Every finding on record at Ottawa Co Riverview Nursing Ho

Based on review of the electronic and paper medical records, review of care conference meeting progress notes, review of a signed Do Not Resuscitate (DNR) order, review of physician orders, review of the plan of care, staff interview, and policy review, the facility failed to ensure a resident's code status was consistent throughout the medical record. This affected one (#8) of 29 residents reviewed for code status in the initial sample pool. The facility census was 86. Findings include:Review of the medical record revealed Resident #8 had an admission date of [DATE]. Diagnoses included Parkinsonism, dementia, type two diabetes mellitus, hypertension, depression, and anxiety.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderate cognitive impairment. Review of Resident #8's plan of care revised [DATE], revealed the resident had chosen a Do Not Resuscitate (DNR), (no Cardiopulmonary Resuscitation (CPR)) code status order. Review of the resident's care plan interventions revealed Resident #8's code status would be reviewed quarterly at care conferences. The DNR form would be placed in front of the physical chart in the sleeve. Staff would obtain the DNR order and if hospitalized , send a copy of the DNR order. Further review of the plan of care revealed no documentation if the resident had chosen DNRCC (Do Not Resuscitate Comfort Care) or DNRCCA (Do Not Resuscitate Comfort Care Arrest).Review of a quarterly care conference note dated [DATE] revealed the resident had chosen a full code status. Review of the signed paper DNR Order form dated [DATE] revealed the box for DNR Comfort Care-Arrest (DNRCCA) had been checked.Review of the quarterly care conference progress notes dated [DATE] and [DATE] revealed Resident #8 had chosen a DNRCC code status. Review of an electronic physician order dated [DATE] revealed the resident had chosen a DNRCC code status. Further review of the electronic medical record revealed the resident's code status was documented as DNRCC. Interview on [DATE] at 11:25 A.M., Registered Nurse (RN) #377 revealed she would check for a resident's code status in the electronic medical record or the physical chart. RN #377 revealed the best place to check would be in the front of the physical chart as it had a copy of the DNR form. RN #377 revealed Resident #8's code status was DNRCC. RN #377 was then asked to review the resident's signed DNR form in the physical chart. RN #377 verified the code status had not matched in the paper medical record and the electronic medical record. RN #377 verified the signed DNR order form was for a DNRCCA code status and the electronic physician order was for a DNRCC code status. Review of the facility policy DNR Status, dated [DATE], revealed a DNR code status should be obtained in writing and faxed to the primary physicians as soon as possible. Once the DNR Form was signed and returned by physician, the charge nurse would write corresponding telephone order in resident's chart. The medical records technician would monitor DNR Code to ensure they were complete and correct according to the signed document. If a discrepancy was found, the medical records technician would inform the charge nurse and ensure the correct actions were taken to correct the discrepancy.

Based on review of the medical record, review of medication administration records, review of physician orders, review of pharmacy guidelines, observation, staff interview, and policy review, the facility failed to ensure a resident was free from a significant medication error. This affected one (#67) of three residents observed for medication administration. The facility census was 86. Findings include:Review of the medical record for Resident #67 revealed an admission date of 11/06/23. Diagnoses included Parkinson's disease, dysphagia, hypokalemia, cardiomegaly, hypertension, hemiparesis and hemiplegia following cerebral infarction.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had mild cognitive impairment.Review of a physician order dated 10/23/25 revealed Resident #67 had orders for potassium chloride extended release 20 milliequivalents (MEQ), two tablets by mouth daily for hypokalemia. There were no physician orders to crush the resident's medications. Review of the Medication Administration Record (MAR) from 02/01/25 through 02/24/25 revealed Licensed Practical Nurse (LPN) #405 had administered Resident #67's two tablets of potassium chloride extended release 20 MEQ on 02/01/25, 02/04/25, 02/05/25, 02/14/25, 02/15/25, 02/19/25, 02/20/25, 02/23/25, and on 02/24/25.Review of the Resident #67's progress notes from 02/01/25 through 02/24/25 revealed no documentation the resident had a change in condition. Observation on 02/25/26 at 7:34 A.M., of medication administration for Resident #67 with Licensed Practical Nurse (LPN) #405 revealed LPN #405 placed senna 8.6 milligrams (mg), vitamin D 25 micrograms (mcg) two tablets, amlodipine 10 mg, Lasix 40 mg, one multivitamin, and two tablets of potassium 20 MEQ in a small plastic sleeve and then placed the medications in the medication crusher. LPN #405 was asked by the surveyor if she was going to crush the resident's potassium. LPN #405 revealed she always crushed the resident's potassium along with his other medications because he had difficulty swallowing them. LPN #405 then revealed the only medication she would not crush for the resident was his omeprazole because it was a capsule. After surveyor intervention the resident's potassium was not crushed. LPN #405 then administered the crushed medications along with two whole tablets of potassium chloride extended release 20 MEQ and one capsule of omeprazole 20 mg in applesauce to the resident. Further observation revealed Resident #67 had difficulty swallowing the whole medications requiring several additional spoonfuls of applesauce to swallow the medication. Interview on 02/25/26 at 4:48 P.M., Registered Nurse (RN) #345 verified nurses should not crush potassium. Further interview on 02/26/25 at 9:05 A.M., RN #345 verified LPN #405 had administered medications including potassium for Resident #67 nine times from 02/01/25 through 02/25/26. Interview on 02/26/26 at 1:33 P.M., LPN #335 revealed Resident #67 was able to take his medication whole in pudding and the resident had no problems taking medications whole. Interview on 02/26/26 at 8:35 A.M., Nurse Practitioner (NP) #411 verified she had not been notified Resident #67 had difficulty swallowing medications. Review of the facility pharmacy document dated 2025 of a list of Do Not Crush Medications revealed potassium chloride extended-release medication should not be crushed. Review of the facility policy Crushing Medications, revealed a medication would be crushed only when it was deemed appropriate per specific medication guidelines, consistent with physician orders. Staff would refer to the pharmacy provider forms for medications that should not be crushed. Nurses administering medications would verify the facility may crush medication order was present in the resident chart.

Based on observation, staff interview, and policy review, the facility failed to ensure residents were treated in a dignified manner. This affected three (#31, #25, #67) of three residents reviewed for dignity. The facility census was 86.Findings include:1.Review of the medical record for Resident #31 revealed an admission date of 12/01/23. Diagnoses included Alzheimer's disease, dementia, muscle weakness, and dysphagia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. The resident was dependent on staff for eating meals. Review of a physician order dated 02/10/24 revealed the resident was ordered a regular diet with mechanical soft texture and thin liquids. Observation on 02/24/26 at 8:45 A.M. revealed Certified Nursing Assistant (CNA) #363 was standing over Resident #31 while feeding the resident bites of food. Further observation revealed an empty chair was near where the resident was sitting at the dining table. Interview on 02/24/26 at 8:47 A.M., CNA #363 verified she was standing while feeding Resident #31. CNA #363 revealed she should be sitting while providing feeding assistance. 2. Review of the medical record for Resident #25 revealed an admission date of 08/06/24. Diagnoses included chronic obstructive pulmonary disease, hypertension, and anxiety. Review of the quarterly MDS assessment dated [DATE] revealed the resident had severe cognitive impairment. The resident required supervision or touching assistance for eating meals. Review of a physician order dated 07/07/25 revealed the resident had an order for a regular diet with pureed texture and nectar thickened liquids. Observation on 02/25/26 at 8:34 A.M. revealed CNA #368 was standing over Resident #25 while feeding the resident bites of food. Interview on 02/25/26 at 8:34 A.M., Licensed Practical Nurse (LPN) #336 revealed staff should not be standing when providing feeding assistance. LPN #336 revealed the staff should be sitting on a stool. Interview on 02/25/25 at 8:39 A.M., CNA #368 revealed Resident #25 normally ate on his own, but she was just helping to feed him. CNA #368 verified she was standing while feeding the resident. CNA #368 verified she should be sitting when feeding a resident. Review of the facility policy Dignity revised 02/2021, revealed residents would be treated with dignity and respect at all times. Resident would be provided with a dignified dining experience. Review of the facility policy Assistance with Meals, revised 03/2022, revealed residents who cannot feed themselves would be fed with attention to safety, comfort, and dignity including for staff to not stand over residents while assisting them with meals. 3. Review of the medical record for Resident #67 revealed an admission date of 11/06/23. Diagnosis included need for assistance with personal care, mild cognitive impairment, and Parkinson's disease. Review of the quarterly MDS assessment dated [DATE] for Resident #67 revealed he had mild cognitive impairment and required maximum assistance for personal hygiene. Review of the nursing progress note dated 01/21/26 at 3:30 P.M. authored by LPN #335 for Resident #67 revealed the resident was dependent for all hygiene needs. Observation on 02/23/2026 at 3:33 P.M. of Resident #67 revealed he had a brown stream like dried substance under his lower lip that ran down his chin and there was a small, pearl sized piece of brown dried clump of a substance that was located just under the bottom lip of Resident #67. Concurrent interview with Resident #67 stated he needs help with activities of daily living (ADL) care and sometimes needs help with eating. Observation on 02/23/2026 at 4:56 P.M. of, following dinner, Resident #67 revealed he remained with the same dried dark stain under his lip and down his chin. Interview with CNA #401 verified the brown stained food that remained under the lip and down the chin for Resident #67. Review of the facility policy titled, Activities of Daily Living (ADLs), Supporting, revised 03/18 revealed residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living. Appropriate care and services will be provided for resident who are unable to carry out ADLs independently to assist with hygiene (bathing, dressing, grooming, and oral care). Review of the facility policy titled, Dignity, revised 02/21 revealed each resident will be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. When assisting with care, residents are supported in exercising their rights, for example, groomed as they wish to be and dignified dining experience.

Based on record review, staff interview, policy review, and review of the facility's hemodialysis center contract, the facility failed to ensure consistent communication occurred between the facility and the dialysis center for residents who received hemodialysis (HD). This affected one (#12) of one resident in the facility who received hemodialysis. The facility census was 86.Findings include: Review of the medical record for Resident #12 revealed an admission date of 11/21/23 with diagnoses of end stage renal disease and dependence on renal dialysis. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/29/26, revealed Resident #12 had impaired cognition and received dialysis. Review of the care plan, initiated 12/18/23, revealed Resident #12 needed hemodialysis related to renal failure. No interventions were in place regarding coordination of care with the hemodialysis clinic. Review of the physician order dated 12/01/24 revealed Resident #12 went to hemodialysis offsite three times weekly on Mondays, Wednesdays, and Fridays. Interview on 02/25/26 at 10:34 A.M. with Licensed Practical Nurse (LPN) #373 and concurrent review of a facility's dialysis communication form, titled Outpatient Dialysis Assessment, revealed the facility completed the top portion (resident vital signs) and sent the form with Resident #12 to the HD clinic. LPN #373 stated the HD Clinic completed the bottom portion of the form and returned it with Resident #12. Review of Resident #12's Outpatient Dialysis Assessment forms, dated 01/26/26 through 02/13/26, revealed the facility did not complete the top portion on 01/26/26, 01/28/26, 01/30/26, and 02/11/26; the HD clinic did not complete the bottom portion on 02/13/26; and no form was available for 02/02/26 and 02/04/26. Interview on 02/25/26 at 9:23 A.M. with the Director of Nursing (DON) confirmed the forms dated 01/26/26, 01/28/26, 01/30/26, 02/11/26, and 02/13/26 were incomplete. A request was made for the facility to provide any additional forms from 01/26/26 through 02/25/26. Review of three additional Outpatient Dialysis Assessment forms, provided by the facility, dated 02/18/26, 02/23/26, and 02/25/26, revealed the facility did not complete the top portion on 02/18/26, and no form was provided for 02/16/26 and 02/20/26. Review of the facility's policy, Hemodialysis Care, revised September 2010, revealed the general medical nurse should keep record of the dialysis log containing pertinent information from dialysis center. Review of the facility's contract with the hemodialysis center for Resident #12 revealed the facility shall ensure all appropriate medical, social, administration and any other pertinent information that will facilitate the adequate coordination of care for the resident accompany the designated resident at the time of transfer to the HD Center.

Based on record review and staff interview, the facility failed to ensure residents were informed about treatment options and alternatives before beginning treatment with psychoactive medications. This affected one (#9) of five residents reviewed for psychoactive medications. The facility census was 86.Findings include:Review of the medical record for Resident #9 revealed an admission date of 10/15/25 with diagnoses of depression, restlessness, anxiety, and protein-calorie malnutrition. Resident #9 was admitted to hospice on 02/21/26. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/22/26, revealed Resident #9 had intact cognition and received an antianxiety medication, and an antidepressant. Review of the physician order initiated 11/15/25 and discontinued 02/23/26 revealed Resident #9 received buspirone (an antianxiety medication) hydrochloride oral tablet 10 milligrams (mg), one tablet twice daily for anxiety. Review of the physician order initiated 12/03/25 and discontinued 02/23/26 revealed Resident #9 received mirtazapine (an antidepressant) tablet 15 mg, one tablet once daily for appetite stimulant/malnutrition. Review of the physician order initiated 01/15/26 and discontinued 02/23/26 revealed Resident #9 received lorazepam (an antianxiety medication) oral tablet 0.5 mg, one table every 8 hours as needed for anxiety. Interview on 02/25/26 at 11:27 A.M. with MDS Licensed Practical Nurse (LPN) #342, and concurrent review of Resident #9's chart, revealed no informed consents were signed prior to initiating the psychoactive medications buspirone, mirtazapine, and lorazepam for Resident #9. MDS LPN #342 verified there should have been consents obtained prior to initiating psychoactive medications.

Based on record review, staff interview, family interview, and facility policy review the facility failed to arrange routine dental care visits for one (#25) of two residents reviewed for dental care. The facility census was 86.Findings include:Review of Resident #25's medical record revealed an admission date of 08/06/24. Diagnoses included dementia, chronic obstructive pulmonary disease, emphysema, and coronary artery disease. Review of Resident #25's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was a [AGE] year old male with a low cognitive function. The resident was dependent on staff for oral hygiene care. Review of Resident #25's care plan revealed he was at risk for altered oral/dental status related to cognitive loss and required assistance with dental care. Interventions were to have dental exams as warranted or desired by the resident. Review of Resident #25's outside services form revealed on 06/25/25 his family gave consent for the resident to see dental services for preventative dental care. Review of Resident #25's medical record found the resident had received no dental care since the consent was signed. Interview with Resident #25's family on 02/23/26 at 1:48 P.M. revealed they had requested dental care for the resident and the facility failed arrange the services. Interview with Licensed Social Worker (LSW) # 343 on 02/25/2026 at 1:33 P.M. revealed the facility had failed to arrange for preventative dental appointments for Resident #25 per family request. Review of the facility policy titled Dental dated 01/06/21 revealed the dental healthcare provider works with social services to coordinate dental visits. Social services was to email add on needs for dental services to the dental provider.

Based on review of the medical record, observation, staff interview, and policy review, the facility failed to ensure proper use and monitoring of a physical restraint. This affected one (#10) of one resident reviewed for restraints. The facility identified one resident with a restraint. The facility census was 86. Findings include:Review of the medical record for Resident #10 revealed an admission date of 05/03/24. Diagnoses included Parkinson's disease, progressive multiple sclerosis, dementia, type two diabetes mellitus, and dysphagia. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition and was never understood. Further review of the MDS revealed the resident required physical restraints used daily as a limb restraint in bed, in chair, and out of bed. The resident was dependent on staff for activities of daily living. Review of the plan of care initiated 05/10/24 revealed the resident had a restraint and used arm protection such as socks, gloves, or sleeves to prevent self-harm from chewing or biting her arm related to decreased safety awareness and dementia. Interventions included to discuss and record with family and caregivers the benefits and risks of the restraint, when the restraint should and would be applied, routines while restrained, and any concerns or issues regarding restraint use. Staff were to ensure there was a valid consent in the medical record prior to initiating the restraint. Further interventions included to evaluate the restraint use quarterly and as needed, evaluate and record continuing risk/benefits, alternatives to the restraint, the need for ongoing use and the reason for restraint use. Staff were to monitor/document/report to the physician as needed changes regarding effectiveness of restraint, less restrictive device if appropriate, and any negative or adverse effects notes including decline in mood, changes in behavior, decreases in activities of daily living performance, decline in cognitive ability or communication, contracture formation, skin breakdown, sign/symptoms of delirium, falls/accidents/injuries, agitation, and weakness. Staff were also to provide the resident with opportunities for restraint-free time daily. Review of a physician order dated 05/03/24 revealed an order to monitor and document incidents of self-injurious behavior such as biting self, scratching self, etc. twice daily for dementia. Review of a physician order dated 12/13/24 revealed the resident was admitted to hospice with a diagnosis of senile degeneration of the brain. Review of a physician order dated 01/07/25 revealed an order for the resident to wear gloves or socks and geri-sleeves (fabric skin protector) to maintain skin integrity two times a day for itching. There were no physician orders for when and how long the restraints should be applied. There were no physician orders for when and how often the restraints should be removed.Review of a restraint consent form dated 05/06/24 revealed the resident's representative was informed of the risks/benefits of the restraint use on 06/04/24. Review of a restraint progress note form initiated 05/10/24 and signed monthly by the nurse practitioner revealed the resident required use of special arm coverage which could be classified as a physical restraint due to limiting access to her own body. The resident was noted with decreased awareness of safety needs related to confusion and memory impairment. The resident's Brief Interview for Mental Status (BIMS) score was zero placing her in the severe cognitive impairment category. Further review of the progress note revealed the resident bites and chews on the skin of her arm causing harm to herself. The resident had episodes of anxiety and restlessness. The resident had diagnoses including Alzheimer's dementia, anxiety, and dermatitis. Continued review of the progress note revealed the resident's representative had been educated to the risks/benefits of the restraint and agreed it was the least restrictive device and consented to use of the device. Nursing was to perform skin integrity checks every shift. Use of the device would be reevaluated regularly. Review of behavior task charting from 11/01/25 through 02/25/26 completed by the certified nursing assistants revealed documentation of behavioral symptoms not directed at others occurred on 12/10/25, 12/18/25, 01/24/26, 01/26/26, and 02/06/26. There was no further documentation describing the type of behavior. Review of the treatment administration records and nurse's notes from 09/06/25 through 02/23/26 revealed no documentation regarding when or how long the restraints should be used. There was no documentation of when or how often the restraints should be removed. There was no documentation of daily skin checks while the resident was wearing the restraints. There was no documentation of how often the resident exhibited biting behaviors. Review of a nurse's note dated 01/03/25 at 8:41 P.M. revealed the resident had increased vocalization and was biting bilateral upper extremities. Review of a nurse's note dated 11/09/25 at 11:33 A.M. revealed the resident attempted to self-remove the arm covering with her teeth and laughed when they were reapplied. Further review of the nurse's notes from 12/01/25 through 02/23/26 revealed no documentation of the resident having biting behaviors.Review of a weekly skin assessment dated [DATE] revealed Resident #10 had no skin breakdown. Observation on 02/24/26 at 7:36 A.M., 1:24 P.M., 2:05 P.M. and 2:20 P.M. revealed the resident had socks covering her hands. The resident was observed sleeping most of the time and there were no observations of the resident attempting to bite her hands. Further observation on 02/25/26 at 8:51 A.M. revealed Resident #10 was sitting in her wheelchair in the dining room with a blanket and socks covering her hands. The resident eyes were open, and the resident made no attempts to bite her hands. Licensed Practical Nurse (LPN) #336 was asked by the surveyor to remove the socks from the resident's hands for a skin inspection. The resident's skin was clean, dry, and free of skin breakdown. Continued observations on 02/25/26 at 12:07 P.M. in the dining room revealed staff attempted to wake the resident for lunch. The resident had the sock restraints on her hands and made no attempts to bite herself. Interview on 02/24/26 at 2:21 P.M. with Registered Nurse (RN) #377 revealed the resident wore socks on her hands to prevent her from biting herself. RN #377 revealed she checked the resident's skin underneath the socks on her hands at least once per shift. RN #377 revealed there was no documentation for the skin checks for the resident's hands. RN #377 revealed they would only document if there was a problem. Interview on 02/25/26 at 8:51 A.M., LPN #336 revealed the resident wore the sock restraints on her hands to prevent her from biting herself. LPN #336 revealed he was not removing the socks to check the resident's skin. LPN #336 revealed the nursing assistants may be removing the socks when they change her. Interview on 02/25/26 at 10:49 A.M. with the Director of Nursing (DON) who also serves as the facility Nurse Practitioner (NP) #411 revealed the resident had itching and took medication for the itching. NP #411 revealed the resident came from another facility with orders for the restraint for her hands and her representative wanted the restraint to remain in place. The DON verified the physician order for the restraint had not specified a specific medical reason for the need for the restraint. The DON further verified there was no documentation how often the resident was required to wear the restraint each day and no documentation when and how often the restraint should be removed. The DON revealed the facility used the restraint protocol. Further interview on 02/26/26 at 8:50 A.M., the DON presented documentation dated 01/05/25 noting the resident had bitten herself. The DON verified she had no documentation of the resident biting herself after this date and would continue to look for the documentation. The DON revealed the resident typically bit herself and staff were not documenting her behaviors. The DON verified the facility had no documentation a less restrictive intervention was attempted prior to using the physical restraint on the resident's hands and no further restraint reductions had been attempted. The DON revealed the resident had declined recently and now was a good time to reevaluate the need for the restraint to her hands. Review of the facility Guidelines for Restraint Use, dated 02/23/07 revealed the facility would identify a specific medical symptom for restraint use and identify the underlying cause of the medical symptom. The facility would rule out other possible interventions. The facility would ensure a physician order specifying the type/reason/duration of the restraint and the physician would reevaluate every 30 days. The comprehensive plan of care would specify at a minimum the type of restraint used, when the restraint would be used and when the restraint should be released. The resident would be monitored every 30 minutes while restrained. Also, the resident would be reassessed and reevaluated for reduction/elimination of the restraint.

Based on review of the medical record, review of care conference meeting documentation, resident and family interview, staff interview, and policy review, the facility failed to ensure residents and resident representatives were invited to care conference meetings. This affected two (#8, #25) of two residents reviewed for care planning. The facility census was 86. Findings include:1.Review of the medical record revealed Resident #8 had an admission date of 09/04/25. Diagnoses included Parkinsonism, dementia, type two diabetes mellitus, hypertension, depression, and anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderate cognitive impairment. Review of the quarterly care conference meeting notes dated 11/26/25 and 02/19/26 revealed the resident was not present at the meetings. There was no documentation the resident had been given an invitation to the meeting and no documentation the resident had refused to attend the meeting. Interview on 02/23/26 at 3:13 P.M., Resident #8 revealed she was not invited to attend her care conference meetings. Interview on 02/25/26 at 11:47 A.M., Social Worker (SW) #343 revealed she coordinated the resident care plan meetings. SW #343 revealed she would send a letter to resident families regarding the planned meeting time and would provide an invitation to the resident for the meeting. SW #343 revealed she had no documentation Resident #8 had been invited to her care plan meetings. 2. Review of Resident #25's medical record revealed an admission date of 08/06/24. Diagnosis included dementia, chronic obstructive pulmonary disease, emphysema, and congestive heart failure. Review of Resident #25's quarterly MDS dated [DATE] revealed the resident was a [AGE] year old male and had a low cognitive function. Interview with Resident #25's family on 02/23/26 at 1:48 P.M. revealed they had not been invited to a care conference for a long period of time. Review of Resident #25's Care Conference note dated 12/11/25 revealed nursing, dietary, social worker, and activities were in attendance at the meeting. No family was in attendance. Review of Resident #25's social service notes dated 06/01/25 through 02/24/26 revealed it was absent of documentation regarding inviting family to care plan conferences. Interview with Licensed Social Worker (LSW) #343 on 02/25/26 at 1:33 P.M. revealed she failed to document when families were invited to care conferences. The LSW verified the family of Resident #25 failed to be invited to meetings. Review of the facility policy titled Resident Participation - Assessment/Care Plan undated revealed an Interdisciplinary Care Conference will take place within 21 days of admission to facility, and then quarterly and as needed thereafter. Care plan meetings are scheduled at the best time of the day for the resident and family when possible. The social services director or designee is responsible for notifying the resident/representative. Notices include the date, time and location of the conference, the name of each person contact and the date he or she was contacted, the method of contact, input from the resident representative if the are not able to attend, and refusal of participation, if applicable.

Based on medical record review, staff interview, and review of the facility policy, the facility failed to follow the bowel protocol. This affected one resident (#95) reviewed for bowel movements. The facility census was 86. Findings include: Review of the medical record for Resident #95 revealed an admission for date 02/12/26. Diagnoses included Alzheimer's, carotid stenosis, anxiety, heart disease, history of recent fall with nondisplaced fracture of the clavicle, and Meniere's disease. Review of the admission assessment dated [DATE] for Resident #95 revealed he was cognitively impaired. Review of the current physicians orders for 02/26 for Resident #95 revealed he was prescribed Tramadol 50 milligrams (mg) for pain, Miralax 17 grams (g) daily (used for constipation prevention), Colace 100 mg twice daily (used for constipation prevention), Milk of Magnesia (MOM) 30 milliliters (ml) as needed daily (used for constipation prevention), and Bisacodyl rectal suppository 10 mg every 24 hours as needed for constipation. Further review of the physician's orders revealed the Bisacodyl 10 mg rectal suppository was ordered on 02/24/26. Review of the bowel movement log for Resident #95 from admission [DATE]) to current revealed no documented bowel movements for six days from 02/18/26 through 02/23/26. Review of the Medication Administration Record (MAR) for 02/26 for Resident #95 revealed an order for MOM 30 mls was in place since 2025 for administration as needed, however, no MOM was administered for no bowel movement for six days. Interview on 02/26/2026 at 7:36 A.M. with the Director of Nursing (DON) stated the facilities bowel program is MOM daily after three days of no bowel movement, and for any resident that is already on bowel aides, MOM 30 mls will be started six days after no bowel movement. The DON verified Resident #95 had no bowel movement for six days and MOM 30 mls was not administered per facility bowel protocol. Review of the facility policy titled, Routine Bowel Program, undated, revealed all resident records will be reviewed daily for adequate bowel elimination and will receive appropriate interventions and/or medications as ordered by their physician to assist the process if/when needed. Each nurse is to ensure that bowel movements (BM) are recorded each shift every day for residents under his/her care. If a resident/patient has a noted absence of BM for three days, the protocol below will be initiated: Milk of Magnesia 30 milliliters (ml) will be administered, if no BM in 24 hours, then repeat dose may be administered every 24 hours, unless otherwise ordered by the physician. If a resident has not had a BM after six days of initiated bowel protocol the charge nurse will notify medical provider for further instructions. If a resident is receiving a routine bowel aid and has not produced a BM for six days, the charge nurse may begin the above protocol. The charge nurse shall notify the appropriate medical provider for further instructions.

Based on observation, staff interview, record review, and policy review, the facility failed to ensure licensed nurses applied lidocaine patches for pain. This affected one (#57) of one resident reviewed for pain management. The facility census was 86.Findings include:Review of the medical record for Resident #57 revealed an admission date of 12/01/25 with diagnoses of pain in left knee, pain in right knee, osteoarthritis, and anxiety, Review of the comprehensive Minimum Data Set (MDS) assessment, dated 12/07/25, revealed Resident #57 had impaired cognition and was dependent on staff for chair to bed transfers. Review of the current physician order, dated 01/27/26, Resident #57 revealed Resident #57 received Lidocaine External Patch 4% applied to bilateral knees topically one time a day for osteoarthritis. Interview and observation on 02/23/26 at approximately 11:30 A.M. revealed Resident #57 dressed and in her wheelchair. Resident #57 stated she had pain in both of her knees and complained about the pain patches on her knee rolling up under her pants. Resident #57 proceeded to pull up the left leg of her pants and show the Lidocaine patch was rolled up and was above her knee. Resident #57 pulled off the patch and began unrolling it. Further observation revealed the pain patch was dated 02/23/26 and was initialed by Licensed Practical Nurse (LPN) #373. Continued interview with Resident #57 on 02/23/26 at approximately 11:40 A.M. and concurrent interview with Certified Nursing Assistant (CNA) #325 revealed CNA #325 applied the Lidocaine patches to Resident #57 when CNA #325 dressed Resident #57 earlier in the morning. CNA #325 stated the nurse left the dated and initialed Lidocaine patches at bedside and CNA #325 applied them after providing personal care and before getting Resident #57 dressed. Interview on 02/23/26 at 12:45 P.M. with LPN #373 confirmed she did not apply Resident #57's Lidocaine patches to Resident #57's knees on 02/23/26 because it was a very busy morning. Review of the policy Administering Medications, revised 04/2019, revealed only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so.

Based on medical record review, observation, staff interview, coroner interview, coroner's office investigator interview, review of the U.S. Food and Drug Administration Guide to Bed Safety Bed Rails in Hospitals, Nursing Homes and Home Healthcare, review of Zenith 9000 Bed Service Manual, review of the Panacea Air Ease Owner's Manual review of policy on Bed Safety and Bed Rails, review of the facility investigation timeline, and review of the county coroner's preliminary findings, the facility failed to thoroughly assess the residents for the risk of entrapment when utilizing bed rails, when the facility assessment did not include compressing the alternating pressure relieving mattress (APM) to measure the potential gap between the mattress and the side rail, the medical needs that will be addressed with the use of bed rails, the risk from the use of bed rails and how these will be mitigated, alternatives that were attempted but failed to meet the residents ' needs, and alternatives that were considered but not attempted and the reasons. This resulted in Immediate Jeopardy and serious life-threatening harm/death for one resident (#200), when his head became wedged between the APM and the right-side grab bar rail, with his legs and lower body near the bed on the floor mat next to the bed, subsequently causing asphyxia leading to death. Additionally, five residents (#31, #35, #58, #60, and #69) were placed at potential risk for harm that was not Immediate Jeopardy as they were at risk of entrapment due to utilizing APM with bed rails and not fully assessed for the potential for possible entrapment. This affected six (#31, #35, #58, #60, #69, and #200) of six residents reviewed for use of bed rails. On 05/28/25 at 2:11 P.M., the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and Assistant Director of Nursing (ADON) were notified Immediate Jeopardy began on 05/19/25 at 4:05 A.M., when Resident #200 was discovered by Registered Nurse (RN) #335 with his head wedged between the mattress and the bed rail and his legs were observed in a kneeling position on the floor mat next to the bed. At this time, Resident #200 was documented to be without vital signs. The Immediate Jeopardy was removed on 05/29/25 at 1:52 P.M., when the facility implemented the following corrective actions: • On 05/19/25, Resident #200 was transported from the facility. • On 05/19/25 at 5:25 A.M., the DON conducted initial staff interviews of Nursing Supervisor #252, RN #335, Certified Nursing Assistant (CNA) #336, and CNA #341, who were the pertinent staff members surrounding the incident. • On 05/19/25 at 7:45 A.M., the DON conducted an initial audit of Resident #200's historical siderail assessments, physician progress notes, medication review audit, pertinent fall history and looking for similarities per facility and CMS guidelines. • On 05/19/25 at 8:00 A.M., the DON, the ADON, RN #404, Registered Nurse Case Manager (RNCM) #385, and LPN #353 completed a whole house siderail audit on all residents utilizing side rails. • On 05/19/25 at 8:10 A.M., LPN #353 ordered Bolsters with anticipation of need to replace side rails. • On 05/19/25 at 8:25 A.M., the DON and Maintenance Director #411 confirmed manufacturer guidelines for air mattress use with siderails to ensure the siderails were compatible with the air mattress being used. • On 05/19/25 at 10:00 A.M., the DON, the ADON, RN #404, RNCM #385, and LPN #353 had a discussion with the Ohio Health Care Association (OHCA) and created a siderail audit tool to be completed weekly for four weeks, monthly for two months, and then as needed thereafter. Results to be discussed with the Quality Assurance and Performance Improvement (QAPI) team. • On 05/19/25 at 12:00 P.M., LPN #353 conducted fall meetings at each nursing station. • On 05/19/25 at 1:00 P.M. and 6:00 P.M., the DON/designee began CNA and nursing education and roles in siderail safety policy and procedure, Food and Drug Administration (FDA) and facility guidelines with all staff present in facility at this time. All facility staff will receive the training that was given at 1:00 P.M. and 6:00 P.M. on 05/19/25 prior to starting their next shift. • On 05/20/25 at 6:30 A.M. and 6:30 P.M., the DON and ADON conducted scheduled nurse's meetings with an agenda of side rail safety with nurses. • On 05/20/25 at 10:00 A.M., the DON/designee conducted a post siderail audit with the goal of discontinuation of siderails, where deemed medically appropriate and agreed upon by the resident. There were five residents (#07, #12, #27, #30, and #40) whose side rails were discontinued at this time. • On 05/20/25 at 6:30 A.M and 6:30 P.M., the DON and ADON or designee completed education on side rail safety policy and procedures, with all nurses and nurse aides on both shifts. All staff education was completed on 05/28/25. • On 05/23/25 on the dayshift, the DON and ADON completed one facility siderail audit tool. • On 05/28/25 at 9:30 A.M., the DON, ADON, RN #404, and RN #384 performed additional audits for all residents utilizing siderail audits, including obtaining measurements when the resident is out of bed. • On 05/28/25 at 10:30 A.M., the DON, ADON, RN #404, and RN #384 updated the facility policy to include gap measurements when resident is out of bed and mattress is compressed. • On 05/28/25 at 10:45 A.M., the DON, ADON, RN #404, and RN #384, updated facility siderail assessment to include gap measurements with resident out of bed and mattress compressibility. • On 05/28/25, the facility siderail use policy was updated to include utilizing appropriate alternative interventions prior to siderail utilization. • On 05/28/25, the DON/designee notified all residents and/or resident representatives with education regarding the new policy and procedure to implement alternative interventions prior to the use of side rails. • On 05/28/25, all siderails were removed facility-wide so that staff can identify appropriate alternative interventions prior to siderail use. • On 05/28/25, the facility implemented a new siderail assessment tool. Tool to be utilized upon resident request, family/resident representative request or identification of failed alternative interventions. • On 05/28/25, the facility implemented a new Siderail Safety Questionnaire V4.2. Siderail questionnaire to be utilized upon initiation of siderail use, at minimum quarterly, and as needed (PRN). • On 05/28/25, the facility implemented a new siderail use consent form to be included in all new admissions as well as upon siderail implementation. Assessment identifies risks such as entrapment and/or up to including death, as well as benefits, such as bed mobility and transfers. • On 05/28/25, the DON/designee will provide education to agency staff before agency staff begin work. Education includes policy updates for siderail use, facility siderail assessment tool and Siderail Safety Questionnaire V4.2. • On 05/28/25, the facility implemented a new bed inspection audit. Maintenance staff will inspect a sample selection of beds monthly along with related equipment to identify hazards or risks. • On 05/28/25, the facility created a new side rail audit. Audits are to be performed weekly for four weeks, monthly for two months, quarterly, and PRN thereafter by the DON/designee. • On 05/28/25, the DON/designee provided education to all nursing staff (nurses and aides) to include policy update for siderail use, facility siderail assessment tool and siderail safety questionnaire V4.2. The DON or designee to complete all facility nursing staff education by 05/29/25. • On 05/29/25, the facility updated the admission checklist reflecting the changes to the side rail assessment. • On 05/29/25, the facility updated the Discharge/Terminal Cleaning Inspection Form to reflect the removal of siderails from beds upon resident discharge. • On 05/29/25 between 8:55 A.M. and 10:00 A.M., interviews with RN #302, CNA #306, CNA #309, CNA #312, CNA #313, CNA #327, CNA #381, Agency RN #397, and Agency RN #398 revealed they were all provided updated side rail education from the facility. All staff that were interviewed could state what the education covered and how it pertained to them in their position. Although the Immediate Jeopardy was removed on 05/29/25, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy), as the facility is still in the process of implementing their corrective action plans and monitoring to ensure on-going compliance. Findings include: 1) Review of the electronic medical record (EMR) for Resident #200 revealed an admission date of 05/24/18, with diagnoses including hemiplegia and hemiparesis following other non-traumatic hemorrhage affecting the left non-dominant side, dysphagia, pain in the right lower leg, depression, hyperkalemia, unspecified lack of coordination, disorder of adrenal gland, iron deficiency anemia, cerebral infarction, cerebrovascular disease, speech and language deficits, atherosclerotic heart disease of native coronary artery, generalized muscle weakness, cognitive communication deficit, abnormalities of gait and mobility, anxiety, history of falling, type two diabetes mellitus, Charcot's joint in right foot and ankle, chronic sinusitis, hyperlipidemia, contact with and suspected exposure to other nonmedicinal chemical hazards, history of pneumonia, orthostatic hypotension, constipation, gastro esophageal reflux disease, pseudobulbar affect disorder and long-term use of insulin. Resident #200 was a do not resuscitate - comfort care (DNR-CC) for life saving measures. Review of the most recent quarterly Minimum Data Set (MDS) assessment, dated 05/16/25, revealed Resident #200 was severely cognitively impaired and was dependent on staff for assistance with activities of daily living. Resident #200 required a Hoyer mechanical lift for transfers. Review of nursing notes for May 1, 2025, to May 18, 2025, revealed Resident #200 would frequently yell out help repeatedly related to his diagnosis of pseudobulbar affect disorder, but could be easily comforted with playing videos of familiar things like farming or sharing memory book. Review of the active monthly physician orders for May 2025 revealed an order for air mattress to bed dated 06/23/23. There were no active orders for any type of side rail, grab bar or positioning devices. Review of Resident #200's care plans revealed no care plan to address the use of any type of side rail, grab bar or positioning device. The care plans had no mention of a bed being placed in a low position off the floor or a mat beside the bed. The care plans did mention Resident #200 being at risk for falls and alterations in sleep patterns. Review of the most recent Siderail Safety Questionnaire for Resident #200, dated 03/01/25, revealed Resident #200 was not alert and oriented, was not able to utilize electric controls independently, was not able to reposition self without help, was a large (over 170 pounds) body type (scale for body types included small: under 120 pounds, medium: 120 pounds to 170 pounds, large: over 170 pounds), there was not a 4.5 inch gap between the mattress and siderail, there was a gap smaller than 2 3/8 inches at the end of the rail between the rail and headboard and/or footboard, the residents representative (Resident #200's brother) had been provided with education regarding risks associated with SR (siderail) used and gave consent for siderail use. The questionnaire did not contain information about the medical needs that will be addressed with the use of bed rails, the risk from the use of bed rails and how these will be mitigated, alternatives that were attempted but failed to meet the residents ' needs, and alternatives that were considered but not attempted and the reasons. Review of the EMR for Resident #200 revealed no documentation to support that the facility attempted any alternatives prior to the installation of side rails for Resident #200. Review of the nursing progress notes dated 05/19/25 at 4:45 A.M. revealed Resident #200 was found at 4:05 A.M., on floor with his head wedged between the bed and siderail. Resident #200 was found without vital signs and verified by the nursing supervisor. The DON, Nurse Practitioner (NP) and Coroner were notified. Coroner enroute to facility. Review of the facility's investigation timeline, dated 05/19/25, revealed at 4:06 A.M., Nursing Supervisor #352 was notified by RN #336 of finding Resident #200 with no pulse and wedged, face down, between the APM and the right-side grab bar, with his legs and lower body near the bed on the floor mat next to the bed. At 4:07 A.M., Nursing Supervisor #352 arrived at Resident #200's room and found Resident #200 wedged, face down, between the APM and the right-side grab bar, with his legs and lower body near the bed on the floor mat next to the bed. At 4:10 A.M., the DON/Nurse Practitioner (NP) was notified of the incident. At 4:16 A.M., the coroner was notified. At 4:19 A.M., the DON called back to the facility for more details, verified Resident #200's code status is DNR-CC, and his last side rail assessment was completed on 03/01/25. At 4:23 A.M., the coroner called back to the facility and will arrive in 30 minutes. At 5:04 A.M., the coroner on site, requested previous four days of documentation and face sheet. At 5:08 A.M., two Ottawa County Deputy Sheriffs arrive. At 5:21 A.M., the DON was on site. Review of the [NAME] County Coroner's Office undated preliminary report revealed the date of examination was 05/20/25, with findings for Resident #200's cause of death to be asphyxia due to neck compression caused by being wedged between safety rail and mattress. Further review revealed anatomic diagnoses (injuries) which included cervical compression mark, anterior and left side of neck, hemorrhage around left greater horn of hyoid bone, and bilateral palpebral conjunctival petechiae (small bruises in the whites of both eyes that can be a sign of compression of the neck and jugular veins from strangulation). Interview on 05/27/25 at 11:41 A.M. with Ottawa County Coroner #394 revealed Resident #200 was observed deceased at the time of his arrival with his head and or neck stuck between the bedrail and the APM. Interview on 05/27/25 at 11:56 A.M. with CNA #336 revealed she was the nurse aide assigned to Resident #200 at the time of his death. CNA #336 stated the last time she saw Resident #200 was approximately 2:30 A.M. on 05/19/25. At that time, Resident #200 was laying on his back in his bed sleeping. CNA #336 stated Resident #200 had been restless for most of the night; at one point he had one leg out of bed and his pressure relieving boot was off. CNA #336 stated at another point during the night, on 05/19/25, CNA #336 repositioned Resident #200 because he had used his right arm to pull himself to the right side of the bed and his face was against the side rail. Further interview with CNA #336 revealed she did not discover Resident #200, but she was notified by RN #335, after RN #335 found Resident #200. CNA #200 stated when she observed Resident #200 his head was wedged, in between the right handrail and the mattress, the handrail was on the temple, Resident #200 was on his right knee, and the other leg was stretched out on the left side, his right arm was holding the side rail. Interview on 05/27/25 at 1:17 P.M. with RN #335 revealed on 05/19/25 at 4:05 A.M., she entered Resident #200's room to administer medications. RN #335 discovered Resident #200 wedged, face down, between the APM and the right-side grab bar, with his legs and lower body near the bed on the floor mat next to the bed. RN #335 stated at the time of discovery; she checked for vital signs. Upon finding no vital signs, RN #335 notified Nursing Supervisor #352. RN #335 stated she was familiar with Resident #200's care and has provided care for him since admission. RN #335 stated Resident #200 has had a recent cognitive decline for the last couple of weeks. Resident #200 would frequently yell at night and would do a 3-5 day stretch of screaming and yelling out at night. Resident #200's cycle of yelling out would end, and he would only scream and yell for half the night until about midnight, then would sleep all night the next night. RN #335 stated staff would go through his memory book to help calm him down. RN #335 stated the nurse aides would report that Resident #200 would kick his feet out of the bed a couple times a night. RN #335 stated she is unaware of Resident #200 sliding out of the bed or having any falls in the night. RN #335 stated Resident #200 has fallen in the past, but it has been years. Interview on 05/28/25 at 6:33 A.M. with Nursing Supervisor #352 revealed he was notified by RN #335 on 05/19/25 at 4:06 A.M., that Resident #200 was found wedged, face down, between the APM and the right-side grab bar, with his legs and lower body near the bed on the floor mat next to the bed and did not have vital signs. Upon Nursing Supervisor #352's arrival to Resident #200's room, Nursing Supervisor #352 again assessed Resident #200 for vital signs, and found none. Observation on 05/28/25 at 7:40 A.M. of Resident #200's unoccupied bed revealed when moderate horizontal compression was applied to the APM, next to the side rail approximately 18 inches from the top of the APM, a gap of five and three-quarter inches was created between the APM and the right-side rail. The side rail was approximately 10 inches long at the top and angled down to approximately six inches at the bottom. There was one side rail on the right side of the bed. Concurrent observation of Resident #200's bed revealed when moderate vertical compression was applied to the APM, next to the side rail approximately 18 inches from the top of the APM, a gap of six inches was created between the APM and the right-side rail. Interview on 05/28/25 at 7:40 A.M. with the ADON verified the five and three-quarter inch gap was created between the APM and the right-side rail when horizontal compression was applied to the APM. Concurrent interview with the ADON verified the six-inch gap that was created between the APM and the right-side rail when vertical compression was applied to the APM. Interview on 05/28/25 at 7:52 A.M. with the DON revealed when assessing for side rail safety, the facility measures the gap between the APM and the side rail when the resident is laying in the bed, on their back. Concurrent interview with the DON revealed the facility does not measure the gap between the APM and side rail when the bed is unoccupied. When the APM is unoccupied, the mattress compresses with less force and causes a larger gap between the side rail and the mattress to be created. Further interview with DON revealed the facility does not measure the gap created when compression is applied to the APM, between APM and the side rail, occupied or unoccupied. Interview on 05/28/25 at 9:06 A.M. with Coroner's Office Investigator (COI) #393 revealed it was reported to him by Nursing Supervisor #352 that Resident #200 fell out of bed and was a DNR-CC. COI #393 was subsequently told by Nursing Supervisor #352 that Resident #200's head was between the side rail and the APM and the lower portion of his body was on the floor next to the bed. COI #393 stated when he arrived at the facility, he found Resident #200 with his head between the APM and the side rail with his lower body on the floor. COI #393 stated that at this time, he felt Resident #200's body and it was warm still, so he checked for a pulse and did not find one. COI #393 stated Resident #200 had no mottling (an irregular arrangement or patches of color on the skins surface), no rigor (stiffening of the joints and muscles of a body a few hours after death), or lividity (discoloration of the skin that occurs after death). Interview on 05/29/25 at 6:15 A.M. with the DON and the Administrator verified the Siderail Safety Questionnaire for Resident #200 did not address the medical needs that will be addressed with the use of bed rails, the risk from the use of the bed rails and how these will be mitigated, alternatives that were attempted but failed to meet the resident's needs, and alternatives that were considered but not attempted and the reasons were not assessed on Resident #200's most recent facility Siderail Safety Questionnaire, dated 03/01/25. Concurrent interview revealed that the facility does not have documentation to support that these items were completed by the facility for Resident #200. 2) Review of the EMR for Resident #31 revealed an admission date of 10/07/24 with diagnoses including central cord syndrome at C3 level of cervical spinal cord, unspecified lack of coordination, abnormal posture, depression, hyperglycemia, disorientation, macular degeneration, cognitive communication deficit, history of falling, and epilepsy. Review of the most recent quarterly MDS assessment, dated 04/10/25, revealed Resident #31 was severely cognitively impaired and required substantial/maximal assistance or was dependent on all functional abilities. Observation on 05/27/25 at 8:48 A.M. of Resident #31's room revealed an approximate seven-inch space between the APM and the half side rail. This observation was not able to be verified with facility staff but was made by two Ohio Department of Health (ODH) surveyors. There was no resident in bed, and there were two side rails on the bed. Review of the most recent facility Siderail Safety Questionnaire for Resident #31, dated 05/19/25, revealed Resident #31 was not alert and oriented, was able to utilize electric controls independently, was not able to reposition self without help, was a medium (120 pounds to 170 pounds) body type, there was not a 4.5 inch gap between the mattress and siderail, there was a gap smaller than 2 and 3/8 inches at the end of the rail between the rail and headboard and/or footboard, the residents representative had been provided with education regarding risks associated with SR (siderail) use and gave consent for siderail use, and Resident #31's representative was his niece. The form did not include the medical needs that will be addressed with the use of bed rails, the risk from the use of bedrails and how these will be mitigated, alternatives that were attempted but failed to meet the residents ' needs, and alternatives that were considered but not attempted and the reasons. Review of the EMR for Resident #31 revealed no documentation to support that the facility attempted any alternatives prior to the installation of side rails for Resident #31. 3) Review of the EMR for Resident #35 revealed an admission date of 05/09/25 with diagnoses including unspecified intracapsular fracture of left femur, age-related osteoporosis with current pathologic fracture, chronic obstructive pulmonary disease (COPD), unspecified severe protein-calorie malnutrition, hypertension (HTN), carpal tunnel syndrome of the left upper limb, solitary pulmonary nodule, generalized muscle weakness, difficulty in walking, need for assistance with personal care, history of falling, presence of left artificial hip joint, and personal history of healed traumatic fracture. Review of the Medicare 5-Day MDS assessment, dated 05/16/25, revealed Resident #35 was cognitively intact and required assistance with all functional abilities. Review of the most recent facility Siderail Safety Questionnaire for Resident #35, dated 05/19/25, revealed Resident #35 was alert and oriented, was able to utilize electric controls independently, was able to reposition self without help, was a small (under 120 pounds) body type, there was not a 4.5 inch gap between the mattress and siderail, there was a gap smaller than 2 3/8 inches at the end of the rail between the rail and the headboard and/or footboard, the resident had been provided with education regarding risks associated with SR (siderail) use and gave consent for siderail use. The form did not include the medical needs that will be addressed with the use of bed rails, the risk from the use of bed rails and how these will be mitigated, alternatives that were attempted but failed to meet the residents ' needs, and alternatives that were considered but not attempted and the reasons. Review of EMR for Resident #35 revealed no documentation to support that the facility attempted any alternatives prior to the installation of side rails for Resident #35. 4) Review of the EMR for Resident #58 revealed an admission date of 11/29/24, with diagnoses including congestive heart failure (CHF), stage three chronic kidney disease (CKD3), type two diabetes mellitus (DM2), benign prostatic hyperplasia (BPH), ischemic cardiomyopathy, parkinsonism, right above the knee amputation, and diffuse large b-cell lymphoma. Review of the most recent quarterly MDS assessment dated [DATE] for Resident #58 revealed Resident #58 was cognitively intact and required assistance needs for all functional abilities ranging from needed substantial assistance to being dependent. Review of the most recent facility Siderail Safety Questionnaire for Resident #58, dated 05/19/25, revealed Resident #58 was alert and oriented, was able to utilize electric controls independently, was not able to reposition self without help, was a medium (120 pounds to 170 pounds) body type, there was not a 4.5 inch gap between the mattress and siderail, there was a gap smaller than 2 and 3/8 inches at the end of the rail between the rail and the headboard and/or footboard, the resident had been provided with education regarding risks associated with SR (siderail) use and gave consent for siderail use. The form did not include the medical needs that will be addressed with the use of bed rails, the risk from the use of bed rails and how these will be mitigated, alternatives that were attempted but failed to meet the residents ' needs, and alternatives that were considered but not attempted and the reasons. Review of the EMR for Resident #58 revealed no documentation to support that the facility attempted any alternatives prior to the installation of side rails for Resident #58. 5) Review of the EMR for Resident #60 revealed an admission date of 04/19/25 with diagnoses of pyothorax without fistula, acute respiratory failure, unsteadiness on feet, cognitive communication deficit, chronic obstructive pulmonary disease, multiple sclerosis, BPH, neuromuscular dysfunction of the bladder, and obstructive sleep apnea (OSA). Review of the Medicare 5-Day MDS assessment, dated 04/21/25, revealed a BIMS Score of 14, indicating Resident #60 was relatively cognitively intact. Concurrent review of the most recent MDS assessment revealed Resident #60 required assistance with all functional abilities except for eating. Review of the most recent facility Siderail Safety Questionnaire for Resident #60, dated 05/19/25, revealed Resident #60 was alert and oriented, was able to utilize electric controls independently, was able to reposition self without help, was a medium (120 pounds to 170 pounds) body type, there was not a 4.5 inch gap between the mattress and siderail, there was a gap smaller than 2 and 3/8 inches at the end of the rail between the rail and headboard and/or footboard, the resident's representative had been provided with education regarding risks associated with SR (siderail) use and gave consent for siderail use. The form did not include the medical needs that will be addressed with the use of bed rails, the risk from the use of bed rails and how these will be mitigated, alternatives that were attempted but failed to meet the residents ' needs, and alternatives that were considered but not attempted and the reasons. Review of the EMR for Resident #60 revealed no documentation to support that the facility attempted any alternatives prior to the installation of side rails for Resident #60. 6) Review of the EMR for Resident #69 revealed an admission date of 02/10/25 with diagnoses of CHF, senile degeneration of brain, cognitive communication deficit, DM2, hypertensive heart disease, atherosclerotic heart disease, and dysphagia. Review of the most recent quarterly MDS assessment, dated 04/09/25, revealed a BIMS Score of 08, indicating Resident #69 was moderately cognitively impaired. Concurrent review of the most recent MDS assessment revealed Resident #69 required assistance with all functional abilities. Review of the most recent facility Siderail Safety Questionnaire for Resident #69, dated 05/19/25, revealed Resident #69 was alert and oriented, was able to utilize electric controls independently, was able to reposition self without help, was a large (over 170 pounds) body type, there was not a 4.5 inch gap between the mattress and siderail, there was a gap smaller than 2 and 3/8 inches at the end of the rail between the rail and the headboard and/or footboard, the resident had been provided with education regarding risks associated with SR (siderail) use and gave consent for siderail use. The form did not include the medical needs that will be addressed with the use of bed rails, the risk from the use of bed rails and how these will be mitigated, alternatives that were attempted but failed to meet the residents ' needs, and alternatives that were considered but not attempted and the reasons. Review of the EMR for Resident #69 revealed no documentation to support that the facility attempted any alternatives prior to the installation of side rails for Resident #69. Interview on 05/29/25 at 6:15 A.M. with the DON and the Administrator verified that the medical needs that will be addressed with the use of bed rails, the risk from the use of the bed rails and how these will be mitigated, alternatives that were attempted but failed to meet the resident's needs, and alternatives that were considered but not attempted and the reasons, were not included on Residents #31, #35, #58, #60 and #69's most recent facility Siderail Safety Questionnaire. Concurrent interview revealed that the facility does not have documentation to support that these items were completed by the facility for Residents #31, #38, #58, #60, and #69. Review of the U.S. Food and Drug Administration (FDA) Guide to Bed Safety Bed Rails in Hospitals, Nursing Homes, and Home Health Care dated September 2013 indicated potential risks of bed rails may include strangling, suffocating, bodily injury or death when

Based on record review, staff interview, review of facility Self-Reported Incidents (SRI's), and review of facility policy, the facility failed to ensure staff reported an allegation of resident to resident sexual abuse to the administrator or designee in a timely manner. This affected two Residents (#10 and #11) of three reviewed for abuse. The facility census was 67. Findings include: Review of Resident #10's medical record revealed an admitted [DATE]. Diagnoses included Alzheimer's disease, dementia, cognitive communication deficit, and major depressive disorder. Review of Resident #10's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of two indicating Resident #10 was severely cognitively impaired. Resident #10 required limited assistance with bed mobility and transfer. Resident #10 required partial/moderate assistance with lower body dressing. Resident #10 had hallucinations, and delusions during the review period. Resident #10 displayed wandering behaviors one to three days during the review period. Review of Resident #10's care plan revised 01/12/24 revealed supports and interventions for risk for self-care deficit, impaired self-ambulating, risk for elopement, impaired cognition, and behavior problem of wandering on memory unit. Review of Resident #11's medical record revealed an admitted [DATE]. Diagnoses included dementia, anxiety disorder, prostate cancer, and cognitive communication deficit. Review of Resident #11's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of three indicating Resident #11 was severely cognitively impaired. Resident #11 required maximal assistance with toilet use, personal hygiene and bathing. Resident #11 required moderate assistance with upper and lower body dressing. Resident #11 was independent with mobility at the time of the review. Resident #11 had delusions during the review period and displayed wandering behaviors one to three days during the review period. Review of Resident #11's care plan revised 01/17/24 revealed supports and interventions for risk for elopement, dementia, self-care deficit, and delusions of believing other residents were his wife. Interventions included observe for nonverbal communication, Tagamet orders for inappropriate sexual behavior, and explain procedures during care. Review of Resident #10 and #11's progress notes revealed on 02/05/24 during nighttime care Resident #10 was found in Resident #11's room. Resident #10's pants were in the process of actively falling down while Resident #11 was standing behind Resident #10 and had his pants down. Two aides separated the residents and assisted Resident #10 with pulling her pants up and removing her from Resident #11's room and back to her room. Resident #11 was assisted with dressing and was assisted with care and transferred to bed. There were no further incidents noted between Resident #10 and Resident #11. Monitoring was increased for safety and inappropriate behaviors. Oncoming shift was notified on 02/06/24 at approximately 6:00 A.M. Review of the facility's Self-Reported Incident (SRI) dated 02/06/24 revealed the incident occurred on 02/05/24 approximately 7:00 P.M. a female resident was found in male resident's room on Memory Care Station. The male resident was standing behind the female resident without his pants. The Administrator was notified at approximately 10:30 A.M. on 2/6/2024 that Resident #10 had been in Resident #11's room the previous evening. The two residents were separated. The State tested Nursing Assistant (STNA) notified the Charge Nurse, who assessed Resident #10 and found her to be without any injuries. The STNA, who separated the residents, indicated that there was no resident-to-resident contact. No notification was found to be made to the Administrator or designee. Upon learning of the alleged incident, the Administrator notified the Ottawa Co. Sheriff's Office. The Sheriff's Office dispatched two detectives to the facility to interview staff as well as both residents involved in the alleged incident. The facility interviewed staff who were on duty on the station the prior evening. The Facility's Nurse Practitioner assessed Resident #10 on the morning on 02/06/24 at approximately 11:30 A.M. and found there to be no remarkable findings. Resident #10 did not display and signs/symptoms of distress, and no changes in behavior was noted. Resident #11 was put on one on one monitoring, he was evaluated by psychiatric services who ordered a medication change, and his room was moved. Interview on 02/15/24 at 11:35 A.M. with Licensed Practical Nurse (LPN) #225 revealed he received report on 02/26/24 from LPN #245 at approximately 6:00 A.M. of the incident that took place in the evening of 02/05/24 between Resident #10 and Resident #11. LPN #225 reported he was told by LPN #245 notifications were made, but when he talked with Licensed Social Worker (LSW) #200 he learned they were not made aware. LSW #200 and the Director of Nursing (DON) found out around 10:00 A.M. on 02/06/24. Interview on 02/15/24 at 11:58 A.M. with the Director of Nursing (DON) and the Administrator verified they were not informed of the 02/05/24 incident between Resident #10 and Resident #11 until 02/06/24 at approximately 10:30 A.M. The incident was believed to have occurred on 02/05/24 during nighttime care which would have been around 8:00 P.M. The DON verified the expectation was for staff to report incidents of potential sexual abuse immediately. Interview on 02/15/24 at 3:04 P.M. with Licensed Social Worker (LSW) #200 verified she had spoken to LPN #225 on 02/06/24 at approximately 9:15 A.M. and first learned of the incident between Resident #10 and Resident #11 that occurred on 02/05/24. The DON was notified around 10:00 A.M. and the Administrator around 10:15 A.M. an SRI was started and LSW #200 reported she began gathering witness statements, Resident #11 was put on one on one supervision, and Resident #10 was evaluated by the Nurse Practitioner. Review of the facility policy titled, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, revised 10/06/22 revealed staff must report all incidents/allegations immediately to the Administrator or designee. This deficiency represents non-compliance investigated under Complaint Number OH00150915.

Based on observation, medical record review, resident and staff interview, and facility policy review, the facility failed to ensure dependent residents received timely assistance with activities of daily living. This affected two (#10 and #36) of four residents reviewed for activities of daily living. The facility census was 50. Findings include: 1. Review of Resident #36's medical record revealed and admitted [DATE]. Diagnoses included atherosclerotic heart disease of native coronary artery without angina pectoris, acute kidney failure, benign prostatic hyperplasia without lower urinary tract symptoms, hyperlipidemia, dysphagia, and cognitive communication deficit. Review of the Minimum Data Set (MDS) assessment, dated 03/16/23, revealed the resident was moderately cognitively impaired. Resident #36 required extensive one person assistance with personal hygiene. Review of the care plan, revised 05/09/23, revealed Resident #36 required assistance with personal hygiene. Observation on 05/15/23 at 11:15 A.M. revealed Resident #36 had long finger nails with the thumb and pointer finger nail appearing to have dirt under the nails. Interview with Resident #36 on 05/15/23 at 11:15 A.M., at the time of the observation, stated he asked twice on 05/13/23 and 05/14/23 to have his finger nails trimmed, and asked staff to trim his finger nails again today. Interview on 05/15/23 at 11:45 A.M. with State tested Nurse Aide (STNA) #491 verified Resident #36's finger nails were long, dirty, and needed trimmed. 47057 2. Review of Resident #10's medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease, diabetes mellitus type II, and cataract in both eyes. Review of the most recent MDS assessment dated [DATE] revealed Resident #10 was assessed with intact cognition, and required extensive one person assistance for personal hygiene. Observation on 05/15/23 at 9:37 A.M. of Resident #10 revealed facial hair on her chin measuring approximately one-half inch long. Interview on 05/15/23 at 9:37 A.M. with Resident #10 stated she was supposed to be shaved by staff on shower days, and the last time she was shaved was about a week ago. Resident #10 stated she preferred to have her facial hair shaved. Observation and interview on 05/16/23 at 10:51 A.M. with Resident #10 revealed the facial hair on her chin remained unshaven. Resident #10 stated she received a shower last evening on 05/15/23 and was not shaved. Reviewed of Resident #10's shower schedule revealed Resident #10 was to be showered on Mondays and Thursdays during second shift. Interview on 05/16/23 at 11:04 A.M. with Registered Nurse (RN) #421 stated nurse aides shaved residents that needed assistance with shaving on the resident's shower days. RN #421 verified Resident #10's shower schedule indicated showers were scheduled on Mondays and Thursdays on second shift and verified the facial hair on Resident #10's chin needed shaved. Review of a facility policy titled, Supporting Activities of Daily Living, revised March 2018, revealed residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.

Based on medical record review, staff interview, and policy review, the facility failed to ensure the resident's advance directives were accurate in the medical record. This affected one (Resident #40) of two residents reviewed for advance directives. The facility census was 83. Findings include: Review of Resident #40's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the paper medical record revealed a document that indicated Resident #40 wished to have a Do Not Resuscitate Comfort Care (DNRCC) code status (only comfort measures be administered before, during, or after the time of person's heart or breathing stops), indicating the DNRCC protocol would be activated immediately. This document was signed on 09/16/19. Review of online medical record revealed the advanced directive of Do Not Resuscitate Comfort Care-Arrest (DNRCC-A) (permits the use of life-saving treatment before the heart or breathing stops) documented. Interview on 01/21/20 at 5:05 P.M. with Minimum Data Set (MDS) Coordinator #200 confirmed Resident #40's signed physician order [REDACTED]. Review of the facility's policy, Code Status Determination Protocol, revised 04/2009, revealed the facility ensures residents preference for determined code status will be honored by facility staff. In addition, the charge nurse will honor the resident's preference/decision and enter into the electronic health records.

Based on observation, staff interview and review of a facility policy, the facility failed to ensure food was prepared and distributed in a sanitary manner. This had the potential to affect 54 residents who receive meals prepared and served in the main dining room at the facility. The facility census was 89. Findings Include: On 09/13/2017 at 11:04 A.M., observation of food plating with food service worker FSW #240 with gloved hands touching utensils, plates, and with same gloves touching hamburger buns and placing American cheese on the hamburger with same gloved hands. This was verified with FSW #240. On 09/13/17 at 11:15 A.M. interview with FSW #240 stated Are we to wear gloves with the buns too? Review of facility policy undated titled Serving Food, the facility will serve food in a safe and manner to prevent contamination. Except when washing fruits and vegetables as specified in paragraph (G) of the rule or as specified in paragraph (A)(4) of this rule, food employees may not contact exposed, ready to eat food with their bare hands and shall use suitable utensils such as deli tissues, spatulas, tongs, single use gloves, or dispensing equipment. Policy implementation: The employee should use tongs, scoops, or gloves to prevent bare hand contact with ready to eat foods as stated in the Ohio Food Safety Code 371.7-1-02.2

Based on observation, staff interview and policy review, the facility failed to ensure nursing staff wore gloves during the administration of a subcutaneous injection of medication. This affected one of (Resident #75) of six residents observed during medication administration. The facility identified 16 residents receiving subcutaneous injections of insulin. The facility census was 89. Findings include Observation on 09/13/17 at 6:40 A.M. revealed Registered Nurse (RN) #301 administered a subcutaneous injection of insulin to Resident #75 without gloves. Interview on 09/13/17 at 6:44 A.M. with RN #301 revealed she was unaware whether facility policy required gloves during the administration of a subcutaneous injection of insulin. Review of facility policy Subcutaneous Injections last revised 03/2011 revealed to put on gloves before administering medication by subcutaneous injection. Review of the Standard Precautions policy last revised 12/2007 revealed to wear gloves when you anticipate direct contact with blood, body fluids mucous membranes, non intact skin, and other potentially infected material.

Based on observation, medical record review, staff and resident interview the facility failed to ensure fall prevention interventions were in place, additionally the facility failed to ensure a wheelchair was inspected prior to use resulting in a fall. This affected one resident (#90) of three residents reviewed for falls. The facility census was 89. Findings include: Medical record review revealed Resident #90 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of fall assessments dated 07/11/17, 09/03/17, 09/09/17 and 09/11/17 revealed Resident #90 was at high risk for falls. Review of physician orders [REDACTED]. Review of the care plan last revised on 09/11/17 revealed to place a mat on the floor next to the bed of Resident #90. Further review of the plan of care revealed no interventions for the use of a floor motion alarm. Observation on 09/12/17 at 2:05 P.M. revealed Resident #90 was in bed. Further observation revealed a floor motion alarm was on the floor in the room. Additional observation revealed there was no mat on the floor next to the bed. Interview on 09/12/17 at 2:07 P.M. with State tested Nursing Assistant (STNA) #200 revealed she assisted Resident #90 to bed around 12:30 P.M. STNA #200 further revealed she placed the motion floor alarm at the end of the bed. STNA #200 revealed the floor mat was not on the floor next to the bed and she must of missed that. STNA #200 revealed she was not sure if the floor mat next to the bed should be used during the day or just at night. Continued interview with STNA #200 revealed, after reviewing the STNA resident care sheet, the mat should be on floor next to the bed. Interview on 09/12/17 at 2:16 P.M. with Licensed Practical Nurse (LPN) #300 revealed the plan of care indicated to place the mat on the floor next to the bed. Further interview with LPN #300 revealed the care plan would be updated for the floor mat to be placed only at night. Continued interview with LPN #300 revealed the floor sensor alarm would also be added to the plan of care. Review of the Managing Falls and Fall Risk policy revealed in conjunction with the attending physician, staff would identify and implement relevant interventions to try to minimize serious consequences of falling. 2. Review of a nursing progress note dated 09/11/17 at 5:54 P.M. revealed Resident #90 continued on 72 hour due to recent episode. Further review of the nursing progress note revealed no injuries were noted. Continued review of the nursing progress note revealed the wheel chair anti-roll back device was adjusted due to moving out from under resident. Review of the care plan revealed on 09/03/17 an anti-roll back device was added to the wheel chair after Resident #90 had a previous fall on 09/03/17. Review of the incident report dated 09/11/17 revealed Resident #90 was found lying in front of wheelchair with no noted injuries. Further review of the incident description revealed the resident related she attempted to sit in the wheelchair and it went out from underneath her. Review of a maintenance work order dated 09/11/17 revealed the anti-rollback bar was missing. Further review of action taken revealed the bar was replaced and adjusted. Additionally, the left brake was replaced and both brakes were adjusted. Review of the fall investigation and interview on 09/12/17 at 4:35 P.M. with Licensed Practical Nurse (LPN) #302 revealed Resident #90 had an unwitnessed fall on 09/11/17 at 9:30 A.M. LPN #302 revealed Resident #90 was found beside her bed on floor in front of wheelchair. LPN #302 revealed Resident #90 tried to transfer herself and the wheelchair rolled out from under her. LPN #302 revealed the immediate intervention included adjustments to the anti-rollback device. LPN #302 revealed the anti-rollback device was loose and needed tightened. LPN #302 revealed the anti-rollback devices were only checked when staff reported a problem with them. Review of the medical record revealed no documentation of the last wheel chair inspection for Resident #90. Observation on 09/12/17 at 2:05 P.M. revealed the wheel chair of Resident #90 had an anti-rollback device in place. Interview on 09/13/17 at 9:26 A.M. with Maintenance Staff (MS) #216 verified the anti-rollback was missing a bar around the wheel. MS #216 revealed he replaced the bar on 09/11/17. Review of the facility wheelchair inspection and maintenance procedure revealed a wheel chair inspection would be performed when a maintenance work order was issued or as required for safety reasons. Further review revealed the Director of Environmental Services would keep all inspection sheets and have them available for review at all times.

Based on observation, medical record review, review of restraint policy, staff and resident interviews, the facility failed to ensure a physical restraint was not placed on a resident without a physician order. This affected one resident (#90) of three residents reviewed for physical restraints. The facility census was 89. Findings include: Review of Resident 90's medical records revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #90's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #90 was cognitively intact. The MDS did not identify the use of restraints. Review of physician orders dated 06/13/17 through 09/13/17 revealed no physician orders for a secure care bracelet (a tracking application designed to prevent persons from leaving the facility using an ankle or wrist band). Review of Resident #90's medical record revealed no signed consent for placement of the secure care bracelet. Review of Resident #90's care plan revealed a secure care bracelet was used for exit seeking and decreased safety awareness and to monitor placement each day. Further medical record review revealed no documentation of monitoring of the secure care bracelet. Observations on 09/12/17 at 2:05 P.M. and 5:09 P.M. revealed Resident #90 had a secure care device placed on her left ankle. Further observations on 09/13/17 at 6:02 A.M. and 8:25 A.M. revealed Resident #90 had a secure care device on her left ankle. Interview on 09/13/17 at 9:32 A.M. with State tested Nursing Assistant (STNA) #206 revealed Resident #90 was wearing a secure care bracelet on her left ankle. Interview on 09/13/17 at 12:33 P.M. with the Director of Nursing (DON) revealed she did not feel the secure care bracelet for Resident #90 was a restraint. The DON revealed there was no physician order for [REDACTED].#90 had some wandering issues when she was first admitted to the facility and the secure care bracelet was intended to be used for a short duration. Further interview with the DON revealed she did not believe Resident #90 needed the secure care bracelet. Continued interview with the DON revealed the secure care bracelet was more for staff and resident safety to alert if the resident was exiting a door. Interview on 09/14/17 at 9:37 A.M. with Resident #90 revealed the facility had placed the bracelet on her ankle so she would not walk out of the building. Further interview with Resident #90 revealed she did not remember whether the facility asked her permission to place the bracelet on her ankle. Review of the facility policy Use of Restraints defined physical restraints as any manual method or physical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restrict freedom of movement or restrict normal access to one's body. Further policy review revealed restraints shall only be used upon written order of a physician and after obtaining consent from the resident and or representative.

Based on medical record review and staff interviews, the facility failed to ensure pharmacy recommendations were completed timely. This affected three (#28, #33 and #68) out of five residents reviewed for unnecessary medications. Facility census was 89. Findings include: 1. Review of Resident #33's medical record identified an admission date of [DATE]. [DIAGNOSES REDACTED]. A pharmacy consultation form (MRR review) dated 07/07/16 identified Resident #33 was receiving a lipid lowering medication, Atorvastatin (Lipitor) 20 milligrams (mg) daily. The report identified Resident #33's previous two laboratory tests (03/10/16 and 06/09/16) listed for Low- Density Lipoprotein (LDL) were less than 40 mg per deciliter (mg/ dl). The pharmacist recommended a dose reduction or discontinuation of the Atorvastatin (lipid lowering drug). The pharmacist listed the rationale for the recommendation as: 2013 American College of Cardiology and American Heart Association (ACC/ AHA) guidelines on treatment of [REDACTED]. The recommendation was submitted to the facility on [DATE]; however, was not reviewed from the Director of Nursing (DON) until 09/09/16. The pharmacy recommendation was addressed by the physician on 09/15/16 which was two months and eight days after the initial recommendation. The physician decreased Resident #33's medication following the guidelines at that time. Review of Resident #33 medication administration records (MAR's) for 07/07/16 to 09/15/16 confirmed the resident received Atorvastatin 20 mg throughout that time. The review of the MAR indicated [REDACTED]. Interview with facility DON occurred on 11/02/16 at 11:05 A.M., regarding the procedure the facility follows for monthly pharmacy reviews/ recommendations. The interview confirmed a pharmacist comes into the facility monthly and reviews all residents medication regimen and provides recommendations. The DON confirmed she receives all the recommendations usually the day after the pharmacy leaves. The DON identified she then reviews the recommendations first and provides them to each physician. The DON confirmed Resident #33's pharmacy recommendation was completed on 07/07/16 and was not reviewed by herself until 09/09/16. The DON identified she then provided it to the physician who reviewed the recommendation and decreased Resident #33's medication on 09/15/16. The DON was asked why it took from 07/07/16 to 09/09/16 for her reviewed of the recommendations and she responded this was timely; and the physician do not pay attention to them anyway. 2. Review of Resident #66's medical record identified admission occurred on 02/08/13 with medical [DIAGNOSES REDACTED]. The record identified Resident #66 was receiving an anti-psychotic medication (Seroquel). Review of Resident #66's pharmacy consultation report dated 07/08/16 evidenced a recommendation to consider a gradual dosage reduction if appropriate, with the end goal of discontinuation of therapy. Federal regulation require that anti- psychotics used to manage behavior or stabilize mood be evaluated quarterly and undergo gradual dose reduction (GDR) in two separate quarters in the first year in which a resident is admitted or after the facility has initiated the medication, then at least annually, unless clinically contraindicated. Interview with the DON on 11/02/16 at 11:05 A.M. confirmed Resident # 66's pharmacy recommendation was sent to the facility on [DATE] and was not addressed until 09/22/16 or two and a half months later. 3. Review of Resident #28's medical record identified admission occurred on 02/16/13 with medical [DIAGNOSES REDACTED]. The record indicated that Resident #28 had been receiving an anti-depressant (Sertraline). A pharmacy consultation report dated June 21, 2016 evidenced a recommendation to consider a GDR if appropriate for Resident #28's Sertraline, with the end goal of discontinuation of therapy. During the survey an interview with LPN (licensed practical nurse) #334 revealed that pharmacy recommendation comes and goes directly to DON. LPN #334 stated that she believes that physician then looks at them when he is scheduled to do his rounds. LPN #334 stated that she believed this to be in 30 to 60 days. LPN #334 confirmed the recommendation was sent to the facility on [DATE] and was not addressed until 10/20/16.

Based on observation, interview and facility policy review, the facility failed to ensure foods were prepared under sanitary conditions. This had the potential to affect 86 residents who received meals from the facility kitchen out of 89 total residents residing in the facility. The facility identified Residents #111, #39 and #11 did not receive meals from the kitchen. Facility census was 89. Findings include: Observation on 11/02/16 at 10:48 A.M. Cook #301 was pealing potatoes and the cook's hair was not completely covered. Cook #301 hair net was not covering the crown of her hair. Cook #301's hair in the front approximate three inches was exposed. Additionally, Cook #301 had had loose hair tendrils dangling at the nape of her neck down to her shoulders. Dietary Manager (DM) #302, was present in the food preparation area and was wearing a hair net which did not cover her bangs. DM #302's hair bangs were exposed and hanging across her forehead down to her eyebrows. Interview with DM #302 and Cook #301 at the time of the observation verified their hair was not fully contained in their hair nets. Additional interview with DM #302 on 11/02/16 at 12:01 P.M. she stated she used hair spray on her bangs and again verified her bangs were not contained in the hair net. She verified she was in the kitchen. She also verified there was food preparation in progress at the time. At 1:19 P.M. DM #302 further stated she had been wearing her hair with the bangs exposed for ten years. DM #302 stated the potatoes that were being prepared did not constitute food preparation. Review of the facility policy titled Hair Restraints revised 04/2009 revealed the policy statement was to ensure hair is restrained effectively. Hair will be restrained to keep hair from contacting exposed food during food preparation and dishing. Hairnets are to be worn in the kitchen and serving areas.