Every finding on record at National Church Residences Bristol Village

Based on record review and interview, the facility failed to ensure nutritional interventions were provided to residents in a timely manner. This affected one resident (#74) of three residents reviewed for nutrition services. The facility census was 36. Findings included: Record review revealed Resident #74 was admitted to the facility on [DATE] with diagnoses including dementia, heart failure, chronic kidney disease stage 3, anemia, gastro-esophageal reflux disease, and atrial fibrillation. Review of a minimum data set (MDS) assessment collected on 11/02/22 revealed Resident #74 had mildly impaired cognition, no behaviors, required set up or clean up assistance with meals, and was receiving a therapeutic diet. Review of orders revealed Resident #74 had an order for a no added salt diet on 10/27/22 and had received an order for Ensure Plus twice a day on 11/22/22. Review of medication administration record (MAR) for November and December 2022 revealed Resident #74 did not receive first administration of Ensure Plus until 12/01/22. Interview on 11/07/23 at 2:02 P.M. with the Director of Nursing (DON) revealed the dietician had made a recommendation for Ensure Plus on 11/22/22, however the physician was out of town and the order was not signed until 12/01/22. The DON stated the facility did have a nurse practitioner to cover for emergent services while the physician was unavailable but she would not sign certain orders such as nutrition recommendations. The DON stated she did not feel this was sufficient and she did not believe the facility had a policy related to physician services. This deficiency represents non-compliance investigated under Complaint Number OH00143598.

Based on record review, facility reported incident review, and interview, the facility failed to complete a thorough investigation for an allegation of physical abuse. This affected one resident (#75) of three residents reviewed for allegations of abuse. The facility census was 36. Findings included: Closed record review revealed Resident #75 was admitted to the facility on [DATE] with diagnoses including respiratory failure, chronic obstructive pulmonary disease, chronic systolic congestive heart failure, dysphagia, anemia, panic disorder, and gastro-esophageal reflux disease. Review of minimum data set assessment collected on 04/04/23 revealed Resident #75 had mild- impaired cognition and did not have behaviors related to refusing care. Review of transfer and discharge records revealed Resident #75 transferred to the hospital on 04/05/23. Review of a facility reported incident completed on 04/03/23 revealed Resident #75's representative spoke with the administrator regarding an allegation of staff forcing her to take a shower. The facility did start an immediate report to appropriate agencies regarding the alleged incident, but the facility did not provide evidence of interviews with Resident #75, like residents, or staff members and the investigation did not include evidence of a skin check or resident assessment being completed. Interview on 11/07/23 at 2:05 P.M. with the Administrator confirmed there were no other records regarding the investigation to review. Review of a policy titled Abuse, Mistreatment, Neglect, Injuries of Unknown Source revealed the facility should interview the resident, the accused, and all witnesses including anyone who worked directly with the resident, came into contact with the resident, or heard or saw the incident occur. After each interview, the interviewee should be allowed to review the statement collected and sign to prove the documentation is an accurate reflection of their view. Policy also stated the facility should review the resident records. This deficiency is cited as an incidental finding to Complaint Number OH00143598.

Based on observation, facility policy and procedure review and interview the facility failed to properly store, date (label), and prepare food to protect against contamination and/or spoilage. This had the potential to affect all 37 residents residing in the facility. Findings Include: 1. On 11/14/22 at 8:45 A.M. and 9:20 A.M. observation in the kitchen revealed three sealed/unopened packages of ham in a large plastic container in the walk in refrigerator. Two packages were thawed and cool to the refrigerator's temperature. One package still had frost/ice on the outside and was frozen to touch. Neither package had a date as to when it was delivered or when it was removed from the freezer to thaw for service. Also, there was one package of a block of cheese that was in a sealed plastic bag, due to the cheese being opened but not fully used. There was no date on the bag of the cheese as to when it was opened. Finally, there was a large metal pan of vegetable soup with no top and no date on the pan, inside the walk in freezer. Interview with Dietary Staff #201 on 11/14/22 at 8:50 A.M. confirmed the ham packages that were in the walk in refrigerator, were originally in the freezer. She confirmed staff typically take frozen items out of the freezer, and allow them to thaw in the refrigerator for three days, and then use them. She confirmed she does not know the exact date when the packages of ham were taken out, but confirmed that one package was still frozen and two were not. She stated she cooked the vegetable soup that morning, and put it in the freezer to cool, because it would be served for the residents to eat in a few days. She indicated there was no lid on the pan of vegetable soup, so it would cool/freeze faster. Interview with Director of Food Services #123 on 11/14/22 at 9:20 A.M. confirmed there was no date on the three packages of ham, block of cheese in the plastic bag, and vegetable soup that was in the freezer. She also confirmed there should be dates on all three items; when the vegetable soup was placed in the freezer, when the ham was removed from the freezer to the refrigerator, and when the cheese was first opened. She also confirmed the pan of vegetable soup should have had a lid on it. Review of facility Refrigerated Storage policy, dated January 2016 revealed perishable foods shall be stored in a manner that optimizes food safety and quality. All pre-dished items shall be covered to prevent off-flavoring, drying, or cross contamination while refrigerated. Food container covers shall be impervious and non-absorbent. Refrigerated items shall bear a label indicating product name and date (month, day, year) product was received, used or first opened. Review of Frozen Storage policy, dated January 2016 revealed all frozen products shall be labeled indicating product name and date of delivery (month, day, and year). Review of facility Thawing policy, dated January 2016 revealed all frozen foods shall be thawed in a manner that optimizes food safety and quality. The dietary manager or designee shall indicate products to be removed from the freezer for thawing. Food shall be thawed under refrigeration that maintains the food temperature at 41 degrees Fahrenheit or below. Food items shall be placed in a pan to collect any juices and shall be placed on the lowest refrigerated unit shelf to prevent cross contamination. Pan shall be checked frequently to prevent overflow. Food items shall be placed in separate pans for thawing (do not thaw chicken with beef or ham.) 2. On 11/16/22 at 10:17 A.M., 10:21 A.M., and 10:25 A.M. Dietary Staff (DS) #201 was observed with a disposable glove on her right hand. DS #201 was observed to place pieces of pork into the blender with her gloved hand. After putting the pork in, she touched the blender, dirty counter top, metal pans, cloth towel, utensil, and blender lid. Then, she put more pork into another blender to make ground textured meat. She used the same gloved hand (did not change glove), to put more of the meal into the blender. After blending the meat to the proper texture, she opened the lid and put the same gloved hand on the inside of the blender to hold the blade intact while dumping the meat into a metal pan. After putting the metal pan of ground meat on the steam table, she took the pork gravy pan to the steam table to put it on the tray line as well. Prior to doing that, she wiped the sides of the gravy pan with the same gloved hand four times, and put the wiped gravy back into the gravy pan. Interview with Dietary Staff #201 on 11/16/22 at 10:26 A.M. confirmed she did not change her gloves throughout the entire preparation and storage process listed above. DS #201 revealed she does not change her gloves while she is working with the same food type (all pork products). Review of facility Disposable Gloves policy, dated October 2020 revealed disposable gloves shall be used for only one task and shall be discarded when damaged or soiled or when interruptions occur in operation. Gloved hands were considered a food contact surface that could become contaminated or soiled. Disposable gloves need to be changed between tasks and as often as hands need to be washed.

Based on record review and staff interview, the facility failed to ensure Resident #18's Pre-Admission Screening and Resident Review (PASARR) documents were accurate related to the resident's condition and diagnoses. This affected one resident (#18) of one resident reviewed for PASARR. Findings Include: Record review revealed Resident #18 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #18 PASARR document, dated 12/16/19 revealed under Section D, it indicated the resident had no mental health diagnoses. However, review of the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) 3.0 assessment, dated 10/10/22 revealed the resident was cognitively intact. On 11/17/22 at 10:09 A.M. interview with Licensed Practical Nurse (LPN) #135 revealed the facility would complete a PASARR/update a PASARR document after 20 days of an initial stay after a resident's admission from the hospital or a resident had left to go to the hospital, and was not back in the facility for 72 hours. LPN #135 revealed the facility did not have a mechanism/procedure to inform her of updated/added mental health diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on record review and staff interview, the facility failed to ensure a new Pre-Admission Screening and Resident Review (PASARR) was competed for Resident #18 following changes to the resident's mental health diagnoses. This affected one resident (#18) of one resident reviewed for PASARR. Findings Include: Record review revealed Resident #18 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #18 PASARR document, dated 12/16/19 revealed under Section D, it indicated the resident had no mental health diagnoses. However, review of the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) 3.0 assessment, dated 10/10/22 revealed the resident was cognitively intact. On 11/17/22 at 10:09 A.M. interview with Licensed Practical Nurse (LPN) #135 revealed the facility would complete a PASARR/update a PASARR document after 20 days of an initial stay after a resident's admission from the hospital or a resident had left to go to the hospital, and was not back in the facility for 72 hours. LPN #135 revealed the facility did not have a mechanism/procedure to inform her of updated/added mental health diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on record review and interview the facility failed to ensure the State Ombudsman was notified of a transfer to the hospital involving Resident #16. This affected one resident (#16) of one resident reviewed for hospitalization . Findings Include: Record review for Resident #16 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 10/12/22 quarterly Minimum Data Set (MDS) 3.0 assessment revealed the resident was cognitively intact, required limited assistance from staff for dressing and supervision (from staff) for bed mobility, transfers, walking in room, eating, toilet use, and personal hygiene. The assessment revealed the resident used a walker and wheelchair to aid in mobility, was occasionally incontinent of bladder and always continent of bowel. Review of a progress note, dated 10/16/22 at 5:40 P.M. revealed the resident was summoning staff to room. The resident was laying in bed rigid, yelling out and complaining of severe intermittent pain to mid abdominal region and also had complaints of pain to the upper chest. The physician was notified and new orders were received to send the resident to the emergency room for evaluation. Review of the medical record revealed no documented evidence the State Ombudsman was notified of the resident being transferred/admitted to the hospital on 10/16/22. Interview with the Administrator on 11/16/22 at 1:40 P.M. revealed the facility was unable to provide written evidence the State Ombudsman was notified of Resident #16's hospital transfer/admission on 10/16/22. The Administrator revealed the facility had not been notifying the State Ombudsman of resident transfers and discharges for the previous four months.

Based on observation, interview and test tray, the facility failed to provide residents with palatable food. This affected seven residents (Residents #37, #18, #36, #2, #93, #20 and #197) and had the potential to affect all residents residing in the facility at this time. The facility also failed to follow the recipe for pureed meat. This had the potential to affect two residents (Residents #15 and #29) identified by the facility as receiving pureed diets. The facility census was 54. Findings include: 1. Review of the facility's menu for the week of 01/20/20 through 01/24/19 revealed lunch for 01/23/20 was cod nuggets, Spanish rice, Key Largo blend vegetables, cornbread and cherry pie. A test tray was completed on 01/23/20 at 11:50 [NAME]M. by surveyors # , # , and # which revealed the cod nuggets and Spanish rice were not palatable due to the rice being mushy and the cod having a rubbery texture. Observation 01/23/20 between 11:30 [NAME]M. and 12:45 P.M. of residents eating lunch revealed Residents #37, #18, #36, #2, #93, #20 and #197, had eaten between 25 percent (%) to 50% of their meals. Interview on 01/23/20 between 11:50 [NAME]M. and 12:45 P.M. with Residents #37, #18, #36, #2, #93, #20 and #197 revealed the food did not taste good, and the cod nuggets were over cooked and too difficult to chew. Interview on 01/23/20 with Dietary #14 confirmed the residents did not consume much of their lunch. 2. Observation on 01/22/20 at 11:00 [NAME]M. of Cook #29 preparing pureed ham for lunch revealed she used one ounce of water to mix in with the pureed ham to ensure the correct texture. Review of the facility's recipe for pureeing meat revealed one ounce of broth was to be used with pork, beef and chicken to ensure correct texture while still preserving the flavor of the meat. Interview on 01/22/20 at 11:02 [NAME]M. with Cook #29 confirmed the use of water with the ham to ensure the correct texture. Interview on 01/22/20 at 11:30 [NAME]M. with Dietary #14 confirmed Cook #29 should have used broth to mix with the ham instead of the water. The facility identified two residents (Residents #15 and #29) as receiving pureed diets.

Based on staff interview, medical record review and observation, the facility failed to ensure each resident's drug regimen was free from medication used without adequate indications for its use. This affected two (Residents #12 and #26) of four residents prescribed [MEDICATION NAME]. The census was 48. Findings include: 1. Review of the record of Resident #12 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired and required extensive assistance of one to two people for all self care and activities of daily living. Review of physician orders [REDACTED]., [MEDICATION NAME] (heart medication), Labetolol (blood pressure), [MEDICATION NAME] (bladder relaxant), [MEDICATION NAME] (insulin), Sertaline (antidepressant), [MEDICATION NAME] ([MEDICAL CONDITION] medication also used to treat [MEDICAL CONDITION] disorder and migraines), Xarelto (blood thinner), and [MEDICATION NAME] (anti-diabetic medication). Review of monthly medication regimen reviews completed by a licensed pharmacist revealed no recommendations related to [MEDICATION NAME]. Review of physician progress notes [REDACTED]. Review of behavior logs from 11/01/18 to 11/08/18 revealed no behaviors were documented. Observation on 11/07/18 at 9:12 A.M. revealed Resident #12 seated in a recliner at her bedside. Resident #12 appeared clean and well kempt. Interview on 11/07/18 at 10:32 A.M. with State tested Nurse Aide #60 revealed Resident #12 was generally very active and participated in most activities. Observation on 11/07/18 at 2:13 P.M. revealed Resident #12 in a wheelchair propelling herself in the common area conversing with other residents. Observation on 11/08/18 at 2:15 P.M. revealed Resident #12 participating in afternoon activities. No behaviors were noted. Interview on 11/08/18 at 2:00 P.M. with Licensed Practical Nurse (LPN) #152, Unit Manager confirmed Resident #12 was receiving [MEDICATION NAME] without a [DIAGNOSES REDACTED]. 2. On 11/07/18 at 9:45 A.M., record review of Resident #26 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was rarely/never understood and scored a 99 on the most recent Minimum Date Set (MDS) assessment on 08/29/18, indicating severe cognitive impairments. The resident had no known drug allergies [REDACTED].>Review of current Physician order [REDACTED]. [MEDICATION NAME] 25 milligram (mg) one tablet by mouth (PO) daily for hypertension, [MEDICATION NAME] 5 mg one tablet PO twice daily for diabetes mellitus type II, [MEDICATION NAME] 100 mg two capsules PO three times a day for [MEDICAL CONDITION], [MEDICATION NAME] 100 mg one tablet PO daily for constipation, Fish Oil 1000 mg one capsule PO daily as supplement, [MEDICATION NAME] 10 mg one tablet PO daily for depression, Milk of Magnesia 400 mg/5 milliliter (ml) give 30 ml PO daily as needed for constipation, [MEDICATION NAME] 325 mg two tablets PO every four hours as needed for pain, Vitamin D3 1000 units one tablet PO daily as supplement, [MEDICATION NAME] 5 mg one tablet PO daily for anxiety/depression, [MEDICATION NAME] 40 mg one tablet PO daily for [MEDICAL CONDITION], [MEDICATION NAME] 5-325 mg one tablet PO every eight hours for pain, [MEDICATION NAME] 20 mg one tablet PO daily for hypertension, [MEDICATION NAME] 20 units subcutaneous (SQ) daily in the morning for diabetes mellitus type II, [MEDICATION NAME] 125 mg one capsule PO daily for dementia, and Aspirin 81 mg one tablet PO daily for hypertension. A Medication Regimen Review was completed for the resident on a monthly basis by a Licensed Pharmacist with the last date of review on 10/26/18. On 10/26/18, a recommendation was made to decrease [MEDICATION NAME] 10 mg daily which was completed by the physician on 11/05/18 to provide [MEDICATION NAME] 10 mg on Monday-Wednesday-Friday then discontinue after 10 days. On 05/22/18, a gradual dose reduction (GDR) of [MEDICATION NAME] was recommended, and was rejected by the physician as a GDR of [MEDICATION NAME] was currently being attempted. On the same date of review, a GDR for [MEDICATION NAME] was recommended with this being changed from twice daily to once daily. Review of written physician orders [REDACTED]. All monitoring and assessments completed for side effects, adverse reactions and extrapyramidial movements. This resident was care planned for all medications with measurable goals and appropriate interventions noted. On 11/07/18 at 3:11 P.M., Interview with Licensed Practical Nurse #152 Unit Manager verified that the physician ordered [MEDICATION NAME] for an active [DIAGNOSES REDACTED]. The nurse stated that the resident was provided with a calm environment with frequent reorientation attempts, and the resident as her full level of function at this time. On 11/08/18 at 8:08 A.M., Observation of Resident #26 revealed the resident was calm and alert while eating breakfast with other residents. The resident was in no apparent distress, and was provided with interventions to reorient as needed per facility staff. On 11/08/18 at 2:03 P.M., Review of information from Medscape revealed [MEDICATION NAME] was an anticonvulsant. Further review revealed [MEDICATION NAME] was used for mania, [MEDICAL CONDITION] and migraine [MEDICATION NAME].

Based on staff interview, observation, and policy review the facility failed to place Resident #71 who was positive for multi drug resistant organism [MEDICATION NAME] resistant [MEDICATION NAME] on contact precautions. This affected one of four residents whose lab work was reviewed. Facility census was 69. Findings include: Record review of Resident #71 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #71 required extensive assistance of one person for toileting and was frequently incontinent of bladder. Review of a laboratory value dated 08/22/17 revealed a urine culture that was positive for [MEDICATION NAME] resistant [MEDICATION NAME] (VRE) for Resident #71. Observation on 08/31/17 at 9:00 A.M. revealed no signs indicating to see nurse prior to going into Resident #71's room. There was no personal protective equipment stored outside the room or in the room. Interview with the Director of Nursing (DON) on 08/31/17 at 9:05 A.M. revealed that she was the infection preventionist for the facility and that she was unaware of any residents in the facility who had VRE. Review of the Center for Disease and Control Management of Multidrug-Resistant Organisms(MDRO) in Healthcare Settings guidelines dated 2006 revealed consider the individual patient's clinical situation and prevalence or incidence of MDRO in the facility when deciding whether to implement or modify Contact Precautions in addition to Standard Precautions for a patient infected or colonized with a target MDRO. For relatively healthy residents (e.g., mainly independent) follow Standard Precautions, making sure that gloves and gowns are used for contact with uncontrolled secretions, pressure ulcers, draining wounds, stool incontinence, and ostomy tubes/bags. For ill residents (e.g., those totally dependent upon healthcare personnel for healthcare and activities of daily living, ventilator-dependent) and for those residents whose infected secretions or drainage cannot be contained, use Contact Precautions in addition to Standard Precautions. For MDRO colonized or infected patients without draining wounds, diarrhea, or uncontrolled secretions, establish ranges of permitted ambulation, socialization, and use of common areas based on their risk to other patients and on the ability of the colonized or infected patients to observe proper hand hygiene and other recommended precautions to contain secretions and excretions. Review of a facility policy titled Contact Precautions dated 10/01/09 revealed that visitors should report to nurses station before entering room. Staff and visitors should wear gown when entering the room if contact with resident or the environment was anticipated and remove gown before leaving the room.

Based on observation, interview, and record review the facility failed to provide dental services for Resident #124. This affected one of one resident reviewed for dental services and one of four residents reveiwed for nutrition. The facility census was 69. Findings include: Medical record review of Resident #124 revealed an admission date of [DATE] with a [DIAGNOSES REDACTED]. Review of an admission assessment dated [DATE] revealed the resident had upper and lower dentures. A dental consent dated 05/04/17 revealed Resident #124 consented for dental treatment. Review of diet communication sheet dated 05/09/17 revealed to change diet from regular to mechanical soft ground meat temporarily due to not being able to wear dentures. Review of a nutritional note dated 05/10/17 revealed Resident #124's gums were sore due to dentures and intervention included to leave dentures out until gums were healed. Review of nutritional notes dated 05/19/17, 06/01/17, and 06/16/17 revealed Resident #124 continued on mechanical soft diet to ease chewing due to unable to wear dentures. Review of quarterly minimum data set assessment dated [DATE] revealed Resident #124 was on a mechanical altered diet with no chewing or swallowing issues and had some cognitive deficits. Review of physician orders [REDACTED].#124 had remained on a mechanically altered diet. Review of Resident #124's care plan revealed Resident #124 had dentures and interventions included to assess for ill fitting dentures, encourage to wear dentures, ensure dentures in good repair, observe gums for redness, bleeding, swelling and report to physician any abnormal findings. Review of a dental roster list dated 08/08/17 revealed Resident #124 was not included on the roster for upcoming facility visits planned for 09/05/17. Observation and interview of Resident #124 on 08/29/17 at 3:18 P.M. revealed she was edentulous and was not able to answer questions regarding oral status due to cognitive deficits. Observation of Resident #124 on 08/30/17 at 5:33 P.M. revealed she was being fed mechanical soft food with no difficulties and she was edentulous. An interview on 08/30/17 at 10:29 A.M. with State tested nursing assistant (STNA) #83 revealed Resident #124 was fed all her meals and did not wear dentures. Interview on 08/30/17 at 3:41 P.M. with Staff #56 and Licensed practical nurse (LPN) #126 revealed Resident #124 did not currently have sores in her mouth. They confirmed the dentist was coming to the faciility on 09/05/17 and she could be added to the list to see if her dentures could be realigned. A follow up interview on 08/30/17 at 3:53 P.M. with LPN #126 verified Resident #124 had not been seen by a dentist since being admitted . Interview on 08/30/17 at 5:33 P.M. with STNA #108 revealed Resident #124 had dentures but did not wear them because they did not fit right.

Based on interview, record review, and policy review the facility failed to complete a comprehensive 14 day Minimum Data Set (MDS) assessment for Resident #140. This affected one of 23 residents whose MDS assessments were reviewed. Findings include: Medical record review for Resident #140 revealed an admitted [DATE] with [DIAGNOSES REDACTED]. Resident #140 was cognitively intact and required extensive one person assistance with all activities and mobility. The admission minimum data set (MDS) assessment dated [DATE] revealed an incomplete 14 day comprehensive assessment. A Review of the facility's MDS policy and procedures with a revision date of November of 2016 revealed all residents should have a completed MDS admission assessment within 14 days of being admitted to the facility. An Interview with MDS Registered Nurse (RN) #118 on 08/30/17 at 8:44 A.M. verified an incomplete 14 day MDS admission assessment dated [DATE] for Resident #140. MDS RN #118 confirmed that all residents should have a completed comprehensive MDS assessment within 14 days after admission to the facility. MDS RN #118 stated the 14 day admission MDS dated [DATE] for Resident #140 was not completed because they were behind on the assessments.

Based on staff interview, observation, and record review the facility failed to ensure staff checked placement of a gastrostomy tube prior to administering medications. This affected one (Resident #88) of one resident with a gastrostomy tube. The facility census was 69. Findings include: Record review of Resident #88 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #88 received tube feedings and a mechanically altered diet. Review of a physician orders [REDACTED]. Observation on 08/30/17 at 9:53 A.M. revealed Licensed Practical Nurse (LPN) #119 crush one tablet of 500 mg [MEDICATION NAME] and administer it through Resident #88's gastrostomy tube. LPN #119 did not check to ensure the gastrostomy tube remained in the correct location prior to the medication administration. Interview with LPN #119 on 08/30/17 at 10:00 A.M. verified that she did not check the placement of the gastrostomy tube prior to administering the medication. Review of a facility policy titled Enteral tubes Medication Administration dated 06/01/14 revealed prior to administering the medication the nurse should verify tube placement using a 60 milliliter syringe by instilling a small amount of air into the feeding tube while simultaneously auscultating over the left upper quadrant of the abdomen with a stethoscope to validate air movement in the stomach.

Based on observation, interview and record review, the facility failed to ensure 39 bottles of outdated medications were identified and disposed of. This had the potential to affect 66 residents receiving oral medications at the facility. Findings include: On 06/15/16 at 4:35 A.M. during observation of the medication storage room for Canal and Emmitt Halls, 19 bottles of Niacin 50 milligrams (mg) were found to have an expiration date of 03/14, 15 bottles of vitamin B 1 were found to have an expiration date of 07/15, four bottles of Vitamin B 6 were found to have an expiration date of 06/15, and one bottle of Zinc 50 mg was found to have an expiration date of 05/16. This was confirmed with the Medical Records Coordinator and Licensed Practical Nurse #12. Review of the facility Storage of Medication policy Section 4.1, dated 09/10, indicated outdated medications were to be immediately removed from stock, disposed of according to procedures for medication disposal and reordered from pharmacy if a current order existed.

Based on observations, staff interviews, record reviews and facility policy reviews, the facility failed to properly wash and store steam table pans in a sanitary manner. This affected 66 of 66 residents who ate food prepared in the facility kitchen. The facility also failed to properly label frozen health shakes when thawed. This affected one (Resident #41) of 66 residents who resided in the facility. Findings include: 1. On 06/13/16 at 9:17 A.M., observation in the facility kitchen revealed food particles on the inside surface of two of ten stacks of steam table pans. Nine of ten stacks of steam table pans had pans with wet inside surfaces; the pans were stacked for use under the steam table and on the steamer. An interview with the dietary manager at the time of the observation, confirmed the pans were wet and should have been air dried prior to stacking. The dietary manager took away the two pans with food particles and restacked the wet pans under the steam table and on the steamer. A review of the facility's undated policy for Sanitation and infection control for manual dishwashing revealed step number three which indicated make sure to remove all traces of food from items. Step number five indicated air dry items on clean sanitized surfaces. 2. On 06/13/16 at 9:14 A.M. observations in the walk in refrigerator in the kitchen revealed seven of ten thawed Health shakes were undated with the date when thawed. An interview with the dietary manager revealed the Health shakes were good for 14 days after thawing and should be dated with the date when thawed. On 06/14/16, the dietary manager provided an undated in-service note to all staff for nutritional supplement that revealed the frozen Health shakes were removed from the walk in freezer every Monday at 11:00 A.M. and placed in the walk in refrigerator to thaw. The Health shakes would be dated on Wednesday at 11:00 A.M. with a date 14 days later. On 06/15/16 medical record review revealed Resident #41 was admitted to the facility on [DATE]. An electronic physician order [REDACTED].M. On 06/15/16 a review of a Nutritional supplements and snacks policy dated 01/2016 revealed no information related to how long frozen Health shakes could be stored.

Based on staff interview and medical record review, the facility failed to obtain physician order laboratory test for two of five residents sampled for unnecessary medication, Resident #21 and Resident # 4. Findings include: 1. Resident #21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 made herself understood, usually understood others, but was severely impaired for daily decision making skills. Review of Resident #21's medical record revealed on 12/30/14 the physician ordered to obtain a complete blood count (CBC), basic metabolic panel (BMP), lipid panel, and hemoglobin A1C ( provides a three month average of blood sugar levels) every three months in January, April, July, and October 7th. Review of Resident #21's laboratory results revealed physician ordered labs were obtained in January 2016. There was also additional lab work completed in February 2016. There were no other lab results in the medical record. Interview with Licensed Practical Nurse (LPN) #12 on 06/15/16 at approximately 3:00 P.M. revealed Resident #21's labs were not drawn in April 2016 as ordered and they should have been. She stated they changed lab company and the new lab would not take standing orders. 2. Resident #44 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician orders for Resident #44 revealed laboratory test orders for a complete blood count (CBC), complete metabolic profile (CMP), [MEDICAL CONDITION] stimulating hormone, and Vitamin D level every 90 days (February, May, August, November). On 05/18/16 the physician ordered laboratory test for a CBC for Resident #44 to be completed in two weeks. Review of the medical record revealed a CBC lab results from 02/17/16 indicating a red blood count (RBC) of 3.06 with a normal range of 3.82-4.97, hemoglobin (HGB) of 10.0 with a normal range of 11.5-15.4, and hematocrit (HCT) of 30.4 with a normal range of 35.3-44.9. The CBC results from 05/18/16 indicated a RBC of 2.86 (normal 3.82-4.97), HGB of 9.3 (normal 11.5-15.4) and HCT of 27.2 (normal 35.3-44.9). Resident #44's RBC had decreased from 3.06 to 2.86, HGB had decreased from 10.0 to 9.3 and HCT from 30.4 to 27.2. There were no laboratory results for the CBC ordered to be drawn on 06/06/16. On 06/15/16 at 10:27 A.M. during an interview with LPN #12 she confirmed there were no laboratory results for the lab work ordered to be completed on 06/06/16 in the medical record for Resident #44. LPN #12 reported on 06/15/16 at 10:42 AM no blood had been drawn by the laboratory for a CBC for Resident #44. Review of the facility policy for Laboratory Testing dated June 2016 revealed the resident's name, room number and the date the test was ordered would be entered on the Lab log Audit Form and a lab slip would be placed behind the log. Review of the Lab Log Audit Form revealed Resident #44 was not identified as having a CBC blood level drawn on 06/06/16.

Based on record review and staff interviews, the facility failed to develop a plan of care (POC) for urinary incontinence for residents with urinary incontinence. This affected one (Resident #77) of two residents triggered for a decline in urinary continence. There were 22 residents with occasional to frequent incontinence who reside in the facility. Findings include: On 03/11/15, record review revealed Resident #77 was admitted to the facility with [DIAGNOSES REDACTED]. A review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed an assessment for occasional urinary incontinence (less than seven episodes of incontinence) during the seven day assessment period. The assessment triggered the need for the development of a urinary incontinence Plan of Care. The resident continued to have occasional to frequent episodes of urinary incontinence. There was no evidence in the resident record of a plan of care for urinary incontinence. On 03/12/2015 at 1:13 P.M., interview with Registered Nurse (RN) #50 verified a POC for urinary incontinence should have been generated with the admission MDS assessment dated [DATE].

Based on observations, staff interviews, and facility policy reviews, the facility failed to dispose of outdated refrigerated medications. This had the potential to affect any resident who required the Pneumococcal Vaccination. The facility census was 64 residents. Findings include: On 03/11/15 at 1:56 P.M., observation in the Emmitt/Canal Medication room refrigerator revealed four vials of pneumococcal vaccine with an expiration date of 02/21/15. The finding was confirmed by Licensed Practical Nurse (LPN) #30. LPN #30 stated the vials should have been discarded. LPN #30 stated the pneumococcal vaccine was used for both the long term care and the rehab units. A review of the facility policy for Medication Storage, dated 09/2010, revealed Medications and biologicals were to be stored properly following manufacturer's recommendations. Procedure 14 indicated outdated medications were to be immediately removed from stock and disposed of according to procedures for medication disposal.

Based on interview and record review, the facility failed to keep the nursing home resident's funds separate from the funds of residents who live in their assisted living facility. This affected 33 residents (Residents #67, #25, #43, #60, #77, #53, #107, #100, #11, #68, #18, #2, #22, #62, #99, #73, #89, #23, #39, #82, #57, #76, #13, #83, #31, #7, #14, #52, #6, #21, #9, #50, and #16) who have their funds maintained in an account at the facility. The facility census was 64 residents. Findings include: On 03/12/15 at 1:30 P.M., review of Bristol Village Fund Balances as of 03/11/15 revealed the nursing home residents' personal funds were held in the same "trust account" with the funds of the residents residing in their assisted living facility. Interview with Business Office Manager #25 on 03/12/15 at 1:32 P.M. revealed there is one account, the trust account, which includes both the nursing home residents' funds and the assisted living residents' funds. On 03/12/15 at 2:15 P.M., review of facility Resident Trust Accounts Policy, dated July 2010, revealed their was no documentation in the policy that the resident funds for the nursing home residents and the assisted living residents were to be kept in separate resident fund accounts.

Based on medical record review and staff interview, the facility failed to administer a medication for bowel regularity. This affected one (Resident #16) of five residents reviewed for unnecessary medications. The facility census was 67. Findings include: Review of the medical record revealed Resident #16 was admitted to facility on 06/04/13 with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the facility's tracking form (bowel movement summary) revealed Resident #16 had no bowel movements on 11/06/13, 11/07/13, 11/08/13. The summary revealed no bowel movements occurred 11/10/13, 11/11/13, 11/12/13, 11/13/13 or 11/14/13. The summary also revealed no bowel movements occurred 11/18/13, 11/19/13, and 11/20/13. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. An interview with Director of Nursing on 11/26/13 at 3:00 P.M. verified Resident #16 did not have a bowel movement on the days recorded on bowel movement summary. The Director of Nursing also confirmed the stimulant laxatives were not administered from 11/01/13 to 11/27/13 and the stimulant laxatives should have been administered every three days if no bowel movement occurred.

Based on record review and staff interview, the facility failed to complete accurate dental assessments. This affected two (Resident #58 and #39) of ten residents reviewed for assessments. The facility census was 67 . Findings include: 1. Review of the medical record revealed Resident #58 was admitted to facility on 06/28/11 with [DIAGNOSES REDACTED]. Review of a nursing general observation assessment dated [DATE] revealed the dental status of the resident to have some/all natural teeth lost (no dentures). Review of the annual Minimum Data Set ((MDS) dated [DATE] revealed "none of the above" for the dental section and "no natural teeth or tooth fragments" was not marked. An interview with Director of Nursing on 11/27/13 at 7:50 A.M. verified Resident #58 was edentulous (had no teeth). 2. Review of the medical record revealed Resident #39 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the nursing general observation assessment dated [DATE] revealed the resident had some/all natural teeth lost (no dentures). Review of the initial MDS dated [DATE] revealed the resident's dental status was marked "none of the above". An interview with Registered Nurse #1 on 11/27/13 at 9:30 A.M. confirmed if a resident was edentulous then the dental status on the MDS should be marked "no natural teeth". Registered Nurse #1 also confirmed Resident #58 and Resident #39's MDS assessments were inaccurate related to the dental status section.

Based on clinical record review and staff interview, the facility failed to ensure appropriate transfer devices were used. This affected one of three sampled residents (Resident #43). Harm occurred when Resident #43 was transferred without the use of a gait belt, fell , and struck her head, which resulted in a laceration which required sutures. Findings include: Clinical record review of Resident #43 revealed the resident was admitted to the facility on [DATE] with medical [DIAGNOSES REDACTED]. The resident was assessed as being alert/oriented and able to make her needs known. The facility also assessed the resident as needing extensive assistance with transferring. Review of the written plan of care revealed the resident was at risk for falls/injury. Review of nurses' notes dated 12/14/10 revealed the nurse was called to the therapy gym. Resident #43 was found on the floor with a large laceration to her forehead. The nurses' notes indicated the resident was sent to the local emergency room and returned with one continuous suture to the laceration. Review of the fall investigation dated 12/15/10 revealed the therapy assistant was transferring the resident from the exercise mat in the therapy gym to her wheelchair. The transfer/gait belt was not in place, and the resident lunged forward and fell , striking her head on a piece of equipment. The investigation revealed staff had not reapplied the gait belt before the transfer. Resident #43 became spastic and subsequently scissored her legs, and she fell . Review of the physician's progress note dated 12/18/10 revealed the resident fell in therapy. No gait belt was used; the resident was sent to the emergency room and received stitches to her forehead. On 01/06/11 at 2:00 P.M., interview with Therapy Manager (TM) #83 revealed the resident was to have a gait belt used for transferring because her movements were very sporadic following her bilateral stroke. TM #83 verified the staff member involved had not reapplied the gait belt prior to transferring the resident. On 01/06/11 at 3:10 P.M., interview with the director of nursing (DON) revealed transfer/gait belts were to be used with any resident requiring staff assistance with transfers or ambulation. The DON also verified the belt was not utilized at the time of the injury. This certification deficiency was an incidental finding identified during investigation of Complaint Number OH 982.