Every finding on record at The Laurels of Middletown

Based on resident interview, observation, and staff interview, the facility failed to ensure the water supplied to the shower room and resident rooms was maintained at a comfortable temperature. This affected 37 out of 37 residents (#9, #13, #14, #17, #18, #21, #25, #28, #29, #31, #33, #34, #39, #41, #44, #45, #48, #49, #52, #54, #56, #57, #60, #61, #62, #63, #64, #66, #67, #73, #78, #81, #82, #84, #85, #87, and #93) who resided on South Hall and utilized the shower room. The facility census was 90 residents. Findings include: Interview on 08/03/26 at 9:51 A.M. with Resident #29 confirmed the facility did not always have hot water available for residents.Interview on 08/05/26 at 2:11 P.M. with Resident #9 confirmed there were occasional issues with lack of hot water.Observation on 08/06/26 at 10:32 A.M. with Maintenance Director (MD) #255 revealed the water temperature at the sink in the room of Residents #29 and #67 was 95 degrees Fahrenheit (F). Interview on 08/06/26 at 10:32 A.M. with MD #255 verified the water temperature in the bathroom sinks of Residents #29 and #67 was 95 degrees F which outside of the appropriate range. Observation on 08/06/26 at 10:36 A.M. with MD #255 revealed the water temperature at the sink in the room of Residents #39 and #48 was 95 degrees F. Interview on 08/06/26 at 10:36 A.M. with MD #255 verified the water temperature in the bathroom sinks of Residents #39 and #48 was 95 degrees F which outside of the appropriate range. Observation on 08/06/26 at 10:38 A.M. with MD #255 revealed the water temperature of the shower room on the South Hall was 93 degrees F. By 10:41 A.M. the water temperature of the shower room on South Hall was 95 degrees F. Interview on 08/06/26 at 10:38 A.M. with MD #255 verified the water temperature of the shower room on the South Hall ranged from 93 to 95 degrees F which was outside of the appropriate range. This deficiency represents noncompliance investigated under Complaint Number 2987155 and Complaint Number 2982196.

Based on medical record review, staff interview, and policy review the facility failed to develop and implement a person-centered comprehensive care plan that addressed residents' medical, physical, mental, and psychosocial needs. This affected two (Residents #7 and #47) of 18 residents sampled. The facility census was 90 residents. Findings include: 1.Review of the medical record for Resident #47 revealed an admission date o 04/08/26 with diagnoses including traumatic subdural hemorrhage with loss of consciousness status unknown sequela, nicotine dependence, and psychoactive substance abuse. Review of the care plan for Resident #47 dated 04/22/26 revealed it did not include the resident's nicotine dependence or psychoactive substance use disorder. Review of the Minimum Data Set (MDS) assessment for Resident #47 dated 07/16/26 revealed the resident had intact cognition and was independent with activities of daily living (ADLs). Interview on 08/05/26 at 3:30 P.M with the Minimum Data Set (MDS) Nurse #276 confirmed Resident #47 should have been care planned for nicotine dependence and psychoactive substance disorder. 2. Review of the medical record for Resident #17 revealed an admission date of 11/13/24 with diagnoses including dementia, psychotic disturbance, mood disturbance, major depressive disorder, generalized anxiety disorder, and chronic kidney disease. Review of the care plan for Resident #17 last updated 07/02/26 revealed it did not include the resident's code status and/or the resident's wishes for end of life care. Review of the MDS assessment for Resident #17 dated 07/04/26 revealed the resident had severely impaired cognition and required staff assistance with ADLs. Interview on 08/04/26 at 5:18 P.M. with Divisional Nurse (DN) #700 verified there was not a care plan for Resident #17 regarding code status. Review of facility policy titled Comprehensive Care Planning dated 02/24/26 revealed the facility would develop a comprehensive person-centered care plan for each resident that included measurable goals and timetables to meet the resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment. This deficiency represents noncompliance investigated under Master Complaint Number 2987155.

Based on medical record review, observation, staff interview, and review of insulin pen manufacturer's instructions, the facility failed to ensure medication error rate was less than five percent (%). The facility had two errors out of 26 medication opportunities for a medication error rate of 7.69%. This affected one (Resident #38) of three residents observed for medication administration. The facility census was 90 residents. Findings include: Review of the medical record for Resident #38 revealed an admission date of 07/08/24 with diagnoses including type two diabetes mellitus, generalized anxiety disorder, and peripheral vascular disease.Review of the Minimum Data Set (MDS) assessment for Resident #38 dated 04/15/25 revealed the resident had intact cognition and required staff assistance with activities of daily living (ADLs.) Review of the physician's orders for Resident #38 revealed an order dated 05/02/25 for Humalog Kwik Pen insulin inject 22 units subcutaneously before meals and an order dated 05/06/25 for Glargine insulin pen inject 54 units subcutaneously in the morning.Observation on 05/20/25 at 7:45 A.M. of medication administration to Resident #38 per Licensed Practical Nurse (LPN) #245 revealed the nurse administered Humalog 22 units and Glargine 54 units subcutaneously to the resident without priming the insulin pens prior to administration.Interview on 05/20/25 at 7:50 A.M. with LPN #245 verified she did not prime Resident #38's insulin pens prior to administration. Review of the directions for Lantus (Glargine) revised November 2018 revealed a safety test was always performed prior to each injection. After applying needle to the pen, select a dose of two units by turning the dosage selector. Take off the outer needle cap and keep it to remove the used needle after injection. Take off the inner needle cap and discard it. Hold the pen with the needle pointing upwards. Tap the insulin reservoir so that any air bubbles rise up towards the needle. Press the injection bottom all the way in and ensure insulin came out of the needle tip.Review of the directions for Humalog Kwik Pen revised 2023 revealed priming your pen meant removing the air from the needle and cartridge that may collect during normal use and ensured that the pen was working correctly. If you do not prime before each injection, you may get too much or too little insulin. To prime your pen, turn the dose knob and select two units. Hold your pen with the needle pointing up, tap the cartridge holder gently to collect air bubbles at the top. Push the dose knob in until it stops and zero was seen in the dose window. This deficiency represents noncompliance investigated under Complaint Number 2987155.

Based on review of the medical record, observation, staff interview, and review of insulin pen manufacturer's instructions, the facility failed to ensure residents were free from significant medication errors. This affected one (Resident #38) of three residents observed for medication administration. The facility census was 90 residents.Findings include: Review of the medical record for Resident #38 revealed an admission date of 07/08/24 with diagnoses including type two diabetes mellitus, generalized anxiety disorder, and peripheral vascular disease.Review of the Minimum Data Set (MDS) assessment for Resident #38 dated 04/15/25 revealed the resident had intact cognition and required staff assistance with activities of daily living (ADLs.) Review of the physician's orders for Resident #38 revealed an order dated 05/02/25 for Humalog Kwik Pen insulin inject 22 units subcutaneously before meals and an order dated 05/06/25 for Glargine insulin pen inject 54 units subcutaneously in the morning.Observation on 05/20/25 at 7:45 A.M. of medication administration to Resident #38 per Licensed Practical Nurse (LPN) #245 revealed the nurse administered Humalog 22 units and Glargine 54 units subcutaneously to the resident without priming the insulin pens prior to administration.Interview on 05/20/25 at 7:50 A.M. with LPN #245 verified she did not prime Resident #38's insulin pens prior to administration. Review of the directions for Lantus (Glargine) revised November 2018 revealed a safety test was always performed prior to each injection. After applying needle to the pen, select a dose of two units by turning the dosage selector. Take off the outer needle cap and keep it to remove the used needle after injection. Take off the inner needle cap and discard it. Hold the pen with the needle pointing upwards. Tap the insulin reservoir so that any air bubbles rise up towards the needle. Press the injection bottom all the way in and ensure insulin came out of the needle tip.Review of the directions for Humalog Kwik Pen revised 2023 revealed priming your pen meant removing the air from the needle and cartridge that may collect during normal use and ensured that the pen was working correctly. If you do not prime before each injection, you may get too much or too little insulin. To prime your pen, turn the dose knob and select two units. Hold your pen with the needle pointing up, tap the cartridge holder gently to collect air bubbles at the top. Push the dose knob in until it stops and zero was seen in the dose window. This deficiency represents noncompliance investigated under Complaint Number 2987155.

Based on medical record review and staff interview, the facility failed provide appropriate assistance for a resident during care to prevent a fall. This effected one (#8) of three residents reviewed for falls. The census was 93.Findings include:Review of the medical record for Resident #8 revealed the resident was admitted to the facility on [DATE]. Diagnoses included nontraumatic intracerebral hemorrhage, traumatic compartment syndrome of the right upper and lower extremities, paraplegia, and dysphagia. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 had impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of six and was assessed to require self-care assistance and mobility assistance.Review of Resident #8's admission comprehensive evaluation dated 09/15/25 revealed for toileting the resident was determined to be a two-person assist.Review of the care plan for Resident #8 dated 09/19/25 revealed he was at risk for fall related injury and falls related to impaired activities of daily living (ADLs) performance and communication deficit. Interventions include placing the resident's bed against the wall and having two staff members present at time of mobility and hygiene care.Review of the medical record for Resident #8 revealed on 09/22/25 he was receiving perineal care by Certified Nurse Aide (CNA) #150. The resident was being turned to his left side when he slid off of his bed, hitting his head on a nearby chair before landing on his back. The resident was alert and responsive, with no visible injuries, but complained of right-sided neck pain. The resident's physician and the resident's family were subsequently notified.During an interview with the Director of Nursing (DON) on 09/26/25 at 5:15 P.M. she explained the expectation for a resident assessed as two-person assist would be provided care by two people. The DON confirmed only one staff member was present and providing care for Resident #8 at the time of the fall on 09/22/25 when there should have been two staff members assisting. This deficiency represents non-compliance investigated under Complaint Number 2575413.

Based on medical record review, review of an incident report, staff interview, and policy review, the facility failed to ensure residents had active orders for a medication prior to administration, resulting in a significant medication error. This effected one (#10) of three residents reviewed for medication administration. The census was 93.Findings include:Review of the medical record for Resident #10 revealed the resident was admitted to the facility on [DATE]. Diagnoses included encephalopathy, epilepsy, asthma, anxiety, dysphagia, and muscle weakness. Resident #10 was discharged from the facility on 08/07/25. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 had severely impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of three and was assessed to require self-care assistance.Review of the facility's incident report dated 07/22/25 revealed, on 07/21/25, Licensed Practical Nurse (LPN) #200 confirmed she administered five (5) milligrams (mg) of oxycodone to Resident #10 earlier that date due to him exhibiting signs of agitation. Resident #10 did not have a current order for oxycodone at the time of the administration. The administration was recorded on the Controlled Drug Record log, but not on the medication administration record due to the inactive order. During an interview on 09/26/25 at 4:07 P.M. with the Administrator, she confirmed the events as detailed in the incident report verifying LPN #200 administered oxycodone to Resident #10 without the resident having an active order for the medication. The Administrator added LPN #200 had not worked in the facility since the incident occurred.Review of the facility policy titled, Medication Administration, revised 10/17/23, revealed medications are administered in accordance with the written orders of the physician. All medication administrations should be recorded in the medication administration record.This deficiency represents non-compliance investigated under Complaint Number 2575413.

Based on observations, staff interviews and policy review, the facility failed to store, prepare, and distribute food in a sanitary manner. This had the potential to affect all 97 residents residing at the facility who receive their meals from the facility kitchen. The facility census was 97. Findings include: 1. During the initial tour of the facility kitchen with the Administration Aide (AA) #266 on 05/20/24 at 7:44 A.M., a trash can located underneath the kitchen hand washing sink which was soiled with splatter running down the sides. Observations revealed a pile of soiled and dirty dishtowels with multiple live gnats flying on and around the dishtowels. The kitchen floor appeared dirty with debris throughout. The dishwasher had food debris all over the top and along the bottom of the dishwasher. Further review of the kitchen revealed a walk-in refrigerator and AA #266 confirmed a large plastic container of sweet potatoes marked 05/16/24 -05/18/24. AA #266 confirmed a large metal container with boiled eggs and water dated 05/11/24. A large metal container of precooked scrambled eggs was dated 05/08/24. AA #266 confirmed the large brown box located directly on the floor of the dry storage area. AA #266 confirmed the large rolling rack of bread with multiple loaves of white bread with an expiration date of 04/17/24. The multiple bags of white bread buns were dated 03/17/24. AA #266 confirmed the identified concerns. Interview on 05/22/24 at 7:51 A.M. with the Dietary Manager (DM) #294 confirmed the large rolling rack of bread and buns arrived from the supplier outdated but frozen. DM #294 stated she spoke with her supplier and the supplier told her to place a sign over the bread that it is edible for seven days passed the thaw date. DM #294 stated she removes the bread from the boxes and placed on the rolling rack and allows it to thaw while on the rack. Interview on 05/22/24 at 8:45 A.M. interview with the Administrator revealed the facility utilizes bread from a vender that is frozen. The Administrator stated the information provided about the bread to be used within seven days of thaw was given to the facility team by the corporate dietician not the vendor. Interview on 05/22/24 at 10:13 A.M. with DM #294 confirmed the facility receives the frozen outdated bread on Tuesday and Thursday. DM #294 stated the staff place the frozen bread and buns on the rolling rack in the dry storage area and allow it to thaw. DM #294 stated the facility updated their policy to show they receive this frozen bread out of date. DM #294 stated the corporate dietician told her the frozen bread was good for seven days after it thaws. DM #294 stated the corporate dietitian obtained this information by a Google search. Review of the facility policy titled, Pest Control, dated 08/27/21, stated the facility pest control program will have an emphasis on the kitchens and areas prone to infestation. The purpose of the policy was to provide an environment free of pests. Review of the facility pest control visits revealed the kitchen was treated on 02/26/24 and 05/07/24, however, could not confirm the treatment was for gnats. 2. Observation and interview with DM #294 and Dietary Cook (DC) #230 on 05/22/24 at 11:38 P.M. during the lunch time tray line revealed the DC #230 picked up the food thermometer and placed it into the pureed brats without cleansing/sanitizing the thermometer to obtain a temperature. Observations revealed DC #230 took the food thermometer and placed it directly into the mechanical soft brats and failed to sanitize the food thermometer. DC #230 was interviewed before he continued to obtain more food temperatures and he stated he did not have to sanitize the food thermometer because he was told not to use alcohol wipes on the food thermometer. DM #294 was standing next to DC #230 and confirmed the facility was advised to no longer sanitize the food thermometers and handed DC #230 a dry paper towel. DC #230 wiped the food thermometer and placed it in the brat sausage to obtain a temperature. DC #230 removed the food thermometer from the brat and wiped with a dry paper towel and obtained a macaroni salad temperature. Once more, DC #230 wiped the thermometer with the dry paper towel and obtained a food temperature from the cucumber and tomato salad. 3. Observation and interview of the facility ice machine on 05/22/24 at 11:53 A.M. with Dietary Aide (DA) #218 confirmed the facility ice machine had a brown substance splattered all along the front of the machine. DA #218 lifted the door to the ice machine and revealed a white plastic cover over the ice. DA #218 confirmed the white plastic cover over the ice had an unknown black spotted substance all along the white plastic tray. DA #218 stated the unknown black substance appeared to be mold. Observation and interview on 05/22/24 at 12:17 P.M. with the DM #294 confirmed the ice machine had brown splatter across the front of the machine. DM #294 pointed to the sticker on the ice machine and stated this ice machine was cleaned in December 2023 and is due to be cleaned in June 2024. DM #294 confirmed inside the ice machine an unknown black substance was spotted all along the top of the white plastic tray. Review of the facility policy titled, Ice Chest and Ice Machine, dated 08/17/21, revealed the facility will clean, disinfect, and maintain ice-storage chests on a regular basis. 4. Observation of the facility lunch tray line on 05/22/24 from 11:50 A.M. to 12:27 P.M. with DM #230 revealed DC #230 donned plastic clear gloves and used his hands to place the brats in the buns instead of tongs. Interview on 05/22/24 at 12:17 P.M. with the DM #294 confirmed DC #230 had used his gloved hands to place the brats into the buns instead of tongs. DM #294 confirmed DC #230 should have used tongs instead of DC #230's gloved hand and also confirmed tongs were available for use. The facility confirmed all 97 residents receive their meals from the kitchen.

Based on observations and resident and staff interviews, the facility failed to provide a clean, comfortable, and sanitary environment for the residents. This affected four (#25, #36, #46 and #51) out of four residents reviewed for the physical environment. The facility census was 97. Findings include: Interview on 05/20/24 at 2:48 P.M. with Resident #46 revealed he was upset that his bed was not comfortable and felt as though it was broken. Resident #46 confirmed his mattress was not lying on the bed correctly. Resident #46 stated his bed does not face the television in his room and he must turn his head to the left to watch television. Resident #46 stated the brown wall beside his bed had a large white drywall substance on it for several months. Interview on 05/21/24 at 8:33 A.M. with Resident #51 revealed he can feel the bed rails on the frame pushing through his mattress. Resident #51 pointed to a large, rounded area on his mattress and the bed rails underneath it. Resident #51 stated he was told by staff he will have a replacement mattress; however, he was never given one. Resident #51 stated he was the paint would be corrected pointing toward several colors of uneven paint behind the head of his bed, however nothing has been done. Observation with interview on 05/21/24 at 9:02 A.M. revealed three walls with multiple black scratches on the walls lightly covered with plaster. The observation revealed the areas had not been painted. Interview with Resident #25 stated her room had looked that way for quite a while. Observation with interview on 05/21/23 at 9:39 A.M. revealed three walls in Resident #36's room to have several areas with plaster but no paint. Interview with Resident #36 stated his room looked that way when he arrived on 04/18/24. Interview on 05/21/24 at 1:45 P.M. with State tested Nurse Aide (STNA) #254 confirmed the large white patched drywall area on the wall next to Resident #46's bed. STNA #254 attempted to fix the footboard of Resident #46 and confirmed the mattress was lying on the bed uneven. STNA #254 confirmed the mattress was curled up into the air on the left side at the top corner and the bottom corner. STNA #254 confirmed the large gap approximately eleven inches wide at the head of the bed between the headboard and mattress because the mattress did not fit on the bed frame appropriately. STNA #254 confirmed Resident #254's bed was placed against the wall and his head must be turned to the left to watch his television in bed. STNA #254 confirmed the importance of television to Resident #46's quality of life. Interview on 05/21/24 at 2:10 P.M. with the Housekeeping Manager (HM) #291 confirmed Resident #51 had a large, rounded area in his mattress that stood up over the bed frame rails. HM #291 confirmed the facility has mattresses downstairs and it could easily be replaced. HM #291 verified the two different colors on the wall in no paint pattern behind Resident #51's bed. On 05/22/24 at 2:31 P.M. interview with Housekeeper #227 confirmed the walls in Resident #25 and #36 rooms had many scratches on the walls which were lightly covered with plaster and had not been painted. Housekeeper #227 stated the walls for both rooms had been that way for several months.

Based on record review, observations, resident and staff interviews, and review of the Resident Assessment Instrument (RAI) Manual 3.0, the facility failed to accurately code Minimum Data Set (MDS) assessments. This affected six (#01, #24, #41, #74, #82, and #92) residents out of the 25 residents reviewed for MDS accuracy. The facility census was 97. Findings include: 1. Review of the medical record for Resident #01 revealed an admitted [DATE] with medical diagnoses of traumatic brain injury, paranoid schizophrenia, psychotic disorder with delusions and seizures. Review of the medical record for Resident #01 revealed an annual MDS assessment, dated 03/28/24, revealed Resident #01 had severe cognitive impairment. The MDS did not have any documentation to support Resident #01's functional status was assessed. Review of section GG of Resident #01's MDS was dashed, and all areas were blank. 2. Review of the medical record Resident #24 revealed an admitted [DATE] with medical diagnoses of atrial fibrillation, anxiety, right sided hemiparesis related to cerebral infarction, hypertensive heart disease, and congestive heart failure. Review of the medical record for Resident #24 revealed a quarterly MDS assessment, dated 03/20/24, which indicated Resident #24 was cognitively intact. The MDS did not have any documentation to support Resident #24's functional status was assessed. Review of section GG of Resident #24's MDS was dashed, and all areas were blank. On 05/23/24 at 10:52 A.M. interview with Administrator confirmed the facility did not have a MDS completion policy but stated the facility followed the procedures and guidelines in the RAI manual to ensure accurate completion of MDS assessments. 43062 3. Record review for Resident #41 revealed he was admitted to the facility on [DATE]. His diagnoses included, essential primary hypertension, bradycardia, orthostatic hypertension, hyperlipidemia, anemia, Parkinson's Disease, insomnia, cognitive impairment, and abdominal aortic aneurysm. Review of the most recent MDS assessment for Resident #41, dated 03/23/24, revealed he had impaired cognition. The facility failed provide an assessment related to the level of care he required. 4. Record review for Resident #74 revealed he was admitted to the facility on [DATE]. His diagnoses included, alcohol, epilepsy, seizures, hyperlipidemia, heart failure, anxiety disorder, alcohol abuse, and metabolic encephalopathy. Review of the most recent MDS assessment dated , 04/15/24, revealed he had impaired cognition. Further review of the MDS assessment revealed he was dependent on staff for medication administration. The facility failed to assess his functioning level according to the assessment. On 05/22/24 at 11:38 AM interview Regional MDS Nurse #320 confirmed the activity of daily living (ADL's) sections were not assessed for Resident #74's MDS dated [DATE], and for Resident #41's MDS dated [DATE]. 44076 5. Review of medical record for Resident #92 revealed admitted [DATE]. The resident was admitted with diagnoses including osteomyelitis, anxiety, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF) and psychoactive substance abuse. The resident remained in the facility. The admission MDS dated [DATE] revealed she had a Brief Interview Mental Status (BIMS) score of 15 indicating intact cognition. She required supervision for her activities of daily living. Section L (oral) revealed the obvious or likely cavity or broken teeth was marked no. Interview on 05/20/24 at 10:32 A.M. with Resident #92 revealed she had a concern for care of her broken lower teeth. Observation at the time of interview revealed she was edentulous on top with several dental carries at the gum level on her lower teeth and broken teeth on her left lower left. Interview and observation with Registered Nurse (RN) #245 on 05/22/24 at 11:38 A.M. verified Resident #92 had several dental carries on her lower teeth and a broken tooth on her lower left. 6. Review of medical record for Resident #82 revealed admitted [DATE]. The resident was admitted with diagnoses including local skin infection, cellulitis of the right and left upper arm, sepsis and bipolar disorder. The resident remained in the facility. The admission MDS dated [DATE] revealed he had a Brief Interview Mental Status (BIMS) score of 15 indicating intact cognition. He required extensive one person assistance for bed mobility, transfers, toileting and eating. Section L of the MDS revealed no documentation of broken or loose teeth, and no obvious cavities or broken natural teeth. Interview on 05/20/20 at 10:10 A.M. with Resident #82 revealed he had concerns for dental carries. Observation revealed multiple blackened, and fragmented teeth on both the upper and lower teeth. On 05/22/24 at 11:38 A.M. interview with Regional MDS Nurse #320 confirmed the MDS assessment for Residents #01, #24, #41, #74, #82, and #92 were not coded accurately as per the RAI manual guidelines. Interview and observation with RN #245 on 05/22/24 at 11:52 A.M. verified Resident #82 had multiple broken/fragmented and blackened teeth. Review of the RAI 3.0 manual, Version 1.18.11 dated October 2023 revealed the MDS assessments are a core set of screening, clinical and functional status data elements which form the foundation of the comprehensive assessment for all residents. The RAI manual stated the MDS assessments should accurately reflect the resident's status.

Based on medical record review, staff interview, and policy review, the facility failed to ensure a Pre-Admission Screening and Resident Review (PASRR) was completed upon admission. This affected one (#25) out of the two residents reviewed for PASRR completion. The facility census was 97. Findings include: Review of the medical record for Resident #25 revealed an admitted [DATE] with medical diagnoses of anoxic brain injury, depression, bipolar disorder, schizoaffective disorder, functional quadriplegia, and convulsions. Review of the medical record for Resident #25 revealed an annual Minimum Data Set (MDS) dated [DATE] which indicated Resident #25 was cognitively intact and was dependent for toilet hygiene, bed mobility, and transfers. Review of the medical record for Resident #25 revealed a Review Results letter, dated 07/22/16, which stated the Pre-Admission Screen determination was not applicable and level of care determination was Intermediate. Further review of the medical record revealed no documentation of a PASRR for the Review Results letter dated 07/22/16. Interview on 05/23/24 at 10:03 A.M. with Administrator confirmed the medical record for Resident #25 did not contain documentation to support the PASRR for the 07/22/16 Review Results letter. Administrator stated she was unable to confirmed Resident #25's PASRR was completed accurately upon admission. Review of the policy titled Review of Pre-Admission Screening and Guest/Resident Review, revised 12/15/22, stated all persons seeing admission to a nursing facility, who are seriously mentally ill and/or have an intellectual/developmental disability, are required to be evaluated to determine if a nursing facility is the appropriate place to receive services. The policy stated the process begins with the completion of the screening, Level 1.

Based on record review, observations, resident and staff interviews, the facility failed to develop a comprehensive care plan to address resident's dental status. This affected two (#82 and #92) of 25 resident care plans reviewed. The facility census was 97. Findings include: 1. Review of medical record for Resident #92 revealed admitted [DATE]. The resident was admitted with diagnoses including osteomyelitis, anxiety, Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure (CHF) and psychoactive substance abuse. The resident remained in the facility. Review of Resident #92's admission Minimum Data Set (MDS) dated [DATE] revealed she had a Brief Interview Mental Status (BIMS) score of 15 indicating intact cognition. She required supervision for her activities of daily living. Record review of the care plan of Resident #92 revealed no dental plan of care. Interview on 05/20/24 at 10:32 A. M. with Resident #92 revealed she had a concern for care of her broken lower teeth. Observation at the time of interview revealed several dental carries at the gum level on her lower teeth and broken teeth on her left lower left. Interview and observation with Registered Nurse (RN) #245 on 05/22/24 at 11:38 A.M. verified Resident #92 had several dental carries on her lower teeth. Interview on 05/23/24 at 2:05 P.M. with Clinical Coordinator RN #324 verified there was no specific dental care plan and no care plan which contained interventions for dental carries. 2. Review of medical record for Resident #82 revealed admitted [DATE]. The resident was admitted with diagnoses including local skin infection, cellulitis of the right and left upper arm, sepsis and bipolar disorder. The resident remained in the facility. Review of Resident #82's admission Minimum Data Set (MDS) dated [DATE] revealed he had a Brief Interview Mental Status (BIMS) score of 15 indicating intact cognition. He required extensive one person assistance for bed mobility, transfers, toileting and eating. Review of Resident #82's care plan revealed there was no dental plan of care. Interview on 05/20/20 at 10:10 A.M. with Resident #82 revealed he had concerns for dental carries. Observation revealed multiple blackened, and fragmented teeth. Interview and observation with RN #245 on 05/22/24 at 11:52 A.M. verified Resident #82 had multiple broken/fragmented and blackened teeth. Interview on 05/23/24 at 2:07 P.M. with the Director of Nursing (DON) verified there was no specific dental care plan and/or no care plan which contained interventions for Resident #82's dental carries.

Based on medical record reviews, resident and staff interviews, and policy review, the facility failed to conduct resident care conferences. This affected three (#24, #54 and #79) residents out of the five residents reviewed for care conferences. The facility census was 97. Findings include: 1. Review of the medical record Resident #24 revealed an admitted [DATE] with medical diagnoses of atrial fibrillation, anxiety, right sided hemiparesis related to cerebral infarction, hypertensive heart disease, and congestive heart failure. Review of the medical record for Resident #24 revealed a quarterly Minimum Data Set (MDS) assessment, dated 03/20/24, which indicated Resident #24 was cognitively intact. Review of the medical record for Resident #24 revealed the facility conducted a quarterly care conference on 03/25/24. Review of the medical record revealed no documentation to support the facility conducted any other care conferences in the past 12 months. Interview on 05/21/24 at 9:28 A.M. with Resident #24 stated he recently had a care conference but that was the first care conference in over a year. 2. Review of the medical record for Resident #54 revealed an admitted [DATE] with medical diagnoses of chronic obstructive pulmonary disease, left above the knee amputation, diabetes mellitus, and end stage renal disease. Review of the medical record for Resident #54 revealed an annual MDS assessment, dated 03/18/24, which indicated Resident #54 was cognitively intact and required maximum staff assistance for bathing and was dependent on staff for toilet hygiene, transfers, and bed mobility. Review of the medical record for Resident #54 revealed the facility conducted a quarterly care conference on 03/12/24. Review of the medical record revealed no documentation to support the facility conducted any other care conferences in the past 12 months. Interview on 05/20/24 at 2:51 P.M. with Resident #54 stated the facility does not offer care conferences to her quarterly. 3. Review of the medical record for Resident #79 revealed an admitted [DATE] with medical diagnoses of chronic respiratory failure, cerebral infarction, left hemiparesis, heart failure and diabetes mellitus. Review of the medical record for Resident #79 revealed a quarterly MDS assessment, dated 04/25/24, which indicated Resident #79 was cognitively intact and was dependent upon staff for bed mobility, transfers, and toilet hygiene. Review of the medical record for Resident #79 revealed the facility conducted a quarterly care conference on 10/30/23. Review of the medical record revealed no documentation to support the facility conducted any other care conferences in the past 12 months. Interview on 05/20/24 at 10:45 A.M. with Resident #79 stated he had not attended a care conference for a very long time. Interview on 05/22/24 at 3:30 P.M. with Administrator confirmed the medical records for Residents #24, #54, and #79 did not contain documentation to support the facility conducted care conferences or offered to hold care conferences. Administrator stated the facility did not have a Social Service designee for a while and care conferences were not done as per policy. Review of the policy titled, 72 Hour Admission Conference, revised 04/19/22, stated the care conference is to be with the resident, family, and members of Interdisciplinary Team (IDT). The policy stated the purpose was to align expectations of service and care and include the resident and family in the care planning process. The process allows the IDT to communicate nursing and therapy goals, and expectations for discharge as indicated. The policy continued to state the first meeting, upon admission, would occur within 72 hours of admission for all residents. The policy stated ongoing meetings would be individually scheduled with residents and family based on their needs, and for the residents that were long term they would have a care conference to coincide with the admission and quarterly assessments.

Based on medical record review, observations, resident and staff interviews and policy review, the facility failed to ensure a resident was provided with hand hygiene. This affected one (#49) out of four residents reviewed for personal hygiene. The facility census was 97. Findings include: Resident #49 was admitted to the facility on [DATE] with a diagnosis of functional quadriplegia, injury of unspecified level of cervical spinal cord, muscle spasms, muscle weakness, anxiety, and depressive disorders. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #49 is cognitively intact. His functional status is listed as set up to dependent on staff for all activities of daily living. For showering the resident is dependent but for toileting he is substantial/maximal assistance. For eating and hygiene he is just set up only. Review of the care plan revealed Resident #49 has a functional ability deficit and requires assistance with self-care/mobility related to impaired mobility, muscle weakness, pain, bowel and bladder incontinence, psychoactive medication usage, right hand splint, Hoyer lift for transfers. Interventions included half side rails for bed mobility, Hoyer lift for transfers, right hand splint as ordered. Keep fingernails trimmed and clean. Provide assistance as needed for each activity until the resident performs skill competently and is safe with level of care; re-evaluate regularly to be certain that the skill level is maintained, and the resident remains safe in the environment. Hand splint to be used Tuesday and Thursday only. Review of the physician orders dated 09/19/23 revealed apply hand splint to right hand twice a week as tolerated. May remove for hand hygiene. Guest may wear hand splint as tolerated and needed. One time a day, every Tuesday and Thursday, for contracture's to right hand. Review of the Treatment Administration Record (TAR) for 03/2024, 04/2024, and 05/2024, revealed Resident #49's hand splint was signed off as completed. Interview on 05/21/24 at 8:30 A.M. with Resident #49 revealed the staff never place his hand splint on his contracture right hand. Resident #49 revealed the last time staff applied the hand splint was months ago. Resident #49 also revealed they never try to wash the contracted hand or fingers. Observation on 05/21/24 at 8:30 A.M., 1:00 P.M., revealed Resident #49 did not have the hand splint applied. On 05/21/24 at 4:40 P.M. observation of Resident #49 revealed the hand splint was still not applied. Observation on 05/22/24 at 10:50 A.M. revealed the hand splint was still not applied. Observation on 05/21/24 and 05/22/24 revealed a sour odor in Resident #49's room that the resident stated was caused by his unattended/foul smelling contracted hand. Observation and interview on 05/22/24 at 10:50 A.M. with Resident #49 revealed the staff did not place the splint on his right contracted hand on 05/21/24 as physician ordered. Resident #49 revealed staff have not placed his splint or washcloth in his hand in months. Resident #49 also revealed the staff had not cleaned his contracted hand in months. Interview with Registered Nurse (RN) #316 at 10:50 A.M. revealed she applied a washcloth to the contracted hand of the Resident on 05/21/24. When asked how she did this she was not able to demonstrate this task. Review of the facility policy titled, Braces and Splints dated 04/05/24 revealed staff will a scheduled program of applying and removing the appliance. Schedule hours to be worn and when skin will be inspected for signs and symptoms of pressure areas, irritations, rashes, etc. and will be reported to charge nurse and attending physician.

Based on medical record review, observations, resident and staff interviews and policy review, the facility failed to ensure a resident's hand splint was applied as physician ordered. This affected one (#49) out of four residents reviewed for range of motion. The facility census was 97. Findings include: Resident #49 was admitted to the facility on [DATE] with a diagnosis of functional quadriplegia, injury of unspecified level of cervical spinal cord, muscle spasms, muscle weakness, anxiety, and depressive disorders. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #49 is cognitively intact. His functional status is listed as set up to dependent on staff for all activities of daily living. For showering the resident is dependent but for toileting he is substantial/maximal assistance. For eating and hygiene he is just set up only. Review of the care plan revealed Resident #49 has a functional ability deficit and requires assistance with self-care/mobility related to impaired mobility, muscle weakness, pain, bowel and bladder incontinence, psychoactive medication usage, right hand splint, Hoyer lift for transfers. Interventions included half side rails for bed mobility, Hoyer lift for transfers, right hand splint as ordered. Keep fingernails trimmed and clean. Provide assistance as needed for each activity until the resident performs skill competently and is safe with level of care; re-evaluate regularly to be certain that the skill level is maintained, and the resident remains safe in the environment. Hand splint to be used Tuesday and Thursday only. Review of the physician orders dated 09/19/23 revealed apply hand splint to right hand twice a week as tolerated. May remove for hand hygiene. Guest may wear hand splint as tolerated and needed. One time a day, every Tuesday and Thursday, for contracture's to right hand. Review of the Treatment Administration Record (TAR) for 03/2024, 04/2024, and 05/2024, revealed Resident #49's hand splint was signed off as completed. Interview on 05/21/24 at 8:30 A.M. with Resident #49 revealed the staff never place his hand splint on his contracture right hand. Resident #49 revealed the last time staff applied the hand splint was months ago. Resident #49 also revealed they never try to wash the contracted hand or fingers. Observation on 05/21/24 at 8:30 A.M., 1:00 P.M., revealed Resident #49 did not have the hand splint applied. On 05/21/24 at 4:40 P.M. observation of Resident #49 revealed the hand splint was still not applied. Observation on 05/22/24 at 10:50 A.M. revealed the hand splint was still not applied. Observation on 05/21/24 and 05/22/24 revealed a sour odor in Resident #49's room that the resident stated was caused by his unattended/foul smelling contracted hand. Observation and interview on 05/22/24 at 10:50 A.M. with Resident #49 revealed the staff did not place the splint on his right contracted hand on 05/21/24 as physician ordered. Resident #49 revealed staff have not placed his splint or washcloth in his hand in months. Resident #49 also revealed the staff had not cleaned his contracted hand in months. Interview with Registered Nurse (RN) #316 at 10:50 A.M. revealed she applied a washcloth to the contracted hand of the Resident on 05/21/24. When asked how she did this she was not able to demonstrate this task. Review of the facility policy titled, Braces and Splints dated 04/05/24 revealed staff will a scheduled program of applying and removing the appliance. Schedule hours to be worn and when skin will be inspected for signs and symptoms of pressure areas, irritations, rashes, etc. and will be reported to charge nurse and attending physician.

Based on medical record review, staff interview and review of the facility policy, the facility failed to provide timely care and services to treat a urinary tract infection. This affected one (#298) out of three residents reviewed for change of condition. The facility census was 97. Findings include: Review of the medical record for Resident #298 revealed an admitted [DATE] with medical diagnoses of pneumonia, chronic obstructive pulmonary disease, atrial fibrillation, hypertension, and neuromuscular dysfunction of the bladder. Further review of the medical record revealed Resident #298 was discharged to the hospital on [DATE] and expired at the hospital. Review of the medical record for Resident #298 revealed an admission Minimum Data Set (MDS) assessment, dated [DATE], which indicated Resident #298 had moderate cognitive impairment and required maximum staff assistance for bed mobility and transfers and was dependent for toilet hygiene and bathing. Review of the medical record for Resident #298 revealed physician orders dated [DATE] for 16 French indwelling catheter for neuromuscular dysfunction of bladder and an order dated [DATE] for repeat urinalysis with culture for dysuria one time only. Review of the medical record for Resident #298 revealed a nurse progress note, dated [DATE] at 5:15 P.M. which stated resident complained of pain with urination, dark colored urine, dysuria, and burning with urination. The note stated the nurse notified the physician and an order to obtain a urinalysis with culture was given. Further review of the medical record revealed a nurse's progress note dated [DATE] at 7:13 A.M. which stated the resident refused any attempt to collect urine specimen as ordered. A nurse's progress note dated [DATE] at 12:16 P.M. stated the urine specimen was obtained as ordered and placed in refrigerator for lab pick up. Review of the medical record revealed no documentation to support the facility attempted to collect the urine specimen on [DATE] or [DATE] or that the resident refused to allow staff to obtain the urine specimen on [DATE] or [DATE]. Further review of the medical record revealed no documentation to support the facility notified the physician of the delay in obtaining the urine specimen. Interview on [DATE] at 10:16 A.M. with Director of Nursing (DON) confirmed the medical record for Resident #298 did not contain documentation to support the facility attempted to obtain the urinalysis with culture from Resident #298 on [DATE] or [DATE]. DON also confirmed the medical record did not contain documentation to support the facility notified the physician of the delay in the order being carried out. Review of the facility policy titled, Physician Order, revised [DATE], stated the physician orders are obtained to provide a clear direction in the care of the resident. This deficiency represents non-compliance investigated under Complaint Number OH00153951.

Based on record review, observations, resident and staff interviews and policy review, the facility failed to ensure a resident was observed to take their medications at the time of administration. This affected one (#74) of five residents reviewed medication administration. The facility census was 97. Findings include: Review of medical record for Resident #74 revealed admitted [DATE]. The resident was admitted with diagnoses including alcohol dependence, epilepsy, dementia without behavior, anxiety and metabolic encephalopathy. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #74 had a Brief Interview Mental Status (BIMS) score of 10 indicating impaired cognition. The activities of daily living were not assessed. Review of Resident #74's medical record revealed a physician orders for 500 micrograms of Vitamin B daily, 50000 of Vitamin D daily, 125 milligrams of Depakote twice daily, 81 milligrams aspirin daily and 500 milligrams Keppra twice daily. Review for Resident #74's medical record revealed there was no order or assessment that permitted the resident to self-administer medications. Observation and interview on 05/20/24 at approximately 9:49 A.M. with Resident #74 revealed he presented a medicine cup which he said contained the pills he needed to take. Interview and observation on 05/20/24 at 9:54 A.M. with Registered Nurse (RN) #268 verified Resident #74 was in possession of eight pills in a medicine cup. RN #268 stated he observed Resident #74 take the pills he administered that morning and was unsure where the pills had come from. RN #268 verified there were eight pills in the medicine cup. RN #268 stated the pills were two Depakote (anti-seizure), two Keppra (anti-convulsant), two vitamin B (supplement), one vitamin D (supplement) and one aspirin (non-steroidal anti-inflammatory drug). Review of the facility policy, Medication Administration last revised 10/17/23 revealed to observe the resident swallow the medication.

Based on medical record review, staff interview and policy review, the facility failed to ensure physician ordered laboratory (lab) work was completed/drawn in a timely manner. This affected two (#52 and #298) out of six residents reviewed for lab services. The facility census was 97. Findings include: 1. Review of Resident #52's medical record revealed he was admitted to the facility on [DATE] with a diagnosis of blindness, urine retention, hemiplegia following cerebrovascular accident, obstructive and reflux uropathy, seizures, diabetes type II, bipolar disorder, depression, and anxiety disorders. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #52 was cognitively intact. His functional status is listed as partial to moderate assistance for all activities of daily living. Review of the physician orders dated [DATE] revealed renal, magnesium, complete blood count (CBC), Thyroid-stimulating hormone (TSH), liver function test (LFT), lipid panel, hemoglobin A1,C iron, vitamin b12, vitamin D, level Depakote, to be drawn every three months. Review of the pharmacy recommendations dated [DATE], [DATE], and [DATE] revealed Resident #52's lab work was recommended. Further review of Resident #52's medical record revealed the labs had not been drawn as of [DATE]. Interview with the Director of Nursing on [DATE] at 10:00 A.M. confirmed the lab work had been missed for Resident #52. 46613 2. Review of the medical record for Resident #298 revealed an admitted [DATE] with medical diagnoses of pneumonia, chronic obstructive pulmonary disease, atrial fibrillation, hypertension, and neuromuscular dysfunction of the bladder. Further review of the medical record revealed Resident #298 was discharged to the hospital on [DATE] and expired at the hospital. Review of the medical record for Resident #298 revealed an admission Minimum Data Set (MDS) assessment, dated [DATE], which indicated Resident #298 had moderate cognitive impairment and required maximum staff assistance for bed mobility and transfers and was dependent for toilet hygiene and bathing. Review of the medical record for Resident #298 revealed physician orders dated [DATE] for 16 French indwelling catheter for neuromuscular dysfunction of bladder and an order dated [DATE] for repeat urinalysis with culture for dysuria one time only. Review of the medical record for Resident #298 revealed a nurse progress note, dated [DATE] at 5:15 P.M. which stated resident complained of pain with urination, dark colored urine, dysuria, and burning with urination. The note stated the nurse notified the physician and an order to obtain a urinalysis with culture was given. Further review of the medical record revealed a nurse's progress note dated [DATE] at 7:13 A.M. which stated the resident refused any attempt to collect urine specimen as ordered. A nurse's progress note dated [DATE] at 12:16 P.M. stated the urine specimen was obtained as ordered and placed in refrigerator for lab pick up. Review of the medical record revealed no documentation to support the facility attempted to collect the urine specimen on [DATE] or [DATE] or that the resident refused to allow staff to obtain the urine specimen on [DATE] or [DATE]. Further review of the medical record revealed no documentation to support the facility notified the physician of the delay in obtaining the urine specimen. Interview on [DATE] at 10:16 A.M. with Director of Nursing (DON) confirmed the medical record for Resident #298 did not contain documentation to support the facility attempted to obtain the urinalysis with culture from Resident #298 on [DATE] or [DATE]. DON also confirmed the medical record did not contain documentation to support the facility notified the physician of the delay in the order being carried out. Review of the facility policy titled, Physician Order, revised [DATE], stated the physician orders are obtained to provide a clear direction in the care of the resident. This deficiency represents non-compliance investigated under Complaint Number OH00153951.

Based on record review, observations, staff interview and policy review, the facility failed to ensure staff followed proper infection control procedure when administering intravenous medication. This affected one (#50) out of five residents observed for medication administration. Facility census was 97. Findings include: Review of medical record for Resident #20 revealed admitted [DATE]. Diagnoses include osteomyelitis, anxiety, and heart failure. Review of Resident #20's admission Minimum Data Set (MDS) dated [DATE] revealed she had a Brief Interview Mental Status (BIMS) score of 15 indicating intact cognition. She was independent with activities of daily living. Observation on 05/21/24 at 9:23 A.M. with Licensed Practical Nurse (LPN) #309 of the Peripherally Inserted Central Catheter (PICC) line medication administration for Resident #20 revealed LPN #309 cleansed the tip of the needleless connector of the PICC line with an alcohol swab and then intentionally dropped the line and it landed on the Resident #20's arm. LPN #309 was prepared to administer the saline flush without recleaning the potentially contaminated tip until the surveyor interviewed LPN #309. LPN #309 verified the tip was no longer sterile after intentionally dropping the line down. Review of the facility policy, Medication Administration last revised 10/17/23 revealed injections should be prepared using aseptic technique in a clean area.

Based on medical record review, staff interview, and policy review, the facility failed to complete weekly wound evaluations of a surgical wound. This affected one (#105) out of three residents reviewed for wound care. The facility census was 101. Findings include: Review of the medical record for Resident #105 revealed an admitted [DATE] with medical diagnoses of status post left below the knee amputation (BKA), diabetes mellitus with neuropathy, depression, bipolar disorder, anemia, and hypertension. Review of the medical record revealed Resident #105 discharged to the hospital on 04/11/24. Review of the medical record for Resident #105 revealed an admission Minimum Data Set (MDS) assessment, dated 02/27/24, which indicated Resident #105 was cognitively intact and required supervision with bed mobility and moderate staff assistance with toilet hygiene, transfers, and bathing. The MDS indicated Resident #105 admitted with a surgical wound and treatment was in place. Review of the medical record for Resident #105 revealed a Nursing Comprehensive Evaluation, dated 02/21/24, which indicated Resident #105 admitted with a surgical wound to left lower extremity status post BKA. The evaluation stated the surgical wound had 20 staples but did not state a measurement or describe the wound characteristics. The evaluation also noted Resident #105 admitted with diabetic ulcers to right plantar foot and to the 3rd digit on right foot and both areas were noted to have measurements. Further review of the medical record revealed a wound evaluation completed 03/19/24 for the surgical wound to the left BKA. The surgical wound measured 0.57 centimeters (cm) in length by 1.97 cm in width and 1.6 cm in depth. The evaluation stated the surgical wound had deteriorated. Review of the medical record for Resident #105 revealed it did not contain documentation to support the facility completed wound evaluations, which included wound measurements and description for Resident #105's left BKA surgical site from 02/20/24 until 03/19/24. Review of the medical record for Resident #105 revealed a Certified Nurse Practitioner (CNP) wound note, dated 03/19/24, which stated Resident #105 had injured the left BKA stump in the bathroom the day before and the incision had opened, had drainage, and increased pain to the area. The note included measurements and a description of Resident #105's wound and the treatment plan. Interview on 04/12/24 at 2:45 P.M. with Licensed Practical Nurse (LPN) #221 confirmed the medical record for Resident #105 did not contain documentation to support the facility completed wound evaluation for the left BKA from 02/20/24 until 03/19/24. Review of the facility policy titled, Skin Management, revised 07/14/21, stated residents admitted with any skin impairment would have the wound location, measurements and characteristics documented in the electronic health record. The policy stated the facility would document weekly on the area until resolved. This deficiency represents non-compliance investigated under Complaint Number OH00152531.

Based on medical record review, staff and guardian interviews, and policy review, the facility failed to provide the correct location for discharge on a discharge notice. This affected one (Resident #204) of three residents reviewed for proper discharges. The facility census was 101. Findings include: Review of the medical record for Resident #204 revealed an admitted [DATE] with medical diagnoses of paranoid schizophrenia, end stage renal disease, and anxiety. Resident #204 was discharged to an acute care hospital on 09/02/23 for increased behaviors and agitation. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #204 was cognitively intact and required supervision at times with bed mobility, toileting, and transfers. Review of the nursing progress note dated 09/01/23, revealed the dialysis center would no longer provide dialysis to Resident #204 because of his increased behaviors and an episode where Resident #204 pulled out his dialysis tubing and experienced bleeding. Further review revealed a note dated 09/02/23, which stated Resident #204 had a change in condition with altered mental status and behavioral symptoms. Review of the progress note revealed Resident #204 pulled items off walls and was throwing them, went into other resident rooms and was throwing their clothes and exposed his penis to a female resident on the unit. Further review of the medical record revealed an immediate discharge from facility letter dated 09/06/23, showing Resident #204 would be discharged due to the facility not being able to meet the needs of the resident and the resident was a danger to himself and other residents. The location of discharge was documented as a behavioral hospital. The letter continued to state upon discharge from the behavioral hospital, the resident would return to the facility. Interview on 09/29/23 at 12:02 P.M. with Resident #204's guardian revealed Resident #204 was transferred to an acute hospital setting, not a behavioral unit, on 09/02/23. Resident #204's guardian stated the facility contacted her on 09/06/23 via phone to notify her Resident #204 was issued an immediate discharge from the facility because he was a harm to himself, and other residents and the facility was not able to meet his needs. Resident #204's guardian stated the facility informed her the immediate discharge notice would be sent to her via certified mail. Resident #204's guardian stated she never received the notice in the mail, so she went to the facility, and they provided her with a copy of the letter. Resident #204's guardian stated the discharge locations on the immediate discharge letter were incorrect and Resident #204 had not been discharged to a behavioral hospital but an acute care hospital. Interview on 09/29/23 at 1:43 P.M. with the Administrator confirmed the immediate discharge letter for Resident #204 stated Resident #204 would be discharged to a behavioral hospital and upon discharge from the behavioral hospital, would return the facility. The Administrator confirmed the information regarding discharge locations stated in the letter were incorrect. The Administrator confirmed Resident #204 discharged from the facility to an acute care hospital and Resident #204 was not to return to the facility. The Administrator also confirmed Resident #204 was sent to the acute hospital setting on 09/02/23 and the immediate discharge letter was sent on 09/06/23. Review of the policy titled, Transfer and Discharge, revised 09/09/22, stated notice of transfer or discharge must be made by the facility in writing at least 30 days before the guest/resident is transferred or discharged and in a manner they can understand. The policy also stated the contents of the notice must include the specific location to which the guest/resident is transferred or discharged (if a change in the destination indicates that the original basis has changed, a new notice is required). This deficiency represents non-compliance investigated under Complaint Number OH00146564.

Based on record review, observation, interview, fall investigation, manufacturer operation manual and policy review, the facility failed to prevent an avoidable fall. This resulted in actual harm for one (Resident #40) resident when she fell to the floor from a mechanical lift after a lift pad strap ripped apart. Resident #40 sustained a fracture to her left leg. The sample was three residents. The facility census was 101. Findings include: Review of the medical record for Resident #40 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly comprehensive assessment, dated 03/29/19, revealed the resident had impaired cognition. She was totally dependent on two staff for bed mobility, transfers and all care. Resident #40 had impairment of both upper and lower extremities. Review of the plan of care, dated 03/27/19, revealed Resident #40 had no falls however required a mechanical lift for transfers with the assistance of two staff and was at risk for falls due to requiring staff assistance for transfer. The goal was to remain free of falls and/or injury. Interventions included provide a safe environment and use the mechanical lift for transfer into the geri chair with two staff as tolerated. Review of the nurses notes dated 04/11/19 at 11:00 A.M., revealed Resident #40 fell from the mechanical lift at 8:05 A.M., when state tested nursing assistants (STNAs) were transferring her to the geri chair. While Resident #40 was up in the air on the lift pad, the lift pad strap snapped and Resident #40 fell to the floor landing on her back. She did not hit her head as one STNA attempted to break her fall. The physician was notified and new orders were received for sacral, lumbar and [MEDICATION NAME] spine X-rays. Review of the local hospital record dated 04/12/19 revealed Resident #40 was seen for evaluation of abnormal diagnostic test. She had a traumatic closed [MEDICAL CONDITION] tibia with fibula with minimal displacement of the left leg. Review of the fall investigation, dated 04/11/19, revealed the strap of the lift pad snapped. The straps on the pad were hard. Resident #40 had a red mark on her back and x-rays were obtained. Later in the evening Resident #40 would not allow anyone to touch her left leg, which was unusual, so more x-rays were ordered. STNA #207 and #210 had completed the transfer as planned. All mechanical lift pads were inspected and three were removed and discarded due to one having a hole and two being faded. During interview on 04/15/19 at 9:20 A.M., Housekeeping/Laundry Aid #204 stated she had washed the mechanical lift pads she said they had always hung them to air dry, however her previous boss told them they could dry them in a dryer. So she had dried them before but did not think they were supposed to. She said they would check them for holes, rips and tears. They had requested new lift pads because they needed more, however she was unsure when she had asked. She said they had removed the worn one and was not sure how it made it back to the blue storage barrel where the STNA's come and get a lift pad. During interview on 04/15/19 at 10:00 A.M., STNA #207 stated she was working on 04/11/19 and assisted in the mechanical lift transfer. She said the lift pad was not torn or ripped. She said STNA #210 had actually gotten the lift pad from the laundry. She said when they lifted Resident #40 up into the air and was moving her to the geri chair, the black strap actually broke off of the lift pad. She tried to catch Resident #40, but could only protect her head and she fell to the ground on her back. Her legs fell across the metal legs of the mechanical lift. She said after the fact they looked at the straps and they were hard and dry rotted and the strap was able to be pulled apart by hand. She stated they had asked for new lift pads six months ago and they had been ordered, but they were not the ones they could use. During interview on 04/15/19 at 10:12 A.M., the Administrator and Director of Nursing (DON) stated they were focused on getting residents up for meals and asked to order two new mechanical lift pads. She stated the STNAs should inspect the pads and the laundry should inspect them. During interview on 04/15/19 at 11:23 A.M., STNA #210 stated she and STNA #207 were in the room transferring Resident #40. When they raised her from the bed and moved her to the chair, the lift pad ripped and the resident fell to the ground. She did not hit her head, but fell on her back. She said after the fact and looking at the lift pad she was able to tear it apart with her hands. During interview on 04/15/19 at 12:50 P.M., Central Supply #212 stated she ordered two mechanical lift pads about one month ago, however they never came because they were on back order until (MONTH) 2019. She said they were ordering two with each order so it would not be a huge bill. The invoice was reviewed and showed two lift pads were ordered on [DATE] but the order was never filled. During interview on 04/15/19 at 3:31 P.M., LPN #213 stated she was called to Resident #40's room by the STNA, who stated during the transfer the mechanical lift pad strap broke and the resident fell to the floor. She assessed the resident and found no signs of pain. The doctor and resident's responsible party were notified. Later in the evening, Resident #40 would not allow STNA #210 to reposition her. The physician was notified of the change in condition and new orders were obtained. She said she called the doctor and notified him of the change and obtained new orders. She said after the incident they inspected the mechanical lift pad and it was dry rotted and stiff. They were able to rip it apart with their hands. Observation on 04/15/19 at 9:35 A.M. revealed Resident #40 was sitting up in the geri chair. She had a soft cast and wrap to the left leg. There were no signs and symptoms of pain or distress. At 11:33 A.M., STNA #207 and #208 performed a mechanical lift transfer with Resident #40. At this time no concerns were noted with the mechanics of the transfer, however when the lift began to move Resident #40's eyes widened and brow raised in fear. The actual lift pad used during the incident was inspected on 04/15/19 at 3:42 P.M The straps had ripped apart, were frayed and faded. Review of the facility policy titled Lift-Hydraulic:, revised (MONTH) 2008, revealed a hydraulic lift may be used at the direction of a physicians order or as a nursing measure, to lift and move guests who are contracted, spastic, heavy, or totally dependent on staff for bed mobility and transfer. At least two staff members are to be present and assist in the use of the hydraulic lift when transferring a guest. Follow the manufacturer's guidelines regarding the operation of and procedure for guest transfer for specific model of hydraulic lift. Review of the Owner's Operator and Maintenance Manual for Patient Slings revealed after each laundering (in accordance with instructions on the sling), inspect sling for wear, tears, and loose stitching. Bleached, torn, cut, frayed, or broken slings are unsafe and could result in injury. Discard immediately. Laundry care noted should be washed with dark colors, washed regularly in a water temperature not to exceed 180 degrees F, DO NOT bleach, Air dry or dry at low temperature. Inspect with each use. This deficiency substantiated Complaint Number OH 769.

Based on record review, observation, interview, review of Self Reported Incident (SRI) and review of facility policy the facility failed to ensure residents received adequate supervision. This resulted in actual harm to Resident #25 when the resident entered another residents room, the other resident shoved Resident #25 and caused her to fall. Resident #25 sustained a [MEDICAL CONDITION] and was admitted to the hospital. The facility also failed to ensure fall devices were in place and residents received adequate supervision with smoking. This affected three Residents (#13, #25, and #84) of four reviewed for supervison to prevent accidents and hazards. The facility census was 101. Findings include: 1. Record review revealed Resident #25 was originally admitted on [DATE]. The resident was sent to the hospital on [DATE] related to a [MEDICAL CONDITION]. The resident was readmitted on [DATE]. [DIAGNOSES REDACTED]. Review of the significant change Minimum Data Set ((MDS) dated [DATE] revealed Resident #25 was readmitted to the facility on [DATE] after repair of her [MEDICAL CONDITION]. The resident was cognitively impaired and totally dependent on one to two staff for all activities of daily living except for eating which she required extensive assist of one. Review of Resident #25's care plans revealed the resident resided on a locked secure unit due to poor safety awareness, sexually inappropriateness, physical and verbal aggression. The care plan addressed hypersexuality as evidenced by writing inappropriate comments on items, sexual ideations of inappropriate contact with staff, frequent verbalizations sexual in nature, and aggressively patting staff on the cheek. Review of progress note dated 07/11/18 revealed Resident #25 was transferred to a psychiatric facility on 07/02/18 and returned to the facility 07/11/18. Review of progress note dated 07/18/18 at 12:43 P.M. by social service staff indicated Resident #25 was unable to have a roommate due to behaviors and history of throwing hot liquids at others. A subsequent progress note on 07/18/18 indicated the resident was transferred to a psychiatric facility. Review of a progress notes dated 07/31/18 revealed the resident returned to the facility and was placed on the secure unit for safety or herself and others. Review of progress note dated 08/08/18 at 11:46 [NAME]M. indicated Resident #25's sister was advised of an incident (no details were documented in the medical record) from last night and of a fall that occurred. Review of progress note dated 08/08/18 at 3:22 P.M. indicated Resident #25 complained of right hip pain. The resident declined pain medications, but accepted ice cream. Review of progress note dated 08/08/18 at 4:29 P.M. indicated x-ray results revealed right [MEDICAL CONDITION] and the resident was sent to the hospital for an evaluation. Review of a SRI dated 08/08/18 revealed Resident #308 complained of Resident #25 touching her inappropriately the night before, specifically touching her breast and between her legs. The other resident was dressed and the touching occurred over top of her clothing. Further review of the SRI revealed staff had observed Resident #25 sitting with Resident #308. Resident #25 did have her hand on Resident #308's leg, directly above her knee. Resident #308 requested for staff to remove Resident #25 as she did not want anyone to think she was gay and she did not want anyone rubbing on her. Interview with Regional Corporate Compliance (RCC) #300 on 01/17/19 at 9:20 [NAME]M. revealed Resident #25 had a severe decline in her abilities since the [MEDICAL CONDITION]. RCC #300 indicated the resident was nonambulatory after the incident on 08/08/18. RCC #300 revealed Resident #25 touched Resident #308 inappropriately, so Resident #308 shoved Resident #25 and caused her to fall,. Resident #25 sustained a [MEDICAL CONDITION] and was admitted to the hospital. RCC #300 stated she did not feel Resident #308 intentionally hurt Resident #25 and Resident #308 had voiced remorse after the incident. Interview on 01/17/19 at 10:05 [NAME]M. with the Administrator and RCC #300 revealed the SRI was completed by the previous Director of Nursing (DON) and they were unaware of what was submitted. RCC #300 verified the SRI should have been submitted as a resident to resident abuse. The SRI should have contained information about Resident #25 being shoved and sustaining a [MEDICAL CONDITION]. Review of former Resident #308's medical record revealed an admitted [DATE] and discharge of 09/05/18. Resident #308's [DIAGNOSES REDACTED]. Review of a MDS assessment dated [DATE] indicated supervision only was required for activities of daily living. Review of Resident #308's care plan dated 10/04/17 indicated alteration in mood and behaviors with history of instigating altercations. Interventions included attempts to determine what may trigger behaviors. 2. Record review revealed Resident #84 was admitted to the facility on [DATE] with the following diagnoses; acute kidney failure, ataxic gait, muscle wasting and atrophy, essential hypertension, lower back pain, generalized anxiety disorder and cocaine abuse. Review of Resident #84's quarterly MDS assessment dated [DATE] revealed the resident's cognition was not assessed. Resident #84 was reported to be independent with toileting and required supervision with bed mobility, transfer, dressing, eating and personal hygiene. Further review of Resident #84's record revealed the resident signed the smoking policy on 12/21/18. Review of Resident #84's smoking assessment dated [DATE] revealed the resident required supervision while smoking. Review of Resident #84's care plan dated 01/12/19 revealed the resident should be supervised while smoking and all smoking materials should be kept by staff members. Observation of Resident #84 on 01/14/19 at 7:45 [NAME]M. revealed the resident was smoking unsupervised in the back of the facility by the ash trays. At the time of the observation, Licensed Practical Nurse (LPN) #74 was interviewed and verified Resident #84 was smoking without supervision in the back of the building. LPN #74 reported residents were not permitted to smoke without supervision. Review of Resident #84's progress note dated 1/14/19 at 9:58 [NAME]M. revealed the resident was note smoking out in the back of the facility towards the parking lot. Observation of Resident #84 on 01/14/19 at 6:00 P.M. revealed the resident was smoking outside in front of the building. Review of Resident #84's Brief Interview for Mental Statues (BIMS) dated 01/15/19 revealed the resident was cognitively intact. Review of the facility's undated Guest Smoking policy revealed residents should be supervised while smoking and all smoking materials should be kept at the nurse's station. 3. Record review revealed Resident #13 was admitted to the facility on [DATE] with the following diagnoses; [MEDICAL CONDITION] with behavioral disturbance, [MEDICAL CONDITION] affecting right dominant side, muscle wasting and atrophy, stiffness of unspecified joint, cognitive communication deficit, restlessness and agitation, restlessness and agitation, [MEDICAL CONDITION] with delusions, [MEDICAL CONDITIONS] and major [MEDICAL CONDITION]. Review of Resident #13's quarterly MDS assessment dated [DATE] revealed the resident was severely cognitively impaired. The resident required extensive assistance with bed mobility, dressing, eating and personal hygiene. Resident #13 also required total dependence with transfers and toileting. Review of Resident #13's care plan dated revealed interventions included fall mat to the side of the bed and a personal alarm to the bed as ordered. Further review of Resident #13's care plan revealed the fall mat and the personal alarm were added to the care plan on 10/03/18. Review of Resident #13's physicians orders (PO) dated 08/17/17 revealed an order for [REDACTED]. Observation on 01/15/19 at 8:35 [NAME]M. revealed Resident #13 was laying in bed. Resident #13 did not have a fall mat to the side of her bed or a clip alarm on at the time of the observation. Observation on 01/15/19 at 9:44 [NAME]M. revealed Resident #13 to be laying in bed. Resident #13 did not have a fall mat to the side of her bed or a clip alarm on at the time of the observation. Observation on 01/15/19 at 10:47 [NAME]M. revealed Resident #13 was laying in bed with a family member and staff member in her room. Resident #13 did not have a fall mat to the side of her bed or a clip alarm on at the time of the observation. Observation on 01/15/19 at 5:39 P.M. revealed Resident #13 was laying in bed with a family member sitting at her bedside. Resident #13 did not have a fall mat to the side of her bed or a clip alarm on at the time of the observation. Observation on 01/16/19 at 9:08 [NAME]M. revealed Resident #13 was laying in bed. Resident #13 did not have a fall mat to the side of her bed or a clip alarm on at the time of the observation. Observation on 01/16/19 at 9:51 [NAME]M. revealed Resident #13 was laying in bed. Resident #13 did not have a fall mat to the side of her bed or a clip alarm on at the time of the observation. Interview with the DON on 01/16/19 at 9:52 [NAME]M. verified Resident #13 was laying in bed without a clip alarm or fall mat to the side of her bed. The DON confirmed Resident #13 had a order and was care planned for a clip alarm while in bed and a fall mat to the side of the bed.

Based on medical record review, staff and resident interviews and policy review the facility failed to ensure residents pain was properly managed and failed to ensure a speciality appointment for pain was scheduled in a timely manner. This resulted in actual harm to Resident #5 who had uncontrolled pain and difficulty sleeping. This affected one (#5)of one resident reviewed for pain management. The facility identified 53 residents on a pain management program. The facility census was 101. Findings include: Medical record review for Resident #5 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE], revealed the resident was cognitively intact. The functional status was extensive assistance for bed mobility, transfers, toilet use and he was independent for eating. Further review of the MDS revealed Resident #5 was on a scheduled pain medication regimen. Review of the physician orders [REDACTED]. Review of PO dated 10/03/17 revealed routine Hydorxcholorquine Sulfate 200 mg one tablet routine twice a day and routine Aspercreme with [MEDICATION NAME] 4%, apply to neck and back every 12 hours for pain. Review of PO dated 11/30/17 revealed routine Neurotin 600 mg three times a day for multiple tender points. Review of PO dated 11/24/18 revealed [MEDICATION NAME] one mg daily for pain. Review of PO dated 11/27/18 revealed routine [MEDICATION NAME] 500 mg one tablet every 12 hours for [MEDICAL CONDITION] arthritis. Review of physician history and physical dated 11/27/18 revealed the resident was seen for increase in pain to lower back and knees and for inability to sleep at night. Resident was started on [MEDICATION NAME] 500 mg twice a day and explained to resident once the pain was under control it should help with him sleeping. Resident voiced understanding. Review of the nurses progress notes dated 11/27/18 at 6:16 P.M. written by Licensed Practical Nurse (LPN) #74, revealed the physician assessed the resident. The physician ordered Naposyn 500 mg every 12 hours routine and to follow up with the [MEDICAL CONDITION] arthritis physician. Review of the Medication Administration Record [REDACTED].M. as a eight three times, as a seven 10 times and as a five two times. Further review of the MAR indicated [REDACTED]. the resident rated his pain as a eight, three times, as a seven, 10 times, as a six and five once. Review of the care plan dated 01/10/19, revealed the resident was at risk for pain related to [MEDICAL CONDITION] arthritis. Interventions included routine pain medications, which offered a good short term relief, monitor for effectiveness of the interventions, monitor for increased level of pain and notify the physician. Interview with Resident #5 on 01/13/19 at 2:39 P.M., revealed his pain was not under control. He stated he had [MEDICAL CONDITION] arthritis and none of his medications helped Interview with LPN #74 on 01/16/19 at 3:46 P.M., revealed she placed the referral for the [MEDICAL CONDITION] arthritis physician on this day. When asked why she didn't make the referral on 11/27/18, she stated she tried to call the office, but did not have time to sit around on hold or wait for a return phone call from the physician's office. She stated there was no evidence in the record to indicate she had attempted to call and make the referral. Review of facility policy titled, Pain Management Program dated (MONTH) 2005, revealed the pain management program will be used by nursing staff to evaluate, provide appropriate interventions, and monitor the effectiveness of the pain regimen for residents experiencing chronic pain in order to promote comfort and the ability to reach the residents highest functional level.

The following deficiency represents an incident of past non-compliance that was subsequently corrected prior to this survey. Based on medical record review and staff interview, the facility failed to ensure safety measures were in place as ordered to prevent a fall with injury. Harm occurred when the facility failed to put in place the ordered soft waist restraint to prevent falls, and Resident #1 fell and fractured her left hip. This affected one former resident of three residents reviewed for soft waist restraints (Resident #1). The facility identified six current residents that utilized soft waist restraints. The facility census was 107. Findings include: Medical record review of Resident #1 revealed that the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. This resident was alert and oriented with intermittent confusion at times with had impared cognition on the most recent quarterly Minimum Data Set (MDS) assessment completed on 09/06/14. The MDS further showed the resident required extensive assistance with all activities of daily living. Resident #1 was assessed as a risk for falls and required the use of a soft waist restraint. This restraint was ordered on [DATE] and to be implemented on a daily basis for resident safety. Review of the incident log and nurses notes revealed that on 10/11/14, a late entry was made that revealed Resident #1 was noted lying on the left side in lateral position on floor by bed, legs extended, torso in natural alignment, head resting on left arm, right arm at side, wheel chair at feet. The note further revealed the resident stated she was getting into bed. Resident #1 was assessed and placed back into bed and was noted to have an abrasion to her left elbow and left shoulder. The note further revealed that the pelvic restraint was noted with lock malfunction. An X-ray was obtained to the left hip and femur because the resident was noted on the left side. The physician and family were notified. At 3:00 P.M., a portable X ray was obtained and the results were as follow: moderate osteoporosis with acute linear fracture to left femur, also linear fracture to left inner trochanter. Notified MD awaiting response. Due to the resident status and currently being under hospice care, surgical interventions were deferred by the physician and family members. During an interview with the Director of Nursing and Administrator on 11/10/14 at 11:00 A.M. they stated that the resident was found on the floor by a housekeeper at the time of the incident. The interview further revealed that the distribution of Posey lap vest (soft waist restraint) was completed by the laundry department following cleaning and a visual inspection to determine that the garment was serviceable. The interview revealed that the Posey restraint was brought to Resident #1's room on 10/11/14 and placed at the foot of the bed for placement by nursing staff. At the time of the incident, the resident was up at the side of the bed with the restraint still lying on the foot of the bed. When asked what the pelvic restraint lock malfunction meant the Administrator stated it was not placed on the resident. The Director of Nursing and Administrator state the nursing assistant assigned to the resident was terminated from the facility following this incident. Interview with Licensed Practical Nurse (LPN) #2 on 11/10/14 at 2:00 P.M. revealed that at the time of the incident, she was at lunch. The incident was reported to her upon her return from lunch. LPN #2 verified that upon her arrival to Resident #1's room, the waist restraint was on the resident. LPN #2 stated that a head to toe assessment was performed at that time and the resident was placed on her bed. LPN #2 stated that first aid was provided to the resident and an order for [REDACTED]. During an interview with State tested Nursing Assistant (STNA) #3 on 11/12/14 at 9:30 A.M. she stated that she was on another hall on the morning of 10/11/14. STNA #3 stated that when she responded to the resident's room, she did not witness any type of restraint on the resident, just that the resident was found on the floor beside her bed. Interview with LPN #1 on 11/12/14 at 9:45 A.M. revealed that she was caring for this resident on the morning of the incident and had passed her medication as usual during the morning hours. LPN #1 stated that the last time that she had witnessed the resident she was still lying in bed. LPN #1 stated at that time the Posey restraint was not on the resident, but still at the foot of the bed where laundry personnel had placed it on that morning. LPN #1 stated she did not know if the restraint had been placed on the resident. Interview with Housekeeping Aide #4 on 11/12/14 at 10:00 A.M. revealed that on the morning of 10/11/14, a Posey waist restraint was provided to nursing staff for placement on Resident #1. She stated that she had not witnessed it being placed on the resident at any time, but also had not seen the resident during that morning prior to her fall. She also stated that it is the responsibility of nursing staff to appropriately fit and place the restraint on the resident following delivery to the floor. The deficiency was corrected on 10/16/14 when Resident #1 had additional interventions implemented with a personal alarm and was subsequently discharged to Hospice of Dayton. Additionally, the deficiency was corrected on 10/16/14 when the facility implemented the following corrective actions: * The STNA that was responsible for Resident #1's care on 10/11/14 was terminated. * A 100 percent facility audit was conducted on all pelvic restraints and no problems observed during audit. This audit was completed on 10/11/14. * On 10/13/14 the facility identified all residents utilizing soft waist restraints and observed to ensure all were correctly applied. * On 10/13/14 in-services of all began on 10/13/14 on waist restraint and fall interventions. This was completed with all staff members by 10/16/14. The in-service included Review of Physical Restraint Policy revealed that this policy was revised in July 2003. * On 10/13/14 monitoring of new interventions began. The monitoring was conducted three times a week for four weeks, then will be weekly for four more weeks, then as needed. The monitoring was reviewed and showed compliance. * Interviews conducted on 11/10/14 with LPN #5, LPN #2, STNA #3 and LPN #1 revealed all were in-serviced and were knowledgeable about the restraint policy and fall interventions. * Observation and record review of two residents Resident #45 and Resident #34 on 11/12/14 at 12:00 P.M. revealed that both residents were assessed to be at risk for falls and required soft waist restraints as a safety precaution. Observations of the residents revealed the interventions.

Based on observation, record review and interview, the facility failed to ensure six sampled residents received physician ordered nutritional supplements to prevent weight loss and promote weight gain. The facility failed to provide one (Resident #9) of three residents identified with significant weight loss the ordered nutritional supplements and diet of ordered consistency to prevent further avoidable weight loss and failed to provide the ordered nutritional supplements to promote weight gain for five (Residents #22, #59, #39, #40, and #16) residents identified at risk for weight loss. The sample was 16. Findings include: 1. Resident #9 was admitted to the facility in October 2010 with [DIAGNOSES REDACTED]. The most recent minimum data set assessment ((MDS) dated [DATE], identified the resident as having severe cognitive impairments, poor communication skills, unable to ambulate, and requiring the physical assistance of two staff persons for bed mobility and transferring from surface to surface, and the physical assistance of one staff person for locomotion, hygiene, and eating. The resident had a current physician's orders [REDACTED]. Resident #9 stood 5'2" tall and weighed 160.4 pounds on admission. The initial MDS assessment dated [DATE] identified the resident as being a risk for nutritional problems related to obesity, swallowing problems, reduced self-feeding abilities, depression, behavior problems, and dementia/[MEDICAL CONDITION]. A comprehensive plan of care related to nutrition was developed with goals which included that the resident would be free from significant weight gain or loss. Review of the Resident #9's weight history recorded by the facility revealed the following weight loss trend: January 2011, 157.2 pounds; February 2011, 152.6 pounds; March 2011, 151.6 pounds; April 2011, 146 pounds; May 2011, 144.8 pounds; June 2011, 141 pounds; July 2011, 137.4 pounds and August 2011, 131.2 pounds. This represents a significant unplanned weight loss of 14 percent over a six month period. Former Registered Dietitian (RD) #103 assessed the resident on 07/05/11 at which time the dietitian noted the resident's [DIAGNOSES REDACTED]. RD #103 noted the resident's meal intakes varied from refusals to consuming 100% of her meals. She noted the resident's July 2011 weight was 137.4 pounds, indicating a significant weight loss of 12.6% in a 6 month period. RD #103 ordered the house supplement with medication pass due to weight loss trends. No labs to review. Following with acceptance of supplement. The house supplement, 60 milliliters (ml) four times a day with medication pass, was ordered and started on 07/05/11. Review of the medical record revealed a physician's orders [REDACTED]. A second physician's orders [REDACTED]. Resident #9's August 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. There was a notation on the August 2011 MAR indicated [REDACTED]. An order to discontinue the supplement was not evident in the resident's medical record. An interview with Director of Nursing (DON) on 09/01/11 at 1:00 P.M. affirmed the resident was getting the house supplement throughout the month of July 2011 based on documentation however, an unknown nurse wrote to discontinue the house supplement at the end of July 2011. The correct order was transcribed onto the August 2011 MAR, and an unknown nurse wrote to discontinue the house supplement with medication administration. The DON verified there was no documentation to support the house supplement had been given to Resident #9 as ordered throughout the month of August 2011. review of the resident's medical record revealed [REDACTED]. Further review of the physician's orders [REDACTED]. On 08/11/11 the physician ordered the resident to receive six ounces of a fortified cereal, "super cereal", at breakfast each morning based on current RD #102's recommendations. The resident was observed during the evening meal on 08/30/11 at 5:14 P.M. eating supper in her room. Licensed Practical Nurse (LPN) #48 was spoon feeding the resident. The resident was served a pureed diet which included ham, potatoes, and vegetable. The pineapple had not been pureed. Resident #9 also received thickened liquids including milk, punch/juice, and water. There was no house supplement served to this resident with her meal, or offered during meal time. LPN #48 verified the menu items and consistency of the items served to the resident during the meal observation. Resident #9 was again observed during the morning meal on 08/31/11 at 9:07 A.M. eating breakfast in her unit dining room. Stated tested Nurse Aide (STNA) #18 was feeding the resident. The resident was served a divided dish which included pureed sausage, scrambled eggs (not pureed), and cream of wheat. Resident #9 also received thickened liquids including milk, orange juice, and water. There was no house supplement served on the tray or offered with the meal. The hot cereal served to the resident appeared no different than the hot cereal served to other residents in the same unit dining room. STNA #18 affirmed the contents of the resident's breakfast tray at the time of the observation. Resident #9's tray card was reviewed while the resident was eating breakfast. The tray card identified the resident was to receive six ounces of fortified cereal. The health shake was not listed on the tray card. On 08/31/11 Dietary Staff (DS) #68 who was preparing and serving the breakfast meal was interviewed at 9:20 A.M. regarding the fortified cereal. The DS #68 shared that she did not believe any resident was on the fortified cereal/super cereal at this time. This was corroborated by other dietary staff working in the kitchen at the same time. She stated all residents were offered a choice of hot or cold cereal this morning. No fortified cereal had been prepared. An interview was conducted with Dietary Director (DD) #82 and RD #102, on 08/31/11, at 11:02 P.M. DD #82 shared that the fortified cereal listed on the card is the "super cereal" and it should have been prepared and served. The DD #82 stated the cooks have the recipe in the kitchen to use for preparation of the fortified cereal/super cereal. The DD #82 reviewed Resident #9's tray card and affirmed the fortified cereal was listed on the card to be served at breakfast. The RD #102 reviewed the resident's tray card and the physician's orders [REDACTED]. The DD #82 provided a copy of the super cereal recipe. Review of the recipe for the super cereal revealed that a six ounce serving of the cereal would provide approximately 536 calories and 14 grams of protein. The DD #82 provided a copy of the health shake's calories and protein. The health shake provided 200 calories and six grams of protein. Review of Resident #9's August 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. There was no observations to support Resident #9 had been receiving the house supplement, health shake, or fortified cereal/super cereal as ordered by her physician in order to prevent further avoidable weight loss and promote weight gain. These supplements had the potential to add 1436 calories and 41 grams of protein to the resident's daily intake. 2. Resident #22 was admitted to the facility in August 2008 and had current [DIAGNOSES REDACTED]. The resident's Minimum Data Set assessment dated [DATE], identified the resident as having severe cognitive impairment, non-ambulatory, and dependent on staff for eating. Resident #22 was identified as having a significant weight loss at the time of the assessment. The resident had a current physician's orders [REDACTED]. Review of the August 2011 physician's orders [REDACTED]. The resident also had an order to receive a four ounce frozen nutritional supplement with each meal. On 08/15/11 the resident's physician wrote an order to discontinue the frozen supplement and start four ounces of health shake at each meal, due to refusals of the frozen supplement. Further review of the resident's medical record revealed [REDACTED]. The resident was observed being fed lunch in the main dining room on 08/31/11 at 1:17 P.M. The resident was served the magic cup which he did not consume. Resident #22 did not receive the four ounces of health shake as ordered by the physician on 08/15/11. Review of the resident's tray card revealed the card was not updated to include the health shake at each meal instead of the magic cup. On 08/31/11, at 01:23 P.M., Registered Dietitian (RD) #102 affirmed the presence of the magic cup, and affirmed that four ounces of health shake should have been provided to the resident after re-checking the physician's orders [REDACTED]. 3. Review of the September 2011 physician order [REDACTED]. The record also stated the resident began receiving hospice services on 06/14/11 due to the [DIAGNOSES REDACTED]. She had poor food intake. The quarterly Minimum Data Set (MDS) assessment dated [DATE], stated the resident had severe cognitive impairment and was dependent on staff to feed her. The nutritional care plan initiated on 04/28/11 stated the resident was at risk for alteration in nutrition related to a BMI less than 18.5, underweight status, [MEDICAL CONDITION], depression, failure to thrive, and chronic anxiety. Interventions included assistance with meals as needed, encourage family members to bring in favorite foods from home, encourage resident to dine in the dining room, honor the resident's food preferences as able, medications as ordered, monitor for signs/symptoms of dehydration, monitor labs as ordered, obtain food preferences, provide diet as ordered, dietician as ordered, weights as ordered, stress tab with zinc as ordered, and fortified food. Review of the resident's weight record located in the weight book revealed upon admission she had a height of 65 inches and a weight of 95 pounds. On 05/16/11 the physician gave orders to administer an appetite stimulant, [MEDICATION NAME] 400 milligrams, daily. A physician order [REDACTED]. When the resident was weighed on 06/22/11, she weighed 90 pounds, a five pound weight loss since her admission on 04/21/11. The dietician's notes stated she had lost 6.3 percent of her weight in one month. The dietician stated in her notes the resident was receiving hospice services and she had been placed on a pureed diet to aid in eating. On 06/22/11 the physician gave orders to increase her house supplement to 120 ml four times daily. Review of the dietary assessment dated [DATE] revealed the resident weighed 87 pounds on 07/06/11, which was an eight pound weight loss since admission. At that time her BMI was at 14.2. She documented the resident's ideal body weight was 125 pounds and her usual body weight was 112 pounds. The dietician made no recommendations to increase her caloric intake including fortified foods or nutritional supplements. On 08/06/11 the resident's weight was recorded in the weight book at 86 pounds which was a 9 pound weight loss, or 10%, in four months. The record contained no documentation for any recommendations made to increase the resident's caloric intake including fortified foods or nutritional supplements. On 08/17/11 Dietician #102 wrote out a telephone order recommending the resident be administered a multivitamin, stress tab with zinc, to be administered daily and fortified mashed potatoes to be served at lunch and dinner. According to the facility's recipe, the fortified potatoes would have added 310 calories of caloric intake, 14 grams of protein, 22 grams of fat, 14 grams of carbohydrates, 509 milligrams of sodium, and 219 milligrams of potassium at breakfast and lunch. During interview with the Dietician #102 on 08/31/11 at 10:00 A.M., she provided a copy of the resident's current tray cards which stated what she was to receive at each meal including supplements. The resident's tray card did not have the fortified potatoes listed for either the lunch or supper meal. The dietician verified at that time the fortified potatoes were not listed, therefore the resident had not received the potatoes since the order was written on 08/17/11. During observation of the resident on 08/31/11 at 12:30 P.M. she was served a pureed diet of pot roast, potatoes and carrots, fruit, and pudding. The resident was not served fortified potatoes which would have added 310 calories to her lunch meal. The resident's tray card listing the foods she was to receive did not have fortified potatoes listed. During interview with Dietary Manager #82 on 08/31/11 at 12:40 P.M., she stated the resident had not received the fortified potatoes and verified the potatoes were not listed on the resident's tray card. During interview with the resident's family member on 08/31/11 at 2:30 P.M., he stated he was unaware the resident was supposed to receive fortified potatoes. He stated the resident loved mashed potatoes and he would bring her in mashed potatoes from a fast food restaurant to eat. There was no observations or documentation to support Resident #59 had been receiving the fortified cereal/super cereal as ordered in order to promote weight gain and prevent further loss. The fortified potatoes had the potential to add 610 calories and 14 grams of protein to the resident's daily intake. 4. Review of Resident #39's accumulative [DIAGNOSES REDACTED]. Review of the 08/18/11 quarterly Minimum Data Set (MDS) assessment revealed the cognitively impaired resident required limited assistance of one staff with eating. Review of the nutritional care plan initiated on 05/04/11 revealed interventions including the provision of adaptive equipment as ordered, the provision of assistance with meals as needed, administer medications as ordered, monitor the consistency of diet served, monitor for signs and symptoms of dehydration, monitor labs as ordered, obtain food preferences, provide the diet as ordered, registered dietician referral as needed, obtain weights as ordered, and provide the supplement health shake as ordered. The resident was on a regular mechanical soft diet with thin liquids. Review of the resident's monthly weights revealed the resident was 62 inches tall and her weights for the past six months were March 2011, 178 pounds; April 2011, 168 pounds; May 2011, 177 pounds; June 2011, 166 pounds; July 2011, 162 pounds; and August 2011, 162 pounds. The resident had a 16 pound, or 9 percent, unplanned weight loss since March 2011. On 08/09/11 the dietary assessment, written by Dietician #102, stated the resident had a gradual loss of weight in the past six months. The dietary assessment also stated the resident's [MEDICATION NAME] level was slightly low representing low visceral protein stores. The dietician documented she spoke with the resident and the resident agreed to drink a health shake at lunch, which would provide 200 calories and 6 grams of protein. On 08/09/11 the physician order [REDACTED]. During observation of the lunch meal on 08/30/11 at 1:00 P.M., the resident was observed feeding herself lunch in the activity lounge. The resident had adaptive cups with tea, water, and punch on her tray, which she was drinking independently. There was no health shake observed. Dietary Manager #82 also observed the tray and the tray card on 08/30/11 at 1:10 P.M. The Dietary Manager verified the tray card stated the resident was to receive a four ounce health shake. The Dietary Manager verified no health shake supplement was served to the resident in accordance with physician orders. During interview with the resident on 08/30/11 at 1:05 P.M., she stated "yes" when asked if she would drink a shake. 5. Review of Resident #40's accumulative [DIAGNOSES REDACTED]. The medical record stated the resident started receiving hospice services on 06/03/11 due to failure to thrive. The quarterly MDS dated [DATE] stated the cognitively impaired resident required supervision of one staff when eating. The residents nutritional care plan dated 01/06/11 had interventions including administer medications as ordered, assist with feeding as needed, avoid foods that cause distress, monitor and record food consumption, monitor for chewing or swallowing problems, monitor for signs of dehydration, monitor labs, provide the diet as ordered, and offer substitutes for poor meal consumption. The resident was on a regular diet with thin liquids. The weight record stated the resident was 65 inches tall and weighed 105 pounds in January 2011; in February 2011, 102 pounds; April 2011, 98 pounds; June 2011, 105 pounds July 2011, 102 pounds; and August 2011, 81 pounds. The resident had a 21 pound, or 7.9 percent weight loss in one month. On 08/11/11 the physician gave telephone orders to serve the resident a frozen nutritional supplement at lunch and dinner. According to the supplement list provided by the dietician, a four ounce frozen supplement would provide 290 calories and 9 grams of protein to the resident. On 08/30/11 at 12:45 P.M., the resident was observed eating lunch in the dining room. The resident was nibbling at her food independently. The resident's tray card was reviewed and stated the resident was to receive a frozen nutritional supplement. There was no frozen supplement on the resident's tray. During interview with Dietary Manager #82 on 08/30/11 at 12:50 P.M., she verified there was no frozen supplement on the resident's tray in accordance with the physician orders. The Dietary Manager entered the doorway of the kitchen and asked Dietary Aide #6 why the frozen supplement was not on the tray. The Dietary Aide stated no resident received a frozen supplement that day because the kitchen had run out of frozen supplements. The Dietary Manager stated she was unaware there were no frozen supplements for the residents. 6. Record review of accumulative [DIAGNOSES REDACTED]. The Minimum Data Set (MDS)assessment dated [DATE] indicated the resident had information recall difficulty and at time rejects care. The assessment indicated the resident required limited assistance with eating. Review of the dietary progress notes dated 05/03/11 revealed the residents weight was 95 pounds and had been stable for two months and overall had a seven percent weight loss in three months. The dietary progress notes dated 08/11/11 documented the resident's weight was 89.6 pounds, a loss of five pounds, or 5.3 percent, in one month. The meal intake was variable from 25 to 50 percent. The resident was focused on drinking and smoking cigarettes. The resident was receiving a house supplement 60 milliliters four times a day with medication administration. The dietician's recommendation and physician orders [REDACTED]. Review of the plan of care for alteration in nutrition and hydration dated on 08/11/11 to start super cereal. Review of the dietary menu card provided by the kitchen staff stated to give six ounces of fortified cereal. During observation of the breakfast meal on 08/31/11 at 9:00 A.M., the resident did not receive fortified cereal. On 08/31/11 Dietary Staff (DS) #68 who was preparing and serving the breakfast meal was interviewed at 9:20 A.M. regarding the "super cereal". DS #68 shared that she did not believe any resident was on the fortified cereal/super cereal at this time. This was corroborated by other dietary staff working in the kitchen at the same time. She stated all residents were offered a choice of hot or cold cereal this morning. No fortified/super cereal had been prepared. An interview was conducted with Dietary Director (DD) #82 and Registered Dietitian (RD) #102, on 08/31/11, at 11:02 P.M. and DD #82 shared that the fortified cereal listed on the card is the "super cereal" and it should have been prepared and served. DD #82 stated the cooks have the recipe in the kitchen to use for preparation of the fortified cereal/super cereal. DD #82 provided a copy of the super cereal recipe. Review of the recipe for the super cereal revealed that a six ounce serving of the cereal would provide approximately 536 calories and 14 grams of protein.