Every finding on record at Rest Haven Nursing Home

Based on record review, interview, and policy review, the facility failed to notify the physician of repeated refusals of ordered weekly weights, as required by the physician order and the resident's plan of care. This affected one resident (#4) of one resident reviewed with weekly weight orders. The facility census was 21. Findings include:Record review for Resident #4 showed an admission date of 06/30/25, with diagnoses including chronic hepatitis C, morbid obesity, and generalized anxiety disorder. The care plan revised on 07/15/25 included interventions to obtain and monitor diagnostic work as ordered and report results to the physician. A subsequent revision on 07/16/25 instructed staff to notify the physician if the resident continuously declined weight measurements.Further review of the plan of care's revealed a revision on 07/16/25, Resident #4 was at risk for complications related to liver disease related to chronic hepatitis C with an intervention including but not limited to notifying medical doctor if continuously declines to be weighed.Review of a physician order dated 08/25/25 revealed an order for weekly weights every Monday on night shift, with directive to notify the physician if the resident refused to be weighed.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #4 was cognitively intact. The resident was assessed to require total dependence on staff for toileting hygiene, shower/bathe, and transfers. This resident also did not exhibit any behaviors regarding rejection of care.Review of the medication administration record (MAR) for September 2025 through May 2026 revealed Resident #4 refused the weekly weight on 09/29/25, 10/13/25, 11/03/25, 11/10/25, 11/17/25, 12/08/25, 12/22/25, 01/05/26, 01/26/26, 02/09/26, 02/16/26, 02/23/26, 03/02/26, 03/09/26, 03/16/26, 03/23/26, 04/06/26, 04/13/26, 04/20/26, 04/27/26, 05/04/26, 05/11/26, 05/18/26 and 05/25/26. However, review of progress notes revealed no documentation that the physician had been notified of these refusals, despite repeated noncompliance with the weight order.During an interview on 05/27/26 at 1:50 P.M. Assistant Director of Nursing #140 confirmed Resident #4 had a weekly weight order since 08/25/25 and that staff failed to notify the physician of multiple documented refusals.Review of the facility's Medication Administration policy, revised 03/14/25, directed staff to report and document refusals.

Based on medical record review and staff interview, the facility failed to ensure Pre-admission Screening and Resident Reviews (PASARR) were completed and updated to reflect a new qualifying diagnosis. This affected one resident (#6) of one resident reviewed for PASARR accuracy. The facility census was 21.Findings include:Record review for Resident #6 revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, anxiety, depression, paranoid schizophrenia added on 12/31/25, alcoholic polyneuropathy, hypertension, and peripheral vascular disease.Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #6 was cognitively intact.Review of the most recent PASARR documentation provided by the facility for Resident #6 revealed it was completed prior to admission on [DATE], with no further documentation which reflected the addition of the new diagnosis.Interview with the Assistant Director of Nursing #140 on 05/27/26 at 2:29 P.M. verified a new PASARR had not been completed after discovery of a qualifying diagnosis for Resident #6.

Based on record review, interviews, and facility policy review, the facility failed to follow a physician's order to hold a dose of Coumadin (warfarin sodium) for Resident #20 after receiving a supratherapeutic International Normalized Ratio (INR) result. This failure resulted in the resident receiving an unnecessary dose of an anticoagulant despite a documented elevated INR level. This affected one resident (#20) of one resident receiving Coumadin. The facility census was 21. Findings include:Record review revealed Resident #20 was admitted on [DATE] with diagnoses including Parkinson's disease, long term anticoagulant use, alcohol dependence in remission, major depressive disorder, and generalized weakness. The plan of care revised on 10/08/25 documented chronic embolism and thrombosis related to mitral valve insufficiency and repair, with an intervention to administer medications as ordered.Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #20 was cognitively intact. The resident was assessed to require supervision or touching assistance with bed mobility and transfers, partial/moderate assistance with toileting hygiene, and substantial/maximal assistance with shower/bathe.Laboratory review revealed the INR result obtained on 05/26/26 and received at 10:19 A.M. indicated a level of 3.7, above the moderate therapeutic range of 2.0-3.0. Despite this supratherapeutic value, review of the physician order dated 05/26/26 at 1:33 P.M. showed an order for warfarin sodium 7 milligrams (mg) daily for two days. Medication Administration Record (MAR) review confirmed the resident received the 7 mg dose on 05/26/26.A progress note entered on 05/27/26 at 10:06 A.M. by Assistant Director of Nursing (ADON) #140 documented that the physician clarified the Coumadin order, directing staff to hold Coumadin for two days, then resume at 6 mg daily, and recheck the INR the following week. At 10:30 A.M., ADON #140 documented the physician was notified that the nurse had misinterpreted the order and entered it incorrectly as an increased dose instead of holding it. As a result, the resident received 7 mg of Coumadin despite the elevated INR. A STAT INR was obtained, revealing a level of 3.8. The physician was updated and ordered Coumadin to be held with an INR recheck on 05/28/26.During an interview on 05/27/26 at 1:45 P.M., ADON #140 stated Resident #20 was the only resident in the facility on Coumadin, with weekly INR draws typically performed on Tuesdays and faxed to both the facility and physician. She reported that orders were usually obtained without issue until 05/26/26, when the resident received Coumadin 7 mg despite the supratherapeutic INR. She confirmed the nurse misunderstood the order, failed to document the elevated INR or communication with the physician in a progress note, and did not question the order despite the resident's INR level. The ADON stated she was developing a more reliable system to prevent miscommunication since laboratory results were faxed to both the physician and facility. She confirmed the resident's therapeutic INR range should be between 2-3.Review of the policy Medication Administration, revised 03/14/25, showed medications must be administered as ordered and per professional standards. Review of the policy Physician, Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist Lab Notification, revised 04/18/25, directed staff to immediately notify the practitioner of INR results, fax results, document communication and resident condition, and implement new orders.

Based on record review and staff interview the facility failed to develop comprehensive resident care plans. This affected four (Residents #01 #08, #11, and #118) of eight residents reviewed for care plans. The facility census was 19 residents. Findings include: 1.Review of the medical record for Resident #118 revealed an admitted [DATE] with diagnosis including chronic obstructive pulmonary disorder (COPD), atherosclerotic heart disease, anxiety, vascular dementia with anxiety, diabetes mellitus type two, major depressive disorder, and panic disorder. Review of the admission Minimum Data Set (MDS) for Resident #118 for dated 05/02/24 the resident was cognitively impaired with verbal behaviors. Resident #118 was dependent on the staff with toileting hygiene, and showers or bathing, and required substantial to maximum assistance with bed mobility, transfers and mobility in her wheelchair. Resident #118 received antipsychotic and antidepressant medications. Review of the physician's orders for Resident #118 dated June 2024 revealed the resident had orders for Seroquel, an antipsychotic medication and Trazodone, an antidepressant medication. Review of the facility fall investigation for Resident #118 dated 05/10/24 revealed the resident had a fall without injuries while ambulating. Review of the physician's orders for Resident #118 dated June 2024 revealed the resident had orders for Seroquel, an antipsychotic medication and Trazodone, an antidepressant medication. Review of the nurse progress note for Resident #118 dated 06/17/24 timed at 5:11 A.M. revealed the resident began to yell out during morning care, was using profanity and was striking the staff and hitting, kicking and pulling the staff's hair. Staff were unable to redirect the resident. Review of the care plan for Resident #118 dated 05/16/24 revealed the resident was at risk for falls, but the care plan did not include goals or interventions. Review of the care plan for Resident #118 dated 05/16/24 revealed the resident had behaviors. but the care plan did not include target behaviors or interventions. Review of the care plan for Resident #118 dated 05/16/24 revealed the resident had the potential to be verbally aggressive, but the care plan did not include goals or interventions. Review of the care plan for Resident #118 dated 05/16/24 revealed the resident had impaired function/dementia and impaired thought processes, but the care plan did not include goals or interventions. Review of the care plan for Resident #118 dated 05/16/24 revealed the resident used psychotropic medications and antidepressant medications, but the plan of care had no goals or interventions. Interview on 06/20/24 at 9:11 A.M. with State tested Nursing Assistant (STNA) #250 confirmed target behaviors, interventions for target behaviors, and fall precautions should be listed on the resident's plan of care. Interview on 06/20/24 at 9:17 A.M. with Registered Nurse (RN) #80 confirmed target behaviors with redirection interventions and fall precautions and interventions should be found on the plan of care. Interview on 06/18/24 at 2:58 P.M. with the Director of Nursing (DON) confirmed the care plans for Resident #118 were not complete in the areas of falls, dementia care, and psychotropic medications to include goals, interventions, and target behaviors. 42728 2. Review of the medical record for Resident #01 revealed an admitted [DATE] with diagnoses including adult failure to thrive, major depressive disorder, and COPD. Review of the admission MDS assessment for Resident #01 dated 04/10/24, revealed the resident was cognitively intact and received antipsychotic medications. Review of the care plan for Resident #01 dated 04/23/24 revealed the resident used psychotropic medications, but the care plan did not include target behaviors or interventions related to the use of the medications. Review of the physician's order for Resident #01 revealed an order dated 05/01/24 for Risperdal 0.5 mg once daily and order dated 05/02/24 for Risperdal 1.0 mg once daily. Interview on 06/20/24 at 9:49 A.M. with the DON confirmed Resident #01 received antipsychotic medication but the care plan did not include target behaviors or interventions related to the use of the medication. 3. Review of the medical record for Resident #11 revealed an admitted [DATE] with diagnoses including major depressive disorder, COPD, and dementia with other behavioral disturbances. Review of the care plan for Resident #11 initiated 12/07/22 revealed it did not include a care plan addressing the use of antipsychotic medications to include target behaviors and interventions. Review of the physician's orders for Resident #11 revealed an order dated 02/25/24 for Risperdal 0.5 twice daily. Review of the quarterly MDS assessment for Resident #11 dated 04/03/24 revealed the resident was cognitively impaired and received antipsychotic medication. Interview on 06/20/24 at 9:49 A.M. with the DON confirmed Resident #11 received antipsychotic medication but the care plan did not include use of the medication, target behaviors or interventions. 33023 4. Review of the medical record for Resident #08 revealed an admitted [DATE] with diagnoses including COPD, osteoporosis, COVID-19, adult failure to thrive, dysphagia, encephalopathy, colitis, chronic kidney disease, depression, congestive heart failure, hypertension, and Alzheimer's disease. Review of the care plan for Resident #08 initiated 12/08/17 revealed there was no care plan for hospice services. Review of the MDS assessment for Resident #08 dated 02/09/24 revealed the resident had severe cognitive impairment. Review of physician's orders for Resident #08 revealed an order dated 03/26/24 for the resident to admit to hospice services. There was no terminal diagnosis included in the order. Interview on 06/18/24 at 11:17 A.M. with the DON confirmed Resident #08 received hospice services, but there was no care plan in place for the resident regarding hospice services.

Based on record review and staff interview the facility failed to complete a discharge assessments when residents were discharged to home. This affected one (Resident #12) of three discharged residents reviewed. The facility census was 19 residents. Findings include: Review of the medical record for Resident #12 revealed an admitted [DATE] with diagnoses including respiratory failure, dysphagia, depression, anemia, depression, B-cell lymphocytic leukemia, adult failure to thrive, protein-calorie malnutrition, polyosteoarthritis, and malignant neoplasm. Review of the Minimum Data Set (MDS) assessment for Resident #12 dated on 02/02/24 revealed the resident had no cognitive impairments. Review of the nurse progress note for Resident #12 dated 03/29/24 revealed the resident was discharged to home on 03/29/24. Review of the medical record for Resident #12 revealed there was discharge assessment was completed for the resident following the discharge on 03/29/24. Interview on 06/18/24 at 08:23 A.M. with the Director of Nursing (DON) confirmed the facility should have completed a discharge MDS assessment for Resident #12 following the resident's discharge from the facility on 03/29/24, but the facility had not done so.

Based on observation, medical record review and staff interview, the facility failed to maintain acceptable standards of infection of control for one (Resident #73) during pressure ulcer dressing changes. This affected one of two residents reviewed for pressure ulcers. Findings include: Review of Resident #73's medical record revealed an admission date of [DATE] with the admitting [DIAGNOSES REDACTED]. Review of the admission skin observation tool dated 10/23/19 revealed the resident was admitted to the facility with a Stage IV (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.) pressure ulcer to the right heel measuring 1.4 centimeters (cm) by 0.6 cm by 0.2 cm and a Stage I (An observable, pressure related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include changes in one or more of the following parameters: skin temperature (warmth or coolness); tissue consistency (firm or boggy); sensation (pain, itching); and/or a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues.) pressure ulcer to her left heel measuring 1.5 cm by 2.0 cm. Review of the resident's nursing admission screening/history dated 12/23/19 revealed the resident was admitted from the local acute care hospital with the [DIAGNOSES REDACTED]. She was alert and oriented to her name only. She was noted to have both long and short term memory problems, confusion and displayed both hallucinations and delusions. The assessment indicated the resident was dependent on staff for activities of daily living. Review of the baseline plan of care dated 12/23/19 revealed the resident had skin impairment upon admission to the facility. Interventions included specialized pressure reduction boots, float heels off the mattress while in bed and low air loss mattress to her bed. Review of the resident's admission physician's orders [REDACTED]. On 12/27/19 at 2:39 P.M. observation of Registered Nurse (RN) #160 provide the physician ordered treatment to the resident's right heel pressure ulcer revealed she entered the resident's room and positioned the resident. She removed the specialized pressure reduction boot pulled her sock off. She washed her hands and donned a clean pair of gloves. She then removed the soiled dressing and placed it in the trash can. She cleansed the wound with normal saline and a 4X4 gauze pad, and patted it dry. She then cut a piece of calcium alginate and placed on the wound. She then covered with the wound with a foam dressing. She then removed her gloves and dated the dressing. She replaced the sock and reapplied the specialized pressure reduction boot. RN #160 verified she did not wash her hands or change her gloves after removing the soiled dressing.

Based on observation, medical record review, staff interview and facility policy and procedure review the facility failed to ensure blood pressures and/or pulse were obtained for two residents (#2 and #15) prior to receiving antihypertensive medications as physician ordered. This affected one of four residents observed for medication administration and one of five residents reviewed for unnecessary medications. Findings include: 1. Review of Resident #15's medical record revealed an admission date of [DATE] with the admitting [DIAGNOSES REDACTED]. Review of the plan of care dated 06/23/19 revealed he was at risk for complications related to the [DIAGNOSES REDACTED]. Interventions included to administer antihypertensive medications as ordered and obtain blood pressure (BP) readings before administration of the antihypertensive medications and daily. Review of the resident's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had clear speech, understood others, made himself understood and had a moderate cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of 10. Review of the resident's monthly physician's orders [REDACTED]. Review of the (MONTH) and (MONTH) 2019 Medication Administration Record [REDACTED]. On 12/28/19 at 9:06 [NAME]M. observation of Licensed Practical Nurse (LPN) #150 administer Resident #15's morning medication revealed the LPN did not obtain a blood pressure or pulse for the resident prior to administering the medication [MEDICATION NAME]. On 12/28/19 at 10:48 [NAME]M. interview with LPN #150 verified the resident's BP and pulse was not obtained prior to administering the residents medication [MEDICATION NAME]. 2. Review of Resident #2's medical record revealed an admission date of [DATE] with the admitting [DIAGNOSES REDACTED]. Review of the resident's plan of care dated 02/24/17 revealed she had the potential for hyper/[MEDICAL CONDITION] related to [DIAGNOSES REDACTED]. Interventions included to administer antihypertensive medications as ordered. Review of the resident's quarterly MDS dated [DATE] revealed the resident had unclear speech, usually understands others, usually makes herself understood and no cognitive deficit as indicated by a BIMS score of 13. Review of the resident's monthly physician's orders [REDACTED]. Review of the (MONTH) and (MONTH) 2019 MAR indicated [REDACTED]. On 12/28/19 10:48 AM interview with LPN #150 verified the resident's BP and pulse were not obtained prior to administering the medication [MEDICATION NAME]. Review of the facility's policy titled, Medication Administration, dated 01/15/19 revealed medications are administered by licensed nurses who are legally authorized to, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Vital signs shall be obtained and recorded as per physician's orders [REDACTED].>

Based on record review, staff interview and review of the Center for Medicare and Medicaid service (CMS) Resident Assessment Instrument 3.0 manual dated 10/01/17 the facility failed to ensure all assessment data was submitted to CMS. This affected four residents (Residents #18, #70, #71, and #120) of 15 reviewed for assessments. The facility census was 22. Findings include: 1. Resident #70 was admitted to the facility on [DATE] with pertinent [DIAGNOSES REDACTED]. Review of Resident #70's medical record revealed quarterly Minimum Data Set (MDS) assessments were completed for Resident #70 on 06/11/18 and 09/18/18. There was no evidence found the MDS had never been submitted to Center for Medicare and Medicaid services (CMS). Interview with Licensed Practical Nurse (LPN) #10 on 10/18/18 at 9:56 A.M. revealed that she was in charge of submitting the MDS assessments and she was under the impression that for residents on hospice care, or private pay the assessments did not have to be submitted to CMS. LPN #10 verified that she did not send Resident #70's quarterly assessments dated 06/11/18 and 09/18/18 to CMS. 2. Resident #71 was admitted to the facility 09/11/18 with pertinent [DIAGNOSES REDACTED]. Review of Resident #71's medical record revealed an admission MDS assessment was completed on 09/20/18. There was no evidence found the MDS had never been submitted to CMS. During interview on 10/18/18 at 9:56 A.M. LPN #10 verified she did not send Resident #71's admission assessment dated [DATE] to CMS. 3. Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Brief Interview for Mental Status (BIMS) assessment, dated 10/12/18, revealed she was moderately cognitively impaired. Review of the resident's quarterly MDS dated [DATE] revealed it had been completed but not submitted to CMS. During interview on 10/18/18 at 10:05 A.M. with LPN #10 she verified Resident #18's quarterly MDS dated [DATE] had not been submitted to CMS. 4. Resident #120 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Brief Interview for Mental Status (BIMS) assessment, dated 09/01/18, revealed she was moderately cognitively impaired. Review of the resident's quarterly MDS dated [DATE] revealed it had been completed but not submitted to CMS During interview on 10/18/18 at 10:05 A.M. with LPN #10 she verified Resident #18's quarterly MDS dated [DATE] had not been submitted to CMS. Review of the CMS Resident Assessment Instrument 3.0 manual dated 10/01/17 revealed nursing homes are required to submit Omnibus Budget Reconciliation Act (OBRA) required Minimum Data Set records for all residents in Medicare-or-Medicaid certified beds regardless of pay source.

Based on record review and staff interview, the facility failed to notify all required parties regarding resident transfers. This affected two (Resident #10 and Resident #18) of two resident's reviewed for hospitalization . The facility census was 22. Findings include: 1. Record review revealed Resident #10 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's Brief Interview for Mental Status (BIMS) assessment, dated 08/27/18, revealed resident was cognitively intact. Review of the resident's nurse notes revealed she was hosptalized on [DATE] due to left flank pain, possible passed kidney stone, and hydro[DIAGNOSES REDACTED]. In review of all her medical record documentation, there was no evidence found to confirm the Long Term Care Ombudsman (LTCO) was notified of this transfer/hospitalization . On 10/18/18 at 10:28 A.M. Administrative Assistant #20 verified the facility had not sent any notification to the LTCO of Resident #10's transfer to the hospital. 2. Record review revealed Resident #18 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's Brief Interview for Mental Status (BIMS) assessment, dated 10/12/18, revealed she was moderately cognitively impaired. Review of the resident's nurse notes revealed she was hosptalized on [DATE] with a [DIAGNOSES REDACTED]. In review of all her medical record documentation, there was no evidence found to confirm the LTCO was notified of this transfer/hospitalization . During an interview on 10/18/18 at 10:28 A.M. with Administrative Assistant #20 she verified the facility had not sent any notification to the LTCO of Resident #18's transfer/hospitalization .

Based on record review and staff interview the facility failed to ensure accurate documentation of nutritional supplement intake for Resident #16. This affected one (Resident #16) of one reviewed for nutrition. The facility census was 22. Findings include: Record review of Resident #16 revealed an admission date of [DATE] with pertinent [DIAGNOSES REDACTED]. Review of a Physicians Order dated 09/23/18 revealed an order for [REDACTED]. Review of Resident #16's medical record revealed no evidence of documentation that Resident #16 received the house supplement. Interview with the Director of Nursing (DON) on 10/18/18 at 1:27 P.M. verified there was no documentation in the resident's medical record specific to intake of the house supplement. The DON stated the supplement intake was included with total fluid intake therefore, they had no way of knowing if or how much house supplement was taken.

Based on observation, record review, and staff interview the facility failed to ensure medications error rates were not greater than 5 percent. This affected one (Resident #10) of six residents reviewed for medication observation. There were two errors out of 25 opportunities for a medication error rate of eight percent. The facility census was 22. Findings include: Resident #10 was admitted to the facility on [DATE] with pertinent [DIAGNOSES REDACTED]. Review of a physician order [REDACTED]. Observation of a medication pass for Resident #10 on 10/17/18 at 8:30 A.M. revealed Licensed Practical Nurse (LPN) #12 passed seven medications [MEDICATION NAME], [MEDICATION NAME], and a menthol patch. LPN #12 verified that this was all of Resident #10's morning medications. Interview with LPN #12 on 10/17/18 at 9:29 A.M. verified that she did not administer the Linzess capsule 290 micrograms and the Potassium 10 milliequivalents tablet. LPN #12 stated she missed them.

Based on observation and staff interview the facility failed to ensure an open bottle of expired [MEDICATION NAME] medication and an open bottle of [MEDICATION NAME] medication without an expiration date were disposed of. This had the potential to affect one resident (Resident #14) who was currently receiving [MEDICATION NAME]. The facility census was 22. Findings include: Observation on [DATE] at 1:00 P.M. in the medication room revealed an opened bottle of [MEDICATION NAME] (an antidiarrheal) with an expiration date of [DATE], and an opened bottle of [MEDICATION NAME] (an [MEDICATION NAME]) with no expiration date on the bottle. Interview with Licensed Practical Nurse (LPN) #12 on [DATE] at 1:00 P.M. verified that the [MEDICATION NAME] bottle expired [DATE] and the [MEDICATION NAME] bottle had no visible expiration date on the bottle, and both medications should have been disposed of.

Based on record review, observation, and staff interview the facility failed to ensure Resident #70 received treatment as ordered to prevent further decrease in range of motion. This affected one resident (Resident #70) of two reviewed for limited range of motion. The facility census was 22. Findings include: 1. Record Review of Resident #70 revealed an admission date of [DATE] with pertinent [DIAGNOSES REDACTED]. Review of the 03/18/18 significant change Minimum Data Set (MDS) assessment revealed the resident had limited range of motion in both upper extremities. Review of a physician's orders [REDACTED].#70 was to have rolled washcloths to bilateral hands at all times. Observation on 10/16/18 at 10:42 A.M. revealed Resident #70 had contractures of both hands (were fixed in a fisted position). There was no rolled washcloth in either of her hands. Observation of Resident #70 on 10/18/18 at 1:10 P.M. again revealed she did not have rolled washcloths in either of her hands. On 10/18/18 at 1:10 P.M. the Director of Nursing (DON) verified the rolled washcloths were not in Resident #70 hands, and that she was ordered to have them at all times in both hands.

Based on observation and staff interview the facility failed to ensure nursing staff information was posted in a prominent place accessible to residents and visitors. This had the potential to affect all 22 Residents who currently resided in the facility. Findings include: Observation on 10/18/18 at 1:45 P.M. revealed no posted nursing staff information could be found in the facility to inform residents and visitors of how many licensed nurses and certified nurse aides were working and how many hours each worked for each shift on that day. Interview with the Director of Nursing (DON) on 10/18/18 at 1:50 P.M. revealed she was unaware of where the nursing staff information was posted. Interview with Employee #11 on 10/18/18 at 2:15 P.M. revealed the staffing information was posted behind the nursing station on a clipboard behind three to four other pieces of paper. Employee #11 verified it was not accessible or visible to residents or visitors.

Based on observation and staff interview the facility failed to ensure resident furnishings and linens were in good repair and safe and comfortable for all resident use. This affected all 23 residents residing in the facility. Findings include: Observation of Resident #11 on 08/07/17 at 11:03 A.M. revealed the resident was in bed asleep. The resident's bed pad was observed to be frayed and worn. Observation of the linen closet with Housekeeping Supervisor #7 on 08/10/17 at 1:36 P.M. revealed two of 10 resident bed pads were threadbare. Housekeeping Supervisor #7 stated she knew the pads were threadbare but no one told her she could throw them away and thus the facility continued to use them. Tour of the facility with Maintenance Supervisor #29 on 08/10/17 from 1:40 P.M. to 1:59 P.M. revealed the sink counter tops in Resident #1, #2, #3, #4, #5, #8, #9, #10, #11, #13, #14, #15, #16, #17, #20, #22, #23, #24, #25, #26, #28, #29, and #30 had had laminate that was cracked pulling away for the board base. Resident #11, #29 and #30 were observed to have over bed tables with edges pulling away from the side of the tables and the covering on the table tops was peeling off. Interview with Maintenance Supervisor #29 confirmed the above findings during the tour.

Based on record review and interview the facility failed to ensure Resident #8 was offered a pneumococcal vaccination and failed to ensure evidence of proof of vaccination or refusal. This affected one resident (Resident #8) of five sampled residents. Findings Include: Record review revealed Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician orders [REDACTED]. Review of Resident #8's medical record revealed the Power of Attorney (POA) signed consent for the influenza vaccine on 10/09/16 and the vaccine was administered on 10/19/16. The medical record did not contain permission or refusal to the pneumococcal vaccine. On 08/10/17 at 3:20 P.M. the Administrator confirmed Resident #8's medical record did not contain evidence Resident #8 had received the pneumococcal vaccine or whether the resident's POA had been given information to accept or decline Resident #8 receiving the pneumococcal vaccine. The Center for Disease Control (CDC) described the pneumococcal vaccine was available to help prevent pneumococcal disease, which is any type of infection caused by Streptococcus pneumoniae bacteria. The vaccine should be administered to all adults [AGE] years or older who had not received the vaccine in the past three years.

Based on record review and staff interview the facility failed to document a response to a pharmacy recommendation for renal function laboratory testing for Resident #20. This affected one resident (Resident #20) of five residents reviewed for unnecessary medication use. Findings include: Record review revealed Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a pharmacy recommendation dated 02/16/17 revealed Resident #20 had not had a renal function laboratory (lab) test completed within the past six months and to consider completing the lab. review of the resident's medical record revealed [REDACTED]. Interview with the Director of Nursing on 08/10/17 at 9:55 A.M. verified she was unable to find a response to the pharmacy recommendation or a renal function lab completed.

Based on record review and interview the facility failed to ensure Resident #17 received specialized services for an intellectual disability (ID). This affected one resident (Resident #17) of one sampled resident reviewed for preadmission screening and resident review (PASRR). The facility identified one resident who had an ID. Findings include: Review of Resident #17's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #17's PASRR dated 06/27/12 revealed she required the level of service of a nursing facility and she required specialized services for ID. Review of Resident #17's plan of care revealed she attended a sheltered workshop for a while and decided she no longer wanted to attend any longer in 2014. There was no evidence in Resident #17's medical record that she was periodically asked if she wanted to restart specialized services. Review of Resident #17's quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #17's speech was clear, she usually understood, she usually understands, and her Brief Interview of Mental Status (BIMS) score was 12, indicating moderate cognitive impairment. Interview with Resident #17 on 08/10/17 at 10:00 A.M. revealed she would like to return to the sheltered workshop. Interview with the Acting Director of Nursing (ADON) #34 on 08/10/17 at 10:45 A.M. confirmed Resident #17 currently did not receive specialized services as she had previously refused to go to the sheltered workshop in the past. Further interview with ADON #34 confirmed there was no evidence Resident #17 was asked periodically if she wanted to restart the specialized services or attend a different type of service/workshop if able.

Based on record review and interview the facility failed to develop and implement comprehensive care plans for Resident #13 related to activities and for Resident #11 related to managing behaviors. This affected two residents (Resident #11 and #13) of 12 residents reviewed for care planning. Findings include: 1. Record review revealed Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 11/07/16 revealed the resident was severely cognitively impaired and a care plan for activities was triggered and marked as it would be completed. Review of the electronic medical record on 08/09/17 revealed no documented care plan for activities. Interview with Registered Nurse (RN) #34 on 08/10/17 at 10:15 A.M. verified an activities care plan for Resident #13 should of been completed but she was unable to find it. 2. Review of Resident #11's medical record revealed the resident was admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #11's monthly physician orders [REDACTED]. Review of Resident #11's plan of care revealed the resident was physically aggressive to staff, wandered into other resident's room, and he was exit seeking. Review of the interventions revealed they were not individualized to manage Resident #11's identified behaviors. Interview of Acting Director of Nursing (ADON) #34 on 08/09/17 at 10:26 A.M. confirmed Resident #11's care plan did not specify the interventions to utilize with Resident #11 behavioral out bursts.

Based on observation, record review and interview the facility failed to ensure adequate indication for the use of psychoactive medication for Resident #11. The facility also failed to ensure non-pharmacological interventions were attempted prior to the administration of anti-anxiety and pain medication for the resident. This affected one resident (Resident #11) of five sampled residents reviewed for unnecessary medication use. Findings include Review of Resident #11's medical record revealed the resident was admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #11 entry Minimum Data Set (MDS) 3.0 assessment, dated 05/18/17 revealed his speech was unclear, he rarely/never understood, he sometimes understands, his short and long term memory were impairment, he had no recall, and severely impaired decision making. Review of Resident #11's monthly physician orders [REDACTED]. Resident #11 also had orders for pain medication, [MEDICATION NAME] every six hours as needed for pain and an anti-anxiety medication, [MEDICATION NAME] 1 mg every six hours as needed for anxiety. Review of Resident #11's plan of care revealed the resident was physically aggressive to staff, wandered into other resident's room, and he was exit seeking. Review of the interventions revealed they were generic and were not individualized to manage Resident #11's behaviors. Review of Resident #11's medication administration records (MAR) for June 2017 revealed he received one dose of [MEDICATION NAME] with no evidence of non-pharmacological interventions attempted on 06/01/17, 06/03/17, 06/04/17, 06/07/17, 06/08/17, 06/09/17, two doses on 06/15/17, 06/16/17, one dose on 06/19/17, 6/20/17, 06/21/17, 06/22/17, 06/23/17, two doses on 06/24/17, one dose on 06/25/17, 06/27/17, 06/28/17 and two dose on 06/29/17. Review of the July 2017 MAR revealed on 07/01/17 he received two doses, on 07/06/17, 07/07/17, 07/08/17, 07/24/17, and 07/30/17 with no evidence of non-pharmacological interventions attempted prior to administration of the medications. Also, Resident #11 received [MEDICATION NAME] with no evidence of non-pharmacological interventions attempted on 06/01/17, 06/02/17, 06/04/17, 06/7/17, 06/07/17, 06/08/17, 06/09/17, 06/10/17, 06/15/17, 06/17/17, 06/19/17, 06/22/17, 06/23/17, 06/24/17, 06/27/17, 06/29/17, and 06/30/17. Review of the July 2017 MAR Resident #11 revealed two doses on 07/01/17, one dose on 07/2/17/07/08/17, and 07/29/17 with no evidence of non-pharmacological interventions attempted prior to administration of the medication. Review of the August 2017 MAR revealed he received one dose on 08/06/17 with no evidence of non-pharmacological interventions attempted prior to the administration of the medication. Observation of Resident #11 on 08/08/17 at 10:36 A.M., 1:14 P.M. and 3:19 P.M. revealed the resident was in bed asleep. Interview with Registered Nurse #33 and Licensed Practical Nurses (LPN's) #10 and #28 on 08/08/17 at 3:30 P.M. revealed if a resident had a behavior it was to be entered in the electronic MAR and a note was to be written regarding his behavior. Interview of Acting Director of Nursing (ADON) #34 on 08/09/17 at 10:26 A.M. confirmed there was no evidence of non-pharmacological interventions attempted on the above dates prior to the administration of the [MEDICATION NAME] and [MEDICATION NAME]. ADON #34 also confirmed the [DIAGNOSES REDACTED]. Review of the facility's as needed pain management dated 08/25/16, revealed assess the resident's pain, administer non-pharmacological interventions.

Based on staff interview, resident interview, record review, personnel file review and hospital record review the facility failed to ensure that Resident #15 received adequate supervision and assistance to prevent a fall. This resulted in actual harm when Resident #15 was assisted by only one staff member during a transfer, fell , and sustained a fractured left femoral bone requiring surgical repair. This affected one (Resident #15) of three residents reviewed for falls. The facility census was 20. Findings include: Record review of Resident #15 revealed an admission date of [DATE] with a discharge to the hospital on [DATE]. The resident had [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #15 was cognitively intact and required extensive assistance of two plus staff for bed mobility, transfer, dressing, and toilet use. Resident #15 was not steady when moving from seated to standing position and could only stabilize with staff assistance. Resident #15 was impaired on one side in the upper and lower extremities and used a wheelchair to aid in mobility. Resident #15 was on a toileting program and was frequently incontinent of bladder and was always continent of bowel. Review of the plan of care for Resident #15 dated 10/26/16 revealed the resident had an activities of daily living self-care performance deficit related to left sided paralysis, stroke, and [DIAGNOSES REDACTED]. The goal was to maintain current level of function. Interventions included extensive assist of two staff members for toileting and transfers. Review of the plan of care for Resident #15 dated 10/26/16 revealed she was at high risk for falls related to left sided paralysis. Interview with the Resident #15 on 12/29/16 at 10:55 A.M. revealed she was supposed to be a two person transfer and on 12/17/16 State tested Nurse Aide (STNA) #10 tried to transfer her alone. During the transfer Resident #15 stated she fell and broke her leg. Resident #15 said she was in pain from the time she fell on [DATE] and the hospital did surgery and put three screws in her left leg. Review of the progress notes dated 12/19/16 at 3:10 P.M. revealed Resident #15's x-ray results of the left hip was positive for a fracture and she was to be sent to the emergency room . Review of the hospital operative report dated 12/20/16 revealed Resident #15 was extremely debilitated and had complete left sided paralysis. She had a fall being transferred and injured her left hip. Resident #15 sustained a femoral neck fracture of the left hip. She had pain associated with the fracture so she was brought to the operating room for open reduction and internal fixation in hopes of affording pain relief. Review of the Progress Notes dated 12/23/16 at 4:54 P.M. revealed Resident #15 was readmitted to the facility after her leg surgery. Interview with the Director of Nursing (DON) on 12/29/16 at 2:05 P.M. verified STNA #10 transferred Resident #15 inappropriately, without assistance, and the resident fell and sustained a leg fracture. The DON stated STNA #10 received a verbal warning and was educated on proper transfers. Review of STNA#10's personnel file revealed that on 12/18/16 she received a verbal warning for transferring a resident to/from commode to wheelchair in the shower room without assistance when the resident (Resident #15) required two person assist. This deficiency substantiates Complaint Number OH 654.