Every finding on record at Riverview Pointe Care Center

Based on kitchen observation, staff interview, review of cleaning schedules and policy review, the facility failed to maintain a clean and sanitary kitchen area and failed to ensure appropriate storage of food. This had the potential to affect all residents residing in the facility. The facility did not identify any residents with a nothing by mouth (NPO) diet order. The facility census was 115. Findings include:Observation of the facility kitchen on 09/15/25 at 8:15 A.M. revealed inside the walk-in freezer there was a box of brown rice and a stack of boxes on top of a box of potato pancakes on the floor. There was also a box of chicken tenders left open to air. Observation inside the walk-in refrigerator revealed half of a pork loin wrapped in plastic wrap resting on top of a container of watermelon chunks also covered in plastic wrap. The pork loin was observed to have released blood and juices onto the container of watermelon. The pork loin was not labeled or dated. There was a spill on the floor of the walk-in refrigerator that appeared to be a clear liquid. There were also several plastic lids and various debris on the floor of the walk-in refrigerator. Observation of a preparation table next to the ice machine revealed a can opener with dried spills on the table. Throughout the kitchen there were various food debris and splatters on food prep tables and equipment. Observation of the preparation sinks across from the ice machine revealed various food debris left in the sink. Observation of dish machine area revealed various food debris and splatter on walls and equipment. The flooring throughout the kitchen was sticky with various food debris and crumbs. The flooring was a light gray color with significant dark/black buildup. Observation of deep fryer revealed the oil was dark and unable to be seen through. There was food debris floating in the oil. There were splatters of oil down front and sides of the equipment. The floors surrounding the deep fryer were slippery. Observation of equipment including range, convection oven, fryer, and tilt skillet revealed dried food splatter and debris. The grates of the range were dark with grease buildup and had various food debris on top. Observation of a reach in cooler revealed a plastic container with two open packages of Canadian bacon with no label or date and a half bag of shredded lettuce with no label and date. The lettuce appeared to be rotten and had an odor. Observation of reach in coolers and freezers throughout the kitchen revealed dried food splatters on the outside and various food debris inside. The handles were sticky to touch. Observation of the dry storage room revealed various debris including cardboard pieces and tape on the floor. Findings were verified with the Licensed Nursing Home Administrator (LNHA) and Diet Tech #879 at the time of the observation. All findings were verified 09/15/25 by 8:30 A.M. Diet Tech #879 indicated she does monthly sanitation audits and had identified some kitchen cleanliness concerns in recent months. Review of the facility policy Dietary/Food Handling dated October 2022 revealed employees shall maintain a clean and sanitary work environment following manufacturing guidelines and Ohio Food Code. Review of the undated Daily Cleaning List: Kitchen Cook revealed insides of coolers would be cleaned on Mondays, the tilt skillet and stove top would be cleaned on Wednesdays, the oven would be cleaned and cooler/freezer would be organized on Thursdays, the fryer and sinks would be cleaned on Fridays, the flat top grill would be cleaned on Saturdays, and labeling and dating in coolers and sweeping/mopping floors on Sundays.

Based on observation, staff interview and review of the facility policy, the facility failed to maintain infection control practices during meal service. This affected five (Residents #28, #32, #67, #03 and #15) had the potential to affect 13 additional (Residents #08, #14, #37, #48, #51, #66, #68, #78, #84, #98, #102, #119 and #130) who received meals from the [NAME] Gardens Hall (KGH) kitchenette. The facility census was 115. Findings include:Observation on 09/15/25 at 12:12 P.M. revealed Certified Nursing Assistant (CNA) #825 entered Resident #28's room with a lunch meal tray. CNA #825 moved things on the bedside table to make room for the meal tray. She used Resident #28's facility phone to make an outside call for Resident #28. CNA #825 then used the bed remote to elevate the head of the bed. CNA #825 then cut Resident #28's food and left the room. At 12:15 P.M., CNA #825 went to the kitchenette on KGH and got another tray without cleansing her hands. She got a meal tray for Resident #32 and took it to her room. Before setting the tray on the bedside table, CNA #825 moved a cup of water. CNA #825 then set the tray down, opened all the containers then cut Resident #32's food. CNA #825 left the room and went to the KGH kitchenette where she washed her hands before getting a new meal tray. CNA #825 took the new meal tray to Resident #67's room. After setting the meal tray on the bedside table, CNA #825 cut her food and opened a can of soda, left the room and returned to the KGH kitchenette. CNA #825 did not wash her hands. In the kitchenette on KGH, she got a cup and filled it with coffee and cream then got the next meal tray and took it to Resident #03. CNA #825 put a clothing protector on him and opened all the lids on his food, cut his food and buttered the roll. She shut his door per his request. CNA #825 washed her hands in the KGH kitchenette. She obtained a cup of hot tea and honey then got a new meal tray. She took the meal tray to Resident #15. Before setting the meal tray down, CNA #825 moved eyeglasses and a drink then pulled Resident #15 up in bed by pulling on the pad under her standing at the head of the bed. CNA #825 used the remote to raise the head of the bed and applied a clothing protector. CNA #825 opened all the lids on her food containers then cut up her food. In the KGH kitchenette CNA #825 washed her hands. Interview on 09/15/25 at 12:32 P.M. CNA #825 was asked when she cleanses her hands when passing meal trays, she replied, after every third resident. She verified she did not cleanse her hands after every resident. Review of the facility policy, Infection Prevention and Control Program (IPCP), dated 11/28/17, revealed the hand hygiene protocol required staff to perform hand hygiene between resident contacts and per facility's established hand hygiene procedure.

Based on medical record review, observation and interview, the facility failed to ensure orders for splints were obtained for Resident #107, who was known to have impairments of range of motion (ROM) to bilateral upper extremities. This affected one (Resident #107) of two residents reviewed for positioning and mobility. The facility census was 115. Findings include:Review of the medical record for Resident #107 revealed an admission date of 04/28/24 with diagnoses including Multiple Sclerosis (MS), contracture of unspecified joint, and restless legs syndrome. Review of the care plan dated 01/02/25 revealed Resident #107 may require assistance with activities of daily living (ADL) related to disease process and condition including MS. Interventions included to provide necessary adaptive equipment to meet daily needs, half side rail for bed mobility, total assistance for ADL, mechanical lift for transfers, and notify therapy of any declines in condition. There was no plan of care to directly address limitations of ROM or hand splints. Review of the Occupational Therapy (OT) Evaluation and Plan of Treatment dated 06/05/25 revealed Resident #107 had bilateral upper extremity contractures, was dependent on staff or all ADL, and had diagnosis of progressive MS. Resident #107 had ROM impairments of bilateral elbows, wrist, and fingers. Resident #107 was noted to have impairments of dexterity, fine motor coordination, mobility and strength limitations which resulted in limitations in areas of self-care and general tasks. OT services to develop and instruct on adaptation techniques, compensatory strategies, facilitate independence with ADL, and assess safety with adaptive equipment. It was recommended Resident #107 wear a palmar guard and to further assess, order, and fabricate other splints. Review of the OT Treatment Encounter Notes from 06/05/25 to 06/18/25 revealed Resident #107 was educated on adaptive equipment to increase independence. Resident #107 practiced ROM techniques with therapy. Review of the OT Discharge summary dated [DATE] revealed Resident #107 was dependent for grasping and holding items. Resident #107 was agreeable to ROM and acquiring adaptive equipment. The adaptive equipment was not specified. It was noted Resident #107's prognosis was good with consistent staff follow-through. Review of the progress notes from June 2025 to September 2025 revealed no evidence of application of hand splints, refusals of such splints, or contraindications to hand splints. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #107 had intact cognition with no noted behaviors. Resident #107 had ROM impairments to bilateral upper and lower extremities. Resident #107 was dependent on staff for ADL. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for August 2025 and September 2025 revealed no evidence of staff applying hand braces to Resident #107 or refusals of such splints. Observation and interview on 09/16/25 at 9:08 A.M. with Resident #107 revealed she reported she felt her arms and hands were more contracted from the last time she received therapy services. Resident #107 reported her hands hurt, and she tried to stretch them herself. Resident #107 stated she had two hand braces that she would have to ask staff to put on her. At the time of interview, Resident #107's left arm was bent at the elbow and brought up to her chest under her neck. Resident #107's hands were visibly contracted. Resident #107's hand splints were hanging on the bed rail. Review of the physician's orders on 09/17/25 revealed there was no evidence of physician's order for hand splints. Interview on 09/18/25 at 7:53 A.M. with Licensed Practical Nurse (LPN) #800 revealed Resident #107 did have ROM issues with her hands. LPN #800 indicated Resident #107 was able to use her right hand more than the left. LPN #800 confirmed Resident #107 had hand splints. LPN #800 indicated staff always offered the hand splints; however, at times, Resident #107 would refuse them. LPN #800 reviewed the physician's orders and verified there was no order for hand splints for Resident #107. Interview on 09/18/25 at 10:51 A.M. with Rehab Director #957 confirmed Resident #107 had been working with therapy on use of hand splints. Rehab Director #957 indicated there was not a discharge order written for hand splints. Rehab Director #957 indicated the hand splints already had Resident #107's name on them, so they left them in her room. Rehab Director #957 indicated there would be no harm caused to Resident #107 by wearing the splints. A physician's order was obtained on 09/18/25 for the splints. Interview on 09/18/25 at 12:58 P.M. with the Director of Nursing (DON) indicated nursing staff should not be applying hand splints without a physician's order. The DON indicated there were no contraindications to the hand splints for Resident #107. Interview on 09/18/25 at 1:55 P.M. with the Licensed Nursing Home Administrator (LNHA) revealed the facility did not have a policy for splints or contracture management.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on review of a facility self-reported incident (SRI), review of facility investigation, review of pharmacy packing slips, review of electronic medication storage (Cubex) sign in logs, staff interview, review of the policy, and review of corrective action, the facility failed to ensure controlled substances (narcotics) received in the facility were accurately recorded and stored according to policy. This had the potential to affect 20 of 20 residents who receive narcotics. The facility census was 118. Findings include: Review of a facility self-reported incident report dated 11/03/23, indicated the facility pharmacy notified the facility Director of Nursing (DON) that during a routine audit on 11/03/23, the pharmacist found there were four oxycodone five milligram (mg) tabs and one Ambien five mg tab unaccounted for in the in-house starter kit. The in-house starter kit is in the electronic Cubex (a locked cabinet with individual sections for each medication). The medications (oxycodone and Ambien) were signed for received on the pharmacy manifest on 10/27/23 by Licensed Practical Nurse (LPN) #259. Medications were to be used for facility stock medications. LPN #259 was suspended, and an in-house investigation was completed by DON. On 11/08/23, the investigation was completed. Based on the facility investigation, the facility was unable to substantiate that misappropriation occurred. Review of the facility investigation into the incident revealed LPN #259 went to the drug testing center and produced a negative drug screen. LPN #259 signed a statement (reviewed) dated 11/06/23 confirming she worked the night shift on 10/26/23 through 10/27/23. The statement stated LPN #259 signed for the pharmacy delivery at 2:00 A.M. LPN #259 revealed in the statement that she did not witness any ambien or oxycodone in the delivery and did not recall seeing any packets or cards with those specific medications. Three additional nurses who worked the night shift on 10/26/23 through 10/27/23 (LPN #229, #247, and #213) were also interviewed and made written statements revealing they also did not see the medication. The emergency supply of controlled substances was audited by the DON, and none were missing. Select residents were interviewed in regard to their experience receiving proper medication and timely medication, no unique findings were noted. Pharmacy noted they reported the missing medications to the pharmacy board. Review of the summary of investigation indicated the allegation of misappropriation was unsubstantiated. Review of the pharmacy packing slip included facility name and dated 10/26/23. The pharmacy packing slip also included Cubex four oxycodone tab five mg and one zolpidem (ambien) five mg. Below the named medications was a statement that read: By signing below you acknowledge that the items above have been received. Below the stated statement was LPN #259's signature. Review of the Cubex medication sign in form dated 10/27/23 revealed the Ambien five mg one tab and the oxycodone five mg four tabs were not signed into the Cubex system. Interview on 11/21/23 at 1:21 P.M., with DON, revealed on 10/27/23 at 2:00 A.M., LPN #259 received a delivery from pharmacy. There were multiple medications including narcotics that were delivered. LPN #259 took the medications delivered and placed them in her medication cart. Once LPN #259 had opened the bag of narcotics, she did not recall seeing the ambien or oxycodone. There were multiple medications including additional narcotics that were accounted for. The facility had no further incidents of missing medications including narcotics. Review of the policy titled; Controlled Substances dated 06/21/17, revealed all controlled medications are delivered to the facility in tamper evident packaging. The authorized individual receiving the medication must verify the contents, quantity, and sign the packaging slip in the presence of the driver. A copy of the packaging slip shall be returned to the pharmacy with the driver. The authorized individual places the new Controlled Drug Receipt/Record/Disposition Form into the logbook. Included are the prescription number, resident's name, and medication for each sheet added or deleted. An authorized individual immediately places the controlled medication into the appropriate storage location. A note at the bottom of the policy in bold print indicated: Note: Controlled Medications must be counted and reconciled with the packing slip, WHILE the driver is present. Discrepancies must be reported to the Pharmacy immediately by phone. As a result of the incident, the facility took the following actions to correct the deficient practice by 11/08/23: On 11/03/23, immediate removal of LPN #259 from the schedule until the investigation was completed. On 11/03/23, LPN #259 received training by the DON on Pharmacy chain of custody procedures. If medications did not match the manifest, immediately notify the pharmacy and DON. Immediately stock all narcotic medications into proper storage (cubex or narcotic drawer) upon receipt. On 11/03/23, residents utilizing narcotics were interviewed and had no concerns related to medications. On 11/03/23, All nurses in the facility were in-service on the Facility Receipt of Controlled Substance: Chain of Custody Process, by DON. On 11/05/23, A controlled substance chain of custody audit was initiated by the DON, on three random residents weekly for two weeks and results will be reported to the Interdisciplinary Team. Review of 11/12/23 and 11/19/23 audits revealed no concerns. On 11/06/23, three additional LPN's who worked the night shift on 10/26/23-10/27/23 were interviewed and were not aware of any delivered oxycodone or Ambien. On 11/08/23, the facility completed investigation of misappropriation. Interview on 11/21/23 between 11:45 A.M. and 11:55 A.M., with Registered Nurse (RN) #304, LPN #282 and #345 verified they received training on 11/03/23 regarding receipt and processing controlled drugs. RN #304, LPN #282 and #345 were able to state the correct process. Review of three (#86, #71, and #100) sampled resident's medical records, who receive narcotics revealed no concern with having narcotics available and receiving them. Review of narcotic logs compared to narcotics in cart revealed no discrepancies on 11/21/23. This deficiency was an incidental finding representing noncompliance while investigating Master Complaint Number OH00147905, and Complaint Number OH00147853 and OH00147845.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, medical record review, witness statements, policy review and interview, the facility failed to assure a physical restraint was used for treatment of a medical symptoms rather than staff convenience for Resident #65. This affected one (Resident #65) of three residents reviewed for restraints. The census was 121. Findings include: Review of the medical record for Resident #65 revealed an admitted [DATE] with diagnoses of dementia with anxiety, anxiety disorder, depression, aphasia, and hemiplegia and hemiparesis following cerebral infarction affecting the right side. Review of the Minimum Data Set (MDS) 3.0 admission assessment dated [DATE] revealed Resident #65 had short and long-term memory problems, was moderately impaired with daily decision making, needed extensive assistance of two-person physical assistance to walk in her room and use a cane/crutch or wheelchair for mobility. Review of the cognitive function care plan dated 08/15/23 revealed Resident #65 had impaired cognitive function due to altered dementia, cerebral vascular accident (CVA), infection, unable to make safe decisions, and experiences of confusion and periods of restlessness. Interventions included to provide a calm and relaxing environment and be patient with the resident. There was no invention to restrain the resident. Review of the fall care plan updated 08/23/23 revealed Resident #65 was at risk for falls due to acute/unstable medication condition, debilitation, weakness, dementia, impaired cognition, infection, memory impairments, poor decision-making skills, restlessness and impulsiveness. There was no invention to restrain the resident. Review of the physician orders from August 2023 revealed there was no order to physically restrain Resident #65. Review of a witness statement dated 08/15/23 authored by Licensed Practical Nurse (LPN) #8 revealed, Resident #65 was very anxious and trying to get out of bed several times, so we put her in the wheelchair for a change of scenery. She then kept trying to get out of the wheelchair. I became worried for her safety when I would have to leave the unit. I put a sheet on her and lightly tied it to where she could stand if she wanted to but as a reminder to not stand. Review of the witness statement dated 08/15/23 authored by State tested Nurse Aide (STNA) #7 revealed, on Sunday 08/13/23 during night shift, I worked Pleasant Valley with LPN #8. We heard alarm sounding again. We went to the room. LPN #8 used a sheet to keep the resident in the chair. I told her I didn't think she could do that. She brought the resident in the hall by the lounge where we could see her. Observation on 09/06/23 at 8:27 A.M. revealed Resident #65 was lying in a low bed, with the left side of her bed against the wall and a mattress to the right side of the bed. Interview, during the observation, with Resident #65 was attempted however unsuccessful due to cognitive impairment. Interview on 09/06/23 at 8:39 A.M. with Registered Nurse (RN) #4 revealed Resident #65 had been at the facility for a month. Resident #65 had recently had a stroke and was paralyzed on the right side. Resident #65 was very anxious and attempted to get up by herself. RN #4 revealed LPN #8 admitted to RN #4 that she could not get Resident #65 to calm down, so she took a sheet and tied her to the chair. Interview on 09/06/23 at 11:00 A.M. with LPN #8 revealed Resident #65 was very, very confused when she first admitted and wanted to communicate however she was unable to. Resident #65 was very restless and would try to stand up to walk when she first arrived at the facility. LPN #8 verified she applied a sheet to Resident #65's lap and tied the ends of the sheet behind the wheelchair in a loose knot to act as reminder not to get up from the chair. LPN #8 did this because she was afraid Resident #65 was going to fall. LPN #8 verified she did not obtain a physician order for the restraint (sheet applied to Resident #65's lap with the ends of the sheet tied in a knot behind the back of the wheelchair to prevent Resident #65 from rising from the wheelchair). Interview on 09/06/23 at 12:35 P.M. with STNA #7 revealed on the night of 08/12/23 into the morning of 08/13/23, STNA #7 got pulled from another hall to work on Pleasant Valley (where Resident #65 resided). STNA #7 was returning from a break when she heard an alarm sounding and saw LPN #8 and another STNA enter Resident #65's room. Resident #65 was trying to stand and LPN #8 assisted Resident #65 into the wheelchair and wheeled her out to the nursing station. LPN #8 had placed a sheet over Resident #65's stomach, took the ends of the sheet and tied a tight knot behind the back of the wheelchair. STNA #7 stated the knot was tied very tight and Resident #65 was struggling in the seat because the sheet was tight up against the resident. STNA #7 stated Resident #65 was unable to untie the knot to get up. Interview on 09/06/23 at 12:48 P.M. with STNA #10 revealed STNA #7 asked STNA #10 to assist with check and changing residents on the Pleasant Valley unit when STNA #10 observed Resident #65 being restrained with a sheet across Resident #65's breast down to her stomach with the ends of the sheet tied tight behind the back of the wheelchair. STNA #10 revealed Resident #65 was crying as she tried to get out of the sheet while sitting by the nurses' station. Observation on 09/06/23 at 1:00 P.M. with the Administrator and Director of Nursing (DON) revealed of a picture of the back of a female resident while sitting in a wheelchair near the nurse's station. The picture showed a folded sheet tightly secured around the backrest of the wheelchair and the ends tightly tied in a knot around the back of the backrest of wheelchair. The resident in the picture appeared to be Resident #65. Interview on 09/06/23 at 1:00 P.M. with the Administrator and DON revealed they were aware of a sheet being used on Resident #65 while she was sitting in a chair. The Administrator and DON said after investigating, the evidence was inconclusive as to whether the sheet was acting as a physical restraint for Resident #65. The DON verified LPN #8 did not obtain a physician order to use a sheet tied behind Resident #65's wheelchair and verified a restraint assessment was not completed for use of the sheet tied behind the wheelchair for Resident #65. Follow up interview on 09/06/23 at 1:20 P.M. with the Administrator verified she was aware that two STNAs observed the sheet tied behind the back of the wheelchair for Resident #65. Review of the facility's Restraint Use policy dated 06/20/15 revealed the facility created and maintained an environment that fostered minimal use of restraints. Physical restraints were defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual could not remove easily which restricted freedom of movement or normal access to one's body. The need of each resident for restraint use was assessed upon admission and as needed. Informed consent for the physical restraint would be obtained from the resident or the legal representative. The plan of care for restraint use as well as the potential risks and benefits would be discussed. A physician's order for the restraint would be obtained. The deficient practice was corrected on 08/17/23 when the facility implemented the following corrective actions: On 08/15/23, all nursing staff was educated on restraint use by the DON/designee. On 08/15/23, an audit of all residents was completed which included a skin check and/or interview. On 08/15/23, LPN #8 was educated on using an inappropriate safety intervention by the DON. On 08/17/23, LPN #8 completed two continuing education modules on Falls in Senior Care: Exploring Prevention, Causes and Treatment and Behavior Management Strategies for Cognitively Impaired Residents. On 08/22/23 and on 08/28/23, a weekly audit of three residents for restraint use was conducted with no concerns by the DON/designee. The audit would continue for another two weeks. On 08/25/23, all nurses were reeducated on restraint use during the nurses meeting by the DON. On 09/06/23, observations revealed no restraint use. This deficiency represents non-compliance investigated under Complaint Number OH00145733.

Based on observation, record review and interview the facility failed to maintain adequate infection control practices during wound care for Resident #49 to prevent the spread of infection. This affected one resident (#49) of one resident reviewed for pressure ulcer care. Findings include: Record review revealed Resident #49 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 08/07/19 revealed the resident had moderate cognitive impairment and required two or more staff to provide extensive physical assistance for mobility in bed. She had orders for daily and as-needed dressing changes. Her most recent assessment by the facility's wound-care nurse practitioner on 10/01/19 identified the resident's wound as being currently a Stage III pressure ulcer (a pressure ulcer that involves full-thickness tissue loss, but with no exposed bone, tendon, or muscle) on the coccyx which had improved since previous assessments and had no signs of infection. The surveyor observed a pressure ulcer dressing change on the coccyx for Resident #49 by Licensed Practical Nurse (LPN) #201 and LPN #202 on 10/03/19 at 9:31 [NAME]M. While staff were exposing the wound, they revealed the resident had an incontinent diarrhea bowel movement which stained both the body and wound dressing. The staff then interrupted the dressing change procedure to provide incontinence care. During this process, Resident #49 was nonverbal and did not appear to understand verbal introductions or instructions. Resident #49 scratched herself at multiple times during the procedure, including areas potentially contaminated by stool (the back and buttocks). The resident did not receive hand-washing during the observation. Upon completion of the incontinence care, the staff began to perform the wound dressing change for Resident #49. LPN #201 removed the old dressing and washed out the wound (which appeared to be a Stage III pressure ulcer) with normal saline and gauze. At that time, the wound had no sign of infection or drainage. LPN #201 then moved to the bathroom to wash her hands before applying the new dressing, while LPN #202 held Resident #49 on her side. While LPN #201 was out of eyeshot, Resident #49 reached down and scratched inside of the uncovered wound with her fingernails, then removed her hand. Following this, scant bloody drainage began coming from the wound. LPN #201 returned to the bedside and began preparation of triad cream (a wound-care cream). LPN #202 did not say anything at this time, or otherwise indicate the wound was contaminated. The surveyor intervened in the procedure at this time and asked staff what the current plan was. LPN #201 said that the wound was now cleaned, and she would apply the triad cream and continue with the dressing change. LPN #202 did not say anything. The surveyor informed LPN #201 the wound now had bloody drainage (being a change from when it was uncovered), and the resident had scratched inside it with a hand potentially contaminated with stool while LPN #201 was not present. Following surveyor intervention, facility staff washed the wound and proceeded with the resident's dressing change. The procedure concluded on 10/03/19 at 10:59 [NAME]M. The surveyor reviewed the above findings with LPN #201 on 10/03/19 at 11:00 [NAME]M. Interview with LPN #202 on 10/03/19 at 11:55 [NAME]M. revealed she stated she did not see the resident scratch the wound. Record review of the facility skin care policy, dated 12/02/15 revealed the facility was to provide needed treatment and services to promote healing and provide necessary treatments for wounds.

Based on record review, observation and interview the facility failed to prepare and stored food under sanitary conditions. This had the potential to affect all 92 residents receiving food/meal trays from the kitchen. The facility census was 92. Findings include: 1. An initial tour of the kitchen was conducted on 08/20/18 at 10:33 A.M. with Food Service Manager (FSM) #44. An industrial size, metal floor mixer was observed with splattered, dried on, white residue all along the metal splash guard that hung above the opening of the mixing bowl. Inside the mixing bowl was a red sediment. The floor mixer was uncovered and located in a passage way between the dish room and the walk-in cooler. Sitting on a steel table across from the floor mixer was a large meat slicer covered in plastic and a table top mixer. The meat slicer had small, dried pieces of food particles on the blade and base. The table top mixer was not covered and had multiple areas of chipped paint and exposed rust all over the beater shaft and splash guard positioned over the mixing bowl. There was dried, white colored residue on the beater shaft area and on the metal splash guard hanging directly over the mixing bowl. On 08/20/18 at 10:39 A.M., FSM #44 said the floor mixer and meat slicer were routinely used for the resident's food production. FSM #44 verified the equipment was not currently being used and been put away dirty. On 08/20/18 at 10:40 A.M., Cook #46 verified the table top mixer that was rusted was routinely used to mix cake batter and various desserts for the resident meals. On 08/20/18 at 10:50 A.M., Registered Dietitian #45 indicated the table top mixer would be taken out of use due to the rust and chipped paint. 2. An observation was made on 08/20/18 at 10:43 A.M. of the walk-in cooler. There was no internal thermometer in the cooler. An external thermometer on the cooler read 41 degrees Fahrenheit (F). Review of a record titled, Refrigerator Temperature Record, (MONTH) (YEAR), that hung on the outside of the cooler door revealed the documented temperatures ranged between 39 degrees F and 42 degrees F. On nine occasions the temperature was recorded at 42 degrees F. On 08/20/18 at 10:45 A.M. interview with FSM #44 said he had not realized staff were documenting 42 degree temperatures on the form. He said he would look into it and he would also put an internal thermometer in the cooler to monitor the temperatures. 3. Review of the facility policy titled, Food Temperature Preparation - CMS Interpretive Guidelines, dated (MONTH) (YEAR) said cooked foods total cooling time to 41 degrees F should not exceed 6 hours. The policy listed various time-temperature controls for food safety including poultry, meat, fish, pork and roasts. The policy stated that within two hours of cooling the food item should be cooled to at least 70 degrees F and within the next four hours the items should be cooled to at least 41 degrees F or below. An interview was conducted on 08/23/18 at 9:51 A.M. with Cook #46 who revealed that the kitchen cooks raw beef, raw chicken breasts, raw turkey and pork roasts one to two days ahead of meal service, stores those items in the cooler and reheats those items to 165 degrees F on the day of service. When the cook was asked how often he takes the temperature of the cooling process of those items after initially cooking them, Cook #46 revealed that he is not monitoring the cooling temperatures according to the policy. Cook #46 explained that after he initially cooks the items he takes a final cooking temperature and then takes another final cooking temperature after reheating the product one to two days later. An interview was conducted on 08/23/18 at 10:04 A.M. with FSM #45 who verified they were not recording cooling temperatures of the foods to be monitored for food safety.

Based on observation, interview and record review the facility failed to provide appropriate pharmaceutical services for medication administration for Resident #20. This affected one of six residents observed for medication administration. Findings include: Record review of Resident #20 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #20 was cognitively intact. Physician's orders for (MONTH) (YEAR) included medications for [MEDICAL CONDITION], muscle relaxants, and antidepressant to be taken by mouth. There were no physician's orders for Resident #20 related to being permitted/capable of unsupervised self administration of medications prepared by the nurse. Review of the current care plan dated 06/08/18 revealed no program allowing Resident #20 to be unsupervised for self-administration of medications prepared by nurse. On 08/21/18 at 8:40 A.M., License Practical Nurse (LPN) #46 prepared medications for Resident #20, including: Aptiom used for [MEDICAL CONDITION], [MEDICATION NAME], a muscle relaxant, [MEDICATION NAME], an antidepressant, and [MEDICATION NAME], for [MEDICAL CONDITION]. LPN #46 put all of the oral medications in a small plastic cup and took them to Resident #20's room. The nurse set the cup of pills down on the bedside table, walked out of the room and closed the door. LPN #46 went back to the medication cart, documented the medication pass on the computer and pushed the cart to the next resident. On 08/21/18 at 8:47 A.M., LPN #46 said Resident #20's care plan reflected his ability to take his medication without supervision. Interview on 08/21/18 at 12:05 P.M. with the Director of Nursing (DON) verified Resident #20 did not have a physician order or care plan for unsupervised self administration of medications. Interview on 08/22/18 at 4:30 P.M. with Resident #20 revealed the nurses always leave his medications with him. He said he had been taking [MEDICAL CONDITION] medications for [AGE] years and likes to take them at certain times. Review of Medication Administration Policy dated 06/21/17 revealed nurses will remain with residents while medications are swallowed.

Based on record review and staff interview the facility failed to ensure physician ordered laboratory services were completed in a timely manner. This affected one (Resident #80) of six residents reviewed for unnecessary medications. Finding include: Resident #80 was admitted to the facility 07/10/12 with [DIAGNOSES REDACTED]. Review of the physician response to pharmacy recommendations dated 03/01/18 revealed a recommendation for a lipid panel for (the) next lab draw. Review of laboratory records for Resident #80 revealed Resident #80 had lab work conducted on 03/05/18, 03/09/18, 03/12/18, 03/17/18, 03/19/18, 03/23/18, 03/28/18, 03/30/18, 04/02/18, 04/04/18, 04/05/18, 04/16/18, 04/17/18, 04/19/18, 04/30/18, 05/14/18, 05/17/18, 05/21/18, 06/01/18, 06/04/18,06/08/18, 06/11/18 and 6/14/18. Review of laboratory records revealed no lipid panels were drawn on Resident #80 during any of the lab draws until 06/16/18. Case Manager #800 verified the lack of timely follow up to laboratory recommendations during an interview on 08/22/18 at 1:45 P.M.

Based on record review and interview, the facility failed to ensure Resident #45's choice was honored for shower preference. This affected one (Resident #45) of three residents reviewed for showers. Findings include: Review of the medical record revealed Resident #45 had an original admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the 12/07/17 Minimum Data Set (MDS) 3.0 assessment indicated Resident #45 was cognitively intact and needed one person physical assistance with bathing. Review of the shower sheets and Activities of Daily Living (ADL) bathing documentation from 12/21/17 to 01/19/18 revealed Resident #45 did not receive a scheduled and desired shower on Mondays 01/01/18, 01/08/18 and 01/15/18. Interview on 01/19/18 at 7:49 A.M. with Resident #45 revealed she did not receive her desired and scheduled shower on 01/15/18 and hasn't received other desired and scheduled showers in the past. Interview on 01/19/18 at 4:00 P.M. with the Director of Nursing and Administrator verified Resident #45 did not receive a scheduled and desired shower on 01/01/18, 01/08/18 and 01/15/18. This deficiency substantiates Complaint Number OH 407.

Based on observation, record review and interview, the facility failed to ensure Resident #34 and Resident #47's ambulation plan of care was implemented. This affected two (Resident #34 and #47) of four residents reviewed for ambulation. Findings include: 1. Record review of Resident #34 revealed an original admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the 05/09/17 physician order [REDACTED].#34 to walk from resident's room to nurse's station then walk back to room daily on dayshift using wheeled walker, gait belt and wheelchair to follow. Review of the 10/31/17 physical therapy discharge summary indicated Resident #34 was recommended to complete a home exercise program. Review of the 10/30/17 resident floor care plan indicated Resident #34 was to ambulate with one-person floor staff using a wheeled walker to/from the bathroom and the dining room and Resident #34 ambulated up to 300 feet with two-wheeled walker with contact-guard-assistance and wheelchair to follow for safety. Review of the 12/21/17 Minimum Data Set (MDS) 3.0 quarterly assessment indicated Resident #34 was cognitively intact, did not walk in her room during the seven-day look back period and needed limited physical assistance of one person when walking in the corridor. Review of the October 2017 to January 2018 walk in corridor on unit activities of daily living documentation revealed Resident #34 was not walked in the corridor on the unit from 10/31/17 to 11/07/17, from 11/09/17 to 11/16/17, from 11/22/17 to 11/27/17, from 12/14/17 to 12/19/17, from 12/22/17 to 12/31/17 and from 01/06/18 to 01/12/18. Review of the December 2017 and January 2018 Treatment Administration Record (TAR) revealed there was no evidence Resident #34 was encouraged to walk from resident's room to nurse's station then walk back to room daily on dayshift using wheeled walker, gait belt and wheelchair to follow. Interview on 01/19/18 with State-tested Nurse Aide (STNA) #9 revealed when there wasn't enough staff, Resident #34 does not get assistance with ambulation as Resident #34 was scheduled to. Observation on 01/19/18 at 9:00 A.M. revealed Resident #34 was using an electronic wheelchair to transport herself from her room to the beauty shop. Interview, during the observation, with Resident #34 revealed she was not being assistance with walking because there wasn't enough staff and stated, all I want to do is walk. Resident #34 also stated she was getting better with walking but not anymore. Interview on 01/19/18 at 3:42 P.M. with Physical Therapist #21 revealed the ambulation program therapy recommendations wasn't given a set timeframe in a week it needed to be completed and the program was up to the resident and the STNA's on how they wanted to work out the program. Interview on 01/19/18 at 4:00 P.M. with the Administrator and Director of Nursing verified there was gaps of ambulation assistance provided for Resident #34. 2. Record review of Resident #47 revealed an original admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the 10/18/17 MDS 3.0 annual assessment indicated Resident #47 was cognitively intact, did not walk in her room during the seven-day look back period and needed limited physical assistance of one person to walk in the corridor. Review of 10/19/17 physical therapy discharge summary revealed Resident #47 was recommended a home exercise program. Review of the 10/17/17 resident floor care plan indicated Resident #45 was to ambulate with one-person floor staff using a wheeled walker to/from the bathroom and the dining room. Review of the October 2017 to January 2018 walk in corridor on unit activities of daily living documentation revealed Resident #47 was not walked in the corridor on the unit from 10/26/17 to 10/31/17, from 11/01/17 to 11/05/17, from 11/07/17 to 11/12/17, from 12/24/17 to 12/27/17, and from 01/01/18 to 01/06/18. Interview on 01/19/18 at 7:45 A.M. with Licensed Practical Nurse (LPN) #8 revealed Resident #47 was not getting assisted with walking like Resident #47 was supposed to. Observation on 01/19/18 at 8:50 A.M. revealed Resident #47 was self-propelling herself in a wheelchair from the dining room to her room. Interview, during the observation, with Resident #47 revealed she was supposed to be assisted with walking to and from the dining room but she wasn't getting assisted with walking. Resident #47 stated, she was losing her ability to walk and wants to walk on her own with a walker or rollator. Interview on 01/19/18 at 3:42 P.M. with Physical Therapist #21 revealed the ambulation program therapy recommendations wasn't given a set timeframe in a week it needed to be completed and the program was up to the resident and the STNA's on how they wanted to work out the program. Interview on 01/19/18 at 4:00 P.M. with the Administrator and Director of Nursing verified there was gaps of ambulation assistance provided for Resident #47. This deficiency substantiates Complaint Number OH 407.

Based on interview and record review, the facility failed to ensure Resident #2's medical record was complete, accurate and contained a functional representation of his actual experience in the facility. This affected two of five records reviewed (Residents #2 and #4). Findings include: 1. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the comprehensive assessment (MDS 3.0) dated 10/02/17 indicated he was severely cognitively impaired. He had physical behavioral symptoms directed toward others (hitting, kicking pushing etc.) on one to three days, verbal behaviors, other behavioral symptoms not directed towards others, required the extensive assistance of two plus staff for activities of daily living, had an indwelling catheter and used a wheelchair for mobility. Review of the behavior plan of care identified the problem of foul language, easily irritated by staff, socially inappropriate, refuses care, playing in feces, impulse control disorder. The interventions included to allow him to vent and validate his feelings, attempt to identify what triggers his behaviors, contact his family for support, decrease stimulation, distraction as needed, offer food and fluid as needed and re-approach at a later time. Review of the depression and anxiety plan of care indicated he had persistent anger at others. The interventions indicated to address his concerns\promptly and provide frequent reminders, allow him to express concerns and feelings through active listening, assist with relaxation techniques, attempt to work through anxieties, explore and encourage strengths, provide calm, reassuring and non-threatening environment, refer to counseling/psychiatry as needed. Review of the pre-admission screening and resident review assessment dated [DATE] indicated Resident #2 did not have a serious mental illness, specialized services were not recommended and nursing facility services were appropriate. Review of the progress notes back to August, 2017 revealed he was consistently yelling, hitting, cussing at staff and other residents. However, there was no documented evidence of the peer to peer incident that occurred with Resident #4. 2. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the comprehensive assessment (MDS 3.0) dated 09/18/17 indicated he had no memory deficits and had modified independents in daily decision making ability. Resident #4 displayed no behavioral symptoms and required supervision with activities of daily living. Review of the plan of care indicated he was at risk for bruising due to the use of a blood thinning medication. His behavior plan of care was related to non-compliance with preventive measures such as lids for his coffee. Review of the progress notes dated 11/04/17 at 7:05 P.M. indicated Resident #4's wife reported to Licensed Practical Nurse (LPN) #27 that Resident #4 reported to her that another resident grabbed his arm earlier in week resulting in bruise on his right arm. The resident did not report it to staff. The resident was unable to give an explanation to staff of the date or time. The wife said he told her it was on Tuesday 10/31/17 and he pointed to the lounge when asking where the incident happened. LPN #27 ensured the resident he was not in immediate danger. This nurse immediately notified the unit manager and the nurse practitioner. Review of the associated non pressure skin grid indicated he had a bruise on the right anterior mid arm measuring 10.5 cm x 8 cm. Interview with Resident #4 via gestures on 11/12/17 at 9:05 A.M. indicated he was trying to throw something away in the garbage can in the lounge. He was very animated as he demonstrated how another resident grabbed his arm and moved it out of the way leaving a bruise. He raised the sleeve of his shirt revealing a large fading light purple bruise. He indicated he was still fearful of the other resident. Interview with LPN #27 on 11/12/17 at 9:50 A.M. said a family member reported to her on Friday 11/03/17 Resident #2 grabbed Resident #4's arm on a Tuesday or Wednesday causing a bruise. She reported Resident #4 was non-verbal and would use gestures and try to speak only in private to his wife who visited often. LPN #27 said she called the assistant director of nursing and the director of nursing. She said the director of nursing indicated she was not sure if they could believe Resident #4. LPN #27 reported she was asked to document that Resident #4 was touched by Resident #2 and not document that he was grabbed. She could put that information in risk management so only the corporation could see it but LPN #27 said she refused and documented the situation as it was reported to her. Interview with the director of nursing (DON) on 11/12/17 at 1:14 P.M. was not sure why there was no documentation in Resident #2's record about this incident. She believed Resident #4 reached across Resident #2 to throw away his trash in effect causing the resident to react and grab. Review of the self-reported incident tracking # 4 dated 11/03/17 was reviewed. The DON's statement indicated the wife reported Resident #4 got into Resident #2's space and Resident #2 grabbed his arm. Her statement indicated the resident reported he did not feel abused and the other resident did not have intent to harm. The nurse practitioner was notified. There was an attempt to call the guardian and got no return call. The statement by the Administrator dated 11/06/17 indicated the resident felt safe in the facility and presented no further concerns. This deficiency substantiated Complaint Number OH 471.

Based on observation and interview, the facility failed to post the nurse staffing information as required. This had the potential to affect all 100 residents in the facility. Findings include: During the initial tour of the facility on 11/12/17 at 5:00 A.M. the nurse staffing information could not be located at the entrance, main reception desk or on any of the four nursing units. On 11/12/17 at 6:25 A.M. the nurse staffing information was posted. Interview with the Administrator at this time verified the nurse staffing information was now posted she was unaware it was not posted. This deficiency was cited as an incidental finding to Master Complaint Number OH 475.

Based on observation and interview, the facility failed to ensure foods and utensils were stored and served in a sanitary manner. This had the potential to affect all 96 residents who received meals from the kitchen. Findings include: 1. Observation on 06/26/17 from 9:43 A.M. to 10:07 A.M. during the initial tour of the kitchen revealed concerns related to sanitary storage of foods and utensils. A used serving scoop was sitting on top of the lid of the brown sugar container. The lid of the chicken base container was covered with dust and debris. There was an accumulation of dust on the overhang of the walk-in refrigerator with two nearby fans, capable of circulating any dislodged dust, that were blowing in the direction of the food. There was dust and debris in the bottom of the drawer where utensils were kept. There were also three pans stacked together with water condensation on the inside and outside of the pans. Dietary Manager (DM) #3 verified the above findings needed to be corrected. 2. Observation on 06/26/17 at 12:13 P.M. revealed Activities Assistant (AA) #10 served Resident #44 a room meal tray. AA #10 touched Resident #44's TV remote control, then put on gloves, and inserted four straws into four different beverages. AA #10 did not wash her hands prior to putting on the gloves. On 06/26/17 at 12:44 P.M., AA #10 verified she should have washed her hands prior to putting on gloves and inserting the straws into Resident #44's beverages. 3. Observation on 06/28/17 at 12:11 P.M. revealed Dietary Aide (DA) #7 taking temperature of foods on the steam table in the Comfort Lane dining room. DA #7 dropped an alcohol swab into a container of orange sauce, reached with her right hand (the one previously used to handle the unsanitized part of the thermometer) into the orange sauce and retrieved the alcohol swab. DA #7 threw the alcohol pad in the trash and washed her hands. At 12:14 P.M., DA #7 was about to serve the orange sauce when the surveyor intervened and Cook #8 removed the orange sauce from the steam table and discarded it.

Based on observation, interview, and policy review, the facility failed to ensure appropriate infection control practices were followed during the laundry process and when cleaning isolation rooms. This affected two (Resident #19 and #98) of two residents currently on isolation precautions and had the potential to affect all 98 residents in the facility. Findings include: Observation of Laundry Aide (LA) #1 on 06/28/17 at 9:20 A.M. revealed LA #1 with gloves on putting blankets into the washing machine. During the process the soiled blankets touched the front of her uniform. Interview with LA #1 revealed she tried but soiled items sometimes came into contact with her clothing and there were no gowns in the laundry room for her to cover herself with when handling soiled items. LA #1 verified she wore the same clothing to collect, sort and wash soiled and contaminated laundry, as she did to transport it to the clean area for drying, folding and distribution to residents. Continued interview with LA #1 on 06/28/17 at 9:23 A.M. revealed all laundry, including items soiled with blood or feces and laundry from residents on isolation precautions was sorted on the same tables. Laundry from residents on isolation precautions was placed in red isolation bags on the unit which could be put directly into the washing machine. However, LA #1 usually emptied the red isolation bags and sorted the laundry on the tables due to trash being mixed in with the laundry. LA #1 said she cleaned the table after sorting isolation laundry with a disinfectant, Klean All Neutral Cleaner. Review of the label revealed none of the ingredients listed were identified as bleach. Interview with the Environmental Services Manager (ESM) #2 on 06/28/17 at 9:39 A.M. revealed they used two disinfectants, Destroy and Klean All for the cleaning of isolation rooms. ESM #2 stated according to facility policy, these products killed all bacteria and were the only products needed to clean surfaces and floors for residents in isolation. ESM #2 confirmed neither product contained bleach. On 06/28/17 at 2:45 P.M. the Director of Nursing (DON) verified LA #1 should wear a protective gown or apron for handling of soiled items, isolation laundry bags should be placed directly and unopened into the washer, and Klean All did not contain bleach. All linens in the facility were being rewashed. On 06/28/17 at 3:42 P.M. the DON revealed there were currently two residents (Resident #19 and Resident #98) in isolation for Methicillin-resistant Staphylococcus aureus (MRSA). The DON verified surfaces in their rooms should be cleaned with a disinfectant that contained bleach. Review of the Infection Control - Laundry/ Linen policy, revised May 2015 revealed employees were to wear a gown or apron when sorting soiled linen. Review of the Isolation Room Cleaning Practice policy dated 04/30/15 revealed bleach was required for the cleaning of all surfaces of isolation rooms. This deficiency substantiates Master Complaint #OH 888.

Based on observation, interview and review of the dining procedure, the facility failed to ensure a dignified dining experience for Resident #91, Resident #66 and Resident #55. This affected three (Resident #91, Resident #66, and Resident #55) of 15 residents who took their meals in the Comfort Lane dining room. Findings include: Observation on 06/26/17 from 12:05 P.M. to 12:12 P.M. revealed Resident #91, Resident #66, and Resident #55 were all sitting at the same dining room table. State tested Nurse Aide (STNA) #4 was passing beverages to other residents in dining room. Resident #91 stated, I'm thirsty. STNA #4 replied that she was going to provide Resident #91 a beverage, but did not do so. STNA #4 and other staff members continued to pass beverages to other residents in the dining room. At 12:12 P.M., all residents in the dining room had received a beverage except for Resident #91, Resident #66 and Resident #55. Continuous observation on 06/26/17 from 12:12 P.M. to 12:36 P.M. revealed Resident #91, Resident #66, and Resident #55 still did not have a beverage. On 06/26/17 continued observation from 12:36 P.M. to 12:43 P.M. in the dining room revealed Resident #91 again stated, I'm thirsty to STNA #4. All three residents were then served a beverage which Resident #91 and Resident #55 immediately began to drink. On 06/26/17 at 12:58 P.M. STNA #4 verified Resident #91 was not served a beverage when she first requested. In fact, Resident #91, Resident #66 and Resident #55 were not served beverages until all the other residents in the dining room were served, which was nearly half an hour after Resident #91 first indicated she was thirsty. STNA #4 revealed she had been instructed not to serve beverages to Resident #91, Resident #66, and Resident #55 because they all sat at the feed table. Resident #55 was known to reach for and grab other residents' beverages. Review of the undated Proper Procedure for Dining Room Service revealed meals tickets should be checked for liquid consistency and beverages served as the residents entered the dining room.

Based on observation, interview and review of menus and instructions for pureed bread mix, the facility failed to ensure planned menus were followed and failed to ensure nutritional adequacy was maintained during preparation of pureed foods. This had the potential to affect six residents (Resident #30, #66, #70, #101, #129, and #135) who received pureed meals and 13 residents (Resident #19, #32, #44, #55, #57, #73, #87, #91, #108, #111, #113, #185, and #186) who received mechanical soft meals from the kitchen. Total facility census was 98. Findings include: 1. Review of the Wednesday lunch menu for 06/28/17 revealed residents ordered a pureed diet were supposed to receive 1/4 cup of pureed bread. Review of the pureed bread mix directions revealed, for the equivalent of eight slices of bread, use 2 cups of water and 1-1/3 cups of pureed bread mix as needed. Observation on 06/28/17 at 10:37 A.M. revealed Cook #8 preparing pureed vegetables with DM #3 present. Cook #8 scooped eight four-ounce servings of oriental vegetables into the blender, added an unmeasured amount of chicken broth, blended it together and poured the pureed oriental vegetables into a large bowl. Cook #8 then took added an unmeasured amount of pureed bread mix to the pureed vegetables and mixed it together. On 06/28/17 at 10:47 A.M. with DM #3 verified Cook #8 should have followed the instructions and measured the pureed bread mix and chicken broth accordingly to ensure appropriate nutritional adequacy was provided to residents who received pureed foods. 2. Review of the Wednesday lunch menu for 06/28/17 revealed residents ordered a mechanical soft diet would receive buttered noodles. Observation on 06/28/17 at 11:59 A.M. revealed there were no buttered noodles on the steam table as indicated on the menu. At 12:46 P.M., Dietary Aide (DA) #7 prepared to serve Resident #87 (who was ordered a mechanical soft diet) cream of rice cereal. Interview at the time with Resident #87 revealed she did not want the cream of rice cereal. DA #7 verified there were no buttered noodles on the steam table to serve. Cook #8 verified buttered noodles had not been prepared and began to do so.

Based on observation, record review, menu review and interview, the facility failed to ensure Resident #85 was served a physician-ordered therapeutic diet. This affected one (Resident #85) of four residents reviewed for nutrition. Findings include: Resident #85 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 04/03/17 Minimum Data Set (MDS) 3.0 quarterly assessment revealed Resident #85 was severely cognitively impaired, needed supervision with eating, was ordered a therapeutic diet and received [MEDICAL TREATMENT]. Review of Resident #85's [MEDICAL TREATMENT] laboratory results revealed on 04/10/17, Resident #85's potassium level was 5.4 mEq/L and on 05/08/17, Resident #85's potassium level was 5.2 mEq/L (normal potassium range is 3.5 - 5.1 mEq/L). Review of the June 2017 physician orders [REDACTED]. Review of the nutrition care plan, revised on 06/08/17, revealed Resident #85 had a potential for alteration in nutrition related to end stage [MEDICAL CONDITION]. Dietary interventions included provide a therapeutic diet as ordered by the physician. Review of the daily menu revealed residents ordered a liberal-renal diet were supposed to receive buttered pasta instead of mashed potatoes for lunch on 06/29/17 (due to the high potassium content in potatoes). Observation on 06/29/17 at 12:34 P.M. revealed Resident #85 was sitting in the dining room feeding himself lunch. Resident #85 had meatloaf, peas and mashed potatoes on his plate. On 06/29/17 at 12:36 P.M. Registered Dietitian (RD) #5 verified Resident #85 was ordered an liberal-renal diet and his potassium level was slightly elevated. The resident was served potatoes, which were potassium rich, when he should have received buttered noodles. At this time Dietary Aide #9 also verified Resident #85 was supposed to receive buttered pasta, which was available on the steam table, instead of potatoes.

Based on observation, interview and record review, the facility failed to ensure dressing changes were completed as ordered. This affected two (Residents #5 and #6) of three residents reviewed for dressing changes. Findings include: 1. Record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Date Set (MDS) 3.0 assessment dated [DATE] revealed Resident #5 was alert and oriented to person and place, able to make his needs known, and required extensive assistance of two plus staff for bed mobility and transfers. Resident #5 was admitted to the facility with two open areas on his back including the right and left scapula. Review of the physician order [REDACTED]. Review of the Skin Grid Pressure 3.0 form dated 05/09/16 revealed the left scapula pressure ulcer stage II, measured 1.4 centimeters (cm) by 1.7 cm by 0.1 cm with small amount of drainage noted and right scapula stage II pressure ulcer measured 0.3 cm x 0.4 cm x 0.1 cm with a small amount of drainage. The form was signed by the wound nurse, Licensed Practical Nurse (LPN) #10. Review of the Wound Documentation form dated May 2016 revealed a facility staff nurse had initialed the dressing change as being completed and the wound area as being assessed on Wednesday, 05/11/16. Review of the Treatment Administration Record (TAR) for May 2016, revealed the staff nurse had initialed that the dressing change was completed on 05/11/16. On Thursday 05/12/16 at 3:15 P.M. an observation with LPN #10 of the dressings on Resident #5's back revealed both the right and the left scapula dressings were dated for Monday, 05/09/16. An interview with LPN #10 on 05/12/16 at 3:20 P.M. verified that no one had completed the dressing changes as ordered on [DATE] as evidenced as her initials being the last one to have performed the dressing change on 05/09/16. She stated she was the last nurse to complete the dressing changes and assess the two pressure ulcer wounds on Resident #5 ' s back. LPN #10 stated the staff nurses were to complete the dressing changes and assess the wounds as ordered, then document when completed. LPN #10 verified the dressing change had not been completed as ordered and verified the documentation was inaccurate, stating that the nursing staff falsely documented that the dressing change was completed when it was not. Review of the facility's Nursing Policy/Procedure Manual, revised date August 2010, revealed the following: Subject: Skin: Dressing- Clean. Purpose: To prevent infection of the wound; to protect adjacent skin surfaces from irritation from wound drainage; to promote wound healing. It explained the procedures for the qualified licensed nurse to follow. When completed the nurse was to document condition of wound, dressing change and patient response in medical record. 2. Record review revealed Resident #6 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #6 was aphasic (unable to speak), never understood and never understands. She was totally dependent on three plus staff members for bed mobility, all activities of daily living, and required a mechanical lift for transfers. Resident #6 was admitted to the facility with a stage IV pressure ulcer on her coccyx. Review of the Skin Grid Pressure 3.0 form dated 05/09/16 revealed Resident #6 had a stage IV pressure ulcer to the coccyx that measured 1.2 cm by 0.7 cm by 0.7 cm and signed as being assessed by the wound nurse, LPN #10. Review of the physician order [REDACTED]. Review of the Wound Documentation form for May 2016, revealed a facility staff nurse had initialed the dressing change as being completed and the wound area as being assessed on Wednesday, 05/11/16. Review of the TAR for May 2016, revealed the staff nurse had initialed that the dressing change was completed on 05/11/16. On 05/12/16 at 3:30 P.M. an observation with the wound nurse, LPN #10 of the dressing on Resident #6's coccyx revealed it was dated for Monday, 05/09/16. An interview with LPN #10 on 05/12/16 at 3:45 P.M. verified no one had completed the ordered dressing changes on 05/11/16 as evidenced by her initials being the last one to have performed the dressing change on 05/09/16. She stated she was the last nurse to complete the dressing change and assess Resident #6's coccyx wound. This deficiency substantiates Complaint Number OH 152.

Based on observation, interview and record review, the facility failed to ensure accurate medical records. This affected two (Residents #5 and #6) of six residents' records reviewed during the complaint investigation. Findings include: 1. Record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #5 was admitted to the facility with two open areas to his back including the right and left scapula. Review of the physician order [REDACTED]. Review of the Wound Documentation form for May 2016 revealed a facility staff nurse had initialed the dressing changes as being completed and the wound areas as being assessed on Wednesday, 05/11/16. Review of theTreatment Administration Record (TAR) for May 2016, revealed the staff nurse had initialed that the dressing change was completed on 05/11/16. On 05/12/16 at 3:15 P.M. an observation with the wound nurse, Licensed Practical Nurse (LPN) #10 of the dressings on Resident #5's back revealed both the right and the left scapula dressings were dated for Monday, 05/09/16. An interview with LPN #10 on 05/12/16 at 3:20 P.M. verified no one had completed the dressing changes as ordered on [DATE] as evidenced by her initials being the last one to have performed the dressing change on 05/09/16. She stated she was the last nurse to complete the dressing changes and assess the two pressure ulcer wounds on Resident #5's back. LPN #10 verified the documentation was inaccurate because the nursing staff falsely documented that the dressing change was completed when it was not. 2. Record review revealed Resident #6 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #6 was admitted to the facility with a stage IV pressure ulcer on her coccyx. Review of Resident #6's Progress Notes revealed on 04/24/16, 05/01/16 and 05/08/16, the nurse had documented that the resident had no pressure areas and no non-pressure areas on the skin. Review of the physician order [REDACTED]. Review of the Wound Documentation form for May 2016, revealed a facility staff nurse had initialed the dressing change as being completed and the wound area as being assessed on Wednesday, 05/11/16. Review of the TAR for May 2016, revealed the staff nurse had initialed that the dressing change was completed on 05/11/16. On 05/12/16 at 3:30 P.M. an observation with the wound nurse, LPN #10, of the dressing on Resident #6's coccyx revealed it was dated for Monday, 05/09/16. An interview with LPN #10 on 05/12/16 at 3:45 P.M. verified the dressing change had not been completed as ordered and verified that the documentation was inaccurate, stating the nursing staff falsely documented that the dressing change was completed when it was not. On 05/13/15 at 2:45 P.M. an interview with LPN #10 and the Director of Nursing verified that the staff nurses were inaccurately documenting in Residents #5 and #6's records when they did not complete dressing changes and did not complete assessments of the wounds. LPN #10 verified the staff were not accurately documenting Resident #6's coccyx wounds in the medical record when the nurses documented there were no non-pressure or pressure areas in the record. This deficiency substantiates Complaint Number OH 152.