Every finding on record at The Pinnacle Rehabilitation and Nursing Center

Based on record review and interview, the facility failed to ensure Resident #73's right hip/femur staples were removed timely. This finding affected one (Resident #73) of three residents reviewed for wounds. The facility census was 71.Findings include: Review of Resident #73's hospital Orthopedics Progress Note dated 03/11/26 at 6:49 A.M. revealed the resident was examined and the pain was controlled with medications. The resident was day two of status post right cephallomedullary nail.Review of Resident #73's hospital Discharge Summary form dated 03/13/26 at 2:46 P.M. revealed the resident was to see Orthopedics Physician #817 in two weeks (03/27/26).Review of Resident #73's closed medical record revealed the resident was admitted on [DATE] with diagnoses including encounter for other orthopedic aftercare, nondisplaced fracture of the greater trochanter of the right femur, subsequent encounter with routine healing and bipolar disorder. Resident #73 was discharged home on [DATE].Review of Resident #73's physician orders revealed an order dated 03/13/26 (discontinued 04/02/26) for the right hip silverlon dressing to remain in place until the follow-up appointment with orthopedics. Monitor every shift and notify the physician if drainage was noted.Review of Resident #73's Orthopedic provider note dated 03/16/26 at 2:32 P.M. revealed the provider spoke with Licensed Practical Nurse (LPN) Unit Manager (UM) #819 and went over new orders including dressing changes and daily skin checks to monitor for infection and the staples may be removed on 03/21/26 if the area was well approximated; Doxycycline 100 milligrams (mg) one by mouth twice daily for seven days with a stop date of 03/18/26 (discontinued by Physician #820 on 03/16/26) and Lovenox anticoagulant 40 mg daily until 04/06/26. A follow-up appointment was made, the address and phone given to call with any concerns.Review of Resident #73's general progress note dated 03/16/26 at 3:07 P.M. authored by LPN UM #819 revealed the staff member spoke with the orthopedic surgeon's office. The resident to be weight bearing as tolerated to the right lower extremity. The staples can be removed on 03/21/26 if the incision was well approximated. A follow up appointment was scheduled for 03/25/26 at 8:30 A.M. The resident was made aware of everything and while in the room, she stated that while using the bedside commode, the right upper thigh felt like it locked, and she had more pain than usual. The physician was notified and an order for an X-ray was obtained. The resident was made aware.Review of Resident #73's Surgical Wound Note dated 03/17/26 revealed the resident was admitted with the right hip surgical dressing and aftercare following an orthopedic surgery.Review of Resident #73's Surgical Wound Care Services form dated 03/31/26 revealed the surgeon removed the staples at the office on the follow-up visit on 03/25/26.Review of Resident #73's physician orders revealed an order dated 04/01/26 (discontinued 04/09/26) to cleanse the right hip and thigh with hibiclens, pat dry, leave open to air daily and as needed.Review of Resident #73's medication administration records (MARS) and treatment administration records (TARS) from 03/16/26 to 04/11/26 revealed the resident's dressing was monitored but the staples were not removed.Telephone interview on 04/22/26 at 11:30 A.M. with Orthopedic Physician Office #818 confirmed they called and gave orders to LPN UM #819 on 03/16/26 at 2:32 P.M. to remove the resident's right hip staples on 03/21/26 if the hip was well approximated.Telephone interview on 04/22/26 at 11:39 A.M. with the Director of Nursing (DON) in attendance of Orthopedic Physician Office #818 confirmed their office spoke to LPN UM #819 and gave orders to remove the staples to Resident #73's right hip if the incision was well approximated.Interview on 04/22/26 at 11:45 A.M. with the DON confirmed Resident #73's staples were not removed per the orthopedic surgeon's orders.Review of the Telephone Orders policy revised 02/2014 revealed verbal telephone orders may be accepted from each resident's Attending Physician.This deficiency represents non-compliance investigated under Complaint Number 2985252.

Based on record review, observation, interview, manufactures guidelines and policy review, the facility failed to ensure Resident #13 rinsed her mouth after using a steroid inhaler. This affected one (Resident #13) of three residents observed for use of steroid inhalers. This also had the potential to affect seven (Residents #4, #9, #12, #33, #43, #59, and #87) identified by the facility as also receiving steroid inhaler treatments.Findings include:Review of the medical record for Resident #13 noted an admission date of 01/21/26. Diagnoses included obstructive pulmonary disease, unspecified asthma, and chronic respiratory failure with hypercapnia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 had intact cognition. Observation on 03/09/26 at 8:02 A.M. of medication administration noted Licensed Practical Nurse (LPN) #404 administering medications to Resident #13. LPN #404 handed Resident #13 an Advair Diskus steroid inhaler, Resident #13 took one breath and gave the inhaler back to LPN #404. LPN #404 did not encourage or prompt Resident #13 to rinse her mouth after inhaling the steroid. During an interview with LPN #404 immediately after the observation, LPN #404 stated [Resident #13] did not like water, so I did not say anything. LPN #404 then stated, I know residents should rinse their mouths with some inhalers, but I am not sure. During an interview on 03/11/26 at 9:35 A.M., Director of Nursing (DON) verified staff should be encouraging residents to rinse their mouths after using a steroid inhaler.Review of the Advair Diskus inhaler guidelines from accessdata.fda.gov, noted after inhalation, the resident should rinse his/her mouth with water without swallowing to help reduce the risk of overgrowth of yeast in the mouth (oropharyngeal candidiasis).Review of the undated facility policy titled Administering Medications through a Metered Dose Inhaler noted staff should provide a gargling solution when administering an inhaler. The policy did not provide direction for staff to encourage residents to rinse their mouths after using a steroid inhaler. Review of the facility policy titled Administering Medications through a Metered Dose Inhaler, dated 2001, noted staff should provide a gargling solution when administering an inhaler. The policy did not provide direction for staff to encourage residents to rinse their mouths after using a steroid inhaler.

Based on record review and interview, the facility failed to ensure Resident #53's legal guardian was notified of the resident's refusal of a planned procedure. This finding affected one (Resident #53) of three residents reviewed for changes in condition. Findings include: Review of Resident #53's medical record revealed the resident was admitted on [DATE] with diagnoses including unspecified dementia, depression and gastrostomy status. Review of Resident #53's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited a memory problem. Review of the Summit County Probate court form dated 10/11/24 revealed the resident's daughter was the guardian of person and estate. Review of the Probate Division Court Document dated 10/24/24 revealed Attorney #815 was appointed Guardian Ad Litem (individual appointed by the court to represent the best interests of someone unable to take care of themselves). Review of Resident #53's progress note dated 04/04/25 at 5:13 P.M. revealed the resident went out for an abdominal CAT (medical imaging test that allows doctors to see inside body) scan with the Certified Nursing Assistant (CNA) accompanying and assisting. Per the CNA, the resident would not transfer onto the exam table for the exam/procedure and repeatedly refused. The test was canceled. Telephone interview on 04/07/25 at 10:36 A.M. with Probate #816 indicated the facility should be calling Resident #53's guardian (daughter) for any changes in the resident's condition. Probate #816 confirmed the facility had appointed a Guardian Ad Litem to make an independent report on the resident's condition and determine if the current guardian (daughter) was in the best interests of the resident. She stated this hearing would be conducted on 04/22/25 but at the current time, the daughter was the valid guardian. Interview on 04/07/25 at 10:47 A.M. with the Director of Nursing (DON) and the Administrator confirmed Resident #53's current legal guardian was not notified of the resident's refusal of her test on 04/04/25. Review of the Notification of Change policy revised 12/2016 revealed the facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status.

Based on observation, interview, and review of manufacturer's safety data sheet , the facility failed to ensure that high touch surfaces were cleaned and disinfected to prevent the spread of infections in the facility. This affected all the residents in the facility. The facility census was 66. Findings include: An observation of the Housekeeper #75 on 10/02/24 at 10:00 A.M. revealed she was had a housekeeping cart with a bucket of water and cleaning solution on the top of the cart and a large bucket of cleaning solution on the bottom shelf of the housekeeping cart with a floor mop in the bucket. An interview with Housekeeping Manager (HM) #76 on 10/02/24 at 3:40 P.M. revealed she had two different types of cleaning products used to clean the facility. HM #76 stated she prepared the laundry carts in the facility and mixed the cleaning solution in the two buckets on each of the four housekeeping carts everyday prior to the housekeepers starting their shift. HM #76 stated she used the all purpose cleaning solution to prepare the bucket located on the top of the laundry cart used for cleaning the high touch surfaces in the resident rooms, bathrooms and in the common areas of the facility. The mop bucket was used to clean the floors in all areas of the facility. HM #76 stated she used the neutralizer and disinfecting cleaning solution for the mop bucket. An observation on 10/02/24 at 3:50 P.M. with HM #76 of the labeling of two different cleaning solutions used to clean the residents' rooms and common areas of the facility revealed the all purpose cleaner did not disinfect the surfaces cleaned. HM #76 verified she had used the all purpose cleaning solution to prepare the bucket used to clean the high touch surfaces including the bathroom sink and the residents' over-the-bed table. An observation of the housekeeping room with the HM #76 on 10/02/24 at 4:00 P.M. revealed there was an automatic dispensing system that was used by the staff to prepare the cleaning solutions in the facility. The system was used by the staff turning the dial to the appropriate solution desired. There were three different compartments. Each compartment was labeled with one of the following solutions : disinfecting, all purpose cleaner, or glass cleaner. The dispenser had the all purpose solution in the compartment labeled disinfecting solution. HM #76 stated the disinfecting solution should have been placed in the disinfecting compartment and not the all purpose solution. An interview with Housekeeper #81 on 10/03/24 at 5:45 A.M. revealed she performed both laundry and housekeeping duties in the facility. Housekeeper #81 stated when the cleaning solution needed changed on the housekeeping cart she emptied the dirty solution down the drain and replaced the cleaning solution in each of the buckets used on the cart. Housekeeper #81 stated she used the all purpose solution to prepare the cleaning solution for the bucket on the top of the cart used to clean the high touch surfaces. Housekeeper #81 stated she used the neutralizer/disinfecting solution for the bucket used to mop the floor in the facility. Housekeeper #81 stated the bucket located on top of the cart was used to clean the high touch surfaces in the residents' room including the bathroom sink and room furniture. A review of the manufacturer's safety data sheet for the concentrated citrus all purpose cleaner revealed the recommended use was for an all purpose cleaner with citrus scent. The safety data sheet indicated no documentation the solution should be used to disinfect surfaces. This deficiency represents non-compliance investigated under Master Complaint Number OH00158482, Complaint Number and OH00158209.

Based on record review, interview, and facility policy review the facility failed to ensure Residents #31, #32, and #55 were treated with dignity and respect. This affected three residents (#31, #32 and #55) of six residents reviewed for dignity and respect and had the potential to affect all residents. The facility census was 67. Findings Include: 1. Review of the medical record for Resident #31 revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), asthma, adult failure to thrive, sleep apnea, and high cholesterol. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 was cognitively intact. Resident #31 required substantial or maximum assistance for showering or bathing, partial or moderate assistance for toileting and personal hygiene, and set up help for eating and oral hygiene. 2. Review of the medical record for Resident #32 revealed an admitted [DATE]. Diagnosis included acute respiratory failure, Parkinson's disease, shortness of breath, muscle atrophy, and prostate cancer. Review of the comprehensive MDS assessment dated [DATE] revealed Resident #32 was cognitively intact. He was totally dependent on staff for toileting and required substantial or maximum assistance for showering or bathing and personal hygiene. 3. Review of the medical record for Resident #55 revealed an admitted [DATE]. Diagnosis included arthritis, diabetes, pancreatitis, pain and swelling of the left knee, and asthma. Review of the comprehensive MDS assessment dated [DATE] revealed Resident #55 was totally dependent on staff for toileting and showering or bathing, required partial or moderate assistance for personal hygiene, and setup help for eating and oral hygiene. Interview on 02/28/24 at 9:07 A.M. with Resident #55 revealed she felt like State tested Nurse's Aide (STNA) #204 was constantly picking on her and demeaning her. STNA #204 told her they promoted independence in the facility and did not consider Resident #55's limitations due to her knee immobility and pain. STNA #204 referred to her as honey or baby which was inappropriate. Interview on 02/28/24 at 9:15 A.M. with Resident's #31 and #32 as well as Resident #32's wife, revealed staff working on the night shift were especially rude. Staff came in at night and turned off the call light without addressing concerns. Resident #32's wife reported she had an issue with one employee who made a nasty comment to her husband. She reported the incident to the Director of Nursing (DON), and it was handled. Interview on 02/28/24 at 9:42 A.M. with the Administrator and DON revealed they were aware of Resident #55's concerns regarding STNA #204. They revealed they had provided verbal counseling to STNA #204. They confirmed they were aware of the concerns with Resident #32 and his wife; they did not have knowledge of Resident #31's concerns. Interview on 02/28/24 at 11:53 A.M., STNA #204 denied Resident #55 reported any concerns to her about disrespect or mistreatment. Review of the personnel file for STNA #204 revealed a hire date of 11/09/15. The file contained an annual employee evaluation dated 10/27/23 with an action plan to work on her attitude and anger. The date of completion for the action plan was 11/30/23. The file contained verbal education dated 04/02/19 for a resident who felt his bath was not completed in an appropriate amount of time, a written warning dated 04/14/19 for arguing with another STNA in the hallway, and a written warning dated 07/31/15 for threatening a fell ow employee with bodily harm. The progressive discipline policy was reviewed with STNA #204 on 10/09/23, highlighting behavior that was offensive to residents, visitors, or fell ow employees, arguing or engaging in disruptive behavior with fell ow employees in resident care areas, using foul or abusive language, threatening a fell ow employee, resident, or visitor, or instigating a physical confrontation with a fell ow employee, resident, or visitor. Review of the facility policy titled Resident Rights, dated December 2016, revealed residents have the right to be treated with kindness, respect, and dignity. Review of the facility policy titled Quality of Life-Dignity, dated August 2009, revealed residents would be treated with dignity and respect at all times, enhancing their self-esteem and self-worth. Staff would speak respectfully to residents and all the times including addressing resident by name. This deficiency represents noncompliance investigated under Complaint Number OH00150977.

Based on observation, record review and interview, the facility failed to ensure the abdominal binder used to secure Resident #99's percutaneous endoscopic gastrostomy (PEG) tube was in place at all times. This finding affected one (Resident #99) of three residents reviewed for care. Findings include: Review of Resident #99's hospital documentation dated 06/15/23 revealed the resident was admitted for a urinary tract infection (UTI) and presented from the facility for a PEG tube (tube through the stomach for fluids and nutrition) removal which was replaced in the emergency room (pre admission to the skilled nursing facility). Review of Resident #99's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including atherosclerotic heart disease, altered mental status and vascular dementia. Review of Resident #99's hospital documentation dated 07/13/23 revealed the resident underwent replacement of a PEG tube on 07/12/23. An abdominal binder was ordered to prevent further PEG tube dislodgement in the future. Review of Resident #99's physician orders revealed an order dated 08/08/23 for an abdominal binder to be in place to protect the PEG tube every shift. Review of Resident #99's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment. Review of Resident #99's nursing progress note dated 12/21/23 at 2:00 A.M. authored by Licensed Practical Nurse (LPN) #804 indicated the resident's PEG tube fell out and was lying next to her. An order was obtained to send the resident to the hospital for a PEG tube replacement. Review of Resident #99's hospital discharge paperwork dated 12/21/23 revealed the PEG tube was reinserted. Observation on 12/22/23 of Resident #99's PEG tube binder revealed the binder was secured and in place. Telephone interview on 12/22/23 at 10:24 A.M. with LPN #804 with the Administrator and Director of Nursing (DON) present revealed she found Resident #99's PEG tube out and lying on the bed. LPN #804 stated the resident did not have a PEG tube binder in place the time of the observation and she was unaware of where the binder went. Review of the Enteral Nutrition policy revised 01/14 indicated if the resident had a feeding tube placed prior to admission or returning to the facility, the Physician and the interdisciplinary team will review the rationale for the placement of the feeding tube, the resident's current clinical and nutritional status, and the treatment goals and wishes of the resident. This deficiency represents non-compliance investigated under Complaint Number OH00148986.

Based on observation and interview the facility failed to provide a clean and sanitary environment for Resident #24 when Resident #24's bedside commode was not emptied in a timely manner. This affected one resident (#24) of three residents reviewed for environment (#24,#30 and #55). The facility census was 50. Findings include: Interview on 09/15/22 at 1:48 P.M. with Resident #24 revealed staff sometimes refused to empty her bedside commode. Observation at time of interview revealed Resident #24's bedside commode contained urine and feces. Resident #24 stated it had not been emptied since the previous night. Resident #24 stated she had asked the staff to empty it this afternoon and no staff had returned to empty the bedside commode. Interview on 09/15/22 at 2:04 P.M. with State tested Nursing Assistant (STNA) #215 revealed she was not aware Resident #24's bedside commode needed to be emptied. STNA #215 entered Resident #24's room at time of interview and confirmed the bedside commode bucket contained urine and feces. Interview on 09/19/22 at 12:23 P.M. with Resident #24 revealed her bedside commode had not been emptied since the previous evening and stated she had asked staff to empty it last night as well as this morning. Observation confirmed there was urine and feces in the bedside commode and a strong odor was detected. Interview on 09/19/22 at 12:35 P.M. with STNA #206 revealed she was not aware Resident #24's bedside commode needed to be emptied. STNA #206 entered Resident #24's room and confirmed the presence of urine and feces in the bedside commode bucket. This deficiency substantiates Complaint Number OH 488.

Based on interview and record review the facility failed to ensure residents were treated with respect and dignity. This affected four residents (#24, #55, #62, and #68) reviewed for respect and dignity and had the potential to affect all residents residing in the facility. The facility census was 68. Findings include: Review of Resident #24's medical records revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #24's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #24 had intact cognition and required limited assistance with toileting and personal hygiene. Review of Resident #55's medical records revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #55's MDS assessment dated [DATE] revealed Resident #55 had intact cognition and required extensive assistance with toileting and personal hygiene. Review of Resident #62's medical records revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #62's MDS assessment dated [DATE] revealed Resident #62 had intact cognition and required extensive assistance with toileting and personal hygiene. Review of Resident #68's medical records revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #68's MDS assessment dated [DATE] revealed Resident #68 had impaired cognition and required extensive assistance with toileting and personal hygiene. Interview on 09/15/22 at 10:38 A.M. with Resident #55 revealed she had concerns related to multiple staff members treating her in disrespectful manner. Resident #55 stated she had requested incontinence care (unable to recall the exact date) from State tested Nursing Assistant (STNA) #209 and STNA #209 had refused to thoroughly dry her stating why you are just gonna wet yourself again anyway. Resident #55 stated STNA #301 had refused to provide her with incontinence care at approximately 4:30 A.M. (date unknown) and told her you are not wet enough to be changed yet and STNA #301 did not return to provide her with incontinence care until approximately 6:30 A.M. Resident #55 stated STNA #300 had offered her water recently (date unknown) and Resident #55 asked for a cup of ice instead of the water. Resident #55 stated STNA #300 told her if you don't take the water now don't ask me for any later. Resident #55 stated she had made her concerns known to the Administrator as well as the Former Director of Nursing (FDON). Resident #55 further stated when Former Specified Resident (FSR) #80 was in the facility Registered Nurse (RN) #210 yelled at FSR #80 for attempting to get out of bed unassisted. Resident #55 stated she informed a floor nurse (LPN #203) about the incident and the nurse informed her she would notify the Administrator. Interview on 09/15/22 at 11:03 A.M. with Resident #62 revealed he had concerns with STNA #215. Resident #62 stated he had some personal papers on his bedside table and STNA #215 entered his room (unknown date) with his breakfast tray. Resident #62 asked STNA #215 not to place his breakfast tray on top of his papers and STNA #215 proceeded to place the tray on top of his papers anyway. When Resident #62 asked STNA #215 to move the tray so he could move his papers, STNA #215 became upset and pushed the bedside table up against the wall and left the room. Resident #62 stated STNA #215 told the Administrator he was the one that had gotten aggressive and pushed the bedside table against the wall. Interview on 09/15/22 at 11:20 A.M. with Licensed Practical Nurse (LPN) #201 revealed she was the unit manager and had been made aware of concerns with Resident #55's care and stated Resident #55 had informed her of STNA #209. LPN #201 stated STNA #209 had received verbal counseling regarding the incident. LPN #201 stated she had not been aware of Resident #55's other concerns. Interview on 09/15/22 at 4:55 P.M. with Registered Nurse (RN) #210 revealed the Administrator had asked that he no longer provide care to Resident #55 or her former roommate (Resident #80) in May 2022 after Resident #55 reported he had yelled at her roommate. Further interview with RN #210 revealed he had also been asked not to provide care for Resident #68 due to the resident had stated he had yelled at her. RN #210 denied he had yelled at Resident #68 and stated the resident's husband had spoken with Resident #68 and he was now allowed to care for her. Interview on 09/15/22 at 5:11 P.M. with the Administrator and Director of Nursing (DON) revealed they had been been made aware Resident #55 had concerns with RN #210 and stated he was not able to care for either her of her roommate. Review of STNA #209's personnel file revealed a written warning dated 09/12/22 that stated she had behaviors that she knew or should know that were offensive to residents. No further explanation was provided in the disciplinary action. Review of STNA #300's personnel file revealed a discussion was had on 06/22/22 regarding Resident #55's care. Documentation stated Resident #55 had stated STNA #300 had offered the resident water and the resident stated she did not want water at this time and employee was accused of saying then dont ask for any water later. Review of RN #210's personnel file revealed a written warning dated 05/17/22 that he was discourteous, and rude to residents. RN #210 had been inserviced on customer service. The personnel file further contained a written warning dated 06/10/21 regarding RN #210 had a verbal confrontation with a resident's family member. Interview on 09/19/22 at 2:40 P.M. with the Administrator revealed she was unable to provide a clear explanation regarding STNA #209's disciplinary action, however confirmed the write up included offensive behaviors. Review of facility policy titled Resident Rights dated December 2016 revealed residents had the right to be treated with respect, kindness and dignity. This deficiency substantiates Complaint number OH 488.

Based on record, interview, observation, and policy review the facility failed to to ensure residents were administered the correct medications as ordered by the physician. This affected one (Resident #68) of three residents reviewed for medication administration. Review of the medical record for the Resident #68 revealed an admitted [DATE] and a discharge date of [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the comprehensive assessment, dated 05/21/21, revealed Resident #68 had intact cognition, needed set up help only for bed and wheelchair mobility, and did not need assistance with meals. Review of the plan of care dated 05/21/21 revealed Resident #68 was on intravenous (IV) antibiotics due to [CONDITION(S)] of the lumbar region related to IV drug use. Interventions included IV antibiotic therapy for six weeks, monitoring for any signs and symptoms of worsening infection every shift, and monitoring for any adverse reactions or side effects from the antibiotic therapy. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #68's Peripherally Inserted Central Catheter (PICC) dressing change was to be completed weekly on Mondays. Review of Medication Administration Records (MAR) for July 2021 revealed Resident #68 received her [MEDICATION(S)] as ordered. There were no adverse effects of the medication. However, on 07/07/21 Resident #68 received approximately five milliliters (ml) of Resident #69's [MEDICATION(S)] (antifungal) 100 milligrams (mg). There were no adverse reactions identified. Review of the MAR for Resident #69 revealed no missed doses of [MEDICATION(S)] 100 mg. Interview on 08/09/21 at 9:30 A.M. to 9:45 A.M. with Registered Nurse (RN) #809 stated on 07/07/21 she hung the wrong IV antibiotic for Resident #68. RN #809 stated that she was having a bad day and did not double check that the medication she administered to Resident #68 was for her. RN #809 stated that Resident #68 put her call light on and said she stopped the IV medication from infusing because she saw it was not her name on the IV bag. RN #809 verified Resident #68 received five ml of Resident #69's [MEDICATION(S)]. RN #809 stated she flushed Resident #68's PICC line with normal saline and notified the physician immediately. RN #809 assessed Resident #68 for any adverse reactions from the [MEDICATION(S)], none were noted. RN #809 then hung the correct antibiotic for Resident #68 which was [MEDICATION(S)] 2 gm. Resident #69 did not miss any doses of his [MEDICATION(S)]. The dose that was used for Resident #68 was replaced by the pharmacy. Interviews on 08/05/21 from 8:00 A.M. to 10:00 A.M. and on 08/09/21 from 7:45 A.M. to 12:30 P.M. with Licensed Practical Nurse (LPN) #800, LPN #801, LPN #805, LPN #806, LPN #808, RN #803, RN #804, State tested Nurse Aide (STNA) #811, and STNA #812 revealed staff had heard that Resident #68 received the wrong medication and that there were no adverse reactions. Review of medication error report dated 07/08/21 revealed Resident #68 received 5 ml of Resident #69's IV [MEDICATION(S)]. RN #809 admitted that she did not verify the resident's name before starting the infusion. The Nurse Practitioner (NP) was notified on 07/07/21 and the Physician was notified on 07/08/21. Resident #68 was monitored and did not have any adverse side effects from receiving the wrong medication. Review of facility policy titled Administering Medications dated December 2012, revealed staff failed to follow proper procedure by ensuring the right medication was given to the right resident.

Based on medical record review, Self-Reported Incident review, police report, policy review and interview, the facility failed to ensure Resident #2 was free from misappropriation. This affected one (Resident #2) of four residents reviewed for abuse. Findings include: Review of the medical record for former Resident #2 indicated an admission date of [DATE], discharge date of [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] indicated Resident #2 was cognitively intact. Review of the Self-Reported Incident (SRI) dated 02/03/20 indicated Resident #2's power of attorney reported the resident's bank account had transactions/purchases that the resident did not create/purchase. The transactions were from 01/18/20, 01/19/20 and 01/20/20. There were written notes in the SRI file indicating that the resident would give her bank card to staff to retrieve snacks for her out of the vending machine. Resident #2 stated that she did not give her debit card to anyone to purchase food outside of the facility. A copy of the bank statement dated 02/03/20 showed money was debited from the account at an insurance company, a video game program, a cellphone carrier, a gas station, a market, and three fast food eateries which added up to $300.35. The bank statement indicated the customer was in a nursing home and someone took her card making multiple charges and attempted to use it on cash applications. The person put the card back after using it, so she was not aware it had been stolen until the statement printed. The facility concluded that misappropriation was suspected. Interview on 10/28/20 at 1:45 P.M. with the Administrator and Director of Nursing verified the misappropriation of resident funds did occur for Resident #2. Review of the police report dated 02/03/20 timed 4:46 P.M. indicated a theft of a credit card occurred for Resident #2. Interview on 10/28/20 at 2:45 P.M. with Police Detective #5 revealed the investigation was still open into Resident #2's suspicious bank account charges. The police department had a suspect however was unable to release any more details. Review of the abuse, neglect, exploitation and misappropriation of resident property policy revised on 11/01/19 indicated the facility would not tolerate misappropriation of resident property and defined misappropriation of resident property as the deliberate misplacement, exploitation or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. This deficiency substantiates Complaint Number OH 774.

Based on medical record review, Self-Reported Incident review, police report, policy review and interview, the facility failed to complete a thorough investigation into Resident #2's misappropriation of funds. This affected one (Resident #2) of four residents reviewed for abuse. Findings include: Review of the medical record for former Resident #2 indicated an admission date of [DATE], discharge date of [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] indicated Resident #2 was cognitively intact. Review of the Self-Reported Incident (SRI) dated 02/03/20 indicated Resident #2's power of attorney reported the resident's bank account had transactions/purchases that the resident did not create/purchase. The transactions were from 01/18/20, 01/19/20 and 01/20/20. Resident #2 stated that she did not give her debit card to anyone to purchase food outside of the facility. The facility called the police department to make a report of the fraudulent charges on her account. The police officer instructed the facility not to question any staff until they reviewed the case and could investigate the charges. The facility concluded that misappropriation was suspected. There were notes in the SRI file indicating the resident would give her bank card to staff to retrieve snacks for her out of the vending machine. There were no other resident interviews in the SRI file. Review of the police report dated 02/03/20 timed 4:46 P.M. indicated a theft of a credit card occurred for Resident #2. Interview on 10/28/20 at 1:45 P.M. with the Administrator and Director of Nursing verified other residents were not interviewed as part of the SRI investigation on 02/03/20. They indicated unsuccessful attempts were made to follow up with the police department sometime in June or July but there was no documentation of when this occurred or to whom they spoke. Interview on 10/28/20 at 2:45 P.M. with Police Detective #5 revealed the investigation was still open into Resident #2's suspicious debit card charges. The police department did have a suspect however was unable to release any more details. Review of the abuse, neglect, exploitation and misappropriation of resident property policy revised on 11/01/19 indicated it was the facility's policy to investigate all alleged violations involving misappropriation of resident property. The person investigating the incident should generally take the following actions: interview the resident, the accused and all the witnesses. Witnesses generally include anyone who: witnessed or heard the incident; came in close contact with the resident the day of the incident (including other residents or family members). If there are no direct witnesses, then the interviews may be expanded. This deficiency substantiates Complaint Number OH 774.

Based on observation and interview the facility failed to prepare, store and maintain the kitchen in a clean and sanitary manner to prevent contamination and food borne illness. This had the potential to affect all 63 of 65 residents who received meals from the dietary department (Resident #27 and #57 received nothing by mouth (NPO)). The facility census was 65. Findings include: A tour of the kitchen was conducted on 09/16/19 at 8:59 [NAME]M. and 09/18/19 at 9:30 [NAME]M. with the Dietary Cook (DC) #200 which revealed the following which were verified with the cook at the time of the observations: Observation of the kitchen revealed white plastic pipes under a two-compartment sink had a heavy build up of a brown unidentifiable substance. Heavy dust build-up was on the juice machine filters. There was a heavy buildup of a brown unidentifiable substance under a two-compartment sink. One small bowl of oatmeal was observed unwrapped and undated sitting on top of the metal plate warmer lid. One metal plate had a brown crust substance on the rim of the plate. The convection oven contained heavy amounts of burnt spillage on the bottom. The drawer containing scoop ladles had multiple food crumbs on the bottom. The ice machine contained dust build up on the vents and outside door. The steamer had dirt and food particle build up underneath of it. The walk-in cooler had a pack of cheese properly wrapped but not dated. Three large metal food storage bins were stored with free standing water. Interview with Food Service Manager (FSM) #207 on 09/18/19 at 10:30 [NAME]M. confirmed the above findings.

Based on record review and interview the facility failed to implement nutritional recommendations for a dietary supplement for Resident #9 in a timely manner. This affected one resident (#9) of four residents reviewed for nutrition. Findings include: Medical record review revealed Resident #9 was admitted to the facility on [DATE] and a most recent re-admission on 02/20/19. The resident had [DIAGNOSES REDACTED]. A physician order, dated 02/20/19 revealed the resident received a regular diet, regular texture with thin liquid consistency. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited mild cognitive impairment. The resident was assessed to require set up assistance with meals and able to feed herself. Review of resident's weights revealed the following weights for 2019: 09/04/2019 - 128.2 pounds (#) 07/05/2019 - 134.2 # 06/01/2019 - 136.2 # 05/31/2019 - 136.2 # 05/03/2019 - 135.6 # 04/05/2019 - 130.2 # 03/05/2019 - 129.6 # 03/01/2019 - 129.6 # 02/01/2019 - 144.4 # 01/03/2019 - 140.4 # Review of the progress notes and dietary note dated 01/29/19 revealed Resident #9 was able to feed herself, had a good appetite and was consuming most of her meals and fluids. Resident #9's skin was noted to be intact but she had [MEDICAL CONDITION] noted on her upper right shoulder. The medical records stated that the resident had maintained a stable weight and no significant weight changes were noted. The documented weight was 140 # on 01/03/19 and this reflected a body mass index (BMI) at 23.4. The dietitian stated the resident continued to be in good nutrition and hydration status and remained at low risk. Review of a dietary note dated 03/03/19 revealed Resident #9 had been recently hosptalized on [DATE] and returned on 02/20/19 secondary to an infection on the right upper arm. Resident #9 was readmitted to the facility on a regular diet with thin liquids and the resident's appetite was noted to be fair since the readmission. Resident #9 had refused some meals and would often eat in her room versus the dining room. Laboratory values were obtained and included in the dietary assessment, dated 03/03/19 and revealed the dietitian had recommended Resident #9 receive a nutritional supplement to support and better meet her nutritional needs. Dietitian #300 recommended the supplement Med +2.0, four ounces, twice a day as this would've provided an additional 480 calories and 20 grams of protein. A nursing note dated 03/05/19 revealed Resident #9 had been identified for a significant weight change of 10.2% loss as the current body weight was 129.6 #. The ideal body weight was documented at 125 # and the usual body weight was noted to be 135 # to 144 # with a BMI of 21.6 at the time. The document stated under the supplements section, recommending Med pass 2.0, 120 milliliters (ml), three times a day to provide 240 kcal and 10 g of protein per serving. The note was authored by Dietician #400. The dietary note dated 03/27/19 revealed Resident #9 had been assessed by Certified Dietary M(CDM) #475. The assessment stated Dietician #400 had agreed with the previous is dietician's recommendation for Resident #9 to receive nutritional support to better meet her needs. Med pass 2.0, four ounces, twice a day for increased protein related to her decreased appetite and increased needs related to infection and wound to the right upper arm. The dietary assessment or quarterly nutrition assessment dated [DATE] revealed the resident had a current body weight of 136 # and the BMI was at 22.7. This was within normal range. The resident remained on regular diet with regular texture, thin consistency diet. The supplements section had no dietary supplements stated. Review of the current care plan for Resident #9 revealed a focus area of altered nutrition had been initiated on 12/13/18. This document revealed Resident #9 was to receive Med pass 2.0, four ounces, twice a day related to poor intake and possible weight loss and was placed on the care plan on 03/27/19. Review of the Medication Administration Record [REDACTED]. Nutritional supplements would have been recorded in the TAR. These records were void of any evidence of a nutritional supplement having been provided to Resident #9. An interview was completed on 09/17/19 at 3:55 P.M. with the Administrator and Director of Nursing and no documentation was provided to evidence the facility staff had followed through with the recommendations to add nutritional supplements to the diet regimen of Resident #9. An interview was completed on 09/19/19 at 8:50 AM with Registered Dietician, (RD) #500. During the interview the dietitian stated any nutritional supplements or recommendations made by the dietitian would have been placed in a log and presented to the physician for approval. Once approval was made these orders would be placed back in the log. The registered dietitian would verify the orders and ensure follow-through was completed upon her next visit into the facility. The registered dietitian stated she had visited the facility every Tuesday and Thursday.

Based on interview and record review, the facility failed to ensure Resident #13's medical record accurately reflected his wandering behaviors. This affected one (Resident #13) of five medical records reviewed for accuracy. The facility census was 68. Findings include: Review of Resident #13's medical record revealed he was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #13's Significant Change Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed his cognition was severely impaired, revealed the resident wandered daily and it significantly intruded on the privacy or activities of others. Resident #13 required supervision of one person for locomotion on and off the unit. Resident #13's Wandering Risk Scale dated 04/07/19 revealed he was at high risk to wander. Resident #13's active comprehensive care plan revealed he is an elopement risk and wandered throughout the facility due to [MEDICAL CONDITION]. Resident #13 wanders aimlessly and can significantly intrude on the privacy or activities of others. Interventions to address this risk revealed the facility would distract the resident with diversions, structured activities, food, conversation, television, and books. The facility would also identify pattern of wandering, including if the wandering was purposeful, aimless, or escapists, to see if the resident was looking for something, and if it indicated the need for more exercise, and to intervene as appropriate. Review of the Resident Monthly Grievance Log for (MONTH) 2019 revealed Resident #8 had a concern about a wandering resident. Review of the Complaint/Grievance Report dated 04/17/19 revealed Resident #8 stated Resident #13 wandered into her room at night. Findings of the investigation included Resident #13 wandered into Resident #8's room and had thought he was going to his room to bed. Resident #8 yelled for help and put on call light and Resident #13 was taken from room. Review of the Resident Monthly Grievance Log for (MONTH) 2019 revealed on 05/08/19 Resident #14 had a concern about a wandering resident. Review of the Complaint/Grievance Report dated 05/08/19 revealed Resident #14 family had a concern that he did not want Resident #13 to wander into his wife's room. Resident #13's medical record did not contain any information about him possibly wandering into Resident #14's room and did not contain information about wandering into Resident #8's room. Interview on 05/20/19 at 8:00 A.M. with Licensed Practical Nurse (LPN) #100 revealed Resident #13 wandered, and had wandered in to Resident #14's room a couple of times. Interview on 05/20/19 at 10:10 A.M. with LPN #100 revealed they would chart wandering in resident progress notes. Interview on 05/20/19 at 10:30 A.M. with Licensed Social Worker (LSW) #206 revealed she completed the behavior portion of Resident #13's MDS on 04/24/19 that included his wandering intrudes on others privacy or activities. LSW #206 revealed she observed Resident #13 go into a residents room one time during the look back period of the assessment, but could not recall when or what resident's room. Interview on 05/20/19 at 12:15 P.M. with LPN #207 revealed she recalled Resident #14's husband calling the police around 05/06/19 after telling the staff Resident #13 was in Resident #14's room. LPN #207 revealed Resident #13 does go into resident rooms, and they usually do one on one with the resident when he does. Interview on 05/20/19 at 1:09 P.M. with the Director of Nursing (DON) revealed there was no evidence in Resident #13's medical record of him wandering into any resident rooms.

Based on interview and record review, the facility failed to ensure Resident #52 was free from verbal abuse. This affected one (Resident #52) of two residents reviewed for abuse. The facility census was 68. Findings include: Review of the medical record revealed Resident #52 was admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #52's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed her cognition was intact, had verbal behavioral symptoms directed towards others occurring one to three days during the seven day look back period, and was independent with transfers and locomotion on the unit. Review of a facility Self Reported Incident (SRI) submitted on 04/24/19 for an allegation of emotional/verbal abuse revealed on 04/24/19 State tested Nursing Assistant (STNA) #200 and Resident #52 were yelling at each other at the central hall nurses station entrance. Unit Manager, Registered Nursing (RN) #203, stepped between Resident #52 and STNA #200 and STNA #200 was escorted away from the resident. The facility substantiated the allegation of verbal abuse. Review of Activity Director #201's hand written Witness Statement dated 04/24/19 revealed she was in her office and heard yelling from the central nursing station and heard a STNA yelling and cursing at residents, saying she's tired of this place and the Unit Manager was in between the STNA and the resident. Review of Licensed Practical Nurse (LPN) #202's hand written Witness Statement dated 04/24/19 revealed she saw STNA #200 yelling at Resident #52 and called the resident a drug addict. The Unit Manager was standing between the STNA and the resident. STNA #200 went out back door screaming, these f****** residents are ridiculous. Review of RN #203's hand written Witness Statement dated 04/24/19 revealed she heard yelling and went to the nursing station and saw STNA #200 and Resident #52 yelling at each other and point their fingers at each other. RN #203 stood between them and directed the STNA to move away from the resident. Resident #52 walked away towards her room and STNA #200 yelled to her that she was a drug addict. Review of RN #204's hand written Witness Statement dated 04/24/19 revealed she heard yelling from an office, went out to the hallway and observed a STNA in the nursing station yelling and pointing her finger at a resident. As the resident turned to head back toward her room, the STNA yelled you are a drug addict. The STNA proceeded to exit the building yelling, F*** all these people, they are all crazy. There were several residents and other people present as this occurred. Review of Employee #205's hand written Witness Statement dated 04/25/19 revealed she witnessed STNA #200 call Resident #52 an explicit name. STNA #200 kept going back and forth with the resident was was getting ready to fight the resident, and the Unit Manager got in between the resident. Review of STNA #200's hand written Witness Statement dated 04/24/19 revealed while walking out the door she did say the resident was a drug addict. Review of STNA #200's Employee Corrective Action Form dated 05/03/19 for the infraction on 04/24/19, revealed she was discharged from the facility for calling a resident and explicit name during a verbal interaction. It was investigated and considered verbal abuse towards the resident. The employee was terminated. Interview on 05/20/19 at 1:42 P.M. with Administrator and Director of Nursing revealed Resident #52 yelled at STNA #200 and confirmed STNA #200 yelled back at the resident. Review of the facility Abuse, Neglect, Exploitation and Misappropriation of Resident Property, revised 10/27/17, revealed the facility would not tolerate Abuse, Neglect, Exploitation of its residents.

Based on interview and record review, the facility failed to ensure interventions were in place to detour Resident #13 from wandering into a resident's room. This affected one (Resident #13) of two residents reviewed for wandering. The facility census was 68. Findings include: Review of Resident #13's medical record revealed he was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #13's Significant Change Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed his cognition was severely impaired, revealed the resident wandered daily and it significantly intruded on the privacy or activities of others. Resident #13 required supervision of one person for locomotion on and off the unit. Resident #13's Wandering Risk Scale dated 04/07/19 revealed he was at high risk to wander. Resident #13's active comprehensive care plan revealed he is an elopement risk and wanders throughout the facility due to [MEDICAL CONDITION]. Resident #13 wanders aimlessly and can significantly intrude on the privacy or activities of others. Interventions to address this risk revealed the facility would distract the resident with diversions, structured activities, food, conversation, television, and books. The facility would also identify pattern of wandering, including if the wandering was purposeful, aimless, or escapists, to see if the resident was looking for something, and if it indicated the need for more exercise, and to intervene as appropriate. Review of the Resident Monthly Grievance Log for (MONTH) 2019 revealed on 05/08/19 Resident #14 had a concern about a wandering resident. Review of the Complaint/Grievance Report dated 05/08/19 revealed Resident #14 family had a concern that he did not want Resident #13 to wander into his wife's room. As a result of the investigation a stop sign was not on door due to painting and it was put back up. Interview on 05/20/19 at 2:52 P.M. with Administrator revealed the stop sign on Resident #14's door was effective in detouring Resident #13 from wandering into her room. Interview with the Administrator on 05/20/19 at 3:32 P.M. stated she was unsure of when Resident #14's hall was actually painted, but it was sometime in between 04/04/19 and 04/26/19, and the stop sign was removed at some point during that time period. This deficiency substantiates Complaint Number OH 246.

Based on record review and interview the facility failed to ensure laboratory tests were obtained to monitor Resident #58's iron and vitamin D blood levels. This affected one resident (Resident #58) of five residents reviewed for unnecessary medications. Findings include: Record review revealed Resident #58 was initially admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #58 had multiple admissions to the hospital for various reasons since her initial admission on 12/13/11. A review of Resident #58's clinical record upon her readmission on 06/19/18 indicated a physician order [REDACTED]. Resident #58's nutrition evaluation progress notes dated 06/21/18 indicated Vitamin D3 was administered to assist in the absorption of calcium. The iron supplement was consistent with treatment for [REDACTED]. A review of Resident #58's laboratory results dated ,[DATE] to 08/2018 indicated no evidence the blood iron level or Vitamin D level was obtained during the past 12 months in the facility or hospital setting. An interview with Resident #58's physician on 08/15/18 at 11:30 A.M. indicated the iron level and Vitamin D blood level should be checked every six months when receiving the supplementation. The physician indicated she had continued the medications the hospital had administered as indicated on the hospital transfer forms when readmitted to the facility on [DATE]. The physician assumed the hospital had obtained an iron level and Vitamin D level while in the hospital. An interview with Director of Nursing and Administrator on 08/15/18 at 2:00 P.M. verified the above findings.

Based on record review, interview and observation the facility failed to ensure a medication error rate of less than five percent. The medication error rate was 7.4% with two errors observed out of 27 opportunities. This affected two (Residents #50 and #66) of seven residents observed during medication administration. The facility census was 55 residents. Findings include: 1. Review of Resident #50's medical record revealed an admission date of [DATE]. Review of Resident #50's physician orders [REDACTED]. Observation on 07/26/17 at 8:27 A.M. revealed Licensed Practical Nurse (LPN) #10 prepared and administered eight medications to Resident #50. LPN #10 prepared [MEDICATION NAME] 400 mg tablet by placing one tablet in the medicine cup and cutting another tablet in half to make a total of 600 milligrams of [MEDICATION NAME]. LPN #10 then crushed the [MEDICATION NAME] (an [MEDICATION NAME]). LPN #10 prepared a total of eight medications and all were placed in chocolate pudding. LPN #10 entered Resident #50's room and administered the medications by mouth to Resident #50. Interview on 07/26/17 at 9:47 A.M. with LPN #10 confirmed the Guafensin 600 milligrams was not the ordered extended release [MEDICATION NAME] that was ordered by the physician to be given to Resident #50. 2. Review of Resident #66's medical record revealed an admission date of [DATE]. Review of Resident #66's physician orders [REDACTED]. Review of the orders revealed may crush meds and cocktail unless contraindicated or on list of meds not to crush. Observation on 07/26/17 at 8:55 A.M. revealed Registered Nurse (RN) #11 prepared and administered Resident #66 three medications. The medications prepared included [MEDICATION NAME] extended release 600 milligrams one tablet and placed in a medication cup with the other two prepared medications. The medications were all placed in a clear see through bag and crushed. The crushed medications were then placed in chocolate pudding and administered to Resident #50. Interview on 07/26/17 at 9:41 A.M. with RN #11 confirmed [MEDICATION NAME] extended release was crushed. RN #11 confirmed the physician order [REDACTED]. Observation and interview wth RN #11 confirmed the [MEDICATION NAME] Extened release packaging stated DO NOT CRUSH.

Based on record review and interview, the facility failed to provide pneumococcal vaccinations (Prevnar 13) in accordance with the Centers for Disease Control and Prevention guidelines. This affected three of five residents reviewed for pnuemococcal vaccinations, with the potential to affect 47 residents who had not refused the pneumoccocal vaccination. The facility census was 55 residents. Findings include: 1. Resident #16 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #16's date of birth was 05/19/47. Review of Resident #16's facility pnuemococcal vaccination record revealed she had the pneumococcal vaccination on 10/21/11. Interview on 07/26/17 at 12:41 P.M. with the Director of Nursing (DON) revealed she was unsure what pneumococcal vaccine the Resident #16 received in the past. 2. Resident #57 was admitted [DATE] on with [DIAGNOSES REDACTED]. Resident #57's date of birth was 11/18/40. Review of Resident #57's facility pnuemococcal vaccination record revealed she had the pneumococcal vaccination in November 2017. Interview on 07/26/17 at 12:41 P.M. with DON revealed she was unsure what pneumococcal vaccine Resident #57 received in the past. 3. Resident #27 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #27's date of birth was 03/01/31. Review of Resident #27's facility pnuemococcal vaccination record revealed he had the pneumococcal vaccination on 10/21/11. Interview on 07/26/17 at 12:41 P.M. with DON revealed she was unsure what pneumococcal vaccine Resident #27 received in the past. DON explained the facility completed an audit to identify what residents needed the Prevnar 13 vaccination. Interview on 07/27/17 at 10:52 A.M. with Medical Director revealed every resident that has had the pneumoccocal vaccine had the [MEDICATION NAME] 23 after age 65, and the facility was seeking clarification on what pneumococcal vaccine to then offer. Review of the Pneumonia Vaccines policy, dated 11/30/14 and revised 09/25/16, revealed if the resident has previously received the pneumoccocal vaccine at age or greater than 65 ([MEDICATION NAME] 23) and not Prevnar 13, the resident may then receive the Prevnar 13 per the physician's orders [REDACTED].

Based on record review and interview, the facility failed to ensure the responsible party was notified of dental recommendations and changes in diet for Resident #19. This affected one (Resident #19) of two residents reviewed for dental care and services. The facility census was 55 residents. Findings include: 1. Review of Resident #19's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #19's face sheet revealed she received Medicaid funding. Review of Resident #19's dental consultation form dated 06/21/16 revealed three teeth on the bottom of the mouth were recommended to be extracted for teeth number 23, 24, and 25. There was no further evidence of family notification or accepting or denying the recommendations to extract the teeth, or evidence the teeth were extracted in Resident #19's medical record. Interview on 07/25/17 at 8:55 A.M. with Family Member #13 revealed in June 2016 the dentist recommended Resident #19 have some teeth pulled. Family Member #13 indicated she was not notified of this to make a decision until April or May 2017. Family Member #13 said she was upset because she could not make a decision a year ago and at this point the resident would not be able to handle the procedure. Interview on 07/26/17 at 11:30 A.M. with Licensed Social Worker (LSW) #12 and the Administrator revealed on June 2016 a couple of fillings were completed and the dentist recommended that three teeth as noted on the consult were recommended to be extracted. LSW #12 confirmed Resident #19's power of attorney for healthcare was not notified until May 2017. Review of the notification of change in condition policy and procedure, revised 06/01/17, revealed the center will promptly notify the patient/resident, the attending physician, and the resident representative when there is a change in the status or condition. The procedure includes the nurse was to notify the attending physician and Resident Representative when there is a need to alter treatment significantly, a new treatment, or discontinutation of a current treatment. 2. Resident #19 had a diet change on 01/24/17 which was recommended by the dietitian based on a Speech Therapy evaluation for dysphagia. Her diet was downgraded from pureed with thin liquids to pureed with honey thickened liquids. Although this recommendation was enacted promptly, there was no documented evidence of family notification for this dietary change. Interview with Unit Manager #22 on 07/26/17 at 2:40 P.M. confirmed nursing was to notify the family/responsible party of any changes including dietary changes. Review of nursing notes for the month of January 2017 verified no family notification was made for this dietary change.

Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse. Harm occurred that was not immediate jeopardy when State tested Nursing Assistant (STNA) #30 pushed Resident #4 while assisting him into bed, and the resident fell backward hitting his face on the siderail. Resident #4 sustained a raised area on his left cheek and a bruise on his left hand. This affected one resident (Resident #4) reviewed for abuse, and had the potential to affect 5 residents who continued to receive care provided by STNA #30 after this incident. The facility census was 56 residents. Findings include: Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was totally dependent on two staff for all activities of daily living. The resident was not interviewable. On 04/11/17 at 1:15 P.M. and 3:05 P.M., Resident #4 was observed in bed, which was against the wall. A perimeter mattress and bed alarm were on the bed, and a mat was on the floor to the right side of the bed. The resident did not respond when his name was called multiple times. Review of the facility Self-Reported Incident (SRI) investigation revealed STNA #30 and STNA #31 were transferring Resident #4 into bed on 03/20/17 at 6:45 P.M. Sometime after the transfer, STNA #31 went to Registered Nurse (RN) #19 and informed her while they were transferring Resident #4, they sat the resident on the edge of the bed. STNA #30 seemed frustrated and pushed the resident's chest, and he fell back in the bed, hitting the left side of his head on the rail. STNA #30 saw STNA #31's facial expression and said, Sorry he is just pissing me off acting like he can't stand. Then she picked up his legs and turned his body straight in bed. STNA #31 said she then left the room. RN #19's witness statement indicated she observed a puffy area on the left upper cheek bone about a quarter in size on 03/20/17 (no time documented). There was no evidence of a witness statement from RN #60 or an assessment from RN #19. Review of the 03/21/17 shower sheet completed by RN #53 revealed the resident had a 4.0 centimeter (cm) by 1.0 cm bruise at the base of thumb and forefingers of the left hand. The Director of Nursing's (DON) statement, dated 03/23/17, revealed she did not contact STNA #30 until 03/23/17. STNA #30 said after this incident, she continued to take four residents outside to smoke, and then put Resident #32 back in bed by herself. Resident #32 was cognitively impaired. Review of STNA #30's punch detail revealed she clocked out at 8:31 P.M. STNA #30 was terminated as of 03/29/17. STNA #31 and RN #60 were no longer employed with the facility. Review of the assessment dated [DATE] from Clinical Nurse Practitioner (CNP) #50 revealed the resident could be resistive to care, and his care often takes lots of time and patience. The resident had a large bruise noted on his left hand which was present the previous day. On 04/11/17 at 1:20 P.M., interview with Licensed Practical Nurse (LPN) #14 revealed she received a phone call from RN #60 on 03/20/17 at 7:40 P.M. RN #60 said there was an incident and called her back from his cellular phone at 7:50 P.M. At that time RN #60 informed LPN #14 of STNA #31's allegation that STNA #30 was physically abusive towards Resident #4. LPN #14 instructed him to remove STNA #30 from care, and keep her with him until the DON called in with further instructions. On 04/11/17 at 2:45 P.M., interview with the administrator verified the concern with the SRI and allowing STNA #30 to continue to care for residents after the allegation of abuse was made to RN #19. This included STNA #30 transferring Resident #32 into bed by herself. Resident #32 was dependent on transfers and was cognitively impaired. On 04/11/17 at 3:15 P.M., telephone interview with RN #19 revealed on 03/20/17 around 6:00 P.M. or 6:30 P.M., STNA #31 informed her of concerns with abuse by STNA #30 while she and STNA #30 were transferring Resident #4 in bed. RN #19 said she went in and looked at the resident's head and she observed a raised area to his cheek bone. She then told RN #60 as this was his resident, and informed him of STNA #31's allegation. RN #19 said after that, she was not involved. RN #60 then spoke with STNA #31 and he called LPN #14. STNA #30 continued to care for resident's, including cognitively impaired residents, on her assignment until about 8:30 P.M. This deficiency resulted from incidental findings discovered during the investigation of Complaint Number OH 515.