Every finding on record at Morris Nursing Home

Based on medical record review, observation, staff interviews, and facility Enhanced Barrier Precautions (EBP) signage, the facility failed to initiate enhanced barrier precautions as required. This affected one resident (#22) of two residents reviewed for EBP. The facility also failed to ensure the separation of clean and dirty linen. This had the potential to affect all residents in the facility. The facility census was 14.Findings include:1.Review of the medical record revealed Resident #22 was admitted to the facility on [DATE] with diagnoses of orthopedic aftercare for right below the knee amputation, indwelling urinary catheter for neurogenic bladder, hypertension, severe sepsis, and alcohol dependence. Review of the Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #22 had intact cognition and was always continent of bowel and had an indwelling catheter in place for the bladder. Review of physician orders for Resident #22 revealed an order dated 12/17/25 for an indwelling urinary catheter due to neurogenic bladder. The catheter was to be changed monthly and as needed and catheter care was to be performed every shift. There was no physician order for EBP. Review of the plan of care for Resident #22 dated 12/17/25 revealed nothing about an indwelling foley catheter or EBP. Observation on 12/22/25 at 9:35 A.M., during initial tour of the facility, revealed Certified Nursing Assistant (CNA) #55 and CNA #56 had just completed direct care to Resident #22 and used only gloves as personal protective equipment. It was also revealed Resident #22 had no signage indicating EBP was in place and there was no personal protective equipment (PPE) available for staff use. Interviews on 12/22/25 at 9:40 A.M. with CNA #55 and CNA #56 revealed no knowledge Resident #22 was to be on EBP. Interview on 12/22/25 at 9:44 A.M. with Registered Nurse (RN) #16 verified Resident #22 had an indwelling urinary catheter and had not been placed on EBP since admission on [DATE]. RN #16 also verified there was no physician order for EBP, no EBP signage in place, and no PPE available for staff use. Review of the facility EBP signage revealed everyone must clean their hands, including before entering and when leaving the room, and that providers and staff must also wear gloves and a gown for the following high-contact resident care activities designated as dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, and device care or use that includes central lines, urinary catheter, feeding tube, tracheostomy, and wound care of any skin opening requiring a dressing. 2.Observation on 12/22/25 at 10:30 A.M. of the laundry area revealed a room approximately twelve (12) feet by twelve (12) feet with only one entrance/exit. Located inside the designated laundry area were two residential-style hot water tanks to the right of the door. To the left was the clean linen cart and a table to fold clean linens. Past this area on the right was a plastic bin (with no cover) used to transport dirty linen, which had to be brought into the room past the clean linen cart and the folding table. The commercial washer and dryer sat on the far wall of the room. The door to the washing machine was located almost directly opposite the door to the dryer with a separation of approximately two (2) feet. A make-shift line for hanging clean personal clothing on hangers was by the dryer and the clean clothing from this line would have to pass the dirty linen bin. There was no barrier separating the dirty linen from the clean linen. There was also no PPE available for staff to utilize when handling dirty linen.Interview on 12/24/25 at 9:30 A.M. with CNA #38 and CNA #40 revealed CNAs are responsible for washing and drying facility linen and resident personal linen. CNA #38 and CNA #40 verified there was no barrier in the laundry room to separate dirty linen from clean linen and the clean linen was stored in the laundry room. They also stated there was no PPE was available when handling dirty linen. 12/24/2025 11:04 AM Interview with the Administrator and Interim DON verified there was no barrier in the laundry room that separated the dirty and clean linen. The DON revealed the barrier that separated the dirty linen from the clean linen was the plastic laundry bin used for dirty linen. Review of the facility policy titled Proper Handling and Storage of Linens, undated, revealed all linen is handled, stored, transported, and processed in a manner that will prevent contamination and maintain a clean environment for residents, staff, and visitors. Clean linens are stored in an area separate from the storage of any soiled linens.

Based on record review, interview, and policy review, the facility failed to ensure resident care conferences occur quarterly with the Interdisciplinary Team and included the resident and/or resident representative. This affected seven residents (#1, #3, #4, #10, #12, #13, #16) out of seven residents reviewed for care conferences. The facility census was 14. Findings include: 1.Record review for Resident #16 revealed this resident was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, dementia, and benign prostatic hyperplasia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed this resident had severe cognitive impairment, required assistance with activities of daily living and was always incontinent of bowel and bladder. Record review for Resident #16 revealed the only care conference held in 2025 was in October. 2. Record review for Resident #3 revealed this resident was admitted to the facility on [DATE] with the following diagnoses: Bipolar Disorder, Chronic Respiratory Failure with Hypoxia, and Type 2 Diabetes Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed this resident had moderate cognitive impairment, required supervision and assistance with activities of daily living, and was always incontinent of bowel and bladder. Record review for Resident #3 revealed the only care conference held in 2025 was in October. Review of the facility policy titled Care Plans, Comprehensive Person-Centered, dated on March 2022, revealed the resident has the right to participate in their treatment, and the facility provides advanced notice of care planning. 3. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE]. Diagnoses included cerebral ischemia, major depressive disorder, unspecified psychosis, hypertension, dementia, and auditory hallucinations. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #1 had severe cognitively impaired. Resident #1 required supervision with eating, was dependent with toileting, dependent with bathing, and dependent with personal hygiene. Review of Resident #1 care conferences held revealed there was no evidence of a care conference sign in sheet to demonstrate a meeting with the Interdisciplinary Team (IDT) or with the resident and/or their representative. Interview on 12/22/25 at 3:45 P.M with the Administrator confirmed care conference sign in sheets were not completed for Residents #1. 4. Review of the medical record revealed Resident #13 was admitted on [DATE]. Diagnoses included dysphagia oral phase, Alzheimer's disease with late onset, dementia, depression, hypertension, and unspecified atrial flutter. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #13 had severe cognitive impairment, was dependent with self-care, supervision for eating, dependent for toileting, dependent for bathing, and dependent for upper and lower body dressing. Review of Resident #13 care conferences held revealed there was no evidence of a care conference sign in sheet to demonstrate a meeting with the Interdisciplinary Team (IDT) or with the resident and/or their representative. Interview on 12/22/25 at 3:45 P.M with the Administrator confirmed care conference sign in sheets were not completed for Residents #13. 5.Resident #10 was admitted to the facility on [DATE]. Diagnoses included rhabdomyolysis, schizoaffective disorder, and chronic kidney disease. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition. Review of Resident #10's medical record revealed Multidisciplinary Care Conferences dated 3/18/2025, 4/6/2025, 8/6/2025, and 11/12/2025. However, there was no evidence of a care conference sign in sheet to demonstrate a meeting with the Interdisciplinary Team (IDT) or with the resident and/or their representative. 6.Resident #12 was admitted to the facility on [DATE]. Diagnoses included type II diabetes mellitus, cerebral Infarction, erythema multiforme, morbid obesity, and hemiplegia and hemiparesis. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition. Review of Resident #12's medical record revealed Multidisciplinary Care Conferences dated 2/11/2025, 4/14/2025, 8/4/2025, and 11/14/2025. However, there was no evidence of a care conference sign in sheet to demonstrate a meeting with the Interdisciplinary Team (IDT) or with the resident and/or their representative. 7. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses of syncope and collapse, history of transient ischemic attack (TIA), diabetes mellitus type II, protein-calorie malnutrition and hypertension. Review of the Minimum Data Set (MDS) Annual assessment dated [DATE] revealed Resident #4 had severe cognitive impairment, was always incontinent of bowel and frequently incontinent of bladder. The resident was dependent for eating, oral and personal hygiene, toileting, bathing, dressing, bed mobility and transfer. Review of the medical record for Resident #4 revealed no documentation Resident #4 or Resident #4's representative participated in the development of the plan of care or that the facility conducted quarterly care conferences for the first quarter of 2025, second quarter of 2025, or third quarter of 2025. Interview on 12/22/25 at 3:45 P.M with the Administrator confirmed care conference sign in sheets were not completed for Resident #1, Resident #3, Resident #4, Resident #10 Resident #12, Resident #l3, and Resident #16.

Based on record review and staff interviews, the facility failed to ensure a performance review for every nurse aide was conducted at least once every twelve months. This affected four (Certified Nurse Aide (CNA) #33, CNA #38, CNA #25, and CNA #40) out of six nurse aides reviewed. The facility census was 14.Findings Include:Record Review of employee files on 12/23/25 at 3:00 P.M revealed CNA #33, CNA #38, CNA #25, and CNA #40 did not have an annual performance evaluation.Interview on 12/24/25 at 8:30 A.M with the Administrator confirmed CNA #33, CNA #38, CNA #25, and CNA #40 did not have an annual performance evaluation.

Based on record review and staff interviews, the facility failed to ensure Nurse aides had at least 12 hours of annual continuing education for four (Certified Nurse Aide (CNA) #33, CNA #38, CNA #25, and CNA #40) out of six nurse aides reviewed. The facility census was 14.Findings Include: Record Review on 12/23/25 at 3:05 P.M revealed CNA #37, CNA #33, CNA #25, CNA #40, and CNA #23 did not have 12 hours of annual continuing education.Interview on 12/24/25 at 8:35 A.M with the Administrator confirmed CNA #37, CNA #33, CNA #25, CNA #40, and CNA #23 did not have 12 hours of annual continuing education.

Based on medical record review, observation, staff interview, and review facility policy, the facility failed to promote dignity while dining. This affected two (#1 and #13) of two residents reviewed for dignity. The facility census was 14. Findings include:Review of the medical record revealed Resident #1 was admitted to the facility on [DATE]. Diagnoses included cerebral ischemia, major depressive disorder, unspecified psychosis, dementia, and auditory hallucinations. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #1 was severe cognitively impaired and required supervision with eating. Review of the medical record revealed Resident #13 was admitted on [DATE]. Diagnoses included dysphagia oral phase, Alzheimer's disease with late onset, dementia, and depression. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #13 had severe cognitive impairment and required supervision for eating. Observations on 12/23/2025 at 12:27 P.M. revealed Resident #1 and Resident #13 in the dining area getting ready to eat lunch. Certified Nursing Assistant (CNA) #55 and CNA #40 were observed applying clothing protectors to Resident #1 and Resident #13. These clothing protectors were designed to hook behind the residents' necks. Interview on 12/23/25 at 12:30 P.M. with CNA #40 confirmed the clothing protectors are used to prevent the food from getting on residents' clothes. CNA #40 stated it is easier to get the food off of the clothing protector than the residents' clothes after they get done eating. Review of the policy titled Community Information and Policies, including Resident Rights revealed the residents rights were to be treated at all times with courtesy, respect, and full recognition of dignity and individuality.

Based on medical record review, staff interview, review of Notice of Medicare Non-Coverage (NOMNC) letters, and policy review, the facility failed to ensure proper notice was provided to the resident and/or resident representative when the facility was discontinuing Medicare services. This affected one resident (#23) of three residents reviewed for Beneficiary Notification. The facility census was 14.Findings include: Review of the medical record revealed Resident #23 was admitted to the facility on [DATE] with diagnoses of cerebral infarction with left (non-dominant) side hemiplegia and hemiparesis, acute and chronic respiratory failure with hypoxia, aphasia, dysphagia, diabetes mellitus type II, hypertension and atrial fibrillation. Review of the Minimum Data Set (MDS) Significant Change of Status assessment dated [DATE] revealed Resident #23 had severe cognitive impairment, required supervision for eating, maximal assistance for oral and personal hygiene, toileting, bathing and dressing, and was dependent for bed mobility and transfers. Review of the facility generated NOMNC for Resident #23, which downloaded to the electronic medical record in the miscellaneous tab, revealed the last covered day of Medicare Part A services was dated as 06/18/25 and was signed and dated by Resident #23's representative on 06/18/25. The NOMNC for Resident #23 the facility provided to the surveyor had a visibly altered date of having been signed by Resident #23's representative on 06/16/25. Interview on 12/23/25 at 1:15 P.M. with the Interim Director of Nursing and Business Office Manger #57 verified Resident #23's NONMC was signed by Resident #23's representative on 06/18/25. The Interim Director of Nursing and Business Office Manager #47 verified the altered date on the copy of Resident #23's NOMNC provided by the facility. Review of the facility policy titled Medicare Advance Beneficiary and Medicare Non-Coverage Notices, revised September 2022, revealed residents are informed in advance when changes will occur to their bills. If the resident's Medicare covered Part A stay or when all of Part B therapies are ending, a Notice of Medicare Non-Coverage (NOMNC) is issued to the resident at least two calendar days before benefits end.

Based on medical record review, review of facility self-reported incident and investigation, staff interview and facility policy review, the facility failed to thoroughly investigate an alleged violation. This affected one (#3) of one resident reviewed for abuse. The facility census was 14. Findings include:Record review for Resident #3 revealed an admission to the facility on [DATE]. Diagnoses included bipolar disorder, chronic respiratory failure with hypoxia, and type two diabetes. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 had moderate cognitive impairment. Review of the self-reported incident dated 11/12/25 revealed Resident #3 reported physical abuse by a staff member. Review of the investigation revealed no documentation of assessing any like residents in the facility for abuse from a staff member.Interview on 12/24/25 at 9:10 A.M. with the Administrator confirmed no additional residents were assessed for the investigation.Review of the facility policy titled Abuse and Neglect Policy, dated November 2018, revealed under the area of Investigation revealed the facility will investigate all allegations of abuse. The investigation will include interviews with residents with first hand knowledge of the incident and written statements from residents with first hand knowledge of the incident.

Based on interview, record review, and review of facility policy, the facility failed to notify the Ombudsman of a transfer to the hospital and failed to provide the bed hold policy to the resident representative in writing. This affected one (#19) of three residents reviewed for transfers. The facility census was 14. Findings include:Review of the medical record revealed Resident #19 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease with acute exacerbation, dysphagia, transient ischemic attack, generalized anxiety disorder. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the Resident #19 had intact cognition. Review of Resident #19 progress note dated 10/09/25 revealed resident left facility at approximately 11:30 PM via stretcher. There was no evidence the resident or resident representative was provided the bed hold policy in writing or the Ombudsman was notified of the transfer. Interview on 12/23/25 at 10:32 A.M. with the Administrator confirmed the Ombudsman was not notified of the transfer of Resident #19 to the hospital. Interview on 12/23/25 at 10:46 A.M. with the Administrator confirmed no bed hold notice or written notice was provided to Resident #19 or Resident #19 representative when transferred out of the facility. Review of the policy titled Transfer or Discharge Facility Initiated, dated 10/2022, read notice of transfer or discharge, notice of transfer is provided to the resident and representative as soon as practicable, notice of facility bed hold policies are provided to the resident and representative within 24 hours of emergency transfer, the facility will send a copy of the discharge notice to a representative of the Office of the State LTC Ombudsman, notice to the Office of the State LTC Ombudsman will occur at the same time the notice of discharge is provided to the resident and resident representative.

Based on interview and record review, the facility failed to ensure residents were free from significant medication errors. This affected one resident (#12) out of five residents who received insulin. The facility census was 14.Findings include:Review of the medical record revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including type II diabetes mellitus, cerebral Infarction, and morbid obesity.Review of the medication orders revealed Insulin Degludec FlexTouch Subcutaneous Solution Pen-injector 100 UNIT/milliliter (ML), inject 80 units subcutaneously every morning and at bedtime. Review of the December 2025 Medication Administration Record (MAR) for Resident #12 revealed on 12/05/2025, 12/07/2025, 12/11/2025, 12/12/2025, 12/17/2025, and 12/22/2025 the morning dose of Insulin was not documented as being administered. Interview on 12/23/2025 at 1:05 P.M. with the Interim Director of Nursing (DON) confirmed the morning scheduled doses of insulin were not documented as being administered on 12/05/2025, 12/07/2025, 12/11/2025, 12/12/2025, 12/17/2025, and 12/22/2025. The Interim DON stated It looks like it wasn't given, I would say it wasn't given because there is no documentation.Review of facility policy titled Medication Handling and Administration Rules, dated 2025, revealed all medication administrations must be recorded in the resident's Medication Administration Record (MAR). Any medication errors, including missed doses or incorrect administration, must be reported immediately.

Based on observation, interview, review of the resident medication list, and policy review, the facility failed to ensure all medications were stored and labeled properly. This had the potential to affected two (#3 and #10) out of 14 residents with medications stored in a medication cart. The facility census was 14. Findings Include: Observation on 12/24/25 at 2:35 P.M with Registered Nurse (RN) #14 revealed in medication cart #1 there were 20 famotidine pills with an expiration date of November 2025. Also, in the medication cart #1 there was one bottle of bisacodyl with an expiration date of July 2025. Interview on 12/24/25 at 2:40 P.M with RN #14 confirmed in medication cart #1 there were 20 famotidine pills with an expiration date of November 2025 and one bottle of bisacodyl with an expiration date of July 2025. Review of the facility medication list by order revealed Resident #3 and Resident #10 had orders for bisacodyl and Resident #3 had orders for famotidine. Review of the facility policy titled Medication Handling and Administration Rules revealed medication must have an expiration date and follow Ohio state regulations and federal guidelines.

Based on observation, resident, family and staff interviews, bed manual review, policy review, and review of the Food and Drug Administration (FDA) guidance, the facility failed to ensure the resident's side rails did not present an entrapment hazard and consent to utilize the side rails was obtained. This affected four (#5, #9, #163 and #164) of 15 residents identified as having side rails. The facility census was 17. Findings included: 1) Review of the medical record for Resident #9 revealed an admission on 07/01/22. Resident #9's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She had an admission Medicare 5-day Minimum Data Set (MDS) assessment dated [DATE]. She had severe cognitive impairment. She needed extensive assist of two staff for bed mobility, transfer, locomotion, dressing, toilet use, and personal hygiene. She needed extensive assist of one staff for eating. She was totally dependent on two staff for bathing. Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 08/15/22 at 1:05 P.M., of Resident #9 lying on an air mattress, with bilateral upper side rails raised and one half foot rail raised. It was noted there was a large gap in the center of the side rails at the top and bottom measured by the surveyor at that time to be 9 inches x 8 inches (all three openings) with a two inch gap between the mattress and side rail. 2) Review of the medical record for Resident #163 revealed an admission on 08/13/22. Resident #163's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He did not have a comprehensive assessment due to being newly admitted . Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 08/15/22 at 12:24 P.M., revealed Resident #163 was observed to be lying in a bed with bilateral side rails raised. There was a large opening in the middle of the side rails. The same style side rail (identified by the facility as being an Advance Series Bed From Hill Rom) was measured by the surveyor as being 9 inches by 8 inches. 3) Review of the medical record for Resident #164 revealed an admitted [DATE]. Resident #164's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She did not have a comprehensive assessment due to being newly admitted . Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Observations on 08/15/22 at 12:26 P.M., revealed Resident #164 was observed to be lying in a bed with bilateral side rails raised. There was a large opening in the middle of the side rails. The same style side rail (identified by the facility as being an Advance Series Bed From Hill Rom) was measured by the surveyor as being 9 inches by 8 inches. Observation on 08/15/22 at 1:28 P.M., with the Director of Patient Services #5 verifying Resident #163's side rail to his right had a large gap in the center measuring 7.5 inches x 7 inches with a two inch gap between the mattress and side rail. The side rail to his left measured 8 inches x 7 inches with a gap of two inches. Resident #164 was also in a bed with the same side rails with a bilateral gap measuring 7.5 inches x 7 inches, with a gap between the mattress and side rails of two inches. Resident #9 had a side rail with an opening measuring 7.5 inches x 8 inches with a two inch gap between the mattress and side rail bilaterally. This was all verified by measurements completed by the Director of Patient Services #5 on 08/15/22 at 1:28 P.M. A list was requested of all residents using the same type of side rail. On 08/15/22 at 1:35 P.M., the Director of Patient Services #5 indicated Resident #5 had the same side rails in use with the same measurements (approximately 7.5 inches x 7 inches). A request was made for a copy of the consent for the side rails. The facility provided consents for each of the residents signed on 08/15/22. There were no previous side rail consents on the record for Residents #5, #9, #163 and #164. This was verified by the DON on 08/17/22 at 3:42 P.M. The facility identified the bed as being an Advance Series Bed From Hill Rom. A review of the service manual did not reveal the dimensions of the side rail openings. Review of the Guidance for Industry and FDA Staff, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment issued on 03/10/06 revealed to reduce the risk of head entrapment, openings in the bed system should not allow the widest part of a small head (head breadth measured across the face from ear to ear) to be trapped. Country-specific anthropometric data show that a 1st percentile female head breadth may be as small as 95 mm (3 ¾ inches). A dimension of 120 mm (4 ¾ inches) encompasses the 5th percentile female head breadth in all data sources used to develop these recommendations, and includes 1st percentile female head breadth as reported in some data sources. It also indicated the FDA was therefore using a head breadth dimension of 120 mm (4 ¾ inches) as the basis for its dimensional limit recommendations. This dimension is consistent with the dimensions recommended by the HBSW (hospital bed safety workshop) and the IEC (international electrotechnical commission). Review of an undated facility policy titled [NAME] Nursing Home Side Rail Policy/Procedure indicated the FDA (Food and Drug Administration) guidelines for bed rails will be followed. 4.) Review of the medical record revealed Resident #5 admission on 03/05/21, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident # 5 had moderately impaired cognition, had no behaviors, did not wander, and rejected care one to three out of seven days per week. Resident # 5 was a two-person assist and required extensive assistance with bed mobility, transfers, locomotion, dressing, toileting, and personal hygiene. Review of Admission assessment dated [DATE] Resident # 5 had half side rails indicated to promote independence and bed mobility and no consent received for bilateral side rails. Review of side rail assessments dated 03/06/21, 09/08/21, 12/07/21, 03/07/21, and 06/03/21 revealed Resident # 5 had expressed no desire to use side rails, Resident # 5 did not use side rails for positioning/support, and use of side rails was not indicated. Review of the medical record revealed Resident # 5 had no signed consent for side rails and there was no risk agreement for using side rails without clinical indication. Review of the medical record revealed Resident # 5 had physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Check placement every day and night shift. Interview on 08/17/22 at 12:42 P.M., with Resident # 5 stated he did not request side rails, he did not use side rails to assist with mobility, and the rails had been on the bed since admission. Resident # 5 stated he had never had any accidents related to side rails. Interview via telephone on 08/18/22 at 11:09 A.M., with Resident #5's daughter/ Power of Attorney (POA) stated she gave consent to provide services to promote all aspects of care upon admission. Stated she was aware of risks versus benefits of side rails.

Based on medical record review, staff interview, and policy review, the facility failed to timely revise care plans to accurately reflect dental and fall prevention needs. This affected two (#10 and #165) of sixteen residents reviewed for care plans. The facility census was 17. Findings include: 1. Review of Resident #10's medical record review admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderately impaired cognition, was delusional, had no behaviors, did not wander, and rejected care one-to-three out of seven days per week. Resident #10 was independent with Activities of Daily Living (ADL's) and required supervision and setup assistance. Review of admission assessment dated [DATE] revealed Resident #10 had full lower dentures and an upper partial/bridge. Review of the facility consent form dated 03/25/20 revealed Resident #10's daughter (POA) declined consent for dental services. Review of Baseline care plan dated 12/07/19 revealed Resident # 10 had dietary care which included diabetic diet, preferred location for eating in the dining room, and wore dentures/partials. Review of the medical record revealed care plan dated 06/02/19 did not represent Resident's #10's need for supervision of dental care, including monitoring that denture and partial were intact/in place, resident behavior of misplacing denture/partial, resident behavior of making frequent statements that denture/partial were broken/missing, or POA's decline of dental services. During an interview on 08/15/22 at 10:17 A.M., Resident #10 stated she had broken her dentures at Christmas eating hard candy and needed new dentures. During an interview on 08/17/2022 at 11:51 A.M., Licensed Practical Nurse (LPN) #46 stated Resident # 10 frequently complained that her dentures were broken or missing. During an interview on 08/17/2022 at 11:57 A.M., the Director of Nursing (DON) stated Resident#10's family did not like taking her out for appointments and did not like to pay for additional services. Interview on 08/17/22 at 1:01 P.M., with Resident #10 re-stated she was out Christmas shopping with her family the Christmas before last (2020) and broke a tooth out of her upper partial. It hurt when it first happened to eat without her partial, but she had no problems now and was not sure if her family was going to replace her partial. The resident stated she had the broken partial in her purse but declined to show it. Interview on 08/17/22 at 3:42 P.M., the DON reviewed Resident #10's care plan dated 06/02/19 and verified there was no care plan for dentures or dental care/concerns. Interview via telephone on 08/18/22 at 8:50 A.M., Resident #10's daughter/POA states the resident had had a lower denture and upper partial for years, and she had regularly broke one of them. The family had them repaired/replaced by a local dentist. For quite a while, especially during COVID, it was difficult to get her to appointments. Around end of July 2022, Resident #10 told the POA's sister during a visit to the facility that her dentures had been stolen, but the dentures were observed by family to be intact in her denture cup on the nightstand. Family had received no recent reports from the facility about broken or missing dentures. Resident #10 frequently misplaced her things, was very forgetful, and became aggressive at times if people tried to look through her possessions. 2) Review of the electronic record revealed Resident # 165 was admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She had an Admission Minimum Data Set (MDS) assessment completed on 07/26/22. She had severe cognitive impairment. She needed extensive assist of two staff for bed mobility, transfer, walking, locomotion, dressing, toilet use, and personal hygiene. She needed extensive assist of one staff for eating. She was totally dependent on one staff for bathing. She was frequently incontinent of bowel and bladder. Review of the medical record revealed Resident #165 had physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of facility post-fall review dated 08/08/22 revealed Resident #165 had an unwitnessed fall with minor injury in her room on 08/06/22 at 2:20 P.M., Resident #165 was re-educated to call light use and asking for assistance prior to transfer. New interventions for the fall included non-skid socks at all times and signs placed at eye-level to remind the resident to use the call light for assistance. The resident had dementia with poor safety awareness. Review of facility post-fall review dated 08/18/22 revealed Resident #165 had an unwitnessed fall with no injury in her room on 08/17/2022 at 12:17 A.M. Previous interventions already in place included non-skid socks, scoop mattress and sensor alarms. The new fall interventions included to keep frequently used items within reach and provide a night light. Interview on 08/18/22 at 1:15 P.M., the DON verified Resident #165's care plan for falls was not updated timely to represent all fall prevention interventions implemented after Resident #165 fell on [DATE]. The DON verified the care plan did not have the intervention for the visual signs which was initiated after the fall on 08/06/2022. The DON stated floor nurse did not make changes to the care plan. The DON, MDS nurse, or clinical manager updated care plans after reviewing falls. Review of a facility policy undated titled Care Planning and Discharge Care Planning Policy/Procedure revealed the chronic care plans will accurately reflect the resident's status and needs.

Based on record review, interview, review of the self-reported incident (SRI), review of the witness statements, and policy review the facility failed to prevent staff to resident abuse. This affected one resident (#01) of three residents reviewed for abuse. The facility census was 17. Finding include: Review of the medical record revealed the Resident #01 was admitted on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set, dated dated dated [DATE] revealed Resident #01 had moderate cognitive deficits, required extensive assistance with activities of daily living (ADL), and was frequently incontinent of bowel and bladder. Review of the care plan dated 10/15/21 revealed Resident #01 had decreased ADL self-performance/mobility due to multiple diagnosis. Review of the nursing note dated as a late entry written on 04/22/22 for 04/20/22 revealed the State tested Nursing Assistant (STNA) #30 reported to the nurse that Resident #01 was being toileted in facility shower room. STNA #30 reported Resident #01 was falling forward after toileting, so she pulled the resident back towards the toilet to prevent the fall forward. Resident #01 fell to the left per STNA #30 and hit the wall. Resident #01 was in his wheelchair when the nurse was notified of the incident. Upon assessment there was a bruise and skin tear noted to left side of forehead along the hairline, the area was cleansed with normal saline, patted dry and the skin tear was re-approximated with three steri-strips. Resident #01 was alert and oriented per baseline with clear speech and with range of motion within in normal limits. Resident #01 had the ability to make his needs known and denied discomfort at the time of the incident. The Medical Director (MD) and the spouse were notified. Review of the SRI number 2 dated 04/21/22 revealed a staff member reported to the facility's Assisted Director of Nursing (ADON) about an incident from the day before where she was assisting another staff member transfer Resident #01 off the toilet. Staff member states the other staff member was getting frustrated and speaking rough at Resident #01 as he was confused and agitated himself. Then as they began to stand him up and he began leaning backwards, the other staff member forced him forwards and he hit his head on the wall. Later that same day, the same staff member in question was toileting Resident #01 alone in the same bathroom. Staff in the dining room could hear staff member in the bathroom speaking loudly and a short time later the staff member opened the door and told the other staff in the dining room to get the nurse, that Resident #01 had hit his head again and broke his glasses leaving a skin tear on forehead. Review of the SRI number 2 Narrative Summary of Incident revealed on 04/20/22 the STNA #25 reported to the ADON that while providing care with STNA #30 on Resident #01 that STNA #30 became verbally abusive and frustrated with Resident #01. While the two STNAs had Resident #01 standing up in front of the toilet, Resident #01 was noted to have leaned backwards and STNA #30 attempted to force him forwards causing him to hit his head on the wall. A short time later Resident #01 was toileted in the shower room again, however only STNA #30 was in the room assisting him. STNA #25 reported that she could hear STNA #30 raising her voice and yelling at Resident #01. STNA #30 then opened the door to the shower room and requested STNA #25 get the nurse due to Resident #01 hitting his head on the wall again and sustained a skin tear to forehead and broke his glasses. STNA #30 reported to nurse that she stood Resident #01 up to clean him and pull his pants up and he started to try to sit. STNA ##30 asked Resident #01 to stand up straight and she continued trying to pull his pants up, but Resident #01 started leaning his legs and torso in the opposite directions. STNA #30 stated she put her arms around Resident #01's waist to pull him straight up and Resident #01 moved forward suddenly, and he hit his head on the wall again causing him to break his glasses and sustain a skin tear. Resident #01 stated during interview That one gal was mad at someone and told me not to talk clamping my mouth shut, then demonstrated by placing his hand over his mouth. Resident #01 said Sometimes they slam me back against the wall. STNA #30 turned one way and I turned another and didn't go fast enough or something and she said, I don't have time that. STNA #30 was placed on immediate suspension pending completion of investigation. Witness interviews were conducted, and statements were collected. Staff and resident questionnaires and interviews were completed. Skin checks were completed on all other residents not able to complete interviews or questionnaires. Staff was re-educated on the Abuse, neglect, and misappropriation policies, Resident Rights, and Dementia/Cognitively impaired resident policies. After thorough investigation, this facility has determined that the evidence supports the abuse allegations had occurred and are substantiated. STNA #30 violated Resident Right 3721.12 (A)(2) that states the resident has the right to be free from physical, verbal, mental, and emotional abuse and to be treated at all times with courtesy, respect, and full recognition of dignity and individuality. Local law enforcement was called, Officer #50 arrived and took the details of the incident, investigation and our conclusion. Officer #50 stated he would start an official report and request a copy of the facility's SRI report. Review of STNA #25's written statement dated 04/21/22 revealed when she was working with STNA #30 on 04/20/22 we transferred Resident #01 off the toilet. STNA #30 was frustrated and became verbally abusive with Resident #01, which only had him more agitated, confused, and upset. As we had Resident #01 standing up he was leaning backwards as opposed to forward, STNA #30 forced him forward and he smacked his head on the wall. We toileted Resident #01 a second time although STNA #30 transferred him off the toilet by herself, I could hear her yelling at Resident #01 from the dining room. STNA #30 then opened the door and requested she get the nurse because Resident #01 hit his head again and had a skin tear and broken glasses. Review of Resident #01's statement on 04/21/22 revealed Resident #01 stated that there was one gal who was mad at someone and told him not to talk clamping my mouth shut Resident #01 demonstrated by putting a hand over his mouth. He stated that sometimes staff slams me back against the wall. Resident #01 stated she turned one way and he turned another and didn't turn fast enough or something. STNA #30 stated she had no time for that. Resident #01 knew the beginning of STNA #30 name but not the last name and stated everything happened the day before. Resident #01 also stated he was not scared then and was not scared now; I just want to have things explained to me. Review of RN #21's statement dated 04/21/22 revealed RN #21 stated that STNA #30 called for her due to Resident #01 receiving a skin tear during toileting while in the shower room. STNA #30 reported that while toileting Resident #01 that Resident #01 went to fall forward, and she grabbed him by the pants, and he fell into the wall. The resident was assessment, and a skin tear was noted to his left forehead. RN #21 completed a treatment to the skin tear, steri-strips applied, and neurological checks initiated. Review of STNA #30's telephone statement revealed Resident #01 asked to go to the restroom, so she took him into the shower room to use the toilet because there is more room for us to move around. When she stood Resident #01 up to clean him and pull his pants up, he started to sit. STNA #30 asked Resident #01 to stand up straight which he started to do. As she was about to pull up his pants, he started to move on her. Resident #01's legs went forward, but his torso and head went back on her. STNA #30 put her arms around his waist to move his hips back towards her slowly. When she did that Resident #01's top half moved forward really quick and he hit his head on the wall. She instantly called for the nurse and she checked him out. STNA #30 was talking loudly because Resident #01 did not have his hearing aids in, and she was not frustrated or agitated. Interview on 05/06/22 at 12:15 P.M., with Resident #01 reported the day he hurt his head STNA #30 seemed angry and upset with him. Resident #01 reported she had never treated him bad before that and that no one had ever treated that bad. He did report he felt safe now that STNA #30 no longer worked there. Interview on 05/06/22 at 12:57 P.M., with the Corporate DON #25 and the Clinical Manager #40 reported that STNA #25 should have reported her concerns when they happened instead of waiting until the next day, however they stated that STNA #25 stated she was afraid of retaliation. A telephone interview on 05/06/22 at 2:13 P.M. with STNA #25 reported the first incident when she was assisting STNA #30 transferring Resident #01 off the toilet was shortly after breakfast and stated STNA #30 was speaking roughly to Resident #01 saying, God expletive Resident #01, what the expletive are you doing? and was really rough with him to keep him standing. STNA #25 stated it was a mistake not to report it the first time STNA #30 was rough with Resident #01 but she was afraid of retaliation because it was a small facility and STNA #30's mom works there too. STNA #25 reported the second incident she could hear STNA #30 yelling at Resident #01 from the dining room and after the nurse treated Resident #01 STNA #25 said to the nurse that it should not have happened that STNA #30 was too rough with Resident #01. Review of the facility policy titled Abuse and Neglect, undated revealed this facility will take measures to prohibit and prevent abuse, the right to be free from neglect, misappropriation of property, or exploitation of residents caused by anyone including facility staff, other residents, consultants, visitors, volunteers, and staff of other agencies serving the resident family members, legal guardians, friend, and other individuals. This deficiency substantiates Complaint Number OH 254.

Based on record review, interview, review of the self-reported incident (SRI), review of witness statements, and policy review the facility failed to timely report and allegation of staff to resident abuse. This affected one resident (#01) of three residents reviewed for abuse. The facility census was 17. Finding include: Review of the medical record revealed the Resident #01 was admitted on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set, dated dated dated [DATE] revealed Resident #01 had moderate cognitive deficits, required extensive assistance with activities of daily living (ADL), and was frequently incontinent of bowel and bladder. Review of the care plan dated 10/15/21 revealed Resident #01 had decreased ADL self-performance/mobility due to multiple diagnosis. Review of the nursing note dated as a late entry written on 04/22/22 for 04/20/22 revealed the State tested Nursing Assistant (STNA) #30 reported to the nurse that Resident #01 was being toileted in facility shower room. STNA #30 reported Resident #01 was falling forward after toileting, so she pulled the resident back towards the toilet to prevent the fall forward. Resident #01 fell to the left per STNA #30 and hit the wall. Resident #01 was in his wheelchair when the nurse was notified of the incident. Upon assessment there was a bruise and skin tear noted to left side of forehead along the hairline, the area was cleansed with normal saline, patted dry and the skin tear was re-approximated with three steri-strips. Resident #01 was alert and oriented per baseline with clear speech and with range of motion within in normal limits. Resident #01 had the ability to make his needs known and denied discomfort at the time of the incident. The Medical Director (MD) and the spouse were notified. Review of the SRI number 2 dated 04/21/22 revealed a staff member reported to the facility's Assisted Director of Nursing (ADON) about an incident from the day before where she was assisting another staff member transfer Resident #01 off the toilet. Staff member states the other staff member was getting frustrated and speaking rough at Resident #01 as he was confused and agitated himself. Then as they began to stand him up and he began leaning backwards, the other staff member forced him forwards and he hit his head on the wall. Later that same day, the same staff member in question was toileting Resident #01 alone in the same bathroom. Staff in the dining room could hear staff member in the bathroom speaking loudly and a short time later the staff member opened the door and told the other staff in the dining room to get the nurse, that Resident #01 had hit his head again and broke his glasses leaving a skin tear on forehead. Review of the SRI number 2 Narrative Summary of Incident revealed on 04/20/22 the STNA #25 reported to the ADON that while providing care with STNA #30 on Resident #01 that STNA #30 became verbally abusive and frustrated with Resident #01. While the two STNAs had Resident #01 standing up in front of the toilet, Resident #01 was noted to have leaned backwards and STNA #30 attempted to force him forwards causing him to hit his head on the wall. A short time later Resident #01 was toileted in the shower room again, however only STNA #30 was in the room assisting him. STNA #25 reported that she could hear STNA #30 raising her voice and yelling at Resident #01. STNA #30 then opened the door to the shower room and requested STNA #25 get the nurse due to Resident #01 hitting his head on the wall again and sustained a skin tear to forehead and broke his glasses. STNA #30 reported to nurse that she stood Resident #01 up to clean him and pull his pants up and he started to try to sit. STNA ##30 asked Resident #01 to stand up straight and she continued trying to pull his pants up, but Resident #01 started leaning his legs and torso in the opposite directions. STNA #30 stated she put her arms around Resident #01's waist to pull him straight up and Resident #01 moved forward suddenly, and he hit his head on the wall again causing him to break his glasses and sustain a skin tear. Resident #01 stated during interview That one gal was mad at someone and told me not to talk clamping my mouth shut, then demonstrated by placing his hand over his mouth. Resident #01 said Sometimes they slam me back against the wall. STNA #30 turned one way and I turned another and didn't go fast enough or something and she said, I don't have time that. STNA #30 was placed on immediate suspension pending completion of investigation. Witness interviews were conducted, and statements were collected. Staff and resident questionnaires and interviews were completed. Skin checks were completed on all other residents not able to complete interviews or questionnaires. Staff was re-educated on the Abuse, neglect, and misappropriation policies, Resident Rights, and Dementia/Cognitively impaired resident policies. After thorough investigation, this facility has determined that the evidence supports the abuse allegations had occurred and are substantiated. STNA #30 violated Resident Right 3721.12 (A)(2) that states the resident has the right to be free from physical, verbal, mental, and emotional abuse and to be treated at all times with courtesy, respect, and full recognition of dignity and individuality. Local law enforcement was called, Officer #50 arrived and took the details of the incident, investigation and our conclusion. Officer #50 stated he would start an official report and request a copy of the facility's SRI report. Review of STNA #25's written statement dated 04/21/22 revealed when she was working with STNA #30 on 04/20/22 we transferred Resident #01 off the toilet. STNA #30 was frustrated and became verbally abusive with Resident #01, which only had him more agitated, confused, and upset. As we had Resident #01 standing up he was leaning backwards as opposed to forward, STNA #30 forced him forward and he smacked his head on the wall. We toileted Resident #01 a second time although STNA #30 transferred him off the toilet by herself, I could hear her yelling at Resident #01 from the dining room. STNA #30 then opened the door and requested she get the nurse because Resident #01 hit his head again and had a skin tear and broken glasses. Review of Resident #01's statement on 04/21/22 revealed Resident #01 stated that there was one gal who was mad at someone and told him not to talk clamping my mouth shut Resident #01 demonstrated by putting a hand over his mouth. He stated that sometimes staff slams me back against the wall. Resident #01 stated she turned one way and he turned another and didn't turn fast enough or something. STNA #30 stated she had no time for that. Resident #01 knew the beginning of STNA #30 name but not the last name and stated everything happened the day before. Resident #01 also stated he was not scared then and was not scared now; I just want to have things explained to me. Review of RN #21's statement dated 04/21/22 revealed RN #21 stated that STNA #30 called for her due to Resident #01 receiving a skin tear during toileting while in the shower room. STNA #30 reported that while toileting Resident #01 that Resident #01 went to fall forward, and she grabbed him by the pants, and he fell into the wall. The resident was assessment, and a skin tear was noted to his left forehead. RN #21 completed a treatment to the skin tear, steri-strips applied, and neurological checks initiated. Review of STNA #30's telephone statement revealed Resident #01 asked to go to the restroom, so she took him into the shower room to use the toilet because there is more room for us to move around. When she stood Resident #01 up to clean him and pull his pants up, he started to sit. STNA #30 asked Resident #01 to stand up straight which he started to do. As she was about to pull up his pants, he started to move on her. Resident #01's legs went forward, but his torso and head went back on her. STNA #30 put her arms around his waist to move his hips back towards her slowly. When she did that Resident #01's top half moved forward really quick and he hit his head on the wall. She instantly called for the nurse and she checked him out. STNA #30 was talking loudly because Resident #01 did not have his hearing aids in, and she was not frustrated or agitated. Interview on 05/06/22 at 12:15 P.M., with Resident #01 reported the day he hurt his head STNA #30 seemed angry and upset with him. Resident #01 reported she had never treated him bad before that and that no one had ever treated that bad. He did report he felt safe now that STNA #30 no longer worked there. Interview on 05/06/22 at 12:57 P.M., with the Corporate DON #25 and the Clinical Manager #40 reported that STNA #25 should have reported her concerns when they happened instead of waiting until the next day, however they stated that STNA #25 stated she was afraid of retaliation. A telephone interview on 05/06/22 at 2:13 P.M. with STNA #25 reported the first incident when she was assisting STNA #30 transferring Resident #01 off the toilet was shortly after breakfast and stated STNA #30 was speaking roughly to Resident #01 saying, God expletive Resident #01, what the expletive are you doing? and was really rough with him to keep him standing. STNA #25 stated it was a mistake not to report it the first time STNA #30 was rough with Resident #01 but she was afraid of retaliation because it was a small facility and STNA #30's mom works there too. STNA #25 reported the second incident she could hear STNA #30 yelling at Resident #01 from the dining room and after the nurse treated Resident #01 STNA #25 said to the nurse that it should not have happened that STNA #30 was too rough with Resident #01. Review of the facility policy titled Abuse and Neglect, undated revealed once the facility becomes aware of any of these alleged violations, whether unfounded or not, the facility must immediately report them to the Administrator. This deficiency substantiates Complaint Number OH 254.

Based on medical record review, observation, staff interview, review of facility policy and review of Centers for Disease Control (CDC) online resource the facility failed to use personal protective equipment (PPE) appropriately in order to prevent the potential spread of the coronavirus (COVID-19). The affected one (#15) resident of one resident reviewed for being a new admission within the last 14 days. This had the potential to affect all 16 residents. The facility reported two admissions in the past 30 days. The facility currently had no active cases of COVID-19. The facility census was 16. Findings include: Medical record review revealed Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #15's admission assessment dated [DATE] revealed Resident #15 was oriented to person, place, time and situation. Resident #15 required extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene and was independent with eating. Review of Resident #15's physician orders [REDACTED]. Observation of the facility on 03/11/21 at 8:54 A.M. revealed Resident #15 was in a private room with a droplet precaution sign on the door. There was no PPE outside of the resident's room. Interview with the Administrator on 03/11/21 at 8:54 A.M. verified Resident #15 was on droplet precautions due to the resident being newly admitted to the facility in the past 14 days. The Administrator also confirmed Resident #15 did not have any PPE located outside his room. Observation of the facility on 03/11/21 at 9:04 A.M. revealed Licensed Practical Nurse (LPN) #3 went in Resident #15's room to provide him with a straw. LPN #3 was wearing a KN95 mask and a face shield but was not wearing a gown or gloves. Interview with LPN #3 on 03/11/21 at the time of the observation verified Resident #15 was on droplet precautions and verified she was not wearing a gown or gloves in Resident #15's room because she was not providing direct care. Observation of the facility on 03/11/21 at 10:28 A.M. revealed Activities #23 was in Resident #15's room while wearing protective eye gear and a KN95 mask. Activities #23 was not wearing a gown or gloves and was observed to pick up a magazine in Resident #15's room and began reading it to him. Activities #23 also assisted Resident #15 by picking up the phone in his room and assisting Resident #15 with holding the phone up to his ear. Activities #23 was observed to pull her KN95 mask down below her nose and mouth while talking to Resident #15 in his room. Interview with Activities #23 on 03/11/21 at 10:35 A.M. verified Resident #15 was on droplet precautions and that she did not wear a gown or gloves into Resident #15's room. Activities #23 also verified she kept pulling her KN95 mask below her nose and mouth because she had asthma. Review of facility policy entitled Infection Control: Contact Precautions updated 03/2020 revealed under gloves and handwashing - in addition to following standard precautions, wear gloves when entering the room. Under gowns - in addition to wearing a gown as you would in standard precautions, wear a gown when entering the room if you anticipate that your clothing will have substantial contact withe the resident, environmental surfaces, or items in the resident's room. Review of an online resource from the CDC (https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html) entitled Responding to COVID-19 in nursing homes dated 04/30/20 revealed all recommended COVID19 PPE should be worn during care of residents under observation, which includes use of an N95 or higher-level respirator, eye protection, gloves, and gown.

Based on medical record review and staff interview, the facility failed to ensure the advance directives on file were accurate. This affected two (#4 and #12) of four residents reviewed for advance directives. The facility census was 18. Findings include: 1. Medical record review for Resident #4 revealed an admission date of [DATE]. Medical [DIAGNOSES REDACTED]. Review of the physician's progress note, dated 06/01/18, and face sheet for Resident #4 revealed a code status of Do Not Resuscitate Comfort Care (DNRCC). A review of the advance directive form in the resident's hard chart revealed a code status of DNR Comfort Care Arrest (DNRCCA). 2. Medical record review for Resident #12 revealed an admission date of [DATE]. Medical [DIAGNOSES REDACTED]. Review of the physician's progress notes, dated 06/07/18 and 02/23/18, revealed a code status of DNRCC. Review of the admission paperwork revealed a code status of DNRCC. Review of the Medication Administration Record [REDACTED]. Review of the advance directive form in the resident's hard chart revealed a code status of DNR. Interview on 07/03/18 at 11:19 A.M. with Director of Nursing (DON) who verified the code status in the electronic chart and in the hard chart did not match for Resident #4 and #12.

Based on medical chart review and staff interview, the facility failed to monitor for signs and symptoms of depression. This affected one (Resident #27) of five residents reviewed for unnecessary medications. This had the potential to affect all nine residents identified as receiving anti-depressant medications. Findings include: Resident #27 was admitted to the facility on [DATE]. A quarterly comprehensive assessment dated [DATE] documented Resident #27 sometimes made herself understood, sometimes understood others, had long and short term memory problems, and was severely impaired for daily decision making. She did not display signs or symptoms of [MEDICAL CONDITION] but did have inattention that was present but fluctuated. She did not wander, reject care, or exhibit any negative behaviors. Resident #27 needed the assistance of two staff for activities of daily living except she needed the assistance of one staff for locomotion on and off the unit, dressing, personal hygiene, and eating. [DIAGNOSES REDACTED]. Review of Resident # 27's care plan for psychosocial well being dated 08/19/14 documented the resident had a [DIAGNOSES REDACTED]. Interview and electronic chart review with the Director of Nursing (DON) on 11/12/14 at 4:00 P.M. revealed staff were monitoring for signs and symptoms of depression by documenting on the Medication Administration Record. They were supposed to monitor Resident #27 for behaviors of restlessness, itching, and picking at her skin. She stated the staff were not monitoring on the behavior sheet if the resident was crying, refusing to eat, or refusing to talk. She stated the staff would have probably made note of it in the nursing notes She verified the signs and symptoms for depression were not being monitored.

Based on medical record review and staff interview, the facility physician failed to document a visit with a resident. This affected one (Resident #27) of five residents reviewed for unnecessary medications. Findings include: Resident #27 was admitted to the facility on [DATE]. A quarterly comprehensive assessment dated [DATE] documented Resident #27 sometimes made herself understood, sometimes understood others, had long and short term memory problems, and was severely impaired for daily decision making. She did not display signs or symptoms of [MEDICAL CONDITION] but did have inattention that was present but fluctuated. She did not wander, reject care, or exhibit any negative behaviors. Resident #27 needed the assistance of two staff for activities of daily living except she needed the assistance of one staff for locomotion on and off the unit, dressing, personal hygiene, and eating. [DIAGNOSES REDACTED]. Review of Resident #27's physician orders revealed on 09/30/14 the physician ordered to decrease [MEDICATION NAME], an anti depressant, for seven days then discontinue; then start [MEDICATION NAME], an anti depressant. There was no progress note in the resident's record indicating the physician had documented this visit. Interview and electronic chart review with the Director of Nursing (DON) on 11/12/14 at 4:00 P.M. revealed the physician had changed the resident's medication but did not document anything in the progress notes about his visit.

Based on medical record review and staff interview, the facility failed to ensure the medical record documentation was complete and accurately documented. This affected two (Residents #23 and #27) of 14 residents reviewed in Stage II. The census was 18. Findings include: 1. Resident #23 was admitted to the facility from the hospital on [DATE] with [DIAGNOSES REDACTED]. The five day admission comprehensive assessment dated [DATE] documented Resident #23 made herself understood, understood others, and was cognitively intact for daily decision making. She did not display signs or symptoms of [MEDICAL CONDITION] or [MEDICAL CONDITION]. She did not wander, reject care, or exhibit any negative behaviors. She needed the assistance of two staff for all activities of daily living except she needed set up for eating and the assistance of one staff for locomotion on and off the unit. The assessment documented the resident was short of breath or had trouble breathing with exertion, when sitting, or when lying flat. The resident was on oxygen therapy prior to admission. Review of Resident #23's physician order [REDACTED]. Review of Resident #23's nursing notes dated 09/08/14 through 09/30/14 documented the resident received oxygen at 2 liters per minute via nasal cannula daily. Review of Resident #23's annual history and physical, dated 09/09/14 and performed by the facility Medical Director (MD), documented the resident received oxygen therapy per nasal cannula. Review of Resident #23's plan of care for mobility, dated 09/18/14 had intervention of tires easily, gets short of breath, make sure oxygen is on daily and nasal cannula is in nostrils properly. Interview with Health Service Supervisor (HSS) on 11/12/14 at 6:36 PM stated Resident # 23 received continuous oxygen therapy daily. HSS reviewed the care plan and stated the oxygen time or rate was not on the resident's plan of care. Interview with the Director of Nursing (DON) on 11/12/14 at 6:51 PM stated there wasn't any other orders for oxygen for Resident # 23. She stated there should have been an order that told the route, amount, and time frame for the oxygen. She stated according to the nurses notes the resident was on 2 liters (L) of oxygen per nasal cannula continuously. Interview with State tested Nursing Assistant (STNA) #41 on 11/13/14 at 1:29 PM stated when Resident #23 first came she would take the oxygen off for 30 to 60 minutes at a time several times a day but shortly after her arrival she required continuous oxygen. 2. Resident # 27 was admitted to the facility on [DATE]. A quarterly comprehensive assessment dated [DATE] documented Resident #27 sometimes made herself understood, sometimes understood others, had long and short term memory problems, and was severely impaired for daily decision making. She did not display signs or symptoms of [MEDICAL CONDITION] but did have inattention that was present but fluctuated. She did not wander, reject care, or exhibit any negative behaviors. Resident #27 needed the assistance of two staff for all activities of daily living except she needed the assistance of one staff for locomotion on and off the unit, dressing, personal hygiene, and eating. [DIAGNOSES REDACTED]. Review of Resident #27's care plan for psychosocial well being dated 08/19/14 documented the resident had a [DIAGNOSES REDACTED]. Interventions included to monitor for signs of depression such as crying, refusing to talk with others, refusal to eat, monitor for side effects, and see psych on a regular basis. Review of Resident # 27's physician orders [REDACTED]. Interview and electronic chart review with the Director of Nursing (DON) on 11/12/14 at 4:00 P.M. stated the staff were monitoring for behaviors of restlessness, itching, and picking at her skin by documenting on the Medication Administration Record [REDACTED]. She stated the staff would have probably made note of it in the nurses notes. She agreed the crying, refusing to eat, and refusing to talk to others were behaviors. The DON also stated stated the physician entered the order to decrease and then discontinue [MEDICATION NAME] and to start [MEDICATION NAME] himself on 09/30/14. She stated he did not document it anywhere else in the chart. She stated he did not make note that he had seen the resident that day. She did not know if there was a policy about this or not.