Every finding on record at Residence at Salem Woods

Based on medical record review, staff interview, and review of the facility policy, the facility failed to obtain a resident's weight upon admission to the facility. This affected one (#16) resident of the three residents reviewed for weight changes. The facility census was 84 residents. Findings include: Review of the medical record for Resident #16 revealed an admitted [DATE] with diagnoses including diabetes mellitus (DM), dysphagia, and acute kidney failure. Review of the care plan for Resident #16 dated 03/15/25 revealed the resident was at risk for alteration in nutrition and hydration and weight loss related to acute kidney failure, hydronephrosis, DM, fatty liver, anemia and poor intakes. Interventions to prevent weight loss included the following: assist/feed meals, monitor laboratory findings as ordered, speech referral as needed, provide supplements as ordered. Review of the Minimum Data Set (MDS) assessment for Resident #16 dated 04/24/25 revealed the resident had impaired cognition and required maximum assistance from the staff with eating. Review of the weight record for Resident #16 revealed a weight of 186.1 pounds on 03/15/25 and a weight of 152.4 pounds on 03/21/25. The Registered Dietitian (RD) crossed out the admission weight of 186.1 pounds dated 03/15/25 and documented the weight as inaccurate. Interview on 04/30/25 at 12:32 P.M. with the RD confirmed she documented Resident #16's admission weight of 186.1 as erroneous. The RD confirmed she spoke Registered Nurse (RN) #38 who stated the facility staff did not obtain Resident #16's weight upon admission but had copied the weight of 186.1 from preadmission hospital records. Interview on 04/30/25 at 1:28 P.M. with RN #38 confirmed she completed the admission assessment for Resident #16 on 03/15/25 but the facility staff did not obtain a weight for the resident. RN #38 confirmed she copied the weight from the resident's preadmission hospital paperwork. Interview with the Director of Nursing (DON) and the RD on 04/30/25 at 3:07 P.M. confirmed facility staff should obtain an actual resident weight upon admission and note the weight in the medical record. The DON and the RD further confirmed the facility did not obtain a weight for Resident #16 upon admission. Further interview confirmed RN #38 copied the admission weight of 186.1 for Resident #16 from the preadmission hospital paperwork and the staff had not actually weighed the resident. Review of the facility policy titled Admission Weights undated revealed residents must have accurate admission weights, and the facility staff should weigh the resident upon admission using a standing scale, a sitting scale or a Hoyer scale. Staff should not use the hospital weight, or a weight reported by the resident.

Based on medical record review, observation staff interview, review of the facility policy, and review of guidelines from the National Pressure Injury Advisory Panel (NPIAP), the facility failed to ensure resident pain was effectively managed during a dressing change. This affected one (Resident #6) of three residents reviewed for pain management. The facility census was 84 residents. Findings include: Review of the medical record for Resident #6 revealed an admitted [DATE] with diagnoses including diabetes, profound intellectual disabilities, anxiety disorder, and aphasia. Review of the care plan for Resident #6 dated 12/28/11 revealed the resident was unable to verbally express pain. Goals of Resident #16's care plan were to decrease the resident's pain to an acceptable level to allow the resident's participation in treatments and activities of daily living (ADLs) and signs of discomfort would be reduced or resolved. Interventions included the following: administer medications as ordered, medications as ordered to manage pain, monitor effectiveness of interventions, monitor for increased pain levels. Review of the Minimum Data Set (MDS) assessment for Resident #6 dated 02/07/25 revealed the resident was non-communicative with severely impaired cognition and was dependent on staff with all activities of daily living (ADLs). Review of the notes per the wound nurse practitioner (NP) for Resident #6 dated 04/10/25 revealed the resident had a full thickness diabetic foot ulcer to his left heel which measured 3.3 centimeters (cm) in length by 3.5 cm in width with the depth unable to be determined. The ulcer contained 30 percent (%) granulation tissue, 20 % slough, and 50 % eschar. Debridement of the wound was postponed due to concerns for Resident #6's discomfort and pain levels. The treatment was changed due to adherence of the dressing to the wound bed to the following order: cleanse the wound with normal saline, apply Medihoney, apply calcium alginate, cover with an ABD pad and wrap with Kerlix. Review of the notes per the wound NP for Resident #6 dated 04/17/25 revealed the resident's diabetic foot ulcer measured 4.2 cm in length by 4.0 cm in depth with a depth unable to be determined. The ulcer contained 10 % granulation tissue, 10 % slough, and 80 % eschar. The resident showed signs of discomfort and pain to the ulcer during the wound NP visit. Review of the Medication Administration Record (MAR) for Resident #6 dated April 2025 revealed the resident had an order for Tramadol twice daily as needed for pain. Resident #6 was not documented for administration of Tramadol on 04/30/25. Observation of wound care for the left diabetic foot ulcer for Resident #6 on 04/30/25 at 9:27 A.M. per Assistant Director of Nursing (ADON) #97 revealed when the nurse began removing the dressing from the resident's left foot, the resident attempted to pull his foot away. As ADON #97 continued with dressing change Resident #6 began whimpering, pulling his foot away, grimacing, moaning and growling in pain, and began biting his fingers and these signs continued throughout the procedure. Interview on 04/30/25 at 9:50 A.M. with ADON #97 confirmed she was unaware if Resident #6 had received pain medication prior to the dressing change and confirmed the resident demonstrated signs of pain and discomfort throughout the procedure such as pulling his foot away, grimacing, moaning and growling in pain, and biting his fingers. ADON #97 confirmed she continued with the treatment despite Resident #6 exhibiting nonverbal indicators of pain. Review of the facility policy titled Pain Assessment and Management dated 03/31/16 revealed assessment and adequate treatment of pain was central to the management of the physical and psychological well-being of residents. The resident's pain should be assessed as needed and if the resident was unable to communicate pain symptoms, the staff should observe for behavior that indicated pain such as restlessness, agitation, groaning or holding of an area. The staff should provide pharmacological interventions in accordance with physician's orders. Review of the online resource per the NPIAP titled Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline at (https://npiap.com/general/custom.asp?page=2014Guidelines) downloaded on 05/14/25, revealed on page 161 that staff should organize care delivery to ensure that it is coordinated with pain medication administration and that minimal interruptions follow. Pain management included performing care after administration of pain medication to minimize pain experienced and interruptions to comfort for the individual. Review of page 165 revealed staff should use adequate pain control measures, including additional dosing, prior to commencing wound care procedures. This statement was based on expert opinion. Wound care procedures including wound manipulation, wound cleansing, debridement, and dressing changes were painful to the patient.

Based on observation, staff interview, review of medication insert, and policy review, the facility failed to ensure medications were dated after opening and were not expired. This had the potential to affect all 87 residents residing in the facility. The facility census was 87. Findings include: 1. Observation on [DATE] at 1:42 P.M. of the medication storage room revealed two 16-ounce bottles of liquid [MEDICATION(S)] Sodium Stool Softener with an expiration date of ,d+[DATE]. Interview on [DATE] at 1:43 P.M. with Licensed Practical Nurse #36 confirmed the expiration date on the two [MEDICATION(S)] Sodium Stool Softener bottles. 2. Observation on [DATE] at 2:00 P.M. of the refrigerator on the 300 Hall revealed a vial of [MEDICATION(S)] ([MEDICATION(S)], Diluted [Stabilized Solution]), used for diagnosing [CONDITION(S)], was opened but was not dated. Interview on [DATE] at 2:01 P.M. with Registered Nurse #89 confirmed the [MEDICATION(S)] solution was opened with no date marked to indicate when the solution had been opened. Review of the packaging insert for the [MEDICATION(S)] solution, revised ,d+[DATE], revealed vials in use for more than 30 days should be discarded. Review of the facility policy titled Medication Storage, dated [DATE], revealed medications and biologicals are stored safely, securely and properly following manufacturer's recommendations or those of the supplier. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication destruction, and reordered from the Pharmacy, if replacements are needed.

Based on observation, staff interview, review of facility recipes, and policy review, the facility failed to properly prepare pureed food. This had the potential to affect all eight facility identified residents (#9, #10, #17, #29, #40, #47, #49, and #56) in the facility who receive a pureed diet. The facility census was 87. Findings include: Observation on 04/12/22 at 9:23 A.M. revealed Cook #21 prepared pureed ham for the lunch meal. Cook #21 stated there was one pureed diet, which was liquified, and the remainder of the pureed diets were standard puree. Cook #21 placed ham into the food processor, turned the food processor on, and then added water to the food processor. Cook #21 continued to add water to the food processor until the ham was a watery consistency. Cook #21 then scooped a portion of the liquified ham mixture into an insulated bowl and informed the surveyor the contents in the bowl were for the liquified pureed diet. Cook #21 then added thickening powder to the ham mixture to create an appropriate pureed-textured ham for the remainder of the pureed diets. Continued observation on 04/12/22 at approximately 9:30 A.M. revealed Cook #21 placed green beans into the food processor to begin preparing the pureed green beans. Cook #21 turned on the food processor and began adding water as well as a small amount of thickener to the green beans until the appropriate consistency was achieved. Interview on 04/12/22 at approximately 9:35 A.M. with Cook #21, verified he prepared the pureed liquified diet by adding enough water to the ham to make all of the ham liquified and utilized thickener to thicken the mixture back to a pureed form, unnecessarily adding more liquid to all of the pureed ham. Cook #21 stated he has always done it that way. Interview on 04/13/22 at approximately 12:15 P.M. with Registered Dietitian (RD) #88, verified water should not be used to aid in the process of making pureed foods. Interview on 04/13/22 at 12:42 P.M. with Dietary Supervisor #65, verified Cook #21 used water when making the pureed ham and pureed green beans on 04/12/22. Review of the Recipe Summary Card titled Pureed Meats (Protein) revealed food should be pureed until meats with a little stock/cooking liquid reach a smooth consistency. If needed, add additional stock or liquid to reach a smooth consistency and add thickener to achieve a mashed potato consistency. Review of the Recipe Summary Card titled Pureed Vegetables revealed food should be pureed until vegetables reach a smooth consistency. If needed, stock or liquid can be added to reach a smooth consistency and add thickener to achieve mashed potato consistency. Review of the facility policy titled Procedure for Thinned-Puree, undated, revealed pureed food was to be prepared according to the recipe and, prior to adding the thickening agent, remove one portion of the food needed to be thinned. The cook should then use broth, milk, juice, or half and half to thin the pureed item, adding one ounce of liquid at a time to achieve the desired consistency.

Based on observation, staff interview, and policy review, the facility failed to properly prepare medications for administration. This had the potential to affect three Residents (#15, #23, and #59) out of 25 residents who reside on the Oak and Pine unit. The facility census was 87. Findings include: Observation on 04/12/22 at 2:59 P.M. of the medication cart on the Oak and Pine unit revealed there were three cups of pre-poured medications prepared for three Residents (#15, #23, and #59) in the top drawer of the cart. Interview with Licensed Practical Nurse (LPN) #80 during the observation on 04/12/22 at 2:59 P.M. revealed the medications pre-poured for Resident #15 included two [MEDICATION(S)] five milligrams (mg) pills, the medication pre-poured for Resident #23 included [MEDICATION(S)] (controlled opoid) 7.5/325 mg, and the medications pre-poured for Resident #59 were [MEDICATION(S)] 500 mg and [MEDICATION(S)] 7.5/325 mg. Interview on 04/12/22 at 3:05 P.M. with the Manager of Clinical Services #87 verified the medications were prepared improperly for Resident #15, #23, and #59, when the medications were pre-poured into a cup and set in the top drawer of the medication cart. Review of the General Guidelines for Medication Administration Policy, dated 06/21/17, revealed only one resident's medication at a time should be prepared and taken into the resident's room. Pre-pouring medications is not an acceptable or safe practice.

Based on personnel file review and staff interview, the facility failed to ensure State tested Nurse Aides (STNA) received annual performance review evaluations. This affected two (STNA #38 and STNA #61) of two STNA's reviewed for annual performance evaluations and had the potential to affect all 87 residents. The facility census was 87. Findings include: 1. Review of STNA #38's personnel file revealed STNA #38 was hired on 07/02/19. Further review of STNA #38's personnel file revealed STNA #38 did not receive an annual performance review evaluation between 07/2020 and 04/14/22. 2. Review of STNA #61's personnel file revealed STNA #61 was hired on 09/03/15. Further review of STNA #61's personnel file revealed STNA #61 did not receive an annual performance review evaluation between 09/03/20 and 04/14/22. Interview on 04/14/22 between 12:30 P.M. and 1:15 P.M. with Human Resources Director #42, verified STNA #61 and STNA #38 did not receive an annual performance review evaluations during the dates specified.

Based on observation, record review and staff interviews, the facility failed to accurately code information on the Minimum Data Set (MDS) assessments. This affected two (#2 and #12) of 23 residents reviewed for MDS accuracy in the final sample. The facility census was 101. Findings include: 1. Review of the medical record for Resident #2 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition and indicated Resident #2 had impairment in functional limitations for both sides of upper and lower extremities. Observation on 10/02/19 at 2:09 P.M. revealed Resident #2 participating in activities. She was observed walking in the common area, drinking juice, flipping pages of a magazine and smacking her hands on a table for attention. There were no functional limitations observed with the resident's upper extremities. Interview with MDS Licensed Practical Nurse (LPN) #37 on 10/03/19 at 1:55 P.M. reported Resident #2 was not cooperative with her, so she coded impairment. When questioned what the specific functional impairment was that she had observed, LPN #37 stated the resident could not move things like her toes. LPN #2 stated she was unaware of any specific functional impairment for Resident #12. Interview with Unit Manager #37 on 10/03/19 at 2:45 P.M. verified she completed the functional resident observations form on 03/21/19 and 06/21/19 for Resident #12 as no impairment. She reported the forms were completed for MDS completion. She stated Resident #2 was able to do the activities she wanted, feed herself, transfer and ambulate independently, and pick up objects. 2. Review of the medical record for Resident #12 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/02/19, revealed Resident #12 had cognitive impairment and had functional limitations on both sides of lower extremities and no impairment of upper extremities. Review of the physical function observation form, dated 07/09/19, indicated Resident #12 had no functional impairment of upper or lower extremities. Observations on 09/30/19 at 2:04 P.M. and 10/03/19 at 4:00 P.M. revealed Resident #12 actively participating in a toss activity in the ELM unit lounge and ambulating to the bathroom without assistive devices. Interview on 10/03/19 at 4:00 P.M. with LPN #6 reported Resident #12 ambulated and toileted self independently and denied resident had any limitations in her legs, knees, or feet. Interview on 10/03/19 at 4:10 P.M. with the Director of Nursing and Corporate Support Registered Nurse #400 verified the MDS coding did not match the facility assessments or staff reports of Residents #2 ' s and #12 ' s functional abilities.

Based on medical record review, review of facility self-reported incidents, and staff interview, the facility failed to implement its policy by not timely reporting allegations of abuse to the administrator and the state agency as required. This affected one (#110) of four residents reviewed for abuse. The facility in-house census was 104. Findings include: Review of the medical record for Resident #110 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the comprehensive admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #110 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating moderately impaired cognition. The resident had minimal depression, displayed potential indicators of [MEDICAL CONDITION] including delusions, and was independent or required only limited physical assistance with activities of daily living. Review of Resident #110's medical record progress note dated 06/15/19 at 10:10 A.M. revealed the resident was transferred to an acute care hospital. Review of Resident #110's medical record progress note dated 06/15/19 at 12:24 P.M., revealed the facility received a call from the acute care hospital social worker informing that the resident had alleged the facility was drugging and having relations with residents and that he probably was also drugged but doesn't know. Review of the facility's self-reported incident (SRI) # 6 dated 06/17/19 at 12:25 P.M. revealed the resident alleged having been drugged and staff were having relations with residents. Interview on 07/01/19 at 4:30 P.M., the Administrator verified the acute care hospital record and progress notes in the Resident #110's chart documented the facility was notified of the resident's allegation of abuse on 06/15/19, and the Administer and the state survey agency were not informed of the allegation until 06/17/19, two days after the facility was made aware of the allegation. Review of the facility policy titled Abuse, Neglect, exploitation and misappropriation of Resident Property (dated 11/21/16) revealed it was the facility's policy to investigate all alleged violations involving Abuse, Neglect, Exploitation, Mistreatment of [REDACTED]. Additionally, the facility should immediately report all such allegations to the Administrator and the Ohio Department of Health. The procedure included all incident and allegations of abuse, neglect, exploitation, mistreatment of [REDACTED]. In response to allegations of abuse, neglect, exploitation or mistreatment, the facility was to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries and misappropriation or resident property, are reported immediately, but no later than two hours after the investigation was made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events do not involve abuse.

Based on medical record review, review of facility self-reported incidents, and staff interview, the facility failed to timely report allegations of abuse to the administrator or the state survey agency as required. This affected one (Resident #110) of four residents reviewed for abuse. The facility in-house census was 104. Findings include: Review of the medical record for Resident #110 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the comprehensive admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #110 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating moderately impaired cognition. The resident had minimal depression, displayed potential indicators of [MEDICAL CONDITION] including delusions, and was independent or required only limited physical assistance with activities of daily living. Review of Resident #110's medical record progress note dated 06/15/19 at 10:10 A.M. revealed the resident was transferred to an acute care hospital. Review of Resident #110's medical record progress note dated 06/15/19 at 12:24 P.M., revealed the facility received a call from the acute care hospital social worker informing that the resident had alleged the facility was drugging and having relations with residents and that he probably was also drugged but doesn't know. Review of the facility's self-reported incident (SRI) # 6 dated 06/17/19 at 12:25 P.M. revealed the resident alleged having been drugged and staff were having relations with residents. Interview on 07/01/19 at 4:30 P.M., the administrator verified the acute care hospital record and progress notes in the Resident #110's chart documented the facility was notified of the resident's allegation of abuse on 06/15/19, and the administer and the state survey agency were not informed of the allegation until 06/17/19, two days after the facility was made aware of the allegation. Review of the facility policy titled Abuse, Neglect, exploitation and misappropriation of Resident Property (dated 11/21/16) revealed it was the facility's policy to investigate all alleged violations involving Abuse, Neglect, Exploitation, Mistreatment of [REDACTED]. Additionally, the facility should immediately report all such allegations to the Administrator and the Ohio Department of Health. The procedure included all incident and allegations of abuse, neglect, exploitation, mistreatment of [REDACTED]. In response to allegations of abuse, neglect, exploitation or mistreatment, the facility was to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries and misappropriation or resident property, are reported immediately, but no later than two hours after the investigation was made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events do not involve abuse.

Based on review of the medical record, staff interview and review of the facility's Abuse Policy, the facility failed to implement their abuse police when they failed to self report a [MEDICAL CONDITION] of unknown origin to the Ohio Department of Health. This affected one (#300) three residents reviewed for falls. The census was 107. Findings include: Review of Resident #300's medical record revealed she was admitted to the facility on [DATE] for [MEDICAL CONDITION] with behavior disturbances. Her quarterly Minimum Data Set (MDS) assessment dated [DATE] documented she had unclear speech, usually understood others, usually made herself understood, but was severely impaired for daily decision making. She did not have signs or symptoms of [MEDICAL CONDITION] or [MEDICAL CONDITION]. She did not have negative behaviors or reject care. She did wander for one to three days of the seven day assessment. She needed extensive one staff assistance with all activities of daily living including ambulating and locomotion. She did not have any falls since the prior assessment. Her MDS [DIAGNOSES REDACTED]. Resident #300's medical record contained the following Nurse' Notes dated 10/04/18 by Licensed Practical Nurse (LPN) # 6 : at 8:33 A.M. the resident complained of severe leg pain and was unable to move her left lower extremity. She was guarding her left hip. Stat X-ray was ordered. At 8:59 A.M. the resident was guarding her right hip and the nurse noted shortening and external rotation. Stat X-ray of right hip, anteroposterior (AP) view only was ordered. At 9:02 A.M. X-ray showed femoral neck fracture. At 9:44 A.M. resident was sent out with squad. There was also a late entry Nurse's Note dated 10/04/18 at 3:19 P.M. made by Registered Nurse (RN) # 3 that documented on 10/03/18 at 4:45 A.M. a Nurse Aide (NA) found the resident on the floor sleeping with her covers. She denied any complaints and no injuries were noted. She was assisted back to bed by the nurse and the NA. The note also documented that at 8 A.M. the resident complained of right hip pain. Interview with LPN #6 on 10/24/18 at 1:25 P.M. stated she discovered Resident #300's injury on day shift 10/04/18. LPN #6 stated that NA #8 came and told her Resident #300 would not stand up so she went and assessed her while the resident was sitting in a chair. She stated the resident would not move her left leg so she obtained an order for [REDACTED]. She stated at that point, she changed the order to a right leg x-ray. LPN #6 stated Resident #300's injury was an injury of unknown origin because the resident couldn't tell you what happened because of her advanced dementia and the incident was not witnessed. Interview with the Director of Nursing (DON) and review of the investigation file on 10/24/18 at 1:59 P.M. stated when asked if she should have Self Reported the fracture to the Ohio Department of Health as an injury of unknown origin she stated yes and no. She explained she didn't report it because she felt like the fracture happened when the resident put herself on the floor but admitted the fracture may have happened at some other time, in which case in would be an Injury of Unknown Origin and should be reported. Review of the facility's Abuse Policy dated 11/21/16 documented on the top of page one it is the facilities policy to investigate all alleged violations involving Abuse, Neglect, Exploitation, Mistreatment of [REDACTED]. Additionally the facility should immediately report all such allegations to the Administrator and the Ohio Department of Health (ODH). This is an incidental finding discovered during the course of the investigation of Complaint Number OH 634.

Based on review of the medical record, staff interview and review of the facility's Abuse Policy, the facility failed to self report a [MEDICAL CONDITION] of unknown origin to the Ohio Department of Health. This affected one (#300) three residents reviewed for falls. The census was 107. Findings include: Review of Resident #300's medical record revealed she was admitted to the facility on [DATE] for [MEDICAL CONDITION] with behavior disturbances. Her quarterly Minimum Data Set (MDS) assessment dated [DATE] documented she had unclear speech, usually understood others, usually made herself understood, but was severely impaired for daily decision making. She did not have signs or symptoms of [MEDICAL CONDITION] or [MEDICAL CONDITION]. She did not have negative behaviors or reject care. She did wander for one to three days of the seven day assessment. She needed extensive one staff assistance with all activities of daily living including ambulating and locomotion. She did not have any falls since the prior assessment. Her MDS [DIAGNOSES REDACTED]. Resident #300's medical record contained the following Nurse' Notes dated 10/04/18 by Licensed Practical Nurse (LPN) # 6 : at 8:33 A.M. the resident complained of severe leg pain and was unable to move her left lower extremity. She was guarding her left hip. Stat X-ray was ordered. At 8:59 A.M. the resident was guarding her right hip and the nurse noted shortening and external rotation. Stat X-ray of right hip, anteroposterior (AP) view only was ordered. At 9:02 A.M. X-ray showed femoral neck fracture. At 9:44 A.M. resident was sent out with squad. There was also a late entry Nurse's Note dated 10/04/18 at 3:19 P.M. made by Registered Nurse (RN) # 3 that documented on 10/03/18 at 4:45 A.M. a Nurse Aide (NA) found the resident on the floor sleeping with her covers. She denied any complaints and no injuries were noted. She was assisted back to bed by the nurse and the NA. The note also documented that at 8 A.M. the resident complained of right hip pain. Interview with LPN #6 on 10/24/18 at 1:25 P.M. stated she discovered Resident #300's injury on day shift 10/04/18. LPN #6 stated that NA #8 came and told her Resident #300 would not stand up so she went and assessed her while the resident was sitting in a chair. She stated the resident would not move her left leg so she obtained an order for [REDACTED]. She stated at that point, she changed the order to a right leg x-ray. LPN #6 stated Resident #300's injury was an injury of unknown origin because the resident couldn't tell you what happened because of her advanced dementia and the incident was not witnessed. Interview with the Director of Nursing (DON) and review of the investigation file on 10/24/18 at 1:59 P.M. stated when asked if she should have Self Reported the fracture to the Ohio Department of Health as an injury of unknown origin she stated yes and no. She explained she didn't report it because she felt like the fracture happened when the resident put herself on the floor but admitted the fracture may have happened at some other time, in which case in would be an Injury of Unknown Origin and should be reported. Review of the facility's Abuse Policy dated 11/21/16 documented on the bottom of page one and the top of page two the definition of an injury of unknown origin was the source of the injury was not observed by any person, the source of the injury could not be explained by the resident, and the injury is suspicious because of the extent of the injury, the location of the injury, the number of injuries observed at one time, or the incidents of injuries over a period of time. This is an incidental finding discovered during the course of the investigation of Complaint Number OH 634.

Based on observation, staff interview, and facility policy review, the facility failed to keep the unit refrigerators at appropriate temperatures, clean and free of expired foods. This had the potential to affect all residents residing in the facility. The facility census was 103. Findings include: 1. Observation of the refrigerator on the OAKS unit on [DATE] at 9:20 A.M., revealed refrigerator temperature was at 45 degrees Fahrenheit (F). Refrigerator was noted to be dirty inside and outside. Reviewed (MONTH) temperature log revealed there were days in (MONTH) (YEAR) when the temperature in the refrigerator was 42 degrees F. Reviewed maintenance log revealed no repairs noted for OAKS refrigerator. Interview on [DATE] at 9:25 A.M., revealed Registered Nurse (RN) #21 verified findings. RN #21 reported the night shift is responsible for cleaning refrigerator. 2. Observation of the refrigerator on the PINE unit on [DATE] at 11:47 A.M., revealed no temperature log. The refrigerator temperature was reading 44 degrees F and not clean. The refrigerator had residue of spilled items and old food particles on the shelves and at the bottom of the refrigerator. There was a container of tomato and onions with no date, container of shredded cheese with no date, no thermometer in the freezer and the door seal of the refrigerator comes off every time the refrigerator door is opened. Reviewed maintenance log revealed no repairs noted for PINE refrigerator. Interview on [DATE] at 11:48 A.M., revealed Licensed Practical Nurse (LPN) #1 verified findings. LPN #1 reported the night shift is responsible for cleaning the refrigerator. 3. Observation of the refrigerator on the WILLOW unit on [DATE] at 12:16 P.M., revealed the refrigerator temperature was at 52 degrees F. Inside the refrigerator there was French onion dip a date of (MONTH) (YEAR) and yogurt with no name. Reviewed maintenance log revealed no repairs noted for WILLOW refrigerator. Interview on [DATE] at 12:20 A.M., revealed LPN #59 verified findings. 4. Observation of the refrigerator on ASH unit on [DATE] at 12:42 P.M., revealed refrigerator temperature was 52 degrees F. Reviewed maintenance log revealed no repairs noted for ASH refrigerator. Interview on [DATE] at 12:20 A.M., revealed LPN #79 verified findings. 5. Observation of the refrigerator on ELM unit on [DATE] at 1:03 P.M., revealed refrigerator temperature was 58 degrees F and the freezer 42 degrees F. There were a few items with no name and date such as a container of strawberries, half gallon of two percent (2%) milk, blue raspberry drink and a liter of 7-up. Reviewed maintenance log revealed no repairs noted for ASH refrigerator. Interview on [DATE] at 12:20 A.M., revealed LPN #4 verified findings. The facility confirmed the observations had the potential to affect all 103 residents residing in the facility. Review policy titled, Infection Control Policy/Procedure Manual revised (MONTH) (YEAR) revealed temperatures must be maintained at the following (Fahrenheit) setting for refrigerated food 41 degrees F or below. Review policy titled, Food Storage-Labeling and Dating, revised (MONTH) (YEAR) revealed all foods should be properly labeled and dated. Review policy titled, Food brought in by family or other visitors will be handled in a way to ensure the safety of residents, dated (MONTH) 21, (YEAR) revealed if not consumed within three days, food will be thrown away by facilty staff and the facility may refrigerate label and dated prepared items in the nourishment refrigerator.

Based on medical record review, observation, policy review, and staff and resident interviews, the facility failed to ensure residents were free from verbal abuse by a staff member. This affected four (#36, #58, #67 and #26) out of 32 residents review in the initial pool sample of the annual survey. The facility census was 103. Findings include: 1. Review of the medical record revealed Resident #36 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed the resident is cognitively intact and had verbal behaviors directed toward others one to three days during the seven day look back period. Review of the functional MDS revealed Resident #36 requires extensive assistance with bed mobility, transfers, dressing, toileting, supervision with personal hygiene, and independent with eating and locomotion. Interview conducted on 08/26/18 at 2:05 P.M. Resident #36 stated State tested Nursing Assistant (STNA) #77 will constantly bang on the door. Resident #36 stated he has asked the aid several times to stop banging and she just says, I ain't banging. Resident #36 stated STNA #77's behavior is past rude, it is abusive. Resident #36 stated STNA #77 talks very disrespectful to him daily, saying things like, you ain't asking anything of me and you're a mean person all the time. Resident #36 stated he is not a mean person, he is just asking her to do her job and she is rude to everyone. 2. Review of the medical record revealed Resident #58 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #58 has minimal cognitive impairment, depression, is independent with locomotion and eating, however requires extensive assistance with bed mobility, toileting, personal hygiene, and total dependence with transfers. Interview conducted on 08/26/18 at 10:24 A.M. and again on 08/27/18 at 4:49 P.M. Resident #58 stated the aids on the unit get smart with the residents. Resident #58 stated if she ask STNA #77 if dinner is on the unit, she will respond with, do you see a sliver cart well then I guess it isn't here. Resident #58 stated STNA #77 would argue with her about anything she would say. Resident #77 stated if she would say her shirt was pink, STNA #77 would say it was orange, just to start an argument with her. 3. Review of the resident record revealed Resident #67 was admitted to the facility 07/28/17. [DIAGNOSES REDACTED]. Review of the minimum data set ((MDS) dated [DATE] revealed the resident is mildly cognitively impaired, has depression, and verbal behaviors directed towards others one to three days during the seven day look back period. Review of the functional MDS revealed the resident is independent with personal hygiene, toileting, eating, dressing, ambulation, transfers, and bed mobility. Interview conducted on 08/26/18 at 12:55 P.M. and again on 08/29/18 at 10:28 A.M. Resident #67 stated STNA #77 yells at the residents. Resident #67 stated she was getting tissues out of the cabinet on 08/25/18, and STNA #77 started hollering at her. Resident #67 stated she told STNA #77 she is not supposed to holler at residents, and she stated, she can do what she wants to. Resident #67 stated, that was abuse yesterday, what she did to me. Resident #67 stated she has had many problems with STNA #77 however she never reported has she was treating her because she was afraid she would retaliate against her, and she was trying to be nice and handle things on her own. Resident #67 stated STNA #77 speaks to her and other residents is in a harsh tone, and she does not like being hollered at. 4. Review of the medical record revealed Resident #26 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the Minimum Data Set(MDS) completed 06/09/18 revealed Resident #26 is mildly cognitively impaired, and is independent with bed mobility, personal hygiene, eating, locomotion, and dressing, requires supervision with transfers, walking, bathing, and extensive assistance with toileting. Observation conducted on 08/26/18 at 11:56 A.M. Resident #26 was observed sleeping in her room, in the recliner next to her bed, when STNA #77 was observed walking into her room with her meal tray. STNA #77 was observed talking to Resident #26 in a loud stern voice, stating you can't sleep now, you need to get up and eat your food is here. Interview attempted with Resident #26 however she was again sleeping. Several attempts were made to interview Resident #26; however all attempts revealed the resident was sleeping in her recliner. Interview conducted on 08/29/18 at 9:27 A.M. the facility Administrator reviewed the abuse allegation investigation for Residents (#36, #58, and #67). Administrator stated all three residents conformed statements of abuse, stating STNA #77 was rude, disrespectful, bangs on the door to lout, and talks down to them. When allegations were brought to the Administrator, STNA #77 was brought in and questioned if there were any issues she had with residents, where she wrote statements about two incidents, one with Resident #58 and another with Resident #67. On both occasions STNA #77's account was different then the residents version of the story. STNA #77 was immediately suspended investigation, and self reported incident (SRI) was filled, and the investigations were still taking place. Interview conducted on 08/29/18 at 10:08 A.M. with Licensed Practical Nurse (LPN) #1 stated she had not had any complaints regarding STNA #77 however stated she has heard her use a stern tone and bad choice of word with non alert residents occasionally depending on her mood. LPN #1 stated she has also heard STNA #77 talk in a stern tone and harsh choice of words with with Resident #58 when the residents was wanting to get out of bed. Review of the facility policy for Abuse, Neglect, Exploitation, and Misappropriation of Residents Property dated 11/21/16 revealed abuse includes verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enabled through the technology. The facility will supervise staff to identity inappropriate behaviors such as using derogatory language, rough handling, ignoring residents.

Based on medical record review, observation, policy review, and staff and resident interviews, the facility failed to implement their abuse policy to ensure residents were free from verbal abuse by a staff member. This affected four (#36, #58, #67 and #26) out of 32 residents review in the initial pool sample of the annual survey. The facility census was 103. Findings include: 1. Review of the medical record revealed Resident #36 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed the resident is cognitively intact and had verbal behaviors directed toward others one to three days during the seven day look back period. Review of the functional MDS revealed Resident #36 requires extensive assistance with bed mobility, transfers, dressing, toileting, supervision with personal hygiene, and independent with eating and locomotion. Interview conducted on 08/26/18 at 2:05 P.M. Resident #36 stated State tested Nursing Assistant (STNA) #77 will constantly bang on the door. Resident #36 stated he has asked the aid several times to stop banging and she just says, I ain't banging. Resident #36 stated STNA #77's behavior is past rude, it is abusive. Resident #36 stated STNA #77 talks very disrespectful to him daily, saying things like, you ain't asking anything of me and you're a mean person all the time. Resident #36 stated he is not a mean person, he is just asking her to do her job and she is rude to everyone. 2. Review of the medical record revealed Resident #58 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #58 has minimal cognitive impairment, depression, is independent with locomotion and eating, however requires extensive assistance with bed mobility, toileting, personal hygiene, and total dependence with transfers. Interview conducted on 08/26/18 at 10:24 A.M. and again on 08/27/18 at 4:49 P.M. Resident #58 stated the aids on the unit get smart with the residents. Resident #58 stated if she ask STNA #77 if dinner is on the unit, she will respond with, do you see a sliver cart well then I guess it isn't here. Resident #58 stated STNA #77 would argue with her about anything she would say. Resident #77 stated if she would say her shirt was pink, STNA #77 would say it was orange, just to start an argument with her. 3. Review of the resident record revealed Resident #67 was admitted to the facility 07/28/17. [DIAGNOSES REDACTED]. Review of the minimum data set ((MDS) dated [DATE] revealed the resident is mildly cognitively impaired, has depression, and verbal behaviors directed towards others one to three days during the seven day look back period. Review of the functional MDS revealed the resident is independent with personal hygiene, toileting, eating, dressing, ambulation, transfers, and bed mobility. Interview conducted on 08/26/18 at 12:55 P.M. and again on 08/29/18 at 10:28 A.M. Resident #67 stated STNA #77 yells at the residents. Resident #67 stated she was getting tissues out of the cabinet on 08/25/18, and STNA #77 started hollering at her. Resident #67 stated she told STNA #77 she is not supposed to holler at residents, and she stated, she can do what she wants to. Resident #67 stated, that was abuse yesterday, what she did to me. Resident #67 stated she has had many problems with STNA #77 however she never reported has she was treating her because she was afraid she would retaliate against her, and she was trying to be nice and handle things on her own. Resident #67 stated STNA #77 speaks to her and other residents is in a harsh tone, and she does not like being hollered at. 4. Review of the medical record revealed Resident #26 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the Minimum Data Set(MDS) completed 06/09/18 revealed Resident #26 is mildly cognitively impaired, and is independent with bed mobility, personal hygiene, eating, locomotion, and dressing, requires supervision with transfers, walking, bathing, and extensive assistance with toileting. Observation conducted on 08/26/18 at 11:56 A.M. Resident #26 was observed sleeping in her room, in the recliner next to her bed, when STNA #77 was observed walking into her room with her meal tray. STNA #77 was observed talking to Resident #26 in a loud stern voice, stating you can't sleep now, you need to get up and eat your food is here. Interview attempted with Resident #26 however she was again sleeping. Several attempts were made to interview Resident #26; however all attempts revealed the resident was sleeping in her recliner. Interview conducted on 08/29/18 at 9:27 A.M. the facility Administrator reviewed the abuse allegation investigation for Residents (#36, #58, and #67). Administrator stated all three residents conformed statements of abuse, stating STNA #77 was rude, disrespectful, bangs on the door to lout, and talks down to them. When allegations were brought to the Administrator, STNA #77 was brought in and questioned if there were any issues she had with residents, where she wrote statements about two incidents, one with Resident #58 and another with Resident #67. On both occasions STNA #77's account was different then the residents version of the story. STNA #77 was immediately suspended investigation, and self reported incident (SRI) was filled, and the investigations were still taking place. Interview conducted on 08/29/18 at 10:08 A.M. with Licensed Practical Nurse (LPN) #1 stated she had not had any complaints regarding STNA #77 however stated she has heard her use a stern tone and bad choice of word with non alert residents occasionally depending on her mood. LPN #1 stated she has also heard STNA #77 talk in a stern tone and harsh choice of words with with Resident #58 when the residents was wanting to get out of bed. Review of the facility policy for Abuse, Neglect, Exploitation, and Misappropriation of Residents Property dated 11/21/16 revealed abuse includes verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enabled through the technology. The facility will supervise staff to identity inappropriate behaviors such as using derogatory language, rough handling, ignoring residents.

Based on medical record review and staff, resident and local transport personnel interviews, the facility failed to obtain weights as physician ordered for one (#18) out of 25 residents reviewed during stage two of the survey. In addition, the facility failed to arrange reliable transportation for medical appointments for three (#13, #32 and #81) of three reviewed for appointments. The facility census was 103. Findings include: 1. Review of the medical record for Resident #18 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident was assessed as cognitively intact, independent for activity of daily living and wheelchair bound. Review of physician's orders [REDACTED]. Review daily weights in the electronic medical records for the past 60 days revealed weights were not taken daily. Interview on 08/29/18 at 10:00 A.M. revealed State tested Nursing Assistant (STNA) #89 that she was no aware of the need of daily weights for Resident #18. Interview on 08/29/18 at 10:20 A.M. revealed Nurse Manager (NM) #36 reported all weights are in the medical charts. 2. Medical record review revealed, Resident #13 was admitted [DATE]. [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #13 had moderate cognitive impairment and required extensive to total assistance with bed mobility, transfers, locomotion on and off unit, dressing, toilet use and personal hygiene. Resident #13 was noted as being always incontinent of bladder and bowel. Review of the hard chart review revealed an order to hold aspirin and fish oil from 07/24/18 through 08/01/18 pre-operation orders. Further hard chart review revealed an order for [REDACTED]. Further physician order [REDACTED].#13 revealed an order dated 07/17/18 which stated on (MONTH) 30, (YEAR) begin clear liquid diet, do not drink red colored beverages or eat red Jello. No solid food of any kind. At 1:00 P.M. take four [MEDICATION NAME] (stool softener) tablets by mouth with 32 ounces of Gatorade (electrolyte drink). At 3:00 P.M. mix the 238-gram bottle of [MEDICATION NAME] (stool softener / laxative) in 64 ounces of Gatorade. Shake the solution until the [MEDICATION NAME] is dissolved. Drink eight ounces every 10 to 15 minutes. Further physician order [REDACTED].#13 revealed an order dated 07/18/18 which stated Resident #13 to be NPO starting at 11:00 P.M. on Monday, (MONTH) 30, (YEAR) for pre-operative orders. Further physician order [REDACTED].#13 revealed an order dated 07/18/18 which stated Surgery at a local hospital on Tuesday, (MONTH) 31, (YEAR) at 10:45 A.M. and arrive at 8:45 A.M. Bowel prep day Monday, (MONTH) 30, (YEAR). Review of the after visit summary for Resident #13's (MONTH) (YEAR) admission revealed she had been admitted for [MEDICAL CONDITION] and altered mental status, was to follow up with per primary care physician in one to two weeks and follow up with her general surgery physician per their instructions typically within two to four weeks. It was noted Resident #13 had been admitted on [DATE], had a colonoscopy and biopsy of mass in colon on 07/06/18, and was discharged back to the facility on [DATE] with antibiotics. Attempted interview on 08/27/18 at 12:55 P.M. with a lethargic Resident #13 who verified she had just had surgery a few days prior on her abdominal area. Interview on 08/28/18 at 8:39 A.M. with Registered Nurse (RN #21) who stated Resident #13 had an abdominal mass and had gone about a month ago and recently had a bowel resection instead of a [MEDICAL CONDITION]. Interview on 08/29/18 at 7:44 A.M. with Licensed Practical Nurse (LPN) #101 who stated Resident #31 had gone out to a local hospital in (MONTH) (YEAR) as she had been septic and a mass was found while she was at the hospital and Resident #13 had surgery recently. LPN #101 stated to her knowledge Resident #13 was unaware of any other surgeries that Resident #13 missed and certainly none missed due to lack of transportation. LPN #101 stated to her knowledge no resident had missed their appointments. Interview on 08/29/18 at 9:23 A.M. and 10:16 A.M. with Director of Nursing (DON) who stated Resident #13 had a surgery in (MONTH) (YEAR) for bowel surgery but to her knowledge the resident had not had any other surgeries that she was supposed to go out for and didn't and no issues with transport. DON further stated Resident #13 went out (MONTH) 14, (YEAR) for a colon surgery, a local transportation company was called and scheduled to pick up Resident #13 on 08/14/18. Further review of progress notes for Resident #13 revealed no further details regarding the survey dated 07/31/18 until a note dated 07/31/18 at 4:20 P.M. by LPN #49 which stated colon surgery rescheduled for 08/14/18. Needs to be there at 9:30 A.M. NPO midnight. Clear liquid diet on 08/13/18. Power of Attorney (POA) is aware. Transportation made through a local transportation company. Waiting for conformation number. Local transportation company did say they will definitely pick her up but can't give me a confirmation number until the first of (MONTH) and they will call to give number. Phone interview on 08/29/18 at 2:07 P.M. with local transportation company who verified their database contained information with names, and addresses for pick ups and drop offs back one year. Local transportation personnel verified their database contained no name that matched the name of Resident #13 on the original scheduled day of surgery 07/31/18 or any other day. During the survey two attempts were made to contact LPN #49 via phone without success. 3. Medical record review revealed, Resident #81 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed Resident #81 had no cognitive impairment and needed extensive assistance with bed mobility, transfers, walking in room, dressing, toilet use and hygiene. Resident #81 was also noted as being frequently incontinent of urine and occasionally incontinent of bowel. Interview on 08/27/18 at 9:25 A.M. with Resident #81 who stated she had an appointment at the eye doctor to remove a cataract on the left eye, last week, and the transportation company picked her up took her to the wrong hospital, and she was supposed to go to another local hospital, the transportation company brought her back to the facility after they had taken her to the wrong hospital, so the appointment was canceled. Resident #81 was waiting on re-scheduling of appointment and surgery. Interview on 08/29/18 at 9:51 A.M. with LPN #42 who stated she had filled out the transportation paperwork for the cataract surgery on 08/23/18 for Resident #81 and placed it in the transportation binder at the nurses' station while waiting on the confirmation number. LPN #42 stated she kept the binder on the desk while waiting on a confirmation number and if she didn't get one by the end of her shift, she would call the transportation company. After receiving the confirmation number LPN #42 would file the transportation sheet under the day of the appointment in the calendar book. LPN #42 stated the transportation was scheduled for 6:30 A.M., the transportation company took Resident #81 to the wrong hospital, the driver brought Resident #81 back to the facility and didn't attempt to take her to the correct hospital. LPN #42 stated Resident #81's surgery has been rescheduled for cataract surgery to her left on on 10/18/18 and she is to arrive by 8:00 A.M. 4. Medical record review revealed, Resident #32 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #32 had no cognitive impairment was required supervision to limited assistance with bed mobility, transfers, walking in and out of room, locomotion on and off unit, and personal hygiene. Resident #32 was noted as being occasionally incontinent of urine and always continent of bowel. Interview on 08/28/18 at 8:48 A.M. with RN #21 who stated she was unaware of appointment on this day for Resident #32. RN #21 stated the nurses are responsible to input the appointments in the electronic charting system, so the order will pop up on the Medication Administration Record [REDACTED]. The nurse would fax over to the transportation company, get a confirmation of pick up and there's a book for that on the other unit, but she didn't know about any book like that on this unit. RN #21 stated had the surveyor not mentioned to her that Resident #32 had an appointment on this day she would not have known. RN #21 stated the ADON does not come to tell the nurses about the appointments. ADON had not told this nurse about Resident #32's appointment on this day. RN #21 stated she needed to call to find out if transportation was in place. Interview on 08/29/18 at 11:42 A.M. with Resident #32 who was out in common area in wheelchair dressed, clean with glasses, stated she didn't go to her appointment yesterday. Interview on 08/29/18 at 12:33 P.M. with DON who stated transportation was to pick Resident #32 up, they didn't show, so the nurse notified the unit manager and activities, plan b would be to use the facility bus, but Resident #32 had missed 30 minutes of her appointment and when the nurse called the pulmonologist office the soonest they could reschedule was 09/25/18. DON stated the company that was supposed to pick her up was a local company and they failed to do so. This deficiency substantiates Complaint Number OH 750.

Based on observation and staff interview, the facility failed to ensure the dining room was cleaned after each meal and to ensure the wall was in good repair. This had the potential to affected seven (#10, #21, #31, #50, #60, #62, and #95) of seven residents observed eating their meal in the ELM 2 dining. Additionally, the facility failed to provide adequate wheelchair cleaning services to maintain Resident #4's wheelchair. This affected one Resident (#4) out of one sampled for wheelchair cleanliness. The facility census was 103. Findings include: 1. Observations on 08/26/18 at 11:50 A.M. revealed ELM 2 dining room floors, tables and walls were covered with crumbs of eggs, cereal and sugar. The left side walls had splattered marks on it and the right-side walls had large scrapes on wall that exposed the drywall and left marks. Observations on 08/26/18 at 12:20 P.M., revealed State tested Nurse Aide (STNA) #2 assisted residents to ELM 2 dining room. The dining room was not clean and continued to be dirty with breakfast debris on the floor. From 12:30 P.M. to 1:30 P.M., Residents #10, #21, #31, #50, #60, #62, and #95 were eating in the dining room. Interview on 08/26/18 at 11:50 A.M., revealed STNA #2 stated housekeeping was responsible for cleaning the dining room after each meal. STNA #2 verified findings. Interview on 08/28/18 at 11:40 A. M., revealed Housekeeping (HK #83) stated she worked that weekend and explained her duties are to clean the dining room after each meal. HK #83 stated she did get to the dining room shortly after lunch. HK #83 stated she is responsible for cleaning the tables, floors and walls. Interview on 08/29/18 at 3:00 P.M., revealed Housekeeping Supervisor (HSK #65) stated all dining rooms are to be cleaned before a residents eat their next meal. 2. Observations on 08/26/18 at 9:50 A.M., on 08/26/18 2:30 P.M., on 08/27/18 at 5:30 P.M., on 08/28/18 4:15 P.M. and on 08/29/18 at 3:10 P.M., revealed Resident #4 sitting in wheelchair. The wheelchair had food with scattered debris and spill splatters particularly on right side at the bottom of wheelchair. Resident #4 body is positioned to lean to the right side of the wheelchair. Interview on 08/29/18 at 3:00 P.M., revealed State tested Nursing Assistant (STNA) #33 stated Resident #4 wheelchair is cleaned at night on his shower days Tuesday and Fridays. STNA #33 reported Resident #4 is constantly getting food and spilling things on the side of his wheelchair. STNA #33 reported she cleans the wheelchair periodically in between shower days. Interview on 08/29/18 at 5:30 P.M., revealed Director of Nursing (DON) verified Resident's #4 wheelchair was dirty. DON stated Resident #4 wheelchair is cleaned on Tuesdays and Fridays. DON verified findings.

Based on medical records, observations and staff interviews, the facility failed to ensure Resident #19's call light was within their reach. This affected one (#19) out of five residents reviewed for concerns with environment. The facility census is 103. Findings include: Review of Resident's #19 medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS) for Resident #19 dated 05/27/18 identified with severely impaired cognitive skills, having unclear speech, usually understanding others, sometimes understood by others, assistance of one staff person to complete all activities of daily living. Observations on 08/26/18 at 12:44 P.M., on 08/27/18 at 6:10 P.M., on 08/28/19 at 2:10 P.M., and on 08/29/18 revealed Resident #19 was sitting in recliner chair in bedroom. Further observations revealed the resident's call light was placed across the room being out of reach for resident. Interview on 08/28/18 at 4:00 P.M., revealed Director of Nursing (DON) verified call light system not in reach for Resident #19 and Resident #64. Interview on 08/29/18 at 3:00 P.M., revealed Maintenance Director (MD) #41 stated the facility can find something to extend the call light so that Resident #19 would be able to use it.

Based on medical record review, observation, and staff and resident interview, the facility failed to ensure a resident was afforded with the choice of when to get out of bed. This affected one (#58) of one reviewed for choices. The facility census was 103. Findings include: Review of the medical record revealed Resident #58 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #58 has minimal cognitive impairment, depression, is independent with locomotion and eating, however requires extensive assistance with bed mobility, toileting, personal hygiene, and total dependence with transfers. Interview conducted on 08/26/18 at 10:21 A.M. with Resident #58 revealed she could not decide when she would like to get up out of the bed. Resident #58 stated she is always told there is not enough staff to get her up. Interview and observation conducted on 08/28/18 at 12:05 P.M. Resident #58 stated she had asked Licensed Practical Nurse (LPN) #76 for assistance getting out of the bed at 11:45 A.M. she stated she would send in the aid. Resident #58 stated State tested Nurses Assistant (STNA) #2 then came into her room and said she could not get me up because she did not have any help, the other aid was busy. Resident #58 stated LPN #76 then came back into her room and stated she would try to help her get up if she had time later after she got caught up with her task. Interview conducted on 08/28/18 at 12:10 P.M. LPN #76 stated Resident #58 requested around 11:40 A.M. to 11:45 A.M. if she would talk to the STNA and get her up before lunch. LPN #76 stated both aids were provided care for other residents at that moment, then they would have to pass lunch trays, and she was busy with her medication pass, but afterwards she would help an aid come and get her out of the bed. LPN #76 stated staff gave Resident #58 a list of time frames when she could call out and easily get assistance getting up. Interview conducted on 08/28/18 at 12:36 P.M. STNA #2 stated the nurse informed her around 11:45 A.M. that Resident #58 was requesting assistance getting out of bed. STNA #2 stated she had just finished up assisting another resident with personal care and then she had to pass the lunch trays, and she told Resident #58 she could not get her up at that time. STNA #2 stated Resident #58 is aware she is to call out after 10:00 A.M. when they are finished with breakfast, 3:00 P.M. after lunch is done, or before supper, if she would like assistance with getting out of bed. Observation conducted on 08/28/18 at 1:20 P.M. Resident #58 was observed getting assisted out of bed into her wheelchair. Interview conducted on 08/29/18 at 8:11 A.M. Corporate Nurse #105 stated she would expect staff to follow basic residents rights, and the resident has the right to get up and or lay down in bed when they wish. The facility does not have a policy for the issue, it is a basic resident right and she would expect staff to follow those rights.

Based on medical record review, staff interviews and policy review, the facility failed to ensure resident Advance Directives were signed by the physician for two residents (#44 and #48). Additionally, the facility failed to ensure the computerized medical record and the paper/hard chart accurately reflected Resident #81's code status. This affected three #41, #48 and #81) out of three residents reviewed for Advanced Directives. The facility census was 103. Findings include: 1. Resident #44 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed an Advance Directive on the chart as Do Not Resuscitate with Comfort Care Measures (DNRCC) signed by the Resident #44's power of attorney (POA) but not signed by a physician. An interview on [DATE] at 9:31 AM with Licensed Practical Nurse (LPN) #1 verified the Advance Directive form on the chart was not signed by the physician. 2. Resident #48 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A medical record review revealed an Advance Directive was on Resident #48's chart with DNRCC selected but there was no physician signature on the form. An interview on [DATE] at 9:31 AM with LPN #1 verified the Advance Directive on the chart was not signed by the physician or guardian and that if the resident were to code, she would initiate cardio-pulmonary resuscitation (CPR). LPN #1 stated the facility has tried to call the guardian a couple of times with no success. 3. Medical record review for Resident #81 revealed an admission date of [DATE]. Medical [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #81 had no cognitive impairment and required extensive assistance for bed mobility, transfers, dressing, toilet use and personal hygiene. Review of the medical record hard chart for Resident #81 revealed a signed Advanced Directive Do Not Resuscitate Form which was marked Do Not Resuscitate Comfort Care Arrest (DNRCCA). Review of the electronic charting system revealed an order for [REDACTED]. Interview on [DATE] at 9:43 A.M. with Licensed Practical Nurse (LPN) #42 who verified the signed Advanced Directive Form in the hard chart stated DNRCCA and the electronic charting system had an incorrect advance directive code status of DNRCC. Review of the facility policy titled, Resident's Rights: Treatment and Advance Directives, revealed on admission, the facility will determine if the resident has executed an Advance Directive and if not, determine whether the resident would like to formulate an Advance Directive. Upon admission, should the resident have an Advance Directive, copies will be made and placed on the chart as well as communicated to the staff.

Based on medical record review and staff interview, the facility failed to issue a Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) to one resident who was cut from Medicare Part A Services and remained in the facility. This affected one (#92) out of three reviewed for liability notices. The facility census was 103. Findings include: Medical record review revealed Resident #92 was admitted [DATE]. Medical [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #92 had moderate cognitive impairment. Review of the beneficiary worksheet for Resident #92 revealed a Notice of Medicare Provider Non-Coverage (NOMNC) which stated skilled services ended 08/10/18 and was signed by the resident's authorized representative on 08/06/18. Resident #92 remained in the facility and did not receive the SNFABN as per Centers for Medicare & Medicaid Guidelines. Interview on 08/28/18 at 4:16 P.M. with Licensed Social Worker (LSW) #97 who verified Resident #92 should have received the SNFABN in addition to the NOMNC since she remained in the facility after the Medicare cut.