Every finding on record at O'Neill Healthcare Fairview Park

Based on medical record review and interview, the facility failed to provide restorative therapy as ordered and/or care planned. This affected four residents (Resident #77, Resident #78, Resident #79, and Resident #120) of four residents reviewed for therapy services. Facility census was 91. Findings include: 1. Review of the medical record for Resident #120 revealed an admission date of 09/18/24. Resident #120 was discharged on 05/28/25. Diagnoses included malignant neoplasm of the prostate, secondary malignant neoplasm of the bone, chronic kidney disease, stage four, dementia, dysphagia and history of falls. Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/06/25, revealed Resident #120 had impaired cognition. Resident #120 required supervision for ambulation. Review of the plan of care dated 10/14/24 revealed Resident #120 was receiving Restorative Nursing Services (RNS) for ambulation baseline of 75-150 feet with contact guard assist (CGA), staff walking close to resident and front wheeled walker (FWW). Interventions included Resident #120 was to receive RNS up to six times a week for 15 minutes a day, and for staff to encourage Resident #120 to participate in the program to achieve goal. The goal was for Resident #120 to maintain ability through the next review as evidenced by continued ambulation of 75-150 feet with CGA and FWW. Review of physician orders for dated 01/14/25 indicated Resident #120 was to receive Restorative Nursing Services (RNS) for ambulation per restorative plan of care. Review of Resident #120's medical record revealed no evidence of restorative nursing services being completed per the plan of care. Interview on 06/23/25 at 2:28 P.M., Certified Nurse Assistant (CNA) #585 revealed Resident #120 was on the restorative program using two-pound weights for lower extremities and ambulation Monday through Friday. CNA #585 revealed she can't complete the therapy when she is pulled to work the floor. CNA #585 stated her being pulled has slowed down in the past two weeks, so she was able to complete her assignments. Interview on 06/23/25 at 4:07 P.M., the Director of Clinical Services (DCS) #701 revealed Resident #120 was not on a restorative therapy program, and therapy was not to assess until the next review period. Interview on 06/25/25 at 9:15 A.M., Regional Administrator #700 and Administrator #601 confirmed the lack of evidence to show Resident #120 received restorative therapy. 2. Review of the medical record for Resident #77 revealed an admission date of 03/15/25. Diagnoses included malignant neoplasm of the stomach and type two diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/22/25, revealed Resident #77 had intact cognition. Resident #77 required maximum assistance for ambulation. Review of the plan of care dated 11/19/24 revealed Resident #77 received RNS ambulation program up to six days a week for 15 minutes a day. Resident #77 also received range of motion and strengthening exercises to maintain /improve strength in both lower extremities using a two-pound ankle weight when seated, two sets for 15 repetitions. Review of the facility restorative care flow record dated April, May and June 2025 revealed Resident #77 did not received therapy for ambulation or strengthening in April 2025, Resident #77 received restorative therapy for ambulation and strengthening three times in May 2025. Resident #77 received no restorative therapy for strengthening in June 2025, but did ambulate 10 times in June 2025. Interview on 06/24/25 at 2:47 P.M. with Resident #77 revealed staff have never used weights during restorative therapy sessions and therapy hasn't been provided in weeks. A family member present who visits throughout the week revealed therapy was not provided in weeks. Interview on 06/25/25 at 9:15 A.M., Regional Administrator #700 and Administrator #601 confirmed the lack of evidence to show Resident #77 received restorative therapy as care planned. 3. Review of the medical record for Resident #78 revealed an admission date of 08/17/25. Diagnoses included hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, difficulty in walking and foot drop, and unspecified foot. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/01/25, revealed Resident #78 had intact cognition. Resident #78 required substantial assistance for mobility. Review of the plan of care dated 04/11/25 revealed Resident #78 received RNS for range of motion, strengthening and transfer exercises six to seven times a week to maintain /improve strength in both lower extremities using a two-pound ankle weight when seated, two sets for 15 repetitions. Review of the facility restorative care flow record dated April, May and June 2025 revealed Resident #78 did not receive restorative therapy for strengthening in April 2025. Resident #78 received therapy for strengthening four times in May 2025 and no restorative therapy for strengthening in June 2025. The flow sheet for June 2025 indicated Resident #78 received assistance with ambulation two times in June. Interview on 06/24/25 at 2:51 P.M., Resident #78 she had not received therapy in months. Interview on 06/25/25 at 9:15 A.M., Regional Administrator #700 and Administrator #601 confirmed the lack of evidence to show Resident #78 received restorative therapy as care planned. 4. Review of the medical record for Resident #79 revealed an admission date of 02/15/25. Diagnoses included hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side and chronic kidney disease. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/01/25, revealed Resident #79 had impaired cognition. Resident #79 required substantial assistance for mobility. Review of the plan of care dated 04/26/24 revealed Resident #79 received RNS for range of motion, strengthening and transfer exercises to six to seven times a week to maintain /improve strength in both lower extremities using a one-pound ankle weight when seated, two sets for 15 repetitions. Review of the facility restorative care flow record dated April, May and June 2025 revealed Resident #79 received one session of restorative therapy for strengthening/transfers in April 2025 and five times in May 2025. Resident #79 did not receive therapy for strengthening/transfers in June 2025. Interview on 06/24/25 at 2:39 P.M., Resident #79 stated she was not receiving restorative therapy like she should. Interview on 06/25/25 at 9:15 A.M., Regional Administrator #700 and Administrator #601 confirmed the lack of evidence to show Resident #79 received restorative therapy as care planned. This deficiency represents non-compliance investigated under Complaint Number OH00166104.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on interview, review of employee personnel files, review of employee handbook and review of abuse policy revealed the facility did not ensure residents were free from potential neglect when staff were sleeping while on duty. This had the potential on 08/05/24 to affect 16 Residents: #1, #4, #9, #10, #13, #18, #20, #22, #28, #29, #36, #44, #58, #76, #85, and #99 when Licensed Practical Nurse (LPN) #608 was assigned to on the south hall was found sleeping. This also had the potential on 09/04/24 to affect 22 Residents: #1, #4, #9, #10, #13, #18, #20, #22, #28, #29, #36, #42, #44, #58, #66, #71, #76, #85, #90, #99, #106, and #107 when LPNs #604 and #613 were assigned to on the south hall were found sleeping. The facility census was 105. Findings included: 1. Review of personnel file for LPN #608 revealed a hire date of 07/02/24 and she received new hire orientation on 07/02/24 which included the handbook regarding the following actions by an employee would be considered gross misconduct and would result in immediate termination that included sleeping while on duty. Review of Daily Schedule for 08/05/24 revealed LPN #608 was assigned to the south hall from 7:00 P.M. to 7:30 A.M. She was assigned the following 16 Residents: #1, #4, #9, #10, #13, #18, #20, #22, #28, #29, #36, #44, #58, #76, #85, and #99. Review of witness statement dated 08/06/24 and completed by LPN #610 revealed she went to lunch and when she came back LPN #608 was sleeping. She revealed she was intentionally noisy, and LPN #608 awoke. Review of witness statement dated 08/07/24 and completed Director of Nursing (DON) revealed she called LPN #608, and LPN #608 verified on 08/05/24 she had nodded off. Review of Termination Report dated 08/12/24 revealed LPN #608 was terminated due to sleeping while on duty. The report was signed by the Administrator, and Human Resource (HR) #614 on 08/12/24. LPN #608 did not sign the termination. Interview on 10/30/24 at 4:13 P.M. with Former Certified Nursing Assistant (CNA) #609 revealed on 08/05/24 she saw LPN #608 sleeping multiple times throughout the shift on 08/05/24. She revealed she would sleep approximately ten to twenty minutes each time as she would wake up and then dose back off. Interview on 10/30/24 at 4:20 P.M. with LPN #610 revealed LPN #608 was sleeping at the nurse's station in front of the computer with her head on the table. She revealed she had her eyes closed and that she startled her when she woke LPN #608 up by making noise. 2. Review of personnel file for LPN #613 revealed a hire date of 04/03/23 and she received new hire orientation on 04/03/23 which included the handbook regarding the following actions by an employee would be considered gross misconduct and would result in immediate termination that included sleeping while on duty. Review of personnel file for LPN #604 revealed a hire date of 11/15/23 as she worked first shift as a CNA until she became licensed as an LPN on 07/26/24. Her first day of training as a nurse was on 09/04/24 from 7:00 P.M. to 7:30 A.M. She received new hire orientation on 11/15/23 which included the handbook regarding the following actions by an employee would be considered gross misconduct and would result in immediate termination that included sleeping while on duty. Review of Daily Schedule for 09/04/24 revealed LPN #613 was training LPN #604 to the south hall from 7:00 P.M. to 7:30 A.M. They were assigned the following 22 Residents: #1, #4, #9, #10, #13, #18, #20, #22, #28, #29, #36, #42, #44, #58, #66, #71, #76, #85, #90, #99, #106, and #107. Review of Termination Report dated 09/05/24 revealed LPN #604 was terminated due to sleeping while on duty. The report was signed by the Administrator, DON and HR #614 on 09/05/24. LPN #604 did not sign the termination. Review of Termination Report dated 09/05/24 revealed LPN #613 was terminated due to failing or refusing to cooperate fully with a facility investigation or inspection. The report was signed by the Administrator, and HR #614 on 09/05/24. LPN #613 did not sign the termination. Review of witness statement dated 09/05/24 and completed by LPN #604 revealed she did not recall falling asleep on 09/04/24. She stated she did watch a movie during down time. Review of witness statement dated 09/05/24 and completed by LPN #613 revealed on 09/04/24 she was sitting in the social area facing the window on the unit and was not sleeping on the job. Review of witness statement dated 09/05/24 and completed by LPN #605 revealed on 09/04/24 she noticed LPN #604 and LPN #613 sleeping from 3:00 A.M. till 4:45 A.M. in the dining room. Review of witness statement date 09/05/24 and completed by CNA #607 revealed she seen two nurses, LPN #604 and LPN #613, both sleeping. Review of witness statement dated 09/05/24 completed by CNA #606 revealed two nurses, LPN #604 and LPN #613, were sleeping. Review of witness statement dated 09/05/24 and completed by CNA #615 revealed on 09/04/24 she seen two nurses, LPN #604 and LPN #613, sleeping in the dining room. Interview on 10/30/24 at 4:16 P.M. with CNA #606 revealed she witnessed both, LPN #604 and 613, sleeping while on duty. She revealed one was sleeping by the window in a chair leaning to one side and her head down but not on the table. She revealed the other was by the piano sitting next to the wall with her eyes closed. She revealed she did not know which nurse was where but that both were sleeping at the same time. Interview on 10/30/24 at 4:47 P.M. with Administrator and DON verified on 08/05/24 LPN #608 was observed to be sleeping while on duty by more than one staff member. LPN #608 was terminated for sleeping on duty. They verified on 09/05/24 LPN #613 was training LPN #604 and both were observed sleeping while on duty by more than one staff member. They verified LPN #604 and LPN #613 were both terminated. Interview on 10/31/24 at 10:02 A.M. with HR #615 revealed any new hire she goes over line by line regarding the employee handbook including sleeping on duty which would result in immediate termination. Review of undated employee handbook revealed the following actions by an employee would be considered gross misconduct and would result in immediate termination that included sleeping while on duty. Review of facility policy labeled, Abuse, Neglect, Involuntary Seclusion, Misappropriation Prevention dated October 2017 revealed all residents would be free from abuse and neglect. Neglect was defined as failure of the facility, its employees or service providers to provide goods and services to a resident that were necessary to avoid physical harm, pain, mental anguish or emotional distress. The deficient practice was corrected on 09/05/24 when the facility implemented the following corrective actions: On 08/12/24 LPN #608 was terminated due to sleeping while on duty. On 09/05/24 LPN #613 was terminated due to failing or refusing to cooperate fully with a facility investigation or inspection regarding her sleeping while on duty. On 09/05/24 LPN #604 was terminated due to sleeping while on duty. On 09/05/24 during employee orientation HR #614 continued to educate all new employees regarding the employee handbook regarding the following actions by an employee would be considered gross misconduct and would result in immediate termination that included sleeping while on duty. On 09/05/24 with the awareness and termination of staff sleeping the DON had been coming in a few times a week at times as early as 2:00 A.M. and rounded on the units to ensure staff were not sleeping. No staff were observed to be sleeping. On 09/05/24 all staff were in serviced by the Administrator that sleeping on duty was not tolerated and would result in immediate termination and staff were in serviced on the abuse policy. On 10/08/24 all staff were in serviced again by the Administrator, DON, and HR #614 that sleeping on duty was not tolerated and would result in immediate termination This deficiency represents non-compliance investigated under Complaint Number OH00158747.

Based on record review, resident interview, observation, staff interview, and resident family interview, the facility failed to ensure dependent residents received proper nail care. This affected one (Resident #58) of three residents reviewed for activities of daily living (ADL) care. The facility census was 105 residents. Findings include: Review of the medical record for Resident #58 revealed an admitted [DATE] with diagnoses including chronic congestive heart failure, high blood pressure, osteoarthritis, major depression, gastroesophageal reflux disease, bilateral artificial knee joints, and cataracts. Review of the consent form for Resident #58 dated 09/17/24 revealed the resident had consented to podiatry care. Interview on 09/23/24 at 10:30 A.M with Resident #58 confirmed her representative had asked the facility to have the podiatrist cut her toenails and assess her feet a long time ago, but the resident was unable to remember the specific date of the request. Resident #58 confirmed her nails needed to be trimmed and neither the staff nor the podiatrist had assisted her. Observation on 09/23/24 at 10:45 A.M of Resident #58's feet revealed both feet had very long thick toenails. Resident #58's toes were overlapped, and the toenails were growing and pressing in the overlapped toes. The skin on Resident #58's feet was dry, red and scaly. Interview on 09/23/24 at 11:00 A.M. with State tested Nursing Assistant (STNA) #110 confirmed Resident #58's toenails were long and thick and needed to be trimmed by a podiatrist. Interview on 09/23/24 at 12:38 P.M. with Resident #58's representative confirmed she had asked the head nurse approximately two months ago to have the podiatrist look at the resident's feet and cut her toenails. Resident #58's daughter stated the facility did not follow-up with her and the podiatrist had not cut the residents toenails or addressed her deformed toes with bunions. Interview on 09/23/24 at 2:34 P.M. with Nursing Unit Manager Licensed Practical Nurse (NUM-LPN) #111 stated the Social Service Director (SSD) had spoken with Resident #58's representative regarding the need for podiatry to evaluate and treat the resident's feet and cut her toenails. NUM-LPN #111 stated the SSD was responsible to ensure the podiatry visit was scheduled. NUM-LPN #111 confirmed she did not speak to Resident #58 or her daughter to follow-up with them regarding the podiatrist or their concern with the care of the resident's feet. Interview on 09/23/24 at 2:23 P.M. with Director of Nursing (DON) confirmed she was not aware of Resident #58's or Resident #58's representative's concern. The DON stated the podiatrist had made a visit to the facility on [DATE] but did not see Resident #58. The DON stated she had contacted Resident #58's daughter who informed her she had asked the SSD to have Resident #58's feet evaluated during the month of August 2024. Interview on 09/23/24 at 2:30 P.M. with the Administrator confirmed she was performing the SSD's job duties while the SSD was on a leave of absence. The Administrator confirmed she had no knowledge of Resident #58's representative's request to schedule a podiatry visit to evaluate the resident's feet and cut her toenails. This deficiency represents non-compliance investigated under Complaint Number OH00156781.

Based on observation, record review and review of the Centers for Disease Control and Prevention (CDC) Infection Control Guidance, the facility failed to implement the appropriate personal protective equipment when entering and leaving a resident's room who was confirmed COVID-19 positive. This finding affected two residents (Residents #7 and #48) who reside on the South 2 hall and had the potential to affect an additional 44 residents residing on the South 2 and South 3 halls including Residents #2, #3, #5, #8, #9, #11, #13, #16, #18, #20, #21, #26, #28, #30, #33, #36, #38, #40, #41, #42, #47, #49, #50, #51, #56, #57, #61, #62, #66, #67, #69, #70, #71, #74, #77, #81, #83, #84, #90, #91, #92, #95, #97 and #100. The facility census was 97. Findings include: Review of Resident #7's medical record revealed the resident was readmitted on [DATE] with diagnoses including cognitive communication deficit, dementia in other diseases and major depressive disorder. Review of Resident 7's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of the facility infection control documentation revealed Resident #7 tested positive for COVID-19 on 10/01/23 and 10/06/23. The documentation indicated the resident was off COVID-19 precautions on 10/12/23. Review of Resident #7's physician orders revealed an order dated 10/09/23 for droplet precautions maintained during all encounters while in COVID isolation. All services to be provided in the room. Review of Resident #48's medical record revealed the resident was admitted on [DATE] with diagnoses including unspecified dementia, hyperlipidemia and major depressive disorder. Review of Resident #48's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment. Review of the facility infection control documentation revealed Resident #48 tested positive for COVID-19 on 09/30/23 and 10/05/23. The documentation indicated the resident was off COVID-19 precautions on 10/11/23. Review of Resident #48's physician orders revealed an order dated 10/01/23 to maintain droplet precautions due to COVID positive. The resident to receive all services including meals, treatments and therapy in the room. Observation on 10/10/23 at 7:38 A.M. with the Administrator revealed State tested Nursing Assistant (STNA) #815 had donned an N95 respirator mask and placed a surgical mask over top of the N95 respirator mask and a isolation gown over top of her clothing. She then went into Residents #7 and #48's resident room and provided care. Further observation revealed STNA #815 removed the isolation gown, washed her hands and left the room with the N95 respirator mask with the surgical mask on top of the N95 respirator mask and walked down the hall. Signage on the door indicated the residents were in droplet isolation precautions. Interview on 10/10/23 at 7:45 A.M. with STNA #815 indicated she forgot to remove the surgical mask which was on top of the N95 respirator mask when leaving Residents #7 and #48's COVID-19 positive room. She also confirmed she did not use eye protection while in Residents #7 and #48's COVID-19 positive room. She stated she could not find the protective goggles and was looking for the goggles in resident rooms. Interview on 10/10/23 at 7:50 A.M. with the Administrator indicated staff were required to place a surgical mask over the N95 respirator mask when going into COVID-19 positive resident rooms and discard the surgical mask when exiting the resident rooms. The Administrator confirmed STNA #815 had not donned eye protection when entering Residents #7 and #48's room who was COVID-19 positive and she did not remove her N95 respirator mask and surgical mask upon exiting the resident's room per the CDC Infection Control guidelines. Review of the CDC Infection Control Guidance updated 05/08/23 revealed face protection when used solely for source control, any of the options listed above could be used for an entire shift unless they become soiled, damaged, or hard to breathe through. If they are used during the care of patient for which a NIOSH (National Institute for Occupational Safety and Health) Approved respirator or facemask was indicated for personal protective equipment (PPE) such as a NIOSH Approved particulate respirators with N95 filters or higher during the care of a patient with COVID-19 infection, facemask during a surgical procedure or during care of a patient on Droplet Precautions, they should be removed and discarded after the patient care encounter and a new one should be donned. This deficiency represents non-compliance investigated under Complaint Number OH00147111.

Based on observation, resident interviews, and staff interviews, the facility failed to ensure a well-maintained environment. This affected 33 of 51 resident occupied rooms (rooms #1, #3, #4, #5, #6, #7, #10, #11, #12, #13, #14, #15, #17, #18, #19, #20, #21, #23, #26, #27, #28, #30, #31, #32, #33, #34, #36, #51, #54, #55, #57, #60, and #63). The facility census is 75. Findings include: Observation on 01/09/22 from 10:00 A.M. to 12:00 P.M. revealed resident occupied rooms #1, #3, #4, #5, #6, #7, #10, #11, #12, #13, #14, #15, #17, #18, #19, #20, #21, #23, #26, #27, #28, #30, #31, #32, #33, #34, #36, #51, #54, #55, #57, #60, and #63 had significant gouges, scrapes, chipped paint, furniture markings, and scratches located on the walls directly behind the headboards of each resident bed. Interview on 01/09/22 at 10:58 A.M. with Resident #268 revealed the wall behind her bed had chipped paint and exposed drywall. Resident #268 revealed the wall was that way when she arrived at the facility. Interview on 01/12/22 at 11:40 A.M. with Resident #4 revealed the wall behind her headboard had scraped paint. Resident #4 revealed no one had inspected her room walls or painted them since being in the facility. Interviews completed throughout the duration of the survey dated from 01/09/22 at 8:00 A.M. through 01/12/22 at 12:00 P.M. with Residents #18, #28, #37, and #60 confirmed the walls behind their headboards were not maintained by facility staff. During a tour of the north unit on 01/12/22 at 11:30 A.M. with the Administrator revealed room #63 had scrapes, chipped paint, and scratches located on the wall directly behind the headboard. The Administrator confirmed the findings. Interview on 01/12/22 at 12:10 PM with the Maintenance Director (MD) #205 revealed he was aware of the resident rooms walls that consisted of significant gouges, scrapes, chipped paint, furniture markings, and scratches located on the walls directly behind the headboards of each resident bed. MD #205 revealed the markings came from the constant moving and rearranging of the facility furniture. MD #205 confirmed the findings.

Based on record review and interview, the facility failed to timely develop comprehensive resident centered nursing care plans to meet the needs of two (Resident's #39 and #52) of 22 residents reviewed for care planning. The facility census was 75. Findings include: 1. Review of the medical record revealed Resident #39 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #39 was cognitively intact, required extensive assistance of two staff for activities of daily living, received [CONDITION(S)] services, had an indwelling Foley catheter and was occasionally incontinent of bowels. Review of the care plan for Resident #39 revealed care plans for falls, assistance of for activities of daily living, bowel incontinence, skin integrity, anti-coagulant therapy, decreased cardiac output, diabetes, and [CONDITION(S)] were not developed or put in place until 01/10/22. Interview on 01/10/22 at 3:00 P.M. with MDS Nurse #217 verified Resident #39's nursing care plans were not developed until 01/12/22, two months after admission. 2. Review of the medical record revealed Resident #52 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent MDS 3.0 assessment dated [DATE] revealed Resident #52 was cognitively intact, required extensive assistance of one staff for activities of daily living, received [CONDITION(S)] care, intravenous medications, and had mild depressive symptoms. Review of the care plan for Resident #52 revealed no nursing care plans were developed. Interview on 01/12/22 at 11:03 A.M. with MDS Nurse #217 verified that no nursing care plans were developed for Resident #52.

Based on observation and staff interview, the facility failed to ensure the dumpster/refuse area was maintained in a clean and sanitary condition. This had the potential to affect all residents residing in the facility. The facility census was 75. Findings include: Observation of the facilities dumpster area with Cook #229 on 01/09/22 at 8:30 A.M. revealed the following: · Three bags of refuse were noted on the ground beside the dumpster. · One of the bags of refuse was open and contained soiled adult briefs and feminine hygiene products. · A bag of trash from a local fast food establishment was also noted next to the dumpster area. · Various other pieces of miscellaneous debris were noted on the ground outside the dumpster area including, plastic gloves, straws, masks and various food particles. Interview with Cook #229 verified the above findings at the time of the observation.

Based on observation, interview and record review, the facility failed to properly prevent and or contain the spread of covid-19. This affected 37, Residents #203, #204, #205, #209, #210, #211, #212, #213, #214, #215, #216, #217, #218, #219, #220, #221, #222, #223, #224, #225, #226, #227, #228, #229, #230, #231, #232, #233, #234, #235, #236, #237, #238, #239, #240, #241, and #242, of 40 residents (Residents #206, #207, and #208) diagnosed with [REDACTED]. This affected two laundry staff, Housekeeping Supervisor #112 and Housekeeper #111 and had the potential to affect all residents. The total census was 68. Findings include: 1. Record review on 06/29/20 revealed three Residents, (Resident #206, #207 and #208) had been diagnosed with [REDACTED]. Record review revealed an additional six residents, Residents #209, #210, #211, #212, #213, and #214, were diagnosed with [REDACTED]. Record review revealed an additional 31 residents were diagnosed with [REDACTED].#203, #204, #205 #215, #216, #217, #218, #219, #220, #221, #222, #223, #224, #225, #226, #227, #228, #229, #230, #231, #232, #233, #234, #235, #236, #237, #238, #239, #240, #241, and #242), between the dates of 06/20/20 through 06/23/20. Record review on 06/29/20 revealed six staff members, State tested Nursing Assistant (STNA) #104, STNA #106, STNA #115, Laundry assistant #116, Licensed Practical Nurse (LPN) #117, and STNA #114, were diagnosed with [REDACTED]. Staffing record review revealed five of the six staff members diagnosed with [REDACTED].#104, STNA #106, STNA #115, Laundry assistant #116 and STNA #114, had routine staff assignments on the south side of the facility. Interview with the Director of Nursing (DON) on 06/29/20 at 9:00 AM revealed all 40 residents resided on the south side of the facility when diagnosed with [REDACTED].#117 worked both north and south of the facility. Review of the facility layout revealed the south side of the facility had two halls which included two person rooms. Room numbers for the south side of the facility were rooms one through 35. The 40 residents that were diagnosed with [REDACTED]. Interview with the DON on 06/29/20 at 9:00 AM revealed on 05/17/20 Residents with a [DIAGNOSES REDACTED].#206 and #207, were transferred to the north side of the facility (which also had two halls) where an isolation unit was implemented at the farther end of one hall. Additional residents (which all resided on the south side) were transferred to the unit (on the north side) as they were diagnosed with [REDACTED]. On 06/23/20 a second covid-19 isolation unit was implemented on the south side of the facility due to the number of residents infected. Interview on 06/30/20 at 12:45 P.M. with the DON and Staff Coordinator #118 revealed the south side of the facility had been broken down to four to five assignments each day, each shift depending on the amount of staff available. Each STNA had been given an assignment by the charge nurse at the beginning of the shift. Record review of the STNAs #104, #106, #114, and #115's schedule and daily assignment sheet during the period of 06/01/20 through 06/22/20, when the last STNA that was diagnosed with [REDACTED]. Interview with the DON on 06/29/20 at 2:15 P.M. revealed the two nurses per shift on the south side worked together on the hall assignments and had no consistent assignment. The DON confirmed no residents had been admitted with covid-19, all residents acquired covid-19 while at the facility. Guidance from the CDC revealed - Long-term care facilities should exercise as best as possible consistent assignment (meaning the assignment of staff to certain patients and residents) for all patients and residents regardless of symptoms or COVID-19 status. Interview on 06/29/20 at 6:23 P.M. with STNA #103 revealed she had routinely worked with residents infected with covid #19 and on the same shift worked with residents who are not infected to cover breaks. Interview with LPN #107 on 06/29/20 at 6:35 P.M. revealed she had also routinely worked with residents on the same day who were infected and who were not infected with covid-19. Interview with LPN # 109 and Registered Nurse (RN) #110 on 06/30/20 between 8:45 A.M. and 8:55 A.M. revealed they had also routinely worked with residents on the same day who were infected and who were not infected with covid-19. Interview on 06/30/20 at 9:30 A.M. with the DON confirmed nurses work daily on all shifts with both covid-19 positive and non covid-19 positive residents. The DON stated, It would not be fair to give more residents to one nurse than the other. 2. Observation on 06/30/20 at 8:55 A.M. revealed Housekeeper #111 transporting a metal laundry cart which had crisscross metal wires, no lid, and no label and contained soiled laundry from the south covid-19 isolation unit. Housekeeper #111 transported the open cart to the laundry area located at the lower level of the facility. Observation on 06/30/20 at 9:00 A.M. revealed Laundry Supervisor #112 took the laundry from the cart and placed it into the washing machine. Laundry Supervisor #112 then removed her gloves, then the apron and walked over to the folding table in the next room and began folding towels. Observation was confirmed with Laundry Supervisor #112 and housekeeper #111 that Laundry Supervisor #112 did not wash her hands, did not use hand sanitizer after placing the soiled clothing from the covid-19 unit into the washer and before folding clean facility use towels. Review of the facility laundry guidelines did not include washing hands or using hand sanitizer after contamination with soiled laundry. The facility guidelines did have a policy which included that soiled laundry will be transported in a leak proof covered container that is labeled. 06/30/30 at 3:30 P.M. with the Administrator revealed she would had expected everyone to wash their hands after removing gloves.

Based on staff interview, self-reported incident (SRI) review and policy review, the facility failed to ensure Resident #171 was free from misappropriation of her debit card. This affected one resident (Resident #171) of one resident reviewed for misappropriation of property. The facility census was 69. Findings include: Review of Resident #171's medical record revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of a quarterly comprehensive assessment dated [DATE] revealed Resident #171 was cognitively intact with a brief interview for mental status (BIMS) score of 13. Review of a nurses' note dated 10/08/19 revealed Resident #171 had a locked drawer in her room to be used as needed. Review of a nurses' note revealed on 11/14/19, Resident #171 was sent to the hospital for a left [MEDICAL CONDITION] and was discharged from the facility. A note dated 11/17/19 revealed Resident #171 passed away at the hospital. Review of a facility self-reported incident dated 09/16/19 revealed an allegation of misappropriation concerning Resident #171's debit card being missing from her purse. The resident's daughter noticed questionable charges on the card, could not find the card and filed a police report. An investigation was conducted including interviews from residents and staff; all staff denied knowledge of the missing card. On 09/17/19, the debit card was found under Resident #171's pillow with a handwritten note that was not signed. The note read, (Resident #171's name), IOU (I owe you) please don't press charges, just trying to get by. I shouldn't have went that far. Just desperate to take care of family. All second shift staff were suspended on 09/17/19 and the police were contacted with this new information. Police then obtained camera footage where some of the questionable charges were made to determine State tested Nursing Assistant (STNA) #305 had been using Resident #171's card. STNA #305 had already been suspended on 09/17/19 and had been previously interviewed that day and had denied knowledge of Resident #171's missing debit card. STNA #305 was subsequently terminated. The facility determined the allegation of misappropriation to be substantiated. Interview with the Administrator on 11/30/19 at 8:47 P.M. revealed she was made aware of the allegation of misappropriation from Resident #171's daughter on 09/16/19. Resident #171's debit card statement had shown local businesses as well as charges from the facility's vending machine, so she thought staff may have taken the card. The Administrator stated STNA #305 had went through the facility's STNA course, background checks, abuse training on hire and after incidents and did not have any red flags to speak of. The Administrator verified she had interviewed STNA #305 on 09/17/19 and she had had no information to provide regarding Resident #171's missing debit card. The Administrator shared after the facility had completed it's SRI investigation, the police had notified her STNA #171 had several criminal charges against her. Review of STNA #305's personnel file revealed a hire date of 02/20/19 and included references, signed acknowledgement of the facility's abuse policy and a background check. STNA #305 was terminated from employment with the facility on 09/19/19 due to theft. Review of the facility policy, Abuse/Neglect/Involuntary Seclusion/Misappropriation Prevention revised (MONTH) (YEAR) revealed all residents would be free from abuse, including misappropriation of residents' property. Misappropriation was defined as the deliberate misplacement, exploitation, wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent.

Based on observation, record review and interview the facility failed to honor resident preferences at meals. This affected 12 residents (Resident #8, #4, #67, #77, #79, #5, #64, #47, #12, #1, #3 and #23) and had the potential to affect all 81 of 81 residents who received meals from the kitchen (Resident #51 was ordered nothing-by-mouth). The facility census was 82. Findings include: Observation on 06/11/19 from 7:43 A.M. to 8:33 A.M. of the breakfast tray line revealed Cook #2, Dietary Aide (DA) #3, DA #4 and Dishwasher #5 were serving food or setting up the meal trays. All the meal trays were observed at the time DA #4 or Dishwasher #5 was inserting the meal trays into the meal cart. At 7:49 A.M., Resident #8's meal ticket indicated she requested wheat toast however white toast was provided on her breakfast plate. Interview, during the observation, with DA #3 verified Resident #8 requested wheat toast and was served white toast instead. At 7:54 A.M., Resident #4's meal ticket indicated she requested strawberry yogurt however Resident #4's meal tray was absent of yogurt. Interview, during the observation, with DA #4 verified Resident #4 requested strawberry yogurt and her meal tray was absent of the strawberry yogurt. At 8:17 A.M., Resident #67's meal ticket indicated he requested seasonal fresh fruit however canned pears were served on his meal tray. Interview, during the observation, with DA #4 verified Resident #67 requested seasonal fresh fruit and was served canned pears instead. At 8:19 A.M., Resident #77's meal ticket indicated he didn't want bacon, ham or sausage however two egg and sausage sandwiches were served on his breakfast plate. Interview, during the observation, with Cook #2 verified Resident #77 requested no sausage and was served two egg and sausage sandwiches. At 8:26 A.M., Resident #79's meal ticket indicated she requested nectar-thickened milk however Resident #79's meal tray was absent of nectar-thickened milk. Interview, during the observation, with DA #4 verified Resident #79 requested nectar-thickened milk and her meal tray was absent of nectar-thickened milk. At 8:29 A.M., Resident #5's meal ticket indicated he requested a double serving of pureed eggs however Resident #79 was given one serving of pureed eggs. Interview, during the observation, with Cook #2 verified Resident #79 was only served one serving of pureed eggs instead of the two servings of eggs Resident #79 requested. Interview on 06/11/19 at 9:10 A.M. with Resident #64 revealed the food she ordered didn't always match the food she was served. Interview on 06/11/9 at 9:13 A.M. with Resident #47 revealed during lunch on 06/06/19 revealed she ordered lettuce and tomato on her meal tray and her meal tray was absent of both the lettuce and tomato. During dinner on 06/06/19, Resident #47 ordered French dressing and was served Ranch dressing instead. Resident #47 revealed she reported her dietary complaints to Licensed Practical Nurse (LPN) #10 every week. Interview on 06/11/19 at 9:16 A.M. with Resident #12 revealed he was served food that wasn't ordered on his meal ticket and he had spoken to the dietary staff regarding this concern several times and nothing changed with his meals being incorrect. Interview on 06/11/19 at 9:24 A.M. with State-tested Nurse Aide (STNA) #7 revealed the resident's meal tickets didn't always match the food the residents were served. STNA #7 often had to call the kitchen to ask for the food missing from the resident's meal tray. Interview on 06/11/19 at 9:29 A.M. with Resident #1 revealed the food she ordered didn't matched the food she was served, and a food or item was always missing from her meal tray. Interview on 06/11/19 at 9:31 A.M. with Resident #3 revealed his meal tray card didn't match the food he was served, and a food or item was always messing from his meal tray. Interview on 06/11/19 at 11:46 A.M. with Licensed Practical Nurse (LPN) #10 revealed Resident #47 had dietary complaints weekly such as Resident #47 was given the incorrect dressing from what she ordered. LPN #10 stated she notified Dietary Manager (DM) #14 of Resident #47's dietary complaints. Observation on 06/11/19 from 11:53 A.M. to 12:25 P.M. of the lunch tray line revealed Cook #2, DA #4, Dishwasher #5, DA #11 and Visiting DM #12 were serving food or setting up the meal trays. All the meal trays were observed at the time Dishwasher #5 or DA #11 was inserting the meal trays into the meal cart. At 11:57 A.M., Resident #4's meal ticket indicated he requested cranberry juice however lemonade was served on his meal tray. Interview, during the observation, with Cook #2 verified Resident #4 was served cranberry juice instead of lemonade because lemonade was the beverage that was being served at lunch. At 12:20 P.M., Resident #23's meal ticket indicated he didn't want seeds however Resident #23 was served a ham and Swiss sandwich on rye bread with seeds in the bread. Interview, during the observation, with Cook #2 verified Resident #23 requested no seeds and was served rye bread with seeds. This deficiency substantiates Complaint Number OH 674.

Based on observation, interview, and record review the facility failed to ensure proper infection control procedures were followed related to isolation procedures when entering and exiting rooms for residents under contact and droplet precautions. This had the potential to affect all 86 residents currently residing in the facility. Findings include: 1. Record review revealed Resident #340 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the interim baseline care plan indicated Resident #340 was placed on contact isolation precautions related to a [DIAGNOSES REDACTED]. On 03/18/19 at 5:30 P.M., observation revealed a sign posted on the outside of the door of Resident #340's room indicating isolation was in progress along with personal protective equipment located by the door including gloves, gowns and masks. While standing outside of the room, State tested Nurse Aide (STNA) #68 entered the room and delivered the resident's tray. Upon exiting the Resident's room, STNA #68 proceeded to the meal cart to retrieve another tray to deliver to another resident. On 03/18/19 at 5:35 P.M., an interview with STNA #68 verified he exited Resident #340's room without washing his hands or using hand sanitizer. STNA #340 proceeded to enter another resident's room and use the resident's bathroom to wash his hands before continuing with the tray pass. Review of the undated facility policy titled Procedures for Airborne, Contact, and Droplet Isolation, revealed under the Contact Precautions section, to wear clean gloves when entering the resident area, remove gloves before leaving the resident area, and to wash hands immediately or use alcohol hand sanitizer. 2. Record review of Resident #34 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident was cognitively impaired. Review of the nursing note dated 03/12/2019 at 5:01 P.M. Resident #34 had a fever of 101.0 degrees Fahrenheit (F) a non-productive cough and wheezing. A nursing note dated 03/14/19 at 5:23 A.M. revealed Resident #34's influenza (flu) swab was positive. Review of Resident #34's care plan dated 03/19/19 revealed Resident #34 was on droplet precautions due to the flu. The interventions included to follow infection control measures per the facility's protocol for droplet precautions. Observation on 03/19/19 at 10:21 A.M. revealed Housekeeping Aide (HA) #35 exiting Resident #34's room without a mask on after having vacuumed the floor. The family member that was in the resident's room was wearing a mask. Interview at this time with HA #35 confirmed she didn't have a mask on and stated she forgot to put one on while in Resident #34's room. Review of the undated facility policy titled Procedures for Airborne, Contact, and Droplet Isolation, revealed under the Droplet Precautions section, to wear a mask when working within three feet the resident.

Based on observation, interview, and record review the facility failed to maintain sanitary conditions in the south and north dietary serveries. This had the potential to affect 85 of 86 residents currently residing in the facility. Resident #285 was identified as receiving nothing by mouth. The facility census was 86. Findings include: Tour of the North nursing unit dietary servery on 03/18/19 at 9:53 A.M. with Dietary Manager (DM) #21 revealed the microwave was dingy white in appearance and on the inside were various dried on food debris. The inner lower paneling was chipped away in three quarter sized areas revealing rusted metal. The upper portion of the inner paneling appeared warped. In the freezer there were brownish stains on the top shelf of the freezer door. Tour of the South nursing unit dietary servery on 03/18/19 at 9:57 A.M. with DM #21 revealed the microwave had various dried on food debris and a burnt area on the inside wall of the microwave. The refrigerator needed some spot cleaning throughout and the top shelf of the inside freezer door had a brownish dried on spill. Interview on 03/18/19 between 9:53 A.M. and 9:57 A.M. DM #21 confirmed the observations and stated the microwave in the North servery needed to be replaced. DM #21 stated the housekeeping staff were responsible for cleaning the serveries. Review of the undated facility policy titled Dietary Department Guidelines, revealed all food preparation equipment, dishes, and utensils must be maintained in a clean, sanitary, and safe manner. Any piece of equipment, dish, or utensil will be discarded when it is cracked, broken, discolored or abraded.

Based on interview and record review, the facility failed to ensure Resident #26 was able to participate in his care planning conferences. This affected one of one residents reviewed for care plan conferences. Findings include: Review of the medical record for Resident #26 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 was cognitively intact. Interview on 03/18/19 at 3:46 P.M. with Resident #26 revealed he had not been invited to or participated in any of the care conferences since his admission. Interview on 03/21/18 at 12:46 P.M. with Social Services (SS) #7 revealed she had been in this position since (MONTH) (YEAR) and care conferences were held quarterly. SS #7 stated Resident #26 had a care conference on 01/07/19 that was attended by the resident's family member. SS #7 stated the resident was asleep and had not been awakened for the care conference. SS #7 stated she had not followed up with Resident #26 after the care conference with the resident's family member. SS #7 stated this care conference was the first she had scheduled for Resident #26 since being new to the position. Interview on 03/21/19 at 1:47 P.M. with the Administrator revealed she was unable to locate documentation of Resident #26's care conferences. The Administrator verified Resident #26 was alert and oriented and should have been included in his care conferences. Review of the facility's policy titled Care Plan Meeting, dated 02/2012 revealed care plan meetings will be held after admission, at least quarterly, or with any change in condition. The resident, responsible party, and outside consulting agencies, when applicable, will be invited to attend care conferences.

Based on resident interview, staff interview, review of the facility Self-Reported Incident (SRI) investigation and the police report, the facility failed to ensure Resident #43 was free from misappropriation of her wallet. This affected one resident reviewed for misappropriation of property. The facility census was 86. Findings include: Review of the medical record for Resident #43 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set, an assessment tool, Version 3.0 dated 01/30/19, indicated the resident was cognitively intact with a BIMS (Brief Interview for Mental Status) score of 13. During an interview with Resident #43 on 03/19/19 at 01:40 P.M., she indicated she noticed her wallet missing on 02/16/19 and notified facility staff. Resident #43 indicated her wallet contained credit cards and identification, but no cash. She stated that as of 03/19/19, there were no charges posted to her credit cards. Review of the facility's investigation into the incident of 02/16/19 revealed interviews with staff and Residents. All staff denied knowledge of the missing wallet. The Administrator indicated Residents in the facility were also interviewed and no other Resident reported any missing items. During an interview on 03/21/19 at 11:59 A.M., the Administrator confirmed that Resident #43 had reported her wallet missing on 02/16/19. The Administrator indicated a Self-Report Incident (SRI) was completed and the facility immediately began an investigation The Administrator reported just as she was about to finalize the investigation, she received a telephone call from a police department in another city. They indicated they had arrested a State tested Nurse Aide (STNA) #496 identified as employed by the facility during a traffic stop, and found a wallet that did not belong to her. The Administrator indicated it was confirmed the wallet belonged to Resident #43. The Administrator stated that she had interviewed STNA #496 on 02/18/19 at 03:00 P.M. and the employee had lied to my face and then went to the Resident and told her she was asked about the wallet. The Administrator indicated she was told that STNA #496 had fake plates on her vehicle and there were two warrants out for her arrest related to traffic tickets. The Administrator indicated that STNA #496 underwent a background check, and received training on abuse, neglect and misappropriation during her orientation upon hire, during all staff meetings and every time there was an incident. The Administrator indicated STNA #496 was hired in (MONTH) (YEAR) and there were no red flags. Review of STNA #496's personnel record revealed a background check, references and an acknowledgement of the facility's Abuse policy. STNA #496's employment was terminated on 02/21/19 due to failure or refusal to cooperate fully with a facility investigation. Review of the policy titled Abuse/Neglect/Involuntary Seclusion/Misappropriation Prevention and dated 10/2017 indicated it is the policy of this facility that all residents will be free from verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion, neglect and/or misappropriation of residents' property. Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongs or money without the resident's consent. Misappropriation means depriving, defrauding or otherwise obtaining the real or personal property of a resident by any means prohibited by the Revised Code. This deficiency substantiates Self-Reported Incident Investigation Control Number OH 851.

Based on interview and record review, the facility failed to ensure a resident received the needed assistance during a transfer resulting in a fall without injury. This affected one of three residents reviewed for falls (Resident #73). Findings include: Review of the medical record for Resident #73 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 assessment of 05/04/18 revealed the resident was cognitively intact with no behaviors, required extensive assist of two for Activities of Daily Living (ADL), with the exception of eating which required only supervision, frequently incontinent of bladder and bowels, with one fall with injury since prior assessment, and no pressure ulcers. Review of the care plan of 03/12/18 revealed care areas for alteration in elimination, history/risk of falls, potential for skin deficits, alterations in cardiac output, risk for altered nutrition/hydration and therapy with goals and interventions appropriate to meet the needs of the resident. Review of the fall log of 03/01/18 to 06/23/18 revealed the resident had falls on 03/31/18 at 11:00 A.M. and 04/20/18 at 9:30 P.M. Review of the fall review of 04/20/18 for Resident #73 revealed the resident suffered a fall and hit her head when State tested Nursing Assistant (STNA) #105, attempted to transfer the resident by himself, when the resident required assistance of two staff for transfers. Interview on 06/23/18 at 12:30 P.M. with the Administrator verified Resident #73 required assistance of two staff for transfers but on 04/20/18 STNA #105 attempted to transfer the resident alone, resulting in a fall without injury for the resident. This deficiency substantiates Complaint Number OH 566.

Based on observation, interview and record review, the facility failed to prepare pureed items in a manner that preserved nutritional value. This affected eight (Residents #12, #23, #32, #39, #57, #59, #374, #475) residents who received pureed meals. Findings include: Observation of puree preparation on 02/06/18 starting at 10:59 A.M. revealed Dietary Staff (DS) #106 put two cups of water and then 11 scoops of baked beans from a slotted spoon into the Vitamix blender and blended the baked beans. DS #106 then poured a runny baked bean mixture into a pan on the steam table. DS #106 never referred to the puree recipe during the preparation period. Interview on 02/06/18 with DS #106 during the puree observation revealed that water was added to the puree mixes beforehand because the blender would clog and not run right without it. DS #106 stated that the baked beans were a nectar-thick mixture and thickener was added once the product was on the steam table because the heat made it thicken. DS #106 added three tablespoons and one teaspoon of the thickener product shortly after the baked beans were on the steamtable. The pureed baked beans maintained a honey-thick consistency. Review of the recipe titled Pureed Baked Beans dated 06/18/17 listed only one ingredient, baked beans. No water or thickener were listed on the recipe and no direction was given on how to thicken or thin the food product. Review of a list of resident diets revealed eight residents, Residents #12, #23, #32, #39, #57, #59, #374, #475, received pureed meals.

Based on record review, staff interview and Ohio Administrative Code review, the facility failed to ensure a level two pre admission screen and resident review (PASRR) assessment was completed timely as required. This affected one (Resident #42) of one resident reviewed for PASRR status. Findings Include: Review of the medical record revealed Resident #42 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #42's admission records revealed the resident was admitted to the facility on a hospital exemption dated 02/16/17 indicating an expected length of stay of less than 30 days. Review of progress notes revealed Resident #42 was discharged to the hospital on [DATE] and 03/07/17 but did not discharge to the community. The 30 day hospital exemption timeline and requirements for submitting timely for a level two evaluation maintained throughout his stay. Review of the Pre Admission Screen and Resident (PASRR) form 3622 revealed Resident #42 had a level two mental illness and a level two resident review was requested by the facility on 05/04/17. A level two resident review was completed by the state agency approving long term nursing home placement on 05/08/17. Review of the Ohio Administrative Code 5160-3-15.2 titled Resident Review Requirements for Individuals Residing in Nursing Facilities revealed when an individuals was admitted under a hospital exemption, the nursing home shall submit a resident review level two request no later than the twenty-ninth day from the date of admission once the nursing facility had reason to believe the individual may need to remain in a nursing facility for thirty days or more. Interview with Social Worker #104 on 02/06/18 at 4:30 P.M. verified the above information and that a level two evaluation was conducted after the required timeframe.

Based on observation, record review and interview, the facility failed to identify behaviors and appropriate interventions. This affected one (Resident #13) of five residents reviewed for unecessary medication. Findings include: Review of the medical record for Resident #13 revealed the resident had [DIAGNOSES REDACTED]. Review of the nurses notes from 10/01/17 to 02/07/18 revealed the resident had episodes of anxiety and yelling out and became very anxious on bath/shower days. The resident would say that she wanted the shower but became fearful and yell out. Review of the care plan for Resident #13 did not include the behaviors or interventions to address the resident's increased anxiety before and during showers, which included exhibiting resistance, yelling out and becoming verbally abusive. An observation on 02/07/18 from 9:40 A.M. to 10:10 A.M. revealed the resident was yelling out and calling Nurse and quieted momentarily when staff arrived but would yell out again. An interview on 02/07/18 at 10:10 A.M. with State tested Nurse Aide #110 revealed she stated Resident #13 was moody, anxious, got mad at staff or her family and cussed at staff, especially during baths or showers. She stated Resident #13 always said thank you and that she felt better after her showers. An interview on 02/07/18 at 10:12 A.M. with Resident #13 revealed she was anxious at times and became scared. An interview on 02/07/28 at 12:52 P.M. with Licensed Practical Nurse #109 revealed Resident #13 frequently yelled out during showers and an additional staff member was required in the shower room to distract the resident, assist in calming her down, and was a witness that although she yelled she was safe and had wanted the shower. An interview on 02/07/18 at 2:55 P.M. with the Director of Nursing confirmed the resident's care plan did not address the resident's behaviors or appropriate interventions.

Based on record review and interview, the facility failed to ensure nonpharmacalogical interventions were attempted prior to administration of an antianxiety medication. This affected one (Resident #13) of five residents reviewed for unnecessary medications. Findings include: Review of the medical record for Resident #13 revealed the resident was admitted on [DATE] and had a [DIAGNOSES REDACTED]. The medication was reordered by the physician on 11/27/17 and 02/07/18. [MEDICATION NAME] was administered on 12/04/17, 01/04/18, 01/05/18 and 01/28/18 without documentation of nonpharmacological interventions being attempted prior to administration of the medication. An interview on 02/08/18 at 11:08 A.M. with Registered Nurse #108 confirmed there was no documentation of nonpharmacological interventions prior to administration of the [MEDICATION NAME] on 12/04/17, 01/04/18, 01/05/18 and 01/28/18 and documentation of monitoring behaviors and side effects of [MEDICAL CONDITION] medications had not been placed on the resident's medication record until 02/06/18.

Based on observation and staff interview, the facility failed to ensure proper placement of urine collection bags to prevent infection. This affected two (Residents #430, #44) of eight residents with urine collection bags. Findings include: 1. Review of the medical record revealed Resident #430 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #430 was alert and oriented, and required extensive assistance with a two person assist for activities of daily living. Review of (MONTH) (YEAR) physician orders [REDACTED]. Observation of Resident #430 on 02/05/18 at 10:14 A.M. revealed the resident's urine collection bag and tubing were on the floor. Interview with State tested Nurse Aide #101 on 02/05/18 at 10:14 A.M. verified that the catheter bag was on the floor, and stated it should not have been on the floor. 2. Review of the medical record revealed Resident #44 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident ' s MDS 3.0 assessment dated [DATE] revealed Resident #44 was alert and oriented, and required extensive assistance with a two person assist for activities of daily living. Review of (MONTH) (YEAR) physician orders [REDACTED]. Observation of Resident #44 on 02/06/18 at 12:52 P.M. revealed the resident's catheter urine collection bag and tubing were on the floor. Interview with Registered Nurse #100 on 02/06/18 at 10:14 A.M. verified that the catheter urine collection bag was on the floor and stated it should not have been on the floor.