Every finding on record at Sunnyslope Nursing Home

Based on a closed record review, review of facility self reported incidents, review of hospital emergency department documentation, facility policy review, and interviews, the facility failed to develop and implement comprehensive, individualized, and effective behavioral health treatment plans and services to prevent resident to resident altercations. This affected two of three residents reviewed for dementia care (Residents #51 and #50). The facility census was 46.Actual Harm occurred on 11/09/25 when Resident #51 sustained significant facial trauma, including ecchymosis and swelling to the left side of the face, left periorbital area, and ear, as well as a closed head injury and head laceration. These injuries resulted from a resident to resident altercation in which Resident #50 struck Resident #51. Following the incident Resident #51 had difficulty opening his mouth to eat, had decreased oral intake, was more lethargic and then began to self-isolate. Prior to the incident, both residents exhibited wandering and/or aggressive behaviors that were not effectively managed by the facility. There was no evidence of effective monitoring or non pharmacological interventions in place to address either resident's behavioral health care needs or prevent resident to resident altercations.Findings include: Review of Resident #50's closed medical record revealed the resident was admitted on [DATE] with diagnoses that included dementia with behavioral disturbance, congestive heart failure, ischemic cardiomyopathy, and anxiety disorder. Resident #50 discharged from the facility on 11/24/25.Review of an order/administration note dated 09/25/25 at 3:42 A.M. authored by Licensed Practical Nurse (LPN) #124 revealed Resident #50 continued to wander in and out of other resident rooms. The resident needed redirection multiple times during the shift. Review of a psychiatric services note dated 09/25/25 revealed Resident #50 was ordered Haldol (an antipsychotic) 10 milligrams (mg) intramuscularly every 24 hours as needed, Ativan (a benzodiazepine used for anxiety ) one mg by mouth every four hours as needed, Ativan one mg by mouth four times a day, and Vistaril (an antihistamine used for anxiety) 50 mg every four hours as needed. An initial evaluation was completed for Resident #50 with a history of vascular dementia, agitation, and anxiety. Resident #50 was sitting in a wheelchair and was currently sedated. The staff reported the resident had a hard time adjusting to the facility. The resident had sundowning (prevalent among people with some form of dementia and characterized by increased confusion and restlessness beginning in the late afternoon and early evening) and became combative with staff at night. On 09/24/25, the resident threw a chair. It was reported Resident #50 was not sleeping at night and had been walking around naked. A new order was given to start Depakote (an anticonvulsant used at times as a mood stabilizer) sprinkles 125 mg at dinner time. Review of a health status note dated 09/26/25 at 9:00 P.M. authored by Registered Nurse (RN) #104 revealed Resident #50 was wandering the hallways and entering other resident rooms frequently. Review of an order/administration note dated 09/27/25 at 4:00 A.M. authored by RN #104 revealed Resident #50 was administered Ativan one mg as needed due to being very anxious and agitated. The resident was wandering into other residents' rooms and pacing the hallways. Continued review of Resident #50's record revealed orders were received on 09/29/25 to discontinue Resident #50's Ativan one mg four times a day and every four hours as needed. Ativan 0.5 mg twice a day was to be started and Ativan one mg every hour as needed. A new order was also received for Trazodone (an antidepressant which has properties to aid sleep) 50 mg at bedtime.Review of Resident #50's plan of care dated 09/29/25 revealed Resident #50 had a mood problem related to repetitive anxious complaints or concerns, anxiousness, restlessness and agitation. Interventions included arranging for a consultation by social services or other counselors, administering medications per order and observing response to treatment, and updating physician as needed. Record review revealed no evidence of any type of non-pharmacological approach/interventions to address the resident's behavioral health care needs and/or mood problems.Continued review of the plan of care dated 09/29/25 revealed Resident #50 had a behavior problem related to disruptive, resisting care, being socially inappropriate, wandering in and out of other resident rooms, exit seeking, and being combative. Interventions included monitoring and documenting behaviors and redirect gently out of rooms. The plan did not include any other type of non-pharmacological intervention other than redirection.Review of a health status note dated 10/06/25 at 11:11 P.M. authored by RN #109 revealed Resident #50 continued to wander in the halls and enter other resident rooms. There was no evidence of any type of intervention being initiated or attempted to address the resident's wandering. Review of a health status note dated 10/13/25 at 5:00 P.M. authored by RN #104 revealed the nurse was at the medication cart and observed Resident #50 ambulating in the hallway. Resident #50 was very agitated and talking to himself and unseen entities. Resident #51 was sitting in a chair next to the nurse's station when Resident #50 approached Resident #51 and hit Resident #51 on the left jaw. As a result of the incident, Resident #50 was placed on increased supervision for 72 hours.Review of new orders dated 10/14/25 revealed Resident #50's Ativan was to be increased to 0.5 mg three times a day and his Depakote increased to 125 mg to twice a day. Resident #50's daughter agreed to the Depakote being increased but did not want Ativan increased. Record review revealed no evidence of any type of non-pharmacological approach/interventions to address the resident's behavioral health care needs and/or mood problems.Review of a health status note dated 10/17/25 at 6:35 P.M. authored by LPN #124 revealed the nurse was at the medication cart and Resident #51 was sitting in a chair by the nurse's station. Resident #50 was ambulating with a wheeled walker and purposely hit Resident #51's feet and legs multiple times with the walker. Resident #51 remained seated and grabbed the walker. Resident #50 yelled to let go. Resident #51 stood up and hit Resident #50 on the left side of the face. Resident #50 grabbed Resident #51's face and left scratches on Resident #51's face.Review of a Self-Reported Incident (SRI) dated 10/17/25 revealed on 10/13/25 at 4:45 P.M. (wrong date and time) Resident #50 hit Resident #51. Resident #51 was sitting at the nurse's station. Resident #50 rammed his walker into Resident #51's legs. Resident #51 stood up and hit Resident #50 in the face. Resident #50 then hit Resident #51 in the face. Resident #50 was sent to the hospital for a psychiatric evaluation and Resident #51 was sent to the hospital for a medical evaluation. Resident #51 had scratches on his face. Review of the hospital after visit summary dated 10/17/25 revealed Resident #50 had vascular dementia with agitation and was sent to the emergency department for a behavioral and explosive outburst. The hospital did not have geriatric psychiatry services available and did not feel the need to transfer Resident #50 to a place that offered geriatric psychiatric services. It was recommended to have an on-call psychiatrist at the nursing facility see Resident #50 as soon as possible and, if able, avoid interactions with the other resident (Resident #51) that Resident #50 had been having altercations with. Review of Resident #51's closed medical record revealed the resident was admitted on [DATE] with diagnoses that included behavioral disturbance and agitation, intermittent explosive disorder, major depressive disorder, psychotic disorder, and delirium. Resident #51 discharged from the facility on 01/06/26.Review of the hospital after visit summary dated 10/17/25 revealed Resident #51 had been assaulted and had a facial contusion and laceration. The laceration to the right check was closed with tissue glue while the resident was in the emergency department. The laceration measured 0.8 centimeters (cm) long by two cm deep. Resident #51 returned to the facility.Review of a health status note dated 10/20/25 at 4:11 P.M. authored by LPN #124 revealed Resident #51 was wandering in and out of rooms multiple times. Resident #51 did not display any agitation or aggression towards staff or peers. Record review revealed no evidence of any type of non-pharmacological approach/interventions to address the resident's wandering at this time. Review of a health status note dated 10/22/25 at 2:18 A.M. authored by RN #108 revealed Resident #51 continuously wandered into other resident rooms and was found in other resident's recliners or beds. Review of a health status note dated 10/25/25 at 10:30 A.M. authored by RN #106 revealed Resident #50 was in his room and a Certified Nursing Assistant (CNA) saw another resident heading towards Resident #50's room. Resident #50 yelled for Resident #51 to get out of his room. The CNA yelled for the nurse because Resident #50 and #51 were fighting. Resident #50's family was notified and came to the facility to sit with Resident #50. As needed Ativan was administered but had no effect. Record review revealed no evidence of any type of non-pharmacological approach/interventions to address the residents' behavior health care needs at this time and/or to prevent additional altercations between the residents. A health status note dated 10/25/25 at 3:53 P.M. authored by RN #106 revealed she was at the nurse's station when she heard a resident yelling to get away. A CNA yelled they needed help. When the nurse arrived at the dining room, Resident #51 was leaning over the recliner holding onto another resident's (#16) shirt and the CNA was trying to get Resident #51 to let go. Resident #51 was placed on 15-minute checks and staff were advised that Resident #51 needed to be one-on-one when out of his room. Record review revealed no evidence of any type of non-pharmacological approach/interventions to address the resident's behavioral health care needs and/or mood problems.Review of new orders received on 10/28/25 revealed an order to stop Resident #50's as needed and scheduled Ativan and to start Klonopin (a benzodiazepine used for anxiety) 0.25 mg twice a day and Klonopin 0.25 mg every day as needed. Record review revealed no evidence of any type of non-pharmacological approach/interventions to address the resident's behavioral health care needs and/or mood problems. Review of a health status note dated 10/29/25 at 5:40 A.M. authored by LPN #124 revealed Resident #50 had been pacing, yelling, and wandering. One-on-one, multiple interventions, and redirection were not effective. However, the note did not include what the interventions were and/or why they were not effective.Review of a health status note dated 10/30/25 at 6:09 P.M. authored by RN #106 revealed Resident #50 was agitated and angry all shift. Resident #50 was yelling and slamming chairs and doors. Resident #50 kept coming to the nurses' station and yelling at another resident. Record review revealed no evidence of any type of non-pharmacological approach/interventions to address the resident's behavioral health care needs and/or mood problems.Review of a health status note dated 11/01/25 at 3:41 P.M. authored by RN #103 revealed Resident #50 was very agitated, verbally aggressive, and threatening towards staff and other residents. Record review revealed no evidence of any type of non-pharmacological approach/interventions to address the resident's behavioral health care needs and/or mood problems.Review of new orders received from psychiatric services revealed to stop Resident #50's current scheduled and as needed Klonopin and start Klonopin 0.5 mg twice a day and Klonopin 0.5 mg daily as needed. Review of a health status note dated 11/07/25 at 6:49 A.M. authored by LPN #124 revealed Resident #51 was up wandering into rooms and rearranged chairs in the dining room. Record review revealed no evidence of any type of non-pharmacological approach/interventions to address the resident's wandering and/or to prevent resident to resident altercations at this time. Review of a health status note dated 11/09/25 at 12:00 A.M. authored by RN #108 in both Resident #50 and #51's chart revealed a loud noise was heard down the hall from the nurse's station. A CNA opened the door to Resident #50's room and called for assistance. Resident #50 was standing in the middle of the room beside a recliner that was flipped upside down. Resident #51 was observed lying on the floor in the doorway with moderate facial bleeding, a swollen and discolored left eye, and a laceration to the right scalp. Residents #50 and #51 were both transferred to the hospital for evaluation. Review of an SRI dated 11/09/25 at 1:57 A.M. revealed Resident #50 hit Resident #51. Staff heard a commotion and found Resident #51 had wandered into Resident #50's room. While in the room, Resident #50 hit Resident #51 in the face. Resident #51 had bruises on his face and Resident #50 had bruised knuckles. Resident #50 and Resident #51 returned from the hospital and were placed on increased supervision. Record review revealed no evidence of any type of non-pharmacological approach/interventions to address the residents' behavioral health care needs and/or mood problems or to prevent resident to resident altercations.Review of a health status note dated 11/09/25 at 5:30 A.M. authored by RN #108 revealed Resident #51 returned from the hospital. Resident #51's left eye laceration was glued, and instructions included for the resident to return to the hospital if there was any change in level of consciousness. Review of a hospital encounter summary dated 11/09/25 for Resident #51 revealed emergency medical technicians reported Resident #51 was sitting on the floor after getting into an altercation with another resident. Resident #51 had facial abrasion and ecchymosis and swelling to left face, eye, and ear. History of present injury revealed Resident #51 wandered into another resident's room and was involved in a physical assault. It was not known by emergency medical services if Resident #51 lost consciousness. Resident #51 arrived with significant facial trauma with periorbital swelling on the left. The hospital visit noted diagnoses included closed head injury and laceration of head without foreign body. Review of a health status note dated 11/09/25 at 8:00 A.M. authored by RN #106 revealed psychiatric services were notified of the incident between Resident #50 and Resident #51. Psychiatric services felt Resident #50 needed to be sent out to have medications adjusted. A pink slip (legal process for involuntary psychiatric commitment, allowing for emergency hospitalization of individuals who may pose a danger to themselves or others due to mental illness) was issued for Resident #50. The decision was made after talking with psychiatric services, the Director of Nursing (DON), and the Assistant Director of Nursing (ADON) to ensure the safety of all residents.Review of an intradisciplinary team (IDT) note dated 11/09/25 at 10:59 A.M. authored by the DON revealed Resident #51 was involved in an incident on 11/09/25 with another resident. Resident #51 had bruising to face and right thigh. Resident #51 was a wanderer and had wandered into another resident's room. Resident #51 had bruising to facial area and right thigh. A door alarm was ordered to alert staff when Resident #51 exited his room. Review of a psychiatric note dated 11/09/25 revealed an emergency tele-psychiatric assessment was completed for Resident #50. When Resident #50 was questioned about his right hand being wrapped in an ace bandage, the resident could not recall what happened. Despite multiple medication changes, Resident #50 continued to be verbally and physically aggressive with staff and other residents. Resident #50 had been sent to the emergency department twice for behaviors. Resident #50 was sent to the hospital on the night of 11/08/25 for punching another resident and returned with an ace wrap to right hand due to a contusion. Staff report Resident #50 experienced visual hallucinations which escalated his agitation and aggression. Resident #50's routinely disagreed with medication adjustments to manage visual hallucinations and aggression. Resident #50 posed a threat to others and required admission to an inpatient behavioral health hospital. An application for emergency admission was sent to the hospital, and staff were asked to continue close monitoring of Resident #50 until he could be transferred out. Review of a health status note dated 11/09/25 at 1:31 P.M. authored by RN #106 revealed Resident #51 was very lethargic. The resident's face was very swollen, and the resident had a hard time opening his mouth to eat, was unsteady on his feet and had to be walked to his room. Review of a health status note dated 11/09/25 at 6:15 P.M. authored by RN #106 revealed Resident #51 had been in bed sleeping most of the day. Resident #51 would answer some yes or no questions but would not open his eyes and moaned with care. The resident ate only 25-percent of his mashed potatoes at dinner. Review of a wound observation form dated 11/10/25 revealed Resident #51 had a laceration to the top of his scalp that measured two centimeters (cm) long by 0.2 cm wide. Resident #51 also had bruising to his entire face and scattered scratches. Review of a psychosocial note dated 11/11/25 at 4:40 P.M. revealed a thirty-day discharge notification was sent to Resident #50's family. Review of a health status note dated 11/12/25 at 6:57 A.M. authored by LPN #124 revealed Resident #51 continued to wander the unit and enter multiple rooms. Resident #51's left eye remained swollen and was dark purple in color. Record review revealed no evidence of any type of non-pharmacological approach/interventions to address the resident's wandering and/or to prevent resident to resident altercations at this time. Review of a health status note dated 11/15/25 at 1:29 P.M. authored by RN #104 revealed Resident #51 remained in his room more than normal and was beginning to self-isolate. Resident #51 moaned and had facial grimacing with incontinence care and repositioning in bed. Review of a health status note dated 11/18/25 at 3:06 P.M. authored by RN #106 revealed Resident #51 had a dark purple bruise from right lateral hip to knee. The note included the bruise was from an incident on 11/09/25 and was getting darker in color. Review of the quarterly MDS assessment dated [DATE] revealed Resident #51's cognition was not assessed. Resident #51 had behaviors not directed towards others, rejected care, and wandered daily. Review of a subsequent discharge MDS dated [DATE] revealed Resident #51 had severely impaired cognition. Physical behavior towards others occurred four to six days. Verbal behaviors towards others and behavioral symptoms not directed towards others occurred one to three days. Resident #51 rejected care four to six days and wandered daily.An interview on 03/18/26 at 8:43 A.M. with RN #106 revealed staff on the behavior unit redirected residents with behaviors as best they could. RN #106 stated psychiatric services were contacted when residents had behaviors. An interview on 03/19/26 at 8:12 A.M. with Social Services #141 verified Resident #50 was pink slipped and went to a psychiatric hospital as a result of an altercation. The facility did also issue a 30-day notice to Resident #50's family after the altercation with Resident #51 on 11/09/25. An interview on 03/19/26 at 1:20 P.M. revealed the Director of Nursing (DON) verified there was an incident on 10/13/25 and 10/17/25 between Resident #50 and #51. The DON revealed SRI tracking number 266519 was for the incident on 10/17/25 but entered the wrong occurrence date (10/13/25) when the SRI was submitted.An interview on 03/19/26 at 1:07 P.M. with the DON revealed staff were to be trained upon hire and annually for Alzheimer's disease, behaviors, caring for those with cognitive impairment, de-escalation techniques, and managing aggressive behaviors. The DON stated managing behaviors was also discussed at all staff meetings. An interview on 03/19/26 at 1:44 P.M. with RN #106 revealed Resident #50 had explosive episodes. RN #106 revealed Resident #50 and #51 did not like each other and staff were to try to keep the residents separated. RN #106 stated she had suggested moving Resident #51, but there was not an empty room to move Resident #51 to. RN #106 stated she kept saying Resident #50 needed help did not believe Resident #50's daughter was receptive to medications and did not want Resident #50 sent out for inpatient psychiatric services. RN #106 stated the staff on the behavior unit just learned residents and what interventions to put in place. RN #106 stated she found out after Resident #50 was admitted he had gone after his granddaughter and a hospice staff member with a knife and that was why he was admitted to a nursing facility. RN #106 stated that music would sometimes help when Resident #50 had behaviors. An interview on 03/23/26 at 9:28 A.M. with the DON revealed the only empty room in November that Resident #51 could be moved to was next to Resident #50. The DON stated she felt it would be better to leave Resident #51 in room across the hall from Resident #50. The DON stated the altercations between Resident #50 and #51 occurred out in the common areas. Resident #50 and #51 would be fine and then suddenly have an aggressive outburst and unfortunately Resident #51 was the one who would receive injuries. The DON verified no new interventions had been put in place after Resident #50 and/or Resident #51 had behaviors other than increased or one-on-one supervision for a limited time. An interview on 03/23/26 at 12:53 P.M. with RN #104 revealed Resident #50 and #51 were redirected and had staff supervision to try to control behaviors. RN #104 revealed Resident #50 and #51 did not like each other. Review of the policy titled Dementia Care dated 12/08/25 revealed care plan goals would be achievable and the facility would provide resources necessary for the resident to be successful in meeting their goals. The care plan interventions would be related to each resident's individual symptomology and rate of dementia progression with the end result being noted improvement or maintained of the expected stable rate of decline associated with dementia. Care and services would be person-centered and reflect each resident's individual goals while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety. The care plan goals and interventions would be monitored on an ongoing basis for effectiveness and would be reviewed/revised as necessary. This deficiency represents non-compliance investigated under Complaint Number 2686113.

Based on medical record review, review of a Self-Reported Incident (SRI), abuse policy review, and interview, the facility failed to prevent a former employee, who verbally abused a resident, from entering the facility, including resident care areas. This affected one (Resident #26) of three residents reviewed for abuse. The facility census was 40. Findings include: Review of the medical record for Resident #26 revealed an admitted [DATE] with diagnoses including Alzheimer's disease, altered mental status, dementia with moderate with agitation, insomnia, anxiety disorder, transient ischemic attack, obstructive sleep apnea and vertigo. The resident received hospice services and expired on [DATE]. Review of SRI #253615, dated [DATE], revealed while on the D Hall nursing station/dining room, Certified Nursing Assistant (CNA) #54 verbally abused Resident #26. License Practical Nurse (LPN) #52 had assisted Resident #26 to the dining room to allow the breakfast tray cart to pass up the hallway. Resident #26 immediately propelled herself back beside the nurse's station, preventing the movement of the breakfast tray cart. CNA #54 approached Resident #26 and said, I am going to hit you in the nose, with the resident stating, please don't hit me. CNA #54 propelled Resident #26 back into the dining room and said, now stay the hell here. Following the incident, CNA #54 was immediately placed on suspension pending the investigation and subsequently resigned from his employment at the facility on [DATE]. The facility substantiated the allegation of abuse. Review of the facility's survey history revealed on [DATE] an onsite complaint investigation identified a concern related to an incident of verbal abuse involving Resident #26 and CNA #54. Non-compliance was identified and certification and licensure violations were issued. Following the incident, the facility implemented corrective actions including immediately suspending CNA #54 and providing education to all staff on the facility's abuse/neglect policy. Interview on [DATE] at 1150 A.M. with an anonymous person revealed she had witnessed CNA #54 on numerous occasions in the facility following the abuse incident and his termination from employment and she has reported this to the Director of Nursing (DON) who had done nothing about it. The Anonymous person stated they observed CNA #54 in the facility and had attended the Christmas party in [DATE]. The anonymous person stated the Director of Nursing also attended the Christmas party and knew CNA #54 was in the facility. Interview on [DATE] at 11:25 A.M. with Licensed Practical Nurse (LPN) #4 verified CNA #54 has been in the facility on several occasions to use the bathroom or sit in the nursing station until she is finished with her shift. LPN #4 stated that she doesn't drive and CNA #54 picks her up from work. Interview on [DATE] at 11:32 A.M. with Therapy Director #9 revealed she had witnessed CNA #54 in the facility following the abuse incident a few times, often in the hallway or in the memory care unit. Interview on [DATE] at 11:42 A.M. with LPN #6 revealed she has witnessed CNA #54 sitting at the nursing station several times while waiting to pick his wife up from work. LPN #6 stated she has reported this to the DON and nothing has happened. LPN #6 stated, he should not be here. Interview on [DATE] at 12:10 P.M. with CNA #7 revealed she witnessed CNA #54 at the Christmas party in December and the DON was also in attendance. CNA #7 stated she had witnessed CNA #54 sitting in the nursing station, usually on the weekends from 5:00 P.M. to 7:00 P.M., while waiting to pick up his wife from work. Interview on [DATE] at 12:25 P.M. with the Administrator revealed he first became aware on [DATE] of CNA #54 having been in the facility after being notified by staff. The Administrator stated he incorrectly thought CNA #54 was picking up his daughter, however, it was his wife, an employee of the facility. The Administrator stated that he contacted CNA #54 and advised him that he was not permitted to enter the facility, and CNA #54 agreed that he would not. The Administrator further stated that this will not happen again. Review of a statement authored by the Administrator, undated, revealed on [DATE] he was made aware that CNA #54, a past employee, was coming into the facility to pick up his daughter. Upon learning this, he contacted CNA #54 and left him a message to contact me (the Administrator). He (CNA #54) called on [DATE] at which time the Administrator informed him that he was not to enter the facility under any circumstance. He responded by saying he understood. Review of the policy titled, Abuse, Neglect, and Exploitation, dated [DATE], revealed it is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. This deficiency represents noncompliance investigated under Master Complaint Number OH00164117 and OH00163189.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of facility self-reported incident (SRI) including investigation, observations, staff and resident interviews and review of facility Abuse, Neglect, and Misappropriation policy, the facility failed to ensure a resident was free from verbal abuse. This affected one resident (#26) of three residents reviewed for abuse. The facility census was 42. Findings Include: Review of Resident #26's record revealed a 09/27/24 admission with diagnoses including Alzheimer's disease, altered mental status, unspecified dementia moderate with agitation, insomnia, anxiety disorder, transient ischemic attack, obstructive sleep apnea, vertigo, myocardial infarction, cardiomegaly, cerebral infarction, congenital renal artery stenosis, and supraventricular tachycardia. Review of a Significant Change in Status minimum data set (MDS) assessment dated [DATE] revealed severely impaired cognitive skills for daily decision making, partial moderate assistance was required with eating, substantial maximal assistance with oral hygiene, bed mobility, toileting, personal hygiene, bathing, upper and lower body dressing, putting on taking off shoes, independent with rolling, partial moderate assistance with sitting to lying, lying to sitting on side of bed, sit to stand, chair bed to chair transfers, and walking 10 feet. Resident #26 also required a secured unit due to diagnosis of dementia with behaviors. Behaviors exhibited included episodes of wandering on the unit with potential for poor decision-making abilities and poor safety awareness. Review of care plan revealed Resident #26 had a potential for mood problems related to Alzheimer's, anxiety, dementia with behavioral disturbance. The resident had repetitive anxious complaints or concerns, and repetitive verbalizations. Direct care staff and social services to practice empathetic listening, conveyance of hope, optimistic attitude, and encouragement of positive coping. Resident #26 also required a secured unit due to diagnosis of dementia with behaviors. Behaviors exhibited included repetitive anxious complaints or concerns, repetitive verbalizations, will exit seek, and spends time looking for her family. Review of facility SRI 253615 dated 11/02/24 revealed on 11/02/24 at 8:00 A.M. while at the D hall nurse's station/dining room Certified Nursing Assistant (CNA)) #54 verbally abused Resident #26. License Practical Nurse (LPN) #52 had assisted Resident #26 to the dining room to allow the breakfast tray cart to pass up the hallway. Resident #26 immediately propelled self back beside nurse's station preventing the movement of the breakfast tray cart. CNA #54 approached Resident #26 and said I am going to hit you in the nose, with the resident stating, please don't hit me. CNA #54 propelled Resident #26 back into the dining room and said, now stay the hell here. LPN #52 and Housekeeper #51 overheard what CNA #54 said to Resident #26. Review of a 11/02/24 statement by Housekeeper #51 included CNA #54 was collecting breakfast trays. Resident #26 was by the nurse station. LPN #52 wheeled Resident #26 into the dining room so CNA #54 could put the cart beside the nurse station. Resident #26 came back out by the nurse station. CNA #54 said I'm gonna punch you in the nose. CNA #54 wheeled her back to the dining room and said now stay the hell here and don't move. She went to find her supervisor. CNA #54 stopped Housekeeping and said I would never hit anyone back here that slipped out of my mouth. A 11/02/24 statement by LPN #52 included she was by the nurse station getting medication and heard CNA #54 state to resident I'm going to punch you in the nose! then he proceeded to push resident in dining room in wheelchair stating now stay the hell here! She was waiting for CNA #54 to walk away and told him he could not talk to residents like that. Housekeeping heard the CNA talk to the resident like that also, and we decided to report it. Review of a 11/02/24 statement written by CNA #54 included he was trying to do breakfast with nurse. CNA #54 was trying to get Resident #26 from being in the way. CNA #54 accidentally said he was going to hit her in the nose. CNA #54 did apologize to her and the nurse. CNA #54 stated he would never hit any of my residents. CNA #54 was immediately suspended pending investigation. Observation on 11/22/24 at 12:26 P.M. revealed Resident #26 was in the Memory Care dining room in her geri chair sleeping. Interview at the time of the observation with CNA #57 revealed she attempted to get Resident #26 to eat lunch and she just kept saying no, no, no. Review of the personnel file for CNA #54 found the CNA began working at the facility on 10/01/20 and received in-service education on abuse, neglect, and misappropriation during his orientation. His last abuse training was 09/27/24. The facility completed a criminal background check with no negative results returned. Reference checks were completed prior to hire. CNA #54's last day worked was 11/02/24 the day of the incident. He called in and resigned 11/08/24. He had two prior unsubstantiated SRI's on 11/25/20 and 01/12/21. Review of facility Abuse, Neglect, Exploitation and Misappropriation of Resident Property Policy (revised 11/2016) revealed it was the intent of the facility to ensure the facility appropriately responds to and investigates all alleged violations involving Abuse, Neglect, Exploitation, Mistreatment of a resident, or Misappropriation of Resident Property, including Injuries of Unknown source. Abuse included verbal abuse, sexual abuse, physical abuse and mental abuse. The policy was followed in the events surrounding the verbal, emotional and threat of physical abuse of Resident #26's by CNA #54. Interview on 11/22/24 at 1:45 P.M. with the Director of Nursing, revealed the facility had no further incidents of abuse from a staff member. The deficient practice was corrected on 11/08/24 when the facility implemented the following corrective actions: Immediate removal of CNA #54 from the schedule with suspension pending investigation on 11/02/24 at 8:10 A.M Immediately following the incident on 11/02/24, Resident #26 had comfort support provided by nursing staff. Resident #26 was given a Brief Interview for Mental Status test 11/02/24 at 10:00 A.M. with no change in psychosocial demeanor. Resident #26 had a head to toe assessment completed on 11/02/24 without significant findings. All residents residing on the secured unit were interviewed 11/02/24 with no significant findings and all non-interviewable residents had head to toe assessment with no significant findings. Resident #26's physician and psychiatry support were notified with no new orders on 11/02/24. Family was notified with no new concerns on 11/02/24. Staff education on the abuse/neglect policy was completed on 11/02/24 to 49 staff, all staff except those on a leave of absence, and staff questionnaire completed. The questionnaires included have they seen abuse, neglect or misappropriation without reporting, Have they been educated on the facility abuse policy and did they know who the abuse coordinator was. Social Worker followed up with Resident #26 on 11/02/24 and due to her cognition does not remember incident. Care plan for Resident #26 reviewed and updated as needed on 11/02/24. Facility staffing reviewed on 11/02/24 and found to be at more than appropriate levels. Social Service followed up on 11/02/24 and Resident #26 remains at baseline with no signs/symptoms of emotional damage, fear, or any other negative effect observed. Resident #26 will continue to be provided emotional support to ensure no lasting effect on resident psychosocial health. The facility substantiated - abuse, neglect or misappropriation verified by evidence on 11/08/24. CNA #54 phoned the facility and resigned 11/08/24. Interviews on 11/22/24 with Registered Nurses (RN's) (#50, #53), and CNA #53 were able to identify types of abuse and procedures for escalating behaviors and abuse allegations. They reported they received training on abuse policies and procedures, escalating behaviors, and dining. On 11/22/24, two additional residents (#29 and #39) were sampled and reviewed for abuse. No concerns were identified. On 11/22/24, surveyor review of the facility SRI's revealed there were no further concerns identified regarding abuse. This deficiency represents non-compliance investigated under Self-Reported Incident Complaint Number OH00159797.

Based on medical record review, staff interview, and observation the facility failed to ensure all Pre-Admission Screening and Resident Review (PASARR) level II services were implemented and a comprehensive individualized plan of care was completed. This affected one resident (#1) of four reviewed for PASARR. Findings included: Record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder, mood disorder, depression, obsessive-compulsive disorder, insomnia, paranoid schizophrenia, and dementia. The resident resided on the secure unit. Review of Resident #1's Preadmission Screening and Resident Review (PASARR) dated 01/12/23 revealed Resident #1 met PASARR inclusion criteria for serious mental illness with the diagnoses of schizoaffective disorder, mood disorder, obsessive-compulsive disorder, insomnia, other systems and signs involving cognitive function and awareness, nicotine dependence, major depression, paranoid schizophrenia, and eating disorder. Recommendation included but not limited to Rehabilitative service a safety plan, behavior management safety plan to decrease inappropriate behaviors and to ensure safety, socialization and recreation activities to decrease isolation, improve mood, and increase peer interaction. The reason for these supports includes: While staying in the nursing home, you should be encouraged to participate in activities you enjoy and to talk with other residents to improve your mood. A behavior management safety plan to ensure your safety and the safety of others helping care for you when feeling easily upset, fearful, or confused. Nutritional consult due to having a history of being diagnosed with an eating disorder where you would choose to not eat and focus on losing weight often noted in your records. Continue with therapy services to improve overall functions and to teach you safety awareness skills for self-care once you are feeling better. Review of Resident #1's PASARR Level II plan of care dated 02/02/18 revealed to follow PASARR recommendations. There was no other intervention listed. Further review of Resident #1's plan of care revealed the resident had behavior problems related to the resident displays aggressive gestures, clenching of fists and sudden changes in mood. Per the resident's sister, resident had been OCD his entire life. He was manipulative with other people including family. The resident avoids others, he will watch form a distance and wait until others clear before leaving his room. Resident self isolates to room. Resident fixates on food/snacks. Difficult to arouse. History of refusing medication when tired. Intervention included to have activities staff to encourage the resident to come out of room for activities and socialization. Discourage ordering double portions and pop/soda per power of attorneys wishes. Encourage the resident to sleep at night and awake in the morning. If the resident was difficult to arouse form medication, notify the physician. Remind the resident of snack times, orders, meals, and meal choices. Anticipate and meet the residents need to attempt to control the behavior problems. Provide a calm reassurance, redirections or distraction and assess effectiveness. Provide positive reinforcement for appropriate behavior. Confront gently and respectfully when behavior is inappropriate and set limits. Provide a quite environment as needed. Include resident or representative in treatment plan. The resident activity plan of care revealed to invite to activities of interest, offer praise for participation, provide activity calendar, and provide items needed for self-directed activities as needed. Review of the task (completed by State tested Nurses' Aides) dated 09/17/24 to 10/17/24 revealed the resident had no physical or verbal behaviors. The resident had wandering behaviors seven days. The resident was noted to refuse activities, however watched television in his room. Further review of Resident #1's paper and electronic medical record revealed no evidence of safety plan or behavior management safety plan. Random observation on 10/15/24 from 9:00 A.M. till 3:30 P.M., 09/17/24 8:00 A.M. to 3:00 P.M., the resident was observed in his room in bed. There was no evidence the resident had participated in an activity or left his room. Interview on 10/15/24 at 11:52 A.M., revealed Resident #1 would not stay awake to complete interview. Interview and observation on 10/15/24 at 3:26 PM with Resident #1 revealed the resident was still in bed. The resident reported he didn't go to activities per his choice. The resident reported he had been on the same medication for [AGE] years and needs bigger medications and he needs medication to help him sleep. The resident confirmed he currently sleeps a lot during the day. Interview on 10/15/24 at 3:32 P.M., with Registered Nurse (RN) #4 confirmed the resident sleeps a lot during the day and doesn't leave his room. The resident overeats and has an obsession with his medications. Interview on 10/17/24 at 8:50 A.M. and 10:51 A.M., with State tested Nurse's Aide (STNA) #56 confirmed the resident sleeps a lot. The staff tries to encourage the resident to get up in the chair, but as soon as they walk out the door, he puts himself back into bed. The STNA reported the resident only leaves his room when staff were cleaning his room due to his obsessive-compulsive disorder. The resident usually refuses meals but would also ask for double or triple of extra food he likes. The STNA reported she was not aware if the resident had safety plan or a behavior management safety plan. Interview on 10/17/24 at 10:59 A.M., with RN #43 revealed she was not aware the resident had a safety plan or a behavior management safety plan. The RN reported Resident #1 behaviors included isolation and he over eats. Interview on 10/17/24 at 11:14 A.M., with the Director of Nursing (DON) and Activity's Director (AD) #9 confirmed the resident refused activities frequently. The AD reported the activities staff just document refusal and the staff doesn't do anything else to encourage the resident from isolating himself to his room or to attend activities. The AD confirmed the only activity the Resident had engaged in was watching television; however, the AD reported the resident does like to window shop on the computer, but she doesn't have any documentation to support the window shopping occurred or when. The facility did not have a comprehensive individualized plan of care to meet the resident social/activities needs per the PASARR level II recommendations. Interview on 10/17/24 at 10:55 A.M. with the Director of Nursing (DON) confirmed the resident did not have a safety plan or a comprehensive behavioral management safety plan per the PASARR level II recommendations.

Based on medical record review, interview, and policy review, the facility failed to ensure a resident representative was invited to attend a care planning conference. This affected one resident (#9) of one resident reviewed for care planning. The facility census was 42. Findings include: Review of the medical record revealed Resident #9 was admitted to the facility on [DATE]. Diagnoses included multiple sclerosis, diabetes mellitus, anxiety disorder, depression, and suicidal ideation. Review of the admission Minimum Data Set (MDS) assessment, dated 08/01/24, revealed the resident was moderately cognitively impaired with behaviors and rejection of care. The resident required staff assistance with activities of daily living (ADLs). Review of Resident #9's Care Conference form, dated 07/29/24, did not indicate the family/responsible party attended or was invited to attend the care conference. Interview on 10/15/24 at 1:39 P.M., Resident #9's daughter/power of attorney (POA) #400 revealed she was concerned because she had not been invited nor attended a care conference for her mother and she would like to attend the care conferences. Interview on 10/16/24 at 4:59 P.M., Social Services Designee (SSD) #11 confirmed Resident #9's POA was not invited and did not attend her mother's care conference on 07/29/24. Interview on 10/17/24 at 8:58 A.M., the Director of Nursing (DON) confirmed Resident #9's POA/family member should have been notified and invited to attend the care planning conference. Review of the facility policy titled, Participation in Care Conference, (dated November 2016), revealed a letter informing the resident and/or their responsible party shall be provided two weeks in advance of the scheduled conference. Care Conference notification letters are to be sent out per Social Services.

Based on medical record review, observation, and staff interviews the facility failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This affected three residents (#1, #10, and #17) out of 13 records reviewed. Findings included: 1. Record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder, mood disorder, depression, obsessive-compulsive disorder, insomnia, paranoid schizophrenia, and dementia. The resident resided on the secure unit. a. Review of Resident #1's Preadmission Screening and Resident Review (PASARR) notification dated 01/12/23 revealed Resident #1 met criteria for serious mental illness and would need specialized services. Review of Resident #1's annual Minimum Date Set (MDS) assessment dated [DATE] revealed the resident wasn't considered to have a serious mental illness by the PASARR. Interview on 10/17/24 at 10:04 A.M., with the MDS Nurse #61 and Social Worker (SW) #11 confirmed Resident #1's MDS was marked inaccurate due to the resident did meet criteria for a serious mental illness on the PASARR dated 01/12/23. b. Review of Resident #1's MDS assessment dated [DATE] revealed Resident #1 used a physical restraint (physical restraints are any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body) due to he used bed rails daily. Review of Resident #1's bed rail/mattress safety assessment completed by the therapy department dated 03/15/24 revealed the resident enabler bar was used per resident request to increase independency. Interview on 10/15/24 at 10:10 A.M., with Registered Nurse (RN) #4 confirmed there was no residents that had physical restraint at this time on the secure unit. Observation on 10/15/24 at 3:26 P.M., revealed the resident had a enabler bar on the left side of the bed. The resident confirmed the bar was used for positioning and did not prevent him from rising or restraining him. Interview on 10/15/24 at 3:20 P.M. and 10/16/24 at 8:57 A.M. with the Director of Nursing (DON) confirmed Resident #1's MDS was coded inaccurately for physical restraints due to the enabler bar was determined by therapy as not a restraint and was only used to aid the resident in positioning only. The enabler bar did not prevent the resident from rising nor does it restrain him. The DON confirmed the MDS nurse had marked everyone with an enabler bar/bedrail as a physical restraint because that was what the facility was told by Centers of Medicare and Medicaid Services (CMS). 2. Medical record review revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including anxiety, metabolic encephalopathy, atrial fibrillation, hypertension, depression, adult failure to thrive, dementia, kidney disease, heart failure, and Alzheimer's. Review of Resident #10 MDS dated [DATE] revealed the resident used a physical restraint (bed rail) daily. Review of Resident #10's bed rail/mattress safety assessment completed by the therapy department and dated 05/24/25 revealed Resident #10's bed rails were not restraints and were used for bed mobility. Review of Resident #10's assessment titled classification of device dated 08/26/24 revealed the resident did not have a device/restraint. Interview on 10/15/24 at 10:10 A.M., with Registered Nurse (RN) #4 confirmed there was no residents that had physical restraint at this time on the secure unit. Observation on 10/15/24 at 3:32 P.M., of Resident #10 revealed the resident had an enabler bar on each side of bed. Interview on 10/15/24 at 3:20 P.M. and 10/16/24 at 8:57 A.M. with the Director of Nursing (DON) confirmed Resident #10's MDS was coded inaccurately for physical restraints due to the enabler bars were assessed and determined not be restraints and were to assist with bed mobility only. 3. Record review revealed Resident #17 was admitted to the facility on [DATE] with diagnoses including diabetes, anemia, bipolar, hypertension, conduct disorder, dementia, depression, restlessness and agitation, hypothyroidism, cirrhosis of the liver, and chronic kidney disease. The resident resided on the secure unit. Review of Resident #17's MDS dated [DATE] revealed the resident used a physical restraint (bed rail) daily. Review of Resident #17's bed rail/mattress assessment dated [DATE] completed by the therapy department revealed the resident's bed rails were required for stand to sit. Observation on 10/15/24 at 3:35 P.M. revealed Resident #17 had a half bed rail on the left side of the bed. The resident was in the dining room with his walker and confirmed the bedrail did not restrict him from any type of movement. Interview on 10/15/24 at 3:20 P.M. and 10/16/24 at 8:57 A.M. with the Director of Nursing (DON) confirmed Resident #17's MDS was coded inaccurately for physical restraints due to the bed rails were assessed and determined not be restraints and were to assist with stand to sit.

Based on medical record review, staff interview, and policy review the facility failed to ensure Pre-Admission Screening and Resident Review (PASARR) assessments were completed accurately upon admission to the facility. This affected one resident (#37) of four residents reviewed for PASARR. Findings include: Medical record review revealed Resident #37 was admitted to the facility on [DATE] with diagnoses including major depressive disorder, intermittent explosive disorder, bipolar, and generalized anxiety disorder. Review of Resident #37's admission orders dated 07/12/24 revealed the resident was ordered Mirtazapine 15 milligrams (mg) 1.5 tablets at bedtime for depression, Rivastigmine 6 mg twice a day for dementia, Ativan 1 mg every four hours as needed for anxiety/agitation and Risperdal 0.5 mg twice a day for dementia. Review of Resident #37's PASARR dated 07/12/24 revealed the resident was marked for mental disorder. The box was checked for other for mental disorder and depression was typed in on the line. There was documented evidence the resident had intermittent explosive disorder, bipolar, and generalized anxiety disorder. The medication section indicated the resident medication included anti-psychotics and anti-anxiety. There was no documented evidence the resident was on an anti-depressant. Interview on 10/15/24 at 11:01 A.M., with Social Worker (SW) #11 confirmed the PASARR was inaccurate on admission and did not include intermittent explosive disorder, bipolar, and generalized anxiety disorder nor the anti-depressant medication. Review of the Pre-Admission Screening and Resident review policy (dated 04/2017 and reviewed and revised 2024) revealed a resident review was required for any nursing facility resident with a serious mental illness or intellectual developmental disability who had experienced a change in mental diagnoses or psychotropic medication. Nursing facilities were required to complete the 3622 accurately and submit it to the if indication of serious mental illness and or developmental disabilities are present. The system allows the NF to complete the form and submit it directly to the department for further review. A resident review was required for any resident had experienced a significant change in condition (mental diagnosis or psychotropic medication).

Based on observation, interview and record review the facility failed to ensure Resident #3's oxygen therapy was set to the correct liters per minute. This affected one resident ( #3) of one resident reviewed for oxygen therapy. The facility census was 42. Findings include: Review of the medical record for Resident #3 revealed an admitted [DATE]. Diagnoses included asthma, chronic obstructive pulmonary disease (COPD), morbid obesity, and chronic respiratory failure with hypoxia. Review of Resident #3's October 2024 physician orders revealed an order dated 07/31/24 to have oxygen at two to five liters per minute via nasal cannula continuously. Review of Resident #3's Comprehensive care plan dated 08/20/24 revealed the resident is at risk for altered respiratory status and difficulty breathing related to shortness of breath. Interventions included to administer medication as ordered, observe need for oxygen therapy, change in respiratory rate or pattern, mental status changes, and oxygen (therapy) at two to five liters a minute to maintain saturation at greater than 90 percent as needed. Observation on 10/15/24 at 11:31 A.M. revealed Resident #3 to be in sitting in her room receiving oxygen therapy. The resident's oxygen set at 10 liters via nasal cannula. Observation on 10/16/24 at 8:53 A.M. revealed Resident #3 to be laying in her bed receiving oxygen therapy via nasal cannula. The oxygen was set at 10 liters. Interview on 10/16/24 at 8:53 A.M. Registered Nurse (RN) #22 confirmed Resident #3's oxygen was incorrectly placed on 10 liters. She verified the order was for the resident to have her oxygen set at two to five liters a minute. At the time of the observation and interview, RN #22 turned down the resident's oxygen at this time.

Based on record review, observation, resident interview, staff interview and policy review, the facility failed to ensure fall prevention interventions were in place for a resident who had a history of falls and was also known to be a fall risk as per the resident's plan of care. This affected one (Resident #42) of two residents reviewed for falls. The facility census was 44. Findings included: A review of Resident #42's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included a history of falls, [CONDITION(S)] and collapse ([CONDITION(S)]), lack of coordination, muscle wasting and atrophy, history of seizures, essential tremors, [CONDITION(S)], adult onset diabetes mellitus, hypertension, [CONDITION(S)] and dementia. A review of Resident #42's physician's orders revealed she had an order that she could be up in a recliner or chair as tolerated. The only fall prevention intervention included as part of the physician's orders was for the use of a fall mat to the side of her bed while the resident was in bed. A review of Resident #42's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had adequate vision with the use of corrective lenses. She did not have any communication issues and was cognitively intact. She was not known to have displayed any behaviors or reject care during the seven days of the assessment period. She required an extensive assist of two for transfers and ambulation. A review of Resident #42's care plans revealed she had a care plan in place for being at risk for falls and fall related injuries related to abnormalities of her gait and mobility, history of a stroke, weakness, [CONDITION(S)], dementia, history of falls, poor safety awareness, medications, and diabetes mellitus. Her interventions included assisting the resident with a wheelchair or walker for mobility as needed and the use of Dycem (non-slip material used to prevent sliding out of a chair) to the seat of her wheelchair when up. That intervention had been in place since 01/18/22. On 05/10/22 at 10:20 A.M., an observation of Resident #42 noted her to be sitting up in her wheelchair in her room reading a book. She was noted to be sitting on a cushion while up in her wheelchair. An interview with the resident, at the time of the observation, revealed she did not have Dycem under her while in her wheelchair as per her fall prevention interventions. Dycem was found folded over and on top of another cushion that was sitting on top of her nightstand. She reported the Dycem was in her wheelchair when she was up yesterday but, was not placed in her wheelchair when they got her up earlier that day. On 05/10/22 at 10:22 A.M., State tested Nursing Assistant (STNA) #300 was asked to verify if Resident #42's Dycem was under her while she was sitting up in her wheelchair. She assisted the resident to a standing position and did not find the Dycem on top of her cushion or below the cushion the resident was sitting on. She acknowledged the Dycem was still on top of another cushion sitting on top of the resident's nightstand. She was asked how the nursing staff knew what fall prevention interventions were to be in place for each resident. She stated they got that information in report and also had a form on their STNA clipboard titled Resident Device List. She checked the Resident Device List for Resident #42 and reported Resident #42 was not identified as having the use of Dycem to her wheelchair. There was a box to check, if the resident had non-slip material in her seat, but that box was left unchecked. A review of the facility's Managing Falls and Fall Risk policy, revised March 2018, revealed the staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The staff would implement a resident-centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls.

Based on medical record review and staff interview the facility pharmacist failed to identify medications ordered for a short time period included stop dates for administration. This affected one (Resident #11) of five reviewed for medications. The facility census was 44. Findings included: Review of Resident #11's medical record revealed an admitted [DATE] with admission diagnoses that included [CONDITION(S)] disorder, [CONDITION(S)] disorder and anxiety. Review of the monthly physician's orders for medications revealed on [DATE], Resident #11 was prescribed the use of [MEDICATION(S)] (anti-anxiety medication) 50 milligrams (mg) every six hours as needed for 14 days for anxiety and agitation. Review of the Medication Administration Record (MAR) revealed no stop date was entered for the medication and was continued beyond the 14 days as ordered on [DATE]. The medication should have had an end date of [DATE]. Further review of the MAR revealed the last time the medication was administered was on [DATE], 30 days after the stop date. Review of the monthly pharmacy review and recommendations revealed monthly review completed on [DATE], [DATE] and [DATE]. The pharmacist did not identify and address the lack of stop date for the medication. Interview with the Director of Nursing on [DATE] at 3:00 P.M. verified the [MEDICATION(S)] was an active and current medication order on the MAR and should have ended after the 14 days expired as ordered by the physician on [DATE].

Based on medical record review and staff interview the facility failed to follow medication orders and discontinue an anti-anxiety medication as ordered by the prescriber. This affected one (Resident #11) of five reviewed for medications. The facility census was 44. Findings included: Review of Resident #11's medical record revealed an admitted [DATE] with admission diagnoses that include [CONDITION(S)] disorder, [CONDITION(S)] disorder and anxiety. Review of the monthly physician's orders for medications revealed on [DATE], Resident #11 was prescribed the use of [MEDICATION(S)] (anti-anxiety medication) 50 milligrams (mg) every six hours as needed for 14 days for anxiety and agitation. Review of the Medication Administration Record (MAR) revealed no stop date was entered for the medication and was continued beyond the 14 days as ordered on [DATE]. The medication should have an end date of [DATE]. Further review of the MAR revealed the last time the medication was administered was on [DATE], 30 days after the stop date. Interview with the Director of Nursing on [DATE] at 3:00 P.M. verified the [MEDICATION(S)] was an active and current medication order on the MAR and should have ended after the 14 days expired as ordered by the physician on [DATE].

Based on observation, record review and staff interview the facility failed to maintain a medication error rate of less than five percent. The medication error rate was calculated to be 5.1% and included two medication errors of 39 observed medication administration opportunities. This affected two residents (#38 and #95) of three residents observed during medication administration. Findings included: 1. On 05/10/22 at 8:00 A.M. observation of medication administration with Registered Nurse (RN) #143 revealed medications administered to Resident #95. The observation revealed Vitamin B12 was not administered as ordered at the time of administration. Review of Resident #95's medical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's medication orders revealed vitamin B12 (vitamin supplement) 500 micrograms (mcg) two tablets every day. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M. On 05/11/22 at 9:00 A.M. interview with the Director of Nursing verified vitamin B12 was not administered to Resident #95 as ordered by the physician. 2. On 05/11/22 at 8:25 A.M. observation of medication administration with Licensed Practical Nurse (LPN) #151 revealed medications administered to Resident #38. The observation revealed omeprazole was not administered at the time of administration. Review of Resident #38's medical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's medication orders revealed omeprazole (proton-pump inhibitor, medication for GERD) 20 milligrams (mg) every day for heartburn. Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M. On 05/11/22 at 8:55 A.M. interview with LPN #151 verified omeprazole not administered to Resident #38 as ordered by the physician.

Based on review of the facility's policies and procedures, review of employee time sheet reports, review of employee COVID-19 test results, review of staff/ visitor screening logs, and staff interview, the facility failed to ensure employees properly quarantined after being exposed to a positive COVID-19 person, and were properly screened for symptoms of COVID-19 upon entrance into the facility. This had the potential to affect all 37 residents in the facility. Findings include: Interview with Dietary Cook (DC)#1 on 11/30/21 at 12:45 P.M. revealed her children tested positive for COVID-19 on 10/31/21. She indicated she was exposed to the children prior to the test. The children remained in the same residence as DC #1, but were isolating themselves in their rooms. DC #1 indicated she advised the facility of the children's positive test results and was told she could continue to work. DC #1 indicated she was tested several times at the facility. On 11/11/21 she went to work and tested upon arrival, a few hours later she was asked to repeat the test due to the prior test being inconclusive. The second test on 11/11/21 was COVID-19 positive and she was sent home to isolate. DC #1 indicated she was unvaccinated for COVID-19. Review of DC #1's COVID-19 testing records revealed negative BinaxNow COVID-19 rapid [MEDICATION(S)] test on 11/02/21, 11/08/21 and 11/10/21. A positive test result for COVID-19 was found on 11/11/21. Review of the facility resident COVID-19 positive cases revealed no resident positives from 10/31/21 to 11/27/21 indicating no spread from DC #1. Review of DC #1's time sheets revealed she worked in the facility after exposure on 11/01/21, 11/02/21, 11/03/21, 11/05/21, 11/06/21, 11/08/21, 11/10/21 and 11/11/21. Review of the facility COVID-19 Entry Screening Checklist for visitor and staff revision date 05/04/20 (completed upon entry for all staff and visitors) revealed no evidence of a screening question for potential exposure to COVID-19 infected persons. Further review of the Screening Checklist revealed screening checklist completed upon entry for DC #1 on 11/01/21, 11/02/21, 11/03/21, 11/05/21 11/06/21, 11/08/21, 11/10/21 and 11/10/21 which indicated no signs or symptoms of COVID-19 and no evidence of any question or indication of exposure to COVID-19 positive persons. Review of the facility policy and procedures revealed no facility policy in place related to employee exposure to COVID-19 infected persons. Policies indicated to follow Center for Disease Control and Prevention (CDC) guidelines. Review of CDC guidelines for Quarantine and Isolation with an updated date of 10/19/21 indicated to quarantine if you have been in close contact (within 6 feet of someone for a cumulative total of 15 minutes or more over a 24-hour period) with someone who has COVID-19, unless you have been fully vaccinated. Anyone who has had close contact with someone with COVID-19 should quarantine for 14 days after their last exposure to that person, unless they are fully vaccinated. Interview with the Administrator and Director of Nursing on 11/30/21 at 1:10 P.M. verified the COVID-19 entry screening checklist does not include a screening question about exposure to COVID-19 infected persons. Interview with the Administrator and Director of Nursing on 11/30/21 at 1:40 P.M. verified DC #1 was exposed to COVID-19 at home when her children tested positive on 10/31/21 and DC #1 continued working in the facility until testing positive on 11/11/21. This deficiency substantiates Complaint Number OH 485.

Based on observation, interview and record review the facility failed to ensure residents' narcotic medications were not misappropriated by staff. This affected three (Residents #1, #5, and #39) of 15 residents reviewed for narcotic medications. Findings include: 1. Review of the medical record for Resident #5 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medication administration records (MARs) for Resident #5 from [DATE] to [DATE] revealed the resident was administered [MEDICATION(S)] 25 milligrams (mg) twice daily as ordered for pain, which is a controlled, schedule V medication. Review of the treatment administration records (TARs) for Resident #5 from [DATE] to [DATE] revealed the resident was assessed for pain each shift and had no reports of unmanaged pain. The TAR also revealed the resident was assessed for [CONDITION(S)] activity each shift with no [CONDITION(S)] activity noted. Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nursing progress notes for Resident #5 dated from [DATE] to [DATE] revealed the resident had complaints of pain which were managed with pain medication which included the controlled medication [MEDICATION(S)]. Review of the quarterly minimum data set 3.0 assessment (MDS) dated [DATE] revealed Resident #5 had moderate cognitive impairment and was on a pain medication regimen. The MDS also revealed Resident #5 was totally dependent on two staff for transfers, toileting, and bathing, was totally dependent on one staff for hygiene, required extensive assistance of two staff for mobility and dressing, and required set up only for eating. Review of the plan of care dated [DATE] revealed Resident #5 was at risk for [CONDITION(S)] activity with interventions which included to administer medications as ordered. The plan of care also revealed the resident had pain with interventions which included to assess for verbal and non-verbal signs of pain, to attempt non-pharmacological pain relief interventions, and to administer medications as ordered. Review of the communication from pharmacy dated [DATE] revealed Licensed Practical Nurse (LPN) #908 had requested a refill for Resident #5's [MEDICATION(S)] 25 mg however, they told the nurse it was too soon to be refilled since 60 doses of [MEDICATION(S)] had been delivered on [DATE]. Review of the facility Self-Reported Incident (SRI) dated [DATE] revealed Registered Nurse (RN) #907 discovered discrepancies in the narcotic count sheets for Resident #1 and Resident #39. The SRI revealed RN #907 notified the DON. The SRI revealed the DON found a fax in the shredder box on which LPN #908 had requested additional [MEDICATION(S)] for Resident #5 from the pharmacy as several had been wasted. The SRI revealed narcotic sheets for Resident #1's [MEDICATION(S)] and Resident #39's [MEDICATION(S)] were blank and were not the original count sheets sent from pharmacy. The SRI revealed the new narcotic count sheets did not reflect the number of pills that had been sent by pharmacy to the facility. The SRI revealed the DON and AIT reviewed video footage and witnessed LPN #908 had made several suspicious entries into the narcotic signature binder and place what appeared to be a card which contained narcotic medications from the narcotic drawer in a garbage bag and leave the floor. The SRI explained the video footage then showed LPN #908 re-entered the resident care area and continued what appeared to be emptying the trash cans and threw away the card which contained narcotic medication, the narcotic count papers and the bag. Review of the police report dated [DATE] revealed LPN #908 confessed to police investigators she had taken 26 doses of [MEDICATION(S)], 25 mg tablets, from Resident #5. Observation on [DATE] at 1:05 P.M. revealed Resident #5 was propelling herself in the corridor. Resident #5 was clean, appropriately dressed for the day, and free from odor. Interview with Resident #5 revealed she had no complaints of pain, and she did not remember missing any medications. Interview on [DATE] at 1:10 P.M. with the Administrator in Training (AIT) revealed on [DATE], Registered Nurse (RN) #907 reported to the Director of Nursing (DON) and her that narcotic/controlled substance count sheets for two residents were not the originals, but copies (they were blank and handwritten). The AIT said she and the DON went to the facility immediately. The AIT said the DON performed audits on all residents who were ordered controlled substances and identified residents with missing medications including Resident #5, who was missing [MEDICATION(S)] medication. The AIT said the pharmacy was notified and Pharmacist #909 came to the facility and performed audits of the narcotic boxes. The AIT said the local police department was also notified. The AIT said she and the DON found communication on which LPN #908 faxed the pharmacy requesting additional [MEDICATION(S)] tablets for Resident #5, explaining that several tablets had been wasted. The AIT said RN #907 was sent for a drug test which was negative and LPN #908 was called and asked to return to the facility. LPN #908 refused to return to the facility for questioning and a drug test. Interviews were attempted on [DATE] at 1:24 P.M. and 3:21 P.M. with LPN #908 to speak about her admitted narcotic diversion. Voicemail messages were left with no return contact. Interview on [DATE] at 1:40 P.M. with RN #907 revealed when she came to work on [DATE], she discovered copied narcotic/controlled substance sign out sheets for a couple residents and the with the original count sheets missing. RN #907 revealed LPN #908 had worked the previous shift before her. RN #907 said she then notified the DON and the AIT and confirmed she attempted to re-order [MEDICATION(S)] for Resident #5. RN #907 said the pharmacy stated the medication had already been filled and it was too early for a refill. RN #907 revealed Resident #5 was assessed and denied pain. Interview on [DATE] at 4:04 P.M. with the DON revealed the facility had no policy related to narcotic administration or narcotic counts and they just used standard nursing practice and guidelines for counting narcotics/controlled substances. Interview on [DATE] at 4:05 P.M. with the AIT confirmed the facility had no policy related to counting narcotic/controlled substances. 2. Review of the medical record for Resident #1 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] #1 was ordered [MEDICATION(S)], a narcotic pain reliever, 50 mg, one tablet in the morning and two tablets in the afternoon for pain. Resident #1 was ordered a pain assessment each shift to be documented on the TAR. Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician reduced the [MEDICATION(S)] order for Resident #1 on [DATE] to 50 mg, one tablet daily for pain. Review of the MARs dated from [DATE] to [DATE] revealed Resident #1 was administered [MEDICATION(S)] 50 mg as ordered. Review of the TARs dated from [DATE] to [DATE] revealed Resident #1 was assessed for pain each shift as ordered. Review of the pharmacy manifest dated [DATE] revealed the facility received 60 tablets of [MEDICATION(S)] 50 mg for Resident #1. Review of the narcotic count sheet dated [DATE] revealed the handwritten narcotic count sheet signed by LPN #908 revealed a starting number of 40 tablets of [MEDICATION(S)] 50 mg for Resident #1. Review of the SRI dated [DATE] revealed RN #907 discovered discrepancies in the narcotic/controlled substance count sheets for Resident #1. RN #907 notified the DON and she found a fax in the shredder box on which LPN #908 had requested additional controlled medication for another resident. The SRI revealed narcotic sheets for Resident #1's [MEDICATION(S)] were blank and were not the original count sheets sent from pharmacy. The SRI revealed the new narcotic count sheets did not reflect the number of pills that had been sent by pharmacy to the facility. The DON and AIT reviewed video footage and witnessed LPN #908 make several suspicious entries into the narcotic signature binder and place what appeared to be a card containing narcotic/controlled medications from the narcotic drawer in a garbage bag and leave the floor. The SRI explained the video footage then showed LPN #908 re-entered the resident care area and continued what appeared to be emptying the trash cans and threw away the card which contained narcotic medication, the narcotic count forms and the trash bag. Review of the police report dated [DATE] revealed LPN #908 confessed to police investigators that she had taken narcotics/controlled medications from multiple residents including 20 doses of [MEDICATION(S)] 50 mg from Resident #1. Review of the plan of care dated [DATE] revealed Resident #1 was at risk for pain with interventions which included to assess for verbal and non-verbal signs of pain, to attempt non-pharmacological pain relief interventions, and to administer pain medications as ordered. Review of the quarterly MDS for Resident #1 dated [DATE] revealed the resident had intact cognition and was taking medication to manage pain. The MDS also revealed Resident #1 was independent for activities of daily living such as transfers, bed mobility, dressing, toileting, and hygiene. Observation on [DATE] at 11:37 A.M. revealed Resident #1 was propelling himself throughout the facility socializing with staff and peers. Resident #1 denied unmanaged pain and had no concerns with medication administration. Interview on [DATE] at 1:10 P.M. with the AIT revealed on [DATE], RN #907 reported to her and the DON the narcotic count sheets for Resident #1's [MEDICATION(S)] was a copy (blank and handwritten) and not the originals. The AIT said she and the DON both came to the facility immediately. The AIT said the DON performed audits on all residents who were ordered controlled substances to see if there were additional packing slip or narcotic count issues. The AIT said Resident #1 was missing [MEDICATION(S)] in addition to missing medications for other residents. The AIT said pharmacy was notified and Pharmacist #909 came to the facility and performed audits of the narcotic boxes. The AIT said the local police department was notified. The AIT said she and the DON found communication where LPN #908 faxed the pharmacy requesting additional controlled medications for another resident. The AIT said RN #907's drug test was negative. The AIT said LPN #908 was called and asked to return to the facility. LPN #908 refused to the facility for questioning or for a drug test. Interviews were attempted on [DATE] at 1:24 P.M. and 3:21 P.M. with LPN #908 to speak about her admitted narcotic diversion. Voicemail messages were left with no return contact. Interview on [DATE] at 1:40 P.M. with RN #907 revealed when she came to work on [DATE], she discovered copied narcotic/controlled substance sign out sheets for two resident's medications, including for Resident #1's [MEDICATION(S)] and the original count sheets were missing. RN #907 verified LPN #908 had worked the previous shift before her. RN #907 said she notified the DON and AIT. RN #907 said Residents #1 was assessed for and denied pain. Interview on [DATE] at 4:04 P.M. with the DON revealed the facility had no policies related to narcotic/controlled substances administration or counting. The DON said they use standard nursing practice and guidelines for counting narcotics. Interview on [DATE] at 4:05 P.M. with the AIT confirmed the facility had no policy related to narcotic/controlled substances counts. 3. Review of the medical record for Resident #39 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The medical record revealed Resident #39 had expired [DATE]. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the plan of care dated [DATE] revealed Resident #39 had the potential for pain related to gout and fracture of left humerous with interventions which included for staff to assess the resident for pain, attempt non-pharmacological pain relief interventions such as a body pillow, and administer pain medications as ordered. Review of the MARs for Resident #39 dated from [DATE] to [DATE] revealed the resident was administered [MEDICATION(S)] 15 mg twice daily for pain as ordered. Review of the MDS dated [DATE] revealed Resident #39 had severe cognitive impairment and was taking pain medications to manage pain. The MDS revealed Resident #39 required extensive assistance from two staff members for transfers, bed mobility, dressing, hygiene, bathing, and toileting. Review of the facility investigation timeline dated [DATE] revealed 30 tablets of [MEDICATION(S)] 15 mg for Resident #39 were delivered to the facility by pharmacy on [DATE]. Review of the narcotic count sheet for Resident #39 dated [DATE] revealed the handwritten narcotic count sheet was signed by LPN #908 and revealed a starting number of 24 tablets of [MEDICATION(S)] 15 mg. Review of the SRI dated [DATE] revealed RN #907 discovered discrepancies in the narcotic count sheets for Resident #39 and another resident. The SRI revealed narcotic count sheets for Resident #39's [MEDICATION(S)] were blank and were not the original count sheets sent from pharmacy. The new narcotic count sheets did not reflect the number of pills that had been sent by pharmacy to the facility. The DON and AIT reviewed video footage and witnessed LPN #908 make several suspicious entries into the narcotic signature binder and place what appeared to be a card which contained narcotic medications from the narcotic drawer in a garbage bag and leave the floor. The video footage then showed LPN #908 re-enter the resident care area and continued what appeared to be emptying the trash cans and she threw away the card which contained narcotic medication, the narcotic count papers and the trash bag. Review of the police report dated [DATE] revealed LPN #908 confessed to police investigators she had taken the six missing doses of [MEDICATION(S)] 15 mg from Resident #39. Interview on [DATE] at 1:40 P.M. with RN #907 revealed when she came to work on [DATE], she discovered copied narcotic/controlled substance sign out sheets for two other resident's medications and the original count sheets were missing. RN #907 verified LPN #908 had worked the previous shift before her. RN #907 said she notified the DON and AIT. Interview on [DATE] at 4:04 P.M. with the DON revealed the facility had no policies related to narcotic/controlled substances administration or counting. The DON said they use standard nursing practice and guidelines for counting narcotics. Interview on [DATE] at 4:05 P.M. with the AIT confirmed the facility had no policy related to narcotic/controlled substances counts.

Based on medical record review, staff interview, and policy review the facility failed to ensure resident representatives/family/guardians were notified of significant weight loss. This affected three sampled residents (#1, #26 and #33) and four additional residents (#18, #20, #29 and #30) identified by the facility to have sustained weight loss. Findings include: 1. Review of the closed medical record for Resident #33 revealed the resident was original admitted to the facility on [DATE] and was re-admitted on [DATE] and then discharged home on[DATE]. [DIAGNOSES REDACTED]. Resident #33's brother was identified to be the responsible representative for notification. Review of the five-day Minimum Data Set (MDS) 3.0 assessment, dated 12/23/20 revealed the resident had impaired cognition and was totally dependent on staff for eating. Review of Resident #33's weights dated 10/28/20 to 12/04/20 revealed on admission (10/28/20) the resident weighed 241.1 pounds. On 11/02/20 his weight was 237.2 which indicated a 3.9-pound weight loss in one week. Two weeks later 11/16/20 the resident weighed 228.6 which indicated a 12.5-pound weight loss in three weeks. The following week (11/23/20) the resident weighed 224.4, which indicated 16.7-pound significant weight loss in one month. Review of the Resident #33's dietary note dated 11/23/20 revealed the resident had significant weigh loss within the month of 5.2%/12.5 pounds. Slight weight loss desirable, however significant weight loss was unplanned. Additional dietary notes revealed on 11/24/20 continued to show a significant weight loss within the month. The resident had a 6.9%/16.7-pound weight loss since admission. On 12/04/20 a significant weight loss for 30 days was noted to be 6.5%/ 15.7 pounds. There was no evidence the resident's representative was notified of the significant weight loss. Review of Resident #33's nursing progress notes, dated 10/28/20 to 12/29/20 revealed no evidence the resident's family/representative was notified of the significant weight loss. Interview on 01/12/21 at 11:29 A.M. with the Director of Nursing (DON) verified Resident #33's brother was the resident's responsible party and was not notified of the resident's significant weight loss on 11/16/20 of 12.5 pounds or 11/23/20 of 16.7 pounds. 2. Review of the medical record for Resident #26 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's son was noted to be the resident's responsible representatives for notification. Review of Resident 26's weights dated 10/05/20 to 12/07/20 revealed on 10/05/20 the resident weighed 151.8. The next month (11/09/20) the resident weighed 147.4, which indicated a 4.4 weight loss in one month. On 12/07/20 the resident weighed 140.0 which was an additional 7.4 pounds weight loss. The resident lost 11.8 pounds in two months. Six months prior, on 06/01/20 the resident weighed 155.6 pounds. Review of Resident #26's dietary note dated 12/11/20 revealed the resident had a significant weight loss of 5%/7.4 pounds in one month and 10%/15.6 pounds in six months. Review of Resident #26's nursing notes, dated 10/01/20 to 01/12/21 revealed no evidence the resident's son was notified of the residents significant weight loss. Interview on 11/12/21 at 11:17 with the DON confirmed the resident's representatives (son) was not notified of the resident's significant weight loss. 3. Review of the medical record for Resident #1 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of resident's guardianship court order, dated 11/05/20 revealed a local attorney was awarded guardianship of Resident #1 on 11/05/20. Review of Resident #1's weights revealed on 11/09/20 the resident weighed 190.8. On 11/16/20 and 11/23/20 he weighed 188.2 (2.6-pound weight loss). On 12/04/20 he weighed 177.6 (10.6-pound weight loss). Review of Resident #1's dietary note, dated 12/04/20 revealed the resident had a significant weigh loss for the month of 6.9%/13.2 pounds since 11/09/20 at 190.8 pounds and 15%/31.4 pounds since 08/31/20 at 209 pounds. There was no evidence the legal guardian was notified of significant weight loss. Review of Resident #1's nursing notes, dated 10/01/20 to 01/12/21 revealed no evidence the resident's guardian was notified of the significant weight loss. Interview on 01/12/21 at 10:30 A.M. and 11:58 A.M. with the DON confirmed the legal representative was not notified of Resident #1's significant weight loss. In addition, during an interview with the DON on 01/12/21 at 11:59 A.M., the DON revealed Resident #18, #20, #29 and #30 were also noted to have sustained significant weight loss in December 2020. She confirmed all five of these residents had legal guardians or family members who were their resident representatives. The DON verified there was no evidence these five resident guardians/representatives had been notified of the resident's significant weight loss. Review of the facility policy titled Weight Management, dated 08/2017 revealed the Director of Nursing (DON)/designee would notify the physician and family of weight changes and interventions and document (the notification) in the nursing notes. This deficiency substantiates Complaint Number OH 747.

Based on observation, record review and staff interview the facility failed to provide respiratory care to meet the total care needs of Resident #2. This affected one resident (#2) of three residents reviewed for the use of oxygen while infected with the COVID-19 virus. Findings include: Review of Resident #2's medical record revealed an admission date of [DATE]. The resident tested positive for COVID-19 on 12/11/20. Review of nursing progress notes revealed the resident was admitted to the hospital 12/19/20 with COVID complications. The resident was short of breath with an oxygen saturation of 83 percent with oxygen on at five liters per minute (LPM) via mask. Resident #2 had a harsh cough and sore throat. Lungs sounds were diminished with crackles and wheezes. Mottling (spotting) of lower extremities was noted. The progress notes indicated the resident returned to the facility on [DATE], appeared confused and was complete care. Physician orders [REDACTED]. The resident's oxygen saturation was recorded at 83% on 12/28/20 at 6:45 P.M. via nasal cannula and 93% at 11:14 P.M. via oxygen mask. There was not a physician order [REDACTED]. The oxygen saturation remained at 93% on 12/29/20 at 12:59 A.M. A [DIAGNOSES REDACTED]. A progress note dated 12/29/20 at 06:27 A.M. revealed the resident's oxygen saturation was 88% with the resident on a 4 LPM non rebreather mask. The resident has been sleepy, easily aroused with verbal and tactile stimulation. The resident was tolerating nectar thick liquids and had an infrequent harsh moist non productive cough. The residents lungs were noted to be diminished throughout. The vital sign record revealed the resident's oxygen saturation on 12/29/20 remained 88% at 10:15 A.M. and 2:47 P.M. and was 82% at 11:24 P.M On 12/30/20 at 1:23 A.M. the saturation was 88%, and at 5:52 A.M. 85%. The saturation was recorded at 84% at 10:18 A.M. There was no evidence of interventions to maintain the oxygen saturation above 90% from 6:23 A.M. 12/29/20 through 10:18 A.M. 12/30/20 when it was recorded between 82-88%. A nurse's note, dated 12/30/20 at 12:42 P.M. revealed oxygen was increased to 5 LPM on a non rebreather mask and the resident's oxygen saturation level increased to 95%. The vital sign record included an oxygen saturation of 91% on 12/30/20 at 3:25 P.M. Interview on 12/30/20 at 4:55 P.M. with the Director of Nursing (DON) verified the was no evidence for over 28 hours of interventions to bring the resident's oxygen saturation up as ordered. The DON verified the saturation readings were below the ordered acceptable range until she was told of the low saturation level when she informed the nurse to increase the oxygen to 5 LPM.

Based on record review and staff interview the facility failed to administer pneumococcal vaccinations as requested. This affected two residents (#1 and #4) of five residents reviewed for pneumococcal immunizations. Findings include: 1. Review of Resident #1's medical record revealed a 10/05/20 admitted with [DIAGNOSES REDACTED]. The resident resided on the locked unit. Review of the Informed Consent for Pneumococcal Vaccine revealed on 10/29/20 the resident's responsible party provided phone consent to administer the vaccine. Review of the medical record revealed no evidence of the pneumococcal vaccine being administered. The record revealed no evidence of the resident having a history of receiving the vaccination. The resident tested positive for COVID-19 on 12/28/20. On 12/30/20 at 4:40 P.M. interview with the Director of Nursing (DON) verified the facility failed to administer the pneumococcal vaccination to Resident #1 as requested. 2. Review of Resident #4's closed medical record revealed a 06/10/20 admitted with [DIAGNOSES REDACTED]. Record review revealed the resident passed away on 12/15/20. Review of the Informed Consent for Pneumococcal Vaccine revealed on 09/08/20 the responsible party provided phone consent to administer the vaccine. Review of the medical record revealed no evidence of the pneumococcal vaccine being administered. The record revealed no evidence of the resident having a history of receiving the vaccination. The resident tested positive for COVID-19 on 12/11/20 and passed away on 12/15/20. On 12/30/20 at 4:40 P.M. interview with the DON verified the facility failed to administer the pneumococcal vaccination to Resident #4 as requested.

Based on review of personnel files, staff interview, and review of the facility abuse policy the facility failed to ensure 19 staff members were checked against the State Nurse Aide Registry (NAR) prior to employment to ensure the employee did not have a finding entered in the State NAR concerning abuse, neglect, exploitation, mistreatment of [REDACTED]. This had the potential to affect all 42 residents currently residing in the facility. Findings include: Review of personnel list and personnel files revealed the non-licensed staff including; Laundry Aide (LA) #15, LA #17, Housekeeping Aide (HA) #18, Environmental Director (ED) #20, Dietary Director (DD) #22, Dietary Aide (DA) #24, Activities Aide (AA) #25, Admission Director (AD) #26, Dietary Cook (DC) #27, DC #30, DC #33 and DC #40, Activities Director (AD) #28, DA #31, HA #37, AA #38, DA #41, Medical records (MR) #46, and HA #52 had not been checked against the State NAR. Interview on 09/04/19 at 10:00 [NAME]M., with Registered Nurse (RN) #53 verified she had no documented evidence the above non-licensed staff were checked against the State NAR to ensure the employee did not have a finding entered in the State NAR concerning abuse, neglect, exploitation, mistreatment of [REDACTED]. Review of the facility Abuse, Neglect, Misappropriation, and Exploitation policy originated dated 11/16 revealed the facility would undertake background checks of all employees and to retain on file applicable record of current employees regarding such checks. The facility would do the following prior to hiring a new employee: 1a. Check with the Ohio NAR and any other nurse assistant registries that the facility had reason to believe contain information on an individual, prior to using the individual as a nursing assistant. b. Check with all applicable licensing and certification authorities to ensure that employees hold the requisite license and/or certification status to perform their job function and do not have a disciplinary action in effect against his or her professional license by state licensure agency because of a finding of abuse, neglect, exploitation or misappropriation of resident property; c. Conduct a criminal background check d. Verify that the applicant was not excluded from any Federally-funded health care programs. 2. All potential employees certify as part of the employment application process that they had not been convicted of an offense or otherwise have been found guilty of an offense that would preclude employment in a nursing facility. 3. It is the ongoing obligation of all employees to alter the facility of any convictions or findings that would disqualify them form continued employment with the facility under Ohio or Federal law, or the facilities policy.

Based on record review and interview the physician failed to document, sign, and date each physician visit. This affected 11 (Residents #3, #4, #5, #7, #8, #11, #23, #29, #31, #33, and #39) of 19 resident records reviewed and had the potential to affect all residents currently residing in the facility. The census was 42. Findings include: 1. Record review revealed Resident #33 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]., [MEDICAL CONDITION], mood disorder, [MEDICAL CONDITION], depression, conduct disorder, [MEDICAL CONDITIONS], contractures, absence of right and left leg below knee, and [MEDICAL CONDITION]. There was no evidence of a signed or dated physician note from 01/2019 to 09/2019. The nurse documented the physician had seen the resident on 01/03/19 and 04/18/19 in the nursing progress notes. 2. Record review revealed Resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. There was no evidence of a signed or dated physician note from 01/2019 to 09/2019. The nurse documented the physician had seen the resident on 01/03/19 and 04/18/19 in the nursing progress notes. 3. Record review revealed Resident #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. There was no evidence of a signed or dated physician note from 01/2019 to 09/2019. The nurse documented the physician had seen the resident on 01/03/19, 04/18/19, and 08/08/19 in the nursing progress notes. 4. Record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. There was no evidence of a signed or dated physician note from 01/2019 to 09/2019. The nurse documented the physician had seen the resident on 01/03/19 and 08/08/19. 5. Record review revealed Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. There was no evidence of a signed or dated physician not from 04/2019 to 09/2019. The nurse documented the physician had seen the resident on 04/18/19. Interview on 09/05/19 at 9:59 [NAME]M. and 2:29 P.M., with Registered Nurse (RN) #55 confirmed the physician had not been completing signed and dated progress notes in the electronic or paper medical records. The physician was just provided written education on documentation and frequency of visits. The RN confirmed the above findings. 6. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the residents medical record for 2019 revealed there were no physician progress notes [REDACTED]. Further review revealed the only evidence the physician saw the resident were the nursing notes dated 06/20/19 and 08/08/19 which stated the physician was here. On 09/05/19 at 11:00 [NAME]M., interview with Registered Nurse (RN) #55 verified there were no physician progress notes [REDACTED]. 7. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the residents medical record for 2019 revealed there were no physician progress notes [REDACTED]. Further review revealed the only evidence the physician saw the resident were the nursing notes dated 04/18/19, 06/06/19 and 08/08/19 which stated the physician was here. On 09/05/19 at 11:00 [NAME]M., interview with Registered Nurse (RN) #55 verified there were no physician progress notes [REDACTED]. 8. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the residents medical record for 2019 revealed there were no physician progress notes [REDACTED]. Further review revealed the only evidence the physician saw the resident were the nursing notes dated 06/06/19 and and 08/08/19 which stated the physician was here. On 09/05/19 at 11:00 [NAME]M., interview with Registered Nurse (RN) #55 verified there were no physician progress notes [REDACTED].#4, #5 or #7. 9. Resident #29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the residents medical record for 2019 revealed there were no physician progress notes [REDACTED]. Further review revealed the only evidence the physician saw the resident were the nursing notes dated 01/03/19, 04/18/19 and 08/08/19 which stated the physician was here. On 09/05/19 at 11:00 [NAME]M., interview with Registered Nurse (RN) #55 verified there were no physician progress notes [REDACTED]. 10. Resident #39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the residents medical record for 2019 revealed there were no physician progress notes [REDACTED]. Further review revealed the only evidence the physician saw the resident were the nursing notes dated 01/03/19 and 08/08/19 which stated the physician was here. On 09/05/19 at 11:00 [NAME]M., interview with Registered Nurse (RN) #55 verified there were no physician progress notes [REDACTED]. On 09/05/19 at 9:30 [NAME]M., interview with Physician #60 revealed when he came to the facility the Director of Nursing (DON) would have a spread sheet with a synopsis and/or concerns about each resident he would visit that day. He took notes on the spread sheet as needed but did not document anything in the medical record. Physician #60 verified there were no physician progress notes [REDACTED]. 11. Resident #8 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #8's medical record revealed the last physician visit progress note was documented 05/30/19. Interview on 09/04/19 at 2:51 P.M. with Registered Nurse (RN) #8 (acting director of nursing) confirmed Resident #8's physician was not documenting his visits with the resident.

Based on record review and interview the physician failed to ensure physician visits were provided timely and at the required frequency for all residents. This affected 11 (Resident #3, #4, #5, #7, #8, #11, #23, #29, #31, #33, and #39) of 19 resident records reviewed and had the potential to affect all residents currently residing in the facility. The facility census was 42. Findings include: 1. Record review revealed Resident #33 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]., [MEDICAL CONDITION], mood disorder, [MEDICAL CONDITION], depression, conduct disorder, [MEDICAL CONDITIONS], contractures, absence of right and left leg below knee, and [MEDICAL CONDITION]. There was no evidence of a signed or dated physician note from 01/2019 to 09/2019. The nurse documented the physician had seen the resident on 01/03/19 and 04/18/19 in the nursing progress notes. There was no evidence the physician visited the resident every 60 days. 2. Record review revealed Resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. There was no evidence of a signed or dated physician note from 01/2019 to 09/2019. The nurse documented the physician had seen the resident on 01/03/19 and 04/18/19 in the nursing progress notes. There was no evidence the physician visited the resident every 60 days. 3. Record review revealed Resident #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. There was no evidence of a signed or dated physician note from 01/2019 to 09/2019. The nurse documented the physician had seen the resident on 01/03/19, 04/18/19, and 08/08/19 in the nursing progress notes. There was no evidence the physician had visited the resident every 60 days. 4. Record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. There was no evidence of a signed or dated physician note from 01/2019 to 09/2019. The nurse documented the physician had seen the resident on 01/03/19 and 08/08/19. There was no evidence the physician had visited the resident every 60 days. 5. Record review revealed Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. There was no evidence of a signed or dated physician not from 04/2019 to 09/2019. The nurse documented the physician had seen the resident on 04/18/19. There was no evidence the physician had visited the resident every 30 days for the first 90 days after admission. Interview on 09/05/19 at 9:59 [NAME]M. and 2:29 P.M., with Registered Nurse (RN) #55 confirmed the physician had not been completing signed and dated progress notes in the electronic or paper medical records nor providing frequency of visits per the regulation. The physician was just provided written education on documentation and frequency of visits. The RN confirmed lack of evidence the physician visited the resident every 60 days. 6. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the residents medical record for 2019 revealed there were no physician progress notes [REDACTED]. Further review revealed the only evidence the physician saw the resident were the nursing notes dated 06/20/19 and 08/08/19 which stated the physician was here. 7. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the residents medical record for 2019 revealed there were no physician progress notes [REDACTED]. Further review revealed the only evidence the physician saw the resident were the nursing notes dated 04/18/19, 06/06/19 and 08/08/19 which stated the physician was here. 8. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the residents medical record for 2019 revealed there were no physician progress notes [REDACTED]. Further review revealed the only evidence the physician saw the resident were the nursing notes dated 06/06/19 and and 08/08/19 which stated the physician was here. 9. Resident #29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the residents medical record for 2019 revealed there were no physician progress notes [REDACTED]. Further review revealed the only evidence the physician saw the resident were the nursing notes dated 01/03/19, 04/18/19 and 08/08/19 which stated the physician was here. 10. Resident #39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the residents medical record for 2019 revealed there were no physician progress notes [REDACTED]. Further review revealed the only evidence the physician saw the resident were the nursing notes dated 01/03/19 and 08/08/19 which stated the physician was here. On 09/05/19 at 11:00 [NAME]M., interview with Registered Nurse (RN) #55 verified there were no physician progress notes [REDACTED]. On 09/05/19 at 9:30 [NAME]M., interview with physician #60 revealed when he came to the facility the director of nursing (DON) would have a spread sheet with a synopsis and/or concerns about each resident he would visit that day. He took notes on the spread sheet as needed but did not document anything in the medical record. Physician #60 verified there were no physician progress notes [REDACTED]. 11. Resident #8 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #8's medical record revealed the last physician visit progress note was documented 05/30/19. Interview on 09/04/19 at 2:51 P.M. with Registered Nurse (RN) #8 (acting director of nursing) confirmed Resident #8's physician was not documenting his visits with the resident and there was a lack of evidence the resident was seen every 60 days by the physician.