Every finding on record at Pleasant View Health Care Center

Based on observation, interview, and review of the facility's Food Preparation and Service policy, the facility failed to ensure that hot and cold food items were maintained within required temperature ranges and that all food items, including alternates, were properly temperature checked prior to service. The facility also failed to monitor and maintain food temperatures throughout tray line and tray cart distribution. This deficient practice had the potential to affect 96 of 97 residents who received meals. Resident #30 received nothing by mouth.Findings include:Observations of the kitchen tray line on 06/11/26 beginning at 11:36 A.M. revealed the lunch menu included roasted turkey with gravy, yams, winter mix vegetables, pears, and a roll. Initial temperatures at the start of tray line service were as follows: roasted turkey 193 degrees Fahrenheit (F); ground turkey 188 degrees F; pureed turkey 200 degrees F; yams 207 degrees F; vegetables 159 degrees F; pureed vegetables 180 degrees F; kielbasa 169 degrees F (alternate); and pears 51 degrees F. The temperature of the gravy, thickened gravy, mashed potatoes (alternate) and Brussels sprouts (alternate) were not taken prior to being served.During an interview at 11:40 A.M., [NAME] #301 stated that temperatures of alternate food items were not taken because they were not considered the main entree. [NAME] #301 further confirmed that cold fruit would be served even if out of the appropriate temperature range and that temperatures were not checked on all items prior to service.Between 11:47 A.M. and 12:31 P.M., ongoing observations of tray line service revealed multiple food items-including pears, gravy, mashed potatoes, yams, roasted turkey, vegetables, Brussels sprouts, chopped turkey, and additional trays of hot and cold foods-being placed on the steam table or removed from refrigeration and served to residents without temperatures being checked. No temperature monitoring was observed for any items on the steam table after meal service began. [NAME] #301 verified these findings during an interview at 12:40 P.M.Review of the facility's 06/11/26 lunch temperature log showed the cold fruit was documented 47 degrees F at the start of lunch service.Review of the facility policy titled Food Preparation and Service, dated 10/2025, showed dietary staff were required to follow safe food handling practices, maintain hot foods above 135 degrees F, maintain cold foods below 41 degrees F, ensure proper temperatures during food distribution and service, and monitor temperatures of items held on steam tables throughout service.2. During an interview on 06/11/26 at 9:49 A.M. with Registered Dietician (RD) #344 reported assisting with Dietary Manager duties.An observation on 06/11/26 at 11:47 A.M. showed a plate warmer being used to conserve food temperature during tray cart assembly.An observation of a test tray on 06/11/26 at 12:30 P.M. revealed the last tray cart was being served, at 12:39 P.M. the test tray was assembled and loaded into the tray cart, at 12:40 P.M. the tray cart left the kitchen and went to Unit-1, at 12:42 P.M. staff members distributed the trays to the residents, and at 12:46 P.M. the temperature of the items were checked and as follows: yams 128 degrees F, roasted turkey 128 degrees F, vegetables 134 degrees F, and pears 57 degrees F.During an interview on 06/11/26 at 12:48 P.M., RD #344 stated they would expect the temperatures of the hot foods to be above 135 degrees F and for the cold fruit to be below 41 degrees F. RD #344 verified the above temperatures and only a plate warmer was used for heat conservation.Review of the facility policy titled Food Preparation and Service, dated 10/2025, revealed dietary employees were to distribute and serve food in compliance with safe food handling practices, hot food was to be held above 135 degrees F, cold food was to be held below 41 degrees F, proper hot and cold temperatures were to be maintained during food distribution and service, and the temperatures of food held in the steam tables was to be monitored throughout the meal service.

Based on record review, observation, interviews, and facility policy review, the facility failed to ensure that respiratory equipment, including oxygen tubing, humidification bottles, and nebulizer masks, was changed according to physician orders, stored properly, and maintained in a clean condition. These failures resulted in the use of outdated and improperly stored respiratory equipment and affected three residents (Residents #21, #27, and #68) of three residents sampled for oxygen or nebulizer therapy. The facility census was 97.Findings include:1. Review of the medical record revealed Resident #68 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), chronic respiratory failure, and congestive heart failure (CHF).Review of the current physician orders revealed an order for continuous oxygen two liters per minute (LPM) via nasal cannula (dated 12/16/22), an order to change oxygen tubing, mask, and cannula weekly every Sunday on night shift and to date the tubing (dated 01/16/26), and an order for Ipratropium-Albuterol (a medication that relaxes airway muscles and improves airflow) one half milligram (mg) and two and a half mg per three milliliters (mL) inhalation every eight hours as needed (PRN) (dated 03/04/25).Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #68 was cognitively intact, did not reject care, was independent with most activities of daily living (ADL), and was on oxygen therapy.Review of the care plan dated 05/19/26 revealed Resident #68 had an altered cardiopulmonary status related to COPD with a goal to be free from signs and symptoms of cardiac problems and an intervention to give oxygen as ordered by the physician.Review of the Medication Administration Record (MAR) from 05/01/26 to 05/31/26 revealed documentation that Resident #68 wore oxygen every day and Resident #68 received Ipratropium-Albuterol on 05/28/26.Review of the Treatment Administration Record (TAR) from 05/01/26 to 05/31/26 revealed Resident #68's disposable oxygen equipment was documented as changed on 05/17/26, 05/24/26, and 05/31/26.Review of the MAR from 06/01/26 to 06/10/26 revealed documentation that Resident #68 wore oxygen every day.Review of the TAR from 06/01/26 to 06/10/26 revealed documentation that Resident #68's disposable oxygen equipment was documented as changed on 06/07/26. An observation on 06/08/26 at 2:43 P.M. revealed Resident #68 was actively using her oxygen concentrator and nasal cannula, the oxygen tubing was dated 05/17/26, the nebulizer mask (a machine that turns a liquid medication into a mist to deliver medication to the lungs) dated 05/17/26, the nebulizer mask was not stored in a bag, and the nebulizer mask was lying directly on the resident's nightstand.An observation on 06/09/26 at 11:57 A.M. revealed Resident #68's oxygen tubing was dated 05/17/26, the oxygen humidification bottle was empty and undated, the nebulizer mask was dated 05/17/26, the nebulizer mask was not stored in a bag, and the nebulizer mask was lying directly on the resident's nightstand.An interview on 06/09/26 at 11:57 with Registered Nurse (RN) #201 revealed oxygen tubing and nebulizer masks were to be changed weekly, nebulizer masks were to be stored in a bag, and oxygen humidification was to be changed when empty and dated. RN #201 verified the above findings at the time of the interview.Review of the undated facility policy titled Oxygen Therapy Use and Maintenance Policy revealed oxygen therapy would be administered according to physician orders, supplies were to be replaced as clinically indicated, and humidification was to be replenished as needed.Review of the undated facility policy titled Aerosolized Nebulizer Therapy revealed nebulizer tubing and mask were to be replaced weekly.2. Review of the medical record revealed Resident #21 was admitted to the facility on [DATE] with diagnoses including stroke, coronary artery disease, and heart failure.Review of the current physician orders revealed an order to change oxygen tubing, mask, and cannula weekly every night shift on Sunday and to date the tubing (dated 08/27/25) and an order for oxygen two to four LPM via nasal cannula every shift to maintain blood oxygen levels above 90 percent (dated 09/02/25).Review of the care plan dated 02/11/26 revealed Resident #21 had an altered cardiopulmonary status with a goal to be free from signs and symptoms of cardiac complications and interventions included to change oxygen and nebulizer tubing weekly and administer oxygen as ordered.Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #21 was moderately cognitively impaired, did not reject care, required maximal assistance or was dependent on staff for most ADL, and utilized oxygen therapy.Review of the MAR from 05/01/26 to 05/31/26 revealed documentation that Resident #21 wore oxygen every day.Review of the TAR from 05/01/26 to 05/31/26 revealed oxygen tubing was documented on 05/03/26, 05/10/26, 05/17/26, 05/24/26, and 05/31/26.Review of the MAR from 06/01/26 to 06/09/26 revealed documentation that Resident #21 wore oxygen every day.Review of the TAR from 06/01/26 to 06/09/26 revealed oxygen tubing was documented as changed on 06/07/26.An observation on 06/08/26 at 2:31 P.M. revealed Resident #21 was utilizing oxygen therapy and there was a layer of grime on the oxygen concentrator on the horizontal surface underneath the handle.An observation on 06/09/26 at 12:03 P.M. revealed the same layer of grime on the oxygen concentrator on the horizontal surface underneath the handle.An interview on 06/09/26 at 12:03 P.M. with RN #201 revealed oxygen concentrators were to be wiped down weekly as part of the oxygen tubing change process. RN #201 verified the above findings at the time of interview.Review of the undated facility policy titled Oxygen Therapy Use and Maintenance Policy revealed residents were to receive oxygen therapy in accordance with infection control standards and oxygen equipment shall be maintained in proper working order.Review of the facility policy titled Cleaning and Disinfection of Resident-Care Items and Equipment, dated 09/2025 revealed re-usable resident-care equipment was to be cleaned and disinfected.3. Review of the medical record revealed Resident #27 was admitted to the facility on [DATE] with diagnoses including stroke, major depressive disorder, diabetes mellitus type two, and high blood pressure.Review of the admission MDS 3.0 assessment dated [DATE] revealed Resident #27 was cognitively intact, did not reject care, and required maximal assistance for most ADL.An observation on 06/08/26 at 2:38 P.M. revealed an undated nebulizer mask stored in the top nightstand drawer, not in a bag.An observation on 06/09/26 at 12:01 P.M. revealed an undated nebulizer mask stored I the top nightstand drawer, not in a bag.An interview with RN #201 revealed nebulizer tubing was to be dated and stored in a bag. RN #201 verified the above findings at the time of interview.Review of the undated facility policy titled Aerosolized Nebulizer Therapy, revealed nebulizer tubing and mask were to be replaced weekly.

Based on record review, observation, interview, and review of the facility policy and procedure, the facility failed to ensure infection prevention protocols were maintained for Resident #6, who required enhanced barrier precautions (EBP). This affected one resident (Resident #6) of 24 residents (Residents #2, #5, #6, #8, #11, #13, #14, #21, # 30, #35, #42, #43, #48, #54, #64, #66, #67, #76, #79, #90, #91, #93, #117, #119) on EBP. The facility census was 97.Findings include:Review of the medical record revealed Resident #6 was admitted on [DATE] with diagnoses including dysfunction of the bladder, major depressive disorder, anxiety, gastro-esophageal reflux disease (GERD), post-traumatic stress disorder (PTSD), atrial fibrillation, gastrostomy status, and diabetes type one.Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #6 had an indwelling urinary catheter and a feeding tube.Review of the June 2026 physician orders revealed no orders for EBP. There was an order to cleanse the suprapubic catheter and apply a clean sponge every shift. Observation of medication administration on 06/10/26 at 6:40 A.M. with Registered Nurse (RN) #207 of Resident #6 revealed RN #207 prepared the morning medication for administration through the percutaneous endoscopic gastrostomy (PEG) tube. Observation of the door to Resident #6's room had no sign to alert staff and/or visitors of the need for EBP or personal protective equipment (PPE) available to use. RN #207 walked into the room, donned gloves and administered the medications through Resident #6's PEG tube. Reusable gowns were observed hanging from the bathroom door. There were no biohazard receptacles located in the room. Observation of suprapubic catheter care on 06/10/26 at 9:30 A.M. with Certified Nursing Assistant (CNA) #253 of Resident #6 revealed CNA #245 entered the room and gathered supplies and donned gloves, emptied the urinary collection bag, completed catheter care and exited the room. CNA had no face shield or gown while emptying the urinary collection bag or completing catheter care.During an interview on 06/10/26 at 4:15 P.M., RN #207 verified she did not wear a gown when administrating Resident #6's medication through the tube. RN #207 verified that Resident #6 was on EBP by the blue dot under his name located on the wall next to the door entrance.During an interview on 06/10/26 at 1:20 P.M., the Director of Nursing (DON) stated the facility opted to have a homelike environment and uses the blue dot to identify residents on EBP. During an interview on 06/11/26 at 2:30 P.M., CNA #245 verified she did not wear gown while completing catheter care with Resident #6. CNA #245 stated she was nervous while providing care. CNA # 245 stated she was aware that Resident #6 was on EBP.Review of the facility policy titled Isolation Categories of Transmission Based Precaution (revised September 2025) stated under EBP, staff will wear gloves and gowns when providing -contact care activities: dressing bathing, transferring in rooms, changing linens, providing hygiene changing briefs, or assisting with toileting, device care of urinary catheter or feeding tube, and wound care.

Based on observation, interview, and review of facility policies, the facility failed to ensure the environment was maintained in a clean and orderly manner. This deficient practice affected two residents (Residents #21 and #89) out of four residents sampled for environmental concerns. The facility census was 97.Findings include:1. An observation on 06/09/26 at 8:15 A.M. of Resident #89's room revealed two exposed wire connections in the wall where a call light panel appeared to have been removed.A follow up observation on 06/09/26 at 12:05 P.M. showed the same two exposed wire connections still present.During an interview on 06/09/26 at 12:05 P.M., Registered Nurse (RN) #201 stated she would not expect exposed wires to be present in a resident room. RN #201 verified the observed conditions at the time of the interview.Review of the facility policy titled Maintenance Service (dated 09/2025) revealed that maintenance services were to be provided throughout the building; maintenance personnel were to maintain the facility in a safe and operable manner; and the building was to be kept in good repair and free from hazards.2. An observation on 06/08/26 at 2:30 P.M. of Resident #21's room revealed the floor at the foot of the bed was sticky with multiple areas of dried red liquid, consistent with a spill. The same dried red substance was also noted on the power strip and on the plug ends of items connected to the power strip.A repeat observation on 06/09/26 at 12:03 P.M. showed the same dried red liquid remained on the floor, the power strip, and the plug ends.During an interview on 06/09/26 at 12:03 P.M., RN #201 verified the observed environmental concerns.Review of the facility policy titled Cleaning and Disinfecting Residents' Rooms (undated) indicated that floors were to be cleaned regularly, when spills occur, and whenever surfaces were visibly soiled.

Based on medical record review, interview, and facility policy review, the facility failed to ensure oral care was provided daily as required for four residents (#81, #82, #100, and #101) of five residents reviewed for oral care. The facility census was 116.Findings include:1. Review of the medical record for Resident #81 revealed an admission date of 04/27/18. Diagnoses included but were not limited to Alzheimer's dementia, vascular dementia with psychotic disturbance, and unspecified protein-calorie malnutrition.Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #81 revealed a Brief Interview of Mental Status (BIMS) score of 08 which indicated moderate cognitive impairment. Review of activities of daily living (ADLs) revealed the resident required maximum assistance for oral hygiene.Review of the care plan for Resident #81, which was last reviewed on 01/26/26, revealed she was dependent on staff assistance for oral hygiene.Review of the task called Denture care AM for the past 30 days for Resident #81 revealed morning (AM) denture care was provided on 03/11/26, 03/12/26, 03/18/26, 03/19/26, 03/26/26, 04/02/26, 04/03/26, 04/06/26. It was marked as not applicable on 03/10/26, 03/13/26, 03/14/26, 03/16/26, 03/17/26, 03/20/26, 03/22/26, 03/23/26, 03/24/26, 03/30/26, 03/31/26, 04/04/26, 04/05/26, and 04/07/26. No morning denture care was noted on 03/08/26, 03/09/26, 03/15/26, 03/21/26, 03/25/26, 03/27/26, 03/28/26, 03/29/26, 04/01/26. Out of 30 opportunities for morning oral care, it was only recorded as provided eight times. Review of task called, Denture Care PM for the past 30 days for Resident #81 revealed evening (PM) denture care was provided on 03/10/26, 03/13/26, 03/14/26, 03/15/26, 03/17/26, 03/20/26, 03/22/26, 03/27/26, 04/01/26, 04/02/26, and 04/07/26. It was indicated as not applicable on 03/11/26, 03/12/26, 03/18/26, 03/19/26, 03/22/26, 03/24/26, 03/25/26, and 04/08/26. Out of 30 opportunities for evening denture care, it was only recorded as provided 11 times. 2. Review of the medical record for Resident #82 revealed an admission date of 02/11/22. Diagnoses included but were not limited to hemiplegia and hemiparesis following cerebrovascular disease, vascular dementia, peripheral vascular disease, dysphagia, and chronic pain syndrome.Review of the five-day MDS 3.0 assessment dated [DATE] for Resident #82 revealed a BIMS score of 15 which indicated intact cognition. Review of activities of daily living (ADLs) revealed the resident required maximum assistance for oral hygiene.Review of Resident #82's care plan reviewed it was last reviewed on 03/22/26. Resident #82 was indicated as being dependent upon staff for oral hygiene.Review of the task called Brush teeth with AM and PM care for the past 30 days for Resident #82 revealed brushing teeth was only offered one time a day for 03/10/26, 03/11/26, 03/12/26, 03/13/26, 03/14/26, 03/17/26, 03/18/26, 03/19/26, 03/20/26, 03/22/26, 03/26/26, 04/03/26, 04/04/26, 04/05/26, 04/06/26, and 04/07/26. There was no evidence brushing teeth was provided on 03/15/26, 03/21/26, 03/25/26, 03/27/26, 03/28/26, 03/29/26, 04/01/26, and 04/02/26. Brushing teeth was marked not applicable on 03/16/26, 03/23/26, 03/24/26, 03/30/26, and 03/31/26. Out of 60 opportunities to brush teeth, it was only recorded as provided 16 times.3. Review of the medical record for Resident #100 revealed an admission date of 09/23/20. Diagnoses included but were not limited to Paranoid schizophrenia, obesity, and dysphagia. Review of the annual MDS 3.0 assessment dated [DATE] for Resident #100 revealed a BIMS score of 14 which indicated intact cognition. Review of activities of daily living (ADLs) revealed the resident required set up for oral hygiene.Review of the care plan for Resident #100 revealed it was last reviewed on 03/26/26. Resident #100 was noted to require maximum staff assistance for oral hygiene.Review of the oral care task for the last 30 days for Resident #100 revealed oral care was provided twice a day on 03/10/26, 03/11/26, 03/12/26, 03/15/26, 03/16/26, 03/17/26, 03/18/26, 03/20/26, 03/21/26, 03/23/26, 03/24/26, 03/25/26, 03/26/26, 03/28/26, 03/29/26, 03/30/26, 03/31/26, 04/01/26, 04/02/26, 04/03/26, and 04/04/26. It was provided one time a day on 03/13/26, 03/14/26, 03/22/26, 03/27/26, 04/05/26, 04/07/26 and 04/08/26. It was indicated as not applicable on 03/22/26, and 04/05/26. Out of 60 opportunities for oral care, 51 times.4. Review of the medical record for Resident #101 revealed an admission date of 03/25/25. Diagnoses included but were not limited to cerebral ischemia, influenza and pneumonia, and stage III chronic kidney disease.Review of quarterly MDS 3.0 assessment dated [DATE] for Resident #101 revealed a BIMS score of 09 which indicated moderate cognitive impairment. Review of activities of daily living (ADLs) revealed the resident required maximum staff assistance for oral hygiene.Review of Resident #101's care plan revealed it was last reviewed on 02/23/26 and indicated Resident #101 required maximum assistance for oral hygiene.Review of the task called Denture Care AM for Resident #101 revealed over the past 30 days, it was offered on 03/10/26, 03/12/26, 03/13/26, 03/14/26, 03/15/26, 03/16/26, 03/21/26, 03/23/26, 03/27/26, 03/28/26, 03/29/26, 03/31/26, 04/01/26, 04/02/26, 04/03/26, 04/04/26, 04/05/26, 04/06/26, and 04/07/26. It was not recorded as offered on 03/08/26, 03/09/26, 03/11/26, 03/17/26, 03/18/26, 03/19/26, 03/20/26, 03/22/26, 03/24/26, 03/25/26, and 03/30/26. Out of 30 opportunities for denture care, it was recorded as provided 20 times.Review of the task called Denture Care PM for Resident #101 revealed over the past 30 days, it was offered on 03/11/26, 03/12/26, 03/13/26, 03/16/26, 03/17/26, 03/18/26, 03/20/26, 03/21/26, 03/24/26, 03/25/26, 03/26/26, 03/30/26, 04/02/26, and 04/08/26. It was indicated as not provided on 03/29/26, 04/01/26, 04/03/26, and 04/04/26. It was indicated as not applicable on 03/10/26, 03/22/26, and 03/23/26. Out of 30 opportunities, PM denture care was recorded as provided 14 times.Interview on 04/08/26 at 11:51 A.M. with the Director of Nursing (DON) revealed oral care is to be provided in the morning and evening and as needed and is to be recorded on the tasks section in the electronic medical record (EMR). The DON confirmed oral care was not provided as required for Residents #81, #82, #100 and #101.Review of the facility policy last reviewed 09/25 called Oral Care Policy revealed (staff) are to review the resident's care plan to assess for any special needs and to notify the nurse of any complaints of mouth pain or refusals. The policy did not specify frequency of oral care or documentation requirements.This deficiency represents non-compliance investigated under Complaint Number 2970282.

Based on record review, resident interview, staff interview, review of facility witness statements, review of facility self-reported incidents, and review of the facility policy, the facility failed to report an allegation of sexual abuse to the State agency. This finding affected one (Resident #47) of three residents reviewed for abuse. Review of the incident witness statement between Residents #47 and #119 authored by the DON dated 08/10/25 revealed the facility received a call reporting Resident #119 was sitting on the roommate's bed having a conversation with him when Resident #47 reported that Resident #119 tried to kiss and grab his genitalia. Resident #47 was assisted out of bed and removed from the room and taken to a common area where he was placed in a recliner. The DON instructed staff to move Resident #47's to a new room with Resident #47's permission. Review of Resident #47's witness statement dated 08/10/25 authored by the DON revealed Resident #119 sat on the resident's bed and tried to kiss and grab the resident (pointing to his groin). Resident #47 pushed Resident #119 away. Resident #47 reported Resident #119 was laughing like nothing happened. Review of Resident #119's witness statement 08/10/25 authored by the DON revealed Resident #119 denied attempts to touch Resident #47 inappropriately and did not recall sitting on Resident #47's bed. Review of Resident #119's closed medical record revealed the resident was admitted on [DATE] and discharged on 08/11/25 with diagnoses including acute respiratory failure with hypoxia, Alzheimer's disease with late onset and dementia. Review of Resident #119's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment.Review of Resident #47's medical record revealed the resident was admitted on [DATE] with diagnoses including anxiety disorder, hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side and hyperlipidemia.Review of Resident #47's admission MDS 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Interview on 08/27/25 at 6:23 A.M. with Resident #47 revealed staff were nice to him except he had one issue with Resident #119. When questioned, Resident #47 stated on 08/09/25 Resident #119 came into his room and sat on his bed and attempted to rub his back and grab his penis. Resident #47 stated he had his pants on, and he pushed Resident #119's hands away when he tried to grab his penis. Interview on 08/27/25 at 7:16 A.M. with the DON revealed Resident #47 did report that Resident #119 tried to kiss him and grab his penis, but Resident #47 pushed Resident #119's hand away. Resident #119 did not connect with Resident #47. The DON stated Resident #47 reported the incident right away but because nothing occurred (did not connect), that was why the facility did not file a self-reported incident (SRI) on abuse. Interview on 08/27/25 at 8:46 A.M. with the Administrator and DON revealed that since the incident between Resident #47 and Resident #119 did not actually occur (no contact), it was not reportable. Review of the facility self reported incidents for August and September 2025 revealed no report to the state agency of the incident between Resident #47 and Resident #119 that the facility investigated on 08/10/25. Review of the Abuse Investigation and Reporting policy dated 09/2024 revealed all reports of resident abuse, neglect, exploitation, misappropriation of resident property, or injuries of unknown source shall be promptly reported to the local, state and federal agencies and thoroughly investigated by facility management. Findings of the abuse investigations would also be reported. This deficiency represents non-compliance investigated under Complaint Number 2580746.

Based on record review and interview, the facility did not ensure Resident #10 was transferred safely to prevent falls per the physician order. This finding affected one (Resident #10) of three residents reviewed for accident hazards. Findings include: Review of Resident #10's medical record revealed the resident was admitted on [DATE] with diagnoses including a non-displaced subtrachanteric fracture of the right femur (closed fracture with routine healing) dated 02/10/25 and a age-related current pathological fracture of the vertebrae with routine healing dated 11/02/23. Review of Resident #10's Annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition, was dependent for toileting and bathing. Review of Resident #10's fall investigation form dated 11/24/24 at 3:55 P.M. revealed the resident was assisted to the toilet and the resident fell to the bathroom floor. The Nurse Practitioner (NP) and brother were notified of the incident. Review of Resident #10's physician orders revealed an order dated 11/25/24 (discontinued 01/03/25) for 2-staff assist for all transfers and the resident was not to be alone in the bathroom. Review of Resident #10's fall care plans revealed an intervention dated 12/02/24 indicating the resident was not to be left alone while in the bathroom and an intervention dated 01/27/25 which indicated a mechanical sling lift due to leg weakness in and out of the bed with two assist in the spa and a grab bar and bedside commode in use. Review of Resident #10's fall investigation form dated 01/03/25 at 11:30 A.M. revealed the resident was toileted and his knees got weak, and he was lowered to the floor. The transfer orders were changed to a mechanical sling lift in and out of bed (Hoyer mechanical lift). (Occurred in the spa and the resident was on a sit-to-stand mechanical lift and his knees got weak and was lowered to the floor. The physician and family were notified). Review of Resident #10's physician orders dated 01/03/25 for transfers mechanical sling lift for transfers in and out of bed. Staff assist for toileting in the spa only with bedside commode and grab bars. Resident #10 was not to be left alone in the bathroom every shift. Review of Resident #10's fall investigation dated 01/06/25 at 5:32 A.M. revealed two certified nursing assistants (CNAs) were transferring the resident out of his bed to the shower chair to get a shower. The CNAs stated the resident did not bend his legs during the transfer, so they had to lower the resident to the floor for safety. The resident revealed his legs gave out trying to transfer. No complaints of pain or injuries. The resident was transferred into the shower chair. The resident's order was a 2-person assist in and out of bed but was recently changed to a mechanical sling lift in and out of bed. The CNAs were not aware of the recent change and were educated to verify orders due to possible changes. The physician and family were notified. Review of Resident #10's fall investigation dated 01/06/25 at 6:00 A.M. revealed the resident was in the spa after receiving a shower. With the assistance of two CNAs, the resident stood up at the grab bar to pull up his pants. While attempting to stand, the resident was not able to keep standing and the resident was lowered to the ground by the CNAs. The resident stated that his legs got tired while standing. The resident was transferred back into the shower chair from the floor. The resident had a recent downgrade in transfers to a mechanical sling lift in and out of bed but was a 2-person assist in the spa using a grab bar (no pivoting). The family and physician were notified. Interview on 02/20/25 at 9:44 A.M. with the Director of Nursing (DON) confirmed when Resident #10's was transferred from the bed to the shower chair on 01/06/25 at 5:32 A.M., staff were required to use a Hoyer mechanical lift and did not use the device, and the resident was unable to maintain his weight and was lowered to the floor. The DON confirmed when Resident #10 was transferred from the shower to stand at the grab bar in the shower (spa) room on 01/06/25 at 6:00 A.M., the CNAs stood the resident to pull up his pants and the resident was unable to hold his weight and was lowered to the floor. The DON confirmed the order was for the staff to only use the grab bar when toileting the resident and the resident was being dressed while standing in the bathroom, which was inappropriate. She confirmed staff were educated and the resident required the use of the Hoyer mechanical lift. Review of the Using a Mechanical Lifting Machine dated 09/2024 revealed at least two nursing assistants were needed to safely move a resident with a mechanical lift. This deficiency represents non-compliance investigated under Complaint Number OH00162322.

Based on interview, resident record review, and review of the facility assessment, the facility failed to provide adequate staff to assure residents received their routine showers. This affected three residents, (Resident #188, #131, and #135) of four residents reviewed for showers/bathing. The facility census was 114. Findings include: 1. Record review for Resident #188 revealed an admitted [DATE]. Diagnosis included retention of urine, obstructive and reflux uropathy, and frontal lobe and executive function deficit following cerebral infarction. Record review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #188 was moderately cognitively impaired. Resident #188 required physical help in part of bathing activity. Record review of the care plan dated 01/16/23 revealed Resident #188 needed assistance with activities of daily living. Interventions included one assist with bathing. Record review of the shower schedule revealed Resident #188 was to receive a shower every Tuesday and Friday. Record review of the shower sheets dated 12/06/22 through 02/14/23 revealed on 12/09/22, 12/27/22, 12/30/22, 01/06/23, 01/10/23, and 02/10/23 Resident #188 did not receive nor was offered a bath or shower for those scheduled days. Record review revealed no alternative days were offered during that period. Interview on 02/14/23 at 9:20 A.M. with Resident #188 revealed he did not always get his showers. Resident #188 revealed some days when he was supposed to get his shower, staff did not even ask him if he wanted a shower. Interview and record review on 02/15/23 at 10:00 A.M. with the Director of Nursing (DON) confirmed Resident #188 did not receive the scheduled showers and was not offered alternative showers for the missed shower. The DON confirmed if a shower was refused, the shower sheet would still be completed. The DON revealed if a resident refused, the State tested Nurse Aide (STNA)would be expected to offer a shower two additional times before notifying the charge nurse. Once the charge nurse was notified of the refusal, the charge nurse would be expected to encourage the resident and document the refusal. 2. Record review for Resident #131 revealed an admitted [DATE]. Diagnosis included neuromuscular dysfunction of the bladder, retention of urine, and Alzheimer ' s disease. Record review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #131 was moderately cognitively impaired. Resident #131 required total dependence for bathing. Record review of the care plan dated 01/05/23 revealed Resident #131 needed assistance with activities of daily living. Interventions included extensive of one with bathing. Record review of the shower schedule revealed Resident #131 was to receive a shower every Monday and Thursday. Record review of the shower sheets for Resident #131 dated 12/01/22 through 02/14/23 revealed on 12/15/22, 12/22/22, 12/29/22, 01/05/23, 01/12/23, 01/26/23, and 02/02/23, Resident #131 did not receive nor was offered a bath or shower for those scheduled days. Record review revealed no alternative days were offered for those scheduled showers that were not given. Interview on 02/14/23 at 10:26 A.M. with Resident #131 revealed at times staff did not give him his showers. Interview and record review on 02/15/23 at 10:05 A.M. with the DON confirmed Resident #131 did not receive the scheduled showers and was not offered alternative showers for the missed shower. The DON confirmed if a shower was refused, the shower sheet would still be completed. 3. Record review for Resident #135 revealed an admitted [DATE]. Diagnosis included acute respiratory failure with hypoxia and lack of coordination. Record review of the Admission Medicare five-day MDS dated [DATE] revealed Resident #135 was cognitively intact. Resident #135 required physical help in part of bathing activity. Record review of the care plan dated 01/30/23 revealed Resident #135 needed assistants with activities of daily living. Interventions included to assist with showers as needed. Record review of the shower schedule revealed Resident #135 was to receive a shower every Tuesday and Friday. Record review of the shower sheets for Resident #135 dated 01/27/23 through 02/14/23 revealed on 01/31/23, 02/03/23, and 02/10/23, Resident #135 did not receive nor was offered a bath or shower for those scheduled days. Record review revealed no alternative days were offered for those scheduled showers that were not given. Interview on 02/14/23 at 10:05 A.M. with Resident #135 revealed she only got one shower, that was it. Resident #135 revealed staff did not offer her showers. Interview and record review on 02/15/23 at 10:10 A.M. with the DON confirmed Resident #135 did not receive the scheduled showers and was not offered alternative showers for the missed shower. The DON confirmed if a shower was refused, the shower sheet would still be completed. Review of the Facility Assessment Tool dated August 2022 revealed the facility required 12 nurses daily providing direct care, 28 to 32 STNA ' s daily, and eight nursing personnel with administrative duties. Review of the staffing tool excluding personnel with administrative duties from 12/07/23 through 12/13/23 with Administrator revealed on 12/07/22 there were 24 STNA ' s and 13 nurses, 12/08/22 there were 24 STNA ' s and 14.5 nurses, 12/09/22 there were 21 STNA ' s and 17.5 nurses, 12/10/23 there were 25 STNA ' s and 11.5 nurses, 12/11/22 there were 26 STNA' s with 14 nurses. Interview with Administrator confirmed administrative staff did not work on weekends for administrative duties and Administrator confirmed the Facility Assessment numbers of staff required did not meet the numbers of staff available on 12/07/22 through 12/11/22. This deficiency represents noncompliance investigated under complaint number OH00139640

Based on interview and record review, the facility failed to ensure residents were free from accidents during transfers by not providing two staff to assist. This affected one resident (Resident #100) of eleven residents reviewed for transfers. The facility census was ninety-four. Findings include: Resident #100 had an admitted [DATE] and a discharge date of [DATE]. Resident #100 had diagnoses which included [CONDITION(S)] and Alzheimer's disease. Review of Resident #100's Minimum Data Set Assessment (MDS) 3.0 dated 03/10/21 revealed the resident was cognitively impaired and required a two person extensive assist for transfers. Review of Resident #100's plan of care dated 02/18/21 revealed the resident requires assistance with her activities of daily living to maintain her quality of life. Interventions included to transfer Resident #100 with the mechanical sit to stand lift with the assist of two staff members. Review of Resident #100's physicians order dated 06/16/20 revealed the resident had an order to be transferred using the mechanical sit to stand lift with the assist of two staff members. Review of Resident #100's progress notes dated 07/23/20 revealed the resident fell during a transfer using the mechanical sit to stand lift. Resident #100's wheelchair was not locked, and she went to sit down and sat on the floor. Review of Resident #100's falls risk assessment dated [DATE] revealed the resident was a high risk for falls. Review of Resident #100's falls investigation dated 07/23/20 revealed State tested Nurse Aide (STNA) #915 reported she had Resident #100 hooked up to the mechanical sit to stand lift and left the resident alone in the spa area to obtain another staff member to assist with the transfer. Interview on 05/17/21 at 3:40 P.M. with Licensed Practical Nurse (LPN) #904 confirmed STNA #915 left Resident #100 in the spa room hooked up to the mechanical sit to stand lift. LPN #904 confirmed STNA #915 should have had a second staff person in the room to begin with and STNA #915 did leave the room to get a second aide to help transfer. LPN #904 confirmed STNA #915 should not have left Resident #100 in room alone and hooked up to the mechanical sit to stand lift. Interview on 05/17/21 at 3:50 P.M. with Director of Nursing (DON) #901 confirmed STNA #915 left Resident #100 in the room alone hooked up to the mechanical sit to stand lift to obtain another staff member for the transfer. This deficiency substantiates complaint OH 872.

Based on observation, record review and interview, the facility failed to ensure Resident #36's dressings were in place as ordered by the physician and failed to complete pressure ulcer wound care per the facility policy and in a manner to prevent contamination/infection. This finding affected one (Resident #36) of three records reviewed for pressure ulcers/wounds. Findings include: Review of Resident #36's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #36's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident exhibited severe cognitive impairment. Review of Resident #36's physician orders [REDACTED]. An order dated 01/20/21 directed nursing staff to clean the sacral pressure ulcer with soap and water and pat dry, pack Mesalt into the open area and cover with a border foam dressing. A physician order [REDACTED]. Observation on 01/25/21 at 7:15 A.M. with Licensed Practical Nurse (LPN) #817 of Resident #36's wound care revealed the resident did not have a dressing on the right heel pressure wound as ordered by the physician. LPN #817 put on a clean pair of gloves, cleaned the right heel, applied Mesalt, applied heel prep and a foam bandage. At 7:18 A.M., LPN #817 removed the dressing on the top of Resident #36's right foot. She did not remove her soiled gloves or wash/sanitize her hands prior to or after removing the old dressing. LPN #817 cleaned the top of the right foot with normal saline, applied a Mesalt dressing and applied a new foam bandage. At 7:21 A.M., LPN #817 removed the bandage to the left heel. She did not remove her soiled gloves and did not wash/sanitize her hands prior to or after removing the old dressing. She then cleansed the left heel with normal saline, applied skin prep and applied a foam dressing. LPN #817 assisted the resident to roll onto her side to observe the resident's coccyx/sacrum. The resident did not have a dressing on her coccyx as ordered by the physician. At 7:23 A.M., the nurse cleansed the resident's coccyx/sacrum with normal saline, applied Mesalt and applied a foam dressing. She did not remove her soiled gloves and wash/sanitize her hands prior to completing wound care on the resident's coccyx/sacrum. She then cleaned up her area, removed her gloves and washed her hands. Interview on 01/25/21 at 7:29 A.M. with LPN #817 revealed she did not remove her gloves and wash or sanitize her hands during Resident #36's wound care because she was nervous. LPN #817 also indicated the staff left the dressing off of the resident's coccyx/sacrum because they knew she was the first resident in the rotation to receive wound care for the day. LPN #817 confirmed she was unaware of the reason Resident #36 did not have the ordered dressing to the right heel pressure ulcer. Review of the facility Wound Care policy, revised 12/07/20, indicated staff were to position the resident, put on exam gloves, loosen tape and remove the dressing, pull their glove over the dressing and discard into appropriate receptacle. They were to wash and dry their hands thoroughly, put on new gloves and complete wound care. Then remove your gloves and wash your hands. This deficiency substantiates Complaint Number OH 242.

Based on interview and record review, and review of facility policy and procedure the facility failed to ensure adequate grooming and personal hygiene for Resident #28 who was dependent on staff for activities of daily living. This affected one of four residents reviewed for activities of daily living. Findings include: Review of the medical record revealed Resident #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly comprehensive assessment (MDS 3.0) dated 09/25/20 indicated she was severely cognitively impaired. She displayed no behaviors and required the extensive to total assist of two plus staff for activities of daily living (ADL). Review of the current comprehensive plan of care indicated Resident #28 required the extensive assistance for bed mobility, transfers, dressing, and personal hygiene. Her ability to complete ADL fluctuated depending on her mood. She required the use of a mechanical lift for transfers. Review of the last 30 days of shower documentation in the electronic record revealed she received six showers in November 2020 with the last one on 11/18/20. Review of the last 30 days of personal hygiene documentation in the electronic record revealed she received 24 bed baths. Review of the hard copy bath records revealed Resident #28 received bed baths on 11/17/20, 11/20/20, 11/24/20, 11/27/20, 11/30/20, 12/01/20 and 12/02/20. On 12/01/20 at 3:36 P.M. Resident #28 was observed in bed on her back. Her eyes were closed and she was grabbing at the air then crossing her arms in front of her. She was very thin. Her granddaughter was at her bedside and reported she was dying. She was asked if she had any concerns and she said no. The resident appeared clean and had no odors. Interview with State tested Nurse Aide (STNA) #105 on 12/01/20 at 2:37 P.M. reported they were not giving showers currently to avoid any cross contamination. She reported usually giving bed baths to three residents per shift. STNA #105 reported not washing residents' hair but using dry shampoo caps instead. Interview with Licensed Practical Nurse (LPN) #104 on 12/02/20 at 9:50 A.M. reported Resident #28's hair matted easily so the shower aides would use extra conditioner on her hair. LPN #104 verified Resident #28 had matted hair currently and the STNA used a spray conditioner to try and loosen it up that morning. Interview with the Directors of Nursing (DON) #101 and #102 on 12/02/20 at 1:51 P.M. revealed formerly the facility utilized bath aides but since the COVID 19 pandemic the shower aides worked as floor STNAs. The facility was only providing bed baths due to having COVID 19 in the facility. Bed baths were to be completed every shift. DON #101 and #102 reported Resident #28 had long thin hair that matted easily even after one night's sleep. Resident #28 moved her head around a lot. The family wanted her hair left long and in a pony tail. The facility suggested she have her hair cut but the family wanted it long so the matting continued off and on during her stay. Review of the policy related to brushing/combing hair (undated) indicated it should be brushed/combed daily and as needed. Review of the bed bath policy (undated) lacked indication shampooing was included. Review of the shampooing hair policy (undated) provided instructions on how to wash hair including on residents who were bedfast and indicated if there were refusals to report them. This deficiency substantiates Complaint Number OH 685.

Based on observation, interview, record and policy review, the facility failed to assess, monitor and develop an individualized plan of care for Resident #16. This affected one of five residents reviewed for impaired skin integrity. Findings include: Review of the medical record revealed Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He tested positive for COVID 19 on 11/18/20. Review of the physician order [REDACTED]. Review of the weekly skin assessment dated [DATE] indicated his skin was intact. The next weekly skin assessment was not until 12/01/20. The skin assessment dated [DATE] indicated he had a skin tear on the back of his right forearm. No characteristics of the skin tear were identified such as measurements or description of the skin tear. Review of the physician orders [REDACTED].M. indicated to clean the wound with normal saline, pat dry with gauze pad, apply clean dry dressing until healed on Tuesday, Thursday and Saturdays. Review of the comprehensive assessment (MDS 3.0) dated 10/02/20 indicated he had moderate cognitive impairment, no behavioral symptoms, required the extensive assistance for mobility, had one fall since admission, was at risk for pressure sores/injury and had skin tears. Review of the care plan related to the potential for the development of pressure ulcers due to impairment mobility indicated the interventions were to administer treatments as ordered, monitor effectiveness, float heels when in bed and pressure reducing device on bed and chair. There was no plan of care related to skin tears. Review of the pressure/non-pressure wound list provided by the facility indicated he developed a skin tear on the right forearm on 11/29/20. Review of the progress note dated 11/29/20 at 10:26 A.M. indicated Resident #16 was noted to be confused and walking in the hallway unassisted with his walker. No skin impairment was identified in the progress note. Resident #16 was observed on 12/01/20 with Licensed Practical Nurse (LPN) #104 at 3:40 P.M. Resident #16 was seated in a standard chair, his walker was in front of him and he was wearing oxygen via a nasal cannula. Both of his arms were severely discolored and/or had tears. No dressings were in place. Interview with Resident #16 on 12/01/20 at 3:40 P.M. indicated he had lost his balance, fell and sustained skin tears. Resident #16 admitted to removing the dressing. Interview with LPN #104 on 12/02/20 at 9:50 A.M. verified the assessment lacked characteristics of the skin tears including measurements, color and location of all skin areas on both arms and the lack of individualized care planning for skin tears and the behavior of removing the dressings. Review of the pressure ulcer/skin breakdown clinical protocol (undated) indicated nursing staff would assess and document the resident's significant risk factors for the development of pressure sores. The nurse shall describe and document/report the following: a full assessment including location, stage, length, width, depth, assess pain, mobility status and current treatments including support surfaces and all active diagnoses.

Based on observation, interview, record review and policy review, the facility failed to ensure a a pressure ulcer was identified timely for Resident #28. This affected one of four residents reviewed for pressure ulcers. The facility census was 84. Findings include: Review of the medical record revealed Resident #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She tested positive for COVID 19 on [DATE]. The resident expired in the facility on [DATE]. Review of the physician orders [REDACTED]. On [DATE] the physician ordered a pressure relief cushion to the Broda (a reclining chair). On [DATE] the physician ordered weekly skin assessments every Monday. Review of the quarterly comprehensive assessment Minimum Data Set 3.0 ((MDS) dated [DATE] indicated she was severely cognitively impaired and displayed no behaviors. Resident #28 required the extensive to total assist of two plus staff for activities of daily living and had no weight loss. Resident #28 was at risk for pressure ulcers but had no unhealed pressure ulcers. The assessment indicated she had a pressure reducing device for the chair and bed and application of ointments other than to the feet. Review of the comprehensive plan of care identified Resident #28 had the potential for pressure ulcer development related to immobility, incontinence and shearing. Resident #28 had recurrent areas of skin impairment to her upper and lower extremities with chronic picking and itching. Resident #28 had severe [MEDICAL CONDITION], purple dusky colored lower extremities with fluctuating [MEDICAL CONDITION] along with healing impairment due to diabetes. The interventions included administer treatments as ordered and monitor for effectiveness, pressure reducing devices to the bed and chair, monitor her nutritional status and obtain and monitor laboratory/diagnostic work as ordered. Review of the weekly skin assessments revealed the last assessment was [DATE] with no identified skin issues and none was completed for [DATE]. Review of the nursing scale for predicting pressure sore risks completed on [DATE] indicated she was at moderate risk for the development of pressure sores. Review of the pressure and non-pressure wound list did not identify Resident #28 as having any wounds. Review of the nursing progress notes revealed the following: · On [DATE] at 6:02 A.M. she was noted to refuse to eat or drink and was combative and spitting. These behaviors continued. · On [DATE] at 1:34 P.M. it was noted the responsible party wished for the resident to remain in the facility for treatment and changed her code status to do not resuscitate comfort care and do not transport to the hospital. The resident continued to decline according to the nursing assessments. · On [DATE] at 11:06 P.M. it was noted that both upper and lower extremities had mottling (Mottling occurs when the heart is no longer able to pump blood effectively. The blood pressure slowly drops and blood flow throughout the body slows, causing one's extremities to begin to feel cold to the touch. Mottled skin before death presents as a red or purple marbled appearance) and the left lower leg had dusky and purple streaks up to the knee. Hourly monitoring continued. The physician continued hypodermoclysis, a method of infusing fluid into subcutaneous tissue. Mottling continued. · On [DATE] at 3:23 P.M. she was noted not responding to verbal stimuli and often raised both arms as if she were grasping items out of the air. She had no nutritional intake and the family was at her bedside. Resident #28 was observed with LPN #104 on [DATE] at 3:36 P.M. lying in bed with her eyes closed. Resident #28 was not responsive to verbal or tactile stimuli. The granddaughter was at the bedside and reported no care concerns but believed Resident #28 was nearing death. LPN #104 was requested to observe Resident #28's elbows. LPN #104 assessed Resident #28's right elbow and remarked that it had a scabbed area the size of a nickel and the left elbow was red but blanchable. Interview with LPN #104 on [DATE] at 3:36 P.M. reported she was not aware Resident #28 had any skin impairment until the observation. Interview with the Director of Nursing (DON) #101 on [DATE] at 4:53 P.M. confirmed the lack of evidence that Resident #28's weekly skin assessments had been done as ordered. The last assessment dated [DATE] identified no skin issues and none was completed for [DATE]. DON #101 verified on [DATE] a pressure ulcer of the right elbow was discovered as unstageable which should have been identified prior to that time, and appropriate interventions put into place. Review of the pressure ulcer/skin breakdown clinical protocol (undated) indicated nursing staff would assess and document the resident's significant risk factors for the development of pressure sores. The nurse shall describe and document/report the following: a full assessment including location, stage, length, width, depth, assess pain, mobility status and current treatments including support surfaces and all active diagnoses. This deficiency substantiates Complaint Number OH 685.

Based on observation, interview, and record review, the facility failed to ensure medications were secured at all times. This had the potential to affect 26 (Resident #5, Resident #6, Resident #8, Resident #11, Resident #12, Resident #17, Resident #26, Resident #27, Resident #29, Resident #33, Resident #35, Resident #37, Resident #46, Resident #47, Resident #54, Resident #59, Resident #63, Resident #67, Resident #68, Resident #70, Resident #76, Resident #78, Resident #[AGE], Resident #89, Resident #95, Resident #99) of 26 residents who were cognitively impaired and independently mobile. Findings include: 1. Observation on 02/25/20 at 7:30 A.M. revealed a medication cart was unlocked on Side 1 in the facility. There were no staff in sight of the medication cart. Interview on 02/25/20 at 7:31 A.M. with Licensed Practical Nurse (LPN) #200 confirmed the medication cart was unlocked. 2. Observation on 02/26/20 at 11:43 A.M. revealed there was an unidentified loose pill in a medication cup on top of the medication cart near the Side 1 nurses station. There were no staff in sight of the medication cart. Interview on 02/26/20 at 11:43 A.M. with LPN #500 confirmed the loose pill on the medication cart and took it off the medication cart. Interview on 02/26/20 at 12:12 P.M. with Director of Nursing (DON) revealed the loose pill was [MEDICATION NAME] 37.5 milligrams (anti-depressant medication), and Resident #102 received this medication. DON revealed the resident was administered multiple medication and the nurse who administered the medications thought she took all the medications. The facility believed the pill was found at bedside and someone had placed the loose pill in the medication cup on the medication cart. 3. Observation on 02/26/20 at 4:20 P.M. revealed the medication cart near the Side 1 nursing station revealed the cart was unlocked. There were no staff in sight of the medication cart. Administrator walked into the hall and confirmed the observation of the medication cart being unlocked. Review of a list of residents who are cognitively impaired and independently mobile revealed Resident #5, Resident #6, Resident #8, Resident #11, Resident #12, Resident #17, Resident #26, Resident #27, Resident #29, Resident #33, Resident #35, Resident #37, Resident #46, Resident #47, Resident #54, Resident #59, Resident #63, Resident #67, Resident #68, Resident #70, Resident #76, Resident #78, Resident #[AGE], Resident #89, Resident #95, Resident #99 had the potential to be affected by unsecured medication.

Based on observation, interview and record review, the facility failed to ensure Resident #11, Resident #14, Resident #28, Resident #43, Resident #56, Resident #[AGE], Resident #114 were were served the proper portion of their pureed lunch according to the menu. This affected seven (Resident #11 Resident #14, Resident #28, Resident #43, Resident #69, Resident #[AGE], and Resident #114 ) of seven residents that were served pureed meals in the small dining room, with the potential to affect all ten residents (Resident #11 Resident #14, Resident#16, Resident #28, Resident #43, Resident #56, Resident #69, Resident #[AGE], Resident #114, and Resident #115) on a pureed diet. Findings include: Review of the facility lunch menu for 02/26/20 revealed residents on a pureed diet should be served pureed meatloaf with gravy using a number six scoop (5 and 1/3 ounces), and the pureed scalloped potatoes and pureed green beans did not have a scoop size listed. Residents on a regular diet were to receive a half cup (4 ounces) of scalloped potatoes and a half cup of green beans. Review of the Portion Control Chart (undated), revealed a number six size scoop is 5 and 1/3 ounces, a number eight size scoop is 4 ounces, and a number ten size scoop is 3 ounces. Review of a list of residents on pureed diet revealed Resident #11 Resident #14, Resident#16, Resident #28, Resident #43, Resident #56, Resident #69, Resident #[AGE], Resident #114, and Resident #115 were on pureed diets. Review of the facility list of what dining rooms residents ate in, revealed Resident #11 Resident #14, Resident #28, Resident #43, Resident #69, Resident #[AGE], and Resident #114 ate in the small dining room. Observation on 02/26/20 at 12:08 P.M. revealed Cook #203 had plated all trays for residents on a pureed diet, who ate in the small dining room. Interview on 02/26/20 at 12:08 P.M. with Cook #203 and Cook #204 revealed their was a number eight size scoop in the pureed meatloaf, pureed scalloped potatoes, and pureed green beans. Interview on 02/26/20 at 12:10 P.M. with Certified Dietary Manager #205 confirmed the above scoop sizes, and revealed the pureed meatloaf should have been served with a number six scoop and the pureed scalloped potatoes and green beans should have been served with a number eight scoop.

Based on medical record review, staff interview and facility policy, the facility failed to notify the physician when Resident #37 refused numerous doses of medication. This affected one resident (Resident #37) of five residents reviewed for unnecessary medications. Findings include: Review of the medical record revealed Resident #37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] Resident #37 had severely impaired cognition and required extensive assistance with activities of daily living. Review of the February 2020 Medication Administration Record [REDACTED]. Review of the nursing progress notes from 02/01/20 to 02/25/20 revealed no documentation of the physician being notified Resident #37 had been refusing numerous medication on numerous days. Interview on 02/26/20 at 10:12 A.M., the Director of Nursing (DON) indicated the resident always refuses her medication, and the physician was aware. She verified there was no documentation the physician had been notified in the medical record. Review of the undated facility policy, Change in a Resident's Condition or Status, revealed the facility shall promptly notify the resident, his or her attending physician, and representative of changes in residents's medical/mental condition and/or status. The nurse would notify the residents attending physician or physic on call when there has been an refusal of treatment or medication two or more consecutive times.

Based on record review and interview, the facility failed to ensure Minimum Data Set (MDS) 3.0 assessments were correct for three residents (Residents #29, #45, and #111) of 25 residents reviewed for MDS accuracy. Findings include: 1. Resident #29 was admitted to the facility with [DIAGNOSES REDACTED]. Review of Resident #29's medical record revealed a quarterly MDS 3.0 assessment dated [DATE]. The MDS revealed Resident #29 received the following medications in the previous seven days, one injection, six days of antipsychotics, seven days of antidepressants, seven days of anticoagulants, seven days of diuretics, and seven days of opioids. Review of Resident #29's December 2019 Medication Administration Record [REDACTED]. Staff interview with Licensed Practical Nurse (LPN) #500 on 02/25/20 at 2:22 P.M. verified Resident #29's 12/11/19 quarterly MDS 3.0 assessment was incorrect and verified the medication discrepancy. 2. Review of the medical record revealed Resident #45 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].#45 received [MEDICAL TREATMENT] on Tuesday, Thursday, and Saturday. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #45 had severely impaired cognition and did not receive [MEDICAL TREATMENT]. Interview on 02/25/20 at 1:38 P.M. MDS Nurse #206 verified the quarterly MDS dated [DATE] was for Resident #45 was coded incorrectly indicating Resident #45 did not receive [MEDICAL TREATMENT]. 3. Review of the medical record revealed Resident #111 was admitted to the facility on [DATE] and discharged on [DATE] to home with the [DIAGNOSES REDACTED]. Review of the discharge return not anticipated assessment revealed Resident #111 was discharged to a acute hospital. Review of the progress notes dated 01/26/20 at 2:15 P.M. revealed Resident #111 was discharged to home. Interview on 02/25/20 at 11:27 A.M. MDS Nurse #206 verified Resident #111 was discharged to home and not an acute hospital. She verified the MDS was coded incorrectly.

Based on observation, interview and record review, the facility failed to ensure Resident #40's pressure ulcer interventions were in place at all times. This affected one (Resident #40) of three residents reviewed for pressure ulcers. Findings include: Resident #40 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #40's physician orders, dated 12/29/19, revealed he should have bilateral heel boots. Resident #40's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed his cognition was moderately impaired, required two person extensive assistance for bed mobility, and was totally dependent on two people for transfers. Observation on 02/24/20 at 10:37 A.M. revealed Resident #40 was sitting in his wheelchair in his room, with his feet resting on food pedals. Resident #40 had a visible dressing to his left foot, with socks on both feet. Review of Resident #40's Wound Evaluation note dated 02/18/20 revealed he had a suspected deep tissue injury to his left heel. Observation on 02/25/20 at 7:41 A.M. with Licensed Practical Nurse (LPN) #200 revealed Resident #40 was lying in bed without bilateral heel protectors on. Both of Resident #40's feet were lying directly on his bed. Interview with LPN #200 at this time confirmed the observation. LPN #200 looked in Resident #40's closet and found one heel boot and was unsure if he should have two heel boots or not. Observation on 02/25/20 at 11:22 A.M. revealed Resident #40 was sitting in his wheelchair with his left foot on the ground and he had socks on. LPN #200 joined the observation and confirmed Resident #40 was wearing socks. LPN #200 revealed she was unsure if the resident should be wearing bilateral heel boots to his feet while out of bed. Interview on 02/25/20 at 11:25 A.M. with LPN #201 revealed Resident #40 should be wearing bilateral heel boots at all times per physician orders.

Based on observation, record review and interview the facility failed to ensure Resident #247 was treated with dignity and respect. The affected one resident (Resident #247) of two residents reviewed for dignified treatment in the facility. Findings include: Record review revealed Resident #247 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was admitted for rehabilitation following a fall at home. Review of Resident #247's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated he needed extensive assistance of one staff member with bed mobility (how one moves to and from a lying position, turns side to side, and positions body while in bed). Interview with Resident #247 on 01/13/19 at 10:36 P.M. revealed he was frustrated with the staff answering his call light and not providing requested assistance at the time they answered. He reported when staff finally provided the needed assistance, they rushed out of his room before he could ask for anything else. He then had to push the call light again to ask for additional assistance and the process repeated in the same manner. During observation of medication pass with Registered Nurse (RN) #400 on 01/15/19 at 8:40 A.M., RN #400 entered Resident #52's room to administer medications through the resident's gastrostomy (feeding) tube. The tube wasn't functional and RN #400 was attempting measures to unclog it. Resident #247, the roommate, was in the bed near the door and called out in a loud voice saying he couldn't find his call light. RN #400 continued to attempt to unclog Resident #52's gastrostomy tube. After a brief pause she walked over to Resident #247 and told the resident it's right here, you have it. Resident #247 responded that he did not have it and when the covers were pulled back he in fact had the TV remote but the call light was in the sheets. RN #400 gave the call light to Resident #247 and without comment or apology for being mistaken walked back to Resident #52's bedside. As RN #400 again sat near Resident #52 waiting for another nurse to bring supplies to unclog the tube at 8:47 A.M., Resident #247 stated loudly, I wondered if I could be pulled up. RN #400 did not respond to the resident. After several minutes, RN #400 asked the surveyor questions about the survey process. Resident #247 continued to watch the surveyor and RN #400 conversing. After about 5 minutes, Resident #247 loudly said, I need to lay on my side. RN #400 said to him, Well, roll to your side. The resident said, That's what they tell me. She did not get up to assist the resident. At about 9:05 A.M., another surveyor walked by the room and looked in to say hello to the resident. He asked her, Could you help me to roll to my side? They tell me I have a wound and I need to lay on my side. She stated that she was a visitor to the facility but would get help for him. RN #400 initially did not add to the conversation, but when asked by the second surveyor who the nursing assistant was, she told the other surveyor who to look for. On 01/15/19, at 10:07 A.M., RN #400 was interviewed about the interaction with Resident #247. She stated he wanted to go home, but consistently would not do anything for himself. She stated he thinks he is paralyzed and we are getting nowhere with him. She verified the record indicated he needed assistance with care but stated he was able to do more for himself that he often did. RN #400 verified the resident had called for assistance to move up in bed and she had not responded to him verbally or physically with help. She stated she had not responded because I would have had to yell for him to hear me. She verified she did not explain to Resident #247 that she was helping the other resident, nor did she call for other staff assistance. RN #400 also verified when the resident asked again for help to roll to his side, she instructed him to roll on his own, did not approach to assist him and did not call for other staff to assist him. Help was not solicited until another surveyor requested staff assistance for the resident. This information was confirmed with the director of nursing on 01/15/19 at 10:50 A.M. She verified the nurse had not treated the resident in a polite, respectful or dignified manner. Resident #247 was interviewed again on 01/15/19 at 11:00 A.M. He stated he did not feel staff responded to his needs and did not think the nurse had heard his initial requests when he called for help earlier in the day. He stated the staff often leave without ensuring he has everything he needs.

Based on record review and interview the facility failed to ensure accurate documentation of Resident #72's and Resident #247's toileting programs was maintained in the resident's medical records. This affected two residents (Resident #72 and #247) of 24 residents whose records were reviewed for accuracy of documentation. Findings include: 1. Resident #72 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #72's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated frequent urinary incontinence with a toileting program initiated. A review of the restorative toileting program initiated on 08/30/18 indicated to check Resident #72 for incontinence and offer to assist to the bathroom at 9:00 A.M., 11:00 A.M., 2:00 P.M., 5:00 P.M. and 8:00 P.M. An review of the documentation dated 01/01/19 to 01/14/19 of the scheduled toileting program indicated inaccurate documentation of the time the toileting was provided. On 01/01/19 the documentation indicated at 10:52 P.M. two entries were documented for 10:52 P.M. which indicated Resident #72 was continent and urinated in toilet/bedpan/urinal, and incontinence brief was dry. On 01/06/19 the documentation indicated Resident #72 was continent and urinated in toilet/bedpan/urinal, and incontinence brief was dry three entries each timed at 2:24 P.M. On 01/07/19 at 8:47 P.M. there were two separate entries at 8:47 P.M. indicating continent and urinated in toilet/bedpan/urinal, and incontinence brief was dry. On 01/09/19 at 2:01 P.M. there were three separate entries documenting Resident #72 was continent and urinated in toilet/bedpan/urinal, and incontinence brief was dry. On 01/11/19 there were three separate entries at 1:50 P.M., 1:51 P.M. and 1:52 P.M. that Resident #72 was continent and urinated in toilet/bedpan/urinal, and incontinence brief was dry. On 01/12/19 there were three entries documented at 1:12 P.M., 1:13 P.M., 1:14 P.M. that Resident #72 was continent and urinated in toilet/bedpan/urinal, and incontinence brief was dry. An interview with Registered Nurse (RN) #1 on 01/14/19 at 2:24 P.M. indicated some of the State tested Nursing Assistants (STNAs) were documenting the number of times the resident was continent/incontinent at the end of their shift, rather than the actual time of the occurrence. RN #1 indicated the STNAs had been inserviced to enter the actual time incontinence care was provided and not to wait until the end of their shift to document the care. RN #1 verified the documentation was inaccurate. 2. Resident #247 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #247's MDS 3.0 assessment, dated 01/10/19 indicated Resident #24 was occasionally incontinent of urine and provided a scheduled toileting program. A review of the scheduled toileting program indicated to provide incontinence care and offer to assist to the bathroom at 8:00 A.M., 12:00 P.M., 4:00 P.M. and 8:00 P.M. A review of Resident #247's documentation of the scheduled toileting program dated 01/07/19 to 01/14/19 indicated on 01/08/19 at 1:59 P.M. and 1:59 P.M. Resident #247 was continent and urinated in toilet/bedpan/urinal, and incontinence brief was dry. On 01/09/19 the documentation indicated two entries timed at 9:31 P.M. that Resident #247 was continent and urinated in toilet/bedpan/urinal, and incontinence brief was dry. On 01/10/19 at 7:02 P.M. two entries indicated Resident #24 was continent and urinated in toilet/bedpan/urinal, and incontinence brief was dry. On 01/13/19 two entries timed at 10:30 P.M. indicated Resident #247 was continent and urinated in toilet/bedpan/urinal, and incontinence brief was dry. An interview with Registered Nurse (RN) #1 on 01/14/19 at 2:24 P.M. indicated some of the State tested Nursing Assistants (STNAs) were documenting the number of times the resident was continent/incontinent at the end of their shift, rather than the actual time of the occurrence. RN #1 indicated the STNAs had been inserviced to enter the actual time incontinence care was provided and not to wait until the end of their shift to document the care. RN #1 verified the documentation was inaccurate.