Every finding on record at Otterbein Lebanon Retirement Community

Based on observation, staff interview, and policy review the facility failed to ensure that the advocates and Ombudsman information and number was posted on a secured unit for residents, families, and visitors. This had the potential to affect all 53 residents residing in the secured unit. The facility census was 141 residents. Findings include: Observation on 08/17/26 at 10:30 A.M. with the Director of Nursing (DON) revealed there was no Ombudsman information posted in the [NAME] building. An observation on 08/18/26 at 8:58 A.M. of the [NAME] Building revealed there was no Ombudsman information posted in the [NAME] building. Interview on 08/18/26 at 10:11 A.M. with the Director of Nursing (DON) verified the Ombudsman contact information was not posted inside the secured memory care units in [NAME] Building. Review of the facility policy titled Ohio Resident Rights and Facility Responsibilities Policy dated 01/22/20 revealed the Administrator shall post all the following prominently within the home a list of residents' rights advocates. This deficiency represents noncompliance investigated under Complaint Number 3132888.

Based on medical record review, observation, staff interview, and policy review, revealed the facility failed to ensure enhanced barrier precautions (EBP) were followed during a dressing change. This affected one (Resident #21) of 26 residents in EBP. The facility census was 141 residents. Findings include: Review of the medical record for Resident #21 revealed an admission date of 07/21/26 with diagnosis including multiple fractures, stage four sacrum pressure ulcer, and hypertensive heart disease. Observation on 08/19/26 at 11:00 A.M. of wound care for Resident #21 per Licensed Practical Nurse (LPN #400) revealed the nurse did not don a gown prior to providing wound care. Interview on 08/19/26 at 11:23 A.M. with LPN #400 verified Resident #21 had orders for EBP and also verified she had not donned a gown during wound care for the resident and she should have done so. Review of the facility policy titled Isolation Precautions Process dated 03/26/25 revealed EBP are used for residents with wounds, and gloves and gowns should be worn during high-contact resident care including wound care. This deficiency represents noncompliance investigated under Complaint Number 2567705.

Based on medical record review, staff interview, and policy review, the facility failed to ensure the accuracy of documentation of medication administration. This affected one (Resident #27) of seven residents reviewed for accuracy of medical records. The facility census was 141. Findings include: Review of the medical record for Resident #27 revealed an admission date of 01/31/26 with diagnoses including urinary tract infection, cerebral aneurysm nonruptured, hypertensive heart disease without heart failure. Review of the Minimum Data Set (MDS) assessment for Resident #27 dated 02/06/26 revealed the resident was cognitively impaired and required staff assistance with activities of daily living (ADLs.) Review of physician's orders for Resident #27 revealed an order dated 01/31/26 for cephalexin oral capsule 500 milligrams (mg) to be given by mouth four times a day for UTI. Review of the Medication Administration Record (MAR) for Resident #27 dated February 2026 revealed the cephalexin for the resident was signed off administered at 9:00 A.M. and 12:00 P.M. Review of the disciplinary action form for Licensed Practical Nurse (LPN) #701 dated 02/19/26 revealed the nurse received written disciplinary action due to withholding Resident #27's morning dose of Cephalexin on 02/05/26 without physician order or approval. Interview on 08/19/26 at 11:21 A.M. with LPN #701 confirmed he did not give the morning dose of Cephalexin to Resident #27 on 02/05/26. LPN #701 stated Resident #27 complained of nausea and he withheld the dose. LPN #701 verified he did not notify the physician that he was going to withhold the dose of Cephalaxin nor did he make a note in Resident #27's record of the resident's nausea and/or notification to the physician regarding whether the dose should be held or given later. Interview on 08/19/26 11:40 A.M. with the Director of Nursing (DON) verified LPN #701 received disciplinary action for withholding Resident #27's 02/05/26 9:00 A.M. dose of medication without a physician's order. The DON stated the facility learned of the omitted dose of medication when the resident's family notified Physician #702 the resident hadn't received the medication. The DON verified Physician #702 called the facility on 02/05/26 to question why Resident #27 had not received the 9:00 A.M. dose of Cephalexin. The DON spoke with LPN #701 and learned the nurse had withheld the dose without a physician's order. The DON stated the physician did give an order to give the 9:00 A.M. dose along with the 12:00 P.M. on 02/05/26. The DON further verified the MAR for Resident #27 was not accurate, because LPN #701 did not give a dose of Cephalexin on 02/05/26 at 9:00 A.M. and LPN #701 had not documented withholding the medication in the resident's medical record. Interview on 08/19/26 at 12:15 P.M. with Physician #702 verified the facility did not contact her regarding the missed dose of Cephalexin for Resident #27 on 02/05/26. Physician #702 stated Resident #27's family notified her of the missed dose, and the physician contacted the DON to find out why the medication had not been given. Review of facility policy titled Medication Administration dated 11/09/21 revealed if a dose of a regularly scheduled medication was withheld or given at a time other than the scheduled time, this will be documented with an explanatory note in the resident's chart including physician notification. This deficiency represents noncompliance investigated under Complaint Number 3107514.

Based on medical record review, staff interview, and policy review, the facility failed to ensure residents were free of significant medication errors. This affected one (Resident #27) of seven residents reviewed for medication administration. The facility census was 141 residents. Findings include: Review of the medical record for Resident #27 revealed an admission date of 01/31/26 with diagnoses including urinary tract infection, cerebral aneurysm nonruptured, hypertensive heart disease without heart failure. Review of the Minimum Data Set (MDS) assessment for Resident #27 dated 02/06/26 revealed the resident was cognitively impaired and required staff assistance with activities of daily living (ADLs.) Review of physician's orders for Resident #27 revealed an order dated 01/31/26 for cephalexin oral capsule 500 milligrams (mg) to be given by mouth four times a day for UTI. Review of the Medication Administration Record (MAR) for Resident #27 dated February 2026 revealed the cephalexin for the resident was signed off administered at 9:00 A.M. and 12:00 P.M. Review of the disciplinary action form for Licensed Practical Nurse (LPN) #701 dated 02/19/26 revealed the nurse received written disciplinary action due to withholding Resident #27's morning dose of Cephalexin on 02/05/26 without physician order or approval. Interview on 08/19/26 at 11:21 A.M. with LPN #701 confirmed he did not give the morning dose of Cephalexin to Resident #27 on 02/05/26. LPN #701 stated Resident #27 complained of nausea and he withheld the dose. LPN #701 verified he did not notify the physician that he was going to withhold the dose of Cephalaxin nor did he make a note in Resident #27's record of the resident's nausea and/or notification to the physician regarding whether the dose should be held or given later. Interview on 08/19/26 11:40 A.M. with the Director of Nursing (DON) verified LPN #701 received disciplinary action for withholding Resident #27's 02/05/26 9:00 A.M. dose of medication without a physician's order. The DON stated the facility learned of the omitted dose of medication when the resident's family notified Physician #702 the resident hadn't received the medication. The DON verified Physician #702 called the facility on 02/05/26 to question why Resident #27 had not received the 9:00 A.M. dose of Cephalexin. The DON spoke with LPN #701 and learned the nurse had withheld the dose without a physician's order. The DON stated the physician did give an order to give the 9:00 A.M. dose along with the 12:00 P.M. on 02/05/26. Interview on 08/19/26 at 12:15 P.M. with Physician #702 verified the facility did not contact her regarding the missed dose of Cephalexin for Resident #27 on 02/05/26. Physician #702 stated Resident #27's family notified her of the missed dose, and the physician contacted the DON to find out why the medication had not been given. Review of facility policy titled Medication Administration dated 11/09/21 revealed if a dose of a regularly scheduled medication was withheld or given at a time other than the scheduled time, this will be documented with an explanatory note in the resident's chart including physician notification. This deficiency represents noncompliance investigated under Complaint Number 2620632.

Based on observation, staff interview, medical record review, and facility policy review, the facility failed to ensure enhanced barrier precautions were followed for one (#27) of six residents reviewed for infection control. The census was 142. Findings included: Review of the medical record revealed the facility admitted Resident #27 on 09/11/19. Diagnoses included unspecified displaced fracture of the second cervical vertebra and sequela and unspecified stage pressure ulcer of sacral region.Review of an admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 09/02/25, revealed Resident #27 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. The MDS assessment indicated the resident had Stage Two (partial-thickness skin loss with exposed dermis) and a Stage Four (full-thickness skin and tissue loss) pressure ulcers and received pressure ulcer/injury care and an application of a nonsurgical dressing (with or without topical medication) other than to feet during the review period. Review of Resident #27's care plan report included a focus area initiated on 09/02/25, and revised on 09/10/25, that indicated the resident had potential impairment to the skin integrity related to an admission with a Stage Four wound on the sacrum and a Stage Two wound on the upper back. Further review revealed an intervention dated 09/02/25 for the resident to require enhanced barrier precautions (EBP).Review of Resident #27's order summary report with active orders as of 09/11/25 contained an order initiated on 09/10/25, for EBP with gloves and gown with treatment and/or care every shift.An observation on 09/09/25 at 11:35 A.M. revealed Resident #27's door frame contained a magnet that indicated EBP and had pictures of hand washing, gloves, and a gown.During an observation on 09/10/25 at 11:56 A.M., Certified Occupational Therapy Assistant (COTA) #6 entered Resident #27's room and told the resident she would help the resident to clean themselves up and assist Resident #27 with lunch. During a concurrent observation and interview on 09/10/25 at 12:11 P.M., COTA #6 exited Resident #27's room carrying a bag of soiled linen. COTA #6 stated she assisted the resident with toileting and was discarding the soiled brief. COTA #6 stated she only donned a pair of gloves to help with toileting Resident #27. COTA #6 stated she was educated to wear gloves, gown, and a mask to toilet a resident who was on EBP. COTA #6 acknowledged she had worn gloves to assist with toileting, but had not donned a gown during care because she was unaware Resident #27 was on EBP. During an interview on 09/10/25 at 12:25 P.M., Assistant Director of Nursing (ADON) #7 stated residents with wounds, indwelling catheters, and intravenous lines should be on EBP. ADON #7 stated staff were educated to know a resident was on EBP based on orders in the resident's medical record and signage posted on the resident's door. ADON #7 confirmed Resident #27's room door had a sign that indicated EBP and pictures of handwashing, gown, and gloves. ADON #7 indicated all staff should don all personal protective equipment (PPE) listed on the signage to provide care which included incontinence care, blood sugar checks, and any other physical care for residents on EBP. During an interview on 09/12/25 at 4:33 P.M., the Director of Nursing (DON) stated staff were required to wear the appropriate PPE to include a gown and gloves when providing high-contact care such as toileting for residents on EBP. During an interview on 09/12/25 at 5:25 P.M., the Administrator stated the expectation was that staff would follow the precautions for EBP when providing care.Review of a facility policy titled, Isolation Precautions Process, revised 03/26/25, revealed a section titled, Procedure, that specified the facility would use the following precaution categories to help reduce the spread of an infectious agent and/or minimize the transmission of the infection. The policy further revealed a section titled, Enhanced Barrier Precautions, that specified these are used for residents with infection or colonization with a multi-drug-resistant organism when contract precautions do not apply, for wounds, and/or for indwelling medical devices. Elements of Enhanced Barrier Precautions include hand washing (see hand washing procedure), gloves and gowns should be worn during high contact resident care including dressing, bathing/showering, changing linens, transferring (when in a resident room), providing hygiene, toileting, device care (use of a central line, urinary catheter, feeding tube, or tracheostomy), and wound care (a skin opening requiring dressing).This deficiency represents non-compliance investigated under Master Complaint Number 2592669.

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure a care plan was developed for a diagnosis of chronic obstructive pulmonary disease. This affected one (#151) of 37 sampled residents reviewed for care plans. The census was 142.Findings included:Review of the medical record revealed the facility admitted Resident #151 on 10/26/23. Diagnoses included chronic obstructive pulmonary disease (COPD) with acute exacerbation, Alzheimer's disease with late onset, and acute respiratory failure with hypoxia. Review of a quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 07/29/25, revealed Resident #151 had a Brief Interview for Mental Status (BIMS) score of three, which indicated the resident had severe cognitive impairment. The MDS assessment indicated the resident required substantial to maximum assistance from staff for activities of daily living (ADLs) and received supplemental oxygen therapy while a resident. Review of Resident #151's care plan report, initiated on 11/15/23 and last revised on 09/02/25, did not contain a problem statement or interventions for the resident's diagnosis of COPD or supplemental oxygen usage.Review of an undated document titled, Magnolia (MZ-300 Hall), revealed a section labeled, Notes/Expressions, that specifically indicated Resident #151 wore supplemental oxygen at times.Review of Resident #151's hard chart located at the nurses' station revealed a copy of the resident's order summary report dated 08/01/25, and the hard chart did not include a care plan for COPD with interventions. Review of Resident #151's progress note dated 03/05/25 indicated the chief complaint was wheezing and chronic supplemental oxygen needs. The note indicated that a nurse practitioner (NP) spoke with Resident #151's family member to discuss supplemental oxygen use, and the family member was agreeable to supplemental oxygen at night and as needed if oxygen saturation levels dropped below 90 percent (%) during the day. The note revealed the assessment/plans for COPD was to increase the resident's Duoneb nebulizer delivery frequency to every six hours around the clock and change the albuterol to every four hours as needed. In addition, the progress note included the use of two liters of supplemental oxygen via nasal cannula at bedtime and removed in the morning if the resident's oxygen saturation was greater than 90% and continued use during the day if oxygen saturations dropped below 90%. The note revealed for chronic respiratory failure with hypoxia, the NP ordered the decongestant Mucinex 600 milligrams (mg) every 12 hours. The note revealed the NP indicated she reviewed all changes to the care plan with the family member. Review of Resident #151's progress note dated 08/06/25 indicated the chief complaint was that Resident #151 was seen for COPD. The note revealed the assessment/plans indicated to continue the current plan of care and monitor for COPD. An observation on 09/09/25 at 8:29 A.M., revealed Resident #151 was in bed resting with eyes closed with supplemental oxygen delivered via a nasal cannula. The observation also revealed a nebulizer mask and machine laying on the bedside table. An observation on 09/09/25 at 4:02 P.M. revealed Resident #151 was sitting in a wheelchair with a nebulizer treatment currently being delivered via a facemask. An observation on 09/11/25 at 8:17 A.M., revealed Resident #151 lying in bed resting with eyes closed and supplemental oxygen delivered via a nasal cannula. During an interview on 09/11/25 at 8:44 A.M., MDS Coordinator #4 stated she completed the MDS assessments for Resident #151. She stated she completed the MDS assessments quarterly and each assigned discipline created a care plan under a category for whatever concern the resident had. She stated she completed the nursing portions of the care plan and if a resident had COPD, a care plan should be developed. She reviewed Resident #151's care plan and confirmed she could not locate a care plan for the diagnosis of COPD. She stated the development of a care plan for COPD for Resident #151 was overlooked and missed. She stated that respiratory was the resident's primary medical concern, and she should have developed a care plan for COPD for Resident #151.During an interview on 09/11/25 at 4:07 P.M., the Director of Nursing (DON) stated MDS Coordinator #4 and Assistant Director of Nursing (ADON) #2 oversaw developing care plans. She stated care plans were reviewed and updated interventions were added to align with physician orders and diagnoses. She stated a care plan should have been developed for Resident #151's diagnosis of COPD and the care plan interventions should be updated as needed. During an interview on 09/11/25 at 4:10 P.M., the Administrator stated he expected the resident's care plan to outline the care that was needed based on the resident's diagnoses and interventions were to be updated as needed. Review of a facility policy titled, Comprehensive Care Planning Policy, effective 11/13/17, indicated it is the policy of the facility for the interdisciplinary team to develop, implement and evaluate the comprehensive, person-centered plan of care, which includes measurable objectives and timeframes to meet a resident's medical, nursing and mental/psychosocial needs that are identified in the comprehensive assessment. The facility encourages the resident and/or resident representative to participate in the care planning process.

Based on observation, staff interview, facility document review and record review, the facility failed to ensure occupied resident rooms were cleaned and maintained in a sanitary condition for two (room [ROOM NUMBER] and room [ROOM NUMBER]) of eight rooms in Magnolia Way. The census was 142.Findings included:1. Review of a document titled, Resident Room Clean Checklist, dated 09/06/25 and signed by Certified Nurse Aide (CNA) #5, for room [ROOM NUMBER] beds A and B, indicated that dusting furniture, windowsill, etc. and removing cobwebs was not completed.An observation of room [ROOM NUMBER] on 09/09/25 at 4:02 P.M. revealed the windowsill had cobwebs.An observation of room [ROOM NUMBER] on 09/10/25 at 11:14 A.M. revealed brown debris scattered on top of the air conditioning unit and cobwebs in the corners of the windowsill. During an interview on 09/10/25 at 11:16 A.M., CNA #5 stated housekeeping did not come to Magnolia and they completed the cleaning. CNA #5 stated staff were given a cleaning list where they initialed what they completed. She stated the process was that each day the CNAs were to clean two resident rooms. CNA #5 stated when in a resident room if they saw something that needed cleaning, they tried to clean it. She stated if they did not get to the room they would tell the nightshift. She stated room [ROOM NUMBER] should have been cleaned on Saturday. She stated she gave the Room Clean Checklist to Assistant Director of Nursing (ADON) #2.During a concurrent interview and observation on 09/10/25 at 11:24 A.M., CNA #5 entered room [ROOM NUMBER] and observed the dirt debris on the top of the air conditioner and the cobwebs in the windowsill and stated it should have been cleaned.During a concurrent interview and observation on 09/10/25 at 11:37 A.M., ADON #2 observed the debris on the top of the air conditioning and cobwebs in the windowsill in room [ROOM NUMBER]. She looked on the Resident Room Checklist and confirmed cobwebs were listed on the form. She stated it was on the form for the CNA to check off, and no one mentioned to her about the debris on the air conditioner or the cobwebs in the windowsill. She stated she would do a maintenance request for the window because there might be something going on with it.2. Review of a document titled, Resident Room Clean Checklist, dated 09/07/25 and signed by CNA #4, for room [ROOM NUMBER] beds A and B, indicated that sweeping under furniture and in the closet and mopping of floors was not completed.An observation of room [ROOM NUMBER] bed A on 09/09/25 at 8:19 A.M. revealed a resident's bed against the wall and the drywall was peeling. Further observation revealed approximately two feet of drywall peelings and dust on the floor.An observation of room [ROOM NUMBER] bed A on 09/10/25 at 11:12 A.M. revealed the resident's bed against the wall but not touching the wall and the same pile of drywall debris and dust was on the floor. The worn area on the wall with the peeling drywall/paper also remained at the head of the bed.During a concurrent interview and observation on 09/10/25 at 11:22 A.M., CNA #5 entered room [ROOM NUMBER] and observed the drywall dust on the floor and stated that it should have been cleaned. The wall with peeling drywall was observed, and she stated that it should be reported to maintenance.During an interview on 09/11/25 at 8:21 A.M., CNA #4 stated they had a sheet they checked off and gave to the nurse, and the nurse gave it to ADON #2. She stated if she did not get to all the cleaning items on the list, she would write on the sheet why or let the other shift know so they could do it. She stated she cleaned room [ROOM NUMBER] on Sunday (09/07/25), and she did not get to everything. She stated she gave report but did not remember if she told the nurse or the next shift that she did not check everything off. She confirmed that she worked 09/10/25 and did not have a chance to clean what she missed.During a concurrent interview and observation on 09/10/25 at 11:31 A.M., ADON #2 observed the drywall debris on the floor in room [ROOM NUMBER] and stated it should have been addressed by staff. She stated that she did not know how long it had been there. ADON #2 stated the nurse aides handed her the daily checklist, and she tried to do rounds each day to address what happened. She stated that if the drywall debris and the scraped-off drywall were there yesterday, it should have been cleaned.Review of an untitled document with a print date of 09/10/25 revealed a list of maintenance work orders from August 2025 to September 2025 for Magnolia Way. The untitled document revealed no work orders for wall damage in room [ROOM NUMBER] until 09/10/25, when it was brought to the facility's attention. In addition, the document revealed no work orders related to room [ROOM NUMBER] until 09/10/25, when the windowsill and debris on the air conditioning unit was brought to the facility's attention.During an interview on 09/10/25 at 3:06 P.M., the Director of Nursing (DON) stated Magnolia Way was considered a small house, and the CNAs were responsible for the cleaning. She stated there were no excuses for them not to clean the rooms. During a follow-up interview on 09/10/25 at 3:41 P.M., the DON stated they did not have a housekeeping policy, but they had a procedure for resident room cleaning that they used.During an interview on 09/11/25 at 12:58 P.M., the Housekeeping Manager stated that for Magnolia Way, the CNAs were responsible for cleaning resident rooms. She stated they never trained any of the CNAs to clean resident rooms and had not been asked to provide training. She stated it was the responsibility of nursing to train the CNAs. She stated that for Magnolia Way they had to create their own cleaning checklists. The Housekeeping Manager stated she was not aware of quality checks for Magnolia Way.During an interview on 09/11/25 at 4:04 PM, the DON stated the CNAs did the cleaning on the days assigned. She stated if they did not complete the cleaning tasks, they needed to let ADON #2 or their supervisor know and follow up. The DON stated the nurses should check too. She stated if there was a major issue they should let maintenance know, and the CNAs could put in a work order. The DON stated it was a team effort.During an interview on 09/11/25 at 4:06 P.M., the Administrator stated staff followed the cleaning schedule, and if they were unable to get to it, they needed to let the supervisor know.Review of a facility document titled, Patient Room Cleaning - Detail Procedure Once Each Week, modified 09/10/25, revealed for staff to dust and clean the patient room from high to low with disinfectant cleaner. Further review revealed for staff to use a disinfectant cleaner and wiping cloth to clean furniture and surface, disinfect the bedframe and mattress while inspecting for tears. Staff are to clean corners and along baseboards using abrasive pad or putty knife and spot clean walls. Staff should continue with daily cleaning procedures.Review of the document titled, Patient Room Cleaning Daily Procedures, modified 09/10/25, revealed staff are to dust mop the floors, inspect the room for quality control, and report maintenance issues to Supervisor.Review of an undated facility document titled, Resident Room Clean Checklist, indicated the Magnolia cleaning schedule for room [ROOM NUMBER] A/B and room [ROOM NUMBER] A/B was on Saturdays. The resident room clean checklist document specified rooms are thoroughly cleaned on these days with other rooms spot cleaned as needed. The resident room clean checklist section titled, Bedroom, revealed a list of cleaning activities. The cleaning activities were to dust furniture, television, bed frame, shelves, tables, windowsill, remove cobwebs, sweep under furniture and in closet, and mop floors (use wet floor sign).This deficiency represents non-compliance investigated under Master Complaint Number 2592669 and Complaint Number 2566253.

Based on medical record review, hospital record review, interviews, and review of the medication reference the facility failed to discontinue laboratory testing, per physician order, resulting in a resident receiving two anticoagulant medications concurrently. This affected one (Resident #92) of three residents reviewed for physician orders. The facility census was 142. Findings include: Review of the medical record revealed Resident #92 was admitted to the facility on [DATE] with diagnoses of atrial fibrillation, congestive heart failure, type II diabetes mellitus, and chronic kidney disease, stage III. Review of the Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #92 had intact cognition and was always incontinent of bowel and frequently incontinent of bladder. The resident required supervision with eating, moderate assistance with oral hygiene, maximal assistance with bathing, bed mobility and transfers and was dependent for personal hygiene, toileting and dressing. Review of the plan of care dated 11/27/23 revealed Resident #92 had a focus area for anticoagulant therapy for the management of atrial fibrillation, which placed the resident at risk for bruising and/or bleeding. The goal was for Resident #92 was to be free from discomfort or adverse reactions related to anticoagulant use. Review of the physician orders revealed Resident #92 had been on Warfarin (an anticoagulant) since admission to the facility on [DATE] with multiple dosage changes from admission to current. The most current orders for Warfarin dated 02/17/25 were for Warfarin 2 milligram (mg), by mouth in the evening every Tuesday, Wednesday, Thursday, Saturday and Sunday and Warfarin 4 mg, by mouth in the evening every Monday and Friday. Additionally, Resident #92 had an order dated 02/17/25 authored by the Medical Director to check the resident's international normalized ratio (INR), on day shift, every two weeks on Mondays and for results to be called to the coumadin clinic. An INR is a blood test that monitors how well a medication like Warfarin is working to thin the blood by providing a numerical value that reflects the blood's tendency to clot. A higher INR value indicates slower clotting. Resident #92's goal was to maintain an INR between 2 and 3. Review of the nurse progress notes from 04/17/25 to 04/18/25 revealed Resident #92 went out to the hospital for a planned elective procedure in the A.M. of 04/17/25 and returned to the facility on [DATE] at approximately 2:00 P.M. Review of post-surgical procedure hospital documents for Resident #92 dated 04/18/25 revealed orders to discontinue Warfarin 2 mg, in the evening every Tuesday, Wednesday, Thursday, Saturday and Sunday and to discontinue Warfarin 4 mg, in the evening every Monday and Friday. A new order was written for Resident #92 to start taking Eliquis (Apixaban) 2.5 mg, one tablet by mouth, two times a day. Review of the facility physician orders written on 04/18/25 revealed the Warfarin 2 mg and 4 mg orders were discontinued and Eliquis 2.5 mg, one tablet twice a day was started. Review of the medication administration records for April 2025 revealed Warfarin 2 mg by mouth in the evening every Tuesday, Wednesday, Thursday, Saturday and Sunday and Warfarin 4 mg by mouth in the evening every Monday and Friday were discontinued on 04/18/25 and Eliquis 2.5 mg, one tablet twice a day was started and administered as ordered from 04/19/25 through 04/30/25. Resident #92 had an INR checked on 04/28/25 with a result of 1.2. Review of the nurse progress note dated 04/28/25 at 3:33 P.M. authored by LPN #415 revealed Resident #92's INR was 1.2. A message was left with the Coumadin Clinic pending return call. Review of nursing progress note dated 04/28/25 and timed 6:02 P.M. authored by LPN #450 revealed a return call was received by the Coumadin Clinic and new orders were received for Warfarin 6 mg by mouth now, start Warfarin 4 mg by mouth on Monday, Wednesday and Friday and Warfarin 2 mg on Tuesday, Thursday, Saturday and Sunday. Resident #92's INR was ordered to be rechecked in one week on 05/05/25. The resident and the medication administration record were updated with new orders. Review of the medication administration record for April revealed Resident #92 did not receive the one-time dose of Warfarin 6 mg as ordered on 04/28/25. Review of the May 2025 medication administration record revealed Resident #92 received Warfarin 2 mg on 05/01/25, 05/03/25 and 05/04/25, Warfarin 4 mg on 05/02/25 and 05/05/25 and Eliquis 2.5 mg twice daily from 05/01/25 through 05/06/25 as ordered. Review of the medication administration notes, when each dose of the Warfarin and Eliquis was administered a drug protocol warning triggered, indicating a possible drug to drug interaction was identified. Review of INR testing results for Resident #92 revealed on 05/06/25 the resident had an INR of 4.5. Review of the nurse's progress note dated 05/06/25 at 11:10 A.M. authored by Registered Nurse (RN) #310 revealed the INR result of 4.5 was called to the Coumadin Clinic and the clinic was notified by RN #310 that Resident #92 was receiving two anticoagulants, Warfarin and Eliquis, at the same time. Orders were received to discontinue the Warfarin and to monitor for signs and symptoms of bleeding. The facility medical director was also notified. Further review of the nursing progress notes revealed on 05/06/25 at 3:56 P.M. the Medical Director gave an order to hold the Eliquis and recheck Resident #92's INR on 05/08/25; if the INR is between 2 and 3 the Eliquis may be restarted. Review of the INR test results from 05/08/25 revealed an INR of 2.4. Eliquis was restarted. Phone interview on 05/15/25 at 2:44 P.M. with Registered Nurse (RN) #310 revealed on 05/06/25 she discovered Resident #92 was receiving two anticoagulants, Eliquis and Warfarin. Upon finding this, RN #310 initiated an incident report and made notifications to the Director of Nursing, the Assistant Director of Nursing #302, the cardiologist, the Medical Director, and Resident #92's family. RN #310 verified this should not have happened, stating when the Warfarin was discontinued on 04/18/25, the INR testing should have also been discontinued as Eliquis does not require INR testing. RN #310 stated, Resident #92 did not require additional medical treatment and did not experience any negative outcome. Phone interview on 05/15/25 at 4:47 P.M. with the Medical Director verified the 04/28/25 order to restart the Warfarin came from the Coumadin Clinic, the same clinic that ordered the Eliquis on 04/18/25, after the elective surgical procedure on 04/18/25. The Medical Director revealed after investigating the root cause of the situation that led to Resident #92 being prescribed both Eliquis and Warfarin was the result of Resident #92 having blood drawn to test an INR level on 04/28/25, and the facility calling the results to the Coumadin Clinic. Since the INR result was 1.2 and below the 2 to 3 range wanted, the Coumadin Clinic ordered Warfarin to be restarted. The Medical Director verified that Eliquis does not require INR testing. Phone interview on 05/16/25 at 11:37 A.M. with the hospital Electrophysiology Registered Nurse (EPRN) #155 verified the clinic had a current medication list for Resident #92 and the medication list should have been checked when the INR results were called in on 04/28/25. EPRN #155 verified the clinic's records showed that on 04/17/25 the resident's Coumadin was discontinued and Eliquis 2.5 mg, one tablet by mouth two times a day, was started. EPRN #155 verified the facility had no reason to perform INR testing when the resident was only receiving Eliquis. Interview on 05/16/25 at 2:45 P.M. with the Director of Nursing (Administrator also present) revealed as part of the daily clinical meeting process progress notes and physician orders for the previous 24 hours and on Mondays for the previous 72 hours are reviewed. The Director of Nursing verified the facility failed to review the 04/28/25 order for Warfarin (Coumadin) because she was on vacation that week. She also verified Eliquis does not require INR testing. Review of Medscape revealed the drug interaction between Eliquis and Warfarin was identified as serious and to use an alternative. Eliquis increases the effects of Warfarin by anticoagulation. Avoid combined use once INR is established in the desired therapeutic range. This deficiency represents non-compliance investigated under Complaint Number OH00165551.

Based on medical record review, interviews and policy review, the facility failed to prevent a resident from receiving two anticoagulant medications concurrently resulting in a significant medication error. This affected one (Resident #92) of three residents reviewed for anticoagulant therapy. The facility identified 30 residents receiving anticoagulant medications. The facility census was 142. Findings include: Review of the medical record revealed Resident #92 was admitted to the facility on [DATE] with diagnoses of atrial fibrillation, congestive heart failure, type II diabetes mellitus, and chronic kidney disease, stage III. Review of the Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #92 had intact cognition and was always incontinent of bowel and frequently incontinent of bladder. The resident required supervision with eating, moderate assistance with oral hygiene, maximal assistance with bathing, bed mobility and transfers and was dependent for personal hygiene, toileting and dressing. Review of the plan of care dated 11/27/23 revealed Resident #92 had a focus area for anticoagulant therapy for the management of atrial fibrillation, which placed the resident at risk for bruising and/or bleeding. The goal was for Resident #92 was to be free from discomfort or adverse reactions related to anticoagulant use. Review of the physician orders revealed Resident #92 had been on Warfarin (an anticoagulant) since admission to the facility on [DATE] with multiple dosage changes from admission to current. The most current orders for Warfarin dated 02/17/25 were for Warfarin 2 milligram (mg), by mouth in the evening every Tuesday, Wednesday, Thursday, Saturday and Sunday and Warfarin 4 mg, by mouth in the evening every Monday and Friday. Additionally, Resident #92 had an order dated 02/17/25 authored by the Medical Director to check the resident's international normalized ratio (INR), on day shift, every two weeks on Mondays and for results to be called to the Coumadin Clinic. An INR is a blood test that monitors how well a medication like Warfarin is working to thin the blood by providing a numerical value that reflects the blood's tendency to clot. A higher INR value indicates slower clotting. Resident #92's goal was to maintain an INR between 2 and 3. Review of the nurse progress notes from 04/17/25 to 04/18/25 revealed Resident #92 went out to the hospital for a planned elective procedure in the A.M. of 04/17/25 and returned to the facility on [DATE] at approximately 2:00 P.M. Review of post-surgical procedure hospital documents for Resident #92 dated 04/18/25 revealed orders to discontinue Warfarin 2 mg, in the evening every Tuesday, Wednesday, Thursday, Saturday and Sunday and to discontinue Warfarin 4 mg, in the evening every Monday and Friday. A new order was written for Resident #92 to start taking Eliquis (Apixaban) 2.5 mg, one tablet by mouth, two times a day. Review of the facility physician orders written on 04/18/25 revealed the Warfarin 2 mg and 4 mg orders were discontinued and Eliquis 2.5 mg, one tablet twice a day was started. Review of the medication administration records for April 2025 revealed Warfarin 2 mg by mouth in the evening every Tuesday, Wednesday, Thursday, Saturday and Sunday and Warfarin 4 mg by mouth in the evening every Monday and Friday were discontinued on 04/18/25 and Eliquis 2.5 mg, one tablet twice a day was started and administered as ordered from 04/19/25 through 04/30/25. Resident #92 had an INR checked on 04/28/25 with a result of 1.2. Review of the nurse progress note dated 04/28/25 at 3:33 P.M. authored by LPN #415 revealed Resident #92's INR was 1.2. A message was left with the Coumadin Clinic pending return call. Review of nursing progress note dated 04/28/25 and timed 6:02 P.M. authored by LPN #450 revealed a return call was received by the Coumadin Clinic and new orders were received for Warfarin 6 mg by mouth now, start Warfarin 4 mg by mouth on Monday, Wednesday and Friday and Warfarin 2 mg on Tuesday, Thursday, Saturday and Sunday. Resident #92's INR was ordered to be rechecked in one week on 05/05/25. The resident and the medication administration record were updated with new orders. Review of the medication administration record for April revealed Resident #92 did not receive the one-time dose of Warfarin 6 mg as ordered on 04/28/25. Review of the May 2025 medication administration record revealed Resident #92 received Warfarin 2 mg on 05/01/25, 05/03/25 and 05/04/25, Warfarin 4 mg on 05/02/25 and 05/05/25 and Eliquis 2.5 mg twice daily from 05/01/25 through 05/06/25 as ordered. Review of the medication administration notes, when each dose of the Warfarin and Eliquis was administered a drug protocol warning triggered, indicating a possible drug to drug interaction was identified. Review of INR testing results for Resident #92 revealed on 05/06/25 the resident had an INR of 4.5. Review of the nurse's progress note dated 05/06/25 at 11:10 A.M. authored by Registered Nurse (RN) #310 revealed the INR result of 4.5 was called to the Coumadin Clinic and the clinic was notified by RN #310 that Resident #92 was receiving two anticoagulants, Warfarin and Eliquis, at the same time. Orders were received to discontinue the Warfarin and to monitor for signs and symptoms of bleeding. The facility medical director was also notified. Further review of the nursing progress notes revealed on 05/06/25 at 3:56 P.M. the Medical Director gave an order to hold the Eliquis and recheck Resident #92's INR on 05/08/25; if the INR is between 2 and 3 the Eliquis may be restarted. Review of the INR test results from 05/08/25 revealed an INR of 2.4. Eliquis was restarted. Phone interview on 05/15/25 at 2:44 P.M. with Registered Nurse (RN) #310 revealed on 05/06/25 she discovered Resident #92 was receiving two anticoagulants, Eliquis and Warfarin. Upon finding this, RN #310 initiated an incident report and made notifications to the Director of Nursing, the Assistant Director of Nursing #302, the cardiologist, the Medical Director, and Resident #92's family. RN #310 verified this should not have happened, stating when the Warfarin was discontinued on 04/18/25, the INR testing should have also been discontinued as Eliquis does not require INR testing. RN #310 stated, Resident #92 did not require additional medical treatment and did not experience any negative outcome. Phone interview on 05/15/25 at 4:47 P.M. with the Medical Director verified the 04/28/25 order to restart the Warfarin came from the Coumadin Clinic, the same clinic that ordered the Eliquis on 04/18/25, after the elective surgical procedure on 04/18/25. The Medical Director revealed after investigating the root cause of the situation that led to Resident #92 being prescribed both Eliquis and Warfarin was the result of Resident #92 having blood drawn to test an INR level on 04/28/25, and the facility calling the results to the Coumadin Clinic. Since the INR result was 1.2 and below the 2 to 3 range wanted, the Coumadin Clinic ordered Warfarin to be restarted. The Medical Director verified that Eliquis does not require INR testing. Phone interview on 05/15/25 at 5:23 P.M. with the Consulting Pharmacist with the Director of Nursing verified the pharmacy should have caught that Resident #92 was ordered two anticoagulants and further stated the pharmacy should not have sent two anticoagulants without speaking with the facility first for clarification. Phone interview on 05/15/25 at 5:32 P.M. with the Pharmacy Manager and the Director of Nursing verified the Pharmacist who filled the 04/28/25 Warfarin order had knowledge Resident #92 was also on Eliquis and made a judgement to fill the order. The Pharmacy Manager verified the Pharmacist should have clarified with the facility before processing and sending the Warfarin prescription on 04/28/25. The Director of Nursing verified it would be the facility's responsibility to confirm the order with the physician, or in this case the Coumadin Clinic. The Director of Nursing verified the order and did trigger as a duplication error message, but because both medications were low doses the pharmacist went ahead and filled the 04/28/25 Warfarin prescription. The Pharmacy Manager revealed she would be consulted if the staff pharmacist had questions. Phone interview on 05/16/25 at 11:12 A.M. with Coumadin Clinic Registered Nurse (CCRN) #150 revealed the clinic maintained an INR result flowsheet for Resident #92 and when results are called in from the facility it is documented on the flowsheet and the resident's current Warfarin order is verified. CCRN #150 was unable to explain how the Warfarin was ordered on 04/28/25 when the resident was already receiving Eliquis. Phone interview on 05/16/25 at 11:37 A.M. with the hospital Electrophysiology Registered Nurse (EPRN) #155 verified the clinic had a current medication list for Resident #92 and the medication list should have been checked when the INR results were called in on 04/28/25. EPRN #155 verified the clinic's records showed that on 04/17/25 the resident's Warafin was discontinued and Eliquis 2.5 mg, one tablet by mouth two times a day, was started. EPRN #155 verified the facility had no reason to perform INR testing when the resident was only receiving Eliquis. Interview on 05/16/25 at 2:00 P.M. with Resident #92 revealed she had no recollection of being administered Warfarin and Eliquis simultaneously. The Resident verified she was feeling better after the elective procedure. Interview on 05/16/25 at 2:45 P.M. with the Director of Nursing (Administrator also present) revealed as part of the daily clinical meeting process progress notes and physician orders for the previous 24 hours and on Mondays for the previous 72 hours are reviewed. The Director of Nursing verified the facility failed to review the 04/28/25 order for Warfarin because she was on vacation that week. She also verified Eliquis does not require INR testing. Review of Medscape revealed the drug interaction between Eliquis and Warfarin was identified as serious and to use an alternative. Eliquis increases the effects of Warfarin by anticoagulation. Avoid combined use once INR is established in the desired therapeutic range. Review of the policy titled, Medication Administration, revised 07/09/21, revealed medications will be administered to residents as prescribed and by persons lawfully authorized to do so in a manner consistent with good infection control and standards of practice. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. The facility has sufficient staff to allow administering of medications without unnecessary interruptions. The individual who administers the medication records the administration on the resident's Medication Administration Record directly after the medication is given. This deficiency represents non-compliance investigated under Complaint Number OH00165551.

Based on record review, observation, resident and staff interview, and review of the facility policy, the facility failed to ensure fall prevention interventions were in place per the resident's plan of care and failed to conduct thorough investigations to determine root cause analysis to identify potential hazards and resident-specific interventions to reduce and/or eliminate falls and falls with injury. This resulted in Actual Harm when Resident #399 experienced repeated falls resulting in a laceration which required surgical repair. Additionally, the facility failed to ensure Resident #26 was provided with adequate supervision and assistance while toileting resulting in an avoidable fall which placed the resident at risk for more than minimal harm that did not result in actual harm to the resident. This affected two (#399 and #26) out of four residents reviewed for falls. The census was 143. Findings include: 1. Review of the medical record for Resident #399 revealed an admitted [DATE] with a diagnosis of syncope and collapse. Review of the Minimum Data Set (MDS) for Resident #399 dated 10/11/22 revealed the MDS was in progress. Review of admission note for Resident #399 dated 10/07/22 revealed nurse received report from hospital that resident was a fall risk and resident was admitted with bruising to her lower extremities from previous falls. Review of the fall risk assessment for Resident #399 revealed resident was at high risk for falls. Review of the baseline care plan for Resident #399 dated 10/07/22 revealed resident was at risk for falls. Interventions included the following: anticipate and meet resident needs, be sure my call light is within reach and encourage me to use it for assistance as needed, encourage resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility, ensure resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair. keep needed items in reach, staff to offer toileting and peri-care to resident upon rising, before and after meals, at bedtime and as needed. Review of nurse progress note for Resident #399 dated 10/08/22 timed at 12:55 A.M. revealed staff found resident on the floor beside her bed sitting on her buttocks. Resident #399 said that she was trying to go to the bathroom. Resident #399 had on non-slip socks on her feet. Resident #399 had two scrapes on her back and complained of pain at the right hip. There was a knot on the back of resident's head. Staff assisted resident back to bed and applied ice to back of resident's head. Resident #399 was sent to the hospital for an evaluation due to fall. Review of hospital note for Resident #399 dated 10/08/22 revealed resident was evaluated at the hospital for the fall and returned to the facility on the same day. Review of nurse progress note for Resident #399 dated 10/11/22 timed at 1:00 A.M. revealed the resident was found on the floor at her doorway. Resident #399 said she tried to get her cane which was located at the end of her bed. Resident #399 said she fell and hit her head resulting in a laceration over the right eyebrow. Resident #399 was sent to the hospital for an evaluation. Recommendation to prevent further falls was put cane at the side of the resident's bed instead of next to the wall at the foot of the bed. Review of hospital note for Resident #399 dated 10/11/22 revealed the resident was admitted to the hospital and treated for recurrent falls and resident presented with a facial hematoma to the right forehead with a three-centimeter (cm) laceration which required surgical repair with four sutures. Resident #399 was also treated for a urinary tract infection (UTI) and was readmitted to the facility on [DATE]. Review of the nurse progress note for Resident #399 dated 10/13/22 revealed resident was readmitted to the facility following hospitalization related to fall on 10/11/22. Resident #399 had a laceration to right forehead above the right eye secured by four sutures and presented with diffuse bruising to the right side of her face. Review of the fall investigation for Resident #399 dated 10/17/22 timed at 1:20 P.M. completed per Registered Nurse (RN) #351 revealed the interdisciplinary team (IDT) met to review the fall from 10/11/22 for Resident #399. Resident #399 was found on floor in room sitting at her doorway and stated she was trying to get her cane. A laceration was noted to the resident's right eyebrow and the resident was transferred to the emergency room for evaluation. New intervention was to ask the physician to conduct a review of resident medications related to repeated falls. Review of the facility fall investigation dated 10/17/22 timed at 5:47 P.M. completed per RN #351 revealed the IDT met to review the fall from 10/08/22 for Resident #399. Resident #399 was found on the floor in her room beside her bed. Resident #399 stated she was attempting to use the bathroom. The new intervention was to keep resident's cane and walker within reach. Interview on 10/17/22 at 3:56 P.M. with RN #351 confirmed the fall investigation for Resident #399's fall on 10/08/22 did not include a root cause analysis regarding the cause of the fall and/or possible contributing factors. RN #351 confirmed the investigation did not indicate if care planned interventions were in place or not at the time of the fall. RN #351 confirmed Resident #399 did not sustain injuries in the fall on 10/08/22 and the IDT team put a new intervention in place following the fall on 10/08/22 which was to ensure resident's cane was within reach. Interview with RN #351 confirmed Resident #399 sustained a repeat fall on 10/11/22 in which she fell trying to reach her cane which was at the foot of resident's bed and not within reach as per the resident's updated plan of care. RN #351 confirmed Resident #399 was sent to the hospital on 10/11/22 and required sutures for a laceration to the forehead sustained during the fall on 10/11/22. RN #351 confirmed the fall investigation for the fall on 10/11/22 for Resident #399 did not include a root cause analysis regarding the cause of the fall and/or possible contributing factors. RN #351 confirmed the investigation did not indicate if care planned interventions were in place or not at the time of the fall. Observation on 10/18/22 at 8:51 A.M. of Resident #399 revealed resident had diffuse bruising to the right side of her face and a bandage over her right eyebrow. Interview on 10/18/22 at 8:51 A.M. with Resident #399 confirmed she had bruised her face when she fell the week before and that she had received stitches to her forehead following the fall. Interview on 10/19/22 at 11:11 A.M. with RN #351 and the Director of Nursing (DON) confirmed the facility had not completed any additional fall investigation for Resident #399's falls on 10/08/22 and 10/11/22. DON confirmed the investigations completed on 10/17/22 for the falls on 10/08/22 and 10/11/22 did not include a root cause analysis regarding the falls. 2. Review of the medical record for Resident #26 revealed an admitted [DATE] with a diagnosis of asthma. Review of the MDS for Resident #26 dated 10/05/22 revealed the resident was cognitively impaired and required extensive assistance of two staff with bed mobility, transfers, and toilet use. Review of fall risk assessment for Resident #26 dated 10/05/22 revealed resident was at risk for falls Review of the care plan for Resident #26 dated 09/14/22 revealed resident was at risk for falls related to antihypertensive medications, deconditioning, gait/balance problems, incontinence, psychoactive drug use, history of falls, poor safety awareness, getting my legs tangled in the blankets, sliding out of chair. Interventions included the following: provide safe environment with even floors free from spills and/or clutter, adequate, glare-free light, a working and reachable call light, the bed in low position at night, right assist bar as ordered, grab bar in bathroom, personal items within reach, offer to assist resident to bed after meals, therapy to evaluate and treat as ordered and as needed, staff to offer toileting and peri-care to resident routinely on rounds and as needed. Review of the care plan for Resident #26 dated 04/21/20 revealed resident had an activities of daily living (ADL) self-care and/or physical mobility performance deficit related to activity intolerance, impulsivity, fatigue, weakness, and history of cerebrovascular accident (CVA). Interventions included for toilet use resident required supervision to limited assistance with transfer using grab bars on the toilet and extensive assistance with incontinence care. Review of facility incident log for October 2022 revealed resident had an unwitnessed fall on 10/15/22. Review of nurse progress note for Resident #26 dated 10/17/22 revealed intervention for the resident's fall on 10/15/22 was as long as resident in room, aide must not leave resident unattended. Review of October 2022 monthly physician orders for Resident #26 revealed an order dated 10/17/22 for to cleanse left hand skin tear with normal saline, pat dry, apply xeroform, cover with gauze, wrap with Kerlix each day. Review of written statement per State tested Nursing Assistant (STNA) #144 dated 10/15/22 revealed aide assisted Resident #36 onto the toilet and left the resident unattended. Review of the statement revealed resident's call light was in reach and that resident's wheelchair was in the bathroom with her and was not locked. Resident #26 was found on the floor of the bathroom. The section of the statement for regarding footwear in place at the time of the fall was blank. The section of the statement regarding additional information to prevent future falls was blank. Observation on 10/17/22 at 2:15 P.M. of Resident #26 revealed her left arm was wrapped with Kerlix gauze. Interview on 10/19/22 at 1:19 P.M. with Registered Nurse (RN) #79 confirmed there was no note in Resident #26's medical record describing the circumstances of the fall. RN #79 confirmed there was a note in Resident #26's medical record dated 10/17/22 per RN #10 which referred to a fall on 10/15/22. RN #79 confirmed she knew Resident #26 had sustained a skin tear during the fall. RN #79 confirmed the facility had not completed a fall investigation of Resident #26's fall on 10/15/22 at the time of the interview. RN #79 confirmed the statement provided by the aide dated 10/15/22 revealed the aide had assisted resident onto to the toilet and left the resident unattended. RN #79 confirmed the facility had not yet completed an investigation regarding Resident #26's fall. RN #79 further confirmed Resident #26 required assistance of staff and should not be left unattended while on the toilet. Review of the facility policy titled Falls Management dated 12/03/19 revealed the IDT will meet to review the fall to determine if further interventions are needed. The care plan will be reviewed and dated to assure it has been updated to reflect the current needs of the resident to prevent a further fall.

Based on review of the facility menus, observations, staff interview and policy review, the facility failed to provide puree food portions as planned by a Registered Dietitian. This had the potential to eight (#27, #14, #24, #73, #65, #35, #71,and #48) residents who received food from the [NAME] Hall kitchettes. The total facility census was 143. Findings include: Review of Registered Dietitian approved puree meal tickets dated 10/20/22 revealed a puree menu and portions of hotdog and bun eight ounces, (#8 scoop, doubled), corn of four ounces, mashed potatoes four ounces, (#8 scoop) and pudding four ounces. Observation on 10/20/22 at 12:15 P.M. of Magnolia steam table serving utensils revealed the residents received puree hotdog of four ounces, mash potatoes of #12 scoop. Interview on 10/120/22 of State tested Nurse Aide, (STNA) # 157, who served the puree meal on the Magnolia unit, verified the residents received the incorrect portion of hotdog, (only one four ounce portion) and mashed potatoes. STNA #157 stated the correct scoops were not available. Observation on 10/20/22 at 12:20 P.M. of the Rose Garden steam table serving utensils revealed the residents received puree mash potato of a #6 scoop. A #20 scoop was used and not observed as a portion amount on a puree ticket. Interview on 10/20/22 at 12:20 P.M. STNA # 13 who served the puree meal on the Rose Garden unit, revealed the puree mash potato was the incorrect scoop and the #20 scoop size (1.75 to two ounces) was used and not on the puree menu. Observation on 10/20/22 at 122:30 P.M. of the [NAME] Lane steam table serving utensils revealed the resident's received hotdog of #12 scoop, and corn of #16 scoop (two to 2.5 ounces). Interview on 10/20/22 at 12:30 P.M., Diet Aide, (DA) # 376, who served the puree meal on the [NAME] Lane unit, verified the scoops used were smaller than the planned menu. DA #376 stated he used the scoops available and was unable to verify the printed number on the scoops for the surveyor. The facility confirmed the incorrect portion sizes had the potential to eight (#27, #14, #24, #73, #65, #35, #71,and #48) residents who received food from the [NAME] Hall kitchettes. Review of facility policy. Portion Control, dated 2021, revealed residents will receive the portions of food as outlined on the menu.

Based on record review, observation, staff interview, and review of the facility policy, the facility failed to ensure staff secured resident's medications. This affected one (#142) of six residents observed for medication administration. The facility census was 143. Findings include: Review of the medical record for Resident #142 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .) Review of the October 2022 monthly physician orders for Resident #142 revealed an order dated 10/11/22 for resident to receive [MEDICATION(S)] once daily. Observation on 10/19/22 at 11:50 A.M. revealed there was a plastic cup with a tablet sitting unattended on top of the Transitional Care Unit (TCU) front medication cart. Interview on 10/19/22 at 11:54 A.M. with Registered Nurse (RN) #260 confirmed the tablet in the plastic cup was [MEDICATION(S)] which he had prepared for Resident #142 and left unattended while he was in the resident's room providing care. RN #260 confirmed medications should be secured at all times and should not be left unattended. Review of the facility policy titled Medication Storage dated 06/21/17 revealed medications should be stored safely and securely and should only be accessible to licensed and authorized personnel.

Based on record review, staff interview, and review of the facility policy, the facility failed to provide an adequate and timely response to a resident with suicidal ideation. This affected one (#366) of 28 residents sampled. The facility census was 143. Findings include: Review of the medical record for Resident #396 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) for Resident #396 dated 09/12/22 revealed the resident was cognitively intact and required extensive assistance of one to two staff with activities of daily living. Review of the nurse progress note for Resident #396 dated 09/08/22 revealed the resident verbalized suicidal ideation to the nurse. Resident #396 said he wanted [MEDICATION(S)] for his pain so he could die. The nurse noted Resident #396 was to have a psychological consult with the facility's psychologist. Review of the care plan for Resident #396 dated 09/12/22 revealed the resident had suicidal ideation's. Interventions included the following: administer medications as ordered and monitor for adverse drug reactions, document negative findings, allow resident time to express concerns and fears, approach and re-approach resident in a calm manner, discuss precipitating factors such as stress, recent losses, etc., encourage activities for resident, encourage resident to share feelings, encourage resident to stay in the common area, encourage relaxation techniques, encourage/assist resident to socialize with staff and other residents, interview resident and determine if resident has a plan to injure himself, keep the door of resident's room open unless care is being provided, psychological referral as needed, refer to social services, refer to spiritual services, remove potentially dangerous items from resident's bed room, monitor resident for suicide warning signs: hopelessness, expressing wanting to die, giving away belongings, comments about what it would be like to die in a specific way, preoccupation with death or suicide, suddenly making final arrangements-wills, funeral plans, insurance, provide resident with one on one interactions with reassurance. Review of October 2022 monthly physician orders for Resident #396 revealed an order dated 10/07/22 for the resident to have a psychological consult with the facility psychologist for voicing the desire to die. Review of the progress notes for Resident #396 dated 09/08/22 through 10/19/22 revealed the notes did not include follow up with resident regarding suicidal ideation's expressed on 09/08/22. Interview on 10/19/22 at 10:18 A.M. with Registered Nurse (RN) #351 confirmed she obtained an order on 10/07/22 for Resident #396 to have a psychological evaluation with the facility's psychologist after she reviewed the nurse progress note for Resident #396 dated 09/08/22. RN #351 confirmed Resident #396 had not yet been evaluated by the facility psychologist and could not offer a rationale for the delay in follow up. Interview on 10/19/22 at 10:20 A.M. with the Administrator confirmed Resident #396's medical record did not include documentation of follow up with resident per social services after he expressed suicidal ideation on 09/08/22. Administrator further confirmed the facility had no record of increased monitoring or evaluation of resident related to the incident on 09/08/22. Review of the facility policy titled Suicide Prevention dated October 2013 revealed any resident exhibiting potential warning signs of suicidal ideation will be reported immediately to the Director of Nursing (DON) and the Administrator. A suicide risk care plan would be implemented immediately. Follow up would include frequent monitoring at a minimum. The Social Worker or designee will talk with the resident one on one asking specific questions about a suicide plan to determine the seriousness of the resident's intentions. Most people do talk about their suicide plan before they attempt to carry it out. Social Services will document daily progress notes regarding the progress and status of the resident.

Based on record review, observation, staff interview, and review of the facility policy, the facility failed to ensure staff practiced appropriate hand hygiene and appropriate personal protective equipment (PPE) doffing practices for residents with Coronavirus Disease 2019 (COVID-19). This affected one (#104) of four facility identified COVID-19 positive residents. The facility also failed to ensure nurses practiced appropriate hand hygiene during medication administration. This affected one (#395) of six residents observed for medication administration. The census was 143. Findings include: 1. Review of the medical record for Resident #407 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the admitting orders for Resident #407 revealed an order dated 10/11/22 for COVID-19 isolation per facility protocol. Review of the medical record for Resident #104 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the progress note for Resident #104 dated 10/12/22 revealed resident tested positive for COVID-19 and was placed in COVID-19 isolation per facility protocol. Observation on 10/17/22 at 12:30 P.M. revealed State tested Nursing Assistant (STNA) #98 exited Resident #407's room wearing an N-95 mask, a face shield, and an isolation gown. Resident #407's room had a zippered barrier in the doorway. STNA #98 doffed the gown in waste receptacle outside Resident #407's room after he had rezipped the barrier to the room. STNA #98 then donned a gown from the isolation cart outside Resident #104's room and started unzipping the barrier to resident's room. Interview on 10/17/22 at 12:31 P.M. with STNA #98 confirmed he should have doffed the gown he was wearing in Resident #407's room before he exited the room, but he forgot so he doffed the gown in the waste receptacle outside the room. STNA #98 further confirmed he did not perform hand hygiene after doffing the gown he wore in Resident #407's room and donning a gown to wear into Resident #104's room. STNA #98 confirmed he did not think it was necessary to perform hand hygiene because he had washed his hands before he exited Resident #407's room. Observation on 10/17/22 at 12:32 P.M. with STNA #98 revealed he entered Resident #104's room to provide care and did not perform hand hygiene after handling the contaminated gown from Resident #407's room and donning a gown to enter Resident #104's room even after discussion with the surveyor. Interview on 10/17/22 at 12:40 P.M. with Registered Nurse (RN) #351 confirmed staff should doff gowns inside the COVID 19 isolation room and should perform hand hygiene after doffing PPE. Review of the facility policy titled Hand Hygiene dated 11/05/21 revealed hand hygiene should be performed after removing PPE. Review of Center for Disease Control (CDC) document titled PPE Sequence undated revealed healthcare workers should wash hands or use an alcohol- based hand-sanitizer immediately after removing PPE. Review of CDC document titled Use Personal Protective Equipment (PPE) When Caring for Patients with Confirmed or Suspected COVID-19 undated revealed the following sequence is required when doffing PPE: remove gown, untie all ties (or unsnap all buttons), rolling the gown down is an acceptable approach, dispose in trash receptacle, healthcare personnel (HCP) may now exit patient room, perform hand hygiene. 2. Review of the medical record for Resident #395 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the October 2022 monthly physician orders for Resident #395 revealed an order dated 10/18/22 for [MEDICATION(S)] 5-325 milligrams ([MEDICATION(S)]-acetaminophen) every four hours as needed for pain. Observation on 10/19/22 at 12:17 P.M. per RN #260 revealed nurse unlocked controlled substance compartment of the medication cart located in the lower portion of the cart and popped a [MEDICATION(S)] tablet for Resident #395 into his hand and then dropped the tablet into a plastic medication cup sitting on top of the cart. Interview on 10/19/22 at 12:17 P.M. with RN #260 confirmed he had handled the medication keys and then touched Resident #395's [MEDICATION(S)] tablet with his hands. RN #260 confirmed he was not supposed to touch resident's oral medication with his bare hands, but he was going to give the medication, because it was a controlled substance, and he didn't want to have to waste the medication. Observation on 10/19/22 at 12:30 P.M. with RN #260 revealed he administered the [MEDICATION(S)] tablet to Resident #395. Review of the facility policy titled Medication Administration dated 11/09/21 revealed medications are administered per infection control standards of practice according to CDC and Centers for Medicare and Medicaid Services (CMS) guidelines.

Based on record review, resident and staff interview, and review of the facility policy, the facility failed to ensure resident preferences regarding bathing were honored. This affected one (#398) of 28 residents sampled. The facility census was 143. Findings include: Review of the medical record for Resident #398 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Minimum Data Set (MDS) for Resident #398 dated 10/09/22 revealed resident was cognitively impaired and required physical assistance of one staff with bathing. Review of section F revealed the resident reported it was very important for him to choose between a tub bath, shower, and bed bath. Review of the care plan for Resident #398 dated 10/02/22 revealed resident was able to express preferences regarding his daily life. Interventions included: resident prefers to assist with his own personal care, resident prefers a shower in the morning. Review of bathing sheet for Resident #398 dated 10/04/22 revealed aide offered to give resident a bed bath, but resident refused said he wants a shower in the morning. Review of bathing sheets for Resident #398 dated 10/07/22 and 10/14/22 revealed resident received a bed bath. Review of bathing sheets for Resident #398 dated 10/11/22 and 10/18/22 revealed resident was bathed but the sheet does not specify what type of bath resident received. Interview on 10/18/22 at 8:45 A.M. with Resident #398 confirmed he had not received a shower since his admission to the facility on [DATE]. Resident #398 confirmed he preferred to take a shower in a shower chair and his preference was to shower in the mornings. Resident #398 confirmed he told staff this preference when he was admitted on [DATE] but he has only received bed baths. Interview on 10/20/22 at 11:39 A.M. with Registered Nurse (RN) #351 confirmed Resident #398's expressed preference upon admission was to receive showers in the morning. RN #351 further confirmed the facility had no record of Resident #398 receiving a shower since his admission to the facility. Review of the facility policy titled Activities of Daily Living (ADL's) undated revealed the facility would include the resident's preference when planning care when possible.

Based on record review, observation, staff interview, and review of the facility policy, the facility failed to ensure residents were provided with appropriate fingernail care. This affected one (#43) of 28 residents sampled. The facility census is 143. Findings include: Review of the medical record for Resident #43 revealed resident was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Minimum Data Set (MDS) for Resident #43 dated 07/14/22 revealed the resident was severely cognitively impaired and required extensive assistance of one staff with bathing and personal hygiene. Review of the care plan for Resident #43 dated 10/28/20 revealed resident had an activities of daily living (ADL) self-care deficit related to cognitive/communication challenges and requires total assistance with, toileting, dressing grooming and eating. Interventions include the following: provide total assistance with dressing and grooming, assist with bathing and showering, check resident's nail length and trim and clean on bath day as necessary, report any changes to the nurse. Review of the care plan for Resident #43 dated 04/03/22 revealed resident received hospice services related to a terminal prognosis/diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of bathing records provided by the facility for Resident #43 for the previous two weeks revealed all bathing assistance was provided by the hospice aide. Review of bath records dated 09/30/22, 10/05/22, 10/07/22, 10/12/22, 10/14/22 revealed the hospice aide provided bathing assistance but it was noted that nail care was not provided. Observation on 10/17/22 at 10:52 A.M. revealed Resident #43's fingernails were long (extending approximately one quarter inch beyond the end of the nail) and had some jagged edges. Interview on 10/17/22 at 10:55 A.M. with State tested Nursing Assistant (STNA) #310 confirmed Resident #43's fingernails were long (extending approximately one quarter inch beyond the end of the nail) and had some jagged edges. STNA #310 confirmed the hospice aides were responsible for nail care and should trim resident's fingernails the next time they came into the facility. Interview on 10/20/22 at 11:40 A.M. with Registered Nurse (RN) #351 confirmed the hospice aides provided bathing for Resident #43 but any staff could trim resident's fingernails as needed. Review of the facility policy titled Activities of Daily Living (ADL's) undated revealed the facility would ensure staff provided ADL assistance as needed to the residents in order to promote dignity and improve quality of life.

Based on record review, staff interview, and review of facility documents and policy, the facility failed to ensure nurses administered insulin as ordered by the physician resulting in a significant medication error. This affected one (#62) of seven residents reviewed for medication administration. The facility census was 143. Findings include: Review of the medical record for Resident #62 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Minimum Data Set (MDS) for Resident #62 dated 08/03/22 revealed the resident was cognitively impaired and required extensive assistance of staff with activities of daily living (ADL's.) Review of the care plan for Resident #62 dated 09/01/20 revealed resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included the following: check resident's blood sugar as ordered by the doctor and report as needed, provide diabetes medication as ordered by the doctor, monitor/document for side effects and effectiveness. Review of the October 2022 monthly physician orders for Resident #62 revealed an order dated 04/23/21 for [MEDICATION(S)] insulin inject 40 units subcutaneously at bedtime. The order did not include parameters or directions for withholding the insulin. Review of the September and October Medication Administration Records (MAR's) for Resident #62 revealed doses of evening doses of [MEDICATION(S)] insulin were withheld/not administered on the following dates: 09/22/22, 09/26/22, 10/02/22, 10/07/22. Review of the nurse progress note per Registered Nurse (RN) #51 dated 09/22/22 revealed Resident #62's evening dose of [MEDICATION(S)] insulin was withheld due to the resident's blood sugar was 90. Review of nurse progress note per RN #51 dated 09/26/22 revealed Resident #62's evening dose of [MEDICATION(S)] insulin was withheld due to resident's blood sugar was 91. Review of nurse progress note per RN #51 dated 10/02/22 revealed Resident #62's evening dose of [MEDICATION(S)] insulin was withheld due to resident's blood sugar was 71. Review of nurse progress note per RN #289 dated 10/07/22 revealed Resident #62's evening dose of [MEDICATION(S)] insulin was withheld due to resident's blood sugar was 81. Review of facility coaching form dated 10/19/22 revealed the Director of Nursing (DON) provided education to RN #51 regarding withholding insulin for Resident #62. Review of the form revealed the nurse did not have a physician's order to withhold the medication nor did the nurse notify the physician after she withheld the medication. Further review of the form revealed nurse should notify the attending physician prior to withholding ordered medications. Interview on 10/19/22 at 3:28 P.M. with the DON confirmed RN #51 and RN #289 had documented withholding long-acting [MEDICATION(S)] insulin as ordered for Resident #62 on 09/22/22, 09/26/22, 10/02/22, and 10/07/22. DON confirmed Resident #62's [MEDICATION(S)] order did not include any parameters for withholding the medication. DON further confirmed Resident #62's medical record did not include documentation of physician notification of the withholding of insulin for Resident #62. Interview on 10/19/22 at 3:49 P.M. with RN #51 confirmed Resident #62's order for long-acting [MEDICATION(S)] insulin did not include parameters for withholding the medication. RN #51 further confirmed she withheld Resident #62's insulin on 09/22/22, 09/26/22, and 10/02/22 based on the resident's blood sugar and her nursing judgment. RN #51 confirmed she did not notify the physician she withheld the medication. Review of the facility policy titled Insulin Administration dated 06/21/17 revealed insulin is a high-risk drug and warrants additional precautions for safe and effective administration. It is important that the nurse is familiar with the type of insulin prescribed. Notify the prescriber as appropriate if insulin is not administered as ordered. [MEDICATION(S)] is a long-acting insulin with an onset of 1.1 to two hours with no significant peak. Duration for [MEDICATION(S)] insulin is a mean of 7.6 to greater than 24 hours. Meal timing is not applicable to [MEDICATION(S)] administration. This deficiency substantiates Complaint Number OH 402.

Based on record review and staff interview, the facility failed to ensure a comprehensive care plan was developed and implemented for Resident #107's behaviors. This affected one (Resident #107) of three residents reviewed for care plans. The facility census was 137. Findings include: Review of the medical record for Resident #107 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #107 had cognitive impairment and required extensive assistance of two staff members for bed mobility and transfers. Review of the plan of care dated 07/25/22 revealed no evidence the facility had developed or implemented a behavior plan of care for Resident #107 related to her throwing herself on the floor from her bed or wheelchair. Review of the progress notes dated 08/01/22 revealed Resident #107 had behaviors including yelling out and threatening staff saying she will fall to the floor. The progress note on 08/03/22 revealed at 4:40 P.M. staff witnessed a fall. Two state tested nursing aides (STNAs) were taking Resident #107 to a shower and Resident #107 refused care. Resident #107 pushed up with both arms on the arm rests and pushed herself out of the wheelchair and onto the floor. Interviews on 08/09/22 from 1:10 P.M. to 1:25 P.M. with STNA #310 and #320 revealed Resident #107 had behaviors and a history of throwing herself to the floor. Interview on 08/09/22 at 4:00 P.M. with Assistant Director of Nursing (ADON) #350 confirmed interventions for Resident #107's behaviors were not updated in Resident #107's care plan. This deficiency substantiates Complaint Number OH 735.

Based on observation, record review, review of the product informational sheet, and interviews, the facility failed to ensure medications were safely stored. This had the potential to affect 34 mobile cognitively impaired residents (#01, #02, #03, #04, #05, #07, #08, #09, #10, #77, #79, #80, #81, #82, #83, #84, #85, #86, #87, #90, #91, #92, #93, #94, #95, #96, #97, #98, #100, #103, #105, #106, #107, and #109) of 43 residents residing in the secured unit. The facility census was 136. Findings Include: Record review for Resident #08 revealed an admitted [DATE]. Her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #08 did not have a MDS assessment completed due to her length of stay at the facility. However, documentation revealed the resident scored a three on her admission Brief Interview for Mental Status (BIMS) dated 05/01/22. This indicated Resident #08 was severely cognitively impaired. Observation on 05/02/22 at 2:35 P.M. revealed Resident #08 had a large clear plastic bag lying on the top of her bedside nightstand. The large plastic bag contained deodorant, toothpaste, mouthwash, bottle of [MEDICATION(S)] #04 and a tube of Arthritis Pain Gel. Interview on 05/02/22 at 2:35 P.M. with STNA #203 verified the large plastic bag was located on the top of Resident #08's bedside nightstand. STNA #203 stated Resident #08 admitted the previous evening from the hospital and the plastic bag was from her hospital stay. STNA #203 confirmed the plastic bag contained deodorant, toothpaste, mouthwash, a bottle of [MEDICATION(S)] #4 and a tube of arthritis pain gel. Review of the [MEDICATION(S)] #4 product informational sheet titled, What is Dyna-Hex 4: Uses, Warnings & Interactions, undated revealed the substance is a wound care agent, and antibacterial cleansing agent. The item is listed as only to be used on the skin and do not swallow or get into the eyes, mouth, or nose. Further review of the product information revealed, this medicine may cause serious and permanent injury when placed in the eyes, ears, or nose. Keep all medicine out of reach of children. Review of the product informational sheet Diclofeanac gel (1%) revealed the drug was to be stored out of reach of children. This citation substantiates Complaint Number OH 626.

Based on observation, record review, review of the safety data sheet and interviews, the facility failed to provide a safe environment for cognitively impaired mobile residents residing on the secured unit. This had the potential to affect 34 Residents (#01, #02, #03, #04, #05, #07, #08, #09, #10, #77, #79, #80, #81, #82, #83, #84, #85, #86, #87, #90, #91, #92, #93, #94, #95, #96, #97, #98, #100, #103, #105, #106, #107, and #109) of 43 residents residing in the secured unit. The facility census was 136. Findings Include: Record review for Resident #04 revealed an admitted [DATE]. His diagnosis included, Alzheimer's disease, [CONDITION(S)], dysphagia, chronic kidney disease stage two, [CONDITION(S)], and [CONDITION(S)]. Review of the five- day minimum data set (MDS) assessment, dated 04/11/22, for Resident #04 revealed he had moderately impaired cognition as evidenced by his brief interview for mental status score of 12. Further review of the MDS assessment revealed Resident #04 required extensive assistance from staff with bed mobility, transfers, toilet use, and limited assistance from staff with walking, personal hygiene, dressing, eating. Observation on 05/02/22 at 2:28 P.M. revealed Resident #04 was lying in bed watching television. Resident #04 had a table located at the foot of his bed. Located on the table was a spray bottle with liquid in it. The label on the spray bottle stated it contained Comet bleach spray. Interview on 05/02/22 at 2:28 P.M. with state tested nurse aide (STNA) #203 confirmed the spray bottle located on the table at the foot of Resident #04's bed contained Comet bleach spray. STNA #203 confirmed the bottle should not be in a resident's room and should be in a locked area out of reach of the residents. Review of the safety data sheet (SDS) titled, Procter& Gamble Professional material safety data sheet for PGP Comet Cleaner with Bleach-ready to use, dated 10/26/2011, stated routes of exposure included inhalation, skin contact and eye contact and ingestion. Ingestion of the product may cause gastrointestinal, irritation, nausea, vomiting and diarrhea. Further review of the SDS sheet revealed the product should be kept out of reach of children. Observation and interview on 05/02/22 at 2:38 P.M. while touring the kitchen areas located on all three [NAME] Hall Units with the Assistant Director of Nursing (ADON) #205 verified the door walking into the kitchen from the living/dining room area on the Rose Garden Hall was unlocked. The kitchen had a large open window next to the unlocked door. Under the window seal was a large three pan steam table. Two of the steam table lids were off and steamed water was uncovered, the third pan was covered with a lid that was hot to touch. The kitchen had a sink with an unlocked cabinet under the sink. The ADON #205 verified the door was unlocked, the steam table was on and hot, and the chemicals were observed under the sink with the open cabinet door. The ADON #205 verified anyone could reach a hand through the open window and touch the hot steam table. The ADON #205 also verified the chemicals located in the unlocked, open cabinet under the sink included two bottles of Comet Bleach Spray. The Surveyor walked back to the kitchen door with ADON #205 and verified the kitchen door remained slightly ajar and had not closed or locked after the tour. The ADON #205 pulled on the door and heard a click and verified it locked on the second try. The ADON #205 walked to the second hallway called Magnolia. The unit was set up the same as the Rose Garden Hall. The kitchen door was located to the side of the living room/dining room and had a lock on the door. However, the door was not closed all the way and the kitchen was unlocked. Looking through the large open window a three-pan large steam table was located under the open window. The ADON #205 verified a hand could reach through the large open window and touch the hot steam table located below the window sill. The steam table had all three lids on the pans, however, they were hot to the touch. Under the unlocked cabinet of the sink ADON #205 verified a container of Micro bleach, Lemon Zip Disinfectant, a bottle of Comet Bleach spray and a spray bottle that contained no label with a dark green liquid substance. The ADON #205 walked into the [NAME] Unit. The kitchen is located right off the living room on this unit. Observed a completely open kitchen with a half wall and half door as you enter the kitchen area. The kitchen area was unlocked to the left of the kitchen was a large three pan steamer and it was hot to touch, next to the steam was an electric flat top grill. The ADON #205 verified the steam table could be reached by reaching over the half wall. Interview on 05/03/22 at 10:05 A.M. interview with the Administrator verified the facility does not have a written policy regarding securing chemicals in a safe location or locking the kitchen doors. Review of the safety data sheet titled, Wepak, Safety Data Sheet, dated 08/16/11, revealed the lemon disinfectant could cause skin corrosion/irritation, serious eye damage/eye irritation, skin sensitization, inhalation issues and directive to call poison control center immediately if ingested. The directions included to keep out of reach of children. Review of the safety data sheet titled, Micro-Kill Bleach Germicidal Bleach Wipes, undated, revealed the product can cause serious eye damage and skin corrosion. Further review of the SDS sheet revealed, This is a pesticide product registered by the Environmental Protection Agency and is subject to certain labeling requirements under federal pesticide law. Review of the safety data sheet (SDS) titled, Procter& Gamble Professional material safety data sheet for PGP Comet Cleaner with Bleach-ready to use, dated 10/26/2011, stated routes of exposure included inhalation, skin contact and eye contact and ingestion. Ingestion of the product may cause gastrointestinal, irritation, nausea, vomiting and diarrhea. Further review of the SDS sheet revealed the product should be kept out of reach of children. This citation substantiates Complaint Number OH 626.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY Based on medical record review, review of personnel files, review of a facility self-reported incident (SRI), staff interviews, and review of facility policies on Social Networking and Abuse, Neglect, Exploitation & Misappropriation of Resident Property, the facility failed to ensure a cognitively impaired resident's rights to privacy and confidentiality were maintained by a facility staff member during provision of personal care. This resulted in Immediate Jeopardy and psychosocial harm for one resident (#1) when State tested Nurse Aide (STNA) #1 engaged in an act meant to humiliate and dehumanize the resident by taking an inappropriate picture while the resident was lying in bed with her buttocks exposed without permission and not in accordance with facility policy. This picture was then posted on a social media website, Snap Chat, resulting in outcomes which one would expect a reasonable person in a similar situation to suffer, subsequently treating the resident as an inanimate object having no emotions or feelings and causing embarrassment and shame for the resident. This affected one (#1) of five residents reviewed for abuse. The facility identified 10 residents who were cognitively impaired and lived on the same unit as Resident #1. The census was 203. On 10/02/17 at 4:15 P.M., Vice President #1, Vice President #2, Executive Director #300, the Administrator Consultant and the Director of Nursing (DON) were notified that Immediate Jeopardy began on 08/29/17 at approximately 7:30 A.M. when STNA #1 took a picture of Resident #1 lying in bed, with blankets and sheets below her waist, with her naked buttocks exposed. STNA #1 sent the picture to STNA #2 by posting the picture on a social media website identified as Snap Chat. The picture potentially could have been viewed by others in the community on Snap Chat. The picture was witnessed being taken by STNA #3, another staff member who was present in the resident's room at the time the photo was taken. During an interview with STNA #3 she indicated STNA #1 made the comment, Ha, ha, isn't this funny when she took the picture of Resident #1. The Immediate Jeopardy was removed on 09/01/17 when staff education was provided regarding the identification of abuse, the abuse policy and procedures, maintaining the residents' rights to privacy and confidentiality during the provision of personal care and utilization of cellular phones and/or photographing mobile devices. Additionally, a Quality Assurance (QA) meeting was held with Physician #100 and the facility's medical director to review the incident and action plan and they agreed with the plan with no further recommendations. The deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) until it was corrected on 09/05/17 when the facility implemented the following: · On 08/29/17 at approximately 10:00 A.M., Assistant Director of Nursing (ADON) #20 began an investigation into STNA #1 taking a compromising photograph of Resident #1 involving nudity. · On 08/29/17 at approximately 10:00 A.M., Resident #1 was assessed by Social Worker (SW) #2 and was noted to be at her baseline, emotionally and behaviorally, with no signs of psychological harm. A request was submitted for the psychologist to complete a full evaluation of the resident on 09/01/17. · On 08/29/17 at approximately 11:30 A.M., Director of Human Resources (DHR) #1, and Executive Director #300 were notified of the incident. STNA #1 was interviewed and confirmed she took the photo without rationale as to her decision. DHR #1 verified the Snap Chat photo and no other resident photos were on the cellular device of STNA #1. STNA #1 was terminated due to poor performance and taking a photo of a resident and sending it to STNA #2 via Snap Chat. · On 08/29/17 at 3:00 P.M., the Interdisciplinary Team (IDT) met regarding the event to review the root cause and developed an action plan. · On 08/29/17 through 09/05/17, Executive Director #300, ADON #20, ADON #30, ADON #40, ADON #50, ADON #60, Development Coordinator #400, Supervisor #1, Supervisor #2, Supervisor #3 and Supervisor #4 began re-educating all nursing staff on the abuse policy, neglect, misappropriation, social media, cell phone usage when providing care and services, and maintaining resident's privacy during care per the facility's personnel information guide in the employee handbook. The re-education of staff included their responsibility to report any new allegations of abuse, the facility's policy and procedure on abuse and cell phone usage with photographing using mobile devices. All nursing staff were given the opportunity to report any knowledge of other violations during the education and no additional concerns were reported. · On 08/29/17 through 09/05/17, ADON #20 and SW #2 interviewed and assessed 33 residents residing in the building where Resident #1 resided using the Privacy/Abuse/Resident Rights assessment tool with no other reports of inappropriate photographs being taken. · On 08/30/17, ADON #20 notified Resident #1's family and Physician #100 of the Snap Chat photograph. · On 09/01/17, a special Quality Assurance (QA) session was held with Physician #100 and the facility medical director to review the incident and action plan. Physician #100 agreed with the plan and had no further recommendations. A follow-up assessment from SW #2 revealed Resident #1 had no awareness or distress related to the event. · Beginning 09/01/17 through 09/30/17 a tool titled Social Media and Abuse Questionnaire was utilized to test all nursing staff for knowledge in regards to the education that was provided. For the next three months, the DON or designee will test the knowledge of 10 random nursing staff regarding the social media, right to privacy and abuse policies. · On 09/05/17, the local Sheriff's department was notified by the Administrator Consultant of STNA #1 taking a Snap Chat photograph of a resident. · On 09/05/17, the facility's social media policy was moved to the first day of the orientation process. · On 09/08/17 per facility request, Psychologist #200 evaluated Resident #1. Psychologist #200 documented Resident #1 had no memory or awareness of having been photographed, shows no indications of distress and remained at her baseline. No further interventions were indicated for Resident #1 and her plan of care appeared appropriate to address her needs. · On 09/13/17 between 10:06 A.M. and 10:43 A.M., interviews were conducted with Licensed Practical Nurses (LPN) #2, #4, #6, #8 and STNA's #4, #5, #6, #7, #8, #9, and #10. All reported they have not seen any staff with cellular phones or photographing mobile devices on the units. They were aware of the strict prohibition of such items and to report anyone seen with them to the charge nurse. Additionally, they have not seen any resident photographs on other staff member's cellular phones nor any form of social media. They all stated they have received training by reviewing the Abuse policy and reviewing resident's rights to privacy and confidentiality. · On 09/13/17, review of Resident #2, #3, #4 and #5's medical records revealed no concerns with potential abuse or provision of privacy. Findings include: Review of Resident #1's medical record revealed an admission date of [DATE]. Medical [DIAGNOSES REDACTED]. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of three which indicated severe cognitive impairment. Further review of the MDS revealed the resident needed limited assistance with walking in and out of her room, and locomotion on the unit. The resident needed extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene. The resident was incontinent of urine and bowel. Review of psychiatric notes dated 04/04/17 revealed Resident #1 had been combative with care, does not adjust well and continues to decline cognitively. This resident was not able to be interviewed due to her severe cognitive impairment. Review of a Self-Reported Incident (SRI) dated 08/29/17 revealed the facility investigated a Snap Chat incident where Resident #1 was photographed by STNA #1. At this time, a statement was completed by STNA #2 who received the Snap Chat photograph. Additionally, a statement was completed by STNA #3 who was in the room with STNA #1 when she took the photograph. Interview on 09/13/17 at 11:17 A.M. with STNA #3 revealed she was present in Resident #1's room to provide morning care when STNA #1 took a picture of the resident. The resident was laying on her side in bed, covers partially covering her with her buttocks exposed. She revealed STNA #1 stated, Ha, Ha, this is funny and she was going to send it to STNA #2. STNA #3 revealed she did not confront STNA #1 because she did not want there to be a confrontation because they were getting ready to provide morning care to Resident #1. She sent a text message to ADON #20 when she was on a 15 minute break. STNA #3 further revealed after this incident, she was in-serviced regarding cell phone use, social media and abuse. Interview on 09/13/17 at 11:42 A.M. with ADON #20 revealed STNA #3 texted her to inform her STNA #1 had taken a photograph of a resident. ADON #20 indicated she interviewed STNA #1 who did not provide a reason as to why she took Resident #1's photograph. ADON #20 interviewed STNA #2 and verified she had received a Snap Chat from STNA #1. ADON #20 further revealed after confirmation of the Snap Chat photograph and interviews, STNA #1 was terminated. Interview on 09/13/17 at 11:57 A.M with STNA #2 revealed she was working on another unit when she received a Snap Chat photo of Resident #1. STNA #2 revealed after this incident, she was in-serviced regarding cell phone use, social media and abuse. Review of the witness statement by STNA #3, dated 08/29/17, revealed on 08/29/17 at approximately 7:30 A.M., STNA #3 and STNA #1 entered Resident #1's room and noticed Resident #1's bare bottom was exposed. STNA #1 laughed and proceeded to take a photo (Snap Chat) and stated she was going to send it to STNA #2. Review of the witness statement by ADON #20, dated 08/29/17, revealed ADON #20 was informed STNA #1 had walked into Resident #1's room and found the resident lying in bed partially covered by a blanket with her backside exposed. STNA #1 proceeded to take a picture of the resident's bottom, laughed and stated she was going to send this picture to STNA #2. ADON #20 notified the DON of the event. ADON #20 spoke with STNA #2 as soon as she arrived back to the unit. STNA #2 stated a picture was sent to her via Snap Chat but she could not retrieve it. STNA #2 wrote a statement. ADON #20 spoke to DHR #1 and explained the situation. DHR #1 called back stating STNA #1 should be terminated and she would be over to the unit to do the termination once the paperwork was received. DHR #1 arrived on the unit and ADON #20 brought STNA #1 into her office. ADON #20 told STNA #1 it was reported to her that STNA #1 had taken a picture of a resident's exposed bottom and sent it to STNA #2. ADON #20 asked STNA #1 what if that was her loved one and how that would make her feel if someone did that to them. STNA #1 provided no response. ADON #20 asked if the picture was still on her cellular phone and asked to see her camera list. Both ADON #20 and DHR #1 witnessed the picture in question was not on STNA #1's phone. STNA #1 signed her termination sheet, but provided no statement. STNA #1 threw her badge on the table and stormed out of the building where ADON #20 witnessed her leaving the parking lot. Review of the witness statement by DHR #1, dated 08/29/17, revealed DHR #1 and ADON #20 met privately with STNA #1 in the office of ADON #20. STNA #1 was told they had been made aware and had confirmed STNA #1 had sent a Snap Chat photo of a resident that was half naked (waist down). ADON #20 and DHR #1 asked STNA #1 if she intended to do this. STNA #1 confirmed she did. When asked why, STNA #1 answered she did not know. DHR #1 asked to see STNA #1's cell phone to confirm the photo had been deleted. DHR #1 searched and did not find the photo in question on STNA #1's phone. DHR #1 told STNA #1 if any photos of residents she had taken and or posted/shared with anyone were found, DHR #1 would file a police report. ADON #20 informed STNA #1 this could be something that caused her to lose her license. DHR #1 and ADON #20 asked STNA #1 if she had anything else to add or any questions. ADON #20 collected STNA #1's badge and escorted her to collect her personal belongings and out of the building. Interview on 10/02/17 at 8:59 A.M. with the DON revealed STNA #1 only worked on the unit where Resident #1 resided. The DON stated the Social Media and Abuse Questionnaire was completed by all staff members by the end of September. The DON further revealed for the next three months the facility will randomly pick 10 staff to complete the questionnaire Interview on 10/02/17 at 11:05 A.M. with STNA #2 revealed on 08/29/17 she received a Snap Chat photo of Resident #1 lying face down, her face was not visible, blankets and sheets were partially covering the resident up to her thighs. Resident #1 was not wearing a brief and her bottom was exposed. STNA #2 stated the Snap Chat photo was deleted once she viewed it. STNA #2 stated she was performing her morning resident care, she opened the Snap Chat photograph and briefly viewed the photo. After completing her morning resident care, STNA #2 went to inform ADON #20 who was already aware of the incident. STNA #2 verified in the Snap Chat photo, there was no bowel movement or urine noted in the photograph. She also verified there were no words attached to the photograph. STNA #2 verified she was educated three times on social media and abuse since this happened. Interview on 10/02/17 at 11:30 A.M. with ADON #20 revealed Resident #1 can be challenging with her care and does take her brief off. ADON #20 revealed STNA #3 sent her a text message on 08/29/17 at approximately 9:00 A.M. ADON #20 was in a meeting in another building (the main campus) which was approximately one to two blocks from the building where the incident took place. ADON #20 returned to the unit at approximately 10:00 A.M. and interviewed STNA #2 who received the Snap Chat photo. ADON #20 then notified DHR #1. ADON #20 began the investigation while waiting for DHR #1 to come assist with the termination of STNA #1. At approximately 11:30 A.M., ADON #20 and DHR #1 interviewed STNA #1 and terminated her. ADON #20 further revealed no other resident photos were on STNA #1's cell phone. After STNA #1's termination the IDT team met at 3:00 P.M. and reviewed the root cause of the problem and developed an action plan. ADON #20 indicated on 08/29/17, SW #2 assessed Resident #1 and documented there were no changes in the resident's psychological and physical baseline. ADON #20 revealed a request was made for the psychologist to evaluate Resident #1. The evaluation was conducted on 09/08/17 with no indications of distress and Resident #1 remains at her baseline emotionally and behaviorally. Interview on 10/02/17 at 11:38 A.M. with the DON revealed during facility orientation the facility reviewed the social media policy extensively. At the end of the facility orientation, the DON indicated she specifically goes over Snap Chat. The DON revealed after review of her records and attendance sheets, STNA #1 was in attendance for that discussion. The DON further indicated no policies have been revised since the incident; however, the social media policy was moved to the first day of orientation. Review of STNA #1's personnel file revealed a hire date of 07/27/17 with no evidence of negative documents contained in the file and no written disciplinary action. Review of the termination notice stated poor performance and an additional notation that STNA #1 took a picture of a resident and sent it to STNA #2 on Snap Chat. The dismissal notice was signed by ADON #20, DHR #1, and Executive Director #300. Review of a facility policy titled Social Networking with an effective date of 09/20/16 revealed Partners are expected to protect the privacy of Otterbein residents and elders. Partners may not publicly discuss residents or elders or disclose photographs, resident recordings, personal information or nonpublic information they may have access to during their course of employment regarding residents or elders. Partners are prohibited from displaying private or public information about residents, especially anything that would be deemed demeaning to residents. Review of a facility policy titled Abuse, Neglect, Exploitation and Misappropriation of Resident Property with an effective date of 12/06/16 revealed Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse and mental abuse, including abuse facilitated or enabled through the use of technology, such as through the use of photographs and recording devices to demean or humiliate a resident. This deficiency substantiates Control Number OH 342. This represents an example of continued non-compliance from the annual survey dated 08/10/17.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY Based on medical record review, review of personnel files, review of a facility self-reported incident (SRI), staff interviews, and review of the Social Networking policy and the Abuse, Neglect, Exploitation & Misappropriation of Resident Property policy, the facility failed to ensure a cognitively impaired resident was free from mental and emotional abuse by a facility staff member during provision of personal care. This resulted in Immediate Jeopardy and psychosocial harm for one resident (#1) when State tested Nurse Aide (STNA) #1 engaged in an act meant to humiliate and dehumanize the resident by taking an inappropriate picture while the resident was lying on bed with her buttocks exposed without permission and not in accordance with facility policy. This picture was then posted on a social media website, Snap Chat, resulting in outcomes which one would expect a reasonable person in a similar situation to suffer, subsequently treating the resident as an inanimate object having no emotions or feelings and causing embarrassment and shame for the resident. This affected one (#1) of five residents reviewed for abuse. The facility identified 10 Residents who were cognitively impaired and lived on the same unit as Resident #1. The census was 203. On 10/02/17 at 4:15 P.M., Vice President #1, Vice President #2, Executive Director #300, the Administrator Consultant and the Director of Nursing (DON) were notified that Immediate Jeopardy began on 08/29/17 at approximately 7:30 A.M. when STNA #1 took a picture of Resident #1 lying in bed, with blankets and sheets below her waist, with her naked buttocks exposed. STNA #1 sent the picture to STNA #2 by posting the picture on a social media website identified as Snap Chat. The picture potentially could have been viewed by others in the community on Snap Chat. The picture was witnessed being taken by STNA #3, another staff member who was present in the resident's room at the time the photo was taken. During an interview with STNA #3 she indicated STNA #1 made the comment, Ha, ha, isn't this funny when she took the picture of Resident #1. The Immediate Jeopardy was removed on 09/01/17 when staff education was provided regarding the identification of abuse, the abuse policy and procedures, maintaining the residents' rights to privacy and confidentiality during the provision of personal care and utilization of cellular phones and/or photographing mobile devices. Additionally, a Quality Assurance (QA) meeting was held with Physician #100 and the facility's medical director to review the incident and action plan and they agreed with the plan with no further recommendations. The deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) until it was corrected on 09/05/17 when the facility implemented the following: · On 08/29/17 at approximately 10:00 A.M., Assistant Director of Nursing (ADON) #20 began an investigation into STNA #1 taking a compromising photograph of Resident #1 involving nudity. · On 08/29/17 at approximately 10:00 A.M., Resident #1 was assessed by Social Worker (SW) #2 and was noted to be at her baseline, emotionally and behaviorally, with no signs of psychological harm. A request was submitted for the psychologist to complete a full evaluation of the resident on 09/01/17. · On 08/29/17 at approximately 11:30 A.M., Director of Human Resources (DHR) #1, and Executive Director #300 were notified of the incident. STNA #1 was interviewed and confirmed she took the photo without rationale as to her decision. DHR #1 verified the Snap Chat photo and no other resident photos were on the cellular device of STNA #1. STNA #1 was terminated due to poor performance and taking a photo of a resident and sending it to STNA #2 via Snap Chat. · On 08/29/17 at 3:00 P.M., the Interdisciplinary Team (IDT) met regarding the event to review the root cause and developed an action plan. · On 08/29/17 through 09/05/17, Executive Director #300, ADON #20, ADON #30, ADON #40, ADON #50, ADON #60, Development Coordinator #400, Supervisor #1, Supervisor #2, Supervisor #3 and Supervisor #4 began re-educating all nursing staff on the abuse policy, neglect, misappropriation, social media, cell phone usage when providing care and services, and maintaining resident's privacy during care per the facility's personnel information guide in the employee handbook. The re-education of staff included their responsibility to report any new allegations of abuse, the facility's policy and procedure on abuse and cell phone usage with photographing using mobile devices. All nursing staff were given the opportunity to report any knowledge of other violations during the education and no additional concerns were reported. · On 08/29/17 through 09/05/17, ADON #20 and SW #2 interviewed and assessed 33 residents residing in the building where Resident #1 resided using the Privacy/Abuse/Resident Rights assessment tool with no other reports of inappropriate photographs being taken. · On 08/30/17, ADON #20 notified Resident #1's family and Physician #100 of the Snap Chat photograph. · On 09/01/17, a special Quality Assurance (QA) session was held with Physician #100 and the facility medical director to review the incident and action plan. Physician #100 agreed with the plan and had no further recommendations. A follow-up assessment from SW #2 revealed Resident #1 had no awareness or distress related to the event. · Beginning 09/01/17 through 09/30/17 a tool titled Social Media and Abuse Questionnaire was utilized to test all nursing staff for knowledge in regards to the education that was provided. For the next three months, the DON or designee will test the knowledge of 10 random nursing staff regarding the social media, right to privacy and abuse policies. · On 09/05/17, the local Sheriff's department was notified by the Administrator Consultant of STNA #1 taking a Snap Chat photograph of a resident. · On 09/05/17, the facility's social media policy was moved to the first day of the orientation process. · On 09/08/17 per facility request, Psychologist #200 evaluated Resident #1. Psychologist #200 documented Resident #1 had no memory or awareness of having been photographed, shows no indications of distress and remained at her baseline. No further interventions were indicated for Resident #1 and her plan of care appeared appropriate to address her needs. · On 09/13/17 between 10:06 A.M. and 10:43 A.M., interviews were conducted with Licensed Practical Nurses (LPN) #2, #4, #6, #8 and STNA's #4, #5, #6, #7, #8, #9, and #10. All reported they have not seen any staff with cellular phones or photographing mobile devices on the units. They were aware of the strict prohibition of such items and to report anyone seen with them to the charge nurse. Additionally, they have not seen any resident photographs on other staff member's cellular phones nor any form of social media. They all stated they have received training by reviewing the Abuse policy and reviewing resident's rights to privacy and confidentiality. · On 09/13/17, review of Resident #2, #3, #4 and #5's medical records revealed no concerns with potential abuse or provision of privacy. Findings include: Review of Resident #1's medical record revealed an admission date of [DATE]. Medical [DIAGNOSES REDACTED]. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of three which indicated severe cognitive impairment. Further review of the MDS revealed the resident needed limited assistance with walking in and out of her room, and locomotion on the unit. The resident needed extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene. The resident was incontinent of urine and bowel. Review of psychiatric notes dated 04/04/17 revealed Resident #1 had been combative with care, does not adjust well and continues to decline cognitively. This resident was not able to be interviewed due to her severe cognitive impairment. Review of a Self-Reported Incident (SRI) dated 08/29/17 revealed the facility investigated a Snap Chat incident where Resident #1 was photographed by STNA #1. At this time, a statement was completed by STNA #2 who received the Snap Chat photograph. Additionally, a statement was completed by STNA #3 who was in the room with STNA #1 when she took the photograph. Interview on 09/13/17 at 11:17 A.M. with STNA #3 revealed she was present in Resident #1's room to provide morning care when STNA #1 took a picture of the resident. The resident was laying on her side in bed, covers partially covering her with her buttocks exposed. She revealed STNA #1 stated, Ha, Ha, this is funny and she was going to send it to STNA #2. STNA #3 revealed she did not confront STNA #1 because she did not want there to be a confrontation because they were getting ready to provide morning care to Resident #1. She sent a text message to ADON #20 when she was on a 15 minute break. STNA #3 further revealed after this incident, she was in-serviced regarding cell phone use, social media and abuse. Interview on 09/13/17 at 11:42 A.M. with ADON #20 revealed STNA #3 texted her to inform her STNA #1 had taken a photograph of a resident. ADON #20 indicated she interviewed STNA #1 who did not provide a reason as to why she took Resident #1's photograph. ADON #20 interviewed STNA #2 and verified she had received a Snap Chat from STNA #1. ADON #20 further revealed after confirmation of the Snap Chat photograph and interviews, STNA #1 was terminated. Interview on 09/13/17 at 11:57 A.M with STNA #2 revealed she was working on another unit when she received a Snap Chat photo of Resident #1. STNA #2 revealed after this incident, she was in-serviced regarding cell phone use, social media and abuse. Review of the witness statement by STNA #3, dated 08/29/17, revealed on 08/29/17 at approximately 7:30 A.M., STNA #3 and STNA #1 entered Resident #1's room and noticed Resident #1's bare bottom was exposed. STNA #1 laughed and proceeded to take a photo (Snap Chat) and stated she was going to send it to STNA #2. Review of the witness statement by ADON #20, dated 08/29/17, revealed ADON #20 was informed STNA #1 had walked into Resident #1's room and found the resident lying in bed partially covered by a blanket with her backside exposed. STNA #1 proceeded to take a picture of the resident's bottom, laughed and stated she was going to send this picture to STNA #2. ADON #20 notified the DON of the event. ADON #20 spoke with STNA #2 as soon as she arrived back to the unit. STNA #2 stated a picture was sent to her via Snap Chat but she could not retrieve it. STNA #2 wrote a statement. ADON #20 spoke to DHR #1 and explained the situation. DHR #1 called back stating STNA #1 should be terminated and she would be over to the unit to do the termination once the paperwork was received. DHR #1 arrived on the unit and ADON #20 brought STNA #1 into her office. ADON #20 told STNA #1 it was reported to her that STNA #1 had taken a picture of a resident's exposed bottom and sent it to STNA #2. ADON #20 asked STNA #1 what if that was her loved one and how that would make her feel if someone did that to them. STNA #1 provided no response. ADON #20 asked if the picture was still on her cellular phone and asked to see her camera list. Both ADON #20 and DHR #1 witnessed the picture in question was not on STNA #1's phone. STNA #1 signed her termination sheet, but provided no statement. STNA #1 threw her badge on the table and stormed out of the building where ADON #20 witnessed her leaving the parking lot. Review of the witness statement by DHR #1, dated 08/29/17, revealed DHR #1 and ADON #20 met privately with STNA #1 in the office of ADON #20. STNA #1 was told they had been made aware and had confirmed STNA #1 had sent a Snap Chat photo of a resident that was half naked (waist down). ADON #20 and DHR #1 asked STNA #1 if she intended to do this. STNA #1 confirmed she did. When asked why, STNA #1 answered she did not know. DHR #1 asked to see STNA #1's cell phone to confirm the photo had been deleted. DHR #1 searched and did not find the photo in question on STNA #1's phone. DHR #1 told STNA #1 if any photos of residents she had taken and or posted/shared with anyone were found, DHR #1 would file a police report. ADON #20 informed STNA #1 this could be something that caused her to lose her license. DHR #1 and ADON #20 asked STNA #1 if she had anything else to add or any questions. ADON #20 collected STNA #1's badge and escorted her to collect her personal belongings and out of the building. Interview on 10/02/17 at 8:59 A.M. with the DON revealed STNA #1 only worked on the unit where Resident #1 resided. The DON stated the Social Media and Abuse Questionnaire was completed by all staff members by the end of September. The DON further revealed for the next three months the facility will randomly pick 10 staff to complete the questionnaire Interview on 10/02/17 at 11:05 A.M. with STNA #2 revealed on 08/29/17 she received a Snap Chat photo of Resident #1 lying face down, her face was not visible, blankets and sheets were partially covering the resident up to her thighs. Resident #1 was not wearing a brief and her bottom was exposed. STNA #2 stated the Snap Chat photo was deleted once she viewed it. STNA #2 stated she was performing her morning resident care, she opened the Snap Chat photograph and briefly viewed the photo. After completing her morning resident care, STNA #2 went to inform ADON #20 who was already aware of the incident. STNA #2 verified in the Snap Chat photo, there was no bowel movement or urine noted in the photograph. She also verified there were no words attached to the photograph. STNA #2 verified she was educated three times on social media and abuse since this happened. Interview on 10/02/17 at 11:30 A.M. with ADON #20 revealed Resident #1 can be challenging with her care and does take her brief off. ADON #20 revealed STNA #3 sent her a text message on 08/29/17 at approximately 9:00 A.M. ADON #20 was in a meeting in another building (the main campus) which was approximately one to two blocks from the building where the incident took place. ADON #20 returned to the unit at approximately 10:00 A.M. and interviewed STNA #2 who received the Snap Chat photo. ADON #20 then notified DHR #1. ADON #20 began the investigation while waiting for DHR #1 to come assist with the termination of STNA #1. At approximately 11:30 A.M., ADON #20 and DHR #1 interviewed STNA #1 and terminated her. ADON #20 further revealed no other resident photos were on STNA #1's cell phone. After STNA #1's termination the IDT team met at 3:00 P.M. and reviewed the root cause of the problem and developed an action plan. ADON #20 indicated on 08/29/17, SW #2 assessed Resident #1 and documented there were no changes in the resident's psychological and physical baseline. ADON #20 revealed a request was made for the psychologist to evaluate Resident #1. The evaluation was conducted on 09/08/17 with no indications of distress and Resident #1 remains at her baseline emotionally and behaviorally. Interview on 10/02/17 at 11:38 A.M. with the DON revealed during facility orientation the facility reviewed the social media policy extensively. At the end of the facility orientation, the DON indicated she specifically goes over Snap Chat. The DON revealed after review of her records and attendance sheets, STNA #1 was in attendance for that discussion. The DON further indicated no policies have been revised since the incident; however, the social media policy was moved to the first day of orientation. Review of STNA #1's personnel file revealed a hire date of 07/27/17 with no evidence of negative documents contained in the file and no written disciplinary action. Review of the termination notice stated poor performance and an additional notation that STNA #1 took a picture of a resident and sent it to STNA #2 on Snap Chat. The dismissal notice was signed by ADON #20, DHR #1, and Executive Director #300. Review of a facility policy titled Social Networking with an effective date of 09/20/16 revealed Partners are expected to protect the privacy of Otterbein residents and elders. Partners may not publicly discuss residents or elders or disclose photographs, resident recordings, personal information or nonpublic information they may have access to during their course of employment regarding residents or elders. Partners are prohibited from displaying private or public information about residents, especially anything that would be deemed demeaning to residents. Review of a facility policy titled Abuse, Neglect, Exploitation and Misappropriation of Resident Property with an effective date of 12/06/16 revealed Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse and mental abuse, including abuse facilitated or enabled through the use of technology, such as through the use of photographs and recording devices to demean or humiliate a resident. This deficiency substantiates Control Number OH 342. This represents an example of continued non-compliance from the annual survey dated 08/10/17

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY Based on medical record review, review of personnel files, review of a facility self-reported incident (SRI), staff interviews, and review of the Social Networking policy and the Abuse, Neglect, Exploitation & Misappropriation of Resident Property policy, the facility staff failed to implement the facility policy to ensure a cognitively impaired resident was free from mental and emotional abuse by a facility staff member during provision of personal care. This resulted in Immediate Jeopardy and psychosocial harm for one resident (#1) when State tested Nurse Aide (STNA) #1 engaged in an act meant to humiliate and dehumanize the resident by taking an inappropriate picture while the resident was lying on bed with her buttocks exposed without permission and not in accordance with facility policy. This picture was then posted on a social media website, Snap Chat, resulting in outcomes which one would expect a reasonable person in a similar situation to suffer, subsequently treating the resident as an inanimate object having no emotions or feelings and causing embarrassment and shame for the resident. This affected one (#1) of five residents reviewed for abuse. The facility identified 10 Residents who were cognitively impaired and lived on the same unit as Resident #1. The census was 203. On 10/02/17 at 4:15 P.M., Vice President #1, Vice President #2, Executive Director #300, the Administrator Consultant and the Director of Nursing (DON) were notified that Immediate Jeopardy began on 08/29/17 at approximately 7:30 A.M. when STNA #1 took a picture of Resident #1 lying in bed, with blankets and sheets below her waist, with her naked buttocks exposed. STNA #1 sent the picture to STNA #2 by posting the picture on a social media website identified as Snap Chat. The picture potentially could have been viewed by others in the community on Snap Chat. The picture was witnessed being taken by STNA #3, another staff member who was present in the resident's room at the time the photo was taken. During an interview with STNA #3 she indicated STNA #1 made the comment, Ha, ha, isn't this funny when she took the picture of Resident #1. The Immediate Jeopardy was removed on 09/01/17 when staff education was provided regarding the identification of abuse, the abuse policy and procedures, maintaining the residents' rights to privacy and confidentiality during the provision of personal care and utilization of cellular phones and/or photographing mobile devices. Additionally, a Quality Assurance (QA) meeting was held with Physician #100 and the facility's medical director to review the incident and action plan and they agreed with the plan with no further recommendations. The deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) until it was corrected on 09/05/17 when the facility implemented the following: · On 08/29/17 at approximately 10:00 A.M., Assistant Director of Nursing (ADON) #20 began an investigation into STNA #1 taking a compromising photograph of Resident #1 involving nudity. · On 08/29/17 at approximately 10:00 A.M., Resident #1 was assessed by Social Worker (SW) #2 and was noted to be at her baseline, emotionally and behaviorally, with no signs of psychological harm. A request was submitted for the psychologist to complete a full evaluation of the resident on 09/01/17. · On 08/29/17 at approximately 11:30 A.M., Director of Human Resources (DHR) #1, and Executive Director #300 were notified of the incident. STNA #1 was interviewed and confirmed she took the photo without rationale as to her decision. DHR #1 verified the Snap Chat photo and no other resident photos were on the cellular device of STNA #1. STNA #1 was terminated due to poor performance and taking a photo of a resident and sending it to STNA #2 via Snap Chat. · On 08/29/17 at 3:00 P.M., the Interdisciplinary Team (IDT) met regarding the event to review the root cause and developed an action plan. · On 08/29/17 through 09/05/17, Executive Director #300, ADON #20, ADON #30, ADON #40, ADON #50, ADON #60, Development Coordinator #400, Supervisor #1, Supervisor #2, Supervisor #3 and Supervisor #4 began re-educating all nursing staff on the abuse policy, neglect, misappropriation, social media, cell phone usage when providing care and services, and maintaining resident's privacy during care per the facility's personnel information guide in the employee handbook. The re-education of staff included their responsibility to report any new allegations of abuse, the facility's policy and procedure on abuse and cell phone usage with photographing using mobile devices. All nursing staff were given the opportunity to report any knowledge of other violations during the education and no additional concerns were reported. · On 08/29/17 through 09/05/17, ADON #20 and SW #2 interviewed and assessed 33 residents residing in the building where Resident #1 resided using the Privacy/Abuse/Resident Rights assessment tool with no other reports of inappropriate photographs being taken. · On 08/30/17, ADON #20 notified Resident #1's family and Physician #100 of the Snap Chat photograph. · On 09/01/17, a special Quality Assurance (QA) session was held with Physician #100 and the facility medical director to review the incident and action plan. Physician #100 agreed with the plan and had no further recommendations. A follow-up assessment from SW #2 revealed Resident #1 had no awareness or distress related to the event. · Beginning 09/01/17 through 09/30/17 a tool titled Social Media and Abuse Questionnaire was utilized to test all nursing staff for knowledge in regards to the education that was provided. For the next three months, the DON or designee will test the knowledge of 10 random nursing staff regarding the social media, right to privacy and abuse policies. · On 09/05/17, the local Sheriff's department was notified by the Administrator Consultant of STNA #1 taking a Snap Chat photograph of a resident. · On 09/05/17, the facility's social media policy was moved to the first day of the orientation process. · On 09/08/17 per facility request, Psychologist #200 evaluated Resident #1. Psychologist #200 documented Resident #1 had no memory or awareness of having been photographed, shows no indications of distress and remained at her baseline. No further interventions were indicated for Resident #1 and her plan of care appeared appropriate to address her needs. · On 09/13/17 between 10:06 A.M. and 10:43 A.M., interviews were conducted with Licensed Practical Nurses (LPN) #2, #4, #6, #8 and STNA's #4, #5, #6, #7, #8, #9, and #10. All reported they have not seen any staff with cellular phones or photographing mobile devices on the units. They were aware of the strict prohibition of such items and to report anyone seen with them to the charge nurse. Additionally, they have not seen any resident photographs on other staff member's cellular phones nor any form of social media. They all stated they have received training by reviewing the Abuse policy and reviewing resident's rights to privacy and confidentiality. · On 09/13/17, review of Resident #2, #3, #4 and #5's medical records revealed no concerns with potential abuse or provision of privacy. Findings include: Review of Resident #1's medical record revealed an admission date of [DATE]. Medical [DIAGNOSES REDACTED]. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of three which indicated severe cognitive impairment. Further review of the MDS revealed the resident needed limited assistance with walking in and out of her room, and locomotion on the unit. The resident needed extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene. The resident was incontinent of urine and bowel. Review of psychiatric notes dated 04/04/17 revealed Resident #1 had been combative with care, does not adjust well and continues to decline cognitively. This resident was not able to be interviewed due to her severe cognitive impairment. Review of a Self-Reported Incident (SRI) dated 08/29/17 revealed the facility investigated a Snap Chat incident where Resident #1 was photographed by STNA #1. At this time, a statement was completed by STNA #2 who received the Snap Chat photograph. Additionally, a statement was completed by STNA #3 who was in the room with STNA #1 when she took the photograph. Interview on 09/13/17 at 11:17 A.M. with STNA #3 revealed she was present in Resident #1's room to provide morning care when STNA #1 took a picture of the resident. The resident was laying on her side in bed, covers partially covering her with her buttocks exposed. She revealed STNA #1 stated, Ha, Ha, this is funny and she was going to send it to STNA #2. STNA #3 revealed she did not confront STNA #1 because she did not want there to be a confrontation because they were getting ready to provide morning care to Resident #1. She sent a text message to ADON #20 when she was on a 15 minute break. STNA #3 further revealed after this incident, she was in-serviced regarding cell phone use, social media and abuse. Interview on 09/13/17 at 11:42 A.M. with ADON #20 revealed STNA #3 texted her to inform her STNA #1 had taken a photograph of a resident. ADON #20 indicated she interviewed STNA #1 who did not provide a reason as to why she took Resident #1's photograph. ADON #20 interviewed STNA #2 and verified she had received a Snap Chat from STNA #1. ADON #20 further revealed after confirmation of the Snap Chat photograph and interviews, STNA #1 was terminated. Interview on 09/13/17 at 11:57 A.M with STNA #2 revealed she was working on another unit when she received a Snap Chat photo of Resident #1. STNA #2 revealed after this incident, she was in-serviced regarding cell phone use, social media and abuse. Review of the witness statement by STNA #3, dated 08/29/17, revealed on 08/29/17 at approximately 7:30 A.M., STNA #3 and STNA #1 entered Resident #1's room and noticed Resident #1's bare bottom was exposed. STNA #1 laughed and proceeded to take a photo (Snap Chat) and stated she was going to send it to STNA #2. Review of the witness statement by ADON #20, dated 08/29/17, revealed ADON #20 was informed STNA #1 had walked into Resident #1's room and found the resident lying in bed partially covered by a blanket with her backside exposed. STNA #1 proceeded to take a picture of the resident's bottom, laughed and stated she was going to send this picture to STNA #2. ADON #20 notified the DON of the event. ADON #20 spoke with STNA #2 as soon as she arrived back to the unit. STNA #2 stated a picture was sent to her via Snap Chat but she could not retrieve it. STNA #2 wrote a statement. ADON #20 spoke to DHR #1 and explained the situation. DHR #1 called back stating STNA #1 should be terminated and she would be over to the unit to do the termination once the paperwork was received. DHR #1 arrived on the unit and ADON #20 brought STNA #1 into her office. ADON #20 told STNA #1 it was reported to her that STNA #1 had taken a picture of a resident's exposed bottom and sent it to STNA #2. ADON #20 asked STNA #1 what if that was her loved one and how that would make her feel if someone did that to them. STNA #1 provided no response. ADON #20 asked if the picture was still on her cellular phone and asked to see her camera list. Both ADON #20 and DHR #1 witnessed the picture in question was not on STNA #1's phone. STNA #1 signed her termination sheet, but provided no statement. STNA #1 threw her badge on the table and stormed out of the building where ADON #20 witnessed her leaving the parking lot. Review of the witness statement by DHR #1, dated 08/29/17, revealed DHR #1 and ADON #20 met privately with STNA #1 in the office of ADON #20. STNA #1 was told they had been made aware and had confirmed STNA #1 had sent a Snap Chat photo of a resident that was half naked (waist down). ADON #20 and DHR #1 asked STNA #1 if she intended to do this. STNA #1 confirmed she did. When asked why, STNA #1 answered she did not know. DHR #1 asked to see STNA #1's cell phone to confirm the photo had been deleted. DHR #1 searched and did not find the photo in question on STNA #1's phone. DHR #1 told STNA #1 if any photos of residents she had taken and or posted/shared with anyone were found, DHR #1 would file a police report. ADON #20 informed STNA #1 this could be something that caused her to lose her license. DHR #1 and ADON #20 asked STNA #1 if she had anything else to add or any questions. ADON #20 collected STNA #1's badge and escorted her to collect her personal belongings and out of the building. Interview on 10/02/17 at 8:59 A.M. with the DON revealed STNA #1 only worked on the unit where Resident #1 resided. The DON stated the Social Media and Abuse Questionnaire was completed by all staff members by the end of September. The DON further revealed for the next three months the facility will randomly pick 10 staff to complete the questionnaire Interview on 10/02/17 at 11:05 A.M. with STNA #2 revealed on 08/29/17 she received a Snap Chat photo of Resident #1 lying face down, her face was not visible, blankets and sheets were partially covering the resident up to her thighs. Resident #1 was not wearing a brief and her bottom was exposed. STNA #2 stated the Snap Chat photo was deleted once she viewed it. STNA #2 stated she was performing her morning resident care, she opened the Snap Chat photograph and briefly viewed the photo. After completing her morning resident care, STNA #2 went to inform ADON #20 who was already aware of the incident. STNA #2 verified in the Snap Chat photo, there was no bowel movement or urine noted in the photograph. She also verified there were no words attached to the photograph. STNA #2 verified she was educated three times on social media and abuse since this happened. Interview on 10/02/17 at 11:30 A.M. with ADON #20 revealed Resident #1 can be challenging with her care and does take her brief off. ADON #20 revealed STNA #3 sent her a text message on 08/29/17 at approximately 9:00 A.M. ADON #20 was in a meeting in another building (the main campus) which was approximately one to two blocks from the building where the incident took place. ADON #20 returned to the unit at approximately 10:00 A.M. and interviewed STNA #2 who received the Snap Chat photo. ADON #20 then notified DHR #1. ADON #20 began the investigation while waiting for DHR #1 to come assist with the termination of STNA #1. At approximately 11:30 A.M., ADON #20 and DHR #1 interviewed STNA #1 and terminated her. ADON #20 further revealed no other resident photos were on STNA #1's cell phone. After STNA #1's termination the IDT team met at 3:00 P.M. and reviewed the root cause of the problem and developed an action plan. ADON #20 indicated on 08/29/17, SW #2 assessed Resident #1 and documented there were no changes in the resident's psychological and physical baseline. ADON #20 revealed a request was made for the psychologist to evaluate Resident #1. The evaluation was conducted on 09/08/17 with no indications of distress and Resident #1 remains at her baseline emotionally and behaviorally. Interview on 10/02/17 at 11:38 A.M. with the DON revealed during facility orientation the facility reviewed the social media policy extensively. At the end of the facility orientation, the DON indicated she specifically goes over Snap Chat. The DON revealed after review of her records and attendance sheets, STNA #1 was in attendance for that discussion. The DON further indicated no policies have been revised since the incident; however, the social media policy was moved to the first day of orientation. Review of STNA #1's personnel file revealed a hire date of 07/27/17 with no evidence of negative documents contained in the file and no written disciplinary action. Review of the termination notice stated poor performance and an additional notation that STNA #1 took a picture of a resident and sent it to STNA #2 on Snap Chat. The dismissal notice was signed by ADON #20, DHR #1, and Executive Director #300. Review of a facility policy titled Social Networking with an effective date of 09/20/16 revealed Partners are expected to protect the privacy of Otterbein residents and elders. Partners may not publicly discuss residents or elders or disclose photographs, resident recordings, personal information or nonpublic information they may have access to during their course of employment regarding residents or elders. Partners are prohibited from displaying private or public information about residents, especially anything that would be deemed demeaning to residents. Review of a facility policy titled Abuse, Neglect, Exploitation and Misappropriation of Resident Property with an effective date of 12/06/16 revealed Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse and mental abuse, including abuse facilitated or enabled through the use of technology, such as through the use of photographs and recording devices to demean or humiliate a resident. This deficiency substantiates Control Number OH 342. This represents an example of continued non-compliance from the annual survey dated 08/10/17

Based on medical record review, observation, resident and staff interview, standing order review and review of documentation from National Pressure Ulcer advisory Panel (NPUAP), the facility failed to implement interventions to prevent avoidable in-house acquired pressure ulcers and failed to provide treatments to promote healing for an unavoidable pressure ulcer. This affected two (#73 and #181) of three residents sampled for pressure ulcers. This resulted in harm for Resident #73 who developed an avoidable pressure ulcer that progressed to an unstageable (blackened in color with necrotic tissue) and developed additional pressure ulcers. The facility identified ten residents with pressure ulcers. Findings include: Review of Resident #73's medical record revealed the resident was admitted on [DATE]. [DIAGNOSES REDACTED]. The resident was assessed with [REDACTED]. Review of the Braden Scale to predict skin risk dated 01/13/15 revealed Resident #73 scored a 14, indicating the resident was at moderate risk for pressure ulcers. The Braden Scale documented Resident #73's risk factors including moisture issues, very limited mobility, and the resident had potential friction/shearing issues. Review of Resident #73's Skin Condition Report dated 01/23/15 documented Registered Nurse (RN) #4 noted a dime-sized area to her coccyx that was bleeding when peri-care was provided. No interventions were noted. Review of Resident #73's Skin Condition Report dated 01/26/15 documented Licensed Practical Nurse (LPN) #12 noted an open area to the coccyx with scant drainage. LPN #12 documented likelihood of healing poor due to overall condition and listed risk factors of end stage disease, decreased mobility, cognition, poor nutrition and inactivity. No interventions were noted. Review of Resident #73's Skin Condition Report dated 01/30/15 documented RN #13 noted a reddened open area measuring 1.0 centimeters (cm) by 7.4 cm by 0.1 cm with deterioration noted. RN #13 documented recent changes were made to the treatment order for this area. Interventions noted pressure reducing or relieving with turning and repositioning were implemented. RN #13 also documented the likelihood of healing due to overall condition as fair with risk factors of decreased mobility and inactivity. RN #13 documented a new reddened abrasion to the rectal area measuring 0.8 cm by 1.8 cm by 0.1 cm. RN #13 documented an additional reddened area to the left lower buttocks measuring 1.5 cm by 2.7 cm by 0.1 cm. Review of the January 2015 Treatment Report revealed no pressure ulcer treatments were documented from 01/23/15 through 01/30/15. Review of the Wound Care Notes dated 02/03/15 by RN #5 (Wound Care Nurse) documented the onset for the coccyx area was 01/28/15. RN #5 documented the wound was unstageable with slough and eschar measuring 6.7 cm by 1.8 cm by 0.4 cm. RN #5 documented provided was notified via phone on 01/28/15 of new consult and on 01/30/15 of wound status. Orders given on that date for low air mattress, pressure relieving cushion in wheelchair, sitting restrictions, alginate/foam to coccyx and foam to buttocks. RN #5 documented Resident #73 complained of minimal discomfort. RN #5 documented the wound to the left buttocks as a Stage III pressure ulcer measuring 1.1 cm by 2.5 cm by 0.1 cm and the area to the right buttocks as a Stage II pressure ulcer measuring 0.8 cm by 1.8 cm by 0.1 cm. Treatment orders for the coccyx was Santyl, alginate foam daily and for the buttocks hydrogel gel with foam change daily and as needed. Review of the Dietary assessment dated on 02/09/15 documented Resident #73 had an unstageable pressure area to her coccyx along with a Stage III and Stage II to her right and left buttocks. Recommendation for Prostat 30 milliliters by mouth three times daily for nutritional support and wound healing was made. Further noted in the assessment documented on 12/02/14 the resident had an abnormal [MEDICATION NAME] of 3.1. Review of Resident #73's Skin Condition Report dated 02/19/15 documented the pressure ulcer the right buttocks was healed, the pressure ulcer to the left buttocks measured 0.5 cm by 1.6 cm by 0.1 cm and the pressure ulcer to the coccyx measured 3.7 cm by 1.5 cm by 0.3 cm. On 02/24/15 at 2:30 P.M., RN #5 was observed performing wound treatment to Resident #73's coccyx and left buttock. RN #5 noted the pressure ulcer to the coccyx was pink and moist measuring 4.1 cm by 1.6 cm by 0.2 cm. The pressure ulcer to the left buttock measured 0.3 cm by 0.5 cm by 0.1 cm. Resident #73 was informed the pressure ulcers were improving. On 02/25/15 at 8:00 A.M., RN #4 was interviewed and stated she noted the area on Resident #73's coccyx on 01/23/15 in the morning at the end of her shift. She stated she informed the on-coming nurse (RN #3) about the area. She stated the area was about the size of a dime and she did not observe any other areas. RN #4 stated she cleansed the area with normal saline and applied A and D ointment to the area. She stated wound treatments are routinely completed on second shift and she was not aware of any other treatment for [REDACTED]. RN #4 stated she took measurements on 01/30/15 the area was noted with slough. On 02/25/15 at 1:35 P.M., RN #3 was interviewed and she stated she received report on the morning of 01/23/15 from RN #4. She further stated RN #4 reported Resident #73 had developed a new pressure ulcer to her coccyx. RN #3 stated she applied a barrier cream to the area but did not cover it with a dressing as the resident was frequently incontinent and she did not think a dressing would help. On 02/25/15 at 1:15 P.M., Resident #73 was interviewed and stated she was aware she had pressure areas to her "bottom" and they did hurt. She stated she went about a week before the areas were treated and one of the areas was completely healed. At the time of the interview Resident #73 was sitting in a chair with a pressure relief cushion. According to the NPUAP, an unstageable pressure ulcer is a full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown dead tissue) and /or eschar (tan, brown or black dead tissue) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Stage III or IV). Review of the Attending Physician Standing Order Protocols, implemented on 07/25/2014 revealed for Stage 1, Stage 2, and Stage 3 Pressure Areas, upon their discovery, the following treatment was to be provided: a) Clean wound with normal saline, b) Apply [MEDICATION NAME] dressing to area, c) Change every 3-7 days and as needed, d) If wound is shallow or a cavity and has exudate, apply alginate sheet or rope, and cover with [MEDICATION NAME] dressing every 3-5 days and as needed e) If wound is shallow and dry apply hydrogel to wound and cover with [MEDICATION NAME] dressing every 3-5 days and as needed. 2. Review of Resident #181's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #181 was severely cognitively impaired, with severe memory impairment, poor appetite, trouble concentrating, and wandering. Resident #181 required extensive assistance for bed mobility, transfers, dressing, toilet use, personal hygiene, and was always incontinent of bladder and bowel. The resident was also noted as resistant to care. Review of the laboratory values, dated 06/05/13 revealed an abnormally low [MEDICATION NAME] level of 2.6, which indicated malnutrition. Records indicated Resident #181 refused all attempts of further blood testing during 2014 and 2015. Record review noted on 08/06/14 Resident #181 weighed 92 pounds and on 02/04/15 weighed 82 pounds and had a body mass index (BMI) of 15.1. This weight loss was documented as a significant weight loss of 10.8 percent. Review of the electronic charting dated 01/08/15 revealed Resident #181 developed a stage two pressure ulcer on her coccyx measuring 5 cm by 2.4 cm by 0.1 cm. Review of the Progress Notes, dated 01/08/15 revealed a treatment order to cleanse the area with normal saline, pat dry, apply calcium alginate and [MEDICATION NAME] (foam dressing) and change every 3 days. Review of the Electronic Medication Administration Report (EMAR), dated 01/09/15 revealed the treatment order was changed to cleanse the pressure ulcer with normal saline, pat dry, apply calcium alginate and [MEDICATION NAME] (foam dressing), and change every Monday, Wednesday, and Friday during the evening shift. Review of the EMAR for January 2015 revealed the treatment was performed as ordered, as indicated by staff initials on the MAR, excluding 01/16/15. Review of the progress noted dated 01/27/15, documented Wound Certified/Certified Nurse Practitioner (CNP#5) noted the coccyx pressure ulcer was a stage III with 50 to 75 percent necrotic slough tissue measuring 2.3 cm by 1.2 cm by 0.2 cm. On 01/28/15, the treatment was changed to cleanse wound with normal saline, apply Santyl ointment (a [MEDICATION NAME] agent), apply calcium alginate, and cover with foam dressing daily, and as needed. Review of the assessment dated on 02/03/15 documented CNP#5 noted the pressure ulcer remained a Stage III measuring 1.7 cm by 0.9 cm by 0.1 cm with 50 to 75 percent necrotic slough. Review of assessment dated [DATE] documented CNP #5 documented the pressure ulcer remained a Stage III measuring 0.4 cm by 0.4 cm by 0.1 cm with no visible necrotic tissue. CNP #5 described the wound was "smaller, improving". On 02/24/15 at 10:52 A.M., CNP #5 and LPN #91 were observed performing the dressing change to Resident #181's coccyx. During the observation it was noted the old dressing was dated 02/19/15. On 02/24/2015 at 11:03:48 A.M., CNP #5 corroborated the coccyx dressing was last changed 02/19/15. CNP #5 indicated the pressure ulcer was larger measuring 3.4 cm by 1.4 cm by 0.1 cm. Review of the Electronic Treatment Administration Record (ETAR), dated 02/16/15 through 02/24/15 revealed "NR" on 02/16/15, 02/17/15, 02/18/15, 02/20/15, 02/21/15, 02/22/15, 02/23/15, and 02/24/15. On 02/25/15 at 2:31 P.M., RN Supervisor #92 revealed "NR" indicated a medication or treatment was not administered, therefore the treatment was not performed on those days. During interview on 02/25/15 at 3:45 P.M., the Director of Nursing acknowledged the treatment for [REDACTED].