Every finding on record at St. Theresa Care Center

Based on observations, resident and staff interviews, review of Resident Council and Food Committee meeting minutes, observation of a meal test tray, and review of facility policy, the facility failed to ensure meals were served at palatable temperatures. This had the potential to affect all residents, except two (#1 and #5) identified by the facility as receiving no food from the kitchen. The facility census was 76.Findings include: Observations on 01/07/26 at 2:47 P.M. of the kitchen revealed the plate warmer equipment was not fully functional. Further observation revealed the hot plate pellet system only had one side of the equipment in service and could hold approximately 30 plates at a time. Interview on 01/07/26 at 2:47 P.M. with [NAME] #300 verified the plate warmer equipment was not fully operational and only one side of the equipment worked. [NAME] #300 stated the equipment had not worked for several months and was not aware of any repairs pending completion. Interview on 01/07/26 at 2:50 P.M. with Dietary Manger (DM) #500 verified the plate warmer equipment had not been in service for several months and was unaware of any plans to repair it. DM #500 stated hot foods should be at least 135 degrees Fahrenheit (F) when served to the residents. DM #500 verified there were resident complaints during the November Food Committee meeting and there were ongoing resident complaints regarding hot food temperatures being cold.Interview on 01/08/26 at 8:50 A.M. with Resident #49 revealed the facility food was not hot enough.Observation on 01/08/26 at 12:45 P.M. of a lunch meal test tray revealed the following temperatures: chicken was 112 degrees F, potatoes were 113 degrees F, and the carrots were 114 degrees F. The food items were not hot when tasted.Interview on 01/08/26 at 1:32 P.M. with Resident #35 revealed the meals served by the facility were not hot enough.Interview on 01/08/26 at 1:40 P.M. with Resident #34 revealed food was not hot when it was served.Interview on 01/08/26 at 2:00 P.M. with Resident #21 revealed meals were cold when served.Review of the Food Committee Meeting minutes dated 09/23/25 revealed the residents in attendance voiced concerns related to hot food temperatures being cold. Review of the Resident Council Meeting minutes dated 11/21/25 revealed residents voiced concerns related to hot food temperatures being cold.Review of the facility policy titled, Temperatures of Safe Food Handling, dated 2023, revealed all hot foods should be served hot at 135 degrees F or higher.This deficiency represents noncompliance investigated under Complaint Number 2665253.

Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to ensure a dignified dining experience. This affected three (#60, #4 and #68) of three residents reviewed for dignity during meal service. The facility census was 76. Findings include:1. Review of Resident #60's medical record revealed an admission date of 09/09/21. Diagnoses included dementia, dysphagia and respiratory failure.Review of the Minimum Data Set, (MDS) assessment, dated 10/26/25, revealed Resident #60 had severely impaired cognition and was dependent on staff for eating.Additional review of the medical record revealed Resident #60 received a puree consistency diet and resided on the memory care unit. 2. Review of Resident #4's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included dementia and dysphagia.Review of the MDS assessment, dated 12/18/25, revealed Resident #4 had severely impaired cognition and was dependent on staff for eating. Additional review of the medical record revealed Resident #4 received a puree consistency diet and resided on the memory care unit. 3. Review of Resident #68's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included dementia and encephalopathy. Review of the MDS assessment, dated 01/06/26, revealed Resident #68 had severely impaired cognition and required staff assistance for eating. Additional review of the medical record revealed Resident #68 received a puree diet and resided on the memory care unit. Observation on 01/08/26 at 12:45 P.M. of the memory care unit dining room revealed Resident #60, Resident #4 and Resident #68 were sitting at the same dining room table with lunch meal trays in front of them. Continued observation revealed Certified Nursing Assistant (CNA) #600 was standing while providing eating assistance to Resident #60, Resident #4 and Resident #68.Interview on 01/08/26 at 12:45 P.M. with CNA #600 verified she stood while providing eating assistance to Resident #60, Resident #4, and Resident #68. CNA #600 confirmed she should sit beside the residents when providing assistance with eating. CNA #600 further stated she stood because she would not have been able to reach all three residents if she sat with them. Interview on 01/08/26 at 12:55 P.M. with the Director of Nursing (DON) confirmed CNA #600 should have sat with Resident #60, Resident #4, and Resident #48 while providing eating assistance. The DON further stated it was a resident dignity concern when staff stood over a resident while providing eating assistance. Review of the facility policy titled, Resident Dignity and Feeding Practices, undated, revealed the staff should sit at eye level with the resident.

Based on medical record review, review of a facility submitted Self-Reported Incident (SRI), review of staff timecards and schedules, review of a police report, staff interview and policy review, the facility failed to prevent potential abuse following an allegation of staff to resident verbal abuse. This affected one (#30) of three residents reviewed for abuse. The facility census was 76.Findings include:Record review for Resident #30 revealed this resident was admitted to the facility on [DATE]. Diagnoses included lack of coordination, Type II diabetes, and anxiety disorder. Review of the most recent Minimum Data Set (MDS) assessment, dated 01/06/26, revealed Resident #30 had intact cognition, as evidenced by a Brief Interview for Mental Status (BIMS) score of 15. Resident #30 was assessed to require setup or clean up assistance for eating, oral hygiene, and dressing, supervision or touching assistance for toileting and personal hygiene, and partial to moderate assistance for showers/bathing. Review of a facility submitted SRI, created 12/24/25 at 9:49 P.M., revealed on 12/24/25, Resident #30 alleged Licensed Practical Nurse (LPN) #126 threatened to harm her under his breath. Resident #30 called the police and the Administrator to report the alleged verbal abuse. The resident reported to the police that they did not need to further pursue the incident due to the resident feeling safe and the notification to the Administrator. The SRI revealed LPN #126 was put on suspension due to the pending investigation. The Administrator spoke on the phone to Resident #30, LPN #126, and the responding police officer. Review of the police report revealed Resident #30 called the police on 12/24/25 at 8:32 P.M. and the police arrived to the scene at 12/24/25 at 8:57 P.M. Review of the timecard punches revealed LPN #126 clocked in on 12/24/25 at 6:59 P.M. and clocked out on 12/25/25 at 7:18 A.M. Review of the staffing schedules revealed LPN #126 did not work on 12/25/25, 12/26/25, 12/27/25, 12/28/25, 12/29/25, and 12/30/25. Interview on 01/08/26 at 10:49 A.M. with the Administrator confirmed she spoke with Resident #30 about the verbal abuse allegations involving LPN #126 on 12/24/25, prior to the police arriving at the facility. The Administrator verified LPN #126 was not suspended immediately, pending outcome of the investigation into the allegation, and LPN #126 finished his shift on another floor. The Administrator stated LPN #126 was suspended for six days at the end of his shift on the morning of 12/25/25. The Administrator confirmed LPN #126 was allowed to finish his shift after the allegation was made due to not feeling as he was a threat. Review of the facility policy titled, Residents Right to Freedom From Abuse, Neglect, and Exploitation, dated 2025, revealed in response to allegations of abuse, neglect, exploitation, or mistreatment, the facility shall prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation was in process. This deficiency represents non-compliance investigated under Complaint Number 2702171.

Based on resident and staff interviews, record review, and facility policy review, the facility failed to ensure the residents had had access to their personal funds outside of normal business hours and on weekends. This affected one (Resident #9) of one resident reviewed for personal funds. Findings included: Review of Resident #9's admission record revealed Resident #9's admission date was 05/25/23. Review of the annual Minimum Data Set (MDS) assessment date 04/04/25 revealed Resident #9 had intact cognition. During an interview on 06/11/25 at 10:12 A.M., Business Office Manager #100 stated she believed residents went to the front desk during the week from 8:00 A.M. to 8:00 P.M. to request money from their personal funds from either Receptionist #12 or Receptionist #13. During an interview on 06/11/25 at 10:23 A.M., Receptionist #12 stated the hours the residents could receive money from their personal fund was Monday through Friday from 8:00 A.M. to 5:00 P.M. Receptionist #12 stated on the weekends, the residents knew they could not obtain any of their money. During an interview on 06/11/25 at 11:35 A.M., Resident #9 stated they used to have a problem with getting money with Former Administrator #140 and it typically took at least three days to get any of their requested money. Resident #9 stated they had not asked for money outside of business hours because they knew they could not get it if they wanted or needed it. During an interview on 06/13/25 at 11:22 A.M., the Administrator stated she expected the residents to have access to their personal funds seven days a week. Review of the facility policy titled Transactions Involving Resident Funds dated 07/01/23 revealed the Business Office Manager, or his/her designee, is responsible for providing residents with receipts for withdrawals and for requested or needed personal items when such funds are withdrawn from the resident's personal funds account managed by the facility. The policy did not address when residents should have access to their personal funds accounts or how personal funds were made available to residents after hours and on weekends. This deficiency represents non-compliance investigated under Complaint Number OH00162377.

2. Review of the Resident #176's medical record revealed an admission date of 05/21/25. Diagnoses included rheumatoid arthritis, chronic pain syndrome, and fibromyalgia. The Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #176 had intact cognition. Review of Resident #176's care plan revealed a focus area initiated 05/21/25, indicating the resident was at risk for alteration in their comfort related to generalized pain, discomfort, fibromyalgia, chronic pain, depression, and rheumatoid arthritis. Interventions directed staff to administer analgesia per orders and to anticipate the resident's need for pain relief and to respond immediately to any complaints of pain. Review of the SRI dated 05/27/25 revealed Resident #176's family expressed to hospital staff that a facility staff member was rough and verbally mean to the resident. The facility notified the State Survey Agency of the allegation of physical and emotional/verbal abuse on 05/27/25 at 3:59 P.M. During an interview on 06/10/25 at 2:50 P.M., the Director of Nursing (DON) stated when she assessed Resident #176's skin on 05/23/25, the resident reported that on the previous night shift, the staff were rough when they repositioned them. The DON stated she treated this allegation more like a grievance rather than an abuse allegation because she thought it was more related to resident care. The DON stated when Resident #176 was at the hospital a few days later, their family member voiced concerns to the hospital case manager related to abuse and care received in the facility on 05/23/25. Per the DON, once the hospital staff notified the facility of the abuse allegation on 05/27/25, the facility reported the allegation of abuse to the State Survey Agency. During a follow-up interview on 06/13/25 at 10:09 A.M., the DON stated she expected staff to report any allegation of abuse immediately. The DON stated she did not feel like Resident #176's concern of staff being too rough with them was an allegation of abuse because of the resident's history having pain. The DON thought it was more of a care concern and that staff needed to take their time when they repositioned the resident. During an interview on 06/13/25 at 10:34 A.M., the Administrator stated she expected all staff to report any allegations of abuse or neglect, then she had two hours to submit the initial report to the State Survey Agency. When Resident #176 reported to the DON that the night shift staff were rough with them, she followed up with the resident and addressed their concerns. The Administrator stated the resident used the key word rough but did not allege abuse the previous night, so they did not report the allegation. The Administrator stated that when the hospital notified her that Resident #176 alleged facility staff were physically rough with them, that was when they submitted the initial report to the State Survey Agency. Review of the facility policy titled Abuse, Neglect and Exploitation with a copyright date of 2025, indicated the facility will have written procedures that included reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specified timeframes: a. Immediately, but not later than twp hours after the allegation is made, if the event that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. This deficiency represents non-compliance investigated under Complaint Numbers OH00166090, OH00164707, and OH00162351. Based on staff interview, record review, review of the facilities Self-Reported Incidents (SRI), and facility policy review, the facility failed to timely report allegations of physical and/or emotional abuse to the State Survey Agency. This affected three (Residents #7, #176, and #276) of five residents reviewed for abuse. The facility census was 80. Findings included: 1. Review of Resident #7's medical record revealed an admission date of 04/21/23. Diagnoses included Alzheimer's disease, dementia with agitation, dementia with psychotic disturbance, and cognitive communication deficit. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was independent in cognitive skills for daily decision making. Review of the Resident #7's progress notes, electronically signed by Licensed Practical Nurse (LPN) #5 and dated 03/04/25 at 7:38 A.M., indicated the resident was attacked by another resident (Resident #276) with an eye glass case on the right side of their head. Resident #7 was heard screaming and stated, I just got hit with eye glasses by this [man/woman] (Resident #276) standing next to me. Resident #7 was immediately assessed and no injury was noted, but the resident complained of pain to the right side of their head and as needed Tylenol (treats mild pain) was administered as requested. The physician, resident family, and management were made aware. Review of Resident #276's medical record revealed an admission date of 03/08/24 with a diagnosis of chronic obstructive pulmonary disease. The quarterly MDS assessment dated [DATE] revealed Resident #276 had severe cognitive impairment. The progress note, electronically signed by LPN #5 and dated 03/04/25 at 7:16 A.M., indicated Resident #276 walked to another resident (Resident #7) and attacked them with an eye glass case in the head. LPN #5 immediately assisted Resident #276 to a different location and educated the resident not to hit other residents with an eye glass case. The physician, resident family, and management were made aware. Review of the facility's SRI from 03/04/25 to 06/11/25 revealed the facility did not report the physical abuse allegation between Resident #276 and Resident #7 to the State Survey Agency. During an interview on 06/12/25 at 9:36 A.M., LPN #5 stated that on the day of the incident (03/04/25), Resident #7 sat in the television room and yelled at Resident #276. Resident #276 responded to Resident #7 by hitting them on their head with their eyeglasses case. LPN #5 stated she reported the incident to risk management immediately after the incident occurred. During an interview on 06/12/25 at 1:25 P.M., Former Administrator #140 stated he did remember the incident between Resident #276 and Resident #7. Former Administrator #140 stated Resident #7 was very territorial and always had to feel in charge. Former Administrator #140 stated he believed the incident had been reported to the State Survey Agency. During an interview on 06/12/25 at 10:38 A.M., the Administrator verified the facility had not submitted a facility-reported incident to the State Survey Agency following the incident between Resident #276 and Resident #7 on 03/04/2025. During an interview on 06/13/25 at 10:10 A.M., the Director of Nursing (DON) stated the management team was initially told that if two cognitively impaired residents did not know what they were doing and had an altercation, the facility could just separate the residents involved and do nothing further. The DON stated she learned any time there was a physical altercation between two residents even if the residents were cognitive impaired, the altercation had to be reported. The DON stated her expectation was any sort of perception of abuse by a staff member or resident-to-resident, no matter how big or small, the allegation would be reported immediately. During a follow-up interview on 06/13/25 at 10:36 A.M., the Administrator stated the time frame to report an allegation of abuse was immediately or within two hours.

Based on staff interview, record review, review of Self-Reported Incidents (SRI) and time cards, and facility policy review, the facility failed to immediately protect the resident(s) from the alleged perpetrator(s) when a resident reported an allegation of staff-to-resident physical abuse. This affected one (Resident #176) of five residents reviewed for abuse. Findings included: Review of the Resident #176's medical record revealed an admission date of 05/21/25. Diagnoses included rheumatoid arthritis, chronic pain syndrome, and fibromyalgia. The Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #176 had intact cognition. Review of Resident #176's care plan revealed a focus area initiated 05/21/25, indicating the resident was at risk for alteration in their comfort related to generalized pain, discomfort, fibromyalgia, chronic pain, depression, and rheumatoid arthritis. Interventions directed staff to administer analgesia per orders and to anticipate the resident's need for pain relief and to respond immediately to any complaints of pain. Review of the SRI dated 05/27/25 revealed Resident #176's family expressed to hospital staff that a facility staff member was rough and verbally mean to the resident. Review of time cards for the timeframe 05/22/25 to 05/27/25 revealed Certified Nursing Assistant (CNA) #3 worked in the facility from 7:14 P.M. on 05/22/25 to 7:19 A.M., on 05/23/25, from 8:05 P.M. on 05/23/25 to 7:16 A.M. on 05/24/25, and from 6:51 P.M. on 05/24/25 to 7:00 A.M. on 05/25/25. Registered Nurse (RN) #4's time cards for the timeframe 05/22/25 to 05/27/25 revealed RN #4 worked in the facility from 6:55 P.M. on 05/22/25 to 7:21 A.M. on 05/23/25 and from 7:09 P.M. on 05/24/25 to 7:18 A.M. on 05/25/25. During an interview on 06/10/25 at 2:50 P.M., the Director of Nursing (DON) stated when she assessed Resident #176's skin on 05/23/25, the resident reported that on the previous night shift, the staff were rough when they repositioned them. The DON stated she treated this allegation more like a grievance rather than an abuse allegation because she thought it was more related to resident care. The DON stated when Resident #176 was at the hospital a few days later, their family member voiced concerns to the hospital case manager related to abuse and care received in the facility on 05/23/25. Per the DON, once the hospital staff notified the facility of the abuse allegation on 05/27/25, the facility reported the allegation of abuse to the State Survey Agency, suspended CNA #3 and RN #4 and began an investigation. During a follow-up interview on 06/13/25 at 10:09 A.M., the DON stated she expected staff to report any allegation of abuse immediately. The DON stated the facility should protect the resident following an allegation of abuse, and the facility should immediately suspend the alleged perpetrator pending investigation. The DON verified CNA #3 and RN #4 were not immediately suspended following the initial allegation on 05/23/25 but were suspended once the facility was notified by the hospital of the allegation on 05/27/25. The DON verified CNA #3 and RN #4 worked in the facility between 05/23/25 and 05/27/25 but did not work with Resident #176. During an interview on 06/13/25 at 10:34 A.M., the Administrator stated she expected all staff to report any allegations of abuse or neglect. When Resident #176 reported to the DON that the night shift staff were rough with them, she followed up with the resident and addressed their concerns. The Administrator stated the resident used the key word rough but did not allege abuse the previous night, so they did not report the allegation. The Administrator stated that when the hospital notified her that Resident #176 alleged facility staff were physically rough with them, that was when they suspended CNA #3 and RN #4 and started the investigation. Review of the facility policy titled Abuse, Neglect and Exploitation, with a copyright date of 2025, under Protection of Resident, the facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to responding immediately to protect the alleged victim and integrity of the investigation and make room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator. This deficiency represents non-compliance investigated under Complaint Numbers OH00166090 and OH00162351.

Based on interview, record review, and facility policy review, the facility failed to refer to the appropriate state-designated authority for a level II pre-admission screening and resident review (PASARR) when residents were diagnosed with a new mental illness diagnosis. This affected one (Resident #21) of five residents reviewed for PASARR. Findings included: Review of Resident #21's medical record revealed an admission date of 04/20/24 with a diagnosis of paranoid schizophrenia. Resident #21 received a diagnosis of anxiety disorder on 02/21/25. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #21 had severe cognitive impairment. Resident #21 had active diagnoses to include anxiety disorder and schizophrenia. Review of Resident #21's care plan revealed a focus area initiated 10/10/24, which indicated the resident was prescribed psychotropic medication, was at risk for adverse reactions, and had a diagnosis of paranoid schizophrenia. Interventions directed the staff to administer psychotropic medications as ordered by the physician and observe for side effective and effectiveness every shift. Resident #21's medial record revealed no evidence the resident was referred to the appropriate state-designated authority for a level II PASARR once the resident was diagnosed with a new mental illness diagnosis on 02/21/25. During an interview on 06/10/25 at 1:31 P.M., the Social Services Director (SSD) #105 stated she was responsible for the residents' PASSARRs in the facility. SSD #105 stated if a resident developed a new mental illness diagnosis after admission, she was responsible for submitting a new PASARR. During an interview on 06/13/25 at 10:19 A.M., the Director of Nursing (DON) stated all she knew about a PASARR was that it was needed upon a resident admission to the facility and related to a mental illness diagnosis. The DON stated the PASARR needed to be updated if a resident received a new mental illness diagnosis. During an interview on 06/13/25 tat 10:43 A.M., the Administrator stated social services should update a resident's PASARR when a resident had a new mental illness diagnosis. Review of the facility policy titled Resident Assessment-Coordination with PASARR Program dated 07/01/23 revealed any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review.

2. Review of Resident #21's medical record revealed an admission date of 04/29/24 with a diagnosis of paranoid schizophrenia. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had severe cognitive impairment and had an active diagnosis of schizophrenia. Resident #21's Preadmission Screening and Resident Review Result Notice dated 05/03/24, indicated the resident had no indications of a serious mental illness and/or developmental disability. During an interview on 06/10/25 at 1:31 P.M., Social Services Director (SSD) #105 stated she was responsible for the residents' PASARRs in the facility, but she did not know who was responsible to ensure the accuracy of the PASARR. SSD #105 stated she assumed the PASARR should be accurate when the resident admitted to the facility from a hospital. SSD #105 stated she should have submitted a new PASARR for Resident #21 since it appeared the one that came from the hospital was inaccurate. During an interview on 06/13/25 at 10:19 A.M., the Director of Nursing (DON) stated all she knew about a PASARR was that it was needed upon a resident admission to the facility and related to a mental illness diagnosis. The DON stated if the facility needed the PASARR, social services and admissions should work closely together to ensure the PASARR was in place. During an interview on 06/13/25 at 10:43 A.M., the Administrator stated the social worker should review a resident's PASARR to make sure it was correct. The Administrator stated she expected a resident's PASARR to be 100% accurate. 3. Review of Resident #24's medical record revealed an admission date of 05/25/23. Diagnoses included generalized anxiety disorder, schizoaffective disorder, bipolar type, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #24 had severe cognitive impairment and had active diagnoses including anxiety disorder, depression, bipolar disorder, and schizophrenia. Resident #24's Hospital Exemption from Preadmission Screening Notification dated 07/20/24, indicated the resident did not have a mental illness diagnosis. During an interview on 06/10/25 at 1:31 P.M., Social Services Director (SSD) #105 stated she was responsible for the residents' PASARRs in the facility, but she did not know who was responsible to ensure the accuracy of the PASARR. SSD #105 stated she assumed the PASARR should be accurate when the resident admitted to the facility from a hospital. During a follow-up interview on 06/10/25 at 1:40 P.M., SSD #95 stated Resident #24's PASARR was inaccurate and it should have been resubmitted to include the resident's new mental diagnosis. During an interview on 06/13/25 at 10:19 A.M., the Director of Nursing (DON) stated all she knew about a PASARR was that it was needed upon a resident admission to the facility and related to a mental illness diagnosis. The DON stated if the facility needed the PASARR, social services and admissions should work closely together to ensure the PASARR was in place. During an interview on 06/13/25 tat 10:43 A.M., the Administrator stated the social worker should review a resident's PASARR to make sure it was correct. The Administrator stated she expected a resident's PASSAR to be 100% accurate. Review of the facility policy titled Resident Assessment-Coordination with PASARR Program, dated 07/01/23, revealed all applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. The Social Services Director shall be responsible for keeping track of each resident's PASARR screening status and referring to the appropriate authority. Based on interview, record review, and facility policy review, the facility failed to ensure the accuracy of the pre-admission screening and resident review (PASARR) for the residents and failed to ensure the PASARR was completed on or before admission to the facility. This affected three (Residents #21, #24, and #38) of five residents reviewed for PASARR. Findings included: 1. Review of Resident #38's medical record revealed an admission date of 12/26/24. Diagnoses included dementia with other behavioral disturbance, psychosis, major depressive disorder, and generalized anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #38 had moderate cognitive impairment and active diagnoses which included anxiety disorder, depression, and psychotic disorder. Resident #38's Preadmission Screening and Resident Review Identification Screen dated 12/26/24, indicated the resident did not have a mental illness diagnosis. During an interview on 06/10/25 at 1:31 P.M., the Social Services Director (SSD) #105 stated she was responsible for the residents' PASARRs in the facility, but she did not know who was responsible to ensure the accuracy of the PASARR. SSD #105 stated she assumed the PASARR should be accurate when the resident admitted to the facility from a hospital. During a follow-up interview on 06/10/25 at 2:06 P.M., SSD #105 stated admissions was responsible for ensuring the PASARR was correct. SSD #105 agreed Resident #38's PASARR was not correct. During an interview on 06/10/25 at 2:00 P.M., Admissions/Marketing Director #110 stated social services was responsible for ensuring a resident's PASARR was correct. Admissions/Marketing Director #110 agreed Resident #38's PASARR was not correct. During an interview on 06/13/25 at 10:19 A.M., the Director of Nursing (DON) stated all she knew about a PASARR was that it was needed upon a resident admission to the facility and related to a mental illness diagnosis. The DON stated if the facility needed the PASARR, social services and admissions should work closely together to ensure the PASARR was in place. During an interview on 06/13/25 tat 10:43 A.M., the Administrator stated the social worker should review a resident's PASARR to make sure it was correct. The Administrator stated she expected a resident's PASARR to be 100% accurate.

Based on observation and interview, the facility failed to ensure the medications were securely stored. This affected one of five medications carts. Findings included: During an observation on 06/12/25 at 6:08 A.M., the surveyor noted an unlocked medication cart parked in the doorway facing a resident's room. Licensed Practical Nurse (LPN) #10 was inside a different resident's room, and the unlocked medication cart was not within her line of sight. During an interview on 06/12/25 at 6:10 A.M., LPN #10 stated medication carts should be locked when not in the line of sight of the nurse, because someone could access the medications stored inside the cart. During an interview on 06/12/25 at 7:03 A.M., the Director of Nursing stated she expected medication carts to be locked when not within the line of sight of the nurse. During an interview on 06/13/25 at 11:19 A.M., the Administrator stated she expected medication carts to be locked any time they were not within the nurse's line of sight to prevent residents from being able to access medications stored inside the carts.

2. During a concurrent interview and medication administration observation on 06/12/25 at 6:39 A.M., Licensed Practical Nurse (LPN) #10 removed a Prilosec (reduces the amount of acid produced in the stomach) and vitamin B-12 (vitamin) tablet from a bottle, placed them in her bare hand before she placed the tablets in a medication cup, and proceeded to administer the medications to Resident #72. LPN #10 verified she touched the two medications with her bare hands and stated she should never touch the medications with her hands, the medication should be dispensed directly into a medication cup to prevent cross contamination. During an interview on 06/12/25 at 7:03 A.M., the Director of Nursing stated she expected when nurses dispensed medications, they should dispense the medications directly into medication cups without touching the medications. During an interview on 06/13/25 at 11:20 A.M., the Administrator stated she expected the nurses to follow their policy during medication administration to ensure medications were not handled prior to administering them to the residents to prevent the possibility of cross contamination. Review of the facility policy titled Medication Administration, with a copyright date of 2025, revealed medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. The policy included to remove medication from source, taking care not to touch medication with bare hand. Based on observation, interview, record review, review of Centers for Disease Control and Prevention (CDC) guidance, and facility policy review, the facility failed to ensure staff performed hand hygiene during the provision of wound care for a resident and failed to ensure staff did not touch medications with their bare hands during medication administration. This affected one (Resident #36) of three residents reviewed for pressure ulcers and one (Resident #72) of six residents observed for medication administration. Findings included: 1. Medical record review revealed Resident #36 was admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #36 had intact cognition. Resident #36 had two stage IV pressure ulcers (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed) that were present on admission/reentry. During a concurrent interview and wound care observation on 06/11/25 at 10:42 A.M., Assistant Director of Nursing (ADON) #150 performed wound care treatment on Resident #36's sacral wound. ADON #150 was assisted by Licensed Practical Nurse (LPN) #2. ADON #150 cleansed the resident's wound, performed the treatment, and dressed the resident's wound without ever changing his gloves. While still wearing the same gloves, ADON #150 wore when he cleansed the resident's round, ADON #150 touched the resident's bed sheets, bed rails, over-the-bed table, eye glasses, cellular phone and pillow. ADON #150 was noted to remove his personal protective equipment, a gown and gloves, then he brought the contaminated items used during wound care up to his chest and pressed them up against his shirt and proceeded to walk through the resident's room with these items in contact with his person. When asked about the break in infection control, ADON #150 replied, What, what was the problem. My gloves are clean. When asked about holding the soiled supplied to his chest, ADON #150 shook his head and had no response. During an interview on 06/13/25 at 10:00 A.M., the Director of Nursing stated she could not believe ADON #150 had such trouble with wound care and commented ADON #150 must have been nervous. During an interview on 06/13/25 at 11:00 A.M., the Administrator stated that was not ADON #150's usual standard, he ADON knew the correct procedure. Review of the facility policy titled Clean Dressing Change, dated 07/01/23, revealed it is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross-contamination. Wash hands and put on clean gloves. Cleanse the wound as ordered, taking care not to contaminate other skin surfaces or other surfaces of the wound. Measure wound using disposable measuring guide. Wash hands and put on clean gloves. Apply topical ointments or creams and dress the wound as ordered. Protect surrounding skin as indicated with skin protectant. Secure dressing. Discard disposable items and gloves into appropriate trash receptacle and wash hands. Review of CDC guidance titled Clinical Safety: Hand Hygiene for Healthcare Workers found at https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html and dated 02/27/24 revealed hand hygiene protects both healthcare personnel and patients. Cleaning your hands reduces the potential spread of deadly germs to patients. Recommendations included on know when to wear (and change) gloves stated gloves are not a substitute for hand hygiene. If your tasks requires gloves, perform hand hygiene before donning gloves and touching the patient or the patients surroundings; always clean your hands after removing gloves. When to change gloves and clean hands included if gloves become soiled with blood or body fluids after a task, if moving from work on a soiled body site to a clean body site on the same patient or if clinical indication for hand hygiene occurs, and before exiting a patient room.

Based on record review, observation, staff interview, review of online resources from the Centers for Disease Control (CDC), and policy review, the facility failed to ensure staff utilized proper handwashing technique while completing wound care. This affected one (#15) of the three Residents (#13, #14, and #15) reviewed for wound care. The facility census was 65. Findings include: Review of the medical record for Resident #15 revealed the resident was admitted on [DATE]. Diagnoses included, but not limited to, Stage IV (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed) sacral decubitus ulcer, depression, pulmonary embolism, and osteomyelitis. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #15 had mild cognitive deficits and required extensive assistance with activities of daily living (ADLs). Review of the care plan dated 04/23/24, revealed Resident #15 had skin breakdown/open area to bilateral gluteal folds and the left fifth toe that was present upon admission. Review of physician orders dated 06/20/24 for Resident #15 revealed resident was ordered to have left buttock cleaned with normal saline or wound cleanser then pat dry. Apply moistened gauze with Dakin's one quarter strength every shift. Observation of wound care /dressing change on 06/30/24 from 10:00 A.M. to 10:19 A.M. for Resident #15 and being completed by Registered Nurse (RN) #31 and Licensed Practical Nurse (LPN) #30, revealed RN #31 removed the resident's incontinence brief and soiled dressings. RN #31 removed her soiled gloves and put on new gloves without sanitizing or washing her hands. RN #31 then cleansed the left buttock area with normal saline, applied Dakin's moistened gauze and covered it with a protective dressing. RN #31 then cleansed the right gluteal fold skin area with normal saline and applied a protective dressing. RN #31 did not wash or sanitize her hands when going from a work area of a soiled body part to a clean body site. Interview on 06/30/24 at 10:31 A.M. with LPN #55 verified that RN #31 did not wash or sanitize her hands when going from a soiled work area to a clean body site. Review of the undated New Hire Orientation on Handwashing guidelines revealed staff were to change gloves between tasks and procedures on the same resident. Review of online resources from CDC (https://www.cdc.gov/handhygiene/providers/guideline.html) dated 01/30/20, revealed healthcare personnel should complete hand hygiene before moving from a work area of a soiled body part to a clean body site on the same patient and healthcare personnel were to perform hand hygiene in accordance with the CDC recommendations.

Based on record review, observations, interviews with staff and Environmental Specialist, review of the facilities approved water management plan and timeline and policy review, the facility failed to timely implement their approved water management plan to potentially prevent a Legionella outbreak. This affected one (#84) out of three residents reviewed for Legionella and had the potential to affect all 68 residents residing in the facility. The facility census was 68. Findings include: Review of the medical record for Resident #84 revealed the resident was originally admitted to the facility on [DATE] and was readmitted following a hospital stay on 10/24/23. Resident #84 left the faciity on [DATE], against medical advice. Diagnoses included diabetes mellitus, illicit drug use, history of respiratory failure, and pneumonia. Review of Resident #84's quarterly Minimum Data Set (MDS) assessment, dated 10/31/23, revealed the resident had intact cognition. Review of Resident #84's medical record revealed the resident went to the emergency roiagnom on [DATE] due to an issue that was not respiratory related and was admitted . Resident #84 was readmitted to the facility on [DATE]. Further review of the hospital documentation from the hospital stay from 10/12/23 to 10/24/23 revealed Resident #84 was diagnosed with Legionella pneumonia while at the hospital. Orders for treatment included an oral antibiotic. Review of Resident #84's nurses notes dated 10/24/23 revealed the hospital notes reflected the resident tested positive for Legionella while at the hospital. The facility called the facility physician, local health department and the Ohio Department of Health. Observation on 03/26/24 from 10:30 A.M. until 11:00 A.M. revealed 64 shower filters are in place throughout the facility. The observations revealed there were no sink filters noted. Interview on 03/26/24 at 11:00 A.M. with the Administrator revealed Resident #84 returned after a two week stay in the hospital and it was discovered the resident had a diagnoses of Legionella pneumonia. The Administrator stated the hospital did not inform the facility of Resident #84's positive Legionella test results. The Administrator stated Resident #84's Legionella test results were noted in the hospital records by the facility staff. The Administrator noted the facility immediately reported Resident #84's positive Legionella results to the local health department and the state agency. The facility began testing at the facility. The Administrator confirmed the facility submitted a plan to the Ohio Department of Health on 12/15/23 regarding the Legionella/water management plan. The Administrator confirmed there was a delay in installing filters on the showers per their Legionella/water management plan and these filters were not installed until 03/09/24. The Administrator further confirmed filters still have not been installed on the sinks per the approved water management plan. The Administrator confirmed no other residents have tested positive for Legionella. Interview with Environmental Specialist #202 via telephone on 03/26/24 at 1:45 P.M. revealed the facility water management plan was approved by the Ohio Department of Health and the Local Health Department (LHD) at the end of 12/23. Environmental Specialist #202 stated part of the facilities approved water management plan included installing filters on showers and sinks and as far as he knew none of the filters were in place. Environmental Specialist #202 stated the water should not be used in those areas if no filters are in place due to the risk of spreading Legionella. Review of the facility approved water management plan and timeline revealed testing for Legionella began on 11/01/23 and an outside consultant was hired. On 12/15/23, Ohio Department of Health approved the facility water management plan sent by the consultant. The approved water management plan indicated the facility was to put filters on showers and sinks in the positive areas. Shower heads were applied to sixty four showers on 03/09/24 which was three months after the recommendations. No filters were placed on the sinks and the staff and residents used the sinks. Filters were applied to the sinks on 04/04/24. Review of facility policy titled Water Management dated 05/17 revealed the facility will have a water management plan to reduce the risk of Legionella in the facility water system. The facility will work to inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water. This deficiency represents non-compliance investigated under Complaint Number OH00152311.

Based on medical record review, resident interview, and staff interview, the facility failed to ensure medical appointments were scheduled timely and transportation was arranged for medical appointments. This affected one (Resident #45) of three residents reviewed for medical appointments. The census was 69. Findings include: Review of Resident #45's medical record revealed Resident #45 was admitted to the facility on [DATE]. Resident #45's diagnoses included but were not limited to type two diabetes, asthma, anxiety disorder, heart failure, tachycardia, acute kidney failure, chest pain, encephalopathy, hypertension, hyperlipidemia, and cognitive communication deficit. Review of Resident #45's Minimum Data Set assessment, dated 01/11/24, revealed Resident #45 was cognitively intact. Review of Resident #45's progress note, dated 09/01/23, revealed social services scheduled a dental/oral surgery appointment for Resident #45 on 01/11/24. The progress note stated she communicated this information, but the note did not specifically state who she communicated this information to. Review of Resident #45's progress notes, dated 11/23/23 and 12/07/23, revealed Resident #45 was asked who his cardiologist was. He stated he did not have one, but he needed to have an exam/stress test prior to his oral surgery to ensure he could handle the procedure. On 12/07/23, the facility documented they would contact a cardiologist to schedule an appointment. There was no other documentation to support an appointment was made with the cardiologist and/or what the result of any communication with the cardiologist was. Review of Resident #45's physician orders, dated 09/01/24 to 01/11/24, revealed there were no physician orders related to Resident #45's oral surgery appointment which was scheduled for 01/11/24. Also, there was no documentation to support any cardiologist appointment was scheduled prior to the oral surgery which was scheduled for 01/11/24. Review of Resident #45's progress notes, dated 01/11/24, revealed the facility called the oral surgery center to confirm Resident #45 had an appointment that day, but also to reschedule the appointment for June 2024. Interview with Resident #45 on 02/02/24 at 11:30 A.M. revealed he knew his oral surgery appointment had been scheduled for 01/11/24. Resident #45 was frustrated that the facility did not schedule transportation for him to go to that appointment. He stated the facility did not know he had an appointment that day, even though it was scheduled. He revealed he needed/wanted to go to the appointment and now he has to wait five more months to have the oral surgery completed. Interview with the Director of Nursing (DON) on 02/02/24 at 2:05 P.M. confirmed Resident #45 had an oral surgery appointment scheduled for 01/11/24, but when that day arrived, no staff were aware of the appointment; so Resident #45 did not go to the appointment. The social worker who was working with him on the appointment, no longer worked in the facility and she did not communicate well enough about the appointment so the staff could be prepared for it. Interview with Licensed Practical Nurse (LPN) #105 on 02/02/24 at 2:50 P.M. revealed the facility staff did not know about Resident #45's oral surgery appointment on 01/11/24. She confirmed there was a progress note that confirmed the appointment was made by the previous social worker, but it was never communicated to the nursing staff and put into his physician orders. She confirmed the next available appointment was not until June 2024. She also confirmed there was no documentation to support the cardiologist was contacted prior to his scheduled appointment on 01/11/24, so even if he did go to his oral surgery appointment, she was not sure if the surgery could have occurred. This deficiency represents non-compliance investigated under Complaint Number OH00150210.

Based on observation and staff interview, the facility failed to ensure the dishwasher was properly functioning to ensure the proper sanitation of dishes. This had the potential to affect 65 out of 65 residents who receive their meals from the kitchen, the facility identified one (#62) resident that received no food by mouth/no meals from the kitchen. The facility census was 66. Findings include: Observation of the facility's dishwasher on 01/09/24 at 8:50 A.M. revealed the temperature of the facility's dishwasher was 120 degrees Fahrenheit (F) but the chemicals were zero parts per million (PPM). There was no chemical observed going through the tubing from the chemical tubes to the dishwasher. The dishwasher was not observed to have any leaks. Interview with Maintenance Director #73 on 01/09/24 at 8:50 A.M. verified the temperature of the facility's dishwasher was 120 degrees F and the chemicals were zero parts PPM. Maintenance Director #73 verified the chemical was not entering the dishwasher from the chemical tubs. Interview with the Administrator on 01/09/24 at 11:47 A.M. revealed the facility's dishwasher was leased and the facility did not have the manufacturer instructions. The Administrator verified the dishwasher was a low temperature dishwasher that required chemicals. The Administrator confirmed 65 out of 65 residents residing in the facility receive their meals from the kitchen and there was one (#62) resident that received no food by mouth/no meals from the kitchen. This deficiency represents non-compliance investigated under Complaint Number OH00149373.

Based on record review, observations, staff and resident interviews, and policy review, the facility failed to ensure appropriate personal protective equipment was used in an isolation room. This affected one (#53) out of three residents reviewed for infection control practices. This had the potential to affect 16 (#42, #43, #44, #45, #46, #47, #48, #49, #50, #51, #52, #54, #55, #56, #57, #58) residents residing on the 3rd floor South Unit floor. The facility census was 66. Findings include: Record review revealed Resident #53 was admitted to the facility on [DATE] with diagnosis of Clostridioides difficile (C-diff), anxiety, depression and dementia. Review of Resident #53 physician orders revealed an order dated 01/09/24 for Isolation: C-Diff. Review of lab results for Resident #53 revealed a positive result for Toxigenic C. difficile DNA with a collection date of 01/05/24 and a reported to facility date of 01/08/24. Review of nurse's progress note dated 01/09/24 8:48 A.M. revealed C-diff results positive for Resident #53, physician made aware, contact isolations in place, awaiting new order from physician. Interview on 01/09/24 at 12:38 P.M. with Resident #53 revealed he is not aware of being in isolation precautions but reports no concerns with infection control. Observation on 01/09/24 at 12:40 P.M. revealed State tested Nursing Assistant (STNA) #51 was in Resident #53's room providing incontinence care to the resident without a gown on. A sign is on the door that reads Please see nurse prior to entering. On the door is a container with gloves available. Outside the door there is a small dresser that is empty. STNA #51 finished peri-care for Resident #53, placing the depends in a clear trash bag with gloves on bilateral hands and a surgical mask on Interview on 01/09/24 at 12:41 P.M. with STNA #51 confirmed she should wear gloves and a gown while in an isolation Resident #53's room who was positive C-Diff. Interview with STNA #51 also confirmed there were no gowns available to use outside of Resident #53's room. STNA #51 confirmed besides providing care for Resident #53 she is also responsible for caring for 16 (#42, #43, #44, #45, #46, #47, #48, #49, #50, #51, #52, #54, #55, #56, #57 and #58) residents who reside on the 3rd floor South Unit floor. Interview on 01/09/24 at 12:42 P.M. with Licensed Practical Nurse (LPN ) #105 revealed Resident #53 is in isolation for C-Diff, and that the staff need to wear gowns and gloves while in the room providing care. LPN #105 also confirmed there were not any gowns available for the staff to use when going into Resident #53's room. Interview on 01/09/24 at 3:35 P.M. with Administrator revealed in C-Diff isolation rooms staff should wear gloves and a gown while in room. Interview with the Administrator confirmed STNA #51 did not wear a gown while providing peri-care. Review of facility policy titled Isolation-Notices of Transmission-Based Precautions revised August 2019 revealed notices will be used to alert personnel and visitors of transmission-based precautions, while protecting the privacy of the resident. Review of the policy also revealed when transmission-based precautions are implemented, the Infection Preventionist (or designee) determines the appropriate notification to be placed on the room entrance door and on the front of the resident's chart so that personnel and visitors are aware of the need for and type of precautions. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on record review and staff interview, the facility failed to complete the comprehensive admission Minimum Data Set (MDS) assessment for Resident #12 within 14 days after admission. This affected one (#12) out of five residents reviewed for MDS assessments. The facility census was 66. Findings include: Review of medical record for Resident #12 revealed an admitted [DATE]. Diagnoses included sequelae of cerebral infarction, burn of unspecified region and vascular dementia. Review of physician orders dated 01/01/24 revealed resident was to receive Eliquis five mg daily due to cerebral infarction, liquid protein two times daily to promote would healing, Silvadene external cream 1% - apply to right lateral thigh, apply adaptic, abdominal dressing and wrap with kerlix daily. Review of the baseline care plan dated 12/12/23 revealed Resident #12 had tested positive for COVID-19 and was at risk for further complications and potentially infecting others, would be free from complications related to infection through the review date and would be free of infection by the review date. Review of the facility Electronic Health Record (EHR) MDS tab for Resident #12 revealed a five day/comprehensive MDS was in progress, but was not completed within fourteen days of admitted [DATE]. There was not a completed five-day admission/comprehensive Minimum Data Set (MDS) assessment to review. Interview on 01/09/24 at 1:21 P.M. with Registered Nurse (RN)/MDS Coordinator #28 revealed Resident #12's five-day admission/comprehensive MDS assessment was not completed, within 14 days of admission as required by CMS. The interview with RN/MDS Coordinator #28 also revealed that the facilities expectation for completion of the five-day admission/comprehensive MDS is within 14 days of admission. Interview on 01/09/24 at 1:38 P.M. with the Administrator confirmed the five-day admission/comprehensive MDS assessment for Resident #12 was not complete as required by CMS, within 14 days of admission. The interview with the Administrator also confirmed the facility does not have a policy for MDS completion expectations but the expectation is within 14 days of admission. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on record review and staff interview, the facility failed to develop a comprehensive person-centered care plan for Resident #12. This affected one (#12) out of five residents reviewed for care plans. The facility census was 66. Findings include: Review of medical record for Resident #12 revealed an admitted [DATE]. Diagnoses included sequelae of cerebral infarction, burn of unspecified region and vascular dementia. Review of physician orders dated 01/01/24 revealed resident was to receive Eliquis five mg daily due to cerebral infarction, liquid protein two times daily to promote wound healing, Silvadene external cream 1% - apply to right lateral thigh, apply adaptic, abdominal dressing and wrap with kerlix daily. Review of the baseline care plan dated 12/12/23 revealed Resident #12 had tested positive for COVID 19 and was at risk for further complications and potentially infecting others, would be free from complications related to infection through the review date and would be free of infection by the review date. There was no information in the baseline care plan dated 12/12/23 related to Resident #12 being on blood thinners and whether she was to remain in the facility long term. There was also no information on the care plan related to a burn injury, treatments, dementia or information related to guardianship or adult protective services being involved with resident's care. Further review of Resident #12's medical record revealed there was no evidence of a comprehensive care plan. Interview on 01/09/24 at 1:21 P.M. with Registered Nurse (RN)/MDS Coordinator #28 revealed Resident #12's comprehensive care plan was not complete as required by CMS, within 21 days from the date of admission. The interview with RN/MDS Coordinator #28 also revealed that the facility expectations for completion of the comprehensive care plan is within 21 days of admission. Interview with RN/MDS Coordinator #28 also confirmed pertinent diagnoses, physician orders, and PASRR information should be included in the care plan and verified. Interview on 01/09/24 at 1:38 P.M. with the Administrator confirmed the comprehensive care plan for Resident #12 was not complete with a completion due date of 12/31/23. The interview with the Administrator also confirmed the facility does not have a policy for care plan completion expectations but that the facilities expectations are within 21 days of admission. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on staff interview, review of the facility policy, and record review, the facility failed to notify residents that the amount of funds in their accounts was 200 dollars less than the social security income resource limit and that the residents may lose eligibility for Medicaid or social security income. This affected three (#17, #19, and #31) of five residents reviewed for personal funds. The facility census was 56. Findings include: 1. Review of Resident #17's chart revealed Resident #17 admitted to the facility on [DATE]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 was cognitively intact. Review of Resident #17's payer source information dated 05/16/23 revealed Resident #17 was on Medicaid from 01/01/20 to 05/03/23 and was changed to Medicare on 05/03/23 when he returned from a hospitalization . Review of Resident #17's account balance dated 05/16/23 revealed Resident #17 had a balance of $2,614.32 in his resident funds account. Review of Resident #17's quarterly statement from 03/02/23 to 05/05/23 revealed Resident #17's account was opened on 03/02/23 with a starting balance of $3,198.79 on 03/14/23. and an ending balance of $2,612.32 on 05/05/23. Review of Resident #17's notifications of spend down revealed no spend down notifications were issued from 03/02/23 until 05/15/23. Interview on 05/17/23 at 1:41 P.M. with Licensed Practical Nurse (LPN) #446 verified Resident #17 received Medicaid and the facility did not notify Resident #17 that the amount of funds in the account was 200 dollars less than the social security income resource limit and the residents may lose eligibility for Medicaid or social security income. 2. Review of Resident #19's chart revealed Resident #19 admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 was cognitively intact. Review of Resident #19's payer source information dated 05/16/23 revealed Resident #19 received Medicaid. Review of Resident #19's account balance dated 05/16/23 revealed Resident #19 had a balance of $3,012.36 in her resident funds account. Review of Resident #19's quarterly statement from 03/02/23 to 05/01/23 revealed Resident #19's account was opened on 03/02/23 and she had an ending balance of $3,012.36 on 05/01/23 and a starting balance of $3,126.03 on 03/14/23. Review of Resident #19's notifications of spend down revealed no spend down notifications were issued from 03/02/23 until 05/15/23. Interview on 05/17/23 at 1:41 P.M. with Licensed Practical Nurse (LPN) #446 verified Resident #19 received Medicaid and the facility did not notify Resident #19 that the amount of funds in the account was 200 dollars less than the social security income resource limit and the residents may lose eligibility for Medicaid or social security income. 3. Review of Resident #31's chart revealed Resident #31 admitted to the facility on [DATE]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 was severely cognitively impaired. Review of Resident #31's payer source information dated 05/17/23 revealed Resident #31 was on Medicaid. Review of Resident #31's account balance dated 05/16/23 revealed Resident #31 had a balance of $5,781.37 in her resident funds account. Review of Resident #31's quarterly statement from 03/02/23 to 05/03/23 revealed Resident #31's account was opened on 03/02/23 with starting balance of $5,663.31 on 03/14/23 and she had an ending balance of $2,228.00 on 05/03/23. Review of Resident #31's notifications of spend down revealed no spend down notifications were issued from 03/02/23 until 05/15/23. Interview on 05/17/23 at 1:41 P.M. with Licensed Practical Nurse (LPN) #446 verified Resident #31 received Medicaid and the facility did not notify Resident #31/financial representative that the amount of funds in the account was 200 dollars less than the social security income resource limit and the residents may lose eligibility for Medicaid or social security income. Review of the facility's resident trust statements, discharges and Medicaid eligibility policy, dated January 2018, revealed resident accounts must not be allowed to accumulate more than that required total Medicaid allowable amount for continuing Medicaid eligibility. Facility management must notify each resident who receives Medicaid benefits when the amount in the resident's account reaches 200 less than the supplemental security income limit.

Based on medical record review, review of the facility policy, and staff interview, the facility failed to develop care plans for a resident's cognitive impairment, wandering, and activity needs. This affected two (#43 and #47) residents out of 17 residents reviewed for accuracy of assessments. The facility census was 56. Findings include: 1. Review of Resident #47's medical record revealed Resident #47 admitted to the facility on [DATE]. Diagnoses including dementia with psychotic disturbance. Review of the progress note dated 05/02/23 revealed Resident #47 was not found in his room at 9:30 P.M. and Resident #47 had made several attempts to leave his room and floor prior. Resident #47 stated he was going home. Staff later found Resident #47 on the first floor. Resident #47 was moved to the secured unit for the night. The progress note dated 05/03/23 revealed Resident #47's physician was in to see Resident #47 and a new order was added to place a wanderguard on the left ankle. Review of the physician order dated 05/03/23 revealed Resident #47 was to have a wanderguard to his left ankle and to check placement and functioning every shift. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 was severely cognitively impaired and Resident #47 was reported to wander. Review of the care plan on 05/16/23 revealed Resident #47 did not have a care plan related to his wandering or dementia. Review of the progress notes dated 05/06/23 revealed Resident #47 was noted wandering on the unit multiple times without his walker or wheelchair. On 05/11/23, Resident #47 became increasingly confused looking for his wife and could not remember where his room was located. On 05/11/23, Resident #47 wandered into another resident's room while social services was doing an evaluation. Interview on 05/18/23 at 9:21 A.M. with Registered Nurse (RN) MDS Coordinator #444 verified Resident #47 did not have a wandering or dementia care plan prior to 05/17/23. 47058 2. Review of Resident #43's medical record revealed Resident #43 was admitted to the facility on [DATE]. Diagnoses included rheumatoid arthritis, major depressive disorder, and cognitive communication deficit disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 was severely cognitively impaired. Resident #43 required extensive assistance with bed mobility, and transfers. Resident #47 required dependent with dressing, toileting, and personal hygiene, and supervision with eating. Review of Resident #43's care plan dated 05/03/23 revealed Resident #43 did not have an activities care plan at the time of admission or in place at the time of survey. Interview on 05/18/23 at 9:21 A.M. with the Director of Nursing (DON) verified Resident #43 did not have an activities care plan prior to 05/17/23. Review of the facility's comprehensive care plan policy dated 01/13/18 revealed the facility will develop a comprehensive care plan no more than seven days after the completion of the comprehensive assessment. The care planning process will include an assessment of the resident's strengths and needs.

Based on record review, resident and staff interviews, and policy review, the facility failed to complete quarterly care conferences for residents and family. This affected four (#9, #17, #21, and #35) of five residents reviewed for care plans. The facility census was 56. Findings include: 1. Review of the medical record for Resident #21 revealed an admitted [DATE]. Diagnoses included type two diabetes mellitus, schizoaffective disorder, convulsions, epilepsy, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had intact cognition. Resident #21 required supervision from staff with transfers and eating, one-person extensive assistance with dressing and toileting, and one-person total dependence with bathing. Review of the care conferences for the last 12 months for Resident #21 revealed she only had two care conferences completed on 11/04/22 and 01/03/23. Interview on 05/17/23 at 1:50 P.M. with Social Services Director (SSD) #418 verified Resident #21 only had two care conferences dated 11/04/22 and 01/03/23 for the last 12 months. Subsequent interview on 05/17/23 at 2:28 P.M. with SSD #418 revealed the care conferences were now being conducted quarterly, but previously, SSD #418 was only completing the care conferences as needed. 39967 2. Review of Resident #17's medical record revealed Resident #17 was admitted to the facility on [DATE]. Diagnoses included type two diabetes mellitus without complications, major depressive disorder, muscle weakness, and dysphagia. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 was cognitively intact. Resident #17 required supervision from staff with transfers, dressing, eating, toileting, and personal hygiene. Resident #17 was independent with bed mobility. Review of Resident #17's care conferences from 11/15/22 to 05/18/23 revealed Resident #17 had one care conference completed on 01/04/23. Interview with Resident #17 on 05/15/23 at 10:54 A.M. revealed Resident #17 had not been invited to any care conferences and did not have the opportunity to participate in the development of his care plan. Interview with Social Services Director (SSD) #418 on 05/17/23 at 2:27 P.M. verified Resident #17 only had one care conference completed on 01/04/23. SSD #418 stated she was doing care conferences as needed but recently started to do care conferences quarterly. 3. Review of Resident #35's medical record revealed Resident #35 was admitted to the facility on [DATE]. Diagnoses included cerebrovascular disease, dysphagia, hypertension, end stage renal disease, irritable bowel syndrome with constipation, and diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35 was cognitively intact. Resident #35 required supervision from staff with bed mobility, transfers, dressing, toileting, personal hygiene, and eating. Review of Resident #35's care conferences from 11/15/23 to 05/18/23 revealed Resident #35 did not have any care conferences completed. Interview with Resident #35 on 05/15/23 at 10:44 A.M. revealed Resident #35 had not been invited to any care conferences and did not have the opportunity to participate in the development of her care plan. Interview with Social Services Director (SSD) #418 on 05/17/23 at 2:27 P.M. verified Resident #35 did not have any care conferences from 11/15/23 to 05/18/23. SSD #418 stated she was doing care conferences as needed but recently started to do care conferences quarterly. 47058 4. Review of the medical record for Resident #9 revealed an admitted [DATE]. Diagnoses included end stage renal disease, vascular dementia, metabolic encephalopathy, major depressive disorder, peripheral vascular disease, hypertension, type two diabetes mellitus, and hyperlipidemia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 had intact cognition. Resident #9 required extensive assistance from staff with transfers, dressing, toileting, and bathing. Resident #9 was incontinent of bowel. Review of Resident #9's care conferences from 09/01/23 to 05/15/23 revealed Resident #9 had one care conference on 04/26/23. Interview with Resident #9 on 05/15/23 at 10:42 A.M. stated he had not been invited to participate in his care planning and he was unsure when or where it had taken place. Interview with Social Services Director (SSD) #418 on 05/17/23 at 2:27 P.M. verified Resident #9 only had one care conference completed on 04/26/23. SSD #418 stated she was doing care conferences as needed but recently started to do care conferences quarterly. Resident #9 was not participating in care planning and only his daughter was participating. Social services provided a hand written note, on plain white paper, without date or signature page of who attended or was invited. Review of the facility policy titled Care Planning - Interdisciplinary Team, dated September 2013, revealed a comprehensive care plan for each resident is developed within seven days of completion of the resident assessment (MDS). The resident, the resident's family, and/or the resident's legal representative/guardian or surrogate were encouraged to participate in the development of and revisions to the resident's care plan.