Every finding on record at Otterbein Union Township

Based on Interview and Record Review, the facility failed to ensure resident care conferences were held quarterly for all residents. This affected Residents #1, #4, #5, #7, #9, #10, #36, and #51. The facility census was 51 at the time of survey. Findings include: 1.Review of the medical record revealed Resident #4 was admitted to the facility on [DATE]. Diagnoses included multiple sclerosis, type II diabetes mellitus, essential hypertension, and acute kidney failure. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact, had no behaviors, did not reject care, and did not wander. Review of Resident #4's medical records revealed that one care conference was documented on 08/29/25 with no further care documentation of care conferences. Interview on 01/14/26 at 1:50 P.M. with Social Service Director (SSD) #125 verified Resident #4 had no further care conferences for 2025. 2.Review of the medical record revealed Resident #9 was admitted to the facility on [DATE]. Diagnoses included Alzheimer's Disease, atherosclerotic heart disease, major depressive disorder, and generalized anxiety disorder. Review of the most recent MDS 3.0 assessment dated [DATE] revealed the resident was cognitively impaired, had no behaviors, did not reject care, and did not wander. Review of Resident #9's medical record revealed Care Conference Summary documentation on 05/20/25 and 08/28/25 with no further care conference documentation noted. 01/14/2026 1:50 PM Interview with SSD #125 verified Resident #9 had no further care conferences for 2025. 3.Review of the medical record revealed Resident #10 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, morbid obesity, dementia without behavioral disturbance, and rheumatoid arthritis. Review of the most recent MDS 3.0 assessment dated [DATE] revealed the resident was cognitively intact, had no behaviors, did not reject care, and did not wander. Record review reveals that Resident #10 has documentation titled Care Conference Summary dated 6/10/25 and 7/1/25 with no further care conferences noted. Interview on 01/14/26 at 1:50 P.M. with SSD #125 verified Resident #10 had no further care conferences for 2025. 4.Review of the medical record revealed Resident #51 was admitted to the facility on [DATE]. Diagnoses included paroxysmal atrial fibrillation, osteoarthritis, anxiety disorder, and spondylosis. Review of the most recent MDS 3.0 assessment dated [DATE] revealed the resident was cognitively intact, had no behaviors, did not reject care, and did not wander. Review of care conference documentation for Resident #51 reveals that care conferences were completed on 12/19/24, 06/02/25, 11/13/25, 11/24/25, and 12/17/25. Further review of care conference documentation dated 06/02/25 revealed no documentation of resident or resident representative attendance or participation in care conference. Interview on 01/14/26 at 1:50 P.M. with SSD #125 verified Resident #51 had no care conferences for from 12/19/2024 through 06/02/2025 and 06/02/2025 through 11/13/2025. 5. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease, acute respiratory failure with hypoxia, myocardial infarction, cerebrovascular accident with right (dominant) side hemiplegia and diabetes mellitus type II. Review of the MDS Quarterly assessment dated [DATE] revealed Resident #1 had intact cognition and was always incontinent of bowel and frequently incontinent of bladder. The resident required set up assistance for eating, moderate assistance for oral and personal hygiene and bed mobility, and maximal assistance for toileting, bathing, dressing and transfers. Review of care conference documentation for Resident #1 revealed there was no documentation that Resident #1 was offered or had a care conference in the second, third and fourth quarters of 2025. Interview on 01/14/25 at 1:47 P.M. with Social Services Director #125 verified the facility failed to provide care conferences for Resident #1 in the second, third and fourth quarters of 2025. 6. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, anxiety disorder, major depressive disorder and heart failure. Review of the MDS Annual assessment dated [DATE] revealed Resident #7 had severe cognitive deficit and was always incontinent of bowel and bladder. The resident required maximal assistance for eating, bed mobility and transfers, and was dependent for oral and personal hygiene, toileting, bathing and dressing. Review of care conference documentation for Resident #7 revealed there was no documentation that Resident #7 was offered or had a care conference in the second and fourth quarters of 2025. Social Services Director #125 provided documentation the facility provided Resident #7 care conferences on 02/05/25 (first quarter) and 08/25/25 (third quarter) but the care conference was attended only by Social Services Director #125 and Resident #7, who the Social Services Director #125 verified had severe cognitive deficit. Interview on 01/14/25 at 1:48 P.M. with Social Services Director #125 verified the facility failed to provide care conferences for Resident #7 in the second and fourth quarters of 2025, and that the care conferences conducted in the first and second quarters of 2025 were meaningless due to Resident #7's severe cognitive deficit. 7. Review of the medical record of Resident #5 revealed an admission date of 09/02/22. Diagnoses included vascular dementia, unspecified dementia, major depressive disorder, and anxiety disorder. Review of the most recent quarterly MDS 3.0 assessment dated [DATE] revealed the resident had severe problems with thinking and memory and demonstrated no behaviors. The resident required maximal assistance for eating, and was dependent for oral hygiene, toileting, bathing, upper and lower body dressing, transfers, personal hygiene and mobilizing her wheelchair. Review of a document titled Care Conference Form dated 03/19/25 for Resident #5 revealed a care conference was conducted on 03/19/25 without the resident but with two resident representatives and review of a document titled Care Conference Summary [NAME] - V 4 dated 08/25/25 did not indicate attendance by either the resident or a resident representative and did not include an explanation for the resident and/or resident representative not being in attendance. Interview with Quality of Life Coordinator (SSD) #125 on 01/14/26 at 12:43 P.M. revealed that care conferences should be completed at least quarterly. Further interview with SSD #125 on 01/15/26 at 8:17 A.M. confirmed care conference documentation dated 03/19/25 and 08/25/25 was accurate as provided, no additional care conference documentation existed for Resident #5, and no additional care conferences had occurred for Resident #5. 8. Review of the medical record of Resident #36 revealed an admission date of 04/20/21. Diagnoses included vascular dementia, cerebral infarction, major depressive disorder, and generalized anxiety disorder. Review of the most recent quarterly MDS 3.0 assessment dated [DATE] revealed the resident had severe problems with thinking and memory and demonstrated no behaviors. The resident required maximal assistance for eating, oral hygiene, upper and lower body dressing, and personal hygiene and was dependent for toileting, bathing, transfers, and mobilizing her wheelchair. Review of a document titled Care Conference Form dated 02/06/25 for Resident #36 revealed a care conference was conducted on 02/06/25 with the resident and no resident representatives and review of a document titled Care Conference Summary [NAME] - V 4 dated 06/02/25 did not indicate attendance by either the resident or a resident representative and did not include an explanation for the resident and/or resident representative not being in attendance of the care conference. Interview with Quality of Life Coordinator (SSD) #125 on 01/14/26 at 12:43 P.M. revealed that care conferences should be completed at least quarterly. Further interview with SSD #125 on 01/15/26 at 8:17 A.M. confirmed care conference documentation dated 02/06/25 and 06/02/25 for Resident #36 was accurate as provided, no additional care conference documentation existed for this resident, and no additional care conferences had occurred for Resident #36.

Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to provide an ongoing activities program. This affected four residents,(Residents #42, #15, #39 and #16) of four residents reviewed for activities. The facility census was 51.Findings Include: 1.Review of the medical record revealed Resident #16 was admitted to the facility on [DATE] with diagnoses of myocardial infarction, chronic obstructive pulmonary disease, congestive heart failure, hypertension and diabetes mellitus type II, Resident #16 currently serves as the House Council President. Review of the Minimum Data Set (MDS) Medicare Five-Day assessment dated [DATE] revealed Resident #16 had intact cognition and was occasionally incontinent of bowel and always incontinent of bladder. The resident required set up assistance for eating, moderate assistance for oral hygiene, bed mobility and transfers, and maximal assistance for personal hygiene, toileting, bathing and dressing. The resident required a manual wheelchair for mobility with assistance from a staff member. Review of the local area temperature website, Weather Spark, on 01/12/26 at 2:00 P.M. the outside temperature was 39 degrees Fahrenheit and on 01/13/26 at 2:00 P.M. the outside temperature was 25 degrees Fahrenheit. Observation on 01/12/26 at 2:00 P.M. and on 01/15/26 at 2:00 P.M. revealed multiple residents transported to an activity located in another unit approximately 30 to 50 yards from the original residents' unit. Interview on 01/14/25 at 9:48 A.M. with Resident #16 revealed Resident #16 did not like that some activities are scheduled in an alternate location which requires her to be transported in her wheelchair, outside, by a staff member. Resident #16 said this is especially difficult in inclement weather. The resident stated she would forego activities, even those she really wanted to attend, if the weather was inclement and the distance was so far away. She stated there was no alternative activity provided if the weather was inclement. Resident #16 also said some activities listed on the calendar either don't match the activity provided or just are not done. Interview on 01/15//25 at 11:16 A.M. the Administrator verified the residents were transported to various units, some up to approximately 50 yards away from the resident's unit, outside in weather. There was no alternative activity offered to those who wanted to go to the activity but chose not to go due to the inclement weather. 2. Record review of Resident #42 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #42 include heart failure, malnutrition, myocardial infarction, quadriplegia, and stenosis of carotid artery and left leg amputation. Review of the Minimum Data Set, (MDS) comprehensive assessment dated 12/20 25 revealed the resident had intact cognition and required maximum assistance for mobility.Review of the Plan of Care revealed Resident #42 had a mood disorder with intervention to provide and activity program developed with meaningful and of interest. This included talking time to express feelings. There was no documentation the resident resisted activities. Review of Resident #42 document, Basic Daily Activity, listed Resident #42 from 12/16/25 through 01/13/26 of only watching television in her room for two shifts. There were no other activities listed as attended.Review of email sent by a Consultant Activity Representative ,(CAR) # 150 , revealed the Resident #42 received a one to one visit by CAR #150 on 12/19/26. There was no note the resident resisted visits of CAR #150.Review of the scheduled and printed resident activity January calendar revealed seven days at 8:00 A.M. Daily Icon activity, 10:00 pet therapy every Tuesday and Thursday, 2:30 Bingo on every Monday and Wednesday, and other once a week repeated day shift activity, such as weekly church service, yoga, and 6:30 P.M. board games. Saturday consisted of each week of 8:00 A.M Daily Icon and 1:00 P.M. puzzles. There were no other activities listed. Sunday consisted of Daily Icon at 8:00 A.M. and Church services at 8:00 A.M. There were no other activities listed. There was a notation of AH ', all house , and numbers, notation the facility unit, location of activities.Interview on 01/13/26 at 1:00 P.M. Resident $#42 stated she was a social person, liked to talk and liked to do crafts. She stated she would like to do crafts, like painting, but is not provided any means to do crafts, with her contacted hands. She does not receive one to one talking time but only rarely. She stated she likes pet visits but the visits are not consistent two times a week as listed on the calendar. She stated she did not know what Daily Icon, as listed on the calendar was, and did not receive any materials in her room by the activities department. Interview on 01/13/26 at 2:07 P.M., the Certified Nursing Assistant, (CNA) # 40 verified that had been no pet therapy on 01/13/26 at10:00 A.M. as listed on the calendar. She stated she did not know what the daily 8:00 A.M. Daily Icon activity was as listed on the calendar. She stated the CNAs do not perform any (AH) all house activities, including Daily Icon. Interview on 01/13/26 at 4:00 P.M. , AD #90 verified she had developed the January calendar and did not know what Daily Icon the activity was. She stated it was an AH activity, which the CNAs should be providing. She verified there were no one on one activities documented for Resident #42 in the CNA charting. There had been no knowledge the resident wanted to do crafts. Interview on 01/14/26 at 1:00 P.M., the CNAs #20 and #30 verified they did not know what Daily Icon activity was and did not provide to the residents, although it was listed as an AH activity , for the CNAs to provide. The CNA verified Resident #42 like to stay in her room and there as no documentation there were one on one activities for the resident. 3. Record review of Resident #15 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #15 include morbid obesity, hypertension, and osteoarthritis. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had intact cognition and was dependent for staff for mobility. The resident was assessed to report participation in religious services was very important and group activities somewhat important.Review of the January activity calendar redealed Sunday consisted of Daily Icon at 8:00 A.M. and Church services at 8:00 A.M. There were no other activities listed.Review of Resident #15 Basic Activity record, revealed the resident only attended church services during the weekdays and not on Sundays.Interview on 01/12/26 at 9:30 A.M the Resident #15 verified going to church services with other residents is important to her. She stated she liked Sunday services but the facility they did not always have them. She stated there were very little weekend activity choices and she would more activity on the weekend. She did not know what Daily Icon activity every Saturday and Sunday was and did not receive any materials for that activity.Interview on 01/13/26 at 3:00 P.M. the Facility Chaplin,(FC) #100 revealed she did not provide weekend church services. Interview on 01/13/26 at 4:00 P.M. , AD #90 verified she had developed the January calendar and did not know who provided Sunday church services at 8:00 A.M. She verified it was listed as AH, all house, activity so the CNAs should be providing the services. She verified Daily Icon was on each Saturday and Sunday at 8:00 A.M. and did not know what it consisted of. She stated it was to be provided by the CNAs. Observation on 01/12/26 through 01/15/26 at 8:00 A.M. revealed no Daily Icon activity was provided in House #19. There was no Therapy pet activity observed on 01/13/26 as listed on the activity calendar.4. Record review of Resident #39 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #39 include heart failure, and insomnia. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had intact cognition and required set up assistance. The residents were assessed for activity interests included having books to read , and attending church services with others. Review of the January activity calendar revealed Sunday consisted of Daily Icon at 8:00 A.M. and Church services at 8:00 A.M. There were no other activities listed.Review of Resident #39 Basic Activity record, revealed the resident attended church services during the weekdays and not on Sundays.Interview on 01/12/26 at 9:40 A.M Resident 39 revealed there was not much activity on the weekends, and with no church services, as was listed on the calendar. She stated she liked games in the evening but games were not listed on the calendar on the weekends. She stated she did not know what Daily Icon activity was and it was not offered. She was not offered additional reading materials. She stated the CNAs on day shift do not do any listed activities due to time constraints ,and evening staff provide board games when it can be fitted into the staff routine.Interview on 01/13/26 at 4:00 P.M. , AD #90 verified she had developed the January calendar and did not know who provided Sunday church services at 8:00A.M. She verified it was listed as AH, all house, activity so the CNAs should be providing the services. She verified Daily Icon was on each Saturday and Sunday at 8:00 A.M. and did not know what it consisted of. She stated Daily Icon was to be provide in the mornings and board games were to be provided in the evenings by the CNAs. Interview on 01/14/26 at 1:00 P.M., the CNAs #20 and #30 verified they did not know what Daily Icon activity was and did not provide to the residents, although it was listed as an AH activity, for the CNAs to provide. Review of the facility policy titled, Engagement and Activity, dated February 2009, revealed the facility will provide a choice of meaningful engagement experiences. The staff is held accountable to properly document the engagement experience.

Based on record review and interviews, the facility failed to provide an activity program directed by a qualified professional. This had the potential to affect 50 residents of the 51 residents receiving the activity program. This did not affect Resident #22. The facility census total was 51. Findings Include: Findings include: Review of personnel file of hired Activity Director, (AD) #90 revealed the AD #90 was hired on 10/21/25. The AD #90 was not licensed or registered by the state. The was no evidence the AD #90 had met the qualifications to be the Activities Director. There was a payment invoice dated on 01/14/26 the AD #90 had been paid to be enrolled in the certification for activity professional.Interviewed with Resident #22 on 01/12/26 at 8:30 A.M. revealed she did not want to attend any activities and did not want any activities provided to her. She wanted left alone in her room and was satisfied with visits from her family.Interview on 01/13/26 at 4:00 P.M. , AD #90 verified she had not met the qualifications to be the Activity Director when she was hired and has not started or completed a qualifying activity director program since hire. She stated she was supposed to start the activity certification program shortly after she was hired but had not been approved to be enrolled. She stated there was not a qualified activity profession overseeing her work, but a sister facility activity person who checked in with her sometimes on the phone. AD #90 stated she had created the activity calendar for all residents for the month of December 2025 and January 2026, completed the residents Minimum Data Set activity assessments and coordinated the Resident Council monthly meetings. Interview on 01/15/26 at 11:16 A.M. the Administrator verified the AD #90 had not met the qualifications to be the Activities Director upon hire on 10/21/25 and has not met the requirements to be the Activities Director since hire. The AD #90 had four days of overlap training from the previous activity director and attended a one-day Activity Director phone conference. There was no documentation provided as evidence AD #90 had direct oversight of the duties she performed as an Activity Director by other certified activity professionals. There had not been payment for AD #90 to be enrolled in an activity certification program until 01/14/26.

Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to provide adaptive feeding devices as ordered by the physician. This affected two residents (Residents #22 and #42) of two residents for adaptive feeding utensils. The facility census was 51.Findings Include:1.Record review of Resident #42 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #42 include heart failure, malnutrition, myocardial infarction, quadriplegia, and stenosis of carotid artery and left leg amputation. Review of the Minimum Data Set, (MDS) comprehensive assessment dated 12/20 25 revealed the resident had intact cognition and required assistance for feeding. The resident received a regular diet with a order for a built up plate and spoons only. Review of admission notes of 01/05/24 revealed the Resident #42 was admitted with right and left had contractures.Review of plan of care revealed the resident was to receive a plate with sides and spoons at meals.Observations on 01/12/26 at the lunch meal and 01/13/26 breakfast and lunch meals, from approximately 8:30 A.M. and 12:30 P.M. Resident #42 did not have a built-up plate at meals. Interviews on 01/12/26 at breakfast and 01/13/26 at breakfast and lunch, the Resident #42 verified she was supposed to receive a built-up plate edge to scoop her food onto the spoon, and she does not always receive them. She verified she had not received them for the past two days. Interview on 01/13/26 at 2:07 P.M. Certified Nursing Assistant, (CNA) #40 verified she had worked on 01/12/26 and 01/13/26 from 7:00 A.M. through 3:00 P.M. and Resident #42 did not receive the built up plate at the breakfast and lunch meal of 01/12/26 and 01/13/26, CNA #40 stated she was unaware Resident #42 was to receive a built-up plate at each meal. Interview on 01/15/26 at 8:55 A.M. the Director of Nursing (DON) verified Resident #42 should have received the built-up plate at all meals, as ordered.2. Record review of Resident #22 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #22 include arthritis. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had intact cognition and required assistance with meals. The resident received a Regular diet and supplement before meals breakfast every day. The resident was to receive a specialized drinking cup and built-up handled utensils and curved handled spoon. Observations on 01/12/26 at the lunch meal and 01/13/26 breakfast and lunch meals, from approximately 8:30 A.M. and 12:30 P.M., Resident #22 did not have a built up handled and curved handled utensils at the meals. Interviews on 01/12/26 at breakfast and 01/13/26 at breakfast and lunch , the Resident #22 verified she was supposed to receive a built utensils and she does not always receive them. She verified she had not received them for the past two days. Interview on 01/13/26 at 2:07 P.M. Certified Nursing Assistant, (CNA) #40 verified she had worked on 01/12/26 and 01/13/26 from 7:00 A.M. through 3:00 P.M. and Resident #22 did not receive the built up handled utensils at the breakfast and lunch meal of 01/12/26 and 01/13/26, CNA #40 stated she was unaware Resident #22 was to receive built up utensils at each meal. Interview on 01/15/26 at 8:55 A.M. the Director of Nursing (DON) verified Resident #22 should have received the built-up food utensils at all meals, as ordered.Review of the facility policy, Adaptive Services, dated June 2008, revealed specialized eating equipment is provided to the residents who need devices to eat more independently.

Based on medical record review and staff interview, the facility failed to provide an Advanced Beneficiary Notice of Non-Coverage (ABN) prior to discharge from Medicare Part A services as required. This affected one (Resident #39) of two residents reviewed for ABNs. The facility census was 51.Findings include: Review of SNF Beneficiary Protection Notification Review document for Resident #39 revealed Resident #39 was not issued a Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (ABN) Form prior to discharge from Medicare Part A services on 09/29/25. Interview on 01/14/25 at 12:58 PM with the Administrator verified Resident #39, who remained in the facility after the discontinuation of Medicare Part A services on 09/29/25, was not issued the Facility Advanced Beneficiary Notice of Non-Coverage (ABN) Form.

Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to provide equipment to prevent physical decline . This affected two residents,(Residents #24 and #42) of two residents reviewed for equipment to prevent physical decline. The facility census was 51. Findings Include: Record review of Resident #24 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #24 include Alzheimer's disease, malnutrition, osteoporosis, adult failure to thrive, and congested heart failure. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had severely impaired cognition and required extensive staff assistance for Activities of Daily Living skills. The resident received hospice care. The resident had physician orders for positioning device to left hand as tolerated and pressure relieving boots at all times as tolerated. Observation on 01/12/26 and 01/13/26 from approximately 9:00 A.M. to 3:30 P.M., Resident #24 did not have a positioning device to left hand and did not have on pressure relieving boots. The resident was observed in a reclining chair in the common area of the unit. The rest was not combative or resistive to care. Interview on 01/13/26 at 1:07 P.M., the Director of Therapy, (DT) #60 verified Residents #24 did have on her hand device or the pressure prevention boots as ordered. Interview on 01/13/26 at 2:07 P.M. Certified Nursing Assistant, (CNA) #40 verified she had worked on 01/12/26 and 01/13/26 from 7:00 A.M. through 3:00 P.M. and Resident #24 did not have a positioning device to left hand and did not have on pressure relieving boots during her shift. CNA #40 stated she was unaware of when the devices were to be applied. Interview on 01/15/26 at 8:55 A.M. the Director of Nursing (DON) verified Resident #24 should have a positioning device to left hand and should have had the pressure relieving boots on at all times. The DON verified the Resident #24 tolerated the devices without resistance and there was no documentation to show the resident did not tolerate the devices on 01/12/26 or 01/13/26. 2. Record review of Resident #42 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #42 include heart failure, malnutrition, myocardial infarction, quadriplegia, and stenosis of carotid artery and left leg amputation. Review of admission notes of 01/05/24 revealed the Resident #42 was admitted with right leg contracture. Review of the Minimum Data Set, (MDS) comprehensive assessment dated 12/20 25 revealed the resident had intact cognition and required maximum assistance for mobility. The resident had a physician order for right knee extension splint up to four to six hours a day as tolerated. Review of plan of care revealed there was no documentation the Resident #42 and refused the application of the right left splint. Review of the Medication Administration Record of January 2026 and December of 2025 revealed the nursing staff had not documented the Resident #42 had refused the application of the right leg splint. Observations on 01/12/26 and 01/13/26 from approximately 9:00 A.M. to 3:30 P.M., Resident #42 did not have on the right knee extension splint. Observation on 01/13/26 at 1:46 P.M with the DT #60 revealed the Resident #42 right leg splint was at the bottom of her closet covered with items. Observation of the interview of Resident #42 by DT #60 revealed the resident was willing to have the right leg splint applied but the inner leg was reddened and the DT #60 deferred treatment to the nurse. The Resident #42 was agreeable to have therapy services to have the right leg splint reapplied. Interviews on 01/12/26 at 9:30 A.M. 01/13/26 ay 8:30 A.M and 01/14/26 at 8:45 A.M. Resident #42 reported the staff had not applied the right leg splint during the 24 hours. The resident stated she had not had the legs splint applied for several months. The resident stated she had refused a few times but the staff had not attempted to reapply the splint for several months. Interview on 01/13/26 at 1:46 P.M. the DT #60 verified the right leg splint was located at the bottom of resident #42 closet. The DT #60 stated she was unaware the Resident #42 had been ongoing refusing the application of the leg splint. Interview on 01/15/26 at 8:55 A.M. the Director of Nursing (DON) verified Resident #42 should have the right knee extension splint applied up to four to six hours a day. The DON verified there was no documentation the resident directly refused the device in the December 2025 and January 2026 MAR, in the plan of care or in the nursing progress notes. There was no facility policy provided regarding application of splint and pressure reliving devices.

Based on observation, staff interviews, and review of facility policy, the facility failed to store foods in a safe and sanitary manner. This had the potential to affect all 51 residents who received food from the kitchen. The facility census was 51. Findings include:Observation on 01/12/22 at 8:55 A.M. with Diet Technician #50 revealed the following concerns in House #16's kitchen. 1. An unopened container of cottage cheese with expiration date 01/10/26. 2. Opened cottage cheese opened date of 12/01/26 and expiration date of 02/27/26. Two containers of opened yogurt, one opened 01/08/26 with expiration date of 02/21/26 and the other container labeled opened on 01/01/26 and expiration date of 02/06/26. No containers had a use by or discard date labeled on the containers.3. Review of the food temperature monitor logs revealed on 01/09/26, all three meals had no food temperatures recorded, 01/07/26 had no breakfast temperatures recorded, and 01/10/26 had no breakfast and lunch meal temperatures recorded.4. Review of the dishwasher log of 01/01/26 through 01/11/26 revealed there were three shifts of temperatures record , day , evening and night shifts. There was no record that three meals of dishwasher temperatures were obtained as well as nighttime food preparation shift dishwasher temperatures were obtained. Observation on 01/12/22 at 9:05 A.M. with Diet Technician #50 revealed following concerns in House #14's kitchen:1. The ventilation hood above the stove had a heavy built up of gray debris hanging from the hood above food on the stove. 2. In the reach in refrigerator, there was an open cottage cheese with an open date of 12/29/35 and with expiration date of 01/28/26. The container had no use by or discard date labeled on the container. 3. In the reach-in refrigerator, the thermometer read 52 degrees Fahrenheit.4. Review of the food temperature monitor logs revealed on 01/12/26 had no breakfast temperatures recorded, and 01/10/26 had no breakfast and lunch meal temperatures recorded.5. Review of the dishwasher log of 01/01/26 through 01/11/26 revealed there were three shifts of temperatures record, day, evening and nightshifts. There was no record that three meals of dishwasher temperatures were obtained as well as nighttime food preparation shift dishwasher temperatures were obtained. Observation on 01/12/22 at 9:35 A.M. with Diet Technician #50 revealed the following concerns in House #15's kitchen:1. Container of opened applesauce opened container of sour cream, and container of opened cottage cheese with no open date. Expiration dates were 05/01/27, 02.04/26 and 02/04/26, respectively. There were no use or discard dates labeling.2. The reach in freezer had no thermometer.3. In the dry storage area, the refrigerator and freezer had no internal thermometer. 4. There was an opened container of food, identified as a resident's food item, dated 12/28/25.5. The inside bottom floor of the oven had several areas of brown dried debris. Observation on 01/12/22 at 9:45 A.M. with Diet Technician #50 revealed the following concerns in House #17's kitchen.1. The ventilation hood above the stove had a heavy built up of gray debris hanging from the hood above food on the stove.2. Open container of coffee creamer dated 01/03/26 with expiration date of 06/20/26. There was no use or discard date.3. Review of the dishwasher log of 01/01/26 through 01/11/26 revealed there were three shifts of temperatures record, day, evening and nightshifts. There was no record that three meals of dishwasher temperatures were obtained as well as nighttime food preparation shift dishwasher temperatures were obtained. Observation on 01/12/22 at 9:55 A.M. with Diet Technician #50 revealed the following concerns in House #19's kitchen.1. The ventilation hood above the stove had a heavy built up of gray debris hanging from the hood above food on the stove.2. Open container of cottage cheese dated 01/01/26 with expiration date of 12/28/25. There was no use or discard date.3. Opened package pf cheese opened 12/16/25 with no de0iscard date and expiration date of 03/18/26. Opened cheese dip dated 01/06/26 with expiration date of 03/18/26.4. Review of the dishwasher log of 01/01/26 through 01/11/26 revealed there were three shifts of temperatures record, day, evening and nightshift. There was no record that three meals of dishwasher temperatures were obtained as well as nighttime food preparation shift dishwasher temperatures were obtained. 5. The reach in freezer had no internal thermometer.6. In the dry storage area, there was an opened clear container containing a white dry substance. There was no label or date.7. The deep freezer had no internal thermometer Interview on 01/12/26 at 9:55 A.M. Diet Technician, (DT) #50 verified all above observations. The DT #50 stated opened foods, without a use or discard date written on the container, could be used up until the expiration date, even though the listed expiration date on the observed food items was up to two months past the opened date. The DT #50 stated she had never used a use by date or discard date, just the expiration date, after the food was opened. The DT #50 verified the stove hood screens needed cleaned, and the oven needed cleaned in House #15. The DT #50 verified the dishwasher log did not reflect three meals of dishes being cleaned, and the additional nightshift meal preparation. There were two meals during first shift and only one area to record the dishwasher temperature for Breakfast and Lunch.Interview on 01/13/26 at 1:00 P.M Certified Nursing Assistant, (CNA) # 30 revealed she had been instructed to use the expiration date of the food items as there was no discard or use date listed on food items. She did not know what the time fame was to discard opened foods, so unless there was noted spoilage, she used the expiration date which could be up to two months from when opened.Interview on 01/15/26 at 2:30, the DT #50 verified she was incorrect regarding the use of expiration date instead of a use by date. DT #50 verified opened foods should be labeled with a date when the product was opened and needed to be discarded within four to seven days of the open date. DT #50 verified without a use or discard date, the CNA would use the expiration date, which would be outside of safe food practices. Review of facility policy titled, Food Storage Best Practice Policy and Procedure, dated Augusts 2022, revealed opened food should be covered, dated, and labeled with the month and day which it was opened and used by four to seven days after the food was opened/prepared. Review of facility policy titled, Hood, Oven Cleaning Procedures, dated September 2007, revealed the hood screens, with a heavy buildup of grease, need cleaned to reduce the risk of fire and to provide a sanitary environment.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on record review, staff interview, review of self-reported incidents (SRI), review of witness statements, review of personnel files, review of X-ray results, and review of facility policy, the facility failed to ensure Resident #32 was transferred per physician orders and in a manner consistent with her plan of care. This resulted in Actual Harm on 06/22/25 at 4:01 P.M. when Certified Nursing Assistant (CNA) #168 attempted to transfer Resident #32 from the bed to a wheelchair by carrying her without additional staff and without the use of a mechanical Hoyer lift. CNA #168 tripped and fell with Resident #32 and the resident sustained an acute fracture of the right humerus, with mild displacement, and soft tissue swelling. This affected one (Resident #32) of the three residents reviewed for falls. The facility identified 11 additional residents who were dependent on a mechanical lift for transfers. The facility census was 58.Findings include::Review of the medical record for Resident #32 revealed the resident was admitted on [DATE]. Diagnoses included atherosclerotic heart disease, diabetes mellitus (DM), dementia, major depressive disorder, anxiety disorder, essential primary hypertension, and hypoglycemia.Review of a physician order dated 09/03/22 for Resident #32, revealed the resident was ordered to be transferred via mechanical Hoyer lift for all transfers. Review of the Care Plan revised on 02/02/24 for Resident #32, revealed the resident required a mechanical lift for all transfers which required two staff members. The Care Plan was revised on 06/23/35 to include a fall with major injury. Review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #32, revealed the resident had impaired cognition. Resident #32 was dependent on staff for all activities of daily living (ADLs) including transfers.Review of comprehensive Fall Risk Screening dated 05/15/25 for Resident #32, revealed the resident was at a high risk for falls. Review of the accident/incident log revealed Resident #32 had a witnessed fall on 06/22/25 at 4:00 P.M. Review of a progress note dated 06/22/25 at 4:01 P.M. for Resident #32, revealed CNA #168 transferred Resident #32 to a wheelchair and tripped during the transfer and Resident #32 fell. Resident #32 was lying flat on her back in front of the dresser with her legs outstretched and her wheelchair next to the bed. Resident #32 complained of right arm pain and had an abrasion to her right elbow which measured approximately three centimeters (cm) by 2 cm. Resident #32 guarded her right arm and cried when the nurse attempted to assess the arm. Review of the facility's SRI (261893) created on 06/22/25 at 5:13 P.M. for allegation of neglect/mistreatment, revealed CNA #168 improperly transferred Resident #32 who required assistance of two staff, and the resident was assessed with a minor abrasion. Registered Nurse (RN) #170 was called to the resident's room where the resident was discovered on the floor of her room. CNA #168 reported she was transferring the resident to a wheelchair by carrying her when CNA #168 tripped during the transfer resulting in the resident falling. The resident was assessed by RN #170 with a small abrasion to the right elbow and wound treatment was initiated. The resident complained of generalized right arm pain but unable to be specific about the pain or a pain level. The resident was contracted at baseline and the resident's range of motion (ROM) in the right arm was not within normal limits. The provider was notified of incident and provided new orders for a stat (immediate) X-ray of the right shoulder and right elbow. The X-ray results were received on 06/23/24 at 12:05 A.M. and Resident #32 had an acute right mildly displaced humeral head fracture. The resident was assessed by the Nurse Practitioner (NP) on 06/23/25 and spoke with family regarding treatment options. A sling was ordered for the resident and no further orthopedic follow up was needed. The resident's pain was managed with Tylenol and ibuprofen, and the family was in in agreement with the treatment plan. CNA #168 indicated she was aware Resident #32 required a two-person transfer via mechanical Hoyer lift and transferred the resident by herself. The facility's investigation was unsubstantiated for abuse/neglect related to the incident not meeting definitions of neglect in the regulations. CNA #168 was terminated on 06/27/25 for violations of company policy regarding delivery of patient care. The SRI was completed on 06/27/25 at 12:34 A.M. and unsubstantiated due to evidence indicating abuse, neglect or misappropriation did not occur.Review of the X-ray report dated 06/22/25 at 11:02 P.M. for Resident #32, revealed an acute fracture involving the neck of the right humerus with mild displacement. Review of a witness statement dated 06/22/25 and authored by Registered Nurse (RN) #170, revealed CNA #112 and #168 stated Resident #32 had a fall. CNA #168 reported she attempted to transfer Resident #32 to a wheelchair but tripped and fell with Resident #32. RN #170 reported she observed Resident #32 on the floor on her back in front of the dresser. RN #170 reported she assessed Resident #32 and identified an abrasion on her right arm approximately three centimeters (cm) by two (cm). RN #170 reported Resident #32 complained of right arm pain. RN #170 report she obtained an order for a stat (immediate) X-ray of the right arm and shoulder. Review of a NP #500 progress note dated 06/23/25 at 1:00 A.M. for Resident #32, revealed the resident was seen for an acute /follow-up visit. The chief complaint was a right arm injury related to a fall and right arm fracture. On 06/22/25 at 4:00 P.M., the resident had a fall related to an improper transfer and the imaging showed an acute mildly displaced humeral head fracture, The resident was placed in a shoulder sling and recommended for a follow-up X-ray in six weeks. The resident's family requested no opioids be ordered due to the resident's tolerance level. Review of an Interdisciplinary Team (IDT) note dated 06/23/25 at 3:32 P.M., revealed RN #170 was alerted by CNA #168 on 06/22/25 at 4:00 P.M. that she tripped as she attempted to transfer Resident #32 to her wheelchair when the resident fell. Resident #32 was lying flat on her back in front of her dresser with her legs outstretched. Resident #32 was assisted off the ground using a Hoyer lift with three staff members. An abrasion was noted to Resident #32's right elbow that measured approximately three cm by two cm. Resident #32 complained of right arm pain, guarded her right arm and cried when the nurse attempted to move and assess the right arm. An X-ray was completed which revealed Resident #32 had an acute right humeral neck fracture. Review of a witness statement dated 06/23/25 and authored by CNA #168, revealed on 06/22/25 around 3:45 P.M., she began her rounds and Resident #32 was in her bed. CNA #168 stated she checked and changed the resident's incontinent brief. CNA #168 indicated that since it was close to dinner time, she attempted to transfer Resident #32 then tripped and fell. CNA #168 sated she fell on her left side and Resident #32 fell on her right side. CNA #168 stated she went to the kitchen and called the nurse to tell her about the fall. Review of a witness statement dated 06/23/25 and authored by CNA #112, revealed on 06/22/25 around 4:00 P.M., she observed CNA #168 go into Resident #32's room then came out and stated Resident #32 was on the floor. CNA #112 called RN #170 to report the resident was on the floor. During an interview on 08/07/25 at 11:07 A.M., the Administrator stated on 06/22/25, CNA #168 completed an improper transfer on Resident #32 by transferring the resident without a Hoyer and without additional staff. Administrator reported CNA #168 tripped and fell with the resident during the transfer and Resident #32 sustained a fractured right arm. The Administrator verified Resident #32 was ordered to be transferred via mechanical Hoyer lift with two staff members for all transfers. The Administrator stated CNA #168 picked up Resident #32 with one arm under her shoulders and one arm under her knees and they both fell. The Administrator stated CNA #168 was terminated for an improper transfer of a Resident #32.Review of the personnel file for CNA #168 revealed a hire date of 05/21/25. CNA #168 had an active and unrestricted license. CNA #168 was terminated on 06/27/25 for an incident that occurred on 06/22/25 when CNA #168 failed to ensure the safety of self and others when she provided care inconsistent with Resident #32's care plan. Resident #32 required a Hoyer mechanical lift with two staff, and CNA #168 transferred Resident #32 without the assistance of another and without a mechanical Hoyer lift. CNA #168 was signed off on competency skills for Hoyer transfers during orientation. Subsequent interview with the Administrator on 08/07/25 at 4:19 P.M., revealed he did not report CNA #168 to the abuse registry because he reported her on the SRI. The Administrator stated he unsubstantiated the allegation of neglect because he felt the facility provided CNA #168 with the appropriate tools to provide the care for Resident #32 and CNA #168 chose not to utilize the tools. The Administrator stated he did not feel this met the definition of neglect, so the SRI investigation was unsubstantiated. During an interview on 08/11/25 at 9:36 A.M., RN #170 stated she was the charge nurse on 06/22/25 when she got the call from CNA #112 who stated Resident #32 had a fall. RN #170 stated there were small houses on the campus where the residents reside. RN #170 stated when she arrived in Resident's #32 house, she learned CNA #168 was the only CNA in the house. RN #170 stated CNA #168 picked up Resident #32 with her arms around her and attempted to pivot her to a wheelchair when both fell to the ground. CNA #168 stated CNA #112 was not in the house at the time of the fall. RN #170 stated Resident #32 had an abrasion on her right elbow and complained of pain in her right arm. RN #170 stated she obtained an order for a stat X-ray and provided pain medication to Resident #32.Review of the undated Kardex form (a quick reference guide for caregivers, providing a snapshot of a resident's status and care plan) for Resident #32, revealed the resident required a mechanical lift with two staff members using a red sling for transfers.Review of the facility policy titled Abuse, Mistreatment, Neglect, Exploitation, and Misappropriation of Resident Property-Ohio only dated 10/25/22, revealed the definition of neglect is the failure of the facility or its staff to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish or emotional distress. Review of the facility policy titled Falls Management dated 12/03/19, revealed the facility would have procedures in place to prevent and/or reduce falls. The definition of a fall is an unintentional coming to rest on the ground, floor, or other lower level. When a Resident is observed on the floor, a fall is considered to have occurred.The deficient practice was corrected on 07/03/25 when the facility implemented the following corrective actions: On 06/22/25 at 5:23 P.M., immediate education was sent out to all employees via a facility application installed on all the employees' phones. The education consisted of ensuring staff followed the residents' care plans, Kardex, physician orders, ensuring all staff utilized a mechanical lift if required and transferring resident with two staff members if required. The Administration was able to verify all employees received the education via a read message returned to the facility. Starting on 06/23/25 and completed on 07/03/25, the DON initiated education for all nursing staff which included nurses and CNA on providing care as documented in the residents' care plan, the importance of utilizing two staff members with resident care when required, safe transfers, utilizing mechanical lifts if required and providing care per physician orders. A return demonstration on resident transfers via Hoyer lift was completed with all nursing staff. A post-education quiz was utilized with all staff to verify the staff's knowledge related to proper transfers, abuse, neglect, and how to access the Kardex or Care Plan. On 06/23/25 and 06/24/25, the DON completed an audit for all current residents who used a Hoyer lift for transfers. The facility identified 11 (#01, #02, #13, #20, #28, #37, #38, #40, #45, #53 and #60) additional residents required the use of a Hoyer lift for transfers and/or to obtain ordered weights. There were no adverse findings.Beginning on 06/23/25, the DON/designee conducted randomized observational audits of mechanical Hoyer lift transfers on at least five residents weekly for four weeks. The results were reported to the Administrator and Quality Assurance and Performance Improvement (QAPI) committee for any modification of intervention or adjustments as needed. On 06/23/25, The DON completed an audit on all current residents to ensure physician orders, Care Plans, and Kardexs were current and up to date and current per physician orders. No additional concerns were identified.On 6/23/25, an ad hoc QAPI meeting was held by the IDT with the medical director in attendance to discuss the incident and review the audits completed of all elder records to ensure physician orders, care plans, and Kardexs were accurate. Additional QAPI meetings were held weekly for four weeks to ensure audits were completed and to review them to determine if any modification of intervention or adjustments were needed.On 06/23/25, the previous physician order dated 09/03/22 related to Resident #32 being transferred via Hoyer, was discontinued and a new order was placed so the physician order would transfer over to the treatment administration record (TAR) which required the nurses to sign off when the transfer was completed via Hoyer. This same order was also completed for the 11 additional residents identified as utilizing a Hoyer for transfers. On 06/25/25, skin assessments were completed for all residents who could not be interviewed. No issues were identified. On 06/27/25, CNA #168 was terminated for an improper transfer related to the transfer with Resident #32.This deficiency represents non-compliance investigated under Complaint Number OH00167463.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, incident investigation review, and staff interview, the facility failed to provide the appropriate level of assistance during resident transfers. This affected one (Resident #34) of the four residents reviewed for falls. The facility census was 58 residents. Findings include: Review of the medical record for Resident #34 revealed an admitted [DATE] with diagnoses including heart failure and morbid obesity. Review of the plan of care for Resident #34 dated 11/07/23 revealed the resident was at risk for falls related to impaired mobility, history of falls, history of a fractured femur, and obesity. Interventions included to ensure two staff members provided all check and change care. Review of the Minimum Data Set (MDS) assessment for Resident #34 dated 06/19/24 revealed the resident had moderately impaired cognition and required complete staff assistance by two staff members for bed mobility, transfers and most activities of daily living (ADL) care. Review of the progress note for Resident #34 dated 06/04/24 timed at 4:23 A.M. per Registered Nurse (RN) #23 revealed the Elder Assistant (EA) notified the nurse Resident #34 was assisted to the floor while the EA was changing and turning the resident. The nurse assessed the resident and noted multiple bruises to the left forearm. Resident #34 denied pain and neurological checks were within normal limits. The nurse called 911 was called for lift assistance and remained with the resident until emergency personnel arrived to transport the resident to the hospital. Follow up interventions included to ensure the assistance of two staff for all check and changes. Review of the fall investigation form for Resident #34 dated 06/04/24 revealed the resident fell when receiving assistance from one staff member. Resident #34 was assisted to the floor while one staff member was changing and turning resident. Review of the investigation statement form for Resident #34 dated 06/04/24 per the Director of Nursing (DON) and Hospice RN #836 revealed the hospice RN and the DON assessed the resident's skin following the fall on 06/04/24 and determined there were various areas of discoloration, no bruising noted to shoulder or legs, discoloration noted to left arm that appear to be related to co-morbidities versus actual bruising. Resident #34 had normal range of motion (ROM) to all extremities and denied pain to the joints. Review of the investigation statement form for Resident #34 dated 06/05/24 per the DON revealed RN #23 reported being called to the resident's room by EA #3 who stated she was providing care to the resident and lowered her to the floor from the bed. Review of the investigation statement form for Resident #34 dated 06/05/24 per Elder Assistant Coach (EAC) #585 for an incident that occurred on 06/04/2024 revealed EA #3 stated was providing incontinence care to Resident #34 and she rolled the resident onto her left side and the resident's legs dropped to the side of the bed so the EA put her body against the resident's upper body, used the remote to lower the bed, and then the EA laid the resident onto the floor. EA #3 reported she was the only staff member providing assistance to Resident #34 on 06/04/24 when the resident was lowered to the floor. Review of the witness statement dated 06/05/2024 timed at 11:30 A.M. per EAC #585 revealed the coach educated EA #3 regarding use of the Hoyer lift and the importance of checking the Kardex/care plan on the electronic charting system when coming onto a shift before providing care to elders to ensure the appropriate level of assistance was provided. Interview on 07/24/2024 at 1:00 P.M. with the Administrator confirmed EA #3 lowered Resident #34 to the floor during care. The Administrator further confirmed Resident #34 was care planned to require the assistance of two staff members for bed mobility and incontinence care, and the incident occurred when EA #3 provided bed mobility and incontinence care with only one staff member. The deficient practice was corrected on 06/08/2024 when the facility implemented the following corrective actions: -On 06/04/24 the DON and Hospice RN #836 assessed Resident #34 for injuries and found no fractures or complaints of pain. -On 06/05/24 the DON provided education for all staff on care delivery and review of the Kardex prior to the delivery of care. -On 06/05/24 the Interdisciplinary Team (IDT) reviewed the incident on 06/04/24 involving Resident #34. -On 06/06/24 the DON completed a 72-hour follow up assessment of Resident #34 -On 06/06/24 Resident #34 had an x-ray of her left hip, pelvis, knee, and ankle with no fractures. -On 06/08/24 the DON completed a 100 percent (%) audit of resident care plans to determine that transfers status, bed mobility, and care needs flowed over to their Kardex. -On 06/08/24 the DON and/or designee began auditing of transfers for residents including Resident #34 and a random sample of other residents who required the assistance of two staff for bed mobility and transfers. The results would be monitored by Quality Assurance and Performance Improvement (QAPI) committee and frequency would be adjusted per recommendations. Monitoring would continue for four weeks with frequency adjusted as needed by QAPI committee. -Interview on 07/24/2024 from 1:00 P.M. through 2:30 P.M. with Caregiver #326, #338, #565, and #867 confirmed they had received education per management staff on or around 06/05/2024 regarding reviewing each residents Kardex prior to the start of their shift on how to properly deliver their care. This deficiency represents noncompliance investigated under Complaint Number OH00155181.

Based on medical record review, staff interview, and review of facility policy, the facility failed to verify a resident's (Resident #55) identity prior to medication administration, resulting in Resident #55 being given another resident's medication. This resulted in actual harm when Resident #55 had a subsequent episode of vomiting and lethargy, leading to the resident being transferred to the emergency room . Additionally, the facility failed to administer pain medication in a timely manner and as ordered by the physician for Resident #107. This affected two (Residents #55 and #107) of six residents reviewed for medication administration. The facility census was 58. Findings included: Medical record review for Resident #55 revealed the resident admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #55's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderate cognitive impairment. Resident #55 required extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. Review of the facility's undated incident submission summary revealed on 05/29/22, Resident #55 was administered the wrong medication by agency staff. The agency staff member was going in order of rooms and failed to verify Resident #55's name and room number with staff. At approximately 10:30 A.M., Resident #55 was given aspirin, calcium, [MEDICATION(S)], [MEDICATION(S)], iron, [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], multivitamin, Profenone, zinc and vitamin D. After the wrong medication was administered, Resident #55 presented with vomiting. The agency nurse contacted the physician who gave orders to send the resident to the emergency room . The nurse also contacted Resident #55's representative and Resident #55 left the facility for the hospital at 11:30 A.M. On 05/29/22 at approximately 12:21 P.M., the facility contacted the emergency room , and the emergency room nurse returned the call and reported Resident #55 was fine and lethargic. Resident #55 also still had episodes of vomiting but was stable. Resident #55 returned from the hospital on 05/29/22 at 8:10 P.M. Review of the progress note dated 05/29/22 revealed Resident #55 was out to the hospital and should be closely monitored and charted on every shift for three days. Per the hospital, the resident was in stable condition. Review of the late entry progress note dated 05/31/22 revealed Resident #55 was administered the wrong medication. The nurse was educated on medication administration and asking facility staff for proper resident identification if unable to determine. The physician and family were notified. Resident #55 returned from the emergency room at 8:10 P.M. with vital signs within normal limits and lungs clear with a moist cough noted. Resident #55 continued on coronavirus quarantine until asymptomatic. Resident #55 denied pain or discomfort. No further emesis noted. All parties were aware. Telephone interview on 08/04/22 at 1:30 P.M. with the Director of Nursing (DON) revealed she received a call from the previous Administrator on 05/29/22. The Administrator informed the DON Resident #55 was administered another resident's medications. Resident #55 received Aspirin 81 milligrams (mg), calcium plus vitamin D 600mg, [MEDICATION(S)] 10 mg, [MEDICATION(S)] 100mg, iron 325 mg, vitamin D 25 micrograms (mcg), [MEDICATION(S)] 300 mg, [MEDICATION(S)] 5 mg, [MEDICATION(S)] 10 mg, [MEDICATION(S)] 40 mg, multivitamin and zinc 50 mg that were not prescribed to her. The DON stated the nurse who administered the wrong medications was an agency nurse, but she could not recall her name. The DON stated the agency nurse was going room to room passing medications and did not realize she was in the wrong room. The DON stated Resident #55 had episodes of vomiting after receiving the wrong medication and was sent to the emergency room . The DON reported Resident #55's representatives were contacted. The DON reported she started medication administration audits after the incident and educated the facility's staff. The DON also reported she notified the agency where the agency nurse was employed, of the incident. The DON educated the nurse that made the medication error but did not put in place, any education for other agency nurses or staff that worked in the facility stating, It's the agencies job to educate their staff. Attempted interview on 08/09/22 at 2:05 P.M. with Staffing Agency #801 was unsuccessful. Review of the facility's medication administration procedure revised 11/09/21 revealed residents are identified before medications are administered. Methods of identification include checking the photograph attached to the medical record, ask the resident to say or spell his or her name, and verify the resident's identification with other community personnel if necessary. 2. Review of Resident #107's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #107's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status score of 15, which indicated the resident was cognitively intact. The MDS revealed the resident required extensive two-person assistance for bed mobility, transfers, and dressing. The resident was totally dependent with two-person assist for toileting and personal hygiene. The resident required supervision with set-up for eating. Review of Resident #107's plan of care dated 07/17/22 revealed the resident had a self-care deficit related to multiple diagnoses. The plan of care identified the resident was at risk for skin breakdown. Interventions included turn and repositioned frequently. The plan of care revealed the resident was at risk for pain with interventions to administer medications as ordered. Review of Resident #107's physician order dated 07/22/22 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .M., 5:00 P.M. and 9:00 P.M.) for pain. Observation on 08/01/22 at 11:59 A.M. revealed Resident #107 was administered the [MEDICATION(S)] 75mg, which was ordered to be administered at 8:00 A.M. Interview on 08/01/22 at 12:10 P.M. Resident #107 reported she did not receive her morning medications until almost noon. Interview on 08/01/22 at 12:34 P.M. with Licensed Practical Nurse (LPN) #92 confirmed the resident's [MEDICATION(S)] was ordered to be administered at 8:00 A.M. LPN #92 confirmed she did not administer the medication timely. LPN #92 revealed she had an admission earlier in the morning which made her medication administration times late. Interview on 08/01/22 at 1:05 P.M. with the Certified Nurse Practitioner (CNP) #325 revealed she was at the facility every Monday and Thursday. The CNP #325 revealed late medication administration was a, common occurrence. Interview on 08/02/22 at 10:44 A.M. with the Director of Nursing confirmed it was the facility's expectation to administer resident's medications within one hour prior or one hour after the scheduled medication ordered time. Review of the facility policy titled, Medication Administration Procedures, revised 11/09/21 revealed medications are administered within one hour before or one hour after scheduled times.

Based on observation, staff interviews, review of manufacture directions, and review of facility policy, the facility failed to store foods in a safe and sanitary manner. This had the potential to affect all 58 residents who received food from the kitchen. The facility census was 58. Findings include: Observation on 08/01/22 at 8:30 A.M. with Diet Technician #31 revealed the following concerns in House #16's kitchen. 1. Two containers of unidentifiable food, unlabeled and undated. 2. Three quarters of a chocolate pie in a pie pan uncovered and undated. 3. Opened potato salad, undated. 4. Container of opened applesauce, undated. 5. Open container of pineapple undated. 6. Container of opened chicken broth, undated. 7. No thermometer in reach of the refrigerator. 8. An undated pan of partially served brownies. Observation on 08/01/22 at 8:45 A.M. with Diet Technician #31 revealed the following concerns in House #17's kitchen: 1. Container of opened applesauce, undated. 2. Container of opened beef broth with expiration date of 07/27/22. 3. Undated open container of cranberry juice. 4. No thermometer in reach of the freezer 5. Package of bread with expiration date of 07/31/22. Observation on 08/01/22 at 9:05 A.M. with Diet Technician #31 revealed following concerns in House #19's kitchen: 1. No thermometer in reach of the refrigerator or freezer 2. Container of opened beef broth with expiration date of 07/28/22. 3. Open containers of sour cream and cottage cheese, undated. 4. Container of opened applesauce, undated. Observation on 08/01/22 at 9:20 A.M. with Diet Technician #31 revealed following concerns in House #15's kitchen: 1. No thermometer in reach of the refrigerator. 2. Container of opened chicken broth with expiration date of 07/20/22. 3. Cheese spread, undated. 4. Open and partially used sour cream, undated. 5. Bagged potatoes stored on the floor in the dry storage area. 6. Two bags of unidentifiable food unlabeled and undated. Observation on 08/01/22 at 9:30 A.M. with Diet Technician #31 revealed following concerns in House #14's kitchen: 1. Container of opened applesauce, undated. 2. Open container of ham salad, undated. 3. No thermometer in reach of the refrigerator. 4. Bag of several unidentifiable containers with food undated and unlabeled. Interview on 08/01/22 at 9:30 A.M. Diet Technician #31 verified all above observations. Interview on 08/09/22 at 1:20 P.M. Registered Dietitian (RD) #800 verified opened foods should be labeled with a date of when the product was opened and needed to be discarded within four to seven days of the open date. Review of facility policy titled, Food Storage Policy and Procedure, dated May 2013, revealed food should be covered, dated, and labeled with the month and day which it was opened and used by four to seven days after the food was opened/prepared. Food containers are stored at least six inches off the floor.

Based on observation, record review, staff interviews, resident interviews, and review of facility policy, the facility failed to provide sufficient staffing to meet the needs of the residents. This affected one (Resident #107) and had the potential to affect twelve residents (#207, #47, #46, #156, #206, #111, #106, #107, #45, #108, #40 and #31) who resided in House #15. The facility census was 58. Findings included: During initial tour of the facility on 08/01/22 from 8:15 A.M. through 9:20 A.M. revealed the facility had five separate homes. Each home was licensed for twelve residents. There were two nurses, Licensed Practical Nurse (LPN) #92 and Registered Agency Nurse (RN) #120 and eight State tested Nurse Aides (STNA) (#8, #9, #35, #38, #46, #52, #76, and #82) present in the facility to care for 58 residents residing in the five houses. Review of Resident #107's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #107's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status score of 15, which indicated the resident was cognitively intact. The MDS revealed the resident required extensive two-person assistance for bed mobility, transfers, and dressing. The resident was totally dependent with two-person assist for toileting and personal hygiene. The resident required supervision with set-up for eating. Further review of the MDS revealed the resident revealed the resident was occasionally incontinent of bowel and bladder. Review of Resident #107's plan of care dated 07/17/22 revealed the resident had a self-care deficit related to multiple diagnoses. The plan of care identified the resident was at risk for skin breakdown. Interventions included turn and repositioned frequently. Interview on 08/01/22 at 12:10 P.M. with Resident #107 revealed no staff who had offered to change or reposition her since 4:00 A.M. The Resident #107 stated she required two staff to change and reposition her. The resident stated there was only one staff member. Resident #107 stated there have been days when she was wet up to her shoulders because there was not enough staff. Resident #107 stated she was uncomfortable and needed repositioned. Interview on 08/01/22 at 12:32 P.M. with State tested Nursing Assistant (STNA) #76 confirmed she began working at 7:00 A.M. and had not repositioned or changed Resident #107 since coming to work. STNA #76 stated she was currently the only direct care staff in House #15 and the resident required two staff for incontinence care. Interviews on 08/04/22 from 7:53 A.M. with STNA #6 and #89 revealed the facility did not have sufficient staff to provide the care and services needed for the residents. STNA #6 stated there are multiple residents who require two people for repositioning and transfers. Interview on 08/04/22 at 10:44 A.M. with Director of Nursing confirmed the facility expectation for the STNAs included resident care, cooking, cleaning, and laundry. The DON stated the night shift cleans the common area and does the laundry. The first shift STNAs responsibilities included cooking, serving, and providing care and services for the residents. The DON revealed it was the responsibility of the STNAs to ask for help from administrative staff if needed. The DON stated the goal was two STNAs were to be assigned to each home. The DON confirmed there were homes with only one STNA to care for the twelve residents. The DON further reported the expectation was if residents required incontinence care, they were checked and respositioned every two hours. Review of the facility Resident Council Meeting Minutes dated 03/29/22 revealed residents voiced concerns related to only one STNA working in a house per shift. Review of the facility policy titled, Scheduling Guidelines Consistent Assignments, dated 01/23/08 revealed the facility must maintain appropriate staffing levels in each home. The policy revealed consistent assignments are essential to the quality and care of the elders. Further review revealed two STNAs per house and two nurses per neighborhood (five homes) were to be scheduled on day shift and afternoon/evening shift and one STNA and one nurse on night shift. This deficiency substantiates Complaint Numbers OH 286, OH 632, and OH 398.

Based on record review, observation, and interview, the facility failed to provide food portions and menus as approved by a Registered Dietitian. This had the potential to affect all 58 residents who received food from the kitchen. The facility census was 58. Findings Include: Review of the facility's approved menu dated 08/01/22 for House #15's lunch meal revealed the following was to be served: Six ounces (oz) of spaghetti with meatballs, four oz of broccoli, four oz of cottage cheese with peaches, one slice of garlic bread and a beverage. Observation on 08/01/22 at 12:40 P.M. revealed Resident #207 was served five slices of peaches, less than one cup of chicken noddle soup, and one slice of bread with butter. Interview on 08/01/22 at 12:41 P.M. Resident #207 reported the lunch portion was, not much food for anyone. Resident #207 stated the portion sizes were dependent upon which State tested Nurse Aide (STNA) or how many STNAs were working. Resident #207 also verified menus were not followed. Observation and interview on 8/01/22 at 1:15 P.M. revealed Resident #206 was serviced five slices of peaches, less than one cup of chicken noodle soup, and one slice of break. Resident #206 verified the food served and reported she had not requested a substitute. Resident #206 reported there was not enough time for staff to prepare meals on most days and there was only one STNA working to prepare meals and care for residents. Interview on 8/01/22 at 1:18 P.M. Household Assistant (HA) #77 reported she prepared lunch and did not follow a menu, but prepared the meal with foods found in the storage room. HA #77 verified she did not use measuring utensils when serving lunch. HA #77 did not have approval from a Registered Dietician (RD) to make food substitutions and did not log substitutions. HA #77 further verified she did not follow recipes when preparing meals, but utilized the meal guideline reference sheet found in the STNA notebook of menus. HA #77 reported broccoli was listed on the lunch menu for 08/01/22 and she did not prepare broccoli or any other vegetable for lunch. Interview on 08/01/22 at 12:27 P.M. with STNA #46 (working in House #14) revealed the menu changed from a hamburger to a tuna noodle casserole, with no vegetables because groceries were not delivered as planned. STNA #46 did not use a recipe and did not use measuring utensils when serving. STNA #46 verified she was the only STNA working in the house and had little time to prepare a full meal. STNA #46 reported she did not have approval from a RD to make food substitutions and did not log substitutions. Interview on 08/02/22 at 10:35 A.M. with STNA #11 (working in House #16) revealed she was the only STNA working to prepare meals and care for 12 residents. STNA #11 verified the menu was not followed as many foods were not delivered and recipes were not provided. STNA #11 further stated measuring utensils were not utilized to follow listed portion sizes and there were no measuring utensils even available for use. STNA #11 reported she did not log food substitutions. Observation and interview on 08/03/22 at 8:50 A.M. with STNA #89 (working in House #16) revealed breakfast served was a croissant roll with eggs, cheese, and bacon, despite the menu listing one egg, two slices of bacon, one cup of cereal, and two slices of toast. STNA #89 stated she did not follow a recipe and used five slices of bacon for 12 residents. STNA #89 stated a RD did not review, provide, or approve recipes or meal substitutions. STNA #89 further verified she did not measure portions per the menu and she, eyeballs, the amount of food she thinks the resident will accept. Interview on 08/03/22 at 11:06 A.M. with HA #77 (working in House #19) revealed the menu listed the following to be served for lunch: Applesauce, ham salad, croissant, and broccoli salad. HA #77 stated none of the ingredients were available and she was substituting the meal with hotdog's, baked beans, potato salad or potato chips. HA #77 stated a RD had not approved the substitution and it was not logged. HA #77 reported she did not know what portion sizes were required and verified she did not have measuring utensils available for use. Observation and interview on 08/03/22 at 11:20 A.M. with STNA #19 (working in House #15) revealed the planned meal was supposed to be four oz of pulled pork sandwich, green beans, pasta salad, and a fruit cup, but she was serving a baked chicken croissant, green beans with potato, fruit cocktail, and pudding. STNA #19 verified she came up with the baked chicken croissant recipe herself and it was not written down. STNA #19 was not measuring the chicken mixture when preparing the croissant. STNA #19 stated she was putting enough in the croissant so it could be folded. Upon insistence of the surveyor, the meat mixture measured two oz, not four oz as listed on the menu for the protein portion. Observation and interview on 08/03/22 at 12:19 P.M. with STNA #6 (working in House #16) revealed she was serving Spaghetti O's, mixed fruit, peanut butter sandwich, and mixed berry pie for lunch. STNA #6 was unaware of required portion sizes and reported she did not have any measuring utensils for use. Review of the planned menu for House #15 dated 08/03/22 revealed the supper meal was to consist of hearty vegetable soup, a roll, pears, and a cookie. There was no entry on the substitution log for baked spaghetti. Interview on 8/04/22 at 8:30 A.M. family member of Resident #156 (in House #15) revealed the supper meal on 08/03/22 consisted of baked spaghetti, applesauce, and no vegetable. Interview on 08/04/22 at 08:47 A.M. Resident #107 verified supper on 08/03/22 had no vegetables served. Interview on 08/04/22 at 10:52 A.M. STNA #38 (working in House #17) verified substitutions of meals were not documented on the substitution logs. Review of substitution logs of Houses #14, #15, #16, #17 and #19 for January 2022 through August 2022 revealed no food substitution entries. Review of Resident Council Meeting Minutes dated 07/27/21 and 10/26/21 revealed Resident #49 reported there were a lot of menu substitutions and the menu was not followed a lot of the time. Review of the Food Substitution Guideline Reference Sheet dated 03/20/20 revealed like foods were to be substituted for like foods. Review of facility policy titled, Food Substitution Log Use, dated 07/21/22 revealed food is substituted in an appropriate, healthy, and safe way. Food will be replaced with the respective food group, the diet technician will be notified of the change to the day's menu, the change will be written on the menu substitution log. Review of the facility policy titled, Family Style Meal Service Policy and Procedure, dated May 2013 revealed the nurse aide will plate food with the appropriate serving portion.

Based on observation, record review, and staff interview, the facility failed to timely notify a physician of a resident's significant weight loss. This affected one resident (#55) out of five residents reviewed for nutrition. The facility census was 58. Findings include: Medical record review revealed Resident #55 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #55's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately cognitively impaired and required extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. Resident #55 required supervision with eating. Resident #55 was reported to have a five percent or more weight loss in the last month or ten percent or more in the last six months and was not on a prescribed weight loss regimen. Review of Resident #55's nutritional care plan dated 05/06/22 revealed Resident #55 was at risk for changes in nutrition. Interventions included review the resident's weights, skin, labs, and intakes routinely and as available and report changes as needed, offer supplements as ordered, offer the diet as ordered by the physician, observe for signs and symptoms of dehydration, offer meal substitutes, encourage the resident to eat and drink, encourage the resident to eat calorically dense foods and encourage the resident to drink all of her fluids when medications are given. Review of Resident #55's weights from 05/01/22 to 08/01/22 revealed Resident #55 weighted 184.2 pounds (lbs.) on 05/01/22, 183.2 lbs. on 05/10/22, 181.4 lbs. on 05/17/22, 182.4 lbs. on 05/31/22, 182.4 lbs. on 06/01/22, 170.0 lbs. on 06/07/22, 170.0 lbs. on 06/16/22, 170.2 lbs. on 06/28/22, 172.9 lbs. on 07/12/22, 160.6 lbs. on 07/26/22 and 159.8 lbs. on 08/01/22. Review of Resident #55's quarterly nutritional screen dated 06/14/22 revealed Resident #55 had a weight loss of five percent or more in the last month or ten percent or more in the last six months and was not on a prescribed weight loss regimen. The assessment reported Resident #55 was on weekly weights and had a significant weight loss over the past 30 days. Review of Resident #55's quarterly nutritional screen dated 08/02/22 revealed Resident #55 had a loss of five percent or more in the last month or ten percent or more in the last six months and was not on a prescribed weight loss regiment. The assessment reported Resident #55 was on weekly weights and had a significant weight loss over the past 30 days. A recommendation of ensure [MEDICATION(S)] 237 milliliters twice a day was recommended to the physician. Review of Resident #55's progress notes from 07/26/22 to 08/02/22 revealed no documentation that Resident #55's weight loss of 7.11 percent or Resident #55's weight loss of 172.9 lbs. to 160.6 lbs. from 07/12/22 to 07/26/22 was addressed by the dietician or physician, or that interventions were put in place for the weight loss prior to 08/02/22. Additional review revealed no documentation the physician was notified of the weight loss. Telephone interview on 08/04/22 at 10:15 A.M. with Registered Dietician (RD) #800 verified Resident #55 did not receive a weekly weight on 07/19/22 as ordered by the physician. RD #800 also verified Resident #55 had a weight loss of 7.11 percent or 172.9 lbs to 160.6 lbs from 07/12/22 to 07/26/22 and Resident #55 was not assessed for the weight loss and no interventions were put in place until 08/02/22. RD #800 also confirmed the physician was not notified of Resident #55's weight loss of 7.11 percent or 172.9 lbs on 07/12/22 to 160.6 lbs on 07/26/22 until 08/02/22.

Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to provide an ongoing activities program. This affected three (Residents #29, #30, and #50) of four residents reviewed for activities. The facility census was 58. Findings include: 1. Medical record review revealed Resident #29 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #29's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively impaired and required extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. The resident activity preferences included group activities, and pet visits. Further review of the medical record and review of the Activity Leisure Logs revealed no documentation showing Resident #29 participated in daily activities. 2. Medical record review revealed Resident #30 admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #30 admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired and required extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. Resident #30 activity preferences included watching TV in room in afternoon and group activities. Further review of the medical record and review of the Activity Leisure Logs revealed no documentation showing Resident #30 participated in daily activities. 3. Review of the Resident #50s chart revealed Resident #50 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #50's admission Minimum Data Set (MDS) assessment dated [DATE]revealed the resident was moderately cognitively impaired and required extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. There were no activity preferences listed on the MDS. Further review of the medical record and review of the Activity Leisure Logs revealed no documentation showing Resident #50 participated in daily activities. Observation on 08/01/22 revealed the facility had five separate houses. Each house was licensed for 12 residents. There were two nurses and eight State tested Nurse Aides (STNA) present in the facility to care for 58 residents. The STNAs were observed assisting residents with care, cooking, and washing dishes. Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no times listed for the activities except for church at 2:00 P.M. on 08/03/22. A weekly pet visit was scheduled on Tuesday, 08/02/22. Review of activity calendars provided from 07/10/22 through 08/13/22 revealed no Bingo was listed as a planned activity. Random observations of residents from 08/01/22 through 08/04/22 from 8:30 A.M. to 4:30 P.M. revealed one activity was presented by a volunteer on 08/03/22 at 2:00 P.M. No other organized planned activities were led or offered by STNAs or other designated staff throughout the facility. Interview on 08/01/22 at 4:38 P.M. the family member of Resident #30, who visits multiple times throughout the week, reported there were no group and/or planned activities for residents. Interview on 08/02/22 at 4:26 P.M. STNA #63 verified the facility has not had an Activity Director since 07/07/22 and no activity staff for the last three years. The STNAs were expected to provide activities as scheduled or alternatives. Activities and any one-on-one activities were to be documented in the Activity Leisure section of the resident's medical electronic record. Interview on 08/03/22 at 8:50 A.M. STNA #89 reported there was not enough time to conduct activities. STNA #89 further reported the facility did not have an Activity Director for over a month and no activity staff. STNA #89 did not have the activity calendar for the current week and was unaware of what activities were scheduled. STNA #89 said daily participation in activities were to be documents in the resident's electronic medical record, for each resident. Interview on 08/03/22 at 11:10 A.M., STNA #26 verified family members have voiced concerns regarding insufficient resident activities. STNA #26 further verified there had been no ongoing activities for over three weeks. Interview on 8/03/22 at 11:45 A.M. STNA #46 verified the facility did not have an Activity Director and there were no designated activity staff to cover each house. STNAs did not have enough time to provide planned activities or one-on-one activities. Observation on 08/03/22 at 1:19 P.M. revealed Resident #30 was sitting in a wheelchair at the dining room table with blocks, which were out of reach from the resident. Resident #30 was not engaged with the blocks and STNA #26, who was present in the area, was not assisting or engaging with the resident. Observation on 08/03/22 from 1:20 P.M. to 2:00 P.M. revealed Resident #50 sitting in a wheelchair at the dining room table without any activity material or engagement. A TV approximately 30 feet away but was not within seeing or hearing distance. The resident was rocking back in forth in the wheelchair, appearing anxious and at times slumped forward with her head on the table. Interview on 08/03/22 at 2:59 P.M. Resident #29 reported she preferred group activities and Bingo was not provided as an activity for several weeks. Resident #29 further stated there was no variety in activities and her preferences were not followed/provided. Resident #29 verified the pet visit scheduled on 08/02/22 did not happen and there was no alternative offered. Interview on 08/03/22 at 3:29 P.M. Diet Tech #31 reported she was filling in as the Activity Director and completed the August activity calendar. The Activity Director position had been vacated for several weeks. Diet Tech #31 verified the facility did not have any activity staff for any of the facility's houses and STNAs were expected to conduct the ongoing activity program. Observation on 08/08/22 at 10:19 A.M. revealed Resident #30 sitting in a wheelchair at the dining room table with blocks, which were out of reach. Resident #50 was sitting in a wheelchair at the dining room table slumped forward with her head on the table. Interview on 08/08/22 at 10:19 A.M. STNA #89 verified Resident #30 and Resident #50 were not being provided effective and preferred activities due to STNAs not having enough time. Review of the facility policy titled, Engagement and Activity, dated April 2013, revealed the STNAs will print an engagement calendar and store it in the binder for reference. The STNAs are to document resident provided activities in the engagement calendar.

Based on observation, staff inteview, and resident interview, the facility failed to provide timely incontinence care. This affected one (Resident #107) of three residents reviewed for incontinence care. The facility census was 58. Findings included: Review of Resident #107's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #107's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status score of 15, which indicated the resident was cognitively intact. The MDS revealed the resident required extensive two-person assistance for bed mobility, transfers, and dressing. The resident was totally dependent with two-person assist for toileting and personal hygiene. The resident required supervision with set-up for eating. Review of Resident #107's plan of care dated 07/17/22 revealed the resident had a self-care deficit related to multiple diagnoses. The plan of care identified the resident was at risk for skin breakdown. Interventions included turn and reposition frequently. Interview on 08/01/22 at 12:10 P.M. with Resident #107 revealed no staff had offered to change or reposition her since 4:00 A.M. Resident #107 stated she required two staff to change and reposition. The resident stated there was only one staff. Resident #107 stated on occasion she was wet up to her shoulders because there was not been enough staff to change her. Resident #107 stated she was uncomfortable and needed repositioned. Interview on 08/01/22 at 12:32 P.M. with State tested Nursing Assistant (STNA) #76 confirmed she began working at 7:00 A.M. and had not repositioned or changed Resident #107 since coming to work. STNA #76 stated she was the only staff present to care for Resident #107 and the resident required two staff for incontinence care. Interview on 08/02/22 at 11:14 A.M. with the Director of Nursing revealed it was the expectation of the facility that residents who required incontinence care were checked and repositioned every two hours. The DON revealed staff were expected to request assistance from administrative staff when other staff were not available. This deficiency substantiates Complaint Numbers OH 398 and OH 286.

Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to timely monitor and address Resident #55's weight loss and failed to ensure weekly weights were completed as ordered by the physician. This affected one (Resident #55) of five residents reviewed for nutrition. The facility census was 58. Findings include: Medical record review revealed Resident #55 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #55's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately cognitively impaired and required extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. Resident #55 required supervision with eating. Resident #55 was reported to have a five percent or more weight loss in the last month or ten percent or more in the last six months and was not on a prescribed weight loss regimen. Review of Resident #55's nutritional care plan dated 05/06/22 revealed Resident #55 was at risk for changes in nutrition. Interventions included review the resident's weights, skin, labs, and intakes routinely and as available and report changes as needed, offer supplements as ordered, offer the diet as ordered by the physician, observe for signs and symptoms of dehydration, offer meal substitutes, encourage the resident to eat and drink, encourage the resident to eat calorically dense foods and encourage the resident to drink all of her fluids when medications are given. Review of Resident #55's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #55's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #55's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #55's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #55's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #55's weights from 05/01/22 to 08/01/22 revealed Resident #55 weighted 184.2 pounds (lbs.) on 05/01/22, 183.2 lbs. on 05/10/22, 181.4 lbs. on 05/17/22, 182.4 lbs. on 05/31/22, 182.4 lbs. on 06/01/22, 170.0 lbs. on 06/07/22, 170.0 lbs. on 06/16/22, 170.2 lbs. on 06/28/22, 172.9 lbs. on 07/12/22, 160.6 lbs. on 07/26/22 and 159.8 lbs. on 08/01/22. Review of Resident #55's quarterly nutritional screen dated 06/14/22 revealed Resident #55 had a weight loss of five percent or more in the last month or ten percent or more in the last six months and was not on a prescribed weight loss regimen. The assessment reported Resident #55 was on weekly weights and had a significant weight loss over the past 30 days. Review of Resident #55's quarterly nutritional screen dated 08/02/22 revealed Resident #55 had a loss of five percent or more in the last month or ten percent or more in the last six months and was not on a prescribed weight loss regiment. The assessment reported Resident #55 was on weekly weights and had a significant weight loss over the past 30 days. A recommendation of ensure [MEDICATION(S)] 237 milliliters twice a day was recommended to the physician. Review of Resident #55's progress note dated 06/10/22 revealed Resident #55 had a five percent weight change over 30 days. Resident #55 tested positive for coronavirus 2019 (COVID-19) at the end of May and complained of a sore mouth on the lower right side. The dentist was called, and Resident #55 had [MEDICATION(S)] that she was using in her mouth. The family and physician were notified of the weight change. Review of Resident #55's progress notes from 07/26/22 to 08/02/22 revealed no documentation that Resident #55's weight loss of 7.11 percent or Resident #55's weight loss of 172.9 lbs. to 160.6 lbs. from 07/12/22 to 07/26/22 was addressed by the dietician or physician, or that interventions were put in place for the weight loss prior to 08/02/22. Review of Resident #55's Treatment Administration Record (TAR) dated July 2022 revealed Resident #55 did not receive her weekly weight as ordered on 07/19/22. Telephone interview on 08/04/22 at 10:15 A.M. with Registered Dietician (RD) #800 verified Resident #55 did not receive a weekly weight on 07/19/22 as ordered by the physician. RD #800 also verified Resident #55 had a weight loss of 7.11 percent or 172.9 lbs to 160.6 lbs from 07/12/22 to 07/26/22 and Resident #55 was not assessed for the weight loss and no interventions were put in place until 08/02/22. RD #800 also confirmed the physician was not notified of Resident #55's weight loss of 7.11 percent or 172.9 lbs on 07/12/22 to 160.6 lbs on 07/26/22 until 08/02/22. Observation on 08/04/22 at 12:26 P.M. revealed Resident #55 to be eating pureed corn, pureed macaroni and cheese, and pureed pears independently with a divided plate and spoon. Review of the facility's weights policy and procedure dated 06/26/09 revealed weights will be taken within the comprehensive review period. The following interventions may be put in place if significant weight change occurs: Review of the current diet order, monitor weights weekly, speak with elderly assistants, nurses, and the resident regarding weight changes, monitor the resident at meal times, make recommendations for interventions and updating the care plan and care card with interventions.

Based on staff interview and review of personnel files, the facility failed to ensure an annual performance review was completed for State tested Nursing Assistant (SNTA) #2. This affected one (STNA #2) of two STNAs reviewed for annual performance reviews. This had the potential to affect all residents at the facility. The facility census was 58. Findings include: Review of State tested Nursing Assistant (STNA) #2's personnel file revealed a date of hire on 02/10/20. Review of the STNA's file revealed no annual performance review was contained in the file. Interview on 08/04/22 at 8:02 A.M. with Business Office Manager #84 confirmed the facility was not able to provide evidence an annual performance review was completed for STNA #2.

Based on medical record review and staff interview, the facility failed to identify the reason for the use of as needed (PRN) narcotic pain medications and provide other interventions prior to the administration of pain medications for one (#22) of six residents reviewed for unnecessary medications. The facility census was 58. Findings include: Review of Resident #22's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #22's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. Review of Resident #22's plan of care dated 05/11/22 revealed the resident was at risk for pain related to poly-[CONDITION(S)], [CONDITION(S)], and decreased mobility. Interventions included topical pain medications, range of motion, and administer pain medications as ordered. Review of Resident #22's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #22's narcotic sheet for the PRN [MEDICATION(S)] HCL 10mg revealed the medication was removed on the following dates and times: On 08/01/22 at 7:05 A.M., at 10:55 A.M., 2:40 P.M., 5:45 P.M., and at 11:00 P.M. by Licensed Practical Nurse (LPN) #92. On 08/02/22 at 12:00 A.M., (one hour later from the 08/01/22 11:00 P.M. dose), 10:00 A.M., and 2:30 P.M. by Agency Registered Nurse (RN) #99. On 08/02/22 at 5:40 P.M., 8:50 P.M., and 11:00 P.M. by LPN #92. Review of Resident #22's Medication Administration Record (MAR) for 08/01/22 revealed the [MEDICATION(S)] HCL was only documented as administered to the resident at 7:01 A.M. and 10:57 A.M. with no reason for the administration documented. Review of the MAR for 08/02/22 revealed no [MEDICATION(S)] HCL 10mg tablets were administered. The medical record contained no documentation of the reason the [MEDICATION(S)] HCL 10 mg was removed from the narcotic storage for administration to Resident #22 on 08/01/22 and 08/02/22. The record did not address if other pain interventions were utilized prior to administration. Interview on 08/04/22 at 1:25 P.M. with the Director of Nursing (DON) confirmed discrepancy between the resident's MAR and the narcotic record. The DON confirmed, per the documentation, the MAR indicated the resident was not administered the [MEDICATION(S)] HCL each time the [MEDICATION(S)] HCL was removed from the narcotic drawer.

Based on observation and staff interview, the facility failed to properly label insulin medication. This affected two (Residents #13 and #21) and had the potential to affect 10 residents (#13, #21, #206, #41, #29, #48, #4, #49, #43, #40) who received insulin at the facility. The facility census was 58. Findings include: Observation and interview on 08/03/22 at 11:23 A.M. revealed the medication cart located in House #17 contained two opened, unnamed, multi-use vials of insulin. Neither vial was labeled with a resident's name or the date it was opened. Agency Registered Nurse (RN) #101 confirmed the [MEDICATION(S)] 100 units per milliliter (ml) belonged to Resident #13 and the [MEDICATION(S)] 100 units per ml belonged to Resident #21. Further observation revealed both bottles were open and approximately half empty. RN #101 confirmed neither insulin vial was labeled with an open-dat and neither insulin vial was in a pharmacy bag or box with the name, order or open date. RN #101 verified all insulin was required to have the opened date written on the vial or container. Review of Resident #13's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #13's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #21's medical record revealed and admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #21's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] #101. Interview on 08/04/22 at 10:11 A.M. with the Director of Nursing confirmed the expectation of the facility was all multi-use medications were labeled with the date the product was opened. Review of the facility's policy titled, Medication Administration Procedure, dated 11/09/21 revealed the policy did not address the labeling of insulin or multi-use medications.