Every finding on record at Piketon Nursing Center

Based on record reviews and interviews, the facility failed to ensure a resident with Post Traumatic Stress Disorder (PTSD) was appropriately assessed to identify the cause of the residents PTSD and minimize triggers and/or re-traumatization. This affected two residents (#7 and #18) out of two residents identified by the facility as having PTSD/trauma. The facility census was 43. Findings include: 1. Record review for Resident #7 revealed the resident was admitted to the facility on [DATE] and had diagnoses including partial intestinal obstruction, edema, ilius, hypertension, atrial fibrillation, Parkinson's disease, depression, anxiety, chronic post-traumatic stress disorder(on admitted [DATE]), schizoaffective disorder, and chronic kidney disorder. Review of the admission Minimum Data Set (MDS) assessment, dated 03/11/25, revealed this resident was assessed to have intact cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 15 out of 15. This resident was assessed to have an active diagnosis of PTSD. Review of the active care plans for Resident #7 revealed no plan of care was in place addressing the cause of PTSD, triggers which may cause re-traumatization, or interventions to reduce the risk of re-traumatization and provide care for PTSD. Review of six Trauma Informed Care Evaluations revealed no determination had been completed to identify the cause of PTSD for Resident #7 and to identify potential triggers which may cause re-traumatization. Interview with Resident #7 on 04/22/25 at 02:09 P.M. revealed this resident has a history of post-traumatic stress disorder because she had been sexually abused as a child. Resident stated she cannot recall anyone ever asking her about this from the facility staff. Interview with Social Services #570 on 04/23/25 at 09:58 A.M. verified the assessments did not capture actual cause of trauma and care plan did not accurately reflect triggers for recurrence. 2. Record review for Resident #18 revealed the resident was admitted to the facility on [DATE] and had diagnoses including dementia, cognitive communication deficit, chronic obstructive pulmonary disease, hypertension, diabetes mellitus type II, hyperlipidemia, PTSD(active diagnosis since 08/18/22), edema, anxiety, depression, and unspecified psychosis. Review of the admission Minimum Data Set (MDS) assessment, dated 01/20/25, revealed this resident was assessed to have severely impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 7 out of 15. This resident was assessed to have an active diagnosis of PTSD. Review of the active care plans for Resident #18 revealed no plan of care was in place addressing the cause of PTSD, triggers which may cause re-traumatization, or interventions to reduce the risk of re-traumatization and provide care for PTSD. Review of two Trauma Informed Care Evaluations revealed no determination had been completed to identify the cause of PTSD for Resident #18 and to identify potential triggers which may cause re-traumatization. Interview with Social Services #570 on 04/23/25 at 11:00 A.M. verified the assessments did not capture actual cause of trauma and care plan did not accurately reflect triggers for recurrence.

Based on record reviews and staff interviews, the facility failed to ensure an order for the administration of as needed Ativan (an anti-anxiety medication) contained a stop date of 14 days or less. This affected one resident (#31) out of the five residents reviewed for unnecessary medications. The facility census was 43. Findings include: Record review for Resident #31 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included anxiety disorder, depression, and diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/27/25, revealed the resident was assessed to have intact cognition. The resident was assessed to have received anti-anxiety medications during the lookback period. Review of the active physicians order, dated 12/08/24, revealed Resident #31 was to be administered 0.5 milligrams (mg) of Ativan every two hours as needed for anxiety. The order did not contain a stop date. Review of the Medication Administration Records (MAR's) for Resident #31, dated 12/22/24 (14 days after the order for Ativan was implemented) through 04/22/25, revealed the resident was documented to have been administered 32 doses of as needed Ativan. Interview with Licensed Practical Nurse (LPN) #290 on 04/22/25 at 3:45 P.M. confirmed the Ativan ordered for Resident #31 was as needed and did not contain a date for which to stop the order.

Based on observations, interviews, record reviews, and review of facility policy, the facility failed to ensure a medication was administered according to physicians order. This affected one resident (#31) out of the five residents reviewed for unnecessary medications. The facility census was 43. Findings include: Record review for Resident #31 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included chronic pain due to trauma, anxiety disorder, depression, and diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/27/25, revealed the resident was assessed to have intact cognition. Review of the active physicians order, dated 12/24/24, revealed Resident #31 was to be administered one milliliter (ml) of Morphine Sulfate (an opioid medication) Oral Suspension 20 milligrams (mg) per five ml's (which was equivalent to four mg's per dose administered) every two hours as needed for breakthrough pain. Review of the facility Controlled Drug Receipt Record/Disposition Forms, dated 12/24/24 through 04/22/25, revealed bottles of Morphine Sulfate Oral Suspension supplied to the facility for administration to Resident #31 were 100 mg's per five ml's (which was equivalent to 20 mg per one ml). One ml of Morphine Sulfate Oral Suspension 100 mg's per five ml's (equaling 20 mg) was documented to have been removed from the bottles by multiple nurses over 300 times for administration to Resident #31. Review of the Medication Administration Records (MAR's) for Resident #31, dated 12/24/24 through 04/22/25, revealed one ml of Morphine Sulfate Oral Suspension 20 mg's per five ml's (equaling four mg's) was documented to have been administered to Resident #31 at each dose. Further record review for Resident #31 revealed the resident had not experienced any episodes of respiratory depression, oversedating, or other adverse side effects of medications between 12/24/24 and 04/22/25. Observation and interview with Licensed Practical Nurse (LPN) #290 on 04/22/25 at 3:45 P.M. confirmed the bottle of Morphine Sulfate Oral Suspension contained in the narcotic lock box on the medication cart used for Resident #31 was a strength of 100 mg's per five ml's which was equal to 20 mg's per one ml. LPN #290 confirmed one ml of the Morphine Sulfate Oral Suspension was removed from the bottle at each dose and administered to Resident #31 so the resident received 20 mg each time. LPN #290 further confirmed the physicians order for Resident #31 was for one ml of Morphine Sulfate Oral Suspension at a strength of 20 mg's per five ml's which was only equivalent to four mg's to be administered at each dose. LPN #290 confirmed the amount administered to the resident at each dose did not match the amount ordered by the physician. Observation of Resident #31 on 04/22/25 at 4:05 P.M. revealed the resident was lying in bed eating grapes and watching television and did not appear to be exhibiting signs or symptoms of pain. Interview with Resident #31 at the time of the observation confirmed facility staff administered pain medication which kept the residents pain at a manageable level and denied any concerns with adverse side effects from medications. Review of the facility policy titled Administering Medications, revised 04/2019, revealed medications are administered in accordance with prescriber orders, including any required time frames. The individual administering the medication checks the label THREE times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.

Based on record reviews and staff interview, the facility failed to ensure spend down notices were provided timely and appropriately. This affected four residents (#17, #24, #28, and #31) out of the five residents whose facility fund accounts were reviewed during the annual survey. The facility census was 40. Findings include: 1. Record review for Resident #17 revealed this resident was admitted to the facility on [DATE] and had diagnoses including cerebral palsy, disorder of muscle, and spastic quadraplegia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/17/23, revealed this resident was rarely/never understood. This resident was assessed to be dependent upon two staff members for bed mobility, transfers, and toileting. Review of the facility Funds Balance Report, dated 09/06/23, revealed the balance in Resident #17's account was $2,021.58. Review of the facility Spend Down Notice for Resident #17 revealed the notice was not dated and did not provide evidence of how or when it was sent to the residents representative. Interview with the Administrator on 09/07/23 at 11:10 A.M. verified the spend down notice for Resident #17 did not provide evidence of the date it was issued or how or when it was provided to the residents representative. 2. Record review for Resident #28 revealed this resident was admitted to the facility on [DATE] and had diagnoses including unspecified dementia, major depressive disorder, and weakness. Review of the annual MDS assessment, dated 08/24/23, revealed this resident had moderately impaired cognition evidenced by a Brief interview for Mental Status (BIMS) assessment score of 07 out of 15. This resident was assessed to require limited assistance from one staff member for bed mobility and supervision for transfers and toileting. Review of the facility Funds Balance Report, dated 09/06/23, revealed the balance in Resident #17's account was $2,932.53. Review of the facility Spend Down Notice for Resident #28 revealed the notice was not dated and did not provide evidence of how or when it was sent to the residents representative. Interview with the Administrator on 09/07/23 at 11:10 A.M. verified the spend down notice for Resident #28 did not provide evidence of the date it was issued or how or when it was provided to the resident. 3. Record review for Resident #31 revealed this resident was admitted to the facility on [DATE] and had diagnoses including chronic obstructive pulmonary disease, dysphagia, and anemia. Review of the annual MDS assessment, dated 08/25/23, revealed this resident had intact cognition evidenced by a BIMS assessment score of 15 out of 15. This resident was assessed to require limited assistance from one staff member for bed mobility, transfers, and toileting. Review of the facility Funds Balance Report, dated 09/06/23, revealed the balance in Resident #17's account was $2,442.41 Review of the facility Spend Down Notice for Resident #31 revealed the notice was not dated and did not provide evidence of how or when it was sent to the residents representative. Interview with the Administrator on 09/07/23 at 11:10 A.M. verified the spend down notice for Resident #31 did not provide evidence of the date it was issued or how or when it was provided to the resident. 4. Record review for Resident #24 revealed this resident was admitted to the facility on [DATE] and had diagnoses including dementia, depressive disorder, and anxiety. Review of the quarterly MDS assessment, dated 07/14/23, revealed this resident had mildly impaired cognition evidenced by a BIMS assessment score of 10 out of 15. This resident was assessed to require supervision for bed mobility, transfers, and toileting. Review of the facility Funds Balance Report, dated 09/06/23, revealed the balance in Resident #17's account was $2,176.44. Review of the facility Spend Down Notice for Resident #23 revealed the notice was not dated and did not provide evidence of how or when it was sent to the residents representative. Interview with the Administrator on 09/07/23 at 11:10 A.M. verified the spend down notice for Resident #24 did not provide evidence of the date it was issued or how or when it was provided to the resident.

Based on interviews, record reviews and facility policy, the facility failed to identify target behaviors with documentation and/or provide an appropriate diagnosis for psychotropic medications for five (Resident #2, #11, #28, #30 and #41) of the eight residents reviewed. The facility census was 40. Findings include: 1. Review of the medical record for Resident #2 revealed an admitted [DATE]. Diagnoses included: anxiety disorder, unspecified intellectual disabilities, unspecified mental disorder due to known physiological condition and schizoaffective disorder. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident is rarely/never understood. This resident was assessed to require extensive assistance with one-person physical assist with bed mobility, dressing, and toileting and extensive assistance with two person physical assist with transfers. Further review of the MDS revealed resident received antianxiety medication seven out of seven days. Review of Resident #2's physician orders dated for 11/28/22 revealed this resident was receiving the following medication: Haloperidol Decanoate 50 milligrams (mg) one time a day starting on the 28th and ending on the 28th every month by injection for schizoaffective disorder. Further review of this resident's physicians order dated for 07/31/23 revealed the following medication: Buspirone HCL 7.5 mg one tablet by mouth three times a day for anxiety disorder. Review of the physicians' orders for Resident #2 revealed no orders since admission on 10/25/22 for documentation of targeted behaviors. Review of the progress notes for Resident #2 for the past thirty days starting on 09/06/23 revealed no documentation of target behaviors from the facility staff. Review of the behavioral task documentation for Resident #2 for the past thirty days starting on 09/06/23 revealed no documentation for target behaviors from the facility staff. Review of Resident #2's care plan dated 08/01/23 revealed no evidence of a care plan containing target behaviors to be monitoring for. Interview with Registered Nurse (RN) #146 on 09/07/23 at 9:29 A.M. revealed the progress notes are where the facility nurses document observed targeted behaviors and under the tasks are where the State tested Nursing Aides (STNA) document targeted behaviors. Verified for the past thirty days starting on 09/06/23, Resident #2 did not have any documentation in the progress notes from the facility nurses for target behaviors and no documentation under tasks from the facility's STNAs for target behaviors. Interview with STNA #161 on 09/07/23 at 9:45 A.M. revealed the behavioral task charting is newer for the facility staff and stated We have only been doing this for about a month the computer charting, in the past I just tell the nurse about behaviors. I do not know where the target behaviors are, but the nurses tell me and if a resident is screaming or crying out that is a behavior. Verified STNA #161 is unsure of where the Resident #2's target behaviors are in the chart and the behavior tasks for the past thirty days since 09/06/23 were blank. Interview with Licensed Practical Nurse (LPN) #130 on 09/07/23 at 10:44 A.M. revealed the care plans for each resident informs them of what target behaviors to look for and in the progress notes are where the documentation of them go for nurses and the task section are for the STNA's. Verified Resident #2's care plan does not have target behaviors to observe for and the progress notes as well as the behavioral task notes for the past thirty days starting 09/06/23 does not have documentation of target behaviors. Interview with the Director of Nursing (DON) on 09/07/23 at 10:50 A.M. verified Resident #2's care plans do not include target behaviors to observe for and the progress notes as well as the behavioral task notes for the past thirty days starting 09/06/23 does not have documentation of target behaviors. 2. Review of the medical record for Resident #28, revealed an admitted [DATE]. Diagnoses included: dementia, major depressive disorder, weakness, anxiety disorder, and generalized anxiety disorder. Review of the most recent MDS 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 7 out of 15 indicating severe cognition. This resident was assessed to require limited assistance with one-person physical assist with bed mobility and dressing and supervision with set up only for eating, toilet use and transfers. Further review of the MDS revealed antianxiety and antidepressant medications were used seven out of seven days. Review of Resident #28's physician orders dated 05/25/22 revealed this resident was receiving Bupropion HCL 100 milligrams (mg) one tablet by mouth one time a day for behavior. Further review of Resident #28's physician orders dated 09/17/22 revealed this resident was receiving the follow medication: Buspirone HCL 10mg one tablet orally a day for behavior. Review of the physicians' orders for Resident #28 revealed no orders since admission on 03/10/21 for documentation of targeted behaviors for facility to observe. Review of the care plans for Resident #28 dated 08/29/23 revealed no evidence of a care plan containing target behaviors to be monitoring for. Interview with RN #146 on 09/07/23 at 9:30 A.M.,verified for the past thirty days starting on 09/06/23, Resident #28 did not have any documentation in the progress notes from the facility nurses for target behaviors and no documentation under tasks from the facility's STNAs for target behaviors. Interview with STNA #161 on 09/07/23 at 9:45 A.M. revealed the STNA #161 is unsure of where the Resident #28's target behaviors are in the chart and the behavior tasks for the past thirty days since 09/06/23 were blank. Interview with LPN #130 on 09/07/23 at 10:45 A.M. revealed Resident #28's care plan does not have target behaviors to observe for and the progress notes as well as the behavioral task notes for the past thirty days starting 09/06/23 does not have documentation of target behaviors. Interview with the DON on 09/07/23 at 10:51 A.M. verified Resident #28's care plans do not include target behaviors to observe for and the progress notes as well as the behavioral task notes for the past thirty days starting 09/06/23 does not have documentation of target behaviors. 3. Review of the medical record for Resident #30, revealed an admitted [DATE]. Diagnoses included: bipolar disorder, polyosteoarthritis, anxiety disorder, major depressive disorder, and atherosclerotic heart disease of native coronary artery without angina pectoris. Review of the most recent MDS 3.0 assessment dated [DATE] revealed resident was cognitively intact. This resident was assessed to require supervision with set up only for: bed mobility, transfers, dressing and eating. Review of Resident #30's physician order dated 04/29/22 revealed Duloxetine 30 mg tablet, give 30 mg orally in the morning related to major depressive disorder. Further review for this resident's physician order dated 05/01/22 revealed Clonazepam 1 mg, give 1 tablet orally three times a day related to anxiety disorder. Review of the physicians' orders for Resident #30 revealed no orders since admission on 04/28/22 for documentation of targeted behaviors for facility to observe. Review of the care plans for Resident #28 dated 08/01/23 revealed no evidence of a care plan containing target behaviors to be monitoring for. Interview with RN #146 on 09/07/23 at 9:31 A.M. verified for the past thirty days starting on 09/06/23, Resident #30 did not have any documentation in the progress notes from the facility nurses for target behaviors and no documentation under tasks from the facility's STNAs for target behaviors. Interview with STNA #161 on 09/07/23 at 9:47 A.M. revealed STNA #161 is unsure of where the Resident #30's target behaviors are in the chart and the behavior tasks for the past thirty days since 09/06/23 were blank. Interview with LPN #130 on 09/07/23 at 10:47 A.M. verified Resident #30's care plan does not have target behaviors to observe for and the progress notes as well as the behavioral task notes for the past thirty days starting 09/06/23 does not have documentation of target behaviors. Interview with the DON on 09/07/23 at 10:52 A.M. verified Resident #30's care plans do not include target behaviors to observe for and the progress notes as well as the behavioral task notes for the past thirty days starting 09/06/23 does not have documentation of target behaviors. 34299 4. Review of the medical record for Resident #11 revealed an admitted [DATE] with diagnoses including Alzheimer's disease, Atrial Fibrillation, anxiety disorder, type two diabetes mellitus, and chronic obstructive pulmonary disorder. Review of the quarterly MDS dated [DATE] revealed Resident #11 had severe cognitive impairment with no behaviors noted. The assessment indicated Resident #11 had no psychiatric or mood disorder and did not receive any antipsychotic medications. Review of the physician orders for 09/23 revealed Resident #11 was ordered and received trazadone (antidepressant medication) 25 milligrams (mg) by mouth at bedtime for Alzheimer's disease. Review of the nursing progress notes from 08/08/23 through 09/07/23 revealed no documented behaviors. Review of the plan of care dated 02/13/23 revealed Resident #11 had a behavioral problem related to combative at times with the staff. Interventions included administer medication as ordered, monitor and document for side effects and effectiveness of medication and anticipate and meet the residents needs. Review of the plan of care dated 10/06/22 revealed Resident #11 received an antidepressant medication. Interventions included administer the antidepressant medication as ordered by the physician, monitor and document side effects and effectiveness every shift, monitor and report any adverse reactions to the antidepressant therapy. Review of the plan of care dated 10/06/22 revealed Resident #11 had a mood problem related to Alzheimer's disease. Interventions included administer medications as ordered, monitor and document for side effects and effectiveness, behavioral health consult as needed, monitor, record and report to the physician any acute episodes of feelings of sadness, loss of pleasure and other feelings of depression. Review of the task section of the STNA kardex revealed no abnormal behaviors documented for past 30 days. Observations of Resident #11 on 09/06/23 at 7:55 A.M., 09/07/23 at 8:45 A.M. revealed Resident #11 had no adverse behaviors. Interview on 09/07/23 at 9:15 A.M. with STNA #165 revealed Resident #11 yelled out at times but had no other adverse behaviors. STNA #165 stated behaviors would be documented on the task section of kardex. Interview on 09/07/23 at 9:31 with RN #138 revealed Resident #11 yelled out at night when the resident became anxious and confused but had no other behaviors. RN #138 stated all behaviors were documented in the nursing progress notes. Interview on 09/07/23 at 9:37 A.M. with the DON confirmed Alzheimer's disease was not a proper diagnosis for the use of trazadone an antidepressant medication. The DON stated the resident would hit her arms and hands against the wall in her room. The facility placed soft cushion like pads on the wall beside residents bed to help prevent injury. 42728 5. Record review for Resident #41 revealed this resident was admitted to the facility on [DATE] and had diagnoses including Schizophrenia, auditory hallucinations, and unspecified psychosis. Review of the quarterly MDS dated [DATE], revealed this resident had mildly impaired cognition evidenced by a BIMS assessment score of 12 out of 15. This resident was assessed to require extensive assistance from two staff members for bed mobility, to be dependent upon one staff member for toileting, to be dependent upon two staff members for transfers, and to require supervision with setup help only for eating. Review of the active care plan, dated 04/07/23, revealed this resident used anti-psychotic medication related to Schizophrenia. No target behaviors were specified in the care plan. Review of the active physicians order, dated 03/20/23, revealed this resident was ordered to be administered 50 milligrams (mg) of Seroquel (an anti-psychotic medication) once a day for a diagnosis of Schizophrenia. Review of the active physicians order, dated 03/21/23, revealed this resident was ordered to be administered two mg of Risperdal (an anti-psychotic medication) twice a day for a diagnosis of Schizophrenia. Interview with the Director of Nursing on 09/07/23 at 9:20 A.M. verified no target behaviors for Resident #41 had been identified in the residents plan of care. Interview with MDS Coordinator #121 on 09/07/23 at 9:30 A.M. revealed Resident #41 had not been referred to psychiatric services or had any behaviors since being admitted to the facility. Review of the facility policy titled Behavioral Assessment, Intervention and Monitoring no dated stated the care plan will include, as a minimum, a description of the behavioral symptoms (target Behaviors) in frequency intensity, duration, outcomes and location and the document any improvements or worsening in the individual's behavior, mood, and function.

Based on observation and interview the facility failed to maintain a clean and sanitary kitchen. This had the potential to affect 39 residents who received meals from the kitchen. The facility census was 40. Findings include: Initial observation on 09/05/23 at 8:30 A.M. revealed the heating/air conditioning vents in the ceilings were rusty, with brown fuzzy like substance noted on the vents and around the vents on the ceiling. Observation on 08/07/23 at 10:30 A.M. revealed the heating/air conditioning vents in the ceiling remained soiled and blowed air over the food preparation and serving areas. The drain pipes under the sinks and dish tank were rusty, black and green like they leaked. The floor had black areas under the drains and the ice machine. Also the corners of the floor were dusty, dirty and black. The wall behind the steam/food holder was streaked with black and brown greasy like substance. The large plastic containers that contained flour and sugar were dusty on top with black like grime. Interview on 09/07/23 at 11:20 A.M. with the Regional Director (cook for the day) confirmed all areas that needed attention and cleaned.

Based on record review, review of facility daily staffing sheets, and staff interviews, the facility failed to ensure resident medical records were maintained in an accurate manner and failed to ensure staff did not document the administration of medications using another staff members name and credentials. This affected the four residents (#2, #10, #28, and #295) reviewed for accurate documentation of medication and treatments. The facility census was 40. Findings include: 1. Record review for Resident #2 revealed this resident was admitted to the facility on [DATE] and had diagnoses including anxiety, depression, and delirium. Review of the annual Minimum Data Set (MDS) assessment, dated 08/06/23, revealed this resident was rarely/never understood. This resident was assessed to require extensive assistance from one staff member for bed mobility and toileting and to require extensive assistance from two staff members for transfers. Review of the Medication Administration Record (MAR) for 08/2023 revealed documentation Resident #2 had been administered medications by LPN #199 on 08/07/23, 08/11/23, 08/12/23, 08/13/23, 08/14/23, 08/16/23, 08/17/23, 08/18/23, 08/19/23, 08/20/23, 08/23/23, 08/26/23, 08/27/23, 08/28/23, 08/30/23, and 08/31/23. Review of the MAR for 09/2023 revealed documentation Resident #2 had been administered medications by LPN #199 on 09/01/23. Review of the facility daily staffing sheets from 08/01/23 through 09/05/23 revealed Licensed Practical Nurse (LPN) #199 was not documented to have worked at the facility. 2. Record review for Resident #10 revealed this resident was admitted to the facility on [DATE] and had diagnoses including Schizophrenia, hypothyroidism, and depressive disorder. Review of the quarterly MDS assessment, dated 07/16/23, revealed this resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 15. This resident was assessed to require supervision for bed mobility, transfers, and toileting. Review of the daily staffing sheets from 08/01/23 through 09/05/23 revealed LPN #199 was not documented to have worked at the facility. Review of the MAR for 08/2023 revealed documentation Resident #10 had been administered medications by LPN #199 on 08/06/23, 08/11/23, 08/12/23, 08/13/23, 08/16/23, 08/17/23, 08/21/23, 08/22/23, 08/25/23, 08/26/23, 08/27/23, 08/30/23, and 08/31/23. Review of the MAR for 09/2023 revealed documentation Resident #10 had been administered medications by LPN #199 on 09/01/23. 3. Record review for Resident #28 revealed this resident was admitted to the facility on [DATE] and had diagnoses including unspecified dementia, major depressive disorder, and weakness. Review of the annual MDS assessment, dated 08/24/23, revealed this resident had moderately impaired cognition evidenced by a BIMS assessment score of 07. This resident was assessed to require limited assistance from one staff member for bed mobility and supervision for transfers and toileting. Review of the daily staffing sheets from 08/01/23 through 09/05/23 revealed LPN #199 was not documented to have worked at the facility. Review of the MAR for 08/2023 revealed documentation Resident #28 had been administered medications by LPN #199 on 08/09/23, 08/11/23, 08/12/23, 08/13/23, 08/16/23, 08/19/23, 08/20/23, and 08/31/23. 4. Record review for Resident #295 revealed this resident was admitted to the facility on [DATE] and had diagnoses including acute osteomyelitis, hypertension, and depressive disorder. Review of the admission MDS assessment, dated 08/31/23, revealed this resident had intact cognition evidence by a BIMS assessment score of 15. This resident was assessed to require limited assistance from one staff member for bed mobility, transfers, and toileting. Review of the daily staffing sheets from 08/01/23 through 09/05/23 revealed LPN #199 was not documented ot have worked at the facility. Review of the MAR for 08/2023 revealed documentation Resident #295 had been administered medications by LPN #199 on 08/25/23, 08/26/23, 08/27/23, and 08/31/23. Review of the MAR for 09/2023 revealed documentation Resident #295 had been administered medications by LPN #199 on 09/01/23. Interview with Medical Records Employee #125 on 09/06/23 at 10:45 A.M. revealed LPN #199 worked at the facility through an agency but had not worked a shift in several months. Interview with the Director of Nursing (DON) on 09/06/23 at 2:15 P.M. verified LPN #199 had not worked at the facility in several months and other staff members had been using LPN #199's credentials to document medication administration to residents. The DON stated she just found out on 09/02/23 from an agency staff member that reported RN#134 was using LPN #199's badge. She verified that RN#134 did not report to her that her badge was not working The DON stated she was on vacation and when she returned on 09/06/23 she had a new badge delivered for Registered Nurse (RN) #134. The DON stated the process was to program badges for each separate staff member to identify each individuals name and license including agency staff. Telephone interview with RN #134 on 09/07/23 at 1:38 P.M. verified she had been using LPN #199's badge to document medication administration to residents as RN #134's badge was not working. She stated she had went prn (as needed) and returned to help out full time and when she returned to work on night shift her badge did not work so she grabbed an angency nurse badge to use. She verified she did not report her broken badge to the DON or Administrator. This deficiency represents non-compliance investigated under Complaint Number OH00146104.

Based on record reviews and staff interview, the facility failed to ensure arbitration agreements provided to residents included written notice of the residents right to rescind the agreement within 30 days of signing. This affected the ten residents (#7, #8, #18, #21, #26, #30, #31, #34, #37, and #41) who the facility identified as having signed arbitration agreements. The facility census was 40. Findings include: Review of the facility provided list of residents who had signed arbitration agreements with the facility revealed there were ten residents ((#7, #8, #18, #21, #26, #30, #31, #34, #37, and #41) who had signed the agreements. Review of the facility Optional Arbitration Agreement form, revised 04/2017, revealed the agreement did not contain notice of the residents rights to rescind the arbitration agreement within 30 days of signing the agreement. Interview with the Administrator on 09/07/23 at 10:00 A.M. verified the facilities written arbitration agreement form did not contain notice of the residents right to rescind the arbitration agreement within 30 days of signing the agreement.

Based on staff interview and observation the facility failed to provide a safe comfortable environment for residents when the wall was scratched in room [ROOM NUMBER] and 20. The toilet seat was soiled in room [ROOM NUMBER], and there was cracked floor tiles in room [ROOM NUMBER]. This affected seven residents (#10, #11, #17, #20, #23, #37, and #95) living in those rooms. The facility census was 40. Findings include: Observation with the Maintenance Director #122 on 09/07/23 from 2:19 P.M. to 2:26 P.M. revealed room [ROOM NUMBER], where Resident #17 and #23 resides, had wall scratches and missing caulking around the toilet. Observation of room [ROOM NUMBER], where Resident #95 resides, had wall scratches behind the resident's bed. Observation of room [ROOM NUMBER], where Resident #20 and #37 resides, had a dark brown substance dried on the the raised toilet seat. Observation of room [ROOM NUMBER], where Resident #10 and #11 resides, revealed a large crack in the floor covering multiple floor tiles. Interview with Maintenance Director #122 on 09/07/23 from 2:19 P.M. to 2:26 P.M. verified the observations and stated he was unaware of these items that needs fixing.

Based on record reviews and staff interview, the facility failed to ensure a Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN) specified the type of skilled services being discontinued. This affected one resident (#33) out of the three residents reviewed for NOMNC and SNFABN notices during the annual survey. The facility census was 40. Findings include: Record review for Resident #33 revealed this resident was admitted to the facility on [DATE] and had diagnoses including dementia, glaucoma, and encephalopathy. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/21/23, revealed this resident was rarely/never understood. This resident was assessed to require extensive assistance from two staff members for bed mobility, transfers, and toileting. Review of the NOMNC and SNFABN, both signed on 01/20/23, revealed the type of service listed as ending had been written in as Skilled Services and did not specify the type of skilled services the resident was being cut from. Interview with the Administrator on 09/06/23 at 1:19 P.M. verified the NOMNC and SNFABN notices for Resident #33 did not specify the type(s) of skilled services the resident was being cut from.

Based on record reviews, staff interviews and facility policy, the facility failed to develop resident centered care plans for behavioral interventions for three (Residents #2, #28 and #30) of the eight residents reviewed. The facility census was 40. Findings include: 1. Review of the medical record for Resident #2 revealed an admitted [DATE]. Diagnoses included: anxiety disorder, unspecified intellectual disabilities, unspecified mental disorder due to known physiological condition and schizoaffective disorder. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident is rarely/never understood. This resident was assessed to require extensive assistance with one-person physical assist with bed mobility, dressing, and toileting and extensive assistance with two-persons physical assist with transfers. The resident received antianxiety medication seven days. Review of Resident #2's physician orders dated for 10/25/22 revealed this resident was receiving the following medication: Haloperidol Decanoate 50 milligrams (mg) one time a day starting on the 28th and ending on the 28th every month by injection for schizoaffective disorder. Further review of this resident's physicians order dated for 07/31/23 revealed the following medication: Buspirone HCL 7.5 mg one tablet by mouth three times a day for anxiety disorder. Review of the physicians' orders for Resident #2 revealed no orders since admission on 04/28/22 for documentation of targeted behaviors as well as no non-pharmacological interventions for the facility staff to utilize. Review of the care plans for Resident #30 dated 08/01/23 revealed no evidence of a care plan containing non-pharmacological interventions as well as no target behaviors to be monitoring for. Interview with Licensed Practical Nurse (LPN) #130 on 09/07/23 at 10:44 A.M. revealed the care plans for each resident informs them of what target behaviors to look for as well as non-pharmacological interventions to use. Verified Resident #2's care plan does not have both non-pharmacological intervention and target behaviors. Interview with the Director of Nursing (DON) on 09/07/23 at 10:50 A.M. verified Resident #2's care plans do not include non-pharmacological interventions for behaviors and no target behaviors to observe for. 2. Review of the medical record for Resident #28, revealed an admitted [DATE]. Diagnoses included: dementia, major depressive disorder, weakness, anxiety disorder, and generalized anxiety disorder. Review of the most recent MDS 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 7 out of 15 indicating severe cognitive loss. This resident was assessed to require limited assistance with one-person physical assist with bed mobility and dressing and supervision with set up only for eating, toilet use and transfers. Further review of the MDS dated [DATE] revealed antianxiety and antidepressant medications seven out of seven days. Review of Resident #28's physician orders dated 05/25/22 revealed this resident was receiving Bupropion HCL 100 milligrams (mg) one tablet by mouth one time a day for behavior. Further review of Resident #28's physician orders dated 09/17/22 revealed this resident was receiving the follow medication: Buspirone HCL 10 mg one tablet orally a day for behavior. Review of the physicians' orders for Resident #28 revealed no orders since admission on 03/10/21 for documentation of targeted behaviors as well as no non-pharmacological interventions for the facility staff to utilize. Review of the care plans for Resident #28 dated 08/29/23 revealed no evidence of a care plan containing non-pharmacological interventions as well as no target behaviors to be monitoring for. Interview with LPN #130 on 09/07/23 at 10:45 A.M. revealed the care plans for each resident informs them of what target behaviors to look for as well as non-pharmacological interventions to use. Verified Resident #28's care plan does not have both non-pharmacological intervention and target behaviors. Interview with the DON on 09/07/23 at 10:51 A.M. verified Resident #28's care plans do not include non-pharmacological interventions for behaviors and no target behaviors to observe for. 3. Review of the medical record for Resident #30, revealed an admitted [DATE]. Diagnoses included: bipolar disorder, polyosteoarthritis, anxiety disorder, major depressive disorder, and atherosclerotic heart disease of native coronary artery without angina pectoris. Review of the most recent MDS 3.0 assessment dated [DATE] revealed a BIMS of 15 out of 15 indicating intact cognition. This resident was assessed to require supervision with set up only for: bed mobility, transfers, dressing and eating. Further review of the MDS dated [DATE] revealed antianxiety and antidepressant medications for seven out of seven days. Review of Resident #30's physician order dated 04/29/22 revealed Duloxetine 30 mg tablet, give 30 mg orally in the morning related to major depressive disorder. Further review for this resident's physician order dated 05/01/22 revealed Clonazepam 1 mg, give 1 tablet orally three times a day related to anxiety disorder. Review of the physicians' orders for Resident #30 revealed no orders since admission on 04/28/22 for documentation of targeted behaviors as well as no non-pharmacological interventions for the facility staff to utilize. Review of the care plans for Resident #30 dated 08/01/23 revealed no evidence of a care plan containing non-pharmacological interventions as well as no target behaviors to be monitoring for. Interview with LPN #130 on 09/07/23 at 10:46 A.M. revealed the care plans for each resident informs them of what target behaviors to look for as well as non-pharmacological interventions to use. Verified Resident #30's care plan does not have both non-pharmacological intervention and target behaviors. Interview with the DON on 09/07/23 at 10:52 A.M. verified Resident #30's care plans do not include non-pharmacological interventions for behaviors and no target behaviors to observe for. Review of the facility policy titled Behavioral Assessment, Intervention and Monitoring no dated stated the care plan will include as a minimum: non-pharmacological approaches will be utilized to the extent possible to avoid or reduce the use of antipsychotic medications to manage behavioral symptoms and specific target behaviors and expected outcomes.

Based on facility interviews, record reviews and Medscape, the facility failed to obtain orders, and/or create care plans, conduct assessments and conduct communications for the appropriate care for three (Resident #25, #37, and # 295) out of twenty five residents reviewed. The facility census was 40. Findings include: 1. Review of the medical record for Resident # 295, revealed an admitted [DATE]. Diagnoses included: acute osteomyelitis, essential hypertension, and type 1 Diabetes Mellitus (DM). Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15 out of 15 indicating intact cognition. This resident was assessed to require limited assistance with one-person physical assist for bed mobility, transfer, dressing and supervision with set up only for eating. Review of the physician's order dated 08/25/23 for Resident #295 revealed an order for an Omnipod 5 G6 Intro (Gen 5) Kit (Insulin Infusion Disposable Pump) 1 unit every 72 hours as needed for type 1 diabetes and insulin aspart 100unit/ml via insulin pump two times a day related to type 1 DM. Further review of the physician orders dated 08/25/23 to 09/06/23 for this resident did not reveal the following orders: -no order for blood glucose checks and/or an order for the Dexcom continuous glucose monitor (CGM) for the facility staff to be aware of the resident's blood glucose levels. -no order for the basal rate of this resident's Omnipod insulin infusion disposable pump. -no order for the sliding scale coverage for this resident for coverage for meals and if blood glucose level is high. -no order for a Glucagon Emergency kit to treat severe low blood glucose as needed -no order to care for the Dexcom CGM and when to renew it Review of the medication administration record (MAR) and treatment administration record (TAR) for Resident #295 from the dates of 08/25/23 to 09/06/23 revealed the following: -no documentation of blood glucose checks and/or the Dexcom CMG results for the facility staff to be aware of this resident's blood glucose levels. -no documentation of the basal rate of the Omnipod insulin infusion disposable pump -no documentation of the sliding scale coverage for this resident for coverage for meals and if blood glucose level is high. -no documentation for the use of a Glucagon Emergency kit to treat severe low blood sugar as needed. -no documentation to care for the Dexcom CGM, when to renew it and location. -no documentation to care for the Omnipod insulin infusion disposable pump, when to renew it and location. -insulin aspart 100unit/ml via insulin pump two times a day at 0800 and 2000 related to Type 1 DM. Review of care plans dated 08/24/23 for Resident # 295 revealed no diabetic care was initiated and implemented as of 09/06/23. Resident refused an interview on 09/06/23 at 10:22 A.M. and refused on 09/07/23 at 9:10 A.M. Interview with LPN #130 on 09/07/23 at 11:08 A.M. confirmed Resident #295 does not have a care plan for her diabetes care as well as no orders/documentation's for the following: -blood glucose checks and/or the Dexcom continuous glucose monitor (CGM). -the basal rate of the Omnipod insulin infusion disposable pump. -the sliding scale coverage for meals and if blood glucose level is high. -a Glucagon Emergency kit to treat severe low blood glucose as needed. -how to care for the Dexcom CGM and when to renew it and location. -how to care for the Omnipod insulin infusion disposable pump, when to renew it and location. Interview with LPN #130 also verified on 09/07/23 at 11:12 A.M. she was not aware of how the Omnipod insulin infusion disposable pump and a Dexcom CGM works, how to change them if needed, and their location on this resident. She was unsure of how the disease process is different from a Type 1 diabetic resident to a Type 2 diabetic resident. Interview with the Director of Nursing (DON) on 09/07/23 at 11:18 A.M. confirmed Resident #295 does not have a care plan for her diabetes care as well as no orders/documentation's for the following: -blood glucose checks and/or the Dexcom continuous glucose monitor (CGM). -the basal rate of the Omnipod insulin infusion disposable pump. -the sliding scale coverage for meals and if blood glucose level is high. -a Glucagon Emergency kit to treat severe low blood glucose as needed. -how to care for the Dexcom CGM and when to renew it and location. -how to care for the Omnipod insulin infusion disposable pump, when to renew it and location. The DON also confirmed the order: insulin aspart 100unit/ml via insulin pump two times a day at 0800 and 2000 related to type 1 DM was not correct as the Omnipod insulin infusion disposable pump continuously maintains this resident's blood glucose level and boluses for meals and if needed for high blood glucose control. Interview with the DON on 09/07/23 at 11:22 A.M. stated when the orders came with her, the hospital did not send the orders for her diabetic care. She has a Dexcom CGM, and we check on her to make sure she is ok. If she was to get low, we would give her orange juice. Verified the facility staff is unaware of this resident's blood sugar levels unless asking the resident so unaware if the residents blood sugar levels are safe and the facility nursing staff were never given education on how the Dexcom CGM and the Omnipod insulin infusion disposable pump function as well as the difference in care for a type 1 DM resident to a type 2 DM resident. According to Medscape, type 1 diabetes is a chronic illness characterized by the body's inability to produce insulin due to the autoimmune destruction of the beta cells in the pancreas. Type 1 diabetics require lifelong insulin therapy. Type 2 diabetes mellitus consists of an array of dysfunctions characterized by hyperglycemia and resulting from the combination of resistance to insulin action, inadequate insulin secretion, and excessive or inappropriate glucagon secretion. Type 2 diabetes care includes: appropriate goal setting dietary and exercise modifications, medications, appropriate self-monitoring of blood glucose (SMBG), regular monitoring for complications and laboratory assessment. According to Medscape, a Continuous subcutaneous insulin infusion (Omnipod): Rapid-acting insulin infused continuously 24 hours a day through an insulin pump at 1 or more basal rates, with additional boluses given before each meal and correction doses administered if blood glucose levels exceed target levels. It replaces the need for multiple injections for short acting and long-acting insulins. According to Medscape, a Continuous Glucose Monitors (CGMs like Dexcom) contain transcutaneous or subcutaneous sensors-depending on whether the devices are externally worn or fully implantable, respectively-that measure interstitial glucose levels every 1-5 minutes, providing alarms when glucose levels are too high or too low or are rapidly rising or falling. CGMs transmit to a receiver, which either is a pager like device or is integral to an insulin pump. Looking at the continuous glucose graph and responding to the alarms can help patients avoid serious hyperglycemia or hypoglycemia. It replaces the need to often obtain 2-4 blood glucose levels each day, including fasting levels and levels checked at various other times that are required. 34299 2. Review of the medical record for Resident #25 revealed an admitted [DATE] with diagnoses including Alzheimer's disease, hypertension, anxiety disorder and season allergies. Review of the quarterly MDS dated [DATE] revealed Resident #25 had severe cognitive impairment. Resident #25 had no impairment to range of motion to bilateral upper extremities, and received no therapy services. Review of the physician orders for 09/23 revealed Resident #25 did not have any orders for range of motion, or resting hand splint to right hand. Review of the plan of care for Resident #25 revealed no plan of care addressing the right hand impaired range of motion or resting had splint. Observation on 09/06/23 at 9:18 A.M. revealed Resident #25 had on a blue resting hand splint to her right hand. Observation on 09/07/23 at 9:10 A.M. revealed Resident #25 had a black soft brace to her right hand. Interview on 09/07/23 at 9:12 A.M. with State tested Nursing Assistant (STNA) #165 revealed Resident #25 had two braces (splints) for her right hand: a blue one for night time and a black one for day time. STNA #165 stated it was not on the kardex (STNA care plan) for Resident #25 to wear the braces. STNA #165 stated the nurse (not identified) told the STNA to put the braces on the resident. STNA #165 stated she did not complete any type of range of motion on Resident #25's right hand. Interview on 09/07/23 at 10:15 A.M. with Certified Occupational Therapy Assistant (COTA) #166 revealed therapy was not providing any services for Resident #25 as she was on hospice care. COTA #166 observed and assessed Resident #25 right hand with surveyor. COTA #166 stated Resident #25 had decreased flexion in right wrist and thumb. The COTA observed the resting hand splint on Resident #25 bed side table and stated the device was used to prevent contracture's and was the correct splint for Resident #25 to wear. However, the therapy department did not provide the splint or any care and services to Resident #25. 31404 3. Record review of Resident #37 revealed an admitted [DATE] with pertinent diagnoses of: schizophrenia, major depressive disorder, shortness of breath, urinary tract infection, benign prostatic hyperplasia, protein calorie malnutrition, constipation, tremor, chest pain, asthma, hyperlipidemia, age related osteoporosis, schizoaffective disorder, dysphagia, Barrett's esophagus with dysplasia, hypertension, hyponatremia, dry mouth, iron deficiency anemia, chronic peptic ulcer, esophageal obstruction, polyp of colon, and nausea. Review of the 07/21/23 annual MDS assessment revealed the resident is cognitively intact and requires limited assistance for bed mobility, transfer, walk in room, dressing, toilet use, and personal hygiene. The resident uses a wheelchair to aid in mobility and is always incontinent of bladder and frequently incontinent of bowel. Review of the medical record on 09/05/23 revealed the resident was admitted to Hospice services on 08/02/22. There was no physicians order stating he was admitted to hospice in the electronic or paper record. Review of the medical record on 09/07/23 revealed there was no communication papers with the hospice company available. Interview with the Director of Nursing (DON) on 09/07/23 at 10:32 A.M. verified there was not a Physicians Order for Resident #37 to be on hospice services. The DON also verified they did not have communication from hospice readily available in the facility.

Based on observation, staff interview, and record review the facility failed to ensure medication error rates were not greater than five percent when Resident #95 did not receive their dose of Eliquis (an anticoagulant blood thinner medication) and gave Resident #37 the wrong dose amount of Vitamin D3. This affected two (Resident #37, and #95) of four residents reviewed for medication administration. The facility had two errors out of 25 opportunities for a medication error rate of eight percent. The facility census was 40. Findings include: 1. Record review of Resident #95 revealed an admitted [DATE] with pertinent diagnosis of: cellulitis, cirrhosis of liver, thrombocytopenia, atherosclerotic heart disease of native coronary artery, atrial fibrillation, type two diabetes mellitus, anemia, and congestive heart failure. Review of a Physicians Order dated 09/01/23 revealed to give apixaban (Eliquis) five milligrams one half tab by mouth every 12 hours. Observation on 09/06/23 at 7:54 A.M. revealed Registered Nurse (RN) #138 administering medications to Resident #95 for morning medication pass. RN #138 administered nine medications but did not administer Eliquis. RN #138 verified she had given all the resident's morning medication and did not give anything earlier on 09/06/23 at 8:09 A.M. Interview with RN #138 on 09/06/23 at 10:20 A.M. verified she did not give Resident #95's morning Eliquis she had just missed the medication. 2. Record review of Resident #37 revealed an admitted [DATE] with pertinent diagnosis of: schizophrenia, major depressive disorder, shortness of breath, urinary tract infection, benign prostatic hyperplasia, protein calorie malnutrition, constipation, tremor, chest pain, asthma, hyperlipidemia, age related osteoporosis, schizoaffective disorder, dysphagia, Barrett's esophagus with dysplasia, hypertension, hyponatremia, dry mouth, iron deficiency anemia, chronic peptic ulcer, esophageal obstruction, polyp of colon, and nausea. Review of the 07/21/23 annual Minimum Data Set (MDS) assessment revealed the resident is cognitively intact and requires limited assistance for bed mobility, transfer, walk in room, dressing, toilet use, and personal hygiene. The resident uses a wheelchair to aid in mobility and is always incontinent of bladder and frequently incontinent of bowel. Review of a Physicians Order dated 06/09/22 revealed to give cholecalciferol (vitamin D3) 1000 units one time a day for supplement. Observation on 09/06/23 at 8:13 A.M. revealed RN #138 administering medications to Resident #37 for morning medication pass. RN #138 administered cholecalciferol (vitamin D3) 400 units to Resident #37. Interview with RN #138 on 09/06/23 at 10:20 A.M. verified she gave Resident #37 the 400 units of cholecalciferol (vitamin D3) instead of 1000 units.

Based on observation, staff interview, record review, and policy review the facility failed to to provide a sanitary environment to prevent the spread and development of communicable disease and infections when they did not cleanse blood glucose monitoring machines appropriately after resident use for Resident #95. The facility identified three Residents (#5, #9, #11) on the 19-27 hallway who received blood glucose monitoring checks. The facility census was 40. Findings include: Record review of Resident #95 revealed an admitted [DATE] with pertinent diagnosis of: cellulitis, cirrhosis of liver, thrombocytopenia, atherosclerotic heart disease of native coronary artery, atrial fibrillation, type two diabetes mellitus, anemia, and congestive heart failure. Review of a Physicians Order dated 09/03/23 revealed to inject novolog insulin per sliding scale before meals and at bedtime. Observation on 09/06/23 at 7:54 A.M. revealed Registered Nurse (RN) #138 used the glucometer to check Resident #95 blood sugar level. RN #138 cleaned the glucometer with alcohol after she was done. Interview with RN #138 on 09/06/23 at 8:21 A.M. verified she cleaned the glucometer with alcohol and when questioned what she uses to clean the glucometer she stated alcohol or a bleach wipe. The Surveyor informed RN #138 that alcohol does not kill blood born pathogens such as human immunodeficiency virus, and hepatitis. RN #138 did not have any bleach containing wipes in her cart and they had to be retrieved out of the storage area. Review of the Assure Prism Multi Glucometer Reference Manual dated 03/01/21 revealed to minimize the risk of transmitting blood-borne pathogens, the cleaning and disinfection procedure should be performed as recommended. A variety of the most commonly used EPA-registered wipes have been tested and approved for cleaning and disinfecting of the Assure Prism multi Blood Glucose Monitoring System. The disinfectant wipes listed below have been shown to be safe for use with this meter. Please read the manufacturer's instructions before using their wipes on the meter: Clorox germicidal wipes, Dispatch hospital cleaner disinfectant towels and bleach, PDI Super Sani-Cloth germicidal disposable wipes, and Caviwipes1.

Based on record review and interview, the facility failed to timely report Resident #15's allegation of misappropriation to the state agency. This affected one resident (Resident #15) out of four residents reviewed for misappropriation of property. Findings include: Record review of Resident #15 medical record revealed this resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #15's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition was intact. Review of a Complaint/Grievance Report completed on 03/10/22, revealed after Resident #15 had returned from the hospital, she discovered 20 dollars was missing from her money jar, which she kept at bedside. This was reported to Social Services Director #7 on 03/10/22, when the Complaint Report was filed, who reported it to Director of Nursing (DON). The plan to resolve the complaint was to explain to the resident to keep her money in a resident fund account, or to obtain a lock box. No record of a lock box was ever obtained, as she declined to initiate a resident fund account. Review of the facilities Self Reported Incident (SRI) history revealed no evidence a SRI was submitted for an allegation of misappropriation of Resident #15's money. Interview with Social Service Director #7 on 04/13/22 at 10:10 A.M. verified Resident #15 had reported some missing money on 03/10/22, after she had returned from the hospital. She stated the resident and her roommate pool money together in a shared glass jar, so the roommate was also questioned after a search of the room was completed. She stated the resident also declined to enroll in a Resident Fund Account by the facility. She verified there was not a Self Reported Incident that was initiated after the Complaint Report was completed. She stated she had reported it to the Director of Nursing on that date. Interview with the Administrator on 04/13/22 at 10:20 A.M. verified a Self Reported Incident was was not completed after the facility had received an allegation of misappropriation of property when twenty dollars was reported as missing on 03/10/11. She verified this was reported by Resident #15 to Social Services Director #7, and a Complaint Form was completed. She verified since there was not an SRI filed, she would start one immediately. She verified this case of misappropriation was just lost after the initial complaint was made by the resident. Interview with DON on 04/13/22 at 10:35 A.M. verified an allegation of misappropriation was reported to her on 03/10/22. She verified that after the initial complaint, it was accidentally forgotten, and the resident just today had received a reimbursement of twenty dollars, and provided with a new lock box on 04/13/22. Review of the facility policy titled Abuse Prevention Policy, revised December 2016, revealed all residents were to be free of any type of abuse, including misappropriation of property. It stated, any allegations are to be investigated and reported immediately to the appropriate state agency. It would be reported according to state and federal guidelines. Review of Self Reported Incident # 3 on 04/13/22 after surveyor intervention, revealed this incident was reported to the state agency on 04/13/22. The date of discovery was noted as being 03/10/22, and confirmed the resident had reported the missing money on 03/10/22, and no other SRI was initiated following the resident's complaint. This citation substantiates Complaint Number OH 452.

Based on record review and interview, the facility failed to investigate Resident #15's allegation of misappropriation. This affected one resident (Resident #15) out of four residents reviewed for misappropriation of property. Findings include: Record review of Resident #15 medical record revealed this resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #15's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition was intact. Review of a Complaint/Grievance Report completed on 03/10/22, revealed after Resident #15 had returned from the hospital, she discovered 20 dollars was missing from her money jar, which she kept at bedside. This was reported to Social Services Director #7 on 03/10/22, when the Complaint Report was filed, who reported it to Director of Nursing (DON). The plan to resolve the complaint was to explain to the resident to keep her money in a resident fund account, or to obtain a lock box. No record of a lock box was ever obtained, as she declined to initiate a resident fund account. Review of the facilities Self Reported Incident (SRI) history revealed no evidence a SRI was submitted for an allegation of misappropriation of Resident #15's money. Interview with Social Service Director #7 on 04/13/22 at 10:10 A.M. verified Resident #15 had reported some missing money on 03/10/22, after she had returned from the hospital. She stated the resident and her roommate pool money together in a shared glass jar, so the roommate was also questioned after a search of the room was completed. She stated the resident also declined to enroll in a Resident Fund Account by the facility. She verified there was not a Self Reported Incident that was initiated after the Complaint Report was completed. She stated she had reported it to the Director of Nursing on that date. Interview with the Administrator on 04/13/22 at 10:20 A.M. verified a Self Reported Incident was was not completed after the facility had received an allegation of misappropriation of property when twenty dollars was reported as missing on 03/10/11. She verified this was reported by Resident #15 to Social Services Director #7, and a Complaint Form was completed. She revealed the allegation of misappropriation was not investigated. She verified this case of misappropriation was just lost after the initial complaint was made by the resident. Interview with DON on 04/13/22 at 10:35 A.M. verified an allegation of misappropriation was reported to her on 03/10/22. She verified that after the initial complaint, it was accidentally forgotten, and the resident just today had received a reimbursement of twenty dollars, and provided with a new lock box on 04/13/22. Review of the facility policy titled Abuse Prevention Policy, revised December 2016, revealed all residents were to be free of any type of abuse, including misappropriation of property. It stated, any allegations are to be investigated and reported immediately to the appropriate state agency. It would be reported according to state and federal guidelines. This citation substantiates Complaint Number OH 452.

Based on medical record review, contract review, and staff interview the facility failed to provide necessary treatment and services to treat constipation, and hospice services. This affected three of three residents (Residents #15, #20, and #22) reviewed for constipation, one of one residents (Resident #15) reviewed for hospice services. Actual harm occurred to Resident #20 when the resident did not receive timely treatment for constipation that resulted in hospitalization of a bowel obstruction. Findings include: 1. Review of Resident #20's medical record revealed she was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #20's annual Minimum Data Set (MDS) 3.0 dated 04/06/21 revealed Resident #20 had no speech, was rarely understood and rarely understands others. Resident #20 had short-term and long-term memory impairment, had no recall, and severely impaired decision making. Resident #20 had no behaviors and did not reject care. Resident # 20 was dependent on two staff for bed mobility and transfers, did not walk, was dependent on two staff for toilet use, and personal hygiene. Review of Resident #20's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .M. If the MOM was ineffective, administer [MEDICATION(S)] suppository via the rectum at 1:00 P.M. If the [MEDICATION(S)] suppository was ineffective, administer one bottle of magnesium [MEDICATION(S)] at 5:00 P.M. If the magnesium [MEDICATION(S)] was ineffective, administer a Fleet enema at 10:00 P.M. If there was no bowel movement after the enema, abdominal pain or distention, bowel sounds increase/decrease at any time notify the physician. At any time do not administer the above medication if any if the following were present: abdominal pain, vomiting and/or rectal bleeding. Review of Resident #20's bowel records revealed on 09/23/21 Resident #20 had a bowel movement. No bowel movements were documented from 09/24/21 to 10/03/21. Review of the bowel record on 09/30/21 LAXED was documented. Review of Resident #20's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #20's October 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #20's progress notes dated 10/01/2021 revealed Resident #20 had a distended abdomen and was sent to the local hospital. Review of Resident #20's hospital discharge summary dated 10/03/21 revealed on 10/01/21 Resident #20 went to the emergency room with reported abdominal distention. A computed tomography (CT) scan revealed bowel obstruction and severe constipation. Resident #20 was treated with magnesium [MEDICATION(S)] and soapsuds enema. Resident #20 had multiple extremely large bowel movements. Review of Resident #20's progress notes revealed on 10/03/21 Resident #20 returned from the hospital. Review of Resident #20's orders revealed magnesium [MEDICATION(S)] 296 ml every 72 hours was ordered and documented as administered as ordered. Interview with the Director of Nursing (DON) on 11/23/21 at 3:25 P.M. confirmed the bowel protocol was not implemented in September 2021 and October 2021 when Resident #20 had no bowel movement from 09/24/21 to 10/01/21. The DON confirmed Resident #20 was admitted to the local hospital and was diagnosed with a bowel obstruction and severe constipation. 2. Review of Resident #15's medical record revealed she was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #15's annual MDS dated [DATE] revealed the following Resident #15's speech was clear, she was understood, understands others, and her cognition was intact. Resident #15 had no behaviors and did not reject care. Resident #15 required extensive assistance of two staff for bed mobility, to transfer, did not walk, no locomotion, extensive assistance of two staff for toilet use, and personal hygiene. Resident #15 had a life expectancy of six months or less and was on hospice. Review of Resident #15's quarterly MDS dated [DATE] revealed Resident #15 rejected care one to three days. Review of Resident #15's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .M. If the MOM was ineffective, administer [MEDICATION(S)] suppository via the rectum at 1:00 P.M. If the [MEDICATION(S)] suppository was ineffective, administer one bottle of magnesium [MEDICATION(S)] at 5:00 P.M. If the magnesium [MEDICATION(S)] was ineffective, administer a Fleet enema at 10:00 P.M. If there was no bowel movement after the enema, abdominal pain or distention, bowel sounds increase/decrease at any time notify the physician. At any time do not administer the above medication if any if the following were present: abdominal pain, vomiting and/or rectal bleeding. Review of Resident #15's bowel records revealed no evidence Resident #15 had a bowel movement from 11/08/21 to 11/12/21 and 11/15/21 to 11/26/21. Review of Resident #15's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with Regional Director of Clinical Operations (RDCO) #77 on 11/30/21 at 1:18 P.M. confirmed there was no evidence Resident #15 had a bowel movement from 11/08/21 to 11/12/21 and 11/15/21 to 11/26/21 and the bowel protocol was not implemented as ordered. Review of Resident #15's record revealed no current hospice care plan and there was no information from hospice provided to the facility. Review of the hospice contract with the hospice service that provided services to Resident #15 dated 10/10/17 revealed hospice would maintain a complete medical record for the hospice recipient and documentation would be maintained in the recipient's nursing home medical record. Interview with DROC #77 on 11/30/21 at 3:50 P.M. revealed Resident #15's hospice provider maintained electronic documentation and previously their documentation was not shared with the facility. 3. Record review for Resident #22 revealed this resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This resident had allergies to [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)]. Review of the quarterly MDS assessment, dated 10/13/21, revealed Resident #22 had intact cognition evidenced by a BIMS assessment score of 15. This resident was assessed to require limited assistance from one staff member for toileting and eating and to require supervision with set up assistance for bed mobility and transfers. Review of the care plan, dated 08/20/21, revealed Resident #22 was at risk for altered bowel elimination. Interventions included to provide medications as ordered. Review of Resident #22's active physicians orders revealed an order to implement the bowel protocol per facility policy if no bowel movement by the third day. Review of the facility Bowel and Bladder Elimination Pattern Evaluation for Resident #22 for 10/2021 revealed the resident was documented as not having a bowel movement from 10/01/21 through 10/09/21, 10/17/21 through 10/23/21, and 10/26/21 through 10/31/21. Review of Resident #22's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #22's progress notes, dated 10/01/21 through 11/01/21, revealed an absence of documentation of Resident #22 not having a bowel movement or of the facility bowel protocol being implemented. Interview with Resident #22 on 11/30/21 at 2:30 P.M. revealed the resident had experienced episodes of constipation which had been reported to staff and had not received any additional medications or treatments for the constipation. Interview with the Director of Nursing on 11/30/21 at 4:45 P.M. verified Resident #22 had not been documented as having a bowel movement for more than three days on multiple occasions in 10/2021 and verified the MAR for 10/2021 contained no documentation of the facility bowel protocol being implemented.

Based on staff interview, review of time punch cards, and review of direct care staff schedule revealed the facility failed to ensure the facility had Registered Nurse (RN) coverage for a consecutive eight hours. This had the potential to affect all 34 residents. Findings include: Review of the nursing staff schedule from 11/01/21 through 11/30/21 revealed the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) were scheduled on 11/25/21 day shift. Review of the time punch cards for the DON revealed zero accumulated hours for 11/25/21. Review of the time punch for the ADON revealed zero accumulated hours for 11/25/21. Interview on 12/01/21 at 3:00 P.M. with the Administrator and the Regional Director of Clinical Operations #77 confirmed there was no RN coverage for the facility on 11/25/21.

Based on resident interviews, group resident interview, review of Resident Council Meeting Minutes, and a test tray the facility failed to serve food that was palatable and at an acceptable temperature. This had the potential to affect 33 of 34 resident (Resident #15 receives nothing from the kitchen) and specifically affected Residents #26, #10, #22, #15, #18, #23, #26, #28, #29, and #31. Findings include: 1. Review of Resident Council meeting minutes revealed on 8/27/21 complaints of cold food, it was not the best food and the food was either over or under cooked. The 09/15/21 resident council minutes revealed the food was cold, the food tasted bad, the broccoli and cauliflower were overcooked, and served in big pieces. Interview of Resident #26 on 11/21/21 at 9:40 A.M. revealed sometimes the hot foods were served cold and were not good. Interview of Resident #10 on 11/21/21 10:30 A.M. revealed hot foods were served cold. Interview with Resident #22 on 11/21/21 at 10:53 A.M. revealed food was not served hot. Interview of Resident #15 on 11/21/21 at 2:35 P.M. revealed sometimes the hot food was not hot. A resident group meeting was held on 11/22/21 at 9:30 A.M. with Resident #18, #23, #28, #29, and #31 stated the hot foods were served cold and it did not taste good. A test tray was requested on 11/29/21. The cart containing the test tray arrived on the unit at 12:05 P.M. The last tray was delivered at 12:25 P.M. At 12:27 P.M. the following temperatures of the food items were obtained. The cheese pizza was 94 degrees Fahrenheit (F) it was cold to the taste, the cheese on the pizza was light brown, the sauce was absorbed by the crust, and the crust was tough and very dry. The green beans were 102 degrees F and cool to taste. The test tray was sampled by two surveyors. 2. Record review for Resident #22 revealed this resident was admitted to the facility on [DATE] with diagnoses including [CONDITION(S)], [CONDITION(S)], acute and chronic respiratory failure, difficult ambulation, parainfluenza, muscle weakness, lack of coordination, [CONDITION(S)], fatigue, shortness of breath, hypertension, anxiety, depression, asthma, fluid aspiration, diabetes mellitis type II, and hypertension. This resident had allergies to [MEDICATION(S)], Levofloxicin, [MEDICATION(S)], [MEDICATION(S)], Amytriptylline, [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/13/21, revealed this resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 15. Interview with Resident #22 on 11/21/21 at 10:53 A.M. revealed the facility does not provide hot food substitutions, and you have to ask for them. 3. Record review for Resident #26 revealed this resident was admitted to the facility on [DATE] with diagnoses including non-displaced [MEDICATION(S)] fracture of right fibula, falls, muscle weakness, urinary tract infection, anxiety, [CONDITION(S)], chronic pain, acute kidney failure, hypertension, bimalleolar fracture, and [CONDITION(S)]. This resident had no known drug allergies. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/19/21, revealed this resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 15. Interview with Resident #26 on 11/21/21 at 9:40 A.M. revealed the resident stated that some of the food is not very good, and is sometimes cold. This deficiency substantiates Master Complaint Number OH 643.

Based on observation, resident interview, resident group interview, resident council meeting minutes, and staff interview the facility failed to ensure accommodation of resident food preferences and failed to offer a food substitute when a resident did not like the food served. This affected 33 of 34 residents (except Resident #15 who received nothing from the kitchen) and specifically affected Residents #7, #18, #23, #28, #29, #30, and #31 . Findings include: Review of Resident Council meeting minutes revealed on 09/15/21 resident council minutes revealed staff never asked the resident's food preferences. The residents stated they never served what is on the menu, and the residents did not have a copy of the menu to ask for a substitution. Observation on 11/21/21 at 12:12 P. M. revealed Resident #18 did not eat her soup and State tested Nursing Assistant (STNA) #16 did not offer Resident #18 a substitute for the food she did not like. Resident #31 did not eat her chips, sandwich, or fruit and ate 50% of her soup. STNA #16 did not offer Resident #31 an alternate for the food items she did not eat Resident #29 did not eat her soup, or her fruit, she at 50 % of her sandwich, and a few chips. STNA #16 did not offer Resident #29 food substitutes for the items she did not eat. Resident #30 was served his meal tray and refused it. STNA #21 told STNA #16 that Resident #30 refused his meal. STNA #16 told STNA #21 she had to ask Resident #30 if he wanted a substitute because he would not ask for one. A resident group meeting was held on 11/22/21 at 9:30 A.M. with Residents #18, #23, #28, #29, and #31 stated they were not offered food substitutes. Observation of Resident #12's breakfast meal on 12/01/21 at 7:56 A.M. revealed Resident #12 ate 10 % of her eggs, 25% of her toast, 0% cooked cereal and 0% of her milk. Interview of STNA #66 revealed she did not offer Resident #12 a replacement meal as the resident was not a big eater. Observation at lunch revealed 12/01/21 at 11:38 A.M. Resident #7 refused her meat and rice and Resident #29 refused her steak, rice, and cooked spinach. STNA #21 did not offer Resident #7 or Resident #29 alternate food for the food items refused. Interview of the Director of Nursing (DON) on 12/01/2021 at 11:40 A.M. confirmed staff should ask residents if they wanted food substitutions.