Every finding on record at The Laurels of Milford

Based on observation, interview, and record review, the facility failed to provide catheter care as prescribed by the provider. This affected one resident, Resident #11, of four residents reviewed for catheter care. The facility census was 109.Findings include:Review of the medical record revealed Resident #11, was admitted to the facility on [DATE]. Diagnoses include malignant neoplasm of rectosigmoid junction, cellulitis of right lower limb, active primary progressive multiple sclerosis, and type II diabetes mellitus.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact with a Brief Interview of Mental Status (BIMS) score of 15. The resident had no behaviors, did not reject care, and did not wander. Resident #11 was coded to have an indwelling catheter and was frequently incontinent of bowel.Review of physician orders for Resident #11 revealed the following order for catheter care:Catheter Care: Change Foley catheter as needed 16 french (fr), Diagnosis (Dx) neuromuscular dysfunction of bladder.Special Instructions: Document catheter (16) and balloon (ml) size insertedOnce A Day - PRNReview of Nurse Practitioner (NP) notes dated 03/03/2026, 04/04/2026, 04/09/2026, 06/23/2026, and 07/24/2026 revealed that catheter care should be completed as follows foley exchange q 30 days.Interview with Director of Nursing (DON) on 08/05/2026 at 7:51 A.M. revealed We do (Resident #11's) catheter changes as needed. We should be following the NP's orders regarding catheter care. I did not realize it said every 30 days.Interview with Assistant Director of Nursing (ADON) on 08/05/2026 confirmed that catheter care was not performed every 30 days as order by facility NP.This deficiency represents non-compliance investigated under Complaint Number 3075605.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure residents were free from significant medication errors. This affected one resident, Resident #16, of two residents observed for medication administration. The facility census was 109. Findings include:Review of the medical record revealed Resident #16 was admitted to the facility on [DATE]. Diagnoses include chronic kidney disease, hepatorenal syndrome, cirrhosis of liver, and chronic viral hepatitis.Review of medication orders for Resident #16 revealed an insulin order as follows:insulin lispro; insulin pen; 100 unit/mL; amt: 4 units; SubcutaneousSpecial Instructions: INJECT 4 UNITS SUBCUTANEOUSLY BEFORE MEALS AND AT BEDTIME FOR Diabetes Mellitus (DM)Before Meals and At Bedtime7:00 A.M., 11:30 A.M., 4:30 P.M., 9:00 P.M.Observation of medication administration with Medication (Med) Tech #222 on 08/08/2026 at 8:38 A.M. for Resident #16 revealed that insulin scheduled to be administered at 7:00 A.M. prior to breakfast was not administered until 9:15 A.M.Interview with Med Tech #222 on 08/04/2026 confirmed the insulin was scheduled to be administered at 7:00 A.M. before meals. Med Tech #222 further confirmed the facility policy is that medications can be administered as much as one hour before to one hour after scheduled administration times and Resident #16's insulin was late.Interview with Director of Nursing (DON) on 08/04/2026 at 11:30 A.M. confirmed the administration of Resident #16's insulin was late and should have been administered between the allotted hours of 6:00 A.M. and 8:00 A.M. per facility policy.Facility policy titled Medication Administration Times revised 11/15/24, states Facility should administer medication administration within sixty (60) minutes before the designated times of administration and should be completed no later than sixty (60) minutes after the designated times of administration.This deficiency represents non-compliance investigated under Complaint Number 3036244.

Based on medical record review, observation, staff interview, and resident interview, the facility failed to provide resident care in a dignified manner. This affected two (Residents #3 and #41) of three residents reviewed for dignity. The facility census was 132 residents.Findings include:1.Review of the medical record for Resident #41 revealed an admission date of 01/13/26 with diagnoses included anxiety, epilepsy, and anxiety. Review of the Minimum Data Set (MDS) assessment for Resident #41 dated 01/18/26 revealed the resident was cognitively intact and was frequently incontinent of urine. Observation on 01/27/26 at 9:45 A.M. revealed Resident #41 had her call light on. Social Services (SS) #243 answered the call light and came to the edge of the doorway and yelled down the hall using the resident's name telling the nurse at the other end of the hallway that the resident had to go to the bathroom. Interview on 01/27/26 at 9:48 A.M with SS #243 confirmed she had called out in the hallway to the nurse that Resident #41 needed to go to the restroom. Interview on 01/27/26 at 9:50 A.M. with Resident #41 confirmed she hoped no residents or visitors heard SS #243 yell down the hall regarding her toileting needs. Interview on 01/27/26 at 10:00 A.M. with the Director of Nursing (DON) confirmed SS #243 should not have yelled Resident #41's name down the hall. Review of the facility policy titled Privacy/Dignity dated 03/12/25 revealed residents should be treated with dignity. 2. Review of the MDS assessment for Resident #3 dated 10/31/25 revealed the resident was cognitively intact. Observation on 01/28/26 at 11:45 A.M. revealed the Surveyor was interviewing Resident #3 with the door closed when Certified Nursing Assistant (CNA) #336 entered the resident's room without permission, left a meal tray, and exited the room. Interview 01/28/26 at 12:00 P.M. with Resident #3 confirmed staff frequently entered the room without permission and she felt she had no privacy. Interview on 01/28/26 at 12:17 P.M. with CNA #336 confirmed staff should knock on residents' doors and wait to be invited in before entering the room. Review of the facility policy titled Privacy/Dignity dated 03/12/25 revealed staff should knock on residents' doors before entering. Residents should be treated with dignity Review of the facility policy dated 03/12/25 revealed staff should knock on resident's doors before entering. Residents should be treated with dignity for all care needs. This deficiency represents noncompliance investigated under Complaint Number 2728079 and Complaint Number 2700797 and Complaint Number 2664306 and Complaint Number 1287403 and Complaint Number 1287402.

Based on observation, resident interview, and staff interview, the facility failed to maintain a homelike, safe environment. This affected three (Residents #3,# 4, #80) reviewed for safe homelike environment. The facility census was 132 residents.Findings include:Based on observation, resident interview, and staff interview, the facility failed to maintain a homelike, safe environment. This affected three (Residents #3,# 4, #80) reviewed for safe homelike environment. The facility census was 132 residents. Findings include: Random observations throughout the day on 01/27/26 and 01/28/26 revealed there were cable boxes hanging over residents' beds and/or resting on the heating unit in the room. The boxes were hanging from the televisions (tvs) by a cord. Interview on 01/27/26 at 10:30 A.M with Resident #80 confirmed he had asked the facility staff on multiple occasions to place the cable box in a safe area and not to place it on his heater. Resident #80 stated the cable box was frequently hot to the touch and the resident further confirmed he thought the cable box looked bad. Interview on 01/28/26 at 9:00 A.M with Resident # 3 confirmed the tv and cable box were located on the wall beside the resident's bed which was against the wall. Resident #3 confirmed the box hung down from the tv over the resident's bed, and the resident was afraid it might hit him in the head. Resident #3 noted he had asked the facility many times to secure it. Interview on 01/29/26 at 11:30 A.M. with Resident #4 confirmed she worried the cable box might get too hot because it was sitting on the heater. Resident #3 noted she had asked the facility to fix it. Interview 02/11/26 at 10:00 A.M with Maintenance Director (MD) #245 confirmed the cable company left the boxes hanging over resident beds or stored on top of heaters. MD#245 further confirmed the boxes were not hung properly and should be fixed. This deficiency represents noncompliance investigated under Complaint Number 2715071 and Complaint Number 2690717 and Complaint Number 2694603 and Complaint Number 2689028 and 2620519 and Complaint Number 2591315 and Complaint Number 1287417 and Complaint Number 1284703 and Complaint Number 1287402.

Based on medical record review, resident interview, staff interview, and review of the facility policy, the facility failed to ensure resident care conferences were held quarterly. This affected two (Residents #13 and #14) and had the potential to affect all of the residents residing in the facility. The facility census was 132 residents.Findings include:1. Review of the medical record for Resident #13 revealed an admission date of 01/30/25 with diagnoses including chronic obstructive pulmonary disease, acute and chronic respiratory failure, diabetes mellitus type two, and morbid obesity. Review of the Minimum Data Set (MDS) assessment for Resident #13 dated 10/22/25 revealed the resident had intact cognition and required staff assistance with activities of daily living (ADLs.) Review of care conference documentation for Resident #13 revealed the facility did not offer or conduct care conferences for the first quarter of 2025 (January, February and March) and third quarter of 2025 (July, August and September) of 2025. Interview on 01/28/26 at 3:00 P.M. with Resident #13 confirmed the facility had not offered or provided care conferences on a quarterly basis. 2. Review of the medical record for Resident #14 revealed an admission [DATE] with diagnoses of malignant neoplasm of rectosigmoid junction, progressive multiple sclerosis, chronic kidney disease stage III, diabetes mellitus type II, and morbid obesity. Review of care conference documentation for Resident #14 revealed the facility did not offer or conduct care conferences for the first quarter of 2025 (January, February and March) and third quarter of 2025 (July, August and September) of 2025. Review of the MDS assessment for Resident #14 dated 01/08/26 revealed the resident had intact cognition and required staff assistance with ADLs. Interview on 01/28/26 at 3:21 P.M. with Resident #14 confirmed the facility had not offered or provided care conferences on a quarterly basis. Interview on 01/29/26 at 3:11 P.M. with the Administrator verified Residents #13 and #14 were not offered or provided care conferences for the first and third quarters of 2025. Review of policy titled Care Planning Conference revised 03/03/25 revealed the interdisciplinary team would hold a care planning conference with the resident and/or their representative upon admission, quarterly, annually, with a significant change, and as needed. The care conference would be used to identify the resident's potential or actual problems, needs, goals, and discharge plans. This deficiency represents noncompliance investigated under Complaint Number 2700797.

Based on medical record review, observation, staff interview and review of the facility policy, the facility failed to ensure proper medication storage of an inhaler. This affected one (Resident #86) of one residents with medications stored on the J2 medication cart with orders for Spiriva inhaler. The facility also failed to label and date an insulin pen upon opening. This affected one unknown resident and had the potential to affect seven residents with medications stored on the J1 cart with orders for insulin. The facility census was 132 residents. Findings include: Review of the medical record for Resident #86 revealed an admission date of 04/06/10 with diagnoses including chronic obstructive pulmonary disease (COPD), emphysema, diabetes mellitus type two, and dementia. Review of the physician's orders for Resident #86 revealed an order dated 10/01/22 for Spiriva inhale once daily related to COPD.Review of the Minimum Data Set (MDS) for Resident #86 dated 01/26/26 revealed the resident was cognitively intact. Observation on 01/29/26 from 2:00 P.M. of medication cart J1 with Licensed Practical Nurse (LPN) #371 revealed the cart contained an open Lantus insulin pen with no resident name or open date. Observation of medication cart J2 with LPN #371 revealed the cart contained a Spiriva inhaler with for Resident #86 with an 18mcg capsule being stored in the chamber.Interview on 01/29/26 at 2:01 P.M. with LPN #371 confirmed the Lantus insulin had no resident name or date. LPN #371 confirmed Resident #86's Spiriva inhaler should not be stored with the capsule in the chamber. The capsule should be placed just prior to administration. Interview on 01/29/26 with Unit Manager (UM) #208 confirmed the insulin pen was not properly labeled and should be discarded. UM #208 confirmed the chamber of a Spiriva inhaler should be empty following a medication administration, and the capsules should be placed in the chamber just prior to administration.Review of facility policy titled Medication Administration dated 10/17/23 revealed staff should never administer medications from an unmarked container and should prepare medications immediately prior to administration.

Based on medical record reviews, review of the facility census, review of the facility bed-board, staff and resident interviews, review of the facility policy, and review of Center for Disease Control and Prevention (CDC) guidance, the facility failed to implement their infection control policy to separate a positive Coronavirus Disease 2019 (COVID-19) resident from a negative COVID-19 resident to potentially prevent the spread of COVID-19. This affected two (Residents #110 and #111) of three residents reviewed for COVID-19 precautions. The facility census was 123. Findings include: 1. Record review for Resident #111 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included atrial fibrillation, depression, and dementia. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed to have intact cognition. 2. Record review for Resident #110 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included diabetes mellitus, need for assistance with personal care, and chronic kidney disease. Review of the quarterly MDS assessment dated [DATE] revealed the resident was assessed to have intact cognition. Review of the physicians order dated 01/08/25 revealed Resident #110 was placed in isolation precautions due to testing positive for COVID-19. Review of the facility census for Resident #110 and Resident #111 revealed the residents remained together in the same room from 01/08/25 through 01/21/25, despite Resident #110 having an active COVID-19 infection. Resident #111 remained free from an active infection or symptoms of COVID-19 through the survey date of 01/24/25. Review of the facility bed-board from 01/08/25 revealed there were seven private rooms were available. Interview with Resident #111 on 01/24/25 at 12:10 P.M. confirmed the resident had remained in the same room with Resident #110 while the resident had an active COVID-19 infection. Resident #111 confirmed he remained free from symptoms of COVID-19 and never tested positive. Interview with the Administrator on 01/24/25 at 1:45 P.M. confirmed Resident #111 tested negative for COVID-19 but had remained in the same room as Resident #111 while the resident had an active COVID-19 infection. The Administrator stated Resident #111 had been exposed to COVID-19 and was not moved to a different room due to concerns additional residents would be exposed. Telephone interview with the Administrator on 02/03/25 at 10:11 A.M. confirmed the facility did not contact the Local Health Department (LHD) to discuss the placement of Resident #111 after the resident's roommate tested positive for infection with COVID-19. Review of the facility policy titled, Coronavirus (COVID-19), last revised 02/15/24, revealed the facility should place a resident with suspected or confirmed SARS-CoV-2 infection in a single person room. The door should be kept closed (if safe to do so). Ideally, the resident should have a dedicated bathroom. When a private room is not available, cohort with a similar resident. Review of CDC guidance titled, Infection Control Guidance: SARS-CoV-2, revealed this guidance applies to all healthcare settings including nursing homes. If a patient tests positive for COVID-19, place the patient in a private room. If cohorting, only patients with the same respiratory pathogen should be housed in the same room. Facilities should consider designating entire units within the facility with dedicated health care professionals to care for COVID-19 patients. This deficiency represents non-compliance investigated under Complaint Number OH00161474.

Based on observation, record review, staff interview, and review of facility policy, the facility failed to report an allegation of resident-to-resident abuse to the state agency. This affected one (Resident #26) of three residents reviewed for abuse. The facility census was 118. Findings include: Record review of Resident #26 revealed an admitted [DATE] with diagnoses of cerebral infarction, type two diabetes mellitus, dementia without behaviors, hyperlipidemia, and anxiety disorder. Review of the 08/05/24 admission Minimum Data Set (MDS) assessment revealed Resident #26 utilized a wheelchair to aid in mobility and required partial/moderate assistance with Activities of Daily Living (ADLs). Review of the progress note dated 09/17/24 at 11:50 A.M. revealed the nurse was informed by a State tested Nurse Aide (STNA) Resident #26 received four scratches to her face and a small bruise to her right cheek from another resident. Residents were separated and first aid was provided. The Administrator, physician, and resident's son were notified. Record review of the progress note dated 09/17/24 at 6:46 P.M. revealed Resident #26 continued to roam in her wheelchair bumping into others. Resident #26 bumped into another resident causing an argument where Resident #26 was scratched in the face. Both residents were separated. Observation of Resident #26 on 09/25/24 at 9:34 A.M. revealed she had an approximately five centimeter (cm) scratch on the left side of her face from above her eye down to her cheek. The resident also had a scratch on the right side of her face that was barely visible and a small bruise. The resident was unable to voice what happened and was unable to be interviewed. Interview with the Director of Nursing (DON) on 09/25/24 at 12:34 P.M. revealed Resident #26 had a scratch and a bruise on her face from Resident #27, and the family didn't think it was intentional so the facility did not file a Self- Reported Incident (SRI). The DON revealed State tested Nurse Aide (STNA) #10 witnessed the incident. Interview with the DON on 09/25/24 at 1:34 P.M. verified Resident #26 still had two visible scratches and a bruise to her face. Interview with STNA #10 on 09/25/24 at 1:50 P.M. revealed she witnessed Resident #27 scratch Resident #26 on 09/17/24. STNA #10 revealed around lunch time, Resident #27 was sitting in the hallway in her wheelchair. Resident #26 attempted to roll by Resident #27 and ran into her wheelchair. Resident #27 talked to Resident #26 for about five seconds and said you are bumping into my wheelchair then swatted at Residents #26's face. STNA #10 said she was was probably 50 feet away when the incident occurred and she was the only staff witness. STNA #10 revealed Resident #26 had four scratches on her face and a bruise after the incident and she did not have any of those marks prior to the altercation. Review of SRIs on 09/25/24 revealed no SRI completed regarding the incident between Resident #26 and Resident #27. Review of the 09/09/22 abuse prohibition policy revealed the facility will notify any state of federal agencies of allegations per state guidelines. This deficiency represents non-compliance investigated under Complaint Number OH00158040.

Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure a resident's pressure ulcer received the necessary treatment, consistent with professional standards of practice, to prevent infection. This affected one (#88) of three residents reviewed for pressure ulcers. The facility identified there were four residents with pressure ulcers. The facility census was 113. Findings include: Medical record review for Resident #88 revealed an admitted [DATE]. Diagnoses included coronary artery disease, cardiovascular attack (CVA) with hemiplegia and hemiparesis, and diabetes mellitus. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #88 was severely cognitively impaired. Her functional status was dependent on staff for eating, toileting, bed mobility. and transfers. Review of the care plan dated 04/03/24 revealed Resident #88 has an actual impairment related to stage three pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed.) to her right gluteus. Observation of a dressing change for Resident #88 on 04/25/24 at 9:00 A.M. revealed Licensed Practical Nurse (LPN) #143 washed her hands and applied gloves and removed the bandage from the resident's bottom. LPN #143 washed her hands and placed on a new pair of gloves. She proceeded to clean the wound with wound cleanser and with the same gloves she took the package of the calcium alginate and opened it and tore off a piece of the calcium alginate and placed it on the wound and then placed a foam dressing over the alginate. She went to the bathroom and removed her gloves and washed her hands. Interview with the LPN #143 on 04/25/24 at 9:20 A.M. confirmed she didn't remove her gloves after cleaning the wound for Resident #88 and verified she should have changed her gloves after cleaning the wound. Review of the facility policy titled Clean Dressing Change dated 09/18/23 revealed the nurse should remove old dressing and discard in the appropriate disposal bag. Remove gloves. Perform hand hygiene. Apply clean gloves. Cleanse the wound/site gently with solution ordered. Wash from the center of the wound/site to the periphery. Observe the wound/site for size, color, appearance, and amount of drainage. Remove gloves, perform hand hygiene (alcohol based hand rub may be used at this point). Apply clean gloves. This deficiency represents non-compliance investigated under Complaint Number OH00153094.

Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure the residents received proper and thorough incontinence care. The affected two (#54 and #88) of three residents reviewed for incontinence care. The facility census was 113. Findings include: 1. Medical record review for Resident #88 revealed an admitted [DATE]. Diagnoses included coronary artery disease, cardiovascular attack (CVA) with hemiplegia and hemiparesis, and diabetes mellitus. Review of the care plan dated 03/01/24 revealed Resident #88 was incontinent for bowel and bladder. Interventions included she used disposable briefs and change with each incontinence episode. Change every two hours and as needed. Wash, rinse and dry after each incontinence episode. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #88 was severely cognitively impaired. Resident #88 was dependent on staff for toileting and was incontinent for bladder and bowel. Observation of incontinence care on 04/25/24 at 9:25 A.M. with Licence Practical Nurse (LPN) #143 and Registered Nurse (RN) #231 revealed Resident #88 was on her back and the brief was taken down in the front of the resident and it was saturated with urine up to the bottom of the resident's stomach. The back of the brief was saturated with urine soaked all the way up the buttocks to the lower back. LPN #143 took a soapy cloth and wiped in a downward motion the right and left side of the leg and proceeded to fold the washcloth and wipe down the middle of the labia. She didn't clean the mons pubis and turned the resident over towards RN #231 and used a soapy washcloth and cleaned the anus, put the brief on the resident, and rolled the resident to herself and RN #231 pulled the brief up and fastened it and there wasn't any cleaning of the buttocks. Interview with RN #231 on 04/25/24 at 9:30 A.M. revealed she thought the incontinence care went alright and confirmed she didn't cleanse the buttocks of the resident on the left side when the resident was rolled for her to place the brief on the resident. Interview with the LPN #143 on 04/25/24 at 9:35 A.M. revealed she had been a LPN for many years and hasn't performed incontinence care for many years. She confirmed she didn't wash down each side of the labia and didn't cleanse the mons pubis or the buttocks. She said this wasn't her practice. 2. Medical record review for Resident #54 revealed an admitted [DATE]. Diagnoses included schizophrenia, dementia, and non-traumatic brain injury. Review of the care plan dated 02/24/24 revealed Resident #54 was incontinent for bowel and bladder. Interventions included she used disposable briefs and change with each incontinence episode. Change every two hours and as needed. Wash, rinse and dry after each incontinence episode. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #54 was moderately cognitively impaired. Resident #54 was dependent on staff for toileting and was incontinent for bowel and bladder. Observation of incontinence care for Resident #54 with State tested Nursing Aide (STNA) #133 and STNA #234 on 04/24/24 at 1:11 P.M. revealed the resident had a bowel movement, so the STNAs rolled her to STNA #234. STNA #133 used a wet soapy washcloth and wiped in an upward motion to remove the stool and one could see visible stool on the washcloth. The STNA took the soapy washcloth and folded it over and over and wiped the labia from the back of the resident. The resident was turned over on her back and STNA #234 started wiping the stool in an upward motion towards the labia. The resident was turned on her side again and STNA #133 used dry washcloths removing stool from the anus until they came out clean. Interview with the STNAs #133 and #234 on 04/24/24 at 1:30 P.M. revealed it wasn't there normal practice to clean a resident starting with the back of her but since she had a bowel movement they decided to start that way. STNA #133 confirmed she used a dry cloth to remove stool instead of a soapy cloth to remove it and confirmed she wiped the labia when the resident was on her side. STNA #234 confirmed she wiped the stool in the wrong motion and this could potentially infect the resident. Review of the policy titled Perineal Care of a Patient Assigned as a Female at Birth dated 06/01/23 revealed perineal care, which includes care of the external genitalia and the anal area, should occur during the daily bath and if the patient is incontinent of urine or stool. The procedure promotes cleanliness and prevents infection. It also removes irritating and odorous secretions, such as smegma, a cheeselike substance that collects on the inner surface of the labia. Wet a washcloth with warm water from a running spigot (or from a bath basin) and apply mild soap. Separate the patient's labia with one hand. Using gentle downward strokes, clean the perineal area from the front to the back of the perineum to prevent intestinal organisms from contaminating the urethra or vagina. Avoid the area around the anus, and use a clean section of the washcloth for each stroke by folding each used section inward to prevent contamination with secretions or discharge. Wet a clean washcloth and rinse thoroughly from front to back because soap residue can cause skin irritation. Pat the area dry with a bath towel because moisture can also cause skin irritation and discomfort. Turn the patient onto the side to the Sims position, if possible, to expose the anal area. Clean, rinse, and dry the anal area, starting at the posterior vaginal opening and wiping from front to back. This deficiency represents non-compliance investigated under Complaint Number OH00153094.

Based on observations, review of staff schedules, review of facility resident census, review of activity calendars, review of activity attendance sheets, policy review, resident and staff interviews, the facility failed to ensure staff was providing scheduled activities during the months of July and August 2023. This affected 81 (Resident #26-#92) of 81 residents residing on the A, B, F G, H and J Units of the facility. The total facility census was 106. Findings include: Review of the activity staff schedule for July 2023 revealed one to three staff were scheduled per day and no staff were scheduled after 4:00 P.M. on Mondays through Fridays. On the weekends staff was limited hours or not at all. On 07/01/23 (Saturday), one staff member was scheduled from 9 A.M. to 2 P.M. On 07/02/23 (Sunday), one staff member was scheduled 9 A.M. to 3 P.M. On 07/08/23 (Saturday), one staff member was scheduled from 10 A.M. to 3 P.M. On 07/09/23 (Sunday), on 07/15/16 (Saturday), on 07/16/23 (Sunday), on 07/29/23 (Saturday), and on 07/30/23 (Sunday), no activity staff was scheduled to work. On 07/22/23 (Saturday) and 07/23/23 (Sunday), a staff member was scheduled as MC (might come). Review of the activity staff schedule for August 2023 revealed one to three staff were scheduled per day and no staff were scheduled after 4:00 P.M. on Mondays through Fridays. On the weekends staff was limited hours or not at all. On 008/05/23 (Saturday), one staff member was scheduled from 9 A.M. to 2 P.M. On 08/06/23 (Sunday), one staff member was scheduled 9 A.M. to 3 P.M. On 08/19/20 (Saturday), on 08/20/23 (Sunday), and on 08/26/23 (Saturday), no activity staff was scheduled to work. On 08/27/23 (Sunday), a staff member was scheduled as MC (might come). On 08/12/23 (Saturday) and on 08/13/23 (Sunday), a staff member was scheduled MOD and one additional staff member was scheduled on 08/13/23, from 10 A.M. to 3 P.M. Review of scheduled activity calendar of July and August 2023 for the A, B, F G, H and J Units, revealed there were 15 days (07/01/23, 07/02/23, 07/09/23, 07/15/23, 07/16/23, 07/22/23, 07/23/23, 07/26/23, 07/27/23, 07/28/23, 07/29/23, 07/30/23, 08/12/23, 08/16/23 and 08/17/23) of non-provided and undocumented resident attended scheduled activities. Review of the August 2023 activity calander for the A, B, F G, H and J Units revealed on 08/16/23 and 08/17/23 at 3:00 P.M. was 15-minute stretch; 4:00 P.M. was scheduled Table Talk; and at 7:00 P.M. was scheduled Shoot the Breeze. Review of the resident census sheet revealed 81 (Resident #26-#92) residents residing on the A, B, F G, H and J Units of the facility. Observation on 08/16/23 at 3:00 P.M. and 4:00 P.M., revealed the scheduled activities on did not occur. Observations on 08/17/23, at 3:00 P.M. and 4:00 P.M., revealed the scheduled activities did not occur. Interview on 08/16/23 at 3:50 P.M., Activity Aide, (AA) # 73 verified the weekend activities were offered only three weekends a month, as there were only three staff to rotate the weekends. AA #73 verified schedule activities after 3:00P.M., were not offered as organized activities and had no staff to lead. No residents were documented as attending activities. AA #73 stated activities listed on the activity calendar after 3:00 P.M. were resident self-directed. Interview on 08/17/23 at 10:15 A.M., the Activity Director, (AD) #150 verified the 15 days of scheduled activities were not documented and could not verify activities were offered on those days. AD #150 verified the activity department had been short of staff and the planned activities on the third weekend could not be an offered, as posted on the activity calendar, as well as planned activities after 3:00 P.M. AD #150 verified not all activities are offered due to activity staff are off on vacation, as was during the week of 07/26/23, 07/27/23, 07/28/23, 07/29/23, and 07/30/23. Interviews of on 08/17/23 from 9:50 A.M through 1:00 P.M., of Residents #95, #97 ad #104 stated activities were not provided as listed on the calendar. The residents stated activities were changed due to staffing and not resident requested. Interviews on 08/17/23 at 4:00 P.M., with Residents #41, #61 and #102 stated after 3:00 P.M., there were no staff to lead the scheduled activities. All three residents stated only one weekend of the month were activities provided. The residents stated they wanted group activities on the weekend and denied scheduled weekend activities had been refused. Review of the facility policy titled, Activities Scheduling dated 08/16/21, revealed Monday through Sunday, four to seven activity programs were offered daily. This deficiency represents non-compliance investigated under Complaint Number OH00145063.

Based on record review, observations, staff interviews, and review of facility policies, the facility failed to ensure tube feedings were administered as ordered. This affected two (#49 and #81) out of the three residents reviewed for tube feedings during the annual survey. The facility census was 110. Findings include: 1. Record review for Resident #49 revealed this resident was admitted to the facility on [DATE] and had diagnoses including neuronal ceroid lipofuscinosis, dysphagia, generalized idiopathic epilepsy, constipation, dyspnea, increased secretion of gastrin, dementia, acute respiratory failure with hypoxia, and gastrostomy status. Review of the annual Minimum Data Set (MDS) assessment, dated 12/06/22, revealed this resident was rarely/never understood. This resident was assessed to be dependent upon two staff members for bed mobility and transfers, to be dependent upon one staff member for eating, and to require extensive assistance from two staff members for toileting. This resident was assessed to have a feeding tube and to have not had significant weight loss. Review of the care plan, most recently revised on 04/14/22, revealed Resident #49 was unable to tolerate nutritionally adequate food and/or fluids by mouth and required use of a feeding tube. Interventions included administer tube feeding as ordered, notify physician if tube becomes dislodged, and provide care to tube site as ordered. Review of the care plan, most recently revised on 01/12/23, revealed Resident #49 had a nutritional risk. Interventions included tube feeding regimen as ordered. Review of the physicians order, dated 11/30/22 and discontinued on 02/12/23, revealed an order to administer Osmolite 1.2 Cal at 60 milliliters (ml) per hour. Review of the active physicians order, dated 02/13/23, revealed an order to administer Isosource 1.5 Cal at 50 ml per hour. Review of the Medication Administration Record (MAR) for 02/2023 revealed on 02/12/23 Osmolite 1.2 Cal had been documented as being administered at 60 ml per hour on night and day shift. On day shift on 2/14/23 Isosource 1.5 was documented as being administered at 50 ml per hour as ordered. Review of the nurses progress note, dated 02/12/23 and timed 9:10 P.M. revealed Osmolite unavailable. Nurse practitioner contacted with new order for Isosource 1.5. Family aware. Observation on 02/12/23 at 7:10 P.M. revealed Resident #49 was receiving the tube feeding solution Osmolite 1.2 Cal at a rate of 38 ml per hour. Interview with Licensed Practical Nurse (LPN) #33 at the time of the observation verified the tube feeding solution was infusing at a rate of 38 ml per hour despite being ordered to be infused at 60 ml per hour. Observation on 02/14/23 at 12:41 P.M. revealed Resident #49 was receiving the tube feeding solution Isosource 1.5 Cal at a rate of 60 ml per hour. Interview with Registered Nurse (RN) #7 at the time of the observation verified the tube feeding solution was infusing at a rate of 60 ml per hour despite being ordered to be infused at 50 ml per hour. 42492 2. Review of the medial record revealed Resident #81 was admitted to the facility on [DATE] with diagnoses that included surgical aftercare following surgery on genitourinary system, conversion disorder, hemiplegia and hemiparesis following cerebral infarction, type II diabetes, unspecified anxiety disorder, and other disorders affecting eyelid function. Review of the most recent MDS assessment dated [DATE] revealed Resident #81 had moderately impaired cognition, had self-directed behaviors, did not wander, and did not reject care. Resident #81 was a two-person assist, required total assistance with transfers, dressing, and locomotion, and required extensive assistance with bed mobility, toileting, and eating. Review of the care plan dated 01/02/23 revealed Resident #81 was at risk for alteration in nutrition/hydration related to multiple diagnoses, chronic disease, need for altered diet, need for enteral nutrition to meet dietary needs, and increased metabolic requirements. Interventions included tube feeding as ordered, Juven 1.5 at 60 ml continuous with 175 ml water flushes every three hours, cater to food preferences within dietary parameters, observe/report signs of malnutrition/dehydration, observe/report intolerance to tube feed, labs as ordered, monthly weights, report significant weight changes, and provide diet as ordered. Review of the medical record revealed Resident #81 had physician orders dated 09/20/22 for Glucerna 1.5 every shift for supplement continuously at 60 ml per hour. Observation on 02/12/23 at 8:31 P.M. revealed Resident #81 lay in bed with eyes closed making sonorous sounds. Tube feed Diabetisource was attached and running at 60 cc per hour with 175 cc water flushed every three hours. Observation 02/13/23 at 10:13 A.M. revealed Resident #81 had bag of Diabetisource tube feeding dated 02/13/23 running at 60 ml per hour with 175 ml waster flushed every three hours. Observation on 02/14/23 at 12:23 P.M. revealed Resident #81 had Diabetisource AC bag hanging and running at 60 ml per hour with 175 ml water flushed every three hours dated 02/14/23 at 12:00 A.M. During an interview on 02/14/23 12:32 P.M. with Licensed Practical Nurse (LPN) #13 stated it used to say on the dashboard in electronic medical record that the Diabetisource was comparable to the Glucerna. LPN #13 verified Resident #81 had orders for Glucerna tube feeding and had Diabetisource tube feeding hanging and running in her room. During an interview on 02/14/23 at 12:34 P.M. Registered Nurse (RN) #7 stated the facility had supply issues and could not always get the Glucerna in. RN #7 stated nurses were supposed to notify the dietitian, and a new order when switching from the Glucerna to the Diabetisource, let the doctor know, and change the order in the electronic medical record. Review of the facility policy titled Enteral Feeding Ready to Hang, effective 01/17/22, revealed the procedure included to verify the physician's order and to administer enteral feeding as ordered.

Based on record review, observations, staff interview, and policy review, the facility failed to implement their policy to ensure oxygen tubing was changed weekly. This affected two residents (#33 and #81) of three residents reviewed for respiratory care. The facility census was 110. Findings include: 1. Review of the medical record for the Resident #33 revealed an admitted [DATE]. Diagnoses included multiple myeloma, chronic diastolic heart failure, unspecified heart failure, Stage III chronic kidney disease, pressure ulcer of the sacral region, unspecified dementia, generalized anxiety disorder, pseudobulbar effect, unspecified depression, and unspecified schizophrenia. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #33 had severely impaired cognition, had verbal and self-directed behaviors, did not reject care, and did not wander. Resident #33 was a two-person physical assist, required extensive assistance for transfers, dressing, toileting, and personal hygiene, and eating, and total assistance for bed mobility and locomotion. Review of the care plan dated 01/23/23 revealed Resident #33 had potential for difficulty breathing and risk for complications related to shortness of breath. Interventions included meds as ordered, oxygen as ordered, encourage cough/deep breathing, observe/report difficulty breathing, and observe/report signs of respiratory distress/anxiety/respiratory infection. Review of the medical record revealed Resident # 33 had physician orders dated 01/21/2023 for Oxygen per nasal cannula to maintain saturation levels greater than 90% Observation on 02/13/23 at 10:02 A.M. revealed Resident #33 wore oxygen per nasal cannula at two liters per minute dated 02/05/23. Observation on 02/14/23 at 12:25 P.M. revealed Resident #33 wore oxygen per nasal cannula at two liters per minute dated 02/05/23. 2. Review of the medial record revealed Resident #81 was admitted to the facility on [DATE] with diagnoses that included surgical aftercare following surgery on genitourinary system, conversion disorder, hemiplegia and hemiparesis following cerebral infarction, type II diabetes, unspecified anxiety disorder, and other disorders affecting eyelid function. Review of the most recent MDS assessment dated [DATE] revealed Resident #81 had moderately impaired cognition, had self-directed behaviors, did not wander, and did not reject care. Resident # 81 was a two-person assist, required total assistance with transfers, dressing, and locomotion, and required extensive assistance with bed mobility, toileting, and eating. Review of care plan dated 01/13/23 revealed Resident #81 was at risk for cardiac complications related to multiple cardiovascular diseases. Interventions included meds as ordered, monitor/report signs of cardiac distress, and give oxygen as ordered. Observation on 02/13/23 at 10:07 A.M. revealed Resident #81 wore oxygen per nasal cannula at two liters per minute dated 02/05/23. Observation on 02/14/23 at 12:26 P.M. revealed Resident #81 wore oxygen per nasal cannula at two liters per minute dated 02/05/23. During an interview on 02/14/23 at 12:27 P.M. Licensed Practical Nurse (LPN) #13 stated oxygen tubing is changed weekly on all units on Sunday night shift. LPN #13 verified oxygen tubing for Residents #33 and #81 were outdated and should have been changed on 02/12/23. Interview with the Administrator on 02/14/23 at 5:30 P.M. revealed there were no physicians orders in place to change oxygen tubing, however, staff were aware oxygen tubing was to be changed every Sunday. Review of policy titled Use of Oxygen dated 08/17/2021 revealed the oxygen cannula should be changed weekly and dated.

Based on record review, staff interview, and review of facility policy, the facility failed to provide complete a wound sample in a timely manner. This affected one (Resident #85) of three residents reviewed for lab services. The facility census was 121. Findings include: Medical record review revealed Resident #85 admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment completed on 05/27/22 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating she was cognitively intact. The resident required extensive assistance of two staff for bed mobility, transfers, locomotion, toilet use and personal hygiene and required extensive assistance of one staff for dressing. The resident did not walk and required supervision for eating. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the lab results revealed a collection date of 01/26/22 and a report date of 01/27/22. It was noted on the report that the specimen was labeled incorrectly as it was missing the resident's social security number or date of birth as the second identifier. The facility was requested to send a new specimen on 01/27/22. Review of the progress note dated 01/30/22 revealed the second wound culture was obtained of the surgical scar drainage, and it was to be picked up by the lab in the next morning. Interview on 06/28/22 at 11:30 A.M. the Administrator and Director of Nursing (DON) verified on 01/27/22, the facility received a call from the lab that evening requesting for a new wound culture to be completed for the resident. The lab would pick the new sample up on 01/28/22 between 3:00 A.M. and 5:00 A.M. The Administrator and DON verified the wound culture was not completed until 01/30/22 and was picked up from the lab on 01/31/22. Interview on 07/25/22 at 6:15 P.M. Resident #85's Primary Care Physician (PCP) reported the expectation was for the facility to complete the wound culture and send it back to the lab as soon as it was discovered it needed to be re-collected. The facility did not have a policy regarding lab services. This deficiency substantiates Complaint Number OH 515.

Based on medical record review and family and staff interview, the facility failed to provide a resident with a safe and orderly discharge by ensuring the correct medications were sent home with a resident upon discharge to home. This affected one resident (#2) of five residents reviewed. The census was 117. Findings include: Review of the medical record for Resident #1 revealed an admission of 01/21/22 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was cognitively intact and required assistance of one to two people for activities of daily living. Review of Resident #1's medications revealed an order upon admission for [MEDICATION(S)] tablet sublingual 0.4 milligrams (mg) one tablet every five minutes as needed for chest pain for three doses, if no relief, call physician. The medication had not been administered during the resident's stay. Review of the medical record for Resident #2 revealed an admitted [DATE] and discharge date of [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's MDS dated [DATE] revealed the resident was cognitively intact. Review of Resident #2's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] #2. Interview on 03/25/22 at 8:45 A.M. with Licensed Practical Nurse (LPN) #200 verified that the medication cart for Resident #1's medications did not contain his [MEDICATION(S)] tablets. Interview on 03/26/22 at 9:00 A.M. Resident #2's family member revealed that after discharge from the facility and returning home, the family discovered that in addition to the medications that Resident #2 was taking, they also discovered a bag with a small bottle in it labeled with Resident #1's name and medication name [MEDICATION(S)]. Interview on 03/26/22 at 10:53 A.M. Registered Nurse (RN) #150 stated that Resident #2's family member came in and was in a hurry to leave, while RN #150 was in the middle of a medication pass. RN #150 did not recall pulling Resident #1's [MEDICATION(S)] bottle but did pull insulin pens which were stored in the same top drawer in bags. RN #150 stated Resident #2's family was very involved and knowledgeable about Resident #2's care and medications, so due to the urgency of the family member, RN #150 did not review each individual medication with them prior to their leaving the facility. RN #150 stated that it was best nursing practice to review the medications with a discharging resident. This deficiency substantiates Complaint Number OH 024.

Based on observation, staff interview, review of facility policy, and review of online resources per the review of online resources per the Center for Medicare and Medicaid Services (CMS) and the Centers for Disease Control (CDC), the facility failed to ensure staff wore eye protection and face masks appropriately to potentially prevent the spread of Coronavirus Disease 2019 (COVID-19). This had the potential to affect 14 (#20, #22, #27, #34, #41, #42, #44, #54, #66, #76, #99, #102, #106 and #125) residents residing on the secured unit who were COVID-19 negative. The census was 125. Findings include: 1. Interview on 01/26/22 at 11:46 A.M. with the Administrator confirmed the facility had 15 COVID positive residents residing in the facility and all staff were required to wear an N-95 mask and eye protection at all times in resident areas. Observation on 01/26/22 at 12:02 P.M. revealed State tested Nursing Assistant (STNA) #250 was seated at the desk of the nurses' station and was not wearing a mask or eye protection. STNA #250 was observed to be chewing something and was holding a peanut butter cracker in her hand. There was an open package of peanut butter crackers and an open can of iced coffee with a straw sitting on the desk in front of her. Licensed Practical Nurse (LPN) #275 was sitting next to her. Resident #125 was sitting in a chair next to the nurses' station which had no walls or barriers surrounding it. At the time of the observation, other residents were in the vicinity. Interview on 01/26/22 at 12:02 P.M. with STNA #250 confirmed she was not wearing a mask or eye protection. When surveyor asked STNA #250 if the facility had a break area where staff could go if they needed to remove their personal protective equipment (PPE) if they needed to consume food or drink, STNA walked away and refused to answer the question. Interview on 01/26/22 at 12:04 P.M. with LPN #275 confirmed STNA #250 had been sitting at the nurses' station and had removed her PPE (mask and face shield) and was consuming peanut butter crackers. LPN #275 further confirmed Resident #125 had been sitting adjacent to the nurses' station while STNA #250 had her PPE removed. LPN #275 further confirmed the facility had two COVID positive residents (#29 and #84) who were residing behind a plastic barricade at the end of the hall. LPN #275 further confirmed the facility had a break area where employees should go if they needed to consume food or beverages because it was not accessible to residents. Interview on 01/26/22 at 1:50 P.M. with the Administrator confirmed staff should not remove their PPE in resident areas and if they needed to do so in order to consume food or beverages, they should do to the designated employee break area. The Administrator confirmed there are 14 (#20, #22, #27, #34, #41, #42, #44, #54, #66, #76, #99, #102, #106 and #125) residents residing on the secured unit who are COVID-19 negative who could potentially be affected by a staff member not wearing personal protective equipment (PPE) correctly. Review of facility policy titled Coronavirus (COVID 19) dated 01/26/22 revealed facility staff would ensure appropriate staff use of PPE to prevent the spread of COVID-19. Healthcare professionals (HCP) should wear a surgical mask or higher level mask at all times while in the facility (per CDC guidelines). HCP working in facilities located in areas with moderate to substantial community transmission are more likely to encounter asymptomatic or pre-symptomatic guests/residents with [CONDITION(S)]-CoV-2 infection. If [CONDITION(S)]-CoV-2 infection is not suspected in a guest/resident (based on symptom and exposure history and guest/resident is not on TBP) a surgical mask or higher level mask and eye protection (face shield or goggles) should be worn during guest/resident care encounters (to ensure the eyes are also protected from exposure to respiratory secretions) and at all times while in the facility (per CDC guidelines). Review of an online resource from CMS titled COVID-19 Nursing Home data at https://data.cms.gov/covid-19/covid-19-nursing-home-data revealed the county in which the facility was situated was experiencing a high spread (red) of COVID-19 with a positivity rate of 28.8 percent (%) for the week ending in 01/25/22. Review of an online resource per the CDC titled Infection Control Guidance for Healthcare Professionals about Coronavirus (COVID-19) at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control.html revealed the use of eye protection in healthcare facilities is recommended in areas with moderate to substantial community transmission and staff should don eye protection (i.e., goggles or a face shield that covers the front and sides of the face) upon entry to the patient room or care area. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on record review, staff interview, and review of the facility policy, the facility failed to include a residents representative in significant changes to the resident's care plan. This affected one (#127) of three residents reviewed for hospice placement. The census was 125. Findings include: Review of the medical record for Resident #127 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan for Resident #127 dated 11/07/21 revealed resident was being followed per hospice for supplemental supports given his terminal status with a goal of maintaining resident's comfort and dignity. Interventions included: Encourage resident/family to express feelings, listen with non-judgmental acceptance, compassion, provide one on one supportive conversations and contacts with resident, encourage support system of family and friends, provide resident/family with information as desired regarding disease process, provide visitations/privacy at any hour per facility policy. Review of the comprehensive significant change Minimum Data Set (MDS) Resident #127 dated 11/08/21 revealed resident was cognitively intact, was coded for unplanned weight loss and receiving hospice services. Review of face sheet for Resident #127 revealed the resident had an individual listed as resident's emergency contact/representative, Resident Representative (RR) #225 noted. Review of nurse progress note for Resident #127 dated 10/11/21 revealed facility called RR #225 to ask him to sign consent forms related to the resident's treatment. Review of the nurse progress note for Resident #127 dated 10/26/21 revealed the facility contacted RR #225 to discuss discharge plans for resident to return home. Review of the nurse progress note for Resident #127 dated 10/28/21 revealed resident requested to change his code status to do not resuscitate comfort care (DNRCC) and expressed interest in possibly pursuing hospice placement. There is no documentation of RR #127 notification of the change in order. Review of the nurse progress note for Resident #127 dated 10/29/21 revealed the physician gave an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . There is no documentation of RR #225 notification of the order. Review of the nurse progress note for Resident #127 dated 10/31/21 revealed resident was sent to the hospital for an evaluation and RR #225 was notified. Review of the nurse progress note for Resident #127 dated 11/05/21 revealed the physician gave an order to admit resident to hospice for end stage [CONDITION(S)]. There is no documentation of RR #225 notification of the order. Review of the care conference note for Resident #127 dated 01/11/21 revealed the facility held a care conference with the resident and discussed the changes to his care plan, resident now on hospice and code status changed to DNRCC. RR #225 did not attend and there was no documentation to indicate he was invited. There was a space on the form where the writer of the note could indicate why RR #225 did not attend but it was blank. Interview on 01/26/22 at 4:00 P.M. with the Administrator confirmed Resident #127's representative was notified of changes in the resident's condition and resident had never expressed a preference for the representative not to be included in resident's care discussions. Interview on 01/27/22 at 4:17 P.M. Social Worker (SW) #200 confirmed Resident #127's representative was not invited to the care conference on 11/11/21 and was not involved in the discussions with resident regarding change in code status and placement in hospice. Review of the facility policy titled Significant Change dated 06/24/21 revealed the facility would complete a significant change assessment if the resident had a significant change in status including going on hospice and the facility would also schedule a care conference to discuss the changes to the resident's care. Further review of the policy revealed the resident's family/representative would be notified of the change and would be invited to the care conference. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on record review, staff interview, and review of facility policy, the facility failed to ensure a resident unnecessary [CONDITION(S)] medications by ensuring orders for as-needed anti-anxiety medication had a duration for the order (stop date). This affected one (#55) of 34 facility-identified residents with orders for anti-anxiety medication. The census was 125. Findings include: Review of the medical record for Resident #55 revealed and admitted [DATE] with a diagnosis of cerebral infarction. Review of Minimum Data Set (MDS) for Resident #55 revealed resident was cognitively impaired and required extensive assistance of two staff with activities of daily living (ADL's). Review of January 2022 monthly physician orders for Resident #55 revealed resident had an order dated 12/06/21 for as needed [MEDICATION(S)] every four hours with no stop date. Resident also had an order for routine [MEDICATION(S)] twice daily dated 11/24/21. Review of the December 2021 Medication Administration Record (MAR) for Resident #55 revealed resident received routine [MEDICATION(S)] twice daily and received addition as needed doses of [MEDICATION(S)] on the following dates: 12/06/21, 12/08/21, 12/10/21, 12/12/21 (received twice on this date), 12/13/21, 12/15/21, 12/16/21, 12/17/21 12/18/21, 12/19/21, 12/20/21, 12/23/21, 12/27/21, 12/28/21. Review of the January 2022 Medication Administration Record (MAR) for Resident #55 revealed the resident received routine [MEDICATION(S)] twice daily and received addition as needed doses of [MEDICATION(S)] on the following dates: 01/03/22 (received twice this date), 01/04/22, 01/07/22, 01/12/22, 01/17/22 01/18/22, 01/24/22, 01/26/22. Review of the pharmacy recommendation for Resident #55 dated 11/16/21 revealed it was a repeat recommendation from 09/28/21 revealed resident had an as needed order for an antianxiolytic, [MEDICATION(S)] without a stop date. Current federal regulations required if the medication could not be discontinued the prescriber should document the indication for use and the duration for the as needed order (stop date). Further review of the pharmacy recommendation revealed the prescriber responded to the recommendation with a rationale for use being the resident gets anxious with care but did not indicate a stop date for the medication. Review of the pharmacy recommendation for Resident #55 dated 01/14/22 revealed it was a repeat recommendation from 09/28/21 and 11/16/21 regarding resident continuing on as needed [MEDICATION(S)] without a stop date. Prescriber responded to the recommendation at the bottom of the page indicating no changes at this time but did not provide a rationale nor a stop date for the medication. Interview on 01/27/22 at with the Administrator confirmed Resident #55's as needed [MEDICATION(S)] order did not include a stop date. Review of facility policy titled Psychoactive Medication Management dated 08/03/21 revealed PRN orders for [CONDITION(S)] medications (Hospice is not exempt) which are not antipsychotic medications are limited to 14 days. The attending physician/prescriber may extend the order beyond 14 days if he or she believes it is appropriate. If the attending physician extends the PRN for the [CONDITION(S)] medication the medical record must contain a documented rationale and a duration for the order. This deficiency substantiates Complaint Number OH 194.

Based on medical record review, staff interview, review of personnel files, review of a job description, review of self-reported incidents (SRI's), and review of facility policy, the facility failed to ensure a resident was free from sexual abuse. This affected one (#5) of three residents reviewed for abuse. Facility census was 124. Findings included: Review of the medical record for the Resident #5, revealed an admission date of [DATE] and discharged on [DATE]. [DIAGNOSES REDACTED]. Review of the most recently completed Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #5 was cognitively intact, had no behaviors, did not reject care, and did not wander. Resident #5 was two-person assist and required limited or supervision with activities of daily livings (ADL's). Review of the plan of care for Resident #5 dated 08/23/20 revealed resident had an ADL self-care deficit and required assistance with ADL's and mobility related to discitis and pain. Interventions included set up assistance or supervision for ADL's. Review of the plan of care revealed nothing pertinent related to abuse allegations. Review of the nurse progress notes for Resident #5 dated from 08/22/20 and discharged on [DATE] revealed no documentation or any indication of a sexual abuse. During random interview with Licensed Practical Nurse (LPN) #31 on 10/08/20 at 3:14 P.M. revealed Registered Nurse (RN) #20 admitted to an inappropriate relationship with Resident #5. LPN #31 stated RN #20 also stated she sent nude pictures of herself to Resident #5. LPN #31 stated the Assistant Director of Nursing (ADON)/RN #11 was immediately notified and she stated she was already aware of allegations. Attempted phone interview with Resident #5 on 10/08/20 at 4:03 P.M. and 4:25 P.M. without success. Phone interview with RN #20 on 10/08/20 from 4:06 P.M. through 4:15 P.M. stated the facility called her on 10/06/20 and advised her Resident #5's girlfriend called the facility and stated she found inappropriate messages and nude pictures of her on Resident #5's phone. RN #20 stated she and Resident #5 were roll playing via text messages. RN #20 verified she sent text messages which contained sexual messages and sent Resident #5 nude pictures of herself while he was a resident of the facility. RN #20 confirmed to kissing Resident #5 on the lips while he was a resident in the facility. RN #20 stated she met with the Director of Nursing (DON) and Administrator on 10/08/20 and resigned her position. Interview with DON on 10/08/20 at 4:33 P.M. revealed Resident #5's girlfriend called the facility on 10/06/20 and stated for RN #20 to keep her vagina in her pants. The DON stated Resident #5's girlfriend further reported she found nude pictures of RN #20 and sexually inappropriate texts between RN #20 and Resident #5 on resident's phone. The DON stated Resident #5's girlfriend was very upset and stated if the facility did not do something about the discovery, she would take it further. The DON stated he called RN #20 on 10/06/20 and instructed her she was under an investigation in reference to the allegation and she was not permitted in the building. The DON stated RN #20 came in 10/08/20 for a meeting and admitted to sending Resident #5 nude pictures of herself and sexually related text messages. The DON stated RN #20 was immediately terminated for inappropriate conduct during the interview. The DON stated he attempted to call Resident #5 about the incident, but he was unable to get in touch with him. The DON also stated the facility had no documented evidence of an investigation being completed for the sexual abuse allegation identified on 10/06/20. Interview with Administrator on 10/08/20 at 4:47 P.M. stated Resident #5's girlfriend called the facility on 10/06/20 and reported the allegations. Administrator stated the girlfriend sent her screen shots of the pictures and texts between Resident #5 and RN #20. Administrator stated she reviewed the pictures and was able to confirm the nude pictures was RN #20. Administrator stated she interviewed RN #20 on 10/08/20 and she admitted to the inappropriate behavioral and was terminated immediately. Administrator stated she attempted to call Resident #5, but the facility did not have a good number and since RN #20 admitted to the relationship, they did not make any more attempts. Administrator stated she did not consider the allegation to be a sexual abuse incident due to both parties being consenting adults so facility did not report the allegation to Ohio Department of Health (ODH) through a SRI; however, the Administrator confirmed the facility had not interviewed Resident #5 regarding the incident/allegation. Administrator also noted the facility did not implement their abuse policy due to not believing the allegation was a sexual abuse incident due to both parties being consenting adults Administrator further stated she had no documented evidence of an investigation being completed for the sexual abuse allegation identified on 10/06/20. Review of personnel file for RN #20 revealed an Employee Disciplinary Record form dated 10/08/20 with violation dated recorded as 10/06/20 at 9:10 A.M. Notes indicated RN #20 engaged in inappropriate sexual conduct with Resident #5 while she was actively working in the facility. Notes also indicated RN #20 was immediately terminated. Personnel file for RN #20 indicated she completed abuse training on 07/20/20. Review of 07/28/20 Job Description for RN Charge Nurse revealed staff will perform their duties in accordance with current, federal, state and local standards, guidelines and regulations that govern the facility. Review of facility SRI's revealed there was no SRI involving an allegation of sexual abuse involving Resident #5. Review of a facility policy titled Abuse Prohibition, Investigation and Reporting dated 07/01/19 revealed the facility will prohibit abuse of guests/residents. The policy defined sexual abuse as non-consensual sexual contact of any type and includes, but is not limited to: unwanted intimate touching of any kind, especially of breasts or perineal area, all types of sexual assault or battery, such as rape, sodomy, and coerced nudity; forced observation of masturbation and/or pornography; and taking sexually explicit photographs and/or audio/video recording of a resident and maintaining or distributing them. This includes but is not limited to, nudity, fondling, and/or intercourse involving a resident. Policy also revealed the Administrator or designee will coordinate an immediate investigation in the accordance with the investigating guidelines in this policy. The policy also revealed the Administrator was responsible for ensuring that all allegations of abuse should be reported immediately the state agency, but no later than two hours after the allegation is made in accordance with federal regulations and state guidelines. This deficiency substantiates Complaint Number OH 300.

Based on medical record review, staff interview, review of personnel files, review of a job description, review of self-reported incidents (SRI's), and review of facility policy, the facility failed to ensure an allegation of sexual abuse was reported to the state agency. This affected one (#5) of three residents reviewed for abuse. Facility census was 124. Findings included: Review of the medical record for the Resident #5, revealed an admission date of [DATE] and discharged on [DATE]. [DIAGNOSES REDACTED]. Review of the most recently completed Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #5 was cognitively intact, had no behaviors, did not reject care, and did not wander. Resident #5 was two-person assist and required limited or supervision with activities of daily livings (ADL's). Review of the plan of care for Resident #5 dated 08/23/20 revealed resident had an ADL self-care deficit and required assistance with ADL's and mobility related to discitis and pain. Interventions included set up assistance or supervision for ADL's. Plan of care revealed nothing pertinent related to abuse allegations. Review of the nurse progress notes for Resident #5 dated from 08/22/20 and discharged on [DATE] revealed no documentation or any indication of a sexual abuse. During random interview with Licensed Practical Nurse (LPN) #31 on 10/08/20 at 3:14 P.M. revealed Registered Nurse (RN) #20 admitted to an inappropriate relationship with Resident #5. LPN #31 stated RN #20 also stated she sent nude pictures of herself to Resident #5. LPN #31 stated the Assistant Director of Nursing (ADON)/RN #11 was immediately notified and she stated she had already been made aware of allegations. Attempted phone interview with Resident #5 on 10/08/20 at 4:03 P.M. and 4:25 P.M. without success. Phone interview with RN #20 on 10/08/20 from 4:06 P.M. through 4:15 P.M. stated the facility called her on 10/06/20 and advised her Resident #5's girlfriend called the facility and stated she found inappropriate messages and nude pictures of her on residents' phone. RN #20 stated she and Resident #5 were roll playing via text messages. RN #20 verified she sent text messages which contained sexual messages and sent Resident #5 nude pictures of herself while he was a resident of the facility. RN #20 confirmed to kissing Resident #5 on the lips while he was a resident in the facility. RN #20 stated she met with the Director of Nursing (DON) and Administrator on 10/08/20 and resigned her position. Interview with DON on 10/08/20 at 4:33 P.M. revealed Resident #5's girlfriend called the facility on 10/06/20 and stated for RN #20 to keep her vagina in her pants. The DON stated the girlfriend further reported she found nude pictures of RN #20 and sexually inappropriate texts between RN #20 and Resident #5 on resident's phone. The DON stated the girlfriend was very upset and stated if the facility did not do something about the discovery, she would take it further. The DON stated he called RN #20 on 10/06/20 and instructed her she was under an investigation in reference to the allegation and she was not permitted in the building. The DON stated RN #20 came in 10/08/20 for a meeting and admitted to sending Resident #5 nude pictures of herself and sexually related text messages. DON stated RN #20 was immediately terminated for inappropriate conduct during the interview. The DON stated he attempted to call Resident #5 about the incident, but he was unable to get ahold of him. The DON also stated the facility had no documented evidence of an investigation being completed for the sexual abuse allegation identified on 10/06/20. The DON also verified the facility did not implement their abuse policy due to not believing the allegation was a sexual abuse incident due to both parties being consenting adults. The DON stated he interviewed several residents and staff about the incident, and no one was aware of the allegations and all residents felt safe but DON stated the facility had no evidence of investigating the allegation. The DON stated he attempted to call Resident #5 about the incident, but he was unable to get ahold of him. The DON stated the Administrator was tasked with making the notifications via SRI's to the state agency. Interview with Administrator on 10/08/20 at 4:47 P.M. stated Resident #5's girlfriend called the facility on 10/06/20 and reported the allegations. Administrator stated the girlfriend sent her screen shots of the pictures and texts between Resident #5 and RN #20. Administrator stated she reviewed the pictures and was able to confirm the nude pictures was RN #20. Administrator stated she interviewed RN #20 on 10/08/20 and she admitted to the inappropriate behavioral and was terminated immediately. Administrator stated she attempted to call Resident #5, but the facility did not have a good number and since RN #20 admitted to the relationship, they did not make any more attempts. Administrator stated she did not consider the allegation to be a sexual abuse incident due to both parties being consenting adults so facility did not report the allegation to Ohio Department of Health (ODH) through a SRI; however, the Administrator confirmed the facility had not interviewed Resident #5 regarding the incident/allegation. Administrator also noted the facility did not implement their abuse policy due to not believing the allegation was a sexual abuse incident due to both parties being consenting adults Administrator further stated she had no documented evidence of an investigation being completed for the sexual abuse allegation identified on 10/06/20. Review of personnel file for RN #20 revealed an Employee Disciplinary Record form dated 10/08/20 with violation dated recorded as 10/06/20 at 9:10 A.M. Notes indicated RN #20 engaged in inappropriate sexual conduct with Resident #5 while she was actively working in the facility. Notes also indicated RN #20 was immediately terminated. Personnel file for RN #20 indicated she completed abuse training on 07/20/20. Review of 07/28/20 Job Description for RN Charge Nurse revealed staff will perform their duties in accordance with current, federal, state and local standards, guidelines and regulations that govern the facility. Review of facility SRI's revealed there was no SRI involving an allegation of sexual abuse involving Resident #5. Review of a facility policy titled Abuse Prohibition, Investigation and Reporting dated 07/01/19 revealed the facility will prohibit abuse of guests/residents. The policy also documented the Administrator or designee will coordinate an immediate investigation in the accordance with the investigating guidelines in this policy. The policy documented the Administrator was responsible for ensuring that all allegations of abuse should be reported immediately to the state agency, but no later than two hours after the allegation is made in accordance with federal regulations and state guidelines. This deficiency is based on incidental findings discovered during the course of this complaint investigation.