Every finding on record at Sienna Hills Nursing & Rehabilitation

Based on observation, review of a service order, review of the facility's grievance/ concern log, review of resident council meeting minutes, resident interview, and staff interview, the facility failed to ensure residents were afforded the right to a comfortable living environment by not maintaining comfortable temperature levels in the facility's shower room while residents were bathing. This had the potential to affect all but three residents (#10, #27, and #33) of the facility's 33 residents, who the facility identified as not having the use of the shared shower room. Findings include: On 04/01/25 at 10:18 A.M., an observation of the facility's only shared shower room located on the 300 hall revealed it did not have a working heater. There was a long heater that was noted to run along the back wall of the shower room that was part of the heat supplied by the facility's boilers. There was no way to turn on the wall unit that was part of the boiler system from inside the shower room. There was another 12 inch by 12 inch heater on a wall that was located to the left side of the shower room. That heater had a knob to turn, but did not function when the knob was turned in any direction. The shower room was slightly cooler than the temperature in the hallway, but staff currently had portable pedestal high velocity shop fan in the shower room that was turned on. Thermostats were checked throughout the facility in the hallways. The thermostat on the 200 hall was a manual thermostat that was behind a metal box on the wall and located about midway down the hall. The metal box was not locked and was able to be raised to access the manual thermostat. It was turned all the way down to 42 degrees Fahrenheit (F.) and was reading 68 degrees F. as the temperature in the hall. The other two halls (100 and 300) had digital thermostats and were reading 69 degrees F. On 04/10/25 at 10:19 A.M., an interview with Certified Nursing Assistant (CNA) #100 and CNA #200 revealed they were the two aides that were working that day. They reported they had already completed their (assigned resident) showers they had scheduled for that day and they included Resident #8, #9, and #28. They denied they had the portable fan on in the shower room when the residents were given their showers. It was not until after the showers had been given that they turned the fans on for their comfort. They were asked about the condition of the heater in the facility's main shower room. CNA #200 reported the smaller fan hanging on the left wall of the shower room had not worked in the past [AGE] years. She denied they were able to get any heat out of the other heating unit that was against the back wall. The CNA's reported it had been a bigger problem during the colder months and they had residents who were refusing to take a shower when scheduled due to it being too cold in the shower room. They would just have to give the residents a complete bed bath instead. She denied it was as much of a problem recently due to it being warmer outside. On 04/01/25 at 11:10 A.M., an interview with Resident #9 confirmed he was one of the residents that were given showers earlier that morning. He reported the facility has had problems with the shower room not being warm enough when he received his showers. He did not feel the shower room was either warm or cold that morning, but it had been cold in the past. He did get cold that morning when he was wet, but it was not bad in there when he was dry. He was not sure how long it had been that the heater in the shower was not working. He knew the facility had used a space heater in the past, but was told they could not use them. He commented that it would be nice to have some heat in the shower room. On 04/01/25 at 11:20 A.M., an interview with Resident #28 confirmed she had been given a shower earlier that morning. She reported it was cold in the shower room and the heater had been broke. It had been broke ever since she had been there and that had been about two years now. They did have a space heater in there, but was told it was dangerous and they had to take it out. It was really cold in there this past winter. She would take her showers anyway despite her being cold when she received them. She stated she would like it to be warmer in the shower room when she received her showers. On 04/01/25 at 11:25 A.M., an interview with Resident #8 confirmed she too received a shower earlier that morning. She did not have any concerns with the temperature of the shower room that day, but had problems over the winter with the shower room being cold. She confirmed the facility used a portable heater during the winter. She was not sure how long the heater in the shower room had been broken, she just knew it was cold in there. She would like the shower room to be warmer when she received her showers. Review of the facility's resident council meeting minutes for the past three months (01/16/25 to 03/19/25) revealed the meeting minutes for the council meeting held on 02/25/25 indicated one of the residents (Resident #28) attending that meeting stated a heater was needed in the shower room when it was cold outside. The meeting minutes did not include a response to the concern to include who was assigned that concern or what was done about it. Review of the facility's grievance/ concern log from 02/06/25 to present revealed Resident #28 voiced concern on 02/25/25 regarding wanting a heater in the shower room in colder weather. The facility's Social Service Director (SSD) was the staff member assigned to that concern. Findings from investigation revealed the heater had been inspected by an outside boiler company. A plan to restore the boiler use was indicated to be in place. On 04/01/25 at 12:18 P.M., an interview with the Administrator revealed the facility had a company come out and check the facility's heater in the shower room. They were awaiting them to come back to give them an estimate in replacing some radiator units on the 300 hall. She was asked to provide the invoice/ service order to show when the boiler company had been out to check the heating problem in the shower room. Review of the service order from an outside boiler company revealed a technician had been out to the facility on [DATE] at 9:00 A.M. He indicated he checked over the facility's boiler system. He indicated when it was very cold, a few areas in the facility were colder than others. He indicated both the 200 and the 300 hallways and rooms ran off one thermostat located in the 200 hall. A smaller area with more radiators could cause the 300 hall to not be as warm. He also indicated, at the end of the 300 hall entrance area, there were two radiators where the heat from those were no longer in use. He surmised, if that area was heated, it may help the two end rooms on the 300 hall stay warm. Also separate T-stats (thermostats). The technician recommended replacing the heaters at the end of the 300 hallway. He also recommended making two zones instead of one to make the heat more even. They could also add supplement heat in alternate cooling only or add radiator in places if short. He took a couple pictures and indicated another representative would have to come out to look at it. It did not mention anything specific to the lack of heat in the shower room, just addressing the lack of heat on the 300 hall, which is where the shower room was located. There was no documented evidence of the other representative from the boiler company returning to the facility to further address the lack of heating issue. After asking for the boiler company service order, a member of the facility's administrative staff was heard contacting the boiler company to get a representative back to the facility. On 04/01/25 at 1:30 P.M., a representative from the boiler company arrived on site and requested to speak with the facility's Administrator. He identified where he was from and informed the staff of who he was there to see. He was then heard telling the Administrator that he was there to give an estimate on the work that needed to be done to their boiler system. He referenced the service order dated 02/25/25 and informed the Administrator that it indicated a couple units were recommended to be replaced. The issue with a lack of heat in the shower room was not specifically mentioned. He left the facility around 2:05 P.M. and informed the facility's administrator that he would get back to her with their recommendations/ estimates. On 04/01/25 at 2:15 P.M., an interview with the facility's Administrator confirmed the boiler company was contacted by the facility and a representative did come out to check things out to be able to give them an estimate of the work that was needing to be done. She confirmed the facility's boiler system was controlled by a single thermostat on the 200 hall. She acknowledged that the manual thermostat on the 200 hall was noted to be turned all the way down to 42 degrees F. and was reading 68 degrees F. when it was checked during the initial tour on 04/01/25. She suspected that a resident likely turned the thermostat down, which also controlled the temperature on the 300 hall. She confirmed there was talk about replacing a couple radiator units at the end of the 300 hall that they hoped with help with the temperature in the main shower room. This deficiency represents non-compliance investigated under Complaint Number OH00163435 and Complaint Number OH00162782.

Based on record review, review of a facility-reported incident, staff statements, and staff interview, the facility failed to ensure staff treated all residents with respect and dignity. This affected one resident (#10) of three residents reviewed for facility-reported incidents (FRI). The facility census was 33 . Findings include: Record review revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including nontraumatic intracerebral hemorrhage, cerebral infarction, and vascular dementia. Review of a minimum data set (MDS) dated [DATE] revealed Resident #10's cognition was severely impaired. Review of a witness statement by Certified Nursing Assistant (CNA) #300 dated 02/13/25 revealed Resident #10 had asked to go back to her room. CNA #300 and #215 took Resident #10 to her room and when they opened the door, CNA #110 was there and stated, I'm not putting her to f*cking bed, I put her to bed once already. CNA #300 stated this was said in front of Resident #10. CNA #300 & #215 laid Resident #10 down and had not asked CNA #110 for help. Review of a witness statement by CNA #215 dated 02/13/25 revealed she and CNA #300 took Resident #10 to her room because she requested to be laid down. Upon entering the room, CNA #110 stated, I'm not putting her to f*cking bed, I already put her to bed once, in front of Resident #110. CNA #215 and #300 put Resident #10 in bed per her request. The nurse was notified of the situation. Review of a witness statement by Licensed Practical Nurse (LPN) #120 dated 02/13/25 revealed it was reported to her by CNAs #300 and #215 that Resident #10 requested to go to bed and the CNAs took her to her room to lay her down, when CNA #110 stated she would not put Resident #10 to bed because she already did once. Review of a FRI dated 02/14/25 revealed a staff member had a verbal incident with Resident #10. Review of an undated statement by the Administrator revealed an interview was completed with CNA #110 who denied cussing in front of Resident #10 but did admit to saying Resident #10 just got up and could stay up for a while. CNA #110 was educated on resident choices and preferences via phone interview. Review of a corrective action form dated 02/14/25 revealed CNA #110 was given a first written warning due to cussing in front of a resident. She was educated on company policies and refused to sign the corrective action form stating, I quit. Interview on 04/02/25 at 3:10 P.M. with Director of Nursing (DON) revealed she had not been employed at the facility at the time of the incident, but the information provided in the witness statements was not what she would consider treating residents with dignity and respect. Review of a policy titled Resident Rights dated 12/2016 revealed residents have the right to a dignified existence and to be treated with respect, kindness, and dignity. This deficiency represents an incidental finding of non-compliance investigated under Complaint Number OH00162782.

Based on observation and staff interview, the facility failed to ensure resident rooms and common areas were maintained in a clean and comfortable manner by repairing and painting walls properly. This had the potential to affect all 34 residents within the facility. Findings include: Observations throughout the survey from 02/03/25 to 02/06/25 revealed numerous resident rooms and common areas with evidence of repaired drywall which had not been properly painted. Observations with the facility administrator on 02/06/25 from 9:30 A.M. to 9:40 A.M. revealed the following areas of disrepair concerns: room [ROOM NUMBER] had drywall repair without evidence of repainting hallway next to room [ROOM NUMBER] had drywall repair without evidence of repainting room [ROOM NUMBER] had drywall repair without evidence of repainting room [ROOM NUMBER] had drywall repair without evidence of repainting room [ROOM NUMBER] drywall repair without evidence of repainting room [ROOM NUMBER] damaged drywall from resident beds room [ROOM NUMBER] drywall repair without evidence of repainting hallway across from 205 drywall without evidence of repainting room [ROOM NUMBER] drywall repair without evidence of repainting room [ROOM NUMBER] drywall repair without evidence of repainting hallway between room [ROOM NUMBER] and shower room drywall without evidence of repainting hallway by room [ROOM NUMBER] drywall without evidence of repainting 307 drywall repair without evidence of repainting During the observations the facility administrator verified all findings.

Based on observation, interview, review of dialysis communication notes, and record review the facility failed to ensure Resident #15 received medication as ordered and the dialysis plan of care was accurate. This affected one (Resident #15) of one reviewed for dialysis. Findings included: Record review revealed Resident #15 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure, type 2 diabetes, morbid obesity, pneumonia, heart failure, sepsis, hypertension, dysphagia, bundle branch block, major depressive disorder, end stage renal disease dialysis dependent. a. Review of the nutritional communication form from dialysis dated 10/28/24, 12/18/24, and 01/27/25 revealed Resident # 15 did not meet his phosphorous goal of 3.0-3.5. Orders to administer calcium acetate at each meal and snack. Review of un-dated mealtimes (provided by the facility) revealed breakfast was at 7:45 A.M., lunch at 12:00 P.M., and dinner at 5:15 P.M. Review of Resident #15's orders and Medication Administration Records (MAR) dated 02/25 revealed calcium acetate (phosphorus binder) was to be given four times a day by mouth at A.M. (7:00 A.M. to 10:30 A.M.), noon, 3:00 P.M., and between 8:00 P.M.- 11:00 P.M. Review of the medication administration audit report from 02/01/25 through 02/04/25 revealed the calcium acetate (phosphorus binder) 667 milligrams (mg) was administered on 02/01/25 at 11:05 A.M., 11:06 A.M., 5:51 P.M., and 7:32 P.M.; 02/02/25 at 6:48 A.M., 10:19 A.M., 3:54 P.M., and 7:32 P.M. on 02/03/25 at 9:19 A.M., 10:31 A.M., 5:02 P.M. and 8:57 P.M. and on 02/04/25 at 8:32 A.M., 12:22 P.M., 5:25 P.M., and 8:13 P.M. Review of Resident #15's progress note dated 02/03/25 revealed the resident was at dialysis and noon medicine given at 10:31 A.M. Interview with Registered Dietician (RD) #32 on 02/05/25 at 12:42 P.M. confirmed the calcium acetate (phosphorus binder) must be given with meals and snacks. The RD reported she had spoken with a facility staff member on January 24 th, 2025, on the importance of taking the calcium acetate (phosphorus binder) with meals and snacks. Interview with the Director of Nursing (DON) on 02/05/24 at 3:11 P.M. confirmed calcium acetate was not being given during mealtimes. Review of undated liberalized medication administration policy revealed the interdisciplinary team, including health care providers, nursing staff, and pharmacists, should work together to develop and implement flexible medication administration plans. b. Review of Resident #15's dialysis care plan revised on 10/23/24 revealed the resident's dialysis days were Tuesdays, Thursdays, and Saturdays and to obtain weights per order. Review of Resident #15's orders dated 02/25 revealed the resident attends an outside dialysis center on Monday, Wednesday, and Friday at 10:30 A.M. and there was no evidence of an order to weigh the resident per the plan of care. Observation and Interview of Resident #15 on 02/03/25 at 9:13 A.M. revealed Resident #15 was preparing to leave the facility. The resident reported he leaves around 9:30 A.M. and returns to the facility around 4:30 P.M., on Monday, Wednesday, and Friday. Interview on 02/04/25 at 9:20 A.M. with Registered Nurse (RN) #105 confirmed Resident #15 had dialysis every Monday, Wednesday, and Friday. Interview on 02/04/25 at 3:20 P.M. with the Director of Nursing (DON) confirmed Resident #15 care plan indicated that the resident was to receive dialysis treatment on Tuesdays, Thursdays, and Saturdays however, he goes on Monday, Wednesdays, and Fridays and the care plan had not been updated to reflect the corrected days he goes and the resident did not have an order for weights per the plan of care.

Based on observation, interview, review of dialysis dietician notes, and medical record review, the facility failed to provide Resident #15 with appropriate diet and snacks as ordered by the dialysis center dietician and failed to ensure communication between the facility dietician and dialysis dietician occurred to provide Resident #15 a comprehensive nutrition plan to meet the resident's needs. This affected one resident (Resident #15) of one reviewed for dialysis. Findings included: Review of Resident #15's medical record revealed an admitted [DATE] with diagnoses including type 2 diabetes, morbid obesity, heart failure, sepsis, hypertension, and end stage renal disease- dialysis dependent. Further review revealed no evidence of dialysis dietician communication notes since 04/23/24. Review of the nutritional communication forms/notes from dialysis dated 10/28/24, 12/18/24 and 01/27/25 (with a faxed date of 02/04/25 on the forms) revealed the dialysis dietician ordered a high protein snack at night, double portions, 132 grams of protein, no added sugar, and no added salt diet. The resident did not meet the albumin goal of greater than or equal to 4.0. Review of Resident #15's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had a brief interview of mental status score of 15 out of a possible 15, indicating the resident was cognitively intact. Review of Resident #15's nutrition plan of care dated 01/23/25 revealed a therapeutic diet low in salt, diabetic, low cholesterol, low concentrated sweets, renal fluid restriction, house supplement, with needs for 90-102 grams of protein a day, and 2,000-2,200 calories per day. There was no mention of the high protein snack at night. Review of Resident #15's physician orders dated 01/24/25 revealed renal, high protein, controlled carbohydrates, no added salt, regular diet with thin liquids. Review of Resident #15's orders dated 02/25 revealed no evidence the resident was ordered a high protein snack at night per dialysis orders Review of the dietary supplement list dated 02/05/25 revealed no high protein snack to be provided to Resident #15 at night. Review of Resident #15's task (Certified Aides Documentation) for February 2025 revealed no evidence the resident was receiving a high protein snack at night. Interview with Resident #15 on 02/05/25 at 8:36 A.M. confirmed he was receiving a snack around 8:00 P.M. daily, however he only received a fudge round or an oatmeal cream pie. He stated the facility does have other things on the cart such as cheese doodles and chips, but he doesn't want those items. Observation of Resident #15's packed lunch on 02/05/25 at 9:44 A.M. revealed the resident received one bologna sandwich with cheese, one Styrofoam bowl with a lid containing cottage cheese, one grape juice, and one four count pack of [NAME] shortbread cookies. Interview on 02/05/25 at 9:44 A.M with the Transportation Driver #73 and Resident #15 confirmed the contents of the resident's packed lunch .The resident confirmed he received the same items in his packed lunch on his scheduled dialysis days of Monday, Wednesday and Friday. Interview on 02/05/25 at 10:47 A.M. with the facility Registered Dietician (RD) #302 revealed Resident #15 should receive three ounces of meat such as turkey, chicken, roast beef, tuna, or even egg salad; ham and bologna should not be given due to the high salt content. Further interview with the RD confirmed there was no order for Resident#15 to be given a high protein snack at night. The RD reported there have been issues with the dietary staff changeover and not providing high protein meals and snacks to Resident #15 and she planned to do further education and in-services with the staff. A subsequent interview with RD #302 on 02/05/25 at 10:50 A.M. verified she had not been provided with dialysis dietician communication forms/notes until recently. Interview with dialysis RD #32 on 02/05/25 at 12:41 P.M. revealed she had not been in contact with the facility dietician, and said she was wondering if they even had a dietician. Interview with RD #32 on 02/05/25 at 12:43 P.M. confirmed she has recommended Resident #15 receive a high proteins snack at bedtime due to albumin goals not being met. She shared she had also recommended high protein options for Residents #15 such as tuna or egg salad sandwiches rather than bologna due to the salt content. Lastly, RD #32 confirmed she re-faxed the dialysis nutrition notes to the facility on [DATE].

Based on medical record review, observation, interviews, and policy review, the facility failed to ensure an individualized, comprehensive plan of care was in place to ensure safe smoking strategies and skin alterations from smoking were timely identified. This affected one resident (Resident #6) of one residents reviewed for smoking. Findings included: Medical record review revealed Resident #6 was admitted to the facility on [DATE] with diagnoses including delusions, paranoid schizophrenia, depression, diabetes, dementia, behavioral disturbances, Alzheimer's, glaucoma, nicotine dependence (cigarettes), and abnormal involuntary movements. Review of Resident #6 smoking assessment dated [DATE] and 01/03/25 revealed the resident had no cognitive loss or dexterity problems. The resident had a visual deficit. The resident smokes five-10 times a day and used a smoking apron and required supervision. The facility stored the lighter and cigarettes. The plan of care was to assure residents were safe while smoking. There was no evidence the resident had or required an extender to prevent the resident from burning himself with a cigarette. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 out of a possible score of 15, indicating the resident was cognitively intact. No impairment of range of motion to the upper or lower body had been identified. The resident had no skin alterations. The resident was partial to moderate assistance with personal hygiene and supervision for mobility. Review of resident weekly skin assessment dated [DATE] revealed the resident had no skin alterations. Further review of skin assessments and progress notes dated 01/30/25 to 02/03/25 at 12:34 P.M., revealed no evidence of skin alterations to the resident's middle right finger. Observation and interview on 02/03/24 at 12:34 P.M. with Resident #6 revealed the resident had a skin alteration on his right middle finger near the first knuckle. Resident #6 confirmed he had burned himself with a cigarette. The resident reported he had a cigarette extender he used when smoking. A follow-up interview on 02/04/25 at 9:22 A.M., revealed he had burned his finger about five days ago with a cigarette. The skin was starting to peel off on one side of the resident's finger. Observation and interview on 02/04/25 at 9:41 A.M., with Registered Nurse (RN) #105 confirmed the resident was to use an extender on the end of his cigarette to prevent him from burning himself. The RN showed the surveyor the extender that was in the cigarette box. The extender was not labeled to identify which resident was to use the extender. Review of Resident #6's nursing note dated 02/03/25 at 10:04 P.M., revealed the nurse noticed an open area on the resident's right middle finger. The resident stated it was a blister that opened. The area was cleaned with normal saline. The physician was notified and new orders received to monitor area every shift and leave open to air. Review of Resident #6 current orders revealed no evidence of an order for an extender to be added to the cigarette. Review of Resident #6's smoking plan of care revealed the resident was supervision at all times for smoking and an apron was to be worn when smoking. There was no evidence of an extender to be added to the cigarette to prevent theresident from being burned. Interview on 02/04/25 at 9:27 A.M., with Certified Nursing Assistants (CNA) #102 and #103 revealed they had just noticed the skin alteration on the resident's finger today. The CNA's reported that the resident smokes the cigarettes to the filter and he was to have a plastic extender applied to the end of the cigarette to prevent him from burning himself. The CNAs reported laundry and housekeeping usually take the residents out to smoke. An interview on 02/04/25 at 10:16 A.M., with Registered Nurse (RN) #106 revealed the resident reported he had a blister that popped. She was not aware he had burned his finger on a cigarette. The RN confirmed she did not do a skin assessment of the area. Interview on 02/04/25 at 10:41 A.M., with the Director of Nursing (DON) confirmed there was no skin assessment completed for the skin alteration until identified during the survey. A CNA had reported yesterday that the resident had burned himself with a cigarette, but she didn't know when the incident occurred. The facility had not started an investigation to determine the cause of the cigarette burn. The DON also verified there was no order for a cigarette extender, the care plan did not reflect the use of a cigarette extender, and the smoking assessment did not identify the resident needed an extender for his cigarette (to prevent burns despite some staff having knowledge of the use of the cigarette extender). The DON confirmed the resident required supervision with smoking and he had the extender for a while and he was known to remove the extender. Review of the facility's policy titled Smoking dated 08/2023 revealed the resident would be evaluated upon admission and routinely to determine if he or she would be able to smoke safely. The facility would make the best effort to establish and maintain safe resident smoking practice.

Based on medical record review, interviews, observations, and policy review the facility failed to ensure Resident #195 was assessed for activity preferences and offered activities to meet his interests. This affected one (Resident #195) of one residents reviewed for activities. Findings included: Record review revealed Resident #195 was admitted to the facility on [DATE] with diagnoses including depression, cerebral infarction, diabetes type one, and difficulty walking. Review of Resident #195's medical record revealed no evidence of an activity assessment. Review of Resident #195's progress notes revealed on 01/24/25 a social services note was entered at 4:08 P.M., that indicated the resident was dependent for all care and administration of medications. The resident had hearing aids and glasses. His speech was clear, and he was easily understood. There was no evidence that the resident's activity preferences were reviewed. Review of Resident #195's task (Certified Nursing Assistants) documentation dated 01/24/25 to 02/03/25 revealed no evidence of which activities the resident attended. There was an activity tab showing if the resident was active, passive, or observed only for activities. The resident was passive for activity on 01/24/25, 01/27/25, 01/28/25, 01/29/25, and 01/31/25 and observed only on 02/01/25. Review of Resident #195's 48-hour care plan dated 01/24/25 revealed no evidence of an activity plan of care. Review of Resident #195's plan of care revealed no evidence of a comprehensive activity plan of care. Further review of Resident #195's plan of care revealed the resident discharge planning plan of care indicated to encourage the resident to attend activities of interest and the potential for mood problems related to depression plan of care indicated to invite/assist resident to activities of choice. An interview on 02/03/25 at 12:31 P.M., with Resident #195 revealed he doesn't attend activities due to the facility didn't offer him activities that he was interested in. Observation on 02/03/25 at 3:42 P.M., and 02/04/25 at 2:19 P.M., revealed the resident was in his room and not participating in the activity program. Interview on 02/04/25 at 8:17 A.M. and 2:22 P.M., with Resident #195 confirmed no one had talked to him regarding his activity preference/interest. The resident reported he liked working on model cars/planes. The resident confirmed he doesn't attend the facility activities because he was not interested in the activities the facility had to offer. Interview on 02/04/25 at 1:36 P.M., with Social Service (SS) #101 revealed she was just re-hired as the social service/activity director about three weeks ago. SS #101 confirmed Resident #195 did not have an activity assessment completed nor an individualized plan of care for activities initiated. SS #101 confirmed the task didn't include the activity the resident attended and she was not sure what active, and passive referred to under the task for activities. The SS confirmed she had spoken to the resident and his wife but there was no documented evidence they had discussed his activities preferences, nor did she know what activities the resident liked. Interview on 02/04/25 at 1:47 P.M., with Activity Assistant (AA) #100 revealed he had only been the activity assistant since 01/29/25. AA #100 confirmed he had not spoken to the resident regarding his activity preferences. The AA reported there had been a lot of turnovers in the activity department lately. AA #100 confirmed the type of activity the resident attended should be under the task tab, however the resident did not have the task and the only documentation in the task was if the resident was active, passive, or observed in an activity. The AA reported he had taken cake or something into the resident the other day, so he documented passive for that activity. AA reported he thought active meant the resident participated and passive was when the resident required assistance and observed the resident did not participate and just watched an activity. AA reported he was going to speak with administrative staff about adding the type of activity to the resident task. Review of the facility's policy titled Activity Programs dated 06/2018 revealed activities were programs designed to meet the interest of and support the physical, mental, and psychosocial well-being of each resident. The activities program was provided to support the well-being of residents and to encourage both independence and community interaction. Activities offered are based on the comprehensive resident-centered assessment and the preferences of each resident. The activities program is ongoing and includes facility-organized group activities, independent individual activities and assisted individual activities. Our activity programs are designed to encourage maximum individual participation.

Based on medical record review and staff interview, the facility failed to ensure a Pre-Admission Screening and Resident Review (PASRR) document accurately reflected an in-patient psychiatric hospitalization /significant change of condition. This affected one (Resident #37) of one residents reviewed for PASRR documents. The census was 34. Findings Include: Medical record review revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including schizophrenia, bipolar disorder, anxiety disorder, dementia, liver disease, multiple sclerosis, anxiety disorder, epilepsy, unspecified intellectual disabilities, and mild cognitive impairment. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/09/25, revealed the resident was cognitively intact. Review of a nursing progress note, dated 10/29/24, revealed Resident #5 was admitted for an inpatient psychiatric evaluation. Review of the psychiatric hospital's Discharge Summary revealed Resident #5 was admitted on [DATE] for increased aggression and agitation. The resident was discharged on [DATE]. Review of the medical record revealed Resident #5's most recent PASRR document was dated 01/31/24 and was not revised/updated following the inpatient psychiatric hospitalization on [DATE]. Interview on 02/03/25 at 4:25 P.M. with the Administrator confirmed Resident #5's PASRR document was not accurate and did not reflect the inpatient psychiatric hospitalization on [DATE].

Based on observation, interview, and record review the facility failed to ensure resident personal items were safe guarded from potential theft. This affected one resident (Resident #15) of one residents reviewed for personal property. Findings included: Medical record review revealed Resident #15 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure, type II diabetes, hypertension, dysphagia, major depressive disorder, end stage renal disease and dialysis dependent. Review of Resident #15's quarterly minimum data set (MDS) dated [DATE] revealed a brief interview of mental status score (BIMS) of 15 (out of 15), meaning cognition intact. Interview on 02/03/25 at 9:01 A.M. with Resident #15 revealed his personal snacks, located in his drawer, have come up missing. The resident believed Resident #6, who shared a [NAME] and [NAME] bathroom, comes in through the bathroom door and takes his snacks. The resident had reported the missing snacks several times to staff, however it continued to happen. Interview on 02/04/25 at 11:28 A.M. with Certified Nursing Aide (CNA) #102 stated about one month ago she saw Resident #6 go into Resident #15's room and take a snack while he was out at dialysis. The CNA stated she had reported it to a nurse but was unable to recall who the nurse was at this time. Interview on 02/04/25 at 11:38 A.M. with Registered Nurse (RN) #105 confirmed Resident #15 did have some complaints of missing snacks. The RN shared that when Resident #15 leaves the facility for dialysis, the staff close the door to his room. Interview on 02/04/25 at 3:25 P.M. with Social Service (SS) #101 revealed she was the person responsible to report resident concerns. SS #101 confirmed no one had reported any issues to her regarding Resident #15's missing snacks. Interview on 3:35 P.M. on 02/04/25 with the Director of Nursing (DON) revealed she has not heard that Resident #15 had any issues with missing items. Interview on 02/05/25 7:22 A.M. with Resident #15 revealed the last time he could recall items missing was about a week or two ago. Specifically, he was missing packs of Oreo cookies that have two cookies each in them and a few bags of chips but he was unsure of the exact amount that was missing. Resident #15 stated had told several staff members about this issue, and they said they would get it taken care of but no one had updated him on the issue or came to further investigate the problem with him. Interview on 02/05/25 at 8:15 A.M. with RN #120 stated she had heard through the grape vine that items in Resident #15's room were going missing. The last she heard about the situation was about two weeks ago. The facility was unsure who was taking the items and she thought they were going to start keeping a closer eye on the room on days Resident #15 left for dialysis but has not heard anything since. Review of concern/missing item log from January 2024 to January 2025 revealed no evidence of missing snacks for Resident #15. Review of missing items policy and procedure revised December 2020 stated the facility will make every attempt to locate any items that come up missing and assist with a resolution. The procedure to be followed is staff will log all missing items and communicate missing items and attempt to locate them, staff will provide information to residents and family about missing items, and lastly family and staff will come up with a resolution that is satisfactory to both parties.

Based on interview, review of the Beneficiary Notice worksheet, review of the Notice of Medicare Non-Coverage (NOMNC) 10123 instructions, and record reviews, the facility failed to provide the Quality Improvement Organization (QIO) name and contact information. This affected four (Resident #1, Resident #11, Resident #33, Resident #34) of five residents reviewed for beneficiary notification. Findings included: 1. Record review revealed Resident #34 was admitted to the facility on [DATE] with a diagnoses including atrial fibrillation, dysphagia, muscle weakness, and cognitive communication deficit. Review of entrance conference worksheet for Beneficiary Notice (resident who has been discharged from Medicare covered Part A stay with benefits days remaining in the past six months) undated revealed Resident #34 was discharged from skilled services on 12/26/24 and had remained in the facility. Review of Notice of Medicare Non-Coverage (NOMNC) 10123 dated 12/24/24 revealed the QIO name and contact information was not provided on the form. 2. Record review revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including hypokalemia, anxiety, multiple sclerosis, and pulmonary embolism. Review of the entrance conference worksheet for Beneficiary Notice undated revealed Resident #11 was discharged from skilled services on 01/26/25 and discharged to home or lesser care. Review of Notice of Medicare Non-Coverage (NOMNC) 10123 dated 1/24/25 revealed the QIO name and contact information was not provided on the form. 3. Record review revealed Resident #33 was admitted to the facility on [DATE] with diagnoses including anemia, vascular dementia, adult failure to thrive, and myocardial infarction. Review of the the entrance conference worksheet for Beneficiary Notice undated revealed Resident #33 was discharged from skilled services on 09/13/24 and remained in the facility. Review of the NOMNC 10123 dated 9/11/24 revealed the QIO name and contact information was not provided on the form. 4. Record review revealed Resident #1 was admitted to the facility on [DATE] with a diagnoses including arthritis, hypertension, cognitive communication deficit, and cerebral infarction. Review of the the entrance conference worksheet for Beneficiary Notice undated revealed Resident #1 was discharged from skilled services on 09/29/24 and remained in the facility. Review of the NOMNC 10123 dated 9/26/24 revealed the QIO name and contact information was not provided on the form. Review of the NOMNC 10123 instruction form dated 12/31/11 revealed the facility was to insert the Quality Improvement Organization (QIO) name and phone number on the NOMNC 10123. QIO was the independent reviewer authorized by Medicare to review the decision to end the services if the resident chose to appeal the decision Interview on 02/06/25 at 09:14 AM with the Administrator confirmed that the QIO name and contact information listed on the notice for the appeal was not provided for Resident #34 and Resident #11, Resident #1 and Resident #33.

Based on observation, interviews, and policy review, the facility failed to ensure appropriate infection control practice were implemented when an indwelling urinary catheter drainage bag was in contact with the floor. This affected one (Resident #185) of one resident reviewed for indwelling urinary catheters. There were no additional residents with urinary catheters residing in the facility. The facility census was 43. Findings include: Review of the medical record revealed Resident #185 was admitted to the facility on [DATE] with diagnoses including obstructive reflex uropathy, acute kidney failure, diabetes mellitus, coronary artery disease, morbid obesity, bipolar disorder, and Fournier gangrene (serious, sometimes fatal, bacterial infection of the external genitalia or scrotum.) Review of the admission Minimum Data Set (MDS) assessment, dated 02/01/25, revealed Resident #5 was cognitively intact. There were no behaviors or rejection of care. The resident required physical assistance from staff for activities of daily living. Review of the Care Plan, dated 02/03/25, revealed Resident #5 had an indwelling supra-pubic catheter related to obstructive uropathy with the goal for the resident to remain free of infection. Interventions included utilizing enhanced barrier precautions and providing catheter care every shift. Observation on 02/03/25 at 8:40 A.M. revealed Resident #5 lying in bed with his indwelling, urinary catheter bag encased within a white, cloth privacy cover. The catheter bag with cover was touching the floor. Subsequent observation on 02/03/25 at 8:55 A.M., revealed the catheter bag with cover continued to touch the floor. During observation and interview on 02/03/25 at 8:56 A.M., the Director of Nursing (DON) confirmed the urinary catheter bag/privacy cover should not be in contact with the floor. Review of the facility's policy titled, Urinary Catheter Care, dated April 2007, revision date 2021, revealed to use standard precautions when handling or manipulating the drainage system and to be sure the catheter tubing and drainage bag are kept off the floor.

Based on record review, review of self-reported incident report (SRI) tracking number 239957, and interview, the facility failed to ensure a comprehensive, resident-centered care plan related to resident behaviors was maintained. This affected one (Resident #1) of three residents reviewed for abuse. The facility census was 29. Findings include: Review of the medical record for Resident #1 revealed an admitted [DATE]. Diagnoses included Down syndrome, morbid obesity, urethral stricture, and impulse disorder. Review of Resident #1's plan of care, dated 08/23/22, revealed the resident received psychotropic medication related to behaviors of agitation and combativeness (flailing arms during personal care and hitting himself during personal care) due to impulse control problems. Interventions included administering medication as ordered and monitoring for target behaviors: agitation, aggression, combativeness, verbal outbursts, and throwing food and drinks onto floor. Review of the annual Minimum Data Set (MDS) assessment, dated 07/21/23, revealed the resident had moderately impaired cognition. The assessment indicated no behaviors nor rejection of care. The resident was totally dependent on two staff members to assist with bed mobility, transfers, toileting, and personal hygiene. Review of the facilities self-reported incident (SRI) tracking number 239957, discovery date 10/08/23, revealed Resident #1 reported to nursing staff that STNA #99 had struck him with her hand the previous night when she came into his room to ask him to turn off his television (tv) because it was too loud. An investigation was immediately initiated. STNA #99 was immediately suspended until the completion of the investigation. Resident #1 was assessed and found to have a mark on his chest that matched his own hand print. During the assessment, Registered Nurse (RN) #100 asked Resident #1 to place his hand over the mark and she confirmed that the resident's hand matched the outline of bruise. During interview with the Administrator, STNA #99 denied hitting the resident as alleged and denied turning off his tv. STNA #99 stated that she did go to his room to remind him that people were sleeping and not to be so loud as he had been yelling at the tv and could be heard down the hall. The resident's guardian and the local sheriff's department were notified. The facility unsubstantiated the allegations due to inconclusive evidence of abuse. Review of Resident #1's skin assessment, dated 10/08/23 at 7:15 P.M., revealed a bruise located on the chest which measured 8.5 centimeters (cm) x 17 cm x 0 depth. During interview and observation on 10/17/23 at 11:10 A.M., Resident #1 stated STNA #99 yelled at him and slapped him on the chest because his tv was too loud. Resident #1 further stated that he wanted to be with his dad and didn't want to be in the facility. The resident denied any further incidents of abuse and stated that he felt safe in the facility. Observation revealed a circular, quarter-sized bruise, yellowish purple in color, and located approximately one inch above the xiphoid process (a small cartilaginous process located in the inferior segment of the sternum) in the middle of the resident's chest. Resident #1 denied pain or discomfort from the bruised area. During interview on 10/17/23 at 9:20 A.M., Registered Nurse (RN) #100 stated that she was notified by STNA #105 on 10/08/23 that Resident #1 alleged a staff member had hit him on the previous night shift. The resident did not know the STNA's name but provided a physical description of the STNA. The resident was assessed, and a bruise was observed in the shape of a hand, in the center of the resident's chest. The resident's hand was placed inside the mark and appeared to match the size and shape of the bruise. The resident did not complain of pain. The Director of Nursing (DON) was notified immediately. RN #100 stated that she had never witnessed any abuse while working in the facility. During interview on 10/17/23 at 12:25 P.M., the DON stated the facility investigation could not substantiate the alleged abuse and it was determined by the evidence that Resident #1's bruise located on his chest was the result of the resident hitting himself while watching wrestling on the night of the alleged incident. The DON confirmed the care plan did not reflect behaviors of hitting himself while watching wrestling, although the facility was aware of the self-hitting behavior during wrestling tv shows prior to the alleged incident. This deficiency is an incidental finding discovered during the course of the investigation.

Based on observation, record review, hospital record review, self-reported incident review, policy review and interview the facility failed to prevent an incident of resident-to-resident sexual abuse/assault involving Resident #13. Actual harm occurred based on the reasonable person concept on 08/22/23 when Resident #13, who was severely cognitively impaired and was unable to provide evidence of consent was sexually assaulted by Resident #26 who was observed fondling the resident's breast and with possible vaginal bleeding (per hospital record review). This affected one (Resident #13) of three residents reviewed for abuse. The facility census was 25. Findings include: Review of the medical record revealed Resident #13 was admitted to the facility on [DATE]. Resident #13 had diagnoses including early onset Alzheimer's disease, muscle contractures of the right hand and right and left elbows, oral phase dysphagia, insomnia, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #13 had severely impaired cognition. The assessment revealed the resident required total assistance from two staff members for bed mobility, transfers, dressing, toilet use and personal hygiene. Review of the resident's progress notes from 08/02/23 to 08/23/23 revealed no documentation of an incident between Resident #13 and another resident involving sexual touching/assault . Review of the medical record revealed Resident #26 was admitted to the facility on [DATE] with diagnoses including Alzheimer's dementia, cognitive communication deficit, dementia with behavior disturbance and other dissociative and conversion disorders. Review of the MDS 3.0 assessment, dated 08/17/23 for Resident #26 revealed the resident had no cognitive impairment, no behaviors and he required only (staff) supervision for activities of daily living. Review of the plan of care for Resident #26 indicated Resident #26 had inappropriate behaviors related to his dementia including refusing care, refusing to speak to staff, refusing to look at staff, and refusing daily living needs like showering and medications. Review of a Nursing Home to Hospital Transfer Form, dated 08/22/23, revealed Resident #26 was transferred to a psychiatric hospital due to behavioral symptoms of agitation and psychosis. Review of a facility Self-Reported Incident (SRI) dated 08/22/23 related Staff Member #100 reported to the Director of Nursing (DON) at 12:55 P.M. he saw Resident #26 standing in Resident #13's room. Staff Member #100 reported Resident #26 had one hand on Resident #13's breast, on top of the sheet, and the resident's other hand was on the bed. Staff Member #100 reported Resident #26 was fully clothed at the time. Staff Member #100 told Resident #26 he was not supposed to be in that room and Resident #26 immediately left the room. Resident #26 was immediately placed on one-on-one supervision until he was transferred from the facility to a psychiatric hospital. The DON notified the administrator at 1:02 P.M. and an investigation began. The investigation noted Resident #26 had a Brief Interview for Mental Status (BIMS) score of 14, (indicating he had intact cognition). A follow up interview was performed with Resident #26 regarding the alleged incident, and he would not respond to the questions. A nursing assessment was completed, and Resident #26 displayed no signs or symptoms of injury and was at baseline for his mood and behavior. During a subsequent interview with Resident #26, he admitted to touching Resident #13's breast but stated he did nothing else. Resident #13 was not able to be interviewed. A nursing assessment was completed for Resident #13. Resident #13 displayed no signs or symptoms of discomfort and no had obvious injuries noted, no signs or symptoms of distress were noted. Resident #13 was at baseline for mood and behavior. However, there was blood seen on her sheet and on her brief. The [NAME] County Sheriff's office was called, and the Medical Director was notified. The Sheriff Deputy arrived at the scene at 2:12 P.M., assessed Resident #13, collected evidence and Resident #13 left the facility by squad at 2:55 P.M. to be transferred to the emergency room (ER) for an evaluation. Review of the hospital ER report dated 8/22/23 at 5:40 P.M. revealed Resident #13 had vaginal blood after possible sexual assault. A sexual assault examination was performed by a nurse. Resident #13 had very rigid extremities and performing a speculum exam required the assistance of four people therefore the examining nurses did not believe an individual would be able to separate the resident's legs to have sexual intercourse. The person that was witnessed (to have been assaulted Resident #13) was not unclothed per report and had only manually grabbed her breasts. A pelvic exam was performed with a nurse, and the resident seemed to have red blood in her vaginal vault. There were no obvious lacerations or a clear source of the bleeding. Review of the signed witness statement from Registered Nurse #101 revealed on 08/22/23 at 1:00 P.M. she was called to the room of Resident #13 by the housekeeper, who stated he found Resident #26 leaning over Resident #13 beds with his left hand fondling her right breast and with his right hand over her gown, When she entered the room of Resident #13 she noticed what appeared to be blood on the sheet next to the resident's right leg, When she pulled the sheet down to perform a body check it was noted her Depend (incontinence brief) was not fastened on the right side. While unfastening the brief completely, blood was noted on the left side of the resident's brief that was bright red in color and she also had blood on her left groin area. The brief was removed and wrapped up in a Chux (disposable pad). The statement indicated the resident appeared to be in no distress. Review of the signed witness statement Staff Member #100 dated 08/22/23 at 12:50 P.M. revealed another resident told him that Resident#26 had walked into another resident's room. When he went into the room, Resident #26 had his right hand on a female resident's right breast. He stated he told Resident #26 he did not belong in that room, and he went back to his own room. Resident #13 did not show any sign of distress. Resident #26 had his left hand on the bed. Review of the signed witness statement from Social Service Director #102 dated 08/22/3 at 3:30 P.M. revealed Resident #26 admitted to touching the breast of Resident #13. Review of the police report dated 08/22/23 at 1:22 P.M. revealed the Sheriff's department received a call from the facility and responded. A female resident was being transported to the hospital and two pieces of evidence were collected . On 08/29/23 at 12:00 P.M. an interview with Staff Member #100 revealed he had seen Resident #26 standing on the side of Resident #13's bed so he walked into the room so he could see him face to face and he saw Resident #13 massaging the breast of Resident #16. He stated Resident #26's other hand was on the resident's bed. He stated he told Resident #26 to stop, he did not belong in Resident #13's room and the resident left the room. He stated he had never seen Resident #26 inappropriate with anyone else. On 08/29/23 at 2:36 P.M. an interview with the DON revealed Resident #26 was admitted from another facility and had not been having any sexual behaviors at that facility. The DON stated Resident #26's niece had seen him at the other facility and Resident #26 did have some inappropriate behaviors which were care planned. The DON indicated Resident #26 would be returning to the prior facility after his current hospitalization . When asked about the possible source of the vaginal blood, the DON said Resident #13 had never had a menses prior to the incident, but the physician stated they could not rule it out. She indicated no one checked Resident #26's hands after the incident to see if there was any blood on his hands. Observation of incontinence care on 08/29/23 at 3:40 P.M. revealed State tested Nursing Assistant (STNA) #103 and STNA #104 provided incontinence care to Resident #13 with no concerns. The resident was relaxed, and they had no issues being able to spread the resident's legs open and access her peri-area. The resident was able to open her legs about two feet apart without difficulty. An interview at this time with STNA #103 revealed that sometimes if the resident did not want you touching her, she would cross her legs and hold them together but normally there were no issues with being able to access her peri-area for hygiene. On 08/30/23 at 9:30 A.M. an interview with LPN #150 revealed the LPN was unaware of any prior issues with Resident #26 acting inappropriate, as he just walked up and down the halls, sat in the dining room or sunroom looking out the windows. On 08/30/23 at 11:00 A.M. an interview with Registered Nurse #101 revealed (following the incident on 08/22/23) she had gone into the room of Resident #13 to do an assessment and noticed blood on the resident's sheet. She stated at first, she did not know what was on the sheet because the resident had green sheets on her bed, and it was not bright red because of the sheet. She stated there was an area on the sheet that looked like someone had wiped blood off of it because it was smeared on the sheet. She stated when she pulled back the top sheet, the resident's brief was opened on the left side which was very unusual because the staff always fastened all briefs up on the residents. She stated there was bright red blood on the resident's brief and on the left side of the resident's groin. She stated it was bright red with no clots in it. She stated she assessed the resident's vagina and rectum but could not tell where the blood was coming from. She indicated she never looked at Resident #26's hand to see if he had blood on them. Review of the facility policy titled, Abuse, Neglect, Exploitation, and Misappropriation of Resident Property, dated 2016 revealed the facility would not tolerate abuse, neglect, exploitation, and misappropriation of resident property. It was the facility's policy to investigate all alleged violations involving abuse, neglect, exploitation, and misappropriation of resident property. Sexual abuse was defined as any nonconsensual sexual contact of any type with a resident. This deficiency represents non-compliance investigated under Control Number OH00145890.

Based on observation and interview the facility failed to ensure a kitchen oven was maintained in safe operating condition. This had the potential to affect all 34 Residents living in the facility. The facility census was 34. Findings included: Observation on 11/28/22 at 8:40 A.M. of the left kitchen oven revealed the door of the oven had a piece of wood wedged into the top of it. An interview at the time of the observation with Dietary #213 revealed the oven door did not close properly so the piece of wood was used to wedge the oven door closed. On 11/29/22 at 10:00 A.M. an interview with Dining Services Director (DSD) #204 revealed the spring in the left oven door was not working correctly and a company came to fix it but ended up making it worse and the door would not close all the way. DSD #204 verified the broke oven door and revealed the facility had been using the piece of wood to wedge the oven door closed for over a week. DSD #204 verified using the piece of wood on a hot oven was not safe operating condition.

Based on observation, interview and facility policy review, the facility failed to ensure an outdoor dumpster lid was completely covering the opening to the dumpster to protect from pest infestation. This had the potential to affect all 34 Residents living in the facility. The facility census was 34. Findings included: Observation on 11/28/22 at 08:30 A.M. of the outdoor dumpster revealed one fourth of the lid was missing leaving the refuse open to air and pests. Observation on 11/29/22 at 12:30 P.M. of the outdoor dumpster revealed one fourth of the lid was missing leaving the refuse open to air and pests. On 11/29/22 an interview with Dining Services Director (DSD) #204 revealed the trash dumpster had been missing part of the lid for a few weeks and the facility probably should have notified the trash company of the broken lid. Review of the facility policy titled, Solid Waste Disposal, undated, revealed garbage containers would be covered at all times.

Based on observation, interview, facility record review and facility policy review the facility failed to ensure food was stored and prepared under sanitary conditions. This had the potential to affect all Residents living in the facility and receiving meals from the kitchen. The were no Residents identified by the facility as receiving nothing by mouth. The facility census was 34. Findings included: 1. Observation on 11/28/22 at 8:40 A.M. of meat in a plastic bag floating in water in the staff hand washing sink. The water was not running in the sink and the sink was plugged to make a pool of water. On 11/28/22 at 9:00 A.M. an interview with Dietary #213 verified the meat should not be thawed in a pool of water or in the staff hand washing sink. She reported the staff the evening before forgot to defrost the meat in the fridge and she was trying to thaw it quickly. Review of the facility policy titled, Food Handling Guidelines, undated, revealed thawing of frozen meat should be done in the following manners: under refrigeration at temperature below 41 degrees Fahrenheit, under potable running water at a temperature of 70 degrees Fahrenheit or below, as part of the conventional cooking process, or in a microwave only when the food will be immediately transferred to conventional cooking facilities as port of a continuous cooking process or when the entire, uninterrupted cooking process takes place in a microwave oven. 2. Observation on 11/28/22 at 8:41 A.M. of both ovens with charred, burned on food evidence the ovens had not been properly cleaned for some time. On 11/28/22 at 9:02 A.M. an interview with Dietary #213 verified the ovens were dirty and she wasn't sure when they were last cleaned. On 11/29/22 at 10:00 A.M. an interview with Dining Services Director (DSD) #204 verified the ovens were only cleaned once every three weeks and the ovens were dirty and needed cleaned. Review of the facility policy titled, Sanitation, undated, revealed ovens were to be free of spills. 3. Observation on 11/28/22 at 8:44 A.M. of Resident Assistant (RA) #228 entering the kitchen and walking past both hazard tape lines on the floor without her hair covered. She walked over to the steam table area which had ham, eggs, and hot cereals without coverings. An interview at the time with RA #228 verified she was not wearing a hair net and had never been told to wear a hairnet or to cover her hair when she was in the kitchen. On 11/28/22 at 8:45 A.M. an interview with Dietary #213 revealed all staff were to wear hair covering once past the second hazard tape line on the floor. Review of the facility policy titled, Personal Hygiene, undated, revealed hair must be kept clean and kept restrained with a hair net or cap covering all hair. 4. Observation on 11/19/22 at 9:30 A.M. of a 106 ounce can of corn with a dent on the edge of the can compromising the seal. An interview at the time with the DSD #204 revealed cans were checked upon delivery, and dented cans were supposed to be put in another room to be donated to a local food bank. She verified the can of corn was dented on the seal and was in the pantry to be used and not with the other items to be donated. Review of the facility policy titled, Receiving, undated, revealed store damaged goods separately from non-damaged goods. 5. Observation on 11/29/22 at 12:30 P.M. of DSD #204 preparing puree. She pureed enchiladas following the recipe. DSD #204 then ran the processor through the chemical dishwasher. Once the dishwasher was done, the processor was placed on the counter to air dry. Observation on 11/29/22 at 12:55 P.M. of DSD #204 continuing the puree process using the processor she had run through the dishwasher. The processor was not dry. DSD #204 put rice in the processor and pureed it following a recipe. On 11/29/22 at 1:00 P.M. an interview with DSD #204 revealed she did not let the processor completely dry and should have to prevent potential contamination. She verified that all dishes are to air dry completely prior to use. 6. Observation on 11/29/22 at 12:35 P.M. of the large can opener with black, crusted food like substance on the puncture blade. An interview at the time with DSD #204 verified the can opener was dirty and it is not on the daily cleaning schedule. Review of the facility policy titled, Sanitation, undated, revealed can openers are to be clean.

Based on observation, interview, record review, and facility policy review the facility failed to ensure Resident #12 had a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . This affected one Resident (#12) of one Resident (#12) reviewed for physical restraints. The facility census was 34. Findings included: Review of Resident #12's medical record revealed she was initially admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #12's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she was minimally cognitively impaired, walked in the room, walked in the corridor, and had locomotion off the unit with supervision and no setup or physical help from staff. Her locomotion on unit required supervision and setup help only. Review of Resident #12's physician orders revealed no order for a Merry [NAME] ( an adaptive device combining a chair and walker which has four wheels and plastic bars surrounding a resident's body so they can not get free from the device without physical help of staff. The device is for residents who are at risk for falling and would normally be placed in a wheelchair for mobility. It allows them to stand from the seat and walk independently from within the bars of the device ). Review of Resident #12's care plan dated 11/10/22 revealed she was noncompliant with fall interventions and the safety precaution intervention of a Merry [NAME] for ambulation throughout facility was initiated on 08/16/22. Observation on 11/28/22 at 3:59 P.M. of Resident #12 walking in facility hallway in a Merry Walker. Observation on 11/29/22 at 8:30 A.M. of Resident #12 sitting in her Merry [NAME] watching television. On 11/30/22 at 8:50 A.M. an interview with Licensed Practical Nurse (LPN) #233 revealed Resident #12 does use a Merry [NAME] for ambulation. After reviewing Resident #12's physician orders, LPN #233 verified there was no order for Resident #12 to have a Merry Walker. LPN #233 verified residents should not be in a Merry [NAME] without an order from the physician. Review of the facility policy titled, Restraint Guidelines, dated 01/01/16, revealed documentation for a restraint should have an order which has been transcribed to the treatment administration record.

Based on observation, interview, record review, and facility policy review the facility failed to ensure oxygen was administered at the correct flow rate. This affected one Resident (#31) of one Resident reviewed for respiratory care. The facility census was 34. Findings included: Review of Resident #31's medical record revealed he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #31's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #31 was cognitively independent and did not receive oxygen. Review of Resident #31's physician order dated 11/25/22 revealed an order to administer oxygen at two liters per minute via a nasal cannula continuously to keep oxygen saturation above 92%. Review of Resident #31's oxygen saturations revealed saturations ranging from 92% to 98%. Review of Resident #31's care plan dated 11/17/22 revealed he was at risk for altered respiratory status related to the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The goal of this care plan was Resident #31 would maintain a normal breathing pattern through the next review. One of the interventions was administer oxygen as ordered. Observation on 11/28/22 at 10:43 A.M. of Resident #31 lying in bed with his oxygen flow rate set at two-and-a-half liters per minute via a nasal cannula. Observation on 11/29/22 at 7:55 A.M. of Resident #31 lying in bed with his oxygen flow rate set at two-and-a-half liters per minute via a nasal cannula. On 11/29/22 at 11:02 A.M. an interview with Licensed Practical Nurse (LPN) #233 revealed the drive to breath for a resident with [CONDITION(S)] was a lower oxygen saturation. Observation on 11/29/22 at 11:05 A.M. of Resident #31's oxygen flow rate with LPN #233 revealed a flow rate of two-and-a-half liters per minute via a nasal cannula. An interview with LPN #233 at the time revealed she was not sure what the oxygen should be flowing at and would like to review Resident #31's order for oxygen. On 11/29/22 at 11:09 A.M. an interview with LPN #233, revealed the oxygen flow rate for Resident #31 was not correct based on the order for two liters per minute via nasal cannula and should be lowered. Review of the facility policy titled, Oxygen Administration, undated, revealed adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered.

Based on record review, observation and interview, the facility failed to provide Resident #25 with activities to meet their preferences and interests. This affected one Resident (#25) of one Resident reviewed for activities. The facility census was 34. Findings include: Review of Resident #25's medical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a severely impaired cognition level. Further review of the MDS assessment indicated Resident #25's activity interests included independent activities such as television and music. Review of the Annual Activity assessment, completed on 05/16/22, indicated Resident #25 preferred independent activities such as 1:1 visits. The assessment further identified Resident #25's favorite activities included television, people watching and sitting in the dining room observing other residents and activities. Review of the activity participation records for Resident #25 revealed no evidence of any 1:1 activities provided, no group activity participation and no evidence of any independent activities. Observations conducted intermittently throughout the annual survey on 11/28/22 and 11/29/22 revealed Resident #25 laying in bed without the television on nor any music playing in the room. Interview with Activity Director (AD) #206 on 11/30/22 at 9:40 A.M. verified no evidence of any activity participation and no activities provided for Resident #25 on 11/28/22 and 11/29/22.

Based on observation, interview, record review and facility policy review the facility failed to ensure staff used appropriate hand hygiene when providing incontinence care. This affected one Resident (#24) of one Resident reviewed for bladder and bowel incontinence. The facility census was 34. Findings included: Review of Resident #24's medical record revealed she was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #24's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she was rarely or never understood and was severely impaired with cognitive skills for daily decision making. Review of the Activity for Daily Living (ADL) assistance section revealed she was totally dependent on two plus persons for physical assistance. The MDS also revealed Resident #24 was always incontinent of bladder and bowel. Observation on 11/30/22 at 10:19 A.M. of incontinence care for Resident #24 provided by State tested Nursing Assistant (STNA) #231 and STNA #225 revealed both STNA #231 and #225 did not wash their hands or use hand sanitizer prior to donning (putting on) gloves. Incontinence care was provided using proper technique. During and after completion of Resident #24's incontinence care, STNA #231 touched the handle on the bedside drawer twice, the bed controls, the over bed table, a hair brush, and a teddy bear while wearing the same gloves he had on to provide the incontinence care. After completion of the incontinence care, both STNA #231 and #225 doffed (removed) their gloves and used hand sanitizer. On 11/30/22 at 10:25 A.M. an interview with STNA #231 and STNA #225 verified neither one of them washed their hands or used hand sanitizer prior to donning their gloves. STNA #231 also verified he touched multiple items in the room with the same gloves he wore to provide incontinence care. Review of the facility policy titled, Hand Washing Guidelines, undated, revealed hands should be washed with soap and water or an antiseptic agent used before and after providing routine care and before putting on gloves.

Based on observation, medical record review, review of hospital Emergency Trauma records, review of a sheriff ' s police report, review of the facility Elopement and Missing Resident policy, staff interview, interview with Physician #55 and interview with Paramedic #70, the facility failed to provide adequate supervision to prevent Resident #9 from eloping from the facility. On 01/21/15 at approximately 9:00 A.M. Resident #9, who resided on a secured unit, was found between one quarter and one half mile from the facility by a passerby lying on the ground in the snow. The resident was minimally responsive but conscious. Resident #9 was subsequently transferred to the emergency room where he was assessed to have severe hypothermia with a body temperature of 75.7 degrees Fahrenheit. The resident was intubated, required mechanical ventilation and was transferred to a second hospital for medical intervention including bypass rewarming. This resulted in Immediate Jeopardy for one (Resident #9) of three residents reviewed for accidents. The facility identified 22 independently ambulatory residents. On 01/28/15 at 11:05 A.M., the Director of Nursing (DON), Administrator and Director of Clinical Services were notified Immediate Jeopardy began on 01/21/15 at 3:05 A.M. when Licensed Practical Nurse (LPN) #30 last observed Resident #9 in his room walking to the bathroom. On 01/21/15 at approximately 6:15 A.M. State tested nursing assistant (STNA) #38 identified Resident #9 could not be located in the facility, was missing and a search was initiated. The resident was found, on 01/21/15 at approximately 9:00 A.M., lying in the snow by a passerby between a quarter and a half mile from the facility. The Immediate Jeopardy was removed on 01/22/15 when the facility implemented the following corrective measures: ? On 01/21/15, the facility notified the door alarm company and had them evaluate all exit doors for functioning, including alarms and locking mechanisms. The maintenance director was assigned to monitor the doors until the arrival of the door alarm company. The company arrived within an hour of notification and determined the doors were all functioning properly. The facility changed all codes and egress times on doors were shortened to ten seconds. ? On 01/21/15, the DON began educating all staff in all departments regarding elopements, elopement drill, the alarm system, door checks and frequency of rounds/supervision and change of shift. The education consisted of the need to observe every resident during rounds. All but two STNAs, who were unavailable, had been educated by 1/22/15 at 2:00 P.M. These STNAs were educated on 01/23/15 at 3:30 P.M. The DON and nursing supervisor followed up the education by interviewing staff members regarding what they had been taught. ? On 01/21/15, the facility assigned a staff member to monitor the patio exit door. The assignment for monitoring of the door was discontinued on 01/26/15. Staff checked every two hours every locked/alarmed door. Upon each check every door was functioning properly. Staff continued to check every door every two hours. ? On 01/21/15, the interdisciplinary team, which included the DON, Minimum Data Set (MDS) nurse, nursing supervisor, social service director and administrator met on 1/21/15 and discussed residents with potential elopement risk. A new assessment was completed for Resident #9 and his care plan was updated. The care plan was updated for one other resident, Resident #3 who the facility identified as a potential elopement risk. ? On 01/21/15, the administrator and DON reviewed the facility staffing and added one additional staff member on midnight shift for the facility. ? On 01/22/15 at 2:00 P.M., the door alarm company changed the key pads for consistency on three separate locked doors, installed a new magnet and replaced the pass lock (bypass function) with an alarm button on the patio door at the request of the administrator. Although the Immediate Jeopardy was removed on 01/22/15 the facility remains out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as monitoring of ongoing corrective measures had not been completed and the facility had not completed a comprehensive and thorough investigation, to determine how Resident #9 was able to elope from the facility without any staff knowledge on 01/21/15. Findings include: Review of Resident #9's closed medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #9 was able to make himself understood and was able to understand others. The assessment revealed the resident exhibited moderate cognitive impairment. The assessment also indicated the resident was independently ambulatory in his room and corridor and did not exhibit wandering behaviors. The assessment also indicated Resident #9 had no balance problems while walking. Record review revealed the resident was also a smoker and participated in supervised outside smoking breaks at the facility. An elopement risk assessment, dated 01/12/15 revealed Resident #9 was physically capable of leaving the facility and was confused to time and place. Resident #9 had no history of wandering or elopements. The elopement assessment revealed Resident #9 resided in a facility with coded locked doors. Review of the nursing progress notes from 08/14/14 through 01/20/15 revealed there were no notes indicating Resident #9 voiced a desire to leave the facility or exhibited exit seeking behaviors. Review of the resident ' s current plan of care revealed a plan was in place that reflected the resident exhibited altered cognitive function with episodes of confusion. The care plan revealed the resident would ask why he was in the facility due to his cognitive deficits and also reflected the resident had a [DIAGNOSES REDACTED]. Review of a nursing progress note dated 01/21/15 at 10:07 A.M. revealed LPN #30, who was the LPN assigned to care for Resident #9 on 01/21/15 during the night shift between 12:00 A.M. and 6:00 A.M. documented that at 2:30 A.M., a STNA was taking Resident #9's roommate to the bathroom. Resident #9 was resting in bed with his eyes closed at that time. At 3:05 A.M., LPN #30 observed Resident #9 standing in his room heading toward the bathroom. LPN #30 advised Resident #9 to put a shirt as it was cold. Resident #9 continued into the bathroom at that time. There was no additional documentation related to any additional interactions between LPN #30 and Resident #9 following this. Review of a nursing progress note, dated 01/21/15 at 5:42 P.M., completed by LPN #35, the LPN assigned to the unit Resident #9 resided on during the dayshift on 01/21/15 documented a nurse aide notified her at 6:15 A.M. that Resident #9 was not in his room. LPN #35 added a nursing note at 5:43 P.M. which indicated after a search of Resident #9's room and the facility, she determined Resident #9 was missing. LPN #35 notified the DON, social worker and administrator at 6:30 A.M. LPN #35 assigned staff to search inside and outside the facility and also contacted the sheriff ' s office. Review of the sheriff's report dated 01/21/15, revealed the sheriff ' s office was dispatched to the facility at 6:55 A.M. and arrived at 7:14 A.M The report reflected a missing male resident last seen at 3:00 A.M. wearing a black sweatshirt, navy blue sweatpants and white tennis shoes. The report revealed while searching for the resident, a deputy was stopped by a vehicle occupied by two community members who alerted him of an " elderly person laying in the yard " of a personal residence. The deputy was escorted to the residence by the two community members and identified the male resident, who was lying in the yard, as Resident #9. The sheriff report indicated the squad was notified and responded accordingly. The resident was transferred to the hospital. Review of the hospital's Emergency Trauma Record, dated 01/21/15 revealed the following information: Resident #9 was brought in by squad after he was found to be missing this morning. The history of present illness revealed the resident had last been seen around 3:00 A.M. when he " went outside to smoke " . The resident was found early this morning laying on the ground in the snow. The resident ' s baseline status was unknown and when the squad first arrived he was not responding at all, but upon arrival to the emergency room he was moving his arms and legs and moaning, although did not do anything purposefully. Vital sign documentation for the resident ' s entire emergency room visit included two temperatures, the resident ' s temperature at 10:04 A.M. was 75.7 degrees Fahrenheit (normal 98.6 degrees) and at 10:51 A.M. was 77.2 degrees Fahrenheit. The resident ' s pupils were minimally reactive to light, his limbs were cold with decreased radial and tibial pulses. Neurologically, the resident ' s eyes opened spontaneously, however he was making incomprehensible sounds. The resident required intubation with mechanical ventilation and after being stabilized was transferred to another hospital for further care and treatment. On 01/22/15 at 7:39 A.M., observations of the residents ' living areas in the facility revealed there were six exits, all with keypads. Off the 100 hall, where Resident #9 resided, was an exit at the end of the hall by the sunroom and an exit to the main lobby. Around the corner of the 100 hall and between the 100 hall and the nursing station was an exit to a patio area with a ramp. There were two exits off the 200 hall, one on either end. The sixth exit was at the end of the 300 hall and led to the basement. On 01/22/15 at 7:39 A.M., Maintenance director #42 was interviewed and stated as part of the facility investigation, he attempted to determine if Resident #9 had left the facility when an ambulance company came to the facility earlier the morning of 01/21/15 to transport another resident, Resident #31. The director was unable to provide evidence as to whether or not this was actually how the resident left the facility without staff knowledge. On 01/22/15 between 7:40 A.M. and 8:15 A.M., the DON and administrator were interviewed. The DON and Administrator verified Resident #9, who resided on a unit that was locked and had a key code to exit, had eloped from the facility on 01/21/15 sometime between 3:05 A.M. and 6:15 A.M. During the interview, the DON indicated maintenance checked the doors every day to determine if they were functioning properly. The doors had been checked on 01/20/15 at 10:00 A.M. The DON stated after Resident #9 was missing, STNA #50 attempted to exit the facility. The STNA discovered she was able to push the patio door, located between the 100 hall and the nursing station open without the alarm sounding. The DON indicated there had been no previous problems with this door. When the sheriff ' s department arrived onsite at the facility on 01/21/15, the DON attempted to demonstrate for law enforcement officers how the door alarm system operated and found the door again opened without alarming. The door alarm company was contacted and arrived onsite on 01/21/15 at 10:30 A.M. The alarm company indicated all six exit doors were found to be operating properly. The facility was afraid there might have been an issue with the locking system and asked the company to change the equipment at that time. During the interview the administrator also indicated that all the facility doors which exited off the resident areas were locked with a key code lock and that none of the residents were provided the codes for exit. On 01/27/15 at 9:43 A.M., interview with LPN #30 revealed she was assigned to care for Resident #9 on 01/21/15. The LPN indicated she saw Resident #9 at 3:05 A.M. when she was on her way to respond to another resident ' s personal alarm. LPN #30 stated she saw Resident #9 heading toward the bathroom that was in his room with no shirt on. LPN #30 stated she informed Resident #9 he should put a shirt on so he didn ' t get cold. LPN #30 stated Resident #9 proceeded to the bathroom and she responded to the personal alarm of Resident #7. LPN #30 stated she did not observe Resident #9 the remainder of the shift which ended at 6:00 A.M. On 01/27/15 at 6:21 A.M., interview with STNA #40 revealed she arrived at work on 01/21/15 around 5:55 A.M. Upon arrival, she completed walking rounds with STNA #38, which involved walking and discussing each resident she was assigned to care for. When rounds were completed, Resident #9 ' s roommate was observed in her bed but Resident #9 was not observed in his bed. The bathroom light was on and the STNAs assumed he was in the bathroom. STNA #40 stated the nursing assistants proceeded with their rounds. At 6:15 A.M., Resident #9 ' s roommate rang her call light to request assistance with toileting. STNA #38 responded to the call light and determined Resident #9 was missing. During the interview the STNA indicated she assisted with searching for Resident #9 and was unable to provide any information as to how or why the resident might have been able to exit the facility without staff knowledge. On 01/27/15 at 6:27 A.M., interview with STNA #38 revealed the nursing assistants had done rounds around 6:00 A.M. for change of shift, which was at the beginning of her shift. During rounds, Resident #9 was not observed in his bed but the bathroom light was on. The STNA indicated Resident #9 was independently ambulatory and able to use the bathroom independently. STNA #38 indicated when she returned to the resident ' s room at 6:15 A.M., she was unable to locate Resident #9 and informed LPN #35. On 01/27/15 at 7:25 A.M., interview with LPN #35 revealed when STNA #38 reported to her that Resident #9 was not in his room she requested STNA #38 look for the resident in the sunroom, located at the end of the 100 unit hall because the light was on. When staff was unable to find Resident #9 in the sun room, she initiated the elopement policy and had staff search the building. LPN #35 stated the night shift nurse, LPN #30, was still in the facility at that time. After searching the facility and identifying the resident could not be located, the local police were called. LPN #35 indicated she was notified the resident was found by the sheriff ' s department. On 01/28/15 at 4:10 P.M. interview with STNA #50 via phone revealed she was the STNA assigned to care for Resident #9 on 01/21/15. The STNA revealed she last saw Resident #9 on 01/21/15 at 2:30 A.M. STNA #50 stated that although she completed rounds at 4:00 A.M. and 6:00 A.M., she did not physically see Resident #9 when she was making rounds at those times. The STNA stated she left the facility at the end of her shift, on 01/21/15 at 6:10 A.M. The STNA stated that when she left she saw the patio door was set on bypass. Being set on bypass meant a key was inserted and turned which allowed the facility to turn off the alarming mechanism. Therefore, the door alarm was bypassed and would not alarm if it was opened. The STNA indicated she thought the door had been set on bypass since the smoke break on 01/20/15 at 8:00 P.M. The STNA stated when she left at 6:10 P.M., she was unaware that Resident #9 was missing from the facility. On 01/28/15 at 4:23 P.M., interview with Resident #9 ' s primary physician, Physician #55 revealed the physician was aware of the incident in which the resident eloped from the facility on 01/21/15. Physician #55 stated in the interview that the resident would not be safe to be outside unattended. On 01/30/15 at 10:20 A.M., telephone interview with Paramedic #70 revealed he was one of the paramedics who responded to the call when Resident #9 was found. The paramedic revealed the call had come in at 9:03 A.M. regarding the resident being located laying in the snow near a tree just over an embankment off the side of the road the facility was on. The paramedic revealed, when he arrived to the scene the resident was observed wearing sweatpants, a light sweatshirt and tennis shoes. The paramedic indicated it had been snowing and freezing rain and the resident ' s clothes were wet when he arrived to the scene. After cutting off the resident ' s clothes, warming packets/blankets and warm intravenous fluids were administered to attempt to warm the resident. The resident was transported to the hospital from the scene for further treatment. Review of the facility Elopement and Missing Resident policy, revised March 2003 revealed if a resident was not found, staff were to search the resident ' s unit and any areas within the facility the resident frequented. If the resident was still not located, the administrator, DON, director of environmental services, and nursing supervisor were to be notified. The person in charge would then coordinate a search and assign staff areas to search. This deficiency substantiates Complaint Number OH 615.