Every finding on record at Otterbein St Marys Retirement Community

Based on staff interview and record review, the facility failed to follow medication parameters during medication administration which resulted in significant medication errors. This affected one Resident (#16) of three reviewed for medication administration. The facility census was 49.Findings include:Review of the medical record for Resident #16 revealed an admission date of 06/03/26. The resident had diagnoses which included Chronic Obstructive Pulmonary Disease (COPD), acute on chronic respiratory failure, Congestive Heart Failure (CHF) and localized edema. The resident remained in the facility.The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #16 had intact cognition and the resident required supervision with transfers, bed mobility, set up with eating, and moderate assistance with toileting hygiene.Review of the care plan revealed a focus for diuretic therapy related to hypertension with interventions including to monitor for the adverse effects of diuretic therapy of dizziness, postural hypotension, and fatigue.Review of physician orders revealed an order for Metoprolol Succinate Extended-Release tablet (blood pressure medication) 25 milligram (mg), give half a tablet one time a day and hold for a systolic Blood Pressure (SBP) of less than 110 millimeters of mercury (mmHg) and a Diastolic Blood Pressure (DBP) of less than 60 mmHg with an order date of 06/10/26. A second order was for Torsemide (diuretic) 20 mg tablet every other day with parameters to hold for a SBP of less than 110 mmHg and a DBP of less than 60 mmHg with an order date of 06/10/26.Review of the daily blood pressures revealed blood pressures were outside of parameters on 06/13/26 the blood pressure was 105 (systolic) mmHg over (/) 58 (Diastolic) mmHg, on 06/06/25 blood pressure was 92/46 mmHg, on 06/16/26 blood pressure was 92/46 mmHg, on 06/17/26 blood pressure was 104/50 mmHg, on 06/18/26 blood pressure was 94/50 mmHg, on 06/19/26 blood pressure was 100/52 mmHg, 06/21/26 blood pressure was 101/70 mmHg, and on 06/23/26 blood pressure was 98/50 mmHg.Record review of the June Medication Administration Record revealed a half of a 25 mg tablet of Metoprolol Succinate was documented as administered on 06/13/26, 06/06/25, 06/16/26, 06/17/26,18/26, 06/19/26, 06/21/26 and on 06/23/26.Record review of the June Medication Administration Record revealed 20 mg tablet of Torsemide was documented as given on 06/13/26, 06/17/26, 06/19/26 and 06/21/26.Interview on 06/24/26 at 1:52 P.M. with the Director of Nursing (DON) verified Metoprolol Succinate and Torsemide blood pressure medications were administered outside of parameters. Review of the facility policy, Medication Administration Procedure, dated 11/21/17 documented medications are administered in accordance with the written orders of the attending physician.

Based on record review, observation, staff interview, and policy review, the facility failed to assess a resident timely after a fall. The affected one (Resident #34) out of five residents reviewed for accidents. The facility census was 49.Review of Resident #34's medical record revealed an admission date of 10/03/25 with diagnoses of Parkinson's disease with dyskinesia, with fluctuations, primary osteoarthritis, psychotic disorder with delusions, dementia with agitation, and major depressive disorder.Review of the Quarterly Minimum Data Set (MDS), dated [DATE] revealed Resident #34 had moderate cognitive impairment, required partial assistance with ambulation, and resident did not have any falls prior to assessment.Review of the Care Plan, dated 10/04/25 revealed Resident #34 was at risk for falls related to decreased mobility, deep brain stimulator, Parkinson's disease, and resident will at times placed self safely on the floor to find my belongings. Interventions included of mat placed on floor beside bed, keep Dycem placed to seat of recliner to prevent sliding, keep remote for his lift chair in its holder to reduce his risk for playing with the remote, anticipate and meet resident needs, educate about safety reminders and what to do if a fall occurs, ensure appropriate footwear is worn when ambulating or mobilizing in wheelchair, and ensure call light/pendant is within reach and encourage to use it for assistance as needed.Review of the Event Note dated 06/22/26 at 2:42 P.M. revealed on 06/22/26 at 10:30 A.M. per CNA when she walked in Resident #34's room, the resident was sitting in front of the recliner and it appeared that he slid out of chair with no injuries noted.Review of the Nurses Note dated 06/22/26 at 10:30 A.M. revealed Resident #34 was found on the floor. Staff assisted resident up. Vital signs and neuro checks started. No noted injury. Moves extremities normally. Denied hitting head. Denied pain/discomfort. Will continue to monitor.Observation on 06/22/26 at 10:03 A.M. revealed Housekeeper #202 tell Certified Nursing Assistant (CNA) #185 Resident #34 was on the floor face down. CNA #185 went into Resident #34's room and assisted the resident into the bedside chair. Interview on 06/22/26 at 10:22 A.M. with CNA #185 confirmed she told Licensed Practical Nurse (LPN) #225 Resident #34 was on the floor and CNA #185 assisted the resident back to bedside chair from a sitting position. Interview also confirmed she did not see any visible injuries.Observation on 06/22/26 at 10:23 A.M. revealed Resident #34 was still not assessed by a nurse after the fall.Interview on 06/22/26 at 10:23 A.M. with LPN #225 confirmed she did not assess Resident #34 because the resident was care planned to be on the floor. When asked at what point staff consider Resident #34 had a fall, LPN #225 stated, she didn't know, she would have to ask the Director of Nursing (DON) for that answer.Interview on 06/22/26 at 10:27 A.M. the DON confirmed Resident #34 is care planned to put himself on the floor if witnessed, but if not witnessed then the facility staff is to follow the fall protocol. Interview on 06/22/26 at 10:29 A.M. with LPN #225 and DON confirmed when Resident #34 was on the floor unwitnessed, it was to be treated as a fall.Observation on 06/22/26 at 10:37 A.M. LPN #225 was assessing Resident #34.Interview on 06/25/26 at 2:16 P.M. with the DON confirmed the charting on Resident #34 did not mention resident was found face down on 06/22/26 at 10:03 A.M. when Housekeeper #202 observed Resident #34 on the floor and reported to CNA #185 he was on the floor face down. Interview confirmed the DON had not interviewed Housekeeper #185 yet, even though the Interdisciplinary Team (IDT) note had already been completed saying resident was found sitting up beside his chair. Interview on 06/25/26 at 2:19 P.M. with Housekeeper #202 confirmed on 06/22/26 at 10:03 A.M. Resident #34 was on the floor face down and she reported to CNA #185 the resident was on the floor face down.Review of the Falls Management policy dated 12/02/25 revealed in the event a fall should occur, the nurse will complete a physical assessment completed for injury, and immediate care will be provided as needed. Following the immediate assessment the physician and representative will be notified.

Based on medical record review and staff interview, the facility failed to ensure a resident's urinary catheter tubing and collection bag was changed as ordered. Additionally, the facility also failed to provide timely incontinence care to a resident. This affected two (#4 and #5) of three residents reviewed for incontinence care. The census was 49. Findings include: 1.Review of Resident #4's medical record revealed an admission date of 08/18/25. Diagnoses listed included vitamin D deficiency, atherosclerotic heart disease, neuromuscular dysfunction of bladder, and spinal stenosis. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #4 was cognitively intact and had an indwelling urinary catheter. Review of physician orders revealed an order dated 08/18/25 to change urinary catheter bag and tubing as needed for catheter change, when visibly soiled or damaged, and every night shift every seven days for maintenance. Review of the treatment administration record (TAR) revealed no documentation of Resident #4's urinary catheter bag or tubing being changed on the scheduled days of 06/09/26 and 06/17/26. The TAR was blank on those days. The last documented day of the urinary and catheter bag being changed was 06/02/26. The next day documented of it being changed was 06/23/26. Interview with the Director of Nursing (DON) on 06/25/2026 at 7:40 A.M. confirmed no documentation of Resident #4 catheter bag and tubing being changed on 06/09/26 and 06/17/26, indicating it had not been completed. 2.Review of the medical record for Resident #5 revealed an admission date of 05/28/23. The resident had diagnoses which included acute transverse myelitis in demyelinating disease of the central nervous system, bacteremia, neuromuscular dysfunction of the bladder, type 2 diabetes, local infection of the skin and subcutaneous tissue, psoriasis and depression. The resident remained in the facility. Review of the quarterly MDS assessment dated [DATE] revealed Resident #5 had a Brief Interview Mental Status (BIMS) score of 14 indicating intact cognition. Resident #5 was dependent upon staff with toileting hygiene and was documented as always incontinent of stool. Review of the care plan revealed a focus for bowel incontinence with interventions including to change and assist with toileting as needed and to provide pericare after each incontinence episode. Observation of pericare on 06/25/26 at 9:58 A.M. with Certified Nursing Assistant (CNA) #173 for Resident#5 revealed CNA #173 had supplies prepared on the bedside table and clear trash bags on the floor beside Resident #5's bed. CNA #173 washed his hands, put on gloves and pulled the curtain around the bed for privacy. CNA #173 removed the tape from the incontinence product to expose the catheter. CNA #173 cleansed the periarea around the catheter with soap and water, rinsed and patted the area dry. The catheter tubing was then cleansed with soap and water, rinsed and patted dry. Resident #5 was observed to be incontinent of stool during care. CNA #173 informed Resident #5 he would come back with the nurse after she had finished her medication pass so she could put the Zinc Ointment (skin protectant) on him. Resident #5 looked at this surveyor and said hurry up and wait. CNA #173 then applied a clean incontinence product (leaving the soiled incontinence product in place beneath him) over Resident #5's groin area and covered him the a sheet. Resident #5 then asked CNA #173 if he changed the incontinence product. CNA #173 explained he put a clean product on the front of him and would return with the nurse and change the soiled product after her medication pass. CNA #173 then tied the soiled linen bag and took off his gloves and gown and placed them in the second trash bag. CNA #173 then went into the bathroom to wash his hands. When he was done, a request was made for him to go into the hallway by this surveyor. During the interview, CNA #173 revealed he had not been in to check Resident #5 for incontinence until the time of the observation. CNA #173 stated he was informed the last incontinence rounding was around 4:00 A.M. or 4:30 A.M. CNA #173 explained he did not provide incontinence care, because the nurse would need to put medication on Resident #5's coccyx. CNA #173 acknowledged incontinence care could be provided since he was aware the Resident #5 was sitting in excrement and the nurse could apply medication later. Interview on 06/25/26 at 11:12 A.M. the Director of Nursing (DON) stated the facility followed [NAME] procedures for incontinence care and provided a written copy of the instruction. A second interview at 2:27 P.M. the DON acknowledged it would be the expectation incontinence care would be provided in a timely manner. Review of the [NAME] documentation titled, Incontinence management, fecal, long-term care, reviewed 12/15/25 documented if a residents incontinence brief or pad becomes soiled, remove it. Clean the perineal area with a skin cleanser after each incontinence episode and apply skin protectant cream.

Based on staff interviews, resident interviews, and record review, the facility to follow Bilevel Positive Airway Pressure (BiPAP) orders as prescribed. This affected one Resident (#16) of three reviewed. The facility census was 49.Findings include: Review of the medical record for Resident #16 revealed an admission date of 06/03/26. The resident had diagnoses which included Chronic Obstructive Pulmonary Disease (COPD), acute on chronic respiratory failure, Congestive Heart Failure (CHF) and localized edema.The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #16 was cognitively intact and he required supervision with transfers, bed mobility, set up with eating, and moderate assistance with toileting hygiene.Review of physician orders revealed an order to apply BiPAP machine with Inspiratory Positive Airway Pressure (IPAP) of ten centimeters of water (cm H20) and Expiratory Positive Airway Pressure (EPAP) of five cmH20, and respirations of 13 and 35 percent (%) Fractured of Inspired Oxygen (FiO2) with three Liters Per Minute (LPM) oxygen bleed in every night shift and as needed for between meals.Review of the June Medication Administration Record (MAR) revealed a nine was documented on 06/06/26, 06/13/26,01/15/26, 06/18/26, 06/19/26 and 06/22/16. Further review of the chart codes revealed a nine was other/see progress notes.Review of the progress notes did not reveal any documentation correlating with the Medication Administration on 06/06/26, 06/13/26,01/15/26, 06/18/26, 06/19/26 or 06/22/26.Interview on 06/22/26 at 11:43 A.M. with Resident #16 stated the staff had not applied the BiPAP machine since his admission. He explained they had informed him they needed a piece to hook the oxygen into it. Observation at the time of the interview did not reveal oxygen tubing to be present.Interview on 06/25/26 at 8:02 A.M. with Registered Nurse (RN) #263 revealed she worked the night shift on 06/06/26, 06/13/26,01/15/26, 06/18/26, 06/19/26 or 06/22/16. She verified she entered a nine on the corresponding dates on the MAR explaining the connector to hook the oxygen to the BiPAP was not available until 06/23/26.Review of the facility policy, Medication Administration Procedure dated 11/21/17 documented Medications are administered in accordance with the written orders of the attending physician.

Based on medical record review, staff interview, observation, and review of facility policy, the facility failed to ensure pressure ulcer treatments were completed as ordered. This affected one (#4) of three residents reviewed for skin alterations. The census was 49. Findings include: Review of Resident #4's medical record revealed an admission date of 08/18/25. Diagnoses listed included vitamin D deficiency, atherosclerotic heart disease, neuromuscular dysfunction of bladder, and spinal stenosis. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #4 was cognitively intact and had no pressure ulcers. Review of a nursing note dated 06/17/26 at 3:50 P.M. revealed the physician was in to see Resident #4. New order for betadine to the right heel and Medihoney (wound treatment gel) and bordered gauze to coccyx. Review of physician orders revealed an order dated 06/17/26 for coccyx apply Medihoney and cover with bordered gauze and right heel apply betadine every dayshift for wound healing. The order was discontinued on 06/19/26. Review of wound physician notes dated 06/17/26 revealed Resident #4 had an unstageable deep-tissue injury to the left heel with intact skin that measured 3 centimeters (cm) x 2.5 cm. Treatment plan was betadine once daily and as needed.Review of wound nurse practitioner notes dated 06/19/26 revealed Resident #4 had an unstageable deep-tissue injury to the left heel with intact skin that measured 2.8 cm x 2.5 cm. Dry, brown/black hard eschar was noted. Will paint with betadine daily, leave open to air. No erythema or drainage noted. Appears stable. Review of the medication administration record (MAR) revealed betadine was not documented as being applied to Resident #4's right heel from 06/19/26 to 06/24/26. There was no current order in place. Further review of the medical record revealed Resident #4's wound to the right heel did not worsen due to no treatments being provided. Interview with the Director of Nursing (DON) on 06/24/26 at 7:15 A.M. confirmed treatment to Resident #4's right heel was stopped on 06/19/26 and not restarted as ordered by the wound nurse practitioner. The treatment order for the coccyx was changed and since that was a combined order, the right heel treatment was mistakenly discontinued too. There was no documentation of the right heel being treated from 06/19/26 until 06/24/26. The DON confirmed the wound physician improperly documented a left heel wound on 06/17/26. Observation of Resident #4's wound care on 06/25/26 at 9:50 A.M. revealed a wound to the right heel with eschar in place.

Based on observation, Centers for Disease Control (CDC) Guidelines, and staff interviews, the facility failed to ensure infection procedures were followed during incontinence care. This affected one resident (#5) of two reviewed for incontinence care and infection control. The facility census was 49. Findings include:Review of the medical record for Resident #5 revealed an admission date of 05/28/23. The resident had diagnoses which included acute transverse myelitis in demyelinating disease of the central nervous system, bacteremia, neuromuscular dysfunction of the bladder, type 2 DM, local infection of the skin and subcutaneous tissue, psoriasis and depression. The resident remained in the facility.The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #5 had a Brief Interview Mental Status (BIMS) score of 14 indicating intact cognition. Resident #5 was dependent upon staff with toileting hygiene and was documented as always incontinent of stool.Review of the care plan revealed a focus for bowel incontinence with interventions which included but were not limited to change and assist with toileting as needed and to provide pericare after each incontinence episode.Observation on 06/25/26 at 10:21 A.M. of incontinence care with Certified Nursing Assistant (CNA) #173 assisted by CNA #183 for Resident #5 revealed Resident #5 was assisted onto his right side and cleansed of stool by CNA #173. Resident #5 was then assisted onto his back. CNA #173 and CNA#183 both used toilet paper to cleanse stool from the groin area. CNA #183 was observed to have excrement on both gloves. CNA #183 was then observed to look at her gloves and then use toilet paper to remove stool from her gloves. CNA #183 continued to assist with cleansing Resident #5 without changing gloves. CNA #183 then pulled the clean incontinence product out from under Resident #5. After Resident #5 was encouraged to return to his back, CNA #183 then used her soiled gloves to readjust the catheter tubing over Resident #5's leg.Interview on 06/25/26 at 10:35 A.M. immediately following incontinence care, CNA #183 verified she had wiped stool from both of her gloves using toilet paper and did not change them until after incontinence care was completed and the repositioning of the catheter tubing had been completed.Review of CDC guidelines revealed instruction was to change gloves and clean hands if gloves become soiled.

Based on medical record review and staff interview, the facility failed to provide wound care as ordered. This affected one (Resident #20) of three reviewed for wounds. The facility census was 47. Findings include: Review of the medical record for Resident #20 revealed an admitted [DATE] with diagnoses including but not limited to displaced bimalleolar fracture (ankle) of right lower leg, fracture of upper end of right tibia (larger bone in lower leg, shinbone), type one diabetes, major depressive disorder, syncope and collapse, other specified disorders of bone density and structure to right thigh, and hypertension. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 was cognitively intact. Resident #20 required extensive assistance for Activities of Daily Living (ADLs) and had surgical wounds. Review of the care plan dated 02/01/24 revealed Resident #20 had actual impairment to skin integrity of the right lower leg related to surgical wound. Interventions included but not limited to follow facility protocols for treatment and injury, keep skin clean and dry, use lotion on dry skin, monitor for side effects of medications, pressure reducing device as ordered, and weekly skin screen. Review of physician orders for Resident #20 revealed orders for nursing staff to change wound vac every Wednesday and Friday, place bridge between wounds and place suction in the middle of the bridge per wound clinic and wound clinic to change dressings. Review of the nursing note dated 03/05/24 revealed Resident #20 returned from the hospital per transport. Resident #20 complained of pain to right leg and ankle. Wound vac in place and draining. Order received from wound clinic to change wound vac on Thursday and Saturday this week. Review of the Treatment Administration Record (TAR) for March 2024 revealed no order put in to change wound vac on Thursday (03/07/24) and Saturday (03/09/24) therefore wound vac was not signed off as being changed. Wound vac was signed off as held on 03/06/24. Starting 03/11/24, wound vac started to be changed by the wound clinic on Monday, Wednesday, and Friday. Interview on 04/03/24 at 4:33 P.M. with the Director of Nursing (DON) verified the order was not put in for the wound vac change on Thursday 03/07/24 and Saturday 03/09/24, therefore it was not completed. This deficiency represents non-compliance investigated under Complaint Number OH00152598.

Based on record review, review of facility policy, and staff interview the facility failed to ensure care was not delayed and a fall was properly assessed for one resident, Resident #1, out of three residents reviewed for falls. The current census is 46. Findings include: Record review of Resident #1 revealed the resident was admitted to the facility on [DATE] and discharged to another facility on 01/05/24. Diagnoses for Resident #1 included displaced fracture of the femur, chronic obstructive pulmonary disease, malnutrition, and heart disease. Review of Resident #1's Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed the resident had intact cognition and was a fall risk. Review of Resident #1's care plans dated 12/2023 revealed a focus for falls. Interventions included non-skid footwear, keeping path free of clutter, and call light within reach at all times. Review of the fall assessment dated [DATE] at 1:30 P.M. revealed the nurse documented her progress note regarding the assessment completed on Resident #1 in the medical records as the time of the fall. Per the fall assessment the resident rated her pain at a level 2 out of 10, (10 being highest level of pain). Per the assessment the nurse documented no injuries due to fall. The fall assessment was unsigned and not a part of the electronic medical record. Review of written physician orders, undated, revealed a written order for x-ray of left hip with two to three views was signed by Certified Nurse Practioner (CNP) #400 and dated 11/28/24. No nurse signature, date, or time was noted on the physician's written order. Review of the radiology report from the radiology provider revealed the order for Resident #1's x-ray was ordered priority STAT and the date of service was 11/28/23 at 11:43 A.M. and reported to the facility on [DATE] at 11:59 A.M Further review of Resident #1's electronic records revealed on 11/27/23 there were no vital signs documented. No nursing assessments were dated 11/27/23 and no fall assessments were documented on 11/27/23. Review of Resident #1's progress notes dated 11/28/23 at 9:03 A.M. Licensed Practical Nurse (LPN) #100 charted her assessment of Resident #1's fall on 11/27/23. On 11/28/23 at 1:18 P.M. the nurse documented the resident was transferred to the hospital at 1:18 P.M. due to the x-ray results showing a hip fracture. Interview on 01/11/24 at 1:20 P.M. with the Director of Nursing (DON) verified there was no electronic order for the x-ray entered into Resident #1's electronic record. The DON verified the written order did not have a nurse's name and was not a part of Resident #1's electronic records. The DON verified there was no order date on the x-ray order but it was signed by CNP #400 on 11/28/23. The DON stated the x-ray was completed on 11/27/23 but the final results were not in the system until 11/28/23. The DON verified there was no fall risk assessment by LPN #100 in the electronic record and the fall investigation had been completed on 11/28/23 by the nurse. The DON verified LPN #100 had not documented on the day of the fall and entered a late entry in the progress notes. Interview on 01/11/24 at 1:45 P.M. with LPN #100 verified after the fall she assessed Resident #1 but the nurse stated she could not remember notifying the family or CNP #400 after the fall. LPN #100 verified she did not follow fall protocols after the fall and did not document the fall assessments or any orders for the x-ray in the record. LPN #100 stated she could not recall talking with CNP #400 after the fall and stated she believed the nurse for the second shift finished the fall protocols on the day after the fall. Interview on 01/11/24 at 2:23 P.M. with CNP #400 stated she was in the facility and assessed Resident #1 on 11/28/23 the day after the fall. Per CNP #400 she could not recall when she was notified of the resident's fall but stated she did fill out the order for the x-ray on 11/28/23 and stated the x-ray was taken on 11/28/23. CNP #400 stated when she assessed Resident #1 the resident's pain level was around two or three, on a scale of 1-10, and the CNP stated she ordered the resident to be sent out after she was given the results of the x-ray. Review of the facility's fall policy titled, Falls Management, dated 12/03/19, revealed in the event of a fall the nurse will document a fall assessment into the electronic medical record, documentation in the medical record's progress note should be a complete assessment and record of the fall and the nurse is to notify the physician and family immediately after the assessment of the resident. This deficiency represents non-compliance investigated under Complaint Number OH00149285

Based on medical record review, staff interview, review of facility investigations, review of a Sheriff's Office incident report, review of the weather forecast, review of hospital discharge documents, and review of facility policy, the facility failed to prevent the elopement of confused residents from the secured memory care unit. This resulted in actual harm when one resident (#20) eloped from the facility without staff knowledge, was outside for approximately three hours in cool weather temperatures and light rain, was subsequently admitted to the hospital for evaluation and stabilization and was diagnosed with hypothermia (a significant and potentially dangerous drop in body temperature most commonly caused by prolonged exposure to cold) and a hypothermic blanket was applied. Furthermore, the resident was diagnosed with hypokalemia (low potassium) requiring intravenous (IV) fluids for hydration and found to have an episode of non-sustained ventricular tachycardia (heart arrythmia). Additionally, the facility failed to prevent the elopement of a second resident (#21) that placed the resident at risk for the potential for more than minimal harm when Resident #21 exited the secured memory care unit and was noted sitting outside the south entrance at the F door by a staff member who was coming on shift. This affected two (#20 and #21) of three residents reviewed for elopement risk. The facility census was 44. Findings Include: 1. Review of the medical record for Resident #20 revealed an admitted [DATE]. Diagnoses included major depressive disorder, schizoaffective disorder, dementia, Alzheimer's disease, delusional disorder, and mood disorder. Resident #20 resided on the secured memory unit. Review of Resident #20's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of five, indicating Resident #20 was severely cognitively impaired. Resident #20 required supervision, set up only for her activities of daily living. Resident #20 displayed verbal behavioral symptoms directed toward others one to three days during the review period. Resident #20 did not display any wandering behaviors at the time of the review. Review of Resident #20's care plan revised 11/03/23 revealed supports and interventions for self-care deficit related to dementia, impaired cognitive function, risk for wandering, and behavior of wandering. Review of Resident #20's Wandering and Elopement Risk assessment dated [DATE] revealed Resident #20 was at low risk. On 10/28/23, Resident #20 was reassessed due to having a history of elopement in the last 30 days and was assessed at high risk for wandering and elopement. Review of the facility's investigation documentation revealed on 10/28/23 at approximately 4:30 A.M. Resident #20 exited the building through the fire door and the door did not alarm when opened. The facility found Resident #20 was missing at approximately 6:30 A.M. when State tested Nursing Assistant (STNA) #136 went to get Resident #20 up for breakfast. The elopement protocol was initiated and 911 was called at approximately 7:00 A.M. On 10/28/23 at 7:20 A.M. Resident #20 was found lying on the ground by the police. Resident #20 was determined to be outside wearing only a two-piece pajama set, socks and shoes for approximately three hours. Resident #20 was transferred to the hospital and was admitted for hypothermia. Review of the Weather Summary for 10/28/23 revealed it was between 53 and 60 degrees and lightly raining during the time Resident #20 had eloped from the facility. Review of the Sheriff's Office Incident Report dated 10/28/23 revealed on 10/28/23 at 7:10 A.M. the facility called 911 and reported a missing person. The missing person was a resident at the facility. A deputy sheriff along with the local police department responded. While the deputy was enroute they were notified the missing resident was located lying on the ground behind one of the buildings. Resident #20 was noted to be responding but very cold and shaking. Review of the Medical Transportation Report dated 10/29/23 revealed Resident #20 was transported back to the facility following a hospital stay for a primary complaint of hypothermia. Review of Resident #20's progress notes revealed on 10/30/23 Resident #20 was seen by the physician for a routine visit and follow up from Resident #20's 10/28/23 hospitalization . It was noted staff reported Resident #20 wandered out of the facility in the early morning hours of 10/28/23 and was found lying on the ground. Resident #20's outdoor exposure was approximately three hours. Her downtime was thought to be approximately two hours after video surveillance was reviewed. In the emergency room she was found to have hypokalemia (low potassium) and admitted for further work-up and management. She was given IV hydration, and a hypothermic blanket was applied. She was also found to have an episode of non-sustained ventricular tachycardia (heart arrythmia). Resident #20 was consulted with cardiology and recommended to be followed. She returned to her baseline status with underlying dementia and confusion. The hospital course was uneventful. Resident #20 returned to the facility with a 48-hour [NAME] monitor (continuously measures the heart's electrical activity) in place and was to follow-up with cardiology in three to four days. Review of the Hospital Discharge documents dated 11/01/23 revealed Resident #20 was admitted to the hospital on 10/28/23 and discharged back to the facility on [DATE]. It was noted Resident #20 was brought into the emergency room due to being confused and found lying on the ground in the rain. Resident #20 was discharged with the diagnoses of altered mental status, non-sustained ventricular tachycardia, volume depletion, elevated lactic acid levels and hypothermia. Interview on 11/08/23 at 11:02 A.M. with the Director of Nursing (DON) and the Administrator verified on 10/28/23 Resident #20 eloped from the facility from a non-functional alarmed door, was missing for approximately three hours, was found by the local police department, was transferred to the hospital for evaluation and admitted . Interview on 11/08/23 at 1:17 P.M. with STNA #136 verified she was the staff who found Resident #20 to be missing. STNA #136 reported she had entered Resident #20's room to get her up for breakfast around 6:40 A.M. on 10/28/23 and found Resident #20 was not in her room. They searched inside and outside of the facility and STNA #136 reported it was the police who found Resident #20 lying on the ground outside. Resident #20 was taken to the hospital after the police found her on 10/28/23 and Resident #20 returned to the facility on [DATE]. Follow-up interview on 11/14/23 at 1:44 P.M. with the DON verified Resident #20 was diagnosed with hypothermia at the hospital following her elopement. 2. Review of Resident #21's medical record revealed an admitted [DATE]. Diagnoses included dementia and insomnia. Resident #21 resided on the secured memory unit. Review of Resident #21's MDS dated [DATE] revealed a BIMS score of two, indicating Resident #21 was severely cognitively impaired. Resident #21 displayed wandering behaviors one to three days during the review period. Review of Resident #21's care plan, revised 10/16/23, revealed supports and interventions for self-care deficit, cognitive impairment, behaviors of resisting care, wandering, yelling out cursing, being sexually inappropriate with staff, and elopement risk. Review of Resident #21's Wandering and Elopement Risk assessment dated [DATE] determined Resident #21 was at low risk for wandering and elopement. Resident #21 was reassessed on 10/28/23 and was found to be at moderate risk. Resident #21 was again assessed on 10/28/23 and was found to be at high risk for wandering and elopement. Review of the facility's investigation for an incident on 10/27/23 revealed at approximately 5:30 P.M. Resident #21 exited the secured unit and was noted to be sitting at the outside entrance of the memory care unit by a staff member. Resident #21 was last noted to be seen in the dining room eating dinner at 5:00 P.M. At 5:25 P.M., STNA #109 left the dining area to assist another resident. Resident #21 was noted to still be at the dining table. At 5:30 P.M. Resident #21 exited the south entrance and STNA #114, who was coming on shift, found Resident #21 sitting in his wheelchair outside the facility by the F door. At 5:37 P.M. The DON was notified, and it was reported a visitor was previously in with another resident and Resident #21 may have exited when the visitor left. Interview on 11/08/23 at 11:02 A.M. with the DON and the Administrator verified on 10/27/23 Resident #21 eloped from the facility. The DON reported Resident #21 was outside the facility for only a few minutes when a staff member, who was coming on shift, found him outside the exit door and brought him back in. The facility investigated what happened and believed Resident #21 followed a visitor out of the building. Interview on 11/14/23 at 1:03 P.M. with STNA #114 verified she was the staff who found Resident #21 outside of the facility. STNA #114 reported she had just returned to the facility when she saw Resident #21 outside the facility in his wheelchair. STNA #114 reported she knew Resident #21 lived on the secured unit and was not able to be outside by himself. STNA #114 asked him what he was up to outside, and he told her he needed to feed the animals. She reassured Resident #21 his animals were taken care of and said it was time to go back in. Resident #21 was cooperative with going back in the building. Review of the facility policy titled, Missing Resident Policy and Procedure, revised 12/21/22 revealed elopement was defined when a resident leaves the nursing community without the location's knowledge or supervision. This deficiency represents non-compliance investigated under Complaint Number OH00148063.

Based on medical record review, staff interview, review of facility investigations, and review of facility policy, the facility failed to report instances of potential neglect related to resident elopement to the state agency. This affected two (#20 and #21) of three residents reviewed for elopement. The facility census was 44. Findings Include: 1. Review of the medical record for Resident #20 revealed an admitted [DATE]. Diagnoses included major depressive disorder, schizoaffective disorder, dementia, Alzheimer's disease delusional disorder, and mood disorder. Resident #20 resided on the secured memory unit. Review of Resident #20's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of five, indicating Resident #20 was severely cognitively impaired. Resident #20 required supervision, set up only for her activities of daily living (ADLs). Resident #20 displayed verbal behavioral symptoms directed toward others one to three days during the review period. Resident #20 did not display any wandering behaviors at the time of the review. Review of Resident #20's care plan, revised 11/03/23, revealed supports and interventions for self-care deficit related to dementia, impaired cognitive function, risk for wandering, and behavior of wandering. Review of Resident #20's Wandering and Elopement Risk assessment dated [DATE] revealed Resident #20 was at low risk. On 10/28/23, Resident #20 was reassessed due to a history of wandering in the last 30 days and was assessed to be high risk for wandering and elopement. Review of the facility's Self-Reported Incidents (SRIs) from 09/14/23 through 11/10/23 revealed no SRI's were submitted for Resident #20. Review of Resident #20's medical record revealed on 10/28/23 at approximately 4:30 A.M. Resident eloped from the facility through a fire door which had not alarmed. Resident #20 was missing from the facility for approximately three hours and was found by the police outside the facility lying on the ground. Resident #20 was transferred to the hospital and was diagnosed with hypothermia. Interview on 11/08/23 at 11:02 A.M. with the Director of Nursing (DON) verified Resident #20 had eloped from the facility on 10/28/23. The DON also verified an SRI had not been completed for Resident #20's elopement. 2. Review of Resident #21's medical record revealed an admitted [DATE]. Diagnoses included dementia and insomnia. Resident #21 resided on the secured memory unit. Review of Resident #21's MDS, dated [DATE], revealed a BIMS score of two, indicating Resident #21 was severely cognitively impaired. Resident #21 displayed wandering behaviors one to three days during the review period. Review of Resident #21's care plan, revised 10/16/23, revealed supports and interventions for self-care deficit, cognitive impairment, behaviors of resisting care, wandering, yelling out, cursing, being sexually inappropriate with staff, and elopement risk. Review of Resident #21's Wandering and Elopement Risk assessment dated [DATE] determined Resident #21 was at low risk for wandering and elopement. Resident #21 was reassessed on 10/28/23 and was found to be at moderate risk. Resident #21 was again assessed on 10/28/23 and was found to be at high risk for wandering and elopement. Review of the facility's Self-Reported Incidents (SRIs) from 09/14/23 through 11/10/23 revealed no SRI's were submitted for Resident #21. Review of Resident #21's medical record revealed on 10/27/23 at approximately 5:30 P.M. Resident #21 eloped from the facility by following a visitor out the door. Resident #21 was found sitting in his wheelchair, unsupervised, outside the facility by a staff returning to work. Interview on 11/08/23 at 11:02 A.M. with the Director of Nursing (DON) and the Administrator verified on 10/27/23 Resident #21 eloped from the facility. The DON also verified an SRI had not been completed for Resident #21's elopement. Review of the facility policy titled, Abuse, Mistreatment, Neglect, Exploitation, and Misappropriation of Resident Property- Ohio Only, revised 10/25/22 revealed neglect was defined as the failure of the facility, it's employees, or facility service providers to provide goods and services to a resident to avoid physical harm, pain, mental anguish, or emotional distress. All allegations involving neglect without serious bodily injury would be reported to the Ohio Department of Health (ODH) immediately, but no later than 24 hours from the time of the incident/allegation was made known to the staff member. The facility would submit an online Self-Reported Incident (SRI) form in accordance to ODH's current instructions. This is an incidental finding discovered during the investigation of Complaint Number OH00148063.

Based on record review, staff interview and policy review, the facility failed to provide each resident or representatives with education regarding the risk and benefits of influenza immunization yearly when influenza vaccines were offered. This affected four (#2, #27, #31 and #36) out of five residents reviewed for immunizations. The facility census was 47. Findings include 1. Medical record review for Resident #2 revealed an admitted major depressive disorder, syncope and collapse, cerebral infarction, poly osteoarthritis, vitamin D, hyperlipidemia, seasonal allergic rhinitis, chronic obstructive pulmonary disease (COPD), anemia, hypertension, chronic bronchitis, dementia without behaviors, chronic kidney disease stage three. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] for Resident #2 revealed the resident had impaired cognition. Resident #2 required extensive assist for bed mobility, transfers, and toileting. Resident #13 required supervision for eating. Review of the Resident #2 influenza immunization information revealed resident immunization was administered on 11/09/22. Further record review for Resident #2 revealed there was no documentation regarding the education provided for risk and/or benefits regarding the influenza immunization. 2. Review of the medical record for Resident #27 revealed an admission on 08/14/20 with diagnoses to include but not limited to dementia without behavioral disturbances, anxiety, major depression, and Alzheimer's disease. Review of the annual MDS assessment dated [DATE] for Resident #27 revealed the resident had impaired cognition. Resident #27 required extensive assist for bed mobility, transfers, and toileting. Resident #27 required supervision for eating. Review of the Resident #27 influenza immunization information revealed resident immunization was administered on 11/09/22. Further record review for Resident #27 revealed there was no documentation regarding the education provided for risk and/or benefits regarding the influenza immunization. 3. Review of the medical record for Resident #31 revealed an admission on 03/09/22 with diagnoses including but not limited to anemia, atrial fibrillation, arthritis, dementia, anxiety and depression. Review of the significant change MDS assessment for Resident #31 revealed the resident had severe cognitive impairment and resident rarely/never understood. Resident #31 required extensive assistance for bed mobility, transfers, eating and toileting. Review of the Resident #31 influenza immunization information revealed resident immunization was administered on 11/04/22. Further record review for Resident #31 revealed there was no documentation regarding the education provided for risk and/or benefits regarding the influenza immunization. 4. Review of the medical record for Resident #36 revealed an admission on 12/04/21 with diagnoses including but not limited to congestive obstructive pulmonary disease, hypertension, peripheral vascular disease, anxiety, depression, respiratory failure. Review of the quarterly MDS assessment dated [DATE] for Resident #36 revealed the resident had intact cognition. Resident #36 required extensive assist for bed mobility, transfers, and toileting. Resident #36 required supervision for eating. Review of the Resident #36 influenza immunization information revealed resident immunization was administered on 11/09/22. Further record review for Resident #36 revealed there was no documentation regarding the education provided for risk and/or benefits regarding the influenza immunization. Interview on 09/14/23 at 2:19 P.M. with the Director of Nursing (DON) revealed the nurse administering the immunization should have checked the box in the immunization section of the electronic health record when education of the risk and benefits of the injections were provided. Additionally, the DON stated the consent for the immunization would be scanned into the medical record and could be found in the miscellaneous tab. Interview on 09/14/23 at 3:20 P.M. with the DON verified the progress notes, the check box in the electronic health record and the miscellaneous tab contained no documentation for any education provided for risks and benefits for Resident #2, #27, #31, and #36. Review of the facility policy titled Influenza and Pneumococcal Immunization dated 06/19/2019 revealed the resident or the resident representative will receive education regarding the benefits and potential side effect of the immunization prior to the administration and annually.

Based on medical record review, observation, staff, physician and resident representative interviews, the facility failed to follow the physicians orders for treatment of a wound. This affected one (#8) of one reviewed for wound care. Additionally, the facility failed to provide care and services to treat a resident's constipation. This affected one (#198) out of one resident reviewed for constipation. The facility census was 47. Findings include: 1. Medical record review for Resident #8 revealed an admission on 06/26/23 with diagnoses including but not limited to myasthenia gravis with exacerbation, type two diabetes, sleep apnea, morbid obesity, major depressive disorder and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #8 revealed the resident had impaired cognition. Resident #8 required limited assistance from one staff member for bed mobility, transfers, and toileting. Resident #8 required application of non surgical dressing and ointments to areas other than feet. Review of the plan of care for Resident #8 revealed resident has microbial infection related to venous ulcers, educate resident on disease management and infection control precautions. Enhanced Barrier Precautions in place. Review of the physician orders for Resident #8 revealed an order dated 08/26/2023 for Santyl External Ointment 250 unit/gram (Collagenase), apply to posterior right calf topically every day shift for wound healing. Apply Santyl and mix with Medihoney and cover with border gauze. Review of the skin and wound evaluation dated 08/01/23 revealed medial calf open area 1.1 centimeter (cm) x 1.4 cm with no depth or undermining documented. Redness of the skin was documented. Observation on 09/13/23 at 9:20 A.M. with Licensed Practical Nurse (LPN) #43 of Resident #8 wound dressing change revealed the resident had removed the dressing to right posterior calf prior to the nurse entering the room. LPN #43 donned gown and gloves and entered bathroom. LPN #43 used a wash cloth and hand soap from the soap dispenser hanging on the wall of the bathroom. LPN #43 washed the wound with a section of the soapy washcloth and then rinsed the wound with a separate area of the washcloth. LPN #43 discarded gloves and completed hand hygiene and new gloves donned. Plurogel was applied to the bordered dressing along with Medihoney and adhered to the wound on the right posterior calf. Interview on 09/13/23 at 9:30 A.M. with LPN #43 stated the physician did not order a specific wound cleanser so she just use the hand soap on the wall and a washcloth. Further interview LPN #43 verified that Plurogel is the same as Santyl and interchangeable. LPN #43 verified the physicians orders stated Santyl and not Plurogel. Interview on 09/13/23 at 9:40 A.M. with Director of Nursing (DON) verified Resident #8's order was for Santyl and the medical supply company advised her that Plurogel was an equivalent to Santyl and was significant savings. DON verified the order was not changed to reflect the interchange of ointment and it should have been. Additionally, the DON stated the wash cloth and hand soap should have not been used to clean wound. The wound should have been cleaned with a wound cleanser and gauze pads. Interview on 09/13/23 at 10:13 A.M. with Wound Physician #202 verified Plurogel was not an equivalent to Santyl and did not know the facility had not been using Santyl as ordered. Further interview with Wound Physician #202 verified that the nurse should not be using the wall hand soap on the wound, but a wound cleanser and will discuss the incident with the DON. Wound Physician #202 verified the wound did not increase in size and continued to heal slowly as with any venous ulcer does. 46613 2. Review of the medical record for Resident #198 revealed an admitted [DATE] with medical diagnoses of sepsis, nondisplaced fracture of left humerus, hypothyroidism, and dementia. Review of the medical record for Resident #198 revealed an admission Minimum Data Set (MDS) assessment, dated 08/30/23, which indicated Resident #198 had severely impaired cognition and required extensive staff assistance with bed mobility, transfers, dressing, and toileting. Review of the MDS revealed Resident #198 was occasionally incontinent of bowel and had no constipation. Review of the medical record for Resident #198 revealed a physician order dated 08/24/23 for Colace (laxative) 100 milligram (mg) by mouth every 24 hours as needed for constipation and 08/28/23 bisacodyl suppository (laxative) 10 mg rectally every 24 hours as needed for constipation. Review of the medical record for Resident #198 revealed no documentation to support Resident #198 had a bowel movement from 08/25/23 through 09/01/23. Review of the medical record for Resident #198 revealed an August 2023 Medication Administration Record (MAR) which did not have documentation to support the facility staff administered any medications for constipation from 08/25/23 to 08/31/23. Interview on 09/11/23 at 11:57 A.M. with Resident #198's representative stated Resident #198 went seven days without a bowel movement before the resident was given medication to help treat his constipation. Resident #198's representative stated she informed staff the resident was having constipation. Interview on 09/13/23 at 11:30 A.M. with Director of Nursing (DON) stated the facility did not have a policy for management of constipation but the facility practice was for nursing staff to administer milk of magnesia when a resident had not had a bowel movement for three days. DON confirmed the medical record for Resident #198 did not have documentation to support Resident #198 had a bowel movement from 08/25/23 to 09/01/23 nor was medication administered to treat the constipation.

Based on medical record review, staff and resident representative interviews, and policy review, the facility failed to include resident representative in the development of a baseline care plan and failed to provide resident representative with a copy of the baseline care plan. This affected one (#198) out of five residents reviewed for baseline care plans. The facility census was 47. Findings include: Review of the medical record for Resident #198 revealed an admitted [DATE] with medical diagnoses of sepsis, nondisplaced fracture of left humerus, hypothyroidism, and dementia. Review of the medical record for Resident #198 revealed an admission Minimum Data Set (MDS) assessment, dated 08/30/23, which indicated Resident #198 had severely impaired cognition and required extensive staff assistance with bed mobility, transfers, dressing, and toileting. Review of the medical record for Resident #198 revealed an Admission Screen and Baseline Care plan assessment was completed by Director of Nursing (DON) on 08/24/23. Further review of the medical record revealed a signature sheet signed by Regional MDS nurse #204 which stated the care plan was reviewed with Resident #198 on 08/25/23 and the resident refused to sign the signature sheet. Review of the signature sheet and review of the medical record did not reveal any documentation to support the baseline care plan was developed or reviewed with Resident #198's representative or that a copy of the baseline care plan was given to the resident representative. Interview on 09/13/23 at 4:50 P.M. with Resident #198's representative confirmed she did not participate in the development or review of Resident #198's baseline care plans. Resident #198's representative also stated she was not given a copy of the baseline care plan. Interview on 09/13/23 at 5:30 P.M. with DON confirmed the medical record for Resident #198 did not have documentation to support the resident representative assisted with the development of the baseline care plan or was given a copy of Resident #198's baseline care plans. Review of policy titled, Baseline Care Plan dated 11/13/17, stated the facility was to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The policy stated the facility would provide the resident and/or representative with a summary of the baseline care plan.

Based on medical record review, staff and hospice staff interviews and review of a hospice contract, the facility failed to collaborate hospice services for the completion of a comprehensive plan of care for a resident admitted hospice services. This affected one (#13) of one reviewed for Hospice services. The facility census was 47. Findings include: Medical record review for Resident #13 revealed an admitted d on 12/09/22 with diagnoses including but not limited to sepsis, electrolyte imbalance, hypothyroidism, anemia, lymphedema, acute osteomyelitis, type two diabetes, obesity, seizures, obstructive sleep apnea, encephalopathy, intracranial abscess and granuloma. Review of the significant Minimum Data Set (MDS) assessment for Resident #13 dated 08/28/23 revealed the resident had intact cognition. Resident #13 required limited assist for bed mobility, extensive assist for transfers and toileting. Resident #13 required supervision for eating. Resident #13 was coded as receiving hospice care in the past 14 days. Review of the hospice plan of care dated 08/21/23 for Resident #13 revealed a focus for facility coordination. Interventions include establish upon admission the care and services to meet the personal care, nutritional, mobility, durable medical equipment, elimination and integrity needs, hospice plan of care to outline services, and collaborate and educate the facility staff on patient/family needs and current interdisciplinary interventions. Review of the plan of care for Resident #13 dated 08/23/23 revealed the resident had an acute plan of care titled end of life care. Interventions included apply skin prep as directed, approach in calm manner, assist with toileting needs, campus staff and hospice staff to coordinate care for resident, comfort foods and liquids as tolerated, comfort measure: music of choice, repositioning, massage and hospice services. Review of the plan of care for Resident #13 dated 08/23/23 revealed resident receives hospice services. Interventions include provision of Activities of Daily Living (ADL's) to compensate for resident's changing abilities, encourage participation to the extent the resident wishes to participate, assess resident coping strategies and respect resident wishes, encourage resident to express feelings, listen with non-judgmental acceptance, compassion, encourage support system of family and friends, keep the environment quiet and calm, keep linens clean, dry and wrinkle free keep lighting low and familiar objects near, observe resident closely for signs of pain, administer pain medications as ordered, and notify physician immediately if there is breakthrough pain, review resident's living will and ensure it is followed, involve family in discussion, hospice nurse will provide services, hospice state tested Nursing Assistant (STNA) will provide services. Review of the physician orders for the month of September 2023 for Resident #13 revealed an order dated 08/22/23 to admit to Hospice. Review of the hospice visit notes dated 08/21/23 through 09/14/23 was silent for any collaboration between the hospice staff and the facility. Interview on 09/13/23 at 9:35 A.M. with Licensed Practical Nurse (LPN) #43 stated hospice will provide a visit schedule to the facility and it is kept at the nursing station. LPN #43 states the nurse comes once a week and not sure of the STNA's visits. Additionally, stated the Hospice provider has a book at the nursing station and may have a schedule there as well. Interview via phone on 09/13/23 at 12:20 P.M. with Hospice Staff #210 stated Resident #13 plan of care was completed and printed on 08/24/23 and sent to the physician for his signature. Hospice Staff #210 verified the physician has not returned the document at this time. Interview on 09/13/23 at 1:10 P.M. with facility Social Worker (SW) #108 verified a care conference did not occur when Resident #13 was admitted to the hospice program. SW #108 verified a significant change assessment was completed at that time. SW #108 stated the facility does not have a MDS nurse at the time and corporate is filling in. Interview on 09/13/23 at 1:52 P.M. with Hospice Registered Nurse (RN) #211 verified there has not been a care conference with the facility to collaborate care services. Further interview with Hospice RN #211 stated the plan of care for hospice care was completed on 08/24/23. Interview on 09/13/23 at 10:20 A.M. with Hospice RN #210 verified the facility binder did not contain the hospice plan of care and provided surveyor a copy for review. Interview on 09/14/23 at 11:30 A.M. with the Director of Nursing (DON) verified a care conference was not conducted to collaborate a plan of care for the Resident #13 and there should have been one. Review of the hospice contract signed 07/23/28 revealed under letter B, hospice will place a copy of the physicians plan of treatment and a copy of the interdisciplinary plan of care in the facilities chart. Additionally, letter G stated the hospice plan of care will be written and maintained at specific intervals for the hospice patient.

Based on observation, staff interview, manufacturer's instructions and facility policy review, the facility failed to properly store medications. This affected one resident (#237) whose medications were found to be preset in one medication cart of two medication carts observed and one medication room of two medication rooms observed for medication storage. The facility had a total of three medication carts and two medication rooms. The facility census was 45. Findings include: 1. Observation on 06/07/21 at 8:07 A.M. on the North Hall at the nurse's station revealed a vial of [MEDICATION(S)] (bronchodilator) 3.0 milligrams (mg.) in 3.0 milliliters (ml.) was laying on the window ledge, unattended, not in a locked container or cart and not in any prescription package. The nurse was in a resident room. Interview with Licensed Practical Nurse (LPN) #49 on 06/07/21 at 8:12 A.M. verified the vial of [MEDICATION(S)] 3.0 mg. in 3.0 ml. was laying on the window ledge, unattended, not locked and not in any prescription package. LPN #49 stated she was not aware it was there and did not leave it there. 2. Observation on 06/09/21 at 7:58 A.M. revealed LPN #30 was at the south unit medication cart. She opened the top drawer of the cart which revealed two medication cups containing preset medications. LPN #30 stated she had prepared the medications earlier and they were for Resident #237. LPN #30 verified rather than administering the medications, she left them in the top drawer while she completed a dressing change for another resident. LPN #30 stated one medication cup contained Resident #237's crushed medications [MEDICATION(S)] (treats nerve pain) 400 mg., [MEDICATION(S)] (treats [CONDITION(S)] disease) 25 micrograms (mcg.), [MEDICATION(S)] (treats heart rhythm problems) 100 mg, [MEDICATION(S)] (antipsychotic) 7.5 mg., aspirin (anti-[CONDITION(S)] and blood thinner) 325 mg., [MEDICATION(S)] (treats anxiety) 15 mg. and [MEDICATION(S)] (treats high blood pressure) 60 mg. The second medication cup contained his [MEDICATION(S)] sprinkles (anticonvulsant) 500 mg. LPN #30 then opened the [MEDICATION(S)] sprinkle capsule, emptied it into the other medication cup, added pudding and proceeded to administer the medications to Resident #237. 3. Observation on 06/10/21 at 10:28 A.M. of the south medication room with LPN #13 revealed one opened vial of influenza vaccine in the refrigerator dated 09/27/20. LPN #13 stated she did not know how long it was good and verified it was opened on 09/27/20. Review of the manufacturer's instructions for the influenza vaccine 2020-2021 formula revealed once the stopper of the multi-dose dial has been pierced the vial must be discarded within 28 days. Review of the facility's policy titled General Guidelines for Medication Storage, dated 07/23/19, revealed medications are stored safely, securely and properly following manufactures' recommendations or those of the supplier. The medications are accessible only to licensed nursing personnel, pharmacy personnel or others authorized to administer medications. Medications are dispensed in packaging/containers that meet regulatory requirements. Medication shall be kept and stored in these packages/containers. Transfer of medications from one container to another is not permitted. Only those authorized to administer medications are allowed access to medications. Medication carts, rooms and medication supplies are locked or attended by those authorized to administer medications.

Based on medical record review, observation, staff interview and review of the facility's policy, the facility failed to accurately assess and routinely monitor residents with pressure ulcers. This affected two (#4 and #25) of three residents reviewed for pressure ulcers. The facility identified four residents with pressure ulcers. The facility census was 45. Findings include: 1. Review of the medical record for Resident #4 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Slough or eschar may be present on some parts of the wound bed.), mononeuropathy, protein calorie nutrition, dementia with behavioral disturbance, muscle weakness, and [CONDITION(S)]. Review of Resident #4's plan of care, dated 03/10/21, revealed the pressure wound was to be assessed and monitored with length, width and depth when possible. The wound perimeter, wound bed and healing process was to be documented with improvements and declines in wound healing reported to the physician accordingly. Review of Resident #4's five-day Minimum Data Set (MDS) assessment, dated 03/11/21, revealed the resident was rarely/never understood with long and short term memory problems. The resident required assistance with bed mobility, transfers and toileting. The resident was admitted to the facility with a stage four pressure ulcer. Review of Resident #4's wound record revealed on 03/05/21, the resident was admitted with a stage four pressure ulcer to the sacrum which measured 11.9 centimeters (cm.) in length by 3.34 cm. in width. There were no measurements documented on 03/10/21, 03/17/21, 04/21/21, 05/21/21 and 06/08/21. The last documented wound measurement was dated 05/26/21 and measured 2.66 cm. in length by 1.83 cm. in width. Continued review of Resident #4's wound documentation revealed it to be silent for documented wound characteristics on 03/05/21, 03/07/21, 03/24/21, 03/31/21, 04/07/21, 04/14/21, 04/28/21, 05/05/21, 05/12/21, 05/14/21 and 05/25/21. Interview on 06/09/21 at 8:50 A.M. with the Director of Nursing (DON) confirmed there to be a lack of wound measurements documented for Resident #4 on 03/10/21, 03/17/21, 04/21/21, 05/21/21 and 06/08/21. The facility uploads photos, however, the measurements were not calculated on the above dates through the computerized system. The DON also confirmed there was a lack of documented wound characteristics documented for Resident #4 on 03/05/21, 03/07/21, 03/24/21, 03/31/21, 04/07/21, 04/14/21, 04/28/21, 05/05/21, 05/12/21, 05/14/21, 05/26/1 and 06/08/21. The DON confirmed Resident #4 was followed by an infectious disease physician for his wound. 2. Review of the medical record for Resident #25 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Subcutaneous fate may be visible but bone, tendon, or muscle is not exposed), obesity, protein calorie malnutrition, muscle weakness, pressure ulcer right buttock - unstageable (slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar), cognitive communication deficit, dysphonia, neuromuscular dysfunction of bladder, and an unstageable sacral region pressure ulcer. Review of Resident #25's plan of care, initiated on 04/06/21, revealed the pressure wounds were to be monitored for effectiveness and to notify the advanced level provider as needed if the area worsens or does not respond. Review of Resident #25's five-day MDS assessment, dated 04/13/21, revealed the resident had intact cognition. The resident required extensive assistance of staff for bed mobility, transfers and toileting. The resident was identified to be at risk for pressure ulcers with a documented unhealed stage three present upon admission. Review of Resident #25's wound record revealed on 04/09/21 the resident was admitted with a stage three pressure ulcer to the coccygeal which measured 7.54 centimeters (cm.) in length by 4.43 cm. in width. The assessment was silent for documented wound characteristics on this date. Continued review of the wound record revealed there were no wound characteristics documented on 04/27/21, 05/04/21 and 05/18/21. Review of the wound record revealed on 06/09/21 the wound was documented as being 2.45 cm. in length and 0.38 cm. in width with 60% slough, moderate serosanguineous drainage with attached epithelial [CONDITION(S)] and fragility surrounding the wound site. Observation of wound care for Resident #25 on 06/09/21 at 7:45 A.M. with LPN #30 revealed the resident to have two small pea sized open areas on the right buttock and one pea size open area near the sacral region. Interview on 06/09/21 with LPN #30 confirmed the resident was admitted with the open areas to the sacral and buttock areas. Interview on 06/09/21 at 8:50 A.M. with the Director of Nursing (DON) confirmed the lack of wound characteristics being documented for 04/09/21, 04/27/21, 05/04/21 and 05/18/21. The DON confirmed the resident to have documented open areas to right buttock that were being monitored as one wound site with one measurement as the wound initially entailed one area. The facility did a house sweep on 06/08/21 and realized they have issues with documentation of skin wounds and were putting a plan of action in place along with staff training. The DON confirmed Resident #25 was being followed by an infectious disease physician and surgeon for her wounds. Interview on 06/09/21 at 1:05 P.M. with Regional Administrator #150 confirmed the facility was lacking in required weekly wound documentation along with lack of documented wound characteristics which they have identified at the time of this survey in progress. Review of the facility's policy titled, Skin Care Management, with a revision date of 11/02/18, revealed with dressing changes or at least weekly at a minimum, documentation should include the date observed, location and staging, size inclusive of length and width of the wound, exudate (odor, color and approximate amount), pain, description of the wound bed to include color and type of tissue (granulation, necrosis, slough or eschar), and description of the wound edges and surrounding tissue.

Based on medical record review, observation, staff interview, and facility policy review, the facility failed to have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This affected one (#93) of two residents reviewed for urinary catheters. The facility identified three residents with an indwelling catheter. The facility census was 45. Findings include: Review of the medical record for Resident #93 revealed she was admitted on [DATE] with diagnoses of acute [CONDITION(S)], dysphagia, [CONDITION(S)], pneumonia, diabetes mellitus and hypertension. Her admission Minimum Data Set (MDS) assessment was not yet completed. Review of the initial plan of care revealed a focus area for the use of a urinary catheter with goals and interventions for the use of the catheter. Further review of Resident #93's medical record revealed there was no diagnoses for the use of a catheter and no physician orders for the use and care of a urinary catheter. Observation on 06/07/21 at 2:47 P.M. revealed Resident #93 had a indwelling urinary catheter draining dark amber urine hanging at the right side of the bed. Observation on 06/08/21 at 12:27 P.M. and at 2:14 P.M. and on 06/09/21 at 10:47 A.M. revealed Resident #93 continued to have a catheter. Interview with Director of Nursing (DON) on 06/09/21 at 12:05 P.M. verified Resident #93 was admitted to the facility with a indwelling catheter. The DON stated she did not know why she had a catheter and would have to look at the hospital notes. Interview with Licensed Practical Nurse (LPN) #30 on 06/09/21 at 12:14 P.M. verified Resident #93 had a indwelling catheter, verified there was no diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 06/10/21 at 9:23 A.M. with Assistant Director of Nursing (ADON) #36 verified there was no diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . ADON #36 verified after reviewing her admission records, they had found no reason for the catheter and Resident #93 should not have continued with the catheter after her admission. ADON #93 stated it was now discontinued and Resident #93 had expressed relief that it was gone. Review of the facility's policy titled Indwelling Urinary Catheter (Foley) Care and Management, dated 11/20/20, revealed to review the necessity of continued urinary caterer use. Remove the catheter according to the physician order or facility protocol as soon as it is no longer clinically indicated.

Based on medical record review, observation, staff interview and facility policy review, the facility failed to ensure their medication error rate of less than five percent (%). There were 35 medication opportunities with 11 medication errors, resulting in a 31% significant medication error rate. This affected one (#94) of six residents observed for medication administration. The facility census was 45. Findings include: Review of the medical record for Resident #94 revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician orders, dated 06/10/21, revealed medications including vitamin C (vitamin) 500 milligrams (mg.), Aspirin (anti-[CONDITION(S)] and blood thinner) 81 mg, calcium [MEDICATION(S)] plus vitamin D (vitamin) 315 mg./200 units, [MEDICATION(S)] (treats high blood pressure) 120 mg., [MEDICATION(S)] complete (vitamin) one tablet, [MEDICATION(S)] (vitamin) 100 mg., [MEDICATION(S)] (treats constipation) 17 grams, [MEDICATION(S)] (treats high blood pressure) 0.1 mg., [MEDICATION(S)] (blood thinner) 2.5 mg., [MEDICATION(S)] (treats high blood pressure) 25 mg. and UTI-stat (helps support urinary tract health) 30 milliliters (ml.). Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M. Observation on 06/10/21 at 9:55 A.M. revealed Licensed Practical Nurse (LPN) #144 prepared medications for Resident #94 which included vitamin C 500 mg., Aspirin 81 mg., calcium [MEDICATION(S)] plus vitamin D 315 mg./200 units, [MEDICATION(S)] 120 mg., [MEDICATION(S)] complete one tablet, [MEDICATION(S)] 100 mg., [MEDICATION(S)] 17 grams, [MEDICATION(S)] 0.1 mg., [MEDICATION(S)] 2.5 mg., [MEDICATION(S)] 25 mg. and UTI-stat 30 ml. LPN #144 administered these medications to Resident #94 on 06/10/21 at 10:10 A.M. When Resident #94 received her medications, she told LPN #144 she usually takes them at 7:30 A.M. every day. This resulted in 11 medication errors out of 35 medication opportunities. Interview with LPN #144 at the time of the observation verified she was late giving the medications for Resident #94 which were due at 7:30 A.M. and should have been administered no later than 8:30 A.M. Interview with Director of Nursing (DON) on 06/09/21 at 8:00 A.M. verified the morning medication administration was scheduled at 7:30 A.M. and the nurses had one hour before and one hour after 7:30 A.M. to complete medication administration. Review of the facility's policy titled Medication Administration, dated 06/21/17, revealed medications will be administered by legally-authorized and trained persons in accordance to applicable state, local and federal laws and consistent with accepted standards of practice.

Based on medical record review, observation, resident and staff interviews, and policy review, the facility failed to ensure non-pressure skin impairments were accurately assessed and routinely monitored. This affected one (#15) of two residents reviewed for non-pressure skin impairments. The facility census was 45. Findings include: Review of the medical record for Resident #15 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) assessment, dated 04/13/21, revealed surgical wounds were present upon admission for Resident #15. Review of the nurse progress notes from admission on 04/09/21 to 06/07/21 revealed no information about a new wound on her right leg at any time. Review of the physician orders, dated 04/09/21, revealed a dry dressing change to the right lower extremity daily. Skin checks to the right lower extremity every shift was ordered on 04/09/21. An immobilizer to the right lower extremity at all times was ordered on 04/10/21. Review of the medical record revealed the facility was using a photographing imaging wound assessment tool and Skin and Wound Evaluation form for Resident #15. Resident #15 had no initial surgical wound assessments upon admission. The first documentation of any wound assessment was a photograph dated 04/19/21 at 6:51 P.M. identified as wound #4, undiagnosed , body location was not set, age was unknown and where the wound was acquired was not set. Dimensions were 71.21 cm area, 23.87 cm length and 10.77 cm width. The image revealed four surgical wounds, one each at the lateral knee, lateral shin, medial knee and medial shin with staples intact. The four surgical wounds were not documented separately. Review of the assessment/photograph, dated 04/20/21 at 1:04 P.M., revealed wound #4 was a surgical wound with staples and the incision was approximated, six days old and present upon admission (eleven days prior). The location of the wound was not identified. Dimensions were 14.2 cm area, (80 percent improvement in one day), 20.92 cm length (12 percent improvement) and 9.77 cm width (9 percent improvement). The four surgical wounds, one each at the lateral knee, lateral shin, medial knee and medial shin with staples intact continued to be evaluated as one wound. The next assessment, dated 04/25/21 at 3:34 P.M., revealed wound #4 was 100 percent healed with zero area, length and width. The location was not identified. The wound was approximated with staples. Treatment included to wash with soap and water and no dressing was ordered. the image revealed staples were still present at the lateral shin, medial shin and medial knee surgical incisions. The lateral knee surgical incision was poorly visualized and the status of staples were unknown visually. No scabbing was visually noted at any of the four surgical wounds. Wound #4 was re-evaluated on 05/01/21 at 10:22 A.M., again identified as surgical with staples, approximated, present upon admission and with no location identified. Dimensions were 47.19 cm area, (232 percent increase), 22.27 cm length and 9.8 cm width. The image of Resident #15's right knee/shin revealed the four surgical wounds appeared well approximated with staples remaining in an undetermined number and with scabbing noted at the lateral shin, medial knee and medial shin. Wound #4 was the only assessment for the four surgical wounds. Wound #4 assessment one day later on 05/02/21 remained essentially the same as the assessment dated [DATE], however the dimensions were 15.55 cm area (67 percent improved), 22.27 cm length and 9.37 cm width. The next assessment was ten days later on 05/12/21 at 6:53 P.M. for wound #4. The location was still not identified, the four surgical wounds were still being evaluated as one wound. The image revealed increase scabbing at the lateral shin about three or four inches in length and about half an inch wide with irregular edges. The next assessment was eleven days later dated 05/23/21 at 3:53 P.M. for wound #4 identified to be surgical with staples at the right calf, well approximated and with zero area, length or width and 100 percent closed. Review of the corresponding wound photograph dated 05/23/21 revealed there were no staples on the four surgical wounds. The medial side of her right knee had two scabbed areas, each about an inch long. The medial side of her calf had one area which appeared to be scabbed about one inch long and half inch wide. Resident #15's lateral shin had a large area which appeared to be scabbed about three to five inches long and about an inch wide, increased in size from 05/12/21. No open areas were visually noted in the photograph. There was no further assessment of the wound from 05/23/21 to 06/08/21. The four surgical wounds were never evaluated separately. The first wound assessment identified as wound #4 was not completed until ten days after admission. There was no weekly wound assessment completed for ten days from 05/02/21 to 05/12/21. Interview with Resident #15 on 06/07/21 at 9:28 A.M. stated she had a wound under her right leg immobilizer. She verified she had surgical wounds from the repair of her fractured fibula and she wore a knee immobilizer. Resident #15 stated there were new wounds on her shin/ankle area in the front. The (unnamed) nurse found the wounds a couple of days ago but did not do anything to it when it was found. The nurse told her that the physician would need to be contacted for a new treatment. The nurse did cover the wound with a dry pad which was an existing treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #15 stated that yesterday (06/06/21), the dry pad was sticking to the wound. The (unnamed) nurse did put a treatment on the new wounds on 06/06/21 then again covered the entire area with the dry pad. Resident #15 stated the staff were not routinely removing the knee immobilizer and not routinely completing dressing changes for the surgical wounds. Observation on 06/07/21 at 9:28 A.M. revealed Resident #15 was wearing a removable knee immobilizer on her right leg from her ankle to above her knee. The knee immobilizer had Velcro straps holding it in place. Observation on 06/08/21 at 2:20 P.M. with Licensed Practical Nurse (LPN) #49 revealed she removed Resident #15's knee immobilizer from her right leg. There were two abdominal (ABD) pads across her shin/calf area, not secured with any tape. LPN #49 removed the two pads revealing another small dressing which looked like [MEDICATION(S)] approximately one inch square under the ABD pad at the medial mid-calf area. LPN #49 verified there was some sort of dressing about one inch square under the ABD pad and near an open wound. She removed it and verified it looked like an [MEDICATION(S)] dressing. LPN #49 verified there was no order for [MEDICATION(S)], only a dry dressing was ordered. Further observation revealed three wounds at the medial mid-calf area. The most distal area appeared to be about 0.5 centimeters (cm.) long and 0.1 cm. and scabbed. The center wound appeared to be about 2.0 cm. long and 0.5 cm. wide, open with scant drainage. The periwound area was red. The third most proximal area was about 2.0 cm. long and 0.5 cm. and scabbed. LPN #49 verified the middle wound at the medial mid-calf area appeared to have been caused by rubbing and was not surgical a wound. LPN #49 verified she had not noted the open wound during her skin inspection that morning and she did not see the [MEDICATION(S)] dressing during her skin inspection that morning. LPN #49 verified Resident #15's medial mid-calf had a new non-surgical wound previously covered with an [MEDICATION(S)] dressing. She could not say how long the wound had been there. LPN #49 verified the open wound was draining and may need separate treatment and she would update the physician. Further observation of the right lower leg revealed a healed surgical incision lateral to the knee. The surgical incision medial to the shin had scabbed areas; the surgical incision medial to the knee had small scabbed areas. The surgical incision lateral to the shin was covered with a large irregular scabbed area three to five inches long and about an inch wide. LPN #49 verified Resident #15 still had these scabbed areas at three of the four surgical incision areas. Interview on 06/09/21 from 9:56 A.M. to 2:38 P.M. with Assistant Director of Nursing (ADON) #36 verified there was no initial assessment of Resident #15's surgical wound incisions upon admission. The four surgical incisions were never evaluated separately but were documented and evaluated as a single surgical wound. The first wound assessment identified as wound #4 was not completed until ten days after admission. Weekly wound assessments were not completed. ADON #36 verified the wounds were documented as 100 percent closed on 04/25/21 and on 05/23/21. ADON #36 verified that was not accurate as evidenced by the photographic images dated 04/25/21 and 05/23/21, showed there was still scabbing present at Resident #15's shin and knee. ADON #36 verified there was no wound assessment completed since 05/23/21 to 06/08/21. ADON #36 viewed the photograph of Resident #15's right leg taken on 05/23/21 and the new photograph taken by LPN #49 on 06/08/21 showing the new wound at her medial mid-calf. ADON #36 verified there was a new wound on the photo dated 06/08/21 which not present on 05/23/21. ADON #36 verified she was not aware of the new open area, there was no documentation of the new open area at her medial mid-calf, no physician notification and no new order for [MEDICATION(S)] or any other treatment of [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on medical record review, resident and staff interview, review of the facility's shower schedules, shower/bath body audit sheets, and review of the state tested nurse aide (STNA) job summary, the facility failed to provide routine showers to a resident who was totally dependent on staff for bathing. This affected one (#15) of one resident reviewed for activities of daily living (ADLs). The facility census was 45. Findings include: Review of the medical record for Resident #15 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) assessment, dated 04/13/21, revealed Resident #15 was cognitively intact. She required extensive assistance to total assistance for activities of daily living (ADLs), including extensive assistance of two staff for dressing and personal hygiene. She was totally dependent on staff for bathing. Review of the plan of care revealed Resident #15 had an impaired ability to perform or complete activities of daily living for herself including dressing and bathing. Interventions included to assist as needed to complete ADLs and encourage independence. Provide hygiene while in bed (due to Resident #15 had a knee immobilizer.) Review of the facility's shower schedules from 04/14/21 to 05/24/21 revealed Resident #15 had showers on Wednesday and Sunday on first shift. After 05/24/21, Resident #15's scheduled shower days were changed to Monday and Thursday on first shift. Review of the tasks documentation for Resident #15 revealed physical assistance with bathing was provided once in the last 30 days (from 05/09/21 to 06/08/21) on 06/05/21. Review of the Shower/Bath Body Audit sheets for 30 days from 05/09/21 to 06/08/21 revealed Resident #15 was bathed on 05/31/21, 06/03/21 and 06/05/21. Review of the South Hall 24-hour Report Sheet, which was not a part of the medical record, revealed Resident #15 was showered on 05/16/21 and 05/23/21 and documented Resident #15 refused a shower on 05/18/21. These showers were not documented anywhere in Resident #15's medical record and no refusals of showers were documented anywhere in Resident #15's medical record. There was no evidence Resident #15 received showers or a bed bath on her scheduled shower days on 05/09/21, 05/12/21, 05/19/21, 05/24/21, 05/27/21 or 06/07/21. Resident #15 was not bathed for a week from 05/09/21 to 05/16/21 and not bathed for a week from 05/23/21 to 05/31/21. Interview on 06/07/21 at 9:40 A.M. with Resident #15 stated she has had only one bed bath in the last month. Resident #15 stated she could not shower due to the immobilizer on her leg. Interview on 06/09/21 at 2:32 P.M. with Licensed Practical Nurse (LPN) #30 verified Resident #15's shower days were on Wednesday and Sunday on first shift from 04/14/21 to 05/24/21. After 05/24/21, Resident #15's scheduled shower days were changed to Monday and Thursday on first shift. Interview on 06/09/21 at 9:04 A.M. with the Director of Nursing (DON) stated Resident #15 takes bed baths and did not want showers. The DON verified bed baths should be documented under the bathing task in Resident #15's medical record. Subsequent interview on 06/09/21 at 2:31 P.M. with the DON verified Resident #15 did not receive showers on her scheduled shower days on 05/09/21, 05/12/21, 05/19/21, 05/24/21, 05/27/21 or 06/07/21. Resident #15 was not bathed for a week from 05/09/21 to 05/16/21 and not bathed for a week from 05/23/21 to 05/31/21. Interview with Regional Administrator #150 on 06/10/21 at 8:38 A.M. stated the facility had no specific policy that defines ADLs including resident showers as they follow resident preference and orders. Review of the State tested Nurse Aid (STNA) Job Summary dated 04/15/19 revealed STNAs duties included to provide resident assistance with bathing.