirt in his drawer. Resident #34 stated he had an accident (bowel incontinence) and had to put on the call light to get help to clean up the mess from the incontinence. Observation of the resident's bathroom revealed the resident's wet clothing remained on the floor of the bathroom and on the floor in front of the resident's bed. Further observation revealed there was fecal matter/smears all over the toilet seat. Interview on 02/17/22 at 10:37 A.M. with STNA #50, revealed she was sitting at the nursing station and confirmed she had answered Resident #34's call light. STNA #50 stated the resident had bowel incontinence in the bathroom and needed help with cleaning up the mess. STNA #50 stated Resident #34 was independent and did not require her help to get cleaned up or get dressed. STNA #50 stated it was responsibility of the STNAs to clean the bathroom. STNA #50 was informed of the current condition of the resident's bathroom toilet seat. Interview on 01/17/22 at 1:21 P.M. with the Director of Nursing (DON) revealed she had observed Resident #34 at 7:20 A.M. and he was not incontinent at that time. The DON revealed Resident #34 was independent. Review of the resident's Minimum Data Set with the DON revealed Resident #34 required limited assistance with one-person assist for toileting and dressing. Review of Resident #34's plan of care with the DON confirmed the plan was silent for goals and interventions related to the resident's assistance with toileting, dressing or activities of daily living. The DON confirmed dignity and respect concerns were identified. Review of the facility's policy titled Quality of Life - Dignity, dated 09/01/18, revealed each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. This deficiency substantiates Complaint Numbers OH 244, OH 586, and OH 693.

Based on review of closed medical record, interviews with facility staff and the Coroner office investigator, review of Emergency Medical Service (EMS) run report, review of hospital records, review of Coroner's report, review of the facility investigation and review of information from the National Dysphagia Diet, the facility failed to provide adequate supervision for a cognitively impaired resident with [DIAGNOSES REDACTED]. [REDACTED]. This resulted in Immediate Jeopardy and serious life-threatening consequences when Resident #06 collapsed in the hallway, with food in his mouth, and subsequently choked and died . This affected one (#06) of four residents sampled for supervision with meals. The facility identified three current residents (#19, #20, and #21) as needing supervision or one-on-one assistance with all PO intake. The facility census was 77. On [DATE] at 1:22 P.M., the Administrator, and Director of Nursing (DON) were notified Immediate Jeopardy began on [DATE] at 10:47 A.M. when Resident #06, who had a [DIAGNOSES REDACTED]. [REDACTED]. On [DATE] at 10:49 A.M., staff did a two finger sweep of his mouth and removed some food (possibly bread). Staff applied oxygen via mask and EMS was called. At 10:55 A.M., EMS arrived and provided life saving measures. At 11:11 A.M., EMS transferred the resident to a local hospital, and at 11:39 A.M. Resident #06 was pronounced dead by the emergency department at the hospital. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: · On [DATE] at approximately 4:45 P.M., Speech Language Pathologist (SLP) #172 assessed and evaluated three (#19, #20, and #21) current residents who were identified as needing supervision or one-on-one assistance with all PO intake. Resident #19 required close supervision at all times and one-on-one feed as needed. Resident #20 required occasional supervision/cues and meal set up by nursing staff and the resident was discharged from speech therapy services and transferred back into nursing care. Resident #21 required occasional supervision throughout meals. · On [DATE] at 5:29 P.M., the Administrator sent a voice friend notification (system wide notification) to all staff to ensure staff were aware of any physician orders [REDACTED]. Staff members were also educated by the Administrator on the different levels of diets. The education consisted of reviewing information regarding pureed diets, mechanical soft diets related to textures, if resident is one-on-one supervision while eating, a staff member must have eyes on the resident at all times, and a resident on one-on-one should have an order to provide oral care after eating. Those residents should have oral care completed following the consumption of their meal. · Auditing will be completed twice weekly for one month and weekly for two months by the DON and/or designee. Initial audit was completed on [DATE] during the breakfast meal by the DON with no negative findings reported. · On [DATE], a Quality Assurance Performance Improvement (QAPI) Plan was implemented regarding following orders of residents who require supervision with meals. Audits will be completed twice weekly for one month and weekly for two months by the DON and/or designee. This plan was discussed with the Medical Director on [DATE]. · On [DATE] from 4:20 P.M. to 4:25 P.M., interviews conducted with State tested Nursing Assistant (STNA) #127, Agency Licensed Practical Nurse (LPN) #175 and Cook #149 revealed they were knowledgeable about the different types of diets and which residents required supervision with meals. Although the Immediate Jeopardy was removed on [DATE], the deficiency remained at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the closed medical record revealed Resident #06 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #06 was discharged to the hospital on [DATE]. Review of Speech Therapy orders dated [DATE] revealed SLP #100 completed an evaluation and developed a plan of care (POC). Resident #06 demonstrated moderate to severe cognitive impairment impacting safety awareness. The SLP recommended frequent oral care, puree diet, nectar thick liquids, and limited mechanical soft pleasure feeds as tolerated with one-on-one close supervision and assistance during all PO intake utilizing safe swallowing precautions and compensatory strategies including [MEDICAL CONDITION] monitoring. The SLP recommended dysphagia and cognitive therapy five times a week for supervision and assistance with all PO intake. Alternate bites/sips. Encourage small bites/sips. Upright and alert during all PO intake. Remain upright for 30 minutes after PO intake. Encourage the resident to eat slowly and provide oral care after PO intake with meals. Review of the POC dated [DATE] revealed Resident #06 had nutrition/hydration status at moderate risk related to [DIAGNOSES REDACTED]. Resident #06 was admitted status [REDACTED]. Resident #06 had a high physical activity level and had difficulty chewing/swallowing. He required assistance and supervision with all PO intake. Interventions included to provide diet as ordered (pureed, nectar thick liquids), mechanical soft pleasure foods, one-on-one close supervision, frequent oral care, crush pills in puree/pudding as tolerated, upright positioning, remain upright for 30 minutes after PO intake, small bites/sips, alternating between solids and liquids and slow rate. Review of physician's orders [REDACTED].#06 had regular pureed texture diet with nectar thick consistency, limited mechanical soft solids for pleasure, with one-on-one close supervision, frequent oral care, crush pills in puree/pudding as tolerated, upright positioning, remain upright for 30 minutes after PO intake, small bites/sips, alternating between solids and liquids, and slow rate. Review of Speech Therapy treatment encounter notes dated [DATE] revealed upon entry to resident room, SLP #100 found Resident #06 was self-feeding without staff members present. SLP #100 spoke with the nursing aide staff to educate on the best strategies for facilitating a meal. The SLP also stressed the importance of close supervision during all PO intake due to significant aspiration risk. The SLP referred to signs in Resident #06's room indicating the need for supervision and oral care. Further review of the notes revealed the SLP visited Resident #06 between mealtimes and he appeared to need oral care. The SLP completed oral care with a Toothette. Per therapy staff, Resident #06 had not been receiving one-on-one supervision for all meals. The SLP again re-educated nursing staff to the importance of supervision during all PO intake as the resident was a choking risk, and the importance of oral care referring to the signs that were posted in his room. Review of a Speech Therapy encounter note dated [DATE] revealed upon SLP #100's approach, Resident #06 was observed to be unattended in his room with a tray in front of him and the resident was self-feeding. SLP #100 re-educated the unnamed attending nurse regarding the importance of safe swallowing precautions including close supervision. Review of a Speech Therapy encounter note dated [DATE] revealed SLP #100 visited between mealtimes and Resident #06 appeared to require oral care. SLP provided oral care with a Toothette. The SLP again educated staff to the importance of supervision with all PO intake as resident was an aspiration pneumonia risk and educated staff to the importance of frequent oral care referring to the signs that were posted in the resident's room. Review of a nursing note dated [DATE] at 6:03 P.M., LPN #134 documented Resident #06 with no negative behaviors noted this shift. Resident #06 was noted pacing the halls of the facility and attempting to run. The nurse obtained several peanut butter and jelly sandwiches and Resident #06 consumed several of the sandwiches which calmed him for a short time frame. Resident #06 was currently sitting in a chair by the nurse's station. Review of a nursing note dated [DATE] at 1:08 P.M., agency LPN #171 documented Resident #06 was observed stumbling in the hallway. An unidentified STNA approached the resident to stabilize ambulation. This attempt was unsuccessful, and the resident lost his balance, stumbled forward and hit his head on the arm of a chair. Resident #06 attempted to get up and LPN #171 insisted the resident stay put. The nurse approached Resident #06 to evaluate the fall and to assess his vitals, Resident #06 was observed choking. Another nurse (LPN #167) approached to assist, Resident #06 was placed in recovery position and food was removed from his mouth. LPN #167 was unable to remove all the food and observed the resident turning blue. Resident #06 became unresponsive. At this time, emergency nine-one-one (911) was called and oxygen was placed with a 100 percent (%) non-rebreather mask at 15 liters per minute. EMS arrived and took over care with compressions, an intravenous (IV) was started in the right antecubital, and the resident was placed on a heart monitor with suction. EMS requested residents code status. A Do Not Resuscitate (DNR) form was present in the chart but was not signed by the Power of Attorney (POA) or by Resident #06. EMS continued to work on the resident when the decision was made to transfer the resident to a local hospital. Resident #06's wife and doctor were notified of the incident. Review of the EMS run report dated [DATE] revealed the squad arrived at the facility on [DATE] at 11:01 A.M. Upon arrival Resident #06 was found lying in the supine position. Resident #06 presented with [MEDICAL CONDITION]. Respirations were absent with a rate of zero. Lung sounds were absent bilaterally. Skin color was normal-appearance normal/dry. Initial impression was [MEDICAL CONDITION]. Staff had placed a non-rebreather mask with oxygen on Resident #06 and stated that he had a pulse. EMS observed copious amounts of food in the resident's mouth. EMS began to suction, Resident #06 was not alert or responsive, and had no signs of injury/bleeding. EMS observed apparent agonal respirations, pulse check was negative, four lead showed pulseless electrical activity (PEA). EMS initiated manual cardiopulmonary resuscitation (CPR) until Lucas Device (mechanical CPR) was attached to Resident #06 at 30 compressions to two breaths rate. Bag valve mask (BVM) ventilations with high flow oxygen initiated. IV access and blood gasses obtained as listed. Automated External Defibrillation (AED) pads placed on Resident #06. Resident given bolus of normal saline per IV with first dose of [MEDICATION NAME]. Between ventilations, EMS attempted to clear Resident #06's airway with suction and forceps. [MEDICATION NAME] administered after three minutes. I-gel 4 (mechanical airway) was placed in resident with BVM ventilations. Resident #06 placed on stretcher and taken to cot, and then to medic unit. Notification made to local hospital during transport. Capnography started without reading, I-gel removed and BVM ventilations continued. Third dose of [MEDICATION NAME] administered. Resident #06 was taken to room [ROOM NUMBER] where care was transferred to an Registered Nurse (RN). The RN's signature was obtained in place of resident due to [MEDICAL CONDITION]. Review of the hospital Emergency Department (ED) Course and Medical Decision Making form dated [DATE] revealed Resident #06 presented pulseless apneic after respiratory arrest (eating). Intubation as per above procedure note identified a large food bolus obstructing his airway. This bolus was removed and resident subsequently intubated. However, at no point did Resident #06 regain spontaneous pulse or pressure. This despite continued CPR and Advanced Cardiac Life Support (ACLS) protocol. Resident #06 was down for over 30 minutes with no return of spontaneous pulse. Further resuscitative efforts were futile, and resident was pronounced deceased at 11:39 A.M. The nurse contacted the resident's family physician and spoke to a nurse practitioner who thought the Medical Director would be comfortable signing the death certificate. Review of the procedures performed in the ED dated [DATE] revealed Resident #06 was placed in the appropriate position. Cricoid pressure (technique used in endotracheal intubation to try to reduce the risk of regurgitation) was not required. Intubation was performed by direct laryngoscopy using a glide scope. Initial visualization identified a large food bolus obstructing the airway. This was manually removed. Subsequently, a glide scope was used up to pass a 7.5 cuffed endotracheal tube. The cuff was then inflated, and the tube was secured appropriately at 22 centimeters to the dental ridge. Initial confirmation of placement included color changes on the carbon [MEDICATION NAME] (CO2) monitor. Review of the hospital nursing note dated [DATE] at 1:36 P.M. revealed nursing requested that security stay with Resident #06 until the body was released to the morgue as Resident #06 was a Coroner's case. Security to come and relieve the RN at bedside. Review of the local County Coroner's report dated [DATE] revealed the cause of death for Resident #06 was choking, aspiration food bolus, impaired gag reflex, and [MEDICAL CONDITION]'s disease with dysphagia. Review of the facility's incident investigation notes dated [DATE] revealed on [DATE] at 10:47 A.M., Resident #06 exited his room and walked towards the nursing station area where he frequently sat, ate, and talked with staff. As he neared the nurse, he lost his balance and fell forward with his hands hitting the leg of a chair and his forehead hitting the arm of the chair, which moved away from him. He crawled several feet across the floor before stopping and laying prone. At 10:48 A.M., Resident #06 was lying prone on the floor with staff in attendance, the resident was moving spontaneously and visibly breathing. At 10:49 A.M., staff turned Resident #06 to his back and did a two finger sweep of his mouth and removed some food (possibly bread) on the second sweep. The nurse confirmed the resident was breathing with use of accessory muscles and he never exhibited signs of choking or the inability to breathe. At 10:50 A.M., Resident #06 was turned to his left side. At 10:51 A.M., the nurse obtained vital signs, the residents' eyes were open, and oxygen was applied via mask. At 10:53 A.M., life squad arrived and turned the resident supine obtaining a carotid pulse. At 10:54 A.M., the squad was checking pupils. At 10:55 A.M. squad was using suction, at 10:56 A.M. squad was checking the residents blood sugar. Resident #06 was still moving his head/body spontaneously. At 10:57 A.M. gasping respirations were visible. At 10:58 A.M. squad began manual compressions/switching to a machine and ambu bag breathing. At 10:59 A.M. gel pads applied and IV started. At 11:01 A.M. squad began to attempt intubation alternating attempts to intubate with ambu bag breathing. At 11:08 A.M., endotracheal (ET) tube in, and squad was using ambu bag hooked to it. At 11:10 A.M. Resident #06 was placed on a stretcher, and at 11:11 A.M. the squad exited the facility. An interview on [DATE] at 12:30 P.M. with the DON reported that staff had given Resident #06 peanut butter and jelly sandwiches when he was upset as this calmed him down. The DON reported the wife said it was okay to give Resident #06 peanut butter and jelly sandwiches to calm him down. (There was no evidence of this in the resident's medical record and no POC for this) A telephone interview on [DATE] at 1:45 P.M. with Coroner's Office Death Investigator #169 confirmed Resident #06's cause of death was choking. An interview on [DATE] at 2:52 P.M. with SLP #168 reported that peanut butter and jelly sandwiches were not appropriate to be given to a resident on a pureed or mechanical soft diet. SLP #168 indicated anyone with moderate to severe dysphagia should be supervised and monitored when eating. Interview on [DATE] at 2:54 P.M. with LPN #134 reported that peanut butter and jelly sandwiches and other snacks were passed out by staff after 7:00 P.M. LPN #134 also reported that any leftovers were put up where residents could not get to them. The only way residents would be able to get snacks were if staff gave them to the residents. An interview on [DATE] at 3:00 P.M. with Dietary Manager (DM) #109 reported that snack carts were prepared before dinner but delivered after 7:00 P.M. Any leftover snacks were returned to the kitchen. DM #109 reported that she made pureed snacks that were appropriate for residents on a pureed diet. A telephone interview on [DATE] at 3:24 P.M. with SLP #100 reported she knew Resident #06 very well and she had told staff, that the resident should never have peanut butter and jelly sandwiches. She reported there were times when she came in between meals and that oral care had not been completed on Resident #06. SLP #100 also stated that she had previously shown up for speech sessions with Resident #06 and his food tray had been given to him and he was eating with no supervision. SLP #100 also reported that she asked her boss for a different assignment because she felt the facility was using unsafe practices. An interview on [DATE] at 3:43 P.M. with LPN #167 reported that on [DATE] she was on break and was called back in because Resident #06 had fallen. She went to assist the other nurse with the assessment and noticed food in Resident #06's mouth so she did a two finger sweep after he was in the correct position. She stated she removed a small piece of food from his mouth and she believed it was bread. She stated he was still breathing, and they placed oxygen on the resident with a non-rebreather mask. She said the squad showed up and took over the resident's care. Review of Level 1 Dysphagia Pureed diets adapted from the National Dysphagia Diet: Standardization for Optimal Care, American Dietetic Association revealed Dysphagia pureed consists of foods that are pureed, homogenous, and cohesive. Foods should be pudding-like. Foods that require bolus formation, controlled manipulation and chewing are not allowed. Things to avoid are peanut butter, and non-pureed bread. This is an incidental finding discovered during the investigation of Complaint Number OH 555.

Based on record review, resident and staff interview, observation, and policy review, the facility failed to conduct an assessment to identify fall risk factors, implement interventions to prevent falls and failed to conduct a thorough fall investigation and a post-fall risk assessment for Resident #279. This resulted in actual harm for Resident #279 when the resident fell from her bed resulting in a laceration to her nose, which required emergent care and sutures. This affected one (#279) of one resident reviewed for falls. The facility also failed to ensure the environment was free of hazards and adequate supervision was provided for two residents. This affected two (Resident #4 and #33) of two residents reviewed for smoking. This had the potential to affect 25 residents the facility identified as residents who smoked. The facility census was 81. Findings include: 1. Review of Resident #279's record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment, dated 03/07/19, revealed the resident was cognitively impaired and was totally dependent on two persons assistance for bed mobility. Review of the nurse's progress note, dated 03/01/19, revealed Resident #279 was found on the floor in her room next to her bed on 03/01/19 at 7:58 P.M. The resident was noted to have a laceration to her nose and there was blood on the resident's face and on the floor and the resident was sent to the hospital emergency room . Another nurse's progress note, dated 03/02/19, revealed Resident #279 returned to the facility from the hospital at 1:40 A.M. with sutures to a laceration on her nose. Review of the hospital record for Resident #279, dated 03/01/19, revealed the resident was evaluated for a fall that had occurred at the facility, the resident received sutures to her nose related to the fall and was sent back to the facility with discharge instructions for the resident to have her sutures removed in five to seven days. Review of physician orders, dated 03/02/19, revealed an order to clean the laceration to resident's nose with mild soap and water one time a day after the first two days and then to apply antibiotic ointment after each cleaning and leave open to air until the area was healed. There was also an order [REDACTED]. Further review of the resident's record revealed it did not include a fall risk assessment upon admission or post-fall on 03/01/19. Review of the resident's fall care plan, dated 03/07/19, revealed the resident had an actual fall with injury on 03/01/19, a laceration to her nose with sutures. Interventions included providing the resident with a wide bed with a bariatric mattress for turning and positioning when in in bed. Review of the facility fall investigation for Resident #279 revealed the facility determined the root cause of the resident's fall on 03/01/19 to be that there did not seem to be enough room in bed for the resident to turn and that there was a safety risk of turning too far beyond edge of bed. Observation of Resident #279 on 03/12/19 at 10:13 A.M. revealed the resident was resting in a wide bed with a bariatric mattress. Resident had sutures to the top of her nose. Interview with Licensed Practical Nurse (LPN) #129 on 03/12/19 at 4:17 P.M. confirmed the nurse had found resident on the floor next to her bed with a laceration to her nose on 03/01/19 at approximately 7:58 P.M. The LPN further confirmed she assessed the resident and sent her to the hospital for evaluation. The LPN confirmed Resident #279 returned to the facility on [DATE] at approximately 1:40 A.M. with sutures to her nose. Interview with Director of Nursing (DON) on 03/12/19 at 11:47 A.M. confirmed the facility had not conducted a fall risk assessment to identify risk factors to prevent falls upon admission for Resident #279. The DON further confirmed the facility did not conduct a fall risk assessment following Resident #279's fall on 03/01/19. Further interview with the DON on 03/12/19 at 12:43 P.M. confirmed the facility's post fall investigation for Resident #279 following resident's fall on 03/01/19 did not include interviews with staff who had cared for resident prior to her being found on the floor on 03/01/19 at 7:58 P.M. Review of the facility's policy titled Assessing Falls and Their Causes, dated (MONTH) 2019, revealed residents must be assessed upon admission and regularly afterward for potential risk of falls and that all falls should be thoroughly investigated. 2. Review of Resident #33's record revealed he was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/20/19, revealed the resident had severe cognitive impairment and he required supervision with dressing and personal hygiene and was independent with eating, toileting, bed mobility and transfers. A review of the care plan for Resident #33 revealed he had the potential for injury related to smoking and the facility was to secure his cigarettes and lighter at the nurse's station. Review of the smoking assessment, dated 11/14/18, documented the need for supervision during smoking, the use of a smoking apron and the need for the facility to store his lighter and cigarettes. During an interview with the Director of Nursing on 03/06/19 at 2:18 P.M., she verified the smoking supplies for all residents per policy should be kept at the nursing station. During an interview with the Administrator on 03/06/19 at 2:20 P.M., she verified the smoking supplies for all residents per policy should be kept at the nursing station. During an observation and interview with Resident #33 on 03/06/19 at 3:12 P.M., he stated he kept his smoking supplies on him and smoked when he wanted without staff supervision. He produced a pack of cigarettes and lighter from his coat pocket. He was wearing his coat at the time of the interview. During an observation and interview with Corporate Registered Nurse (RN) #64 on 03/06/19 at 3:55 P.M., revealed an observation of Resident #33's room and verified Resident #33 had cigarettes and lighter in his possession. RN #64 further verified Resident #33's had severe cognitive impairments, his care plan documented he needed to keep his supplies at the nursing station and the resident's smoking assessment documented he required supervision and a smoking apron to smoke. 3. Review of Resident #4's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the admission MDS assessment, dated 08/16/18, revealed the resident had no cognitive impairment and was independent to supervision for most activities of daily living (ADLs). Review of the resident's smoking assessment, dated 08/16/18, revealed the resident could smoke independently. Observation and interview on 03/04/19 at 10:45 A.M. with Resident #4 stated she keeps her cigarettes and lighters with her because when she leaves them at the nurses' station desk they disappear. Resident #4 pulled a red pack of cigarettes from her coat pocket with a lighter. Resident #4 stated she smokes when she wants and that her sister buys cigarettes and brings them in to her. Interview on 03/06/19 at 2:10 P.M. with the Director of Nursing (DON) revealed the residents keeping smoking materials at bedside was an ongoing challenge. The DON verified that by policy, residents were not to keep smoking materials at bedside, and must keep them at the nurse's station. The DON denied anyone reporting missing cigarettes when kept at nurse's station. Interview on 03/06/19 at 2:15 P.M. with the Administrator verified the policy states smoking materials were to be kept at the nurse's station and not at the bedside and denied that anyone reported missing cigarettes. Interview on 03/06/19 at 2:20 P.M. with Social Worker (SW) #109 verified the policy and stated the facility had just received locking bags to keep smoking materials in for each resident. SW #109 stated she would have the master key for each bag and the independent smokers would have their key. Review of the facility's policy titled Supervised and Independent Resident Smoking Policy, dated 02/01/19, revealed the facility shall establish and maintain safe resident smoking practices. It stated no resident shall hold on their person or in the room. This included cigarettes and lighters.

Based on record review and staff interview the facility failed to provide a functioning motion alarm and care planned interventions to prevent falls and the potential for injury. This affected two residents (#28, #147) of three residents reviewed for accidents and resulted in harm for Resident #28 when she fell and fractured her hip and femur. There were four residents identified for accident. Findings Include: 1. Review of the medical record revealed Resident #28 was admitted to the facility on [DATE]. She had a [DIAGNOSES REDACTED]. Resident #28's minimum data set (MDS) assessment dated [DATE] revealed Resident #28 had short and long term memory problems and was moderately impaired in decision making skills. The MDS stated Resident #28 required extensive assist of one staff member for transfer and ambulated with extensive assistance of one person. The MDS stated Resident #28 had no pain and had a history of [REDACTED]. Review of the medical record also revealed Resident #28 was transported from the facility to the hospital on [DATE] after suffering a fall. The nurse's noted dated 06/05/10 at 3:20 A.M. revealed Resident #28 was found on the floor in the unity room, which was located across the hall from the resident's room. According to documentation Resident #28 got out of bed and ambulated across the hall and suffered a fall. Documentation revealed the resident had an alarming mat on the floor next to her bed to alert staff if she attempted to get up. Nurse's notes stated the alarm failed to sound at that time. Resident #28 was transported to the hospital and was diagnosed with [REDACTED]. Resident #28 returned to the facility on [DATE]. A review of the MDS dated [DATE] stated Resident #28 had not ambulated during the assessment period and had moderate pain daily. The MDS further stated Resident #28 had a hip fracture in the last 180 days. On 09/09/10 interview of nurse #252 revealed she was the nurse on duty the night Resident #28 fell . Nurse #252 said the mat was in place and was plugged in but did not alarm. She stated the nurse aides were in Resident #28's room ten minutes prior to take her to the bathroom and the alarm had worked at that time. Nurse #252 stated the alarm used was the "gray box" and stated the facility had a problem with that type of alarm in the past not functioning. Nurse #252 stated some of the alarms had not sounded when residents had got out of bed. The incident report dated 06/05/10 identified the intervention of switching alarm boxes, to prevent further falls. Interview with the Assisted Director of Nurses (ADON) at 10:14 A.M. it was stated the facility had two types of alarm boxes a gray one and a newer blue one. The ADON stated there were ten new alarms in the facility at the time of survey and the old gray boxes were still used for residents. The facility continued to use the old fall alarm system after knowing the old system did not work consistently which had placed Resident #28 at risk for fall and injury. Interview with staff member #251 on 09/09/10 at 2:29 P.M. revealed the old gray boxes were being phased out. The facility had identified a problem with the gray boxes prior to Resident #28's admission. Staff #251 stated the telephone type cord on the gray boxes which plugged into the back of the box could be pulled out, the plastic clips that holds the cord in break, also the battery box covers get lost. The gray box he showed the surveyor did not have a cover over the battery housing and was covered with masking tape. Staff member #251 stated the newer blue box had a protective cap over the telephone type cord, which protected it and a screw driver was needed to remove the back of the box which housed the battery. Staff member #251 stated staff was informed the gray boxes were not good and should be replaced but the previous administrator did not want all the gray boxes replaced, due to the cost, and she asked the staff member to phase them out. On 9/09/10 at 2:40 P.M. the surveyor observed Resident #28 in therapy. Physical therapist #253 stated she was evaluating the resident at the request of the family. Resident #28 was no longer able to stand and walk. The resident was observed seated in a tilt back wheel chair with side padded foot rests. 2. Record review revealed Resident #147 was admitted to the facility on [DATE]. Per the accumulative [DIAGNOSES REDACTED]. Review of fall risk assessment dated [DATE] indicated a score of twenty, a score of above ten represents high risk. Review of interim care plan for risk for falls dated 09/03/10 indicated to maintain bed in lowest position as one of the interventions. During three separate observations made on 09/08/10 at 6:00 P.M., 09/09/10 at 8:15 A.M. and on 09/09/10 at 3:10 P.M. Resident #147 was lying in bed with both side rails up and her bed was not in the lowest position. During an interview on 09/09/10 at 3:20 P.M. with state tested nursing assistant (STNA) #17 she verified that Resident #147's bed was in the high position. She further stated she had failed to lower the bed after providing care to Resident #147.