Every finding on record at Mt Healthy Christian Home

Based on record review, observation, staff interview, and review of the facility policy, the facility failed to provide adequate supervision to prevent falls with injury. This resulted in Actual Harm to dependent Resident #20 when a staff member who was providing incontinence care to the resident without additional staff assistance turned away from the resident to discard cleaning materials and the resident fell from the bed. Resident #20 sustained the following injuries from the fall from the bed: a scalp laceration which required repair with sutures, a sternal fracture, a fracture of the left clavicle, a fracture of the second rib on the left side, a closed fracture of the spinous process of the thoracic vertebra and the transverse process of the lumbar vertebra. This affected one (Resident #20) of three residents reviewed for falls. The facility census was 66. Findings include: Review of the medical record for Resident #20 revealed an admitted [DATE] with diagnoses including type two diabetes, hypertensive chronic kidney disease, dysphagia, cerebrovascular disease, vascular dementia, psychotic disorder with delusions, osteoporosis, anemia, atherosclerotic heart disease, gastro-esophageal reflux disease, osteoarthritis, glaucoma, hypertension and cardiomyopathy. Review of the Minimum Data Set (MDS) assessment for Resident #20 dated 02/07/24 revealed the resident was moderately cognitively impaired and was dependent on staff assistance for all activities of daily living (ADLs) including toileting and bed mobility for which she required the assistance of two staff. Review of the care plan for Resident #20 dated 02/08/24 revealed the resident was at risk for falls and/or fall related injury related to wheelchair use, history of fall related injury, impaired vision, incontinence, medication use, required use of a mechanical lift with transfers and had diagnoses of polyarthritis, dementia, severe depression, and psychosis. The resident was dependent on staff and Hoyer lift for transfers. Interventions included the following: Dycem to wheelchair under Roho cushion, use Hoyer lift for all transfers, monitor, anticipate and intervene for fall risk factors, place call light within reach, encourage call light use and answer promptly, provide environmental adaptations as appropriate, and assist with and monitor positioning. Review of the care plan for Resident #20 dated 02/08/24 revealed the resident had an ADL self-care deficit and required total assistance of one to two staff with incontinence needs. The care plan was updated on 03/20/24 to indicate the resident required two staff for incontinence care. Review of the fall risk assessment for Resident #20 dated 03/10/24 revealed the resident was at moderate risk for falls and took medications and had diagnoses which contributed to her fall risk. The residents' risk factors also included wheelchair use and disorientation. Review of the progress note for Resident #20 dated 03/20/24 timed at 6:58 P.M. revealed the aide notified the nurse that the resident was on the floor on her left side next to the bed with a moderate amount of blood noted on the floor. The nurse called 911 to transport the resident to the hospital. Review of the fall investigative summary for Resident #20 dated 03/20/24 revealed during peri-care the resident changed the position of her body causing her to roll from the bed. State tested Nurse Aide (STNA) #98 attempted to intervene but was unable stop the resident from falling out of bed. Staff assessed Resident #20 for injury and called 911. Staff applied pressure to the resident's head laceration while awaiting transfer to the hospital. Resident #20 returned with a head laceration and multiple fractures. New interventions for Resident #20 were staff to ensure the resident was a two-person assist for peri care, and her low air loss mattress was replaced with a standard pressure reduction mattress. Review of the progress note for Resident #20 dated 03/21/24 timed at 1:52 P.M. revealed the interdisciplinary team (IDT) met to discuss the resident's fall. The IDT determined the root cause of the fall was the change to the resident's weight distribution on the low air loss mattress when the resident changed positions during peri-care. The new interventions were replacing the mattress and ensuring two people assisted the resident with peri-care. Review of the hospital notes for Resident #20 dated 03/21/24 revealed the resident fell from the bed and sustained a scalp laceration repaired with sutures, a sternal fracture, a fracture of the left clavicle, a fracture of the second rib on the left side, a closed fracture of the spinous process of the thoracic vertebra and of the transverse process of the lumbar vertebra. Review of the progress note for Resident #20 dated 03/21/24 timed at 4:06 P.M. revealed the resident returned to the facility with a laceration with sutures to the left side of her forehead, edema to the left side of her face, bruising to her right arm and a sling on her left arm for clavicle fracture support. Observation on 04/04/24 at 11:35 A.M. of Resident #20 revealed the resident was lying on a standard mattress and had bruising to the entire left side of her face from her forehead and extending to her neck. The bruising was brown and green in color and appeared to be fading. There was evidence of a laceration to the resident's head which appeared as a dark circle to the left side of the resident's forehead. Resident #20 was wearing a sling on her left arm and was unable to be interviewed due to cognitive impairment. Interview on 04/04/24 at 2:10 P.M. with STNA #98 confirmed she was doing a routine check and change for Resident #20 on 03/20/24. STNA #98 was holding onto the resident with one hand and giving peri care with the other hand. STNA #98 confirmed she turned slightly to dispose of the wipe while still keeping one hand on Resident #20 and felt Resident #20 start to slip. STNA #98 confirmed she tried to intervene and keep Resident #20 from falling out of bed, but she was unable to prevent the fall. STNA #98 confirmed after Resident #20 slipped to the floor she noted blood coming from the resident's head, so she called for the nurse who assessed the resident and sent her to the hospital via 911. STNA #98 further confirmed Resident #20 was supposed to be a two person assist for checks and changes, but they were short of help that day and the care was provided at the shift change, so she completed the task on her own. STNA #98 further confirmed she felt the resident's weight shift on the low air loss mattress contributed to the fall and the facility got the resident a standard mattress after the fall. Interviews on 04/04/24 at 4:40 P.M. with STNA #38 and at 4:50 P.M. with STNA #67 confirmed if a resident had been determined to be dependent for toileting and incontinence care, two staff should provide assistance, and the care should never be completed with just one aide. Interview on 04/04/24 at 5:00 P.M. with the Administrator and the Director of Nursing (DON) confirmed Resident #20 had a fall from the bed on 03/20/24 which occurred when STNA #98 was providing incontinence care to the resident by herself without the assistance of an additional STNA. The Administrator and the DON confirmed Resident #20 sustained the following injuries as a direct result of the fall from the bed on 03/20/24: a scalp laceration which required repair with sutures, a sternal fracture, a fracture of the left clavicle, a fracture of the second rib on the left side, a closed fracture of the spinous process of the thoracic vertebra and the transverse process of the lumbar vertebra. Further interview confirmed the facility's IDT met on 03/21/24 and made the decision to replace Resident #20's low air loss mattress with a standard mattress and to update the resident's care plan to indicate Resident #20 required the assistance of two staff with incontinence care. Interview confirmed prior to Resident #20's fall on 03/20/24 the resident's care plan indicated the resident required the assistance of one to two staff with incontinence care and left it up to the judgment of the STNAs performing the care to determine if one or two staff should be used. Review of the policy titled Falls (undated) revealed the nurse and the physician would identify residents with a history of falls and risk factors for falling. The nurse would complete a fall risk assessment for each resident, and the staff, and the physician would identify pertinent interventions to prevent falls. This deficiency represents noncompliance investigated under Complaint Number OH00152423.

Based on observation, staff interview, review of facility policy, and review of online resources per the Centers for Disease Control (CDC) and the Centers for Medicare and Medicaid Services (CMS) the facility failed to ensure staff wore appropriate personal protective equipment (PPE) to prevent the spread of Coronavirus (COVID-19). This had the potential to affect 13 (Residents #4, #7, #10, #20, #21, #25, #31, #32, #34, #41, #44, #53 and #54)residing on the Five South Unit; and failed to ensure staff practiced appropriate hand hygiene during meal service. This affected three (Residents #3, #14 and #28) of 18 residents observed for meal service on the Four North Unit. The census was 63. Findings include: 1. During observation on 10/12/21 at 11:30 A.M., State tested Nursing Assistant (STNA) #98 was eating in the resident lounge area and was not wearing PPE. During interview on 10/12/21 at 11:30 A.M., STNA #98 confirmed she was not wearing PPE and was eating while in the resident area. During interview on 10/14/21 at 11:37 A.M., the Director of Nursing (DON) confirmed staff should wear a surgical mask and eye protection in resident at all times. Review of the facility policy titled COVID-19 Infection Control, undated, revealed staff should wear face masks and eye protection in resident areas. Review of an online resource from the CDC (https://www.cdc.gov/Coronavirus/2019-ncov/hcp/long-term-care-strategies.html) revealed the following guidance regarding facemasks: ensure all healthcare care personnel (HCP) wear a facemask while in the facility. 2. During observation on 10/13/21 at 8:58 A.M., STNA #189 revealed she was working in a resident area providing direct resident care and was not wearing proper eye protection. STNA #189 was wearing prescription eyeglasses with side pieces (eye glass wings). During interview on 10/13/21 at 8:58 A.M., STNA #189 confirmed she had brought the eye glass wings from home and thought they were a substitute for eye protection provided by the facility. During interview on 10/14/21 at 11:37 A.M., the DON confirmed staff should currently wear a face shield or goggles as eye protection in resident areas. Review of the facility policy titled COVID-19 Infection Control undated revealed staff should wear eye protection that covers the front and sides of the face. Review of an online resource from CMS titled COVID-19 Nursing Home data at https://data.cms.gov/stories/s/COVID-19-Nursing-Home-Data-Test-Positivity-Rates/q5r5-gjyu/ revealed the county in which the facility was situated was experiencing a moderate spread of COVID 19 with a positivity rate of 9.8 percent (%) for the week ending in 10/05/21. A review of an online resource per the CDC and NIOSH at https://www.cdc.gov/niosh/topics/eye/eye-infectious.html revealed prescription eyeglasses are not considered eye protection and while the use of prescription safety glasses with side protection are available, they do not provide protection against splashes or droplets as goggles and/or face shields do. 3. During observation on 10/12/21 at 12:43 P.M., STNA #250 served food to Resident #14 in the 4 North dining room, served a tray to Resident #28 in the resident's room, and served at tray to Resident # 3 in the residents room and did not perform hand hygiene between trays. During interview on 10/12/21 at 12:46 P.M., STNA #250 confirmed she did not wash or sanitize hands between delivering meal trays to Residents #3, #14, and #28.

Based on record review, observation and interview, the facility failed to ensure a dependent resident's wheelchair was equipped with a calf board and foot rests. This affected one (Resident #2) of three residents reviewed for activities of daily living assistance. The census was 63. Findings include: Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the minimum date set assessment dated [DATE] revealed Resident #2 had moderately impaired cognition, and required extensive assistance with bed mobility, transfers and locomotion. Review of care plan dated 09/30/2021 revealed Resident #2 had an ADL self-care performance deficit related to weakness, pain due to [CONDITION(S)] and leg contractures. She required a calf board to the wheelchair due to the leg contractures. During observation on 10/12/21 at 11:04 A.M. revealed Resident #2 was seated in her wheelchair with no foot pedals or calf board. The resident's legs were dangling from the wheelchair with no support. During observation on 10/13/2021 at 2:03 P.M. Resident #2 was seated in the 4 North dining room in her wheelchair. The wheelchair had the calf board folded beneath the seat of the wheelchair. The resident's legs were not supported. During interview on 10/13/2021 at 2:04 P.M., Registered Nurse (RN) #133 and the Director of Nursing (DON)verified the calf board was folded under the seat of the wheelchair and not supporting Resident #2's legs. During interview on 10/14/21 at 9:01 A.M., the DON stated Resident #2 did not use foot pedals on her wheelchair, and the calf board was not applied correctly to the wheelchair.

Based on record review, observation, interview and policy review, the facility failed to ensure residents were assisted with placement of hearing aids. This affected one (Resident #34) of three residents reviewed for hearing impairment. The census was 63. Findings include: Review of the medical record for Resident #34 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) for Resident #34 dated 08/24/21 revealed the resident was cognitively intact and required extensive assistance of two staff with activities of daily living (ADL). She had a communication impairment and required the use of bilateral hearing aids to hear adequately. Review of the care plan dated 02/03/21 revealed resident had a communication impairment and required bilateral hearing aids to hear adequately. Interventions included the following: assist to wear hearing aids daily, maintain hearing aids in good working order, keep clean and replace batteries as needed, arrange for maintenance as needed. Review of the nurse aide assignment sheet for Resident #34 dated 10/13/21 revealed resident wore bilateral hearing aids. During observation on 10/13/21 at 11:15 A.M., Resident #34 revealed resident was not wearing hearing aids and exhibited difficulty hearing. During interview on 10/13/21 at 11:15 A.M., Resident #34 stated she was not wearing her hearing aids and was having difficulty hearing. She said her hearing aids were in her nightstand and staff were supposed to assist her with putting them in her ears when she woke up. During interview on 10/13/21 at 11:26 A.M., State tested Nursing Assistant (STNA) #198 confirmed Resident #34 was not wearing hearing aids and was exhibiting difficultly hearing without them. STNA #198 confirmed the nurse aide assignment sheet for the resident said she was to wear bilateral hearing aids, but she thought the nurse was responsible for assisting resident with hearing aids. During interview on 10/13/21 at 11:27 A.M., Licensed Practical Nurse (LPN) #202 confirmed Resident #34 wore hearing aids, which she kept in her nightstand. LPN #202 stated she thought the resident managed her hearing aids independently and did not require staff assistance with them. During observation on 10/13/21 at 11:28 A.M. with LPN #202, a check of the resident's nightstand revealed one hearing aid was in the nightstand in a box and the other hearing aid was missing. Review of the facility policy titled Care of Hearing Aids, undated, revealed staff should review residents care plan to assess needs of the resident regarding hearing aids, assess resident's knowledge of operating the hearing aid, and should notify supervisor if hearing aid is lost or damaged.

Based on observation, staff interview, and review of the facility's policy, the facility failed to handle soiled laundry and trash in an appropriate and sanitary manner. This had the potential to affect the eight residents residing on the first floor and 17 residents residing on the fifth floor. The facility census was 63. Findings include: Observation on 0[DATE] at 6:00 A.M. revealed there were two large bags had been placed on the floor in the resident hallway on the Faith Center hall on the first floor. Interview on 0[DATE] at 6:20 A.M. with Licensed Practical Nurse (LPN) #[AGE] confirmed the bags in the resident hallway contained soiled resident laundry which had been gathered by staff and placed on the floor in the resident hallway. LPN #[AGE] further confirmed the bags would be there until approximately 7:00 A.M. when the laundry department would collect them. Observation on 0[DATE] at 6:23 A.M. revealed two clear plastic bags which appeared to contain trash including soiled incontinence products were placed on the floor in the resident hallway of the fifth floor adjacent to rooms 501-509. Interview on 0[DATE] at 6:24 A.M. with State tested Nursing Assistant (STNA) #70 confirmed the plastic bags on the floor of the fifth floor hallways contained trash including soiled incontinence products and had been placed there by staff. Interview on 0[DATE] at 7:30 A.M. with the Director of Nursing (DON) confirmed soiled laundry and trash should not be placed on the floor in the resident hallways. Review of the facility's undated policy titled Personal Laundry revealed all soiled laundry is processed as if contaminated with infectious waste. Review of the facility's undated policy titled Trash Removal revealed the trash should be removed from the resident's room and disposed of properly in garbage receptacles. This was an incidental finding during the course of the complaint investigation.

Based on record review, staff interview, review of the hospital records, and review of the facility's policy, the facility failed to provide appropriate denture care for residents who were dependent on staff for personal hygiene. This affected one (Resident #1) of three residents reviewed for activities of daily living. The facility census was 63. Findings include: Review of the medical record for Resident #1 revealed an admission date of [DATE] with a [DIAGNOSES REDACTED]. Review of the admission nursing assessment, dated 12/30/19, revealed the resident had partial upper dentures and full lower dentures, which fit well. Review of the Minimum Data Set (MDS) assessment, dated 01/03/20, revealed the resident was cognitively impaired and required extensive assistance of one staff with personal hygiene. Review of the care plan, dated 0[DATE], revealed the resident had partial upper dentures and full lower dentures and required assistance with oral care related to a [DIAGNOSES REDACTED]. Review of the nurse aide care card, undated, revealed the resident had dentures. review of the resident's medical record revealed [REDACTED]. Review of the nursing progress note, dated 02/05/20 at 7:35 A.M., revealed the resident had a fever, was moaning and crying out, was unable to take oral meds and exhibited increased shaking of the mouth and hands. The nurse notified the attending physician and the resident's representative of the resident's condition. The nursing progress note, dated 02/05/20 at 8:00 A.M., revealed the resident was sent to the emergency room for evaluation. Review of timeline provided by the facility regarding Resident #1's hospitalization on [DATE] revealed the resident was sent to the hospital via the emergency services, 9-1-1 at 8:02 A.M. The timeline stated the hospital physician noted at 6:45 P.M. the resident's dentures were impacted. The timeline revealed the hospital nurse noted on 02/05/20 at 8:28 P.M. during the admission nursing assessment the resident's mouth was crusted with dry skin and her dentures were difficult to remove. Review of the physician's hospital note, dated 02/05/20 at 6:50 P.M., revealed the resident's dentures were fairly badly impacted in her oral cavity. Interview on 0[DATE] at 6:25 A.M. with State tested Nursing Assistant (STNA) #70 confirmed the resident's dentures should be removed at night and they should be cleaned and/or soaked. STNA #70 further confirmed the day shift aides would replace dentures when getting the resident ready for the day. Interview on 0[DATE] at 7:30 A.M. with the Director of Nursing (DON) confirmed Resident #1 had upper and lower dentures and did not use any type of denture adhesive. The DON further confirmed the resident had dentures in her mouth when she left the facility in the morning on 02/05/20 at 8:00 A.M. and she had refused mouth care prior to leaving the facility. The DON also confirmed denture care should be done every night and should include removing the dentures and cleaning them and storing the dentures in a denture cup overnight while the resident was sleeping. Interview on 0[DATE] at 9:58 A.M. with Licensed Practical Nurse (LPN) #130 confirmed she attempted mouth care for Resident #1 at approximately 6:00 A.M. on 02/05/20 and resident's upper and lower dentures were in her mouth at that time. LPN #130 further confirmed she started caring for Resident #1 on [DATE] at 7:00 P.M. and she did not observe resident's dentures had been removed from her mouth. LPN #130 confirmed State tested Nursing Assistant (STNA) #140 was the aide caring for resident on nightshift starting [DATE] into 02/05/20 and should have removed resident's dentures and allowed them to soak overnight. LPN #130 could not confirm Resident #1's dentures had been removed from her mouth and cleaned on [DATE]. Review of the facility's undated policy titled Denture Care revealed the facility would provide ongoing care for residents with dentures which included removal of dentures, cleaning them, and reinserting them into the resident's mouth. This deficiency substantiates Complaint Number OH 090.

Based on observation, staff interview, pharmacy Recommended Minimum Medication Storage Parameters, and [MEDICATION NAME] manufacturing recommendations for storage, the facility failed to properly store, label, and dispose open vials of medications. This had the potential to affect 22 new admissions within the last 30 days. The facility census was 69. Findings include: Observation on 03/13/19 at 10:30 A.M. with Licensed Practical Nurse (LPN) #90 of the fifth floor medication room revealed an open vial of [MEDICATION NAME] ([MEDICATION NAME] PPD) with no open date on label. Interview on 03/13/19 at 10:33 A.M. with LPN #90 verified that the vial of [MEDICATION NAME] was open and did not know the date it was opened. Observation on 03/13/19 at 10:46 A.M. with Registered Nurse (RN) #144 of the Rehab floor medication room revealed an open vial of [MEDICATION NAME] in the refrigerator with no date on the label. Interview on 03/13/19 at 10:49 A.M. with RN #144 verified that there was no date on the vial of [MEDICATION NAME] and was not aware of when it was opened. Review of the pharmacy Recommended Minimum Medication Storage Parameters (dated 03/31/17) revealed store in the refrigerator at 36-46 degrees Fahrenheit. Protect from light. Date when opened and discard unused portion in 30 days. Review of the [MEDICATION NAME] manufacturers recommendations for storage, revealed vials in use for more than 30 days should be discarded due to possible oxidation and degradation which may affect potency.

Based on observations, record review, review of facility policy and staff interviews, the facility failed to ensure staff provided a dignified dining experience while feeding Resident #56 during meal time. This affected one (#56) of four residents who were total dependent for assistance in eating on the fifth floor. The facility census was 69. Findings include: Medical record review revealed Resident #56 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/05/18, revealed Resident #56 was severely impaired and required extensive assistance with two people assistance for Activities of Daily Living (ADL). Resident #56 was unable to make daily decisions, had unclear speech, rarely understood others and vision was highly impaired. Observations on 03/12/19 at 5:55 P.M., revealed State tested Nursing Assistant (STNA) #91 was texting on personal cell phone while feeding Resident #56 in bed. Interview on 03/12/19 at 6:00 P.M., revealed STNA #91 verified she was using her personal cell phone while feeding Resident #56 in bed and she reported she was not allowed to use personal cell phone while working with residents. Interview on 03/13/19 at 11:00 A.M., revealed the Administrator reported possession and use of personal electronic devices were prohibited and each employee signed a contract acknowledging the policy. Reviewed STNA #91 contract for not using personal electronic devices was signed on 02/05/19 by STNA #91. Reviewed policy titled, Social Media and Personal Electronic Device Policy dated 10/07/16 stated, Possession of cellular phones, tablets, other electronic recording devices, camera phones and push-to-talk phones within Christian Village Communities facilities is prohibited with the following approved exception; employees may keep their devices in a locker within the building and may use their devices only during designated break and meal times and in employee break areas or other designated areas.

Based on observations and staff interview, the facility failed to display the Ohio Department of Health survey results, where residents and visitors could visibly access them. This had the potential to affect all 69 residents residing in the facility. Findings include: A tour of the fourth and fifth floor of the facility on 03/11/19 at 7:00 P.M., revealed the Survey Results were not readily accessible to residents or visitors without having to ask for them. No sign was posted to identify where the survey results were located. On 03/12/19 at 4:13 P.M., during the resident council meeting, Residents #7, #10, #20, #25, #44 and #52 reported they were unaware of the posting of the Ohio Department of Health survey results. Observation on 03/12/19 at 5:00 P.M., revealed first floor, fourth floor and fifth floor showed no signs posted to identify where survey results were located. On 03/12/19 at 6:30 P.M., interview with Activities Director (AD) #77 revealed the State Survey Results were on first floor but only had (YEAR) results. AD #77 verified that residents and visitors on all three floors did not have access to state survey results for the past three years. AD #77 reported the facility was painting and decorating and perhaps forgot to repost survey results on each floor.

Based on observation, record review, and staff interview the facility failed to discard expired medications. This affected two (#15 and #25) of four residents the facility identified who received insulin from the 400-406 medication cart and had the potential to affect all resident who receive stock medication from the facility. The total facility census was 67. Findings include: Observation of 400-406 medication cart on 01/23/18 at 10:00 A.M. revealed the Basilar quick pen for Resident #15 was opened on 12/14/17, and the [MEDICATION NAME] pen for Resident #25 was opened on 12/19/17. There were no other insulin pens in the medication cart for either Resident #15 or #25. Observation of Resident #15's Medication Administration Record [REDACTED].M., nightly after 01/10/18 when the medication expired. Observation of Resident #25's MAR indicated [REDACTED].M. nightly after 01/15/18 when the medication expired. Observation of the medication room on the fourth floor on 01/25/18 at 11:05 A.M. revealed there were 15 cans of Nephro (supplement) stored in the medication room that had an expiration date of 06/2016, and a box of 60 [MEDICATION NAME] calcium with D chews (vitamin chews) that was unopened and had an expiration date of 12/2013. Review of the undated policy titled Storage of Medications revealed the facility shall not use discontinued, outdated or deteriorated drugs or biological's. All such drugs shall be returned to the dispensing pharmacy or destroyed. Interview with the Registered Nurse #20 on 01/23/18 at 10:05 A.M., verified the two insulin pens were expired and both Resident #15 and Resident #25 continued to receive the medication after the medication was expired. Interview with Licensed Practical Nurse #10 on 01/25/18 at 11:05 A.M.,verified there was expired Nephro supplement and [MEDICATION NAME] chews in the 400 hall medication room.

Based on record review and staff interviews, the facility failed to ensure laboratory results were obtained per physician orders. This affected one (#58 ) of three residents reviewed for laboratory test related to nutrition. The facility census was 68. Findings include: Review of Resident #58's medical record revealed an admitted [DATE], with [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. The order was signed by a Physician Assistant. The medical record revealed the only laboratory results were dated 01/23/18 ordered STAT (immediately). Interview on 01/24/18 at 9:43 A.M. with Licensed Practical Nurse (LPN) #41 verified the ordered laboratory results from 01/03/18 were not in the medical record. Interview on 01/25/18 at 12:30 P.M., with Registered Nurse (RN) #30 and the Director of Nursing (DON) revealed a CBC result dated 01/04/18 with a notation on the bottom of form indicating BMP specimen for 01/04/18 was hemolyized (clotted) and needed to be drawn again. RN #30 and the DON stated the facility never received the BMP results. The DON denies any method to ensure physician ordered lab results are completed. The DON failed to produce a facility policy for laboratory testing.

Based on observation and staff interview, the facility failed to maintain proper infection control practices when utilizing personal protective gear. This affected one (#30) of one residents randomly observed. The total facility census was 68. Findings include: Observation on 01/23/18 at 10:30 A.M. revealed Resident #24 and #61 (who were in the same room), had a container outside the door which had personal protective equipment stored in it. State tested Nursing Assistant (STNA) #25 exited the room with a mask on her chin. At that time, STNA #25 was questioned if personal protective equipment was needed to be worn when entering room? The STNA #25 stated yes the residents are in isolation for the influenza. STNA #25 was then observed entering Resident #30's room with the mask still on her chin. STNA #25 was heard to ask Resident #30, if they were ready to get up and the resident responded no. STNA #25 stated she would return later. STNA #25 exited the room and did not have the mask on her chin upon exiting the room. Interview with STNA #25 on 01/23/18 at 10:33 A.M., verified she exited the room where the residents were isolated with a mask on and then entered Resident #30's room who was not in isolation (still wearing the mask she had on in the isolation room).

Based on observation, staff interviews, record review and policy review, the facility failed to discard medications that had expired. This affected one (#116) of five residents medications observed for the presence of expired medication and had the potential to affect residents who received stock medications. The census was 70. Findings include: 1. On [DATE] at 11:31 A.M. an observation of the Central Stock Medication Supply was conducted with Licensed Practical Nurse (LPN) Supervisor #3. Five bottles of Lactulose Solution 10 grams (g)/ five milliliters (ml) had an expiration date of ,[DATE], two bottles of Lactulose Solution 10 g/ five ml had an expiration date of ,[DATE], three bottles of Prenatal Multivitamins had an expiration date of ,[DATE], two bottles of Oyster Shell 250 milligrams (mg) plus Vitamin D had an expiration date of ,[DATE], two bottles of Zinc Sulfate 220 mg (supplement) with an expiration date of ,[DATE], and one bottle of Senior Tab (Multivitamin with minerals) with an expiration date of ,[DATE]. On [DATE] at 11:45 A.M. an interview with LPN Supervisor #3 verified all the above medications were expired and should not have been in the stock medications. 2. Chart review for Resident #116 revealed resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Physician order [REDACTED].#116 was prescribed Vitamin E 400 mg daily by mouth. On [DATE] at 9:03 A.M. observation of the Four (4) North medication cart with LPN #6 revealed a bottle of Vitamin E 400 mg had an expiration date of ,[DATE] for Resident #116 with an admitted [DATE]. On [DATE] an interview during observation of medication cart LPN #6 verified that the bottle of Vitamin E 400 mg was expired and brought to cart from the Central Stock Medication Supply. Review of the Over the Counter Medications Policy (not dated) revealed Over the Counter medication dates will be checked upon receipt and when dispersed by authorized designees (supervisors or central supply) for expiration dates.

Based on record review, observations and staff interview, the facility failed to administer medication as physician ordered resulting in a medication error rate that was greater than five percent. This affected one (#14) of four residents observed during medication pass observations and resulted in two medication errors out of 32 medication opportunities or a 6.25% medication error rate. Facility census was 70. Findings include: During observation of the medication pass on 11/02/16 at 8:56 A.M., Resident #15 was observed receiving her medications. Registered Nurse (RN) #5 prepared and administered eight and half medications to the resident including I-Caps one tablet, [MEDICATION NAME] 25 milligrams (mg), Aspirin 81 mg, [MEDICATION NAME] 12.5 mg, [MEDICATION NAME] 60 mg, Multivitamin one tablet, Vitamin E 400 mg, and [MEDICATION NAME] 10 MilliEquivalents (mEq). During reconciliation of Resident #15's medications after the medication pass it was discovered that the resident was also ordered to receive [MEDICATION NAME] 5 mg and [MEDICATION NAME] Packet 3.4 grams (one packet in liquid) which was omitted. This omission constituted two medication errors for Resident #15. On 11/02/16 at 10:47 A.M. an interview was conducted with RN #5 verified that Resident #15 had not been given the [MEDICATION NAME] 5 mg and [MEDICATION NAME] Packet 3.4 grams (one packet in liquid) during the initial medication pass observed.

Based on record review, review of a Self-Reported Incident (SRI) and the facility's investigation, and interviews with staff, the facility failed to ensure staff carried out activities that promoted each resident's dignity and failed to assist each resident to maintain and enhance his/her self-esteem and self-worth by taking inappropriate pictures of a resident, using derogatory language and posting it on social media. This resulted in actual harm when one (#9) State tested Nurse Aide (STNA) engaged in actions meant to humiliate one (#1) confused resident by taking an inappropriate picture/video without permission. The picture was taken over the course of the weekend from May 13th to the 15th, 2016 and was posted on social media when taken, resulting in intentional humiliation and psychological harm of the resident. The picture identified the resident was in a gown, was all covered up with an emoji (a digital image to express an idea or emotion) over her face and all that showed was her hair and one ear. This affected one (#1) of three residents reviewed for dignity. The facility census was 65. Findings include: Review of Resident #1's most recent quarterly Minimum Date Set (MDS) assessment dated [DATE], revealed Resident #1 (the Specified Resident) was admitted to the facility on [DATE]. According to the MDS, Resident #1 had minimal difficulty hearing and her vision was adequate. She was sometimes able to make herself understood and sometimes understood and was sometimes able to respond adequately to simple direct communication only. She had a Brief Interview for Mental Status (BIMS) score of four, indicating she was cognitively impaired. Under signs and symptoms for [MEDICAL CONDITION], the MDS assessment identified Resident #1 as inattentive (easily distracted, out of touch or difficulty following what was said) and she had disorganized thinking. Under functional status on the MDS, Resident #1 was identified as requiring extensive assistance with bed mobility (of two), transferring, dressing, toilet use, personal hygiene, and extensive assistance with locomotion. According to the assessment, the resident did not walk during the assessment period. She was coded as always incontinent of bowel and bladder. She was on an antidepressant and an anticoagulant. The [DIAGNOSES REDACTED]. Review of the Self-Reported Incident (SRI) Form dated 05/18/16, revealed Resident #1 was emotionally/verbally abused when State tested Nurse Aide (STNA) #9, posted a picture of Resident #1 with a smiley face emoji covering her face on social media (Facebook). According the SRI form, STNA #12 and STNA #38 reported to the Director of Nursing (DON) on 05/17/16 at 5:30 P.M., that STNA #9 had posted a a video on Facebook that had a resident from the facility in it. According to the report, the video had a header on it with the facility's name. According to the report at the time of the investigation, the video had been removed from social media, however, STNA #9 still had it on her cell phone and showed it to the DON. According to the SRI Form, the video showed the resident sitting in the bathroom with an emoji covering three fourths of her face. According to the report, STNA #9 was lifting the residents white hair up and stated, [***] is this your hair, is that all you can do. On 05/26/16 at 1:30 P.M., the DON was interviewed via telephone. She stated on 05/17/16 at about noon, STNA #12 informed her that STNA #9 had posted a video of Resident #1 on social media. She stated she attempted to locate the video on social media and was not able to locate it. She stated she immediately removed STNA #9 from the floor and took her to the Human Resource office. She stated STNA #9 stated she had removed the video from social media, however, she still had it on her phone and she showed it to the DON. According to the DON, she stated she watched the entire video STNA #9 had on her phone. She stated on the video all you could see was the resident's shoulders and head. She stated the resident was in a gown and was all covered up with an emoji over her face so all that showed was her hair and one ear. She stated it was possible to tell they were in the facility's shower room. She stated nothing was exposed and if you were not familiar with the resident's hair and voice you would not know who it was. She stated in the video, STNA #9 stated, Is this your hair? Is this the best you have [***] ? The DON stated Resident #1 stated something like, Honey what are you talking about? The DON stated she heard STNA #38 had heard about it and told STNA #9 to delete it. She stated STNA #9 was walked out of the building and was told never to step back onto the property. She stated she did not know what date the video was recorded nor when it was initially posted on Facebook nor for how long it was on Facebook. She stated STNA #9 just told her she had done it recently and would not say when she did it. She verified the staff who had knowledge of the video did not report it to her nor the Administrator in a timely manner. She stated she had begun in-servicing staff immediately on the facility policy related to prohibiting staff from taking pictures or videos of residents and regarding reporting all abuse violations and the use of cell phones/taking pictures and videos of residents the same day it was reported to her. During the investigation STNA #38 was interviewed on 05/26/16 at 1:45 P.M. She stated she could not remember the exact date she saw the video, however, it was sometime between Friday 05/13/16 and Sunday 05/15/16. She stated STNA #5, STNA #24, and STNA #67 were in the hall looking at the video with the sound muted. She stated she did not see the whole video, only in passing. She stated all that could be seen was the resident's hair and one ear because there was an emoji covering the residents face. She stated STNA #9 was working the day she observed the video and she told her to remove the video and she did. She stated she did not report it to anyone. STNA #5, STNA #24, and STNA #12, were each interviewed and they confirmed STNA #38's statement. STNA #67 was interviewed on 05/27/16 at 11:09 A.M. and she stated she did not see the video and had no knowledge of it until after the fact. Interview with the Administrator on 05/27/16 at 1:00 P.M., revealed the above incident occurred and verified STNA #9 was terminated. This deficiency substantiates Control Number OH 558.

Based on record review, review of a Self-Reported Incident (SRI) and staff interview, the facility failed to ensure one alleged incident of abuse involving Resident #1 was immediately reported to the Administrator. This affected one (#1) of three residents reviewed for abuse/neglect. The facility census was 65. Findings include: Review of Resident #1's most recent quarterly Minimum Date Set (MDS) assessment dated [DATE], revealed Resident #1 (the Specified Resident) was admitted to the facility on [DATE]. According to the MDS, Resident #1 had minimal difficulty hearing and her vision was adequate. She was sometimes able to make herself understood and sometimes understood and was sometimes able to respond adequately to simple direct communication only. She had a Brief Interview for Mental Status (BIM) score of four, indicating she was cognitively impaired. Under signs and symptoms for [MEDICAL CONDITION], the MDS assessment identified Resident #1 as inattentive (easily distracted, out of touch or difficulty following what was said) and she had disorganized thinking. Under functional status on the MDS, Resident #1 was identified as requiring extensive assistance with bed mobility (of two), transferring, dressing, toilet use, personal hygiene, and extensive assistance with locomotion. According to the assessment, the resident did not walk during the assessment period. She was coded as always incontinent of bowel and bladder. She was on an antidepressant and an anticoagulant. The [DIAGNOSES REDACTED]. Review of the Self-Reported Incident (SRI) Form (with tracking # 6) dated 05/18/16, revealed Resident #1 was emotionally/verbally abused when State tested Nurse Aide (STNA) #9, posted a picture of Resident #1 with a smiley face emoji covering her face on social media (Facebook). According the SRI form, STNA #12 and STNA #38 reported to the DON on 05/17/16 at 5:30 P.M., that STNA #9 had posted a a video on Facebook that had a resident from the facility in it. According to the report, the video had a header on it with the facility's name. According to the report at the time of the investigation, the video had been removed from social media, however, STNA #9 still had it on her cell phone and showed it to the DON. According to the SRI Form, the video showed the resident sitting in the bathroom with an emoji covering three fourths of her face. According to the report, STNA #9 was lifting the residents white hair up and stated, [***] is this your hair, is that all you can do. On 05/26/16 at 1:30 P.M., the Director of Nursing (DON) was interviewed via telephone. She stated on 05/17/16 at about noon, STNA #12 informed her that STNA #9 had posted a video of Resident #1 on social media. She stated she attempted to locate the video on social media and was not able to locate it. She stated she immediately removed STNA #9 from the floor and took her to the Human Resource office. She stated STNA #9 stated she had removed the video from social media, however, she still had it on her phone and she showed it to the DON. According to the DON, she stated she watched the entire video STNA #9 had on her phone. She stated on the video all you could see was the resident's shoulders and head. She stated the resident was in a gown and was all covered up with an emoji over her face so all that showed was her hair and one ear. She stated it was possible to tell they were in the facility's shower room. She stated nothing was exposed and if you were not familiar with the resident's hair and voice you would not know who it was. She stated in the video, STNA #9 stated, Is this your hair? Is this the best you have [***] ? The DON stated Resident #1 stated something like, Honey what are you talking about? The DON stated she heard STNA 38 had heard about it and told STNA #9 to delete it. She stated STNA #9 was walked out of the building and was told never to step back onto the property. She stated she did not know what date the video was recorded nor when it was initially posted on Facebook nor for how long it was on face book. She stated STNA #9 just told her she had done it recently and would not say when she did it. She verified the staff who had knowledge of the video did not report it to her nor the Administrator in a timely manner. She stated she had begun in-servicing staff immediately on the facility policy related to prohibiting staff from taking pictures or videos of residents and regarding reporting all abuse violations and the use of cell phones/taking pictures and videos of residents the same day it was reported to her. During the investigation STNA #38 was interviewed on 05/26/16 at 1:45 P.M. She stated she could not remember the exact date she saw the video, however, it was sometime between Friday 05/13/16 and Sunday 05/15/16. She stated STNA #5, STNA #24, and STNA #67 were in the hall looking at the video with the sound muted. She stated she did not see the whole video, only in passing. She stated all that could be seen was the resident's hair and one ear because there was an emoji covering the residents face. She stated STNA #9 was working the day she saw it and she told her to remove it and she did. She stated she did not report it to anyone. STNA #5, STNA #24, and STNA #12, were each interviewed and they confirmed STNA #38's statement. STNA #67 was interviewed on 05/27/16 at 11:09 A.M. and she stated she did not see the video and had no knowledge of it until after the fact. On 05/26/16, Resident #1 was interviewed. She stated she was doing good. The resident was pleasantly confused and smiling during the interview. When ask if any staff had ever talked to her in a rude manner, she stated no. When ask if staff treat her with respect and dignity, she stated yes and added they were very good. She was asked if anyone had ever abused her verbally, sexually, or physically and she stated they had not. Review of the facility abuse policy revealed it was the facility's policy for all employees to report all alleged incidents of abuse including verbal abuse, to their supervisor immediately and for it to be reported immediately to the Administrator. Further review of the policy revealed the facility's definition of verbal abuse included oral, written or gestural language that willfully included disparaging and derogatory terms. Interview with the Administrator on 05/27/16 at 1:00 P.M., revealed the incident was not reported to him until approximately noon on 05/17/16. This deficiency substantiates Control Number OH 558.

Based on record review, review of a Self-Reported Incident (SRI) and staff interview, the facility failed to ensure one alleged incident of abuse involving Resident #1 was immediately reported to the Administrator per policy. This affected one (#1) of three residents reviewed for abuse/neglect. The facility census was 65. Findings include: Review of Resident #1's most recent quarterly Minimum Date Set (MDS) assessment dated [DATE], revealed Resident #1 (the Specified Resident) was admitted to the facility on [DATE]. According to the MDS, Resident #1 had minimal difficulty hearing and her vision was adequate. She was sometimes able to make herself understood and sometimes understood and was sometimes able to respond adequately to simple direct communication only. She had a Brief Interview for Mental Status (BIM) score of four, indicating she was cognitively impaired. Under signs and symptoms for [MEDICAL CONDITION], the MDS assessment identified Resident #1 as inattentive (easily distracted, out of touch or difficulty following what was said) and she had disorganized thinking. Under functional status on the MDS, Resident #1 was identified as requiring extensive assistance with bed mobility (of two), transferring, dressing, toilet use, personal hygiene, and extensive assistance with locomotion. According to the assessment, the resident did not walk during the assessment period. She was coded as always incontinent of bowel and bladder. She was on an antidepressant and an anticoagulant. The [DIAGNOSES REDACTED]. Review of the Self-Reported Incident (SRI) Form (with tracking # 6) dated 05/18/16, revealed Resident #1 was emotionally/verbally abused when State tested Nurse Aide (STNA) #9, posted a picture of Resident #1 with a smiley face emoji covering her face on social media (Facebook). According the SRI form, STNA #12 and STNA #38 reported to the DON on 05/17/16 at 5:30 P.M., that STNA #9 had posted a a video on Facebook that had a resident from the facility in it. According to the report, the video had a header on it with the facility's name. According to the report at the time of the investigation, the video had been removed from social media, however, STNA #9 still had it on her cell phone and showed it to the DON. According to the SRI Form, the video showed the resident sitting in the bathroom with an emoji covering three fourths of her face. According to the report, STNA #9 was lifting the residents white hair up and stated, [***] is this your hair, is that all you can do. On 05/26/16 at 1:30 P.M., the Director of Nursing (DON) was interviewed via telephone. She stated on 05/17/16 at about noon, STNA #12 informed her that STNA #9 had posted a video of Resident #1 on social media. She stated she attempted to locate the video on social media and was not able to locate it. She stated she immediately removed STNA #9 from the floor and took her to the Human Resource office. She stated STNA #9 stated she had removed the video from social media, however, she still had it on her phone and she showed it to the DON. According to the DON, she stated she watched the entire video STNA #9 had on her phone. She stated on the video all you could see was the resident's shoulders and head. She stated the resident was in a gown and was all covered up with an emoji over her face so all that showed was her hair and one ear. She stated it was possible to tell they were in the facility's shower room. She stated nothing was exposed and if you were not familiar with the resident's hair and voice you would not know who it was. She stated in the video, STNA #9 stated, Is this your hair? Is this the best you have [***] ? The DON stated Resident #1 stated something like, Honey what are you talking about? The DON stated she heard STNA 38 had heard about it and told STNA #9 to delete it. She stated STNA #9 was walked out of the building and was told never to step back onto the property. She stated she did not know what date the video was recorded nor when it was initially posted on Facebook nor for how long it was on face book. She stated STNA #9 just told her she had done it recently and would not say when she did it. She verified the staff who had knowledge of the video did not report it to her nor the Administrator in a timely manner. She stated she had begun in-servicing staff immediately on the facility policy related to prohibiting staff from taking pictures or videos of residents and regarding reporting all abuse violations and the use of cell phones/taking pictures and videos of residents the same day it was reported to her. During the investigation STNA #38 was interviewed on 05/26/16 at 1:45 P.M. She stated she could not remember the exact date she saw the video, however, it was sometime between Friday 05/13/16 and Sunday 05/15/16. She stated STNA #5, STNA #24, and STNA #67 were in the hall looking at the video with the sound muted. She stated she did not see the whole video, only in passing. She stated all that could be seen was the resident's hair and one ear because there was an emoji covering the residents face. She stated STNA #9 was working the day she saw it and she told her to remove it and she did. She stated she did not report it to anyone. STNA #5, STNA #24, and STNA #12, were each interviewed and they confirmed STNA #38's statement. STNA #67 was interviewed on 05/27/16 at 11:09 A.M. and she stated she did not see the video and had no knowledge of it until after the fact. On 05/26/16, Resident #1 was interviewed. She stated she was doing good. The resident was pleasantly confused and smiling during the interview. When ask if any staff had ever talked to her in a rude manner, she stated no. When ask if staff treat her with respect and dignity, she stated yes and added they were very good. She was asked if anyone had ever abused her verbally, sexually, or physically and she stated they had not. Review of the facility abuse policy revealed it was the facility's policy for all employees to report all alleged incidents of abuse including verbal abuse, to their supervisor immediately and for it to be reported immediately to the Administrator. Review of the policy revealed the facility's definition of verbal abuse included oral, written or gestural language that willfully included disparaging and derogatory terms. Interview with the Administrator on 05/27/16 at 1:00 P.M., revealed the incident was not reported to him per facility policy until approximately noon on 05/17/16. This deficiency substantiates Control Number OH 558.

Based on record review and interview, the facility failed to ensure residents have ready access to their personal funds on the evenings and weekends. This potentially affected 19 residents who have their funds managed by the facility. The facility census was 61. Findings include: On 8/10/15 at 4:01 P.M., a confidential interview with a resident indicated they cannot get money out of their account on the weekends. The resident stated they need to remember to get money on Monday through Friday. A review of resident funds was conducted on 8/11/15. The facility managed personal funds for 19 residents. On 8/11/15 at 9:30 A.M., the Business Office Manager #5 indicated if residents want money outside of her working hours, Monday through Friday 8:00 A.M. to 4:30 P.M., the staff have to call her, and she will come in. She said this has never happened. She stated there is nothing set up for the weekends related to residents having access to money. Review of the admission packet revealed, under the section Money, You may open a Personal Savings Account or Resident Trust Account where we will keep your money in a safe place until you need it. This works like a savings account where you (or your authorized individual) can come to the business office and make deposits or withdrawals during the hours of 9:00 A.M. to 4:00 P.M. Monday through Friday.

Based on record review, observation and interview, the facility failed to ensure a resident who had a history of [REDACTED]. This affected one (Resident #101) of three resident's reviewed for falls. The facility identified 13 residents who have fallen in the past 30 days. Findings include: Review of Resident #101's medical record indicated the resident was admitted on [DATE] and had [DIAGNOSES REDACTED]. The resident had a history of [REDACTED]. The resident's comprehensive assessment dated [DATE] indicated the resident as cognitively impaired and required extensive assistance with activities of daily living (ADL) including transferring and locomotion. Review of the nurses notes indicated the resident had multiple falls without injury while at the facility. According to the notes on 04/29/14, Resident #101 had another fall. The resident was found sitting on the floor in front of her wheelchair in her room. To prevent additional falls the facility implemented the new intervention of a personal senor alarm (PSA) to her wheelchair seat. During observation on 05/01/14 at 10:30 A.M. Resident #101 was in her wheelchair in the common area near the nursing station. The resident's PSA was not in place. Nursing Supervisor #5 verified the resident's alarm was not in place at that time.