Every finding on record at Trinity Health Care of Mingo

Based on record review and staff interviews the facility failed to ensure the comprehensive care plan in the area for dental services for resident #5 and activity preferences for Resident's #8 and #50 were developed. This was found true for three (3) of 25 residents' care plans reviewed during the long-term care survey process. Resident identifiers #8, #50, and #5 Facility Census: 82 a) Resident #8 During record review on 08/27/25 at approximately 2:00 PM of Resident #8's section F of the Minimum Data Set (MDS) revealed the resident enjoys Music, Pets, Religious activities and doing things with groups of people. Further record review of resident #8's personalized care plan interventions revealed the following interventions; Staff will assist her to/from group activities as needed Staff will give her verbal praise for her attendance in any group activity Staff will invite/encourage her to attend group activities of her choice. Staff will post a monthly activity calendar in her room for her review. Music, Pets, religious activities, which were activities she enjoys doin were not in Resident #8's care plan. An interview with the Activity Director on 08/27/25 at 2:30 PM who stated I'll be right back, let me fix that now. Confirming the residents preferences for activities should have been in the care plan. b) Resident # 50 During record review on 08/26/25 3:30 PM of resident #50's most recent activity evaluation revealed they enjoy Religious/spiritual; activities, parties, music, radio, and watching TV. Further record review of Resident #50's care plan revealed the following interventions; Staff will assist her to and from group activities for choice Staff will thank her for allowing them to visit her Staff will turn on television on for audible stimulation Staff will visit her room and attempt simple short conversations. Nothing in the residents person centered care plan mentions resident #50's preferences for religious/spiritual activities, music/radio, or that the facility provides residents with a monthly activity program calendar. The activity Director confirmed the care plan as missing resident preferences on 08/28/25 at 2:30 PM c) Resident #5 During an interview on 08/25/25 at 1:58 PM, Resident #5 stated she needed to have a tooth pulled, but she wasn't sure if the extraction had been scheduled. She had an obviously carious front tooth. The resident stated she was beginning to have twinges of pain in the front tooth. Review of Resident #5's medical records showed a consultation report from a dentist dated 12/06/24. The dentist recommended extraction of her remaining maxillary (upper jaw) teeth. The resident's annual Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) contained the following notes in the Care Area Assessment (CAA) process: Resident has natural teeth; she has some missing teeth and potential caries. Dental exam performed at [Dental Clinic] on 12/6/24; resident referred to [Oral Surgery Clinic] for surgical extraction of remaining maxillary dentition #6-#12 and we are awaiting appointment date and time. Resident currently denies oral/tooth pain .Dental care to be addressed with interventions to ensure resident receives proper dental/oral hygiene and dental care at outside facilities, as well as observation for any oral pain or difficulties with chewing/swallowing. Review of Resident #5's comprehensive care plan did not show a focus related to dental status. The resident's Activities of Daily living focus contained an intervention to perform oral care every shift. On 08/27/2025 at 11:12 AM, Assistant Director of Nursing (ADON) #57 confirmed Resident #5 was not care planned for dental issues. She stated she would revise the resident's care plan.

Based on record review and staff interview, the facility failed to ensure a complete and accurate Minimum Data (MDS) assessment in the area of hospice. This deficient practice had the potential to affect one (1) of one (1) residents reviewed for the care area of hospice. Resident Identifiers: #62. Facility Census: 82.Findings included:a) Resident #62 Review of Resident #62's physician's orders showed an order written on 03/14/25 for Hospice Care, Do Not Resuscitate, Comfort Treatments. Review of Resident #62's comprehensive care plan confirmed the resident was receiving hospice services. Resident #62's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 05/01/25 documented the resident was receiving hospice services. Resident #62's quarterly MDS with ARD 07/17/25 documented the resident was not receiving hospice services. On 08/26/25 at 3:33 PM, the Director of Nursing (DON) confirmed Resident #62's MDS with ARD 07/17/25 was incorrect and should have indicated the resident was receiving hospice services. The DON stated she corrected the MDS.

Based on record review, staff interview, and policy review, the facility failed to ensure that a comprehensive activities assessment was completed for one (1) of two (2) residents (Resident #8) reviewed for activities during the long-term care survey. Facility census: 82. Resident identifier: #8 Findings Include:a) Resident #8The facility's policy titled Timeframe for Completion of Activities Assessment on New Admissions states: An initial activities interest screening shall be completed by Activities staff or designee within 72 hours of admission to identify immediate preferences and needs. A full Activities Assessment, consistent with the Minimum Data Set (MDS) and facility policy, shall be completed within 14 calendar days of admission. The Activities Assessment will be used to develop an individualized Activity Care Plan. completed and entered in the resident's comprehensive care plan within 7 days after completion of the MDS assessment reference date, per CMS guidelines.On 08/27/25 at 12:30 PM, record review revealed that Resident #8 had an Activity evaluation opened on 04/21/25; however, the evaluation was incomplete, remained in progress, and was not signed.Further review revealed no evidence of an initial activities interest screening within 72 hours of admission or a comprehensive activities assessment within 14 days, as required by facility policy and federal regulation.During an interview conducted on 08/27/25 at 12:45 PM, the Activities Director (AD) stated: I'm not sure how that happened, it was not completed, and I will go do that right now, confirming the assessment had not been completed since the resident's admission.

Based on observation, record review, and staff interview the facility failed to ensure hazardous chemicals were stored and used safely, creating a potential chemical exposure hazard for residents residing in the long-term care facility, this was a random opportunity for discovery. Facility Census: 82. Findings include:a) On 08/25/25 at 11:25 AM, the NA (Nurse Aide) cart was observed to contain a container of Sumer Sani-Cloth Germicidal Wipes.During an interview on 08/25/25 at 11:30 AM, the Infection Preventionist (IP Nurse #81) stated, These aint suppose to be on the NA cart, we use these to wipe equipment down after use like, the lifts, glucose machines, vitals machines, I'll educate staff now, and removed the wipes from the cart. confirming they should not be accessable to residents expecially residents who does not have capacity.Recoird Review completed on 08/25/25 at 12:12 PM of the Safety Data Sheet (SDS) revealed the following hazards:Causes serious eye irritationMay cause drowsiness or dizzinessFlammable liquid and vaporMay be harmful if swallowed or inhaled

Based on observation, record review, and staff interview, the facility failed to provide respiratory services in accordance with professional standards of practice. For one (1) of one (1) residents reviewed for the care area of respiratory care, the supplemental oxygen flow rate was not set to the rate ordered by the physician. Resident Identifier: #74. Facility Census: 82.Findings included: a) Resident #74 Review of Resident #74's physician's orders showed an order written on 08/01/25 for oxygen at 3 liters per minute (LPM) via nasal cannula per concentrator as needed for chronic obstructive pulmonary disorder (COPD). An observation on 08/25/25 at 1:05 PM showed the resident was in bed with oxygen 1.5 LPM infusing via nasal cannula. An observation on 08/26/25 at 9:35 AM showed the resident was in bed with oxygen 2 LPM infusing via nasal cannula. An observation on 08/27/25 at 10:35 AM showed the resident was in bed with oxygen 2 LPM infusing via nasal cannula. This was confirmed by the Director of Nursing (DON). The DON increased the resident's oxygen to 3 LPM in accordance with the physician's order.

Based on observation, record review, resident interview, and staff interview, the facility failed to obtain dental services to meet the resident's needs. This deficient practice had the potential to affect one (1) of one (1) residents reviewed for the dental care area. Resident identifier: #5. Facility census: 82.Findings included:a) Resident #5 During an interview on 08/25/25 at 1:58 PM, Resident #5 stated she needed to have a tooth pulled, but she wasn't sure if the extraction had been scheduled. She had an obviously carious front tooth. The resident stated she was beginning to have twinges of pain in the front tooth. Review of Resident #5's medical records showed a consultation report from a dentist dated 12/06/24. The dentist recommended extraction of her remaining maxillary (upper jaw) teeth. A referral was to be made to an oral surgery clinic. The resident's annual Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) contained the following note in the Care Area Assessment (CAA) process: Resident has natural teeth; she has some missing teeth and potential caries. Dental exam performed at [Dental Clinic] on 12/6/24; resident referred to [Oral Surgery Clinic] for surgical extraction of remaining maxillary dentition #6-#12 and we are awaiting appointment date and time. Resident currently denies oral/tooth pain.On 08/27/25 at 2:18 PM, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) #57 confirmed Resident #5 had not had the dental extractions recommended by the dentist on 12/06/24. They contacted the oral surgery clinic, who provided them with documentation regarding a referral made on 04/22/25. The oral surgery clinic stated they had left messages with the resident's daughter twice. The oral surgery clinic also stated the surgeon who was to perform the surgery had since left the clinic. ADON #57 stated the oral surgery clinic was asked to call the facility to schedule an appointment for tooth extraction.

Based on observation, record review, and staff interview, the facility failed to provide physician-ordered adaptive eating devices for one (1) of two (2) residents reviewed for the care area of nutrition. Resident identifier: #48. Facility census: 82. Findings included: a) Resident #48 Review of Resident #48's physician's orders showed the following orders: NAS (no added salt) and LCS (low concentrated sugar) diet, pureed texture, honey thick consistency Cup with lid d/t [due to] aspiration precaution. No straws d/t (due to) aspiration precautions. All these orders were written on 07/11/25. On 08/27/25 at 11:18 AM, Nurse Aide (NA) #14 was observed setting up Resident #48's lunch tray on his overbed table while the resident was in bed. The resident had a carton of honey thickened beverage with a straw in it. Resident #48's tray ticket stated, No straws. NA #14 confirmed Resident #48 was to have no straws according to his tray ticket. NA #14 removed the straw from the beverage carton and obtained a lidded cup from the kitchen for the resident's beverage. On 08/27/25, the Director of Nursing confirmed Resident #48 was not using straws due to aspiration precautions.

Based on review record, staff interviews, reportable's (immediate and five (5) day), and staff education, time line of the incident and plan of correction, the facility failed to ensure a resident was protected from neglect. Resident #42 sustained a fractured hip and a subdural hematoma from an unwitnessed event. The resident was sent to a local hospital where the subdural hematoma had ceased and the hip was repaired. This caused physical harm to the resident and will be cited a G at F600. Resident identifier: #42 Facility census: 81. Findings included: a) Resident #42 Resident #42 was originally admitted on [DATE]. Diagnoses included Alzheimer's disease, history of falling, left artificial hip joint, hypertension, heart failure, adult failure to thrive, and Dementia severe with agitation. An annual Minimum Data Set (MDS) with Assessment Reference Date (ARD) 01/16/24 had a Brief Interview of Mental Status (BIMS) of 3. The BIMS score of three (3) indicates severe cognitive impairment. A review of the 5-day PPS MDS with an ARD of 02/22/24 found that the resident was dependent for toileting, shower/bath, maximum assistance for dressing, sit to lying; partial to moderate assistance lying to sitting, sit to stand, chair/bed to chair, toileting; walking not attempted due to medical condition or safety. Uses a wheelchair for transportation and wheeling self around facility. On 03/12/24 at 9:01 AM a review of the reportable for Resident #42 was conducted. Adult Protective Services (APS) was notified on 03/02/24 and referral was not assigned for investigation. OHFLAC and Ombudsman were notified on 03/02/24 and the five (5) day follow up was completed on 03/06/24. Another immediate reporting was completed on 03/06/24 when after the five (5) day followup found possible neglect. This was reported to OHFLAC, Ombudsman, APS and the Nurse Aide Registry. A five (5) day followup was again completed on 03/11/24. An incident report was completed on 03/02/24 at 7:15 AM. A review of reportable folder found statements from Nurse Aides (NA) and Licensed Practical Nurse (LPN). NA #26 made the following statement on 03/02/24 (typed as written) I (name redacted),took care of (resident first name) the night of March 1, 2024. That night me and my partner took her to bed and changed her and she was fine. Then at 3am we did another check and we put hipster's and pants on her up above her knees. She was being hateful and we left them up above her knees but did not fall on us at all. Then at 5am we did another bed check she was fine she aslrp but we checked her and she was dried so we left her alone and went and change the other resident in her room. but she was fine we seen nothing wrong with her and no places on her. She still didn't fall on us that time either. A telephone interview with NA #26 conducted on 03/02/24 at 7:58 PM revealed NA #26 confirmed her statement as read to her. She confirmed that the hipsters were half way down thigh . wasn't all the way up. NA #26 confirmed she had education regarding abuse and neglect and hipsters. NA #61 NA #61 made the following statement on 03/02/24 (typed as written) On my shift on March 1st, I took care of (resident name redacted). She stayed up late. I changed her and put her in bed. I checked on her through the night, I did not change her every bed check because she wasn't wet, but I was in there to check on her room mate. But around 3 something in the morning I did change her because she was wet. I did not notice anything out of the ordinary she was the same combated resident. She was saying a few foul words and smacking but she was changed anyways, I did not fight with her to get her pants up, I left them half up, I come back to do my last check in there, changed her room mate and checked (resident first name redacted) after, and she was dry so I did not wake (resident name redacted) up I left her alone. But Resident did not show any signs out of the ordinary or I would have reported to the nurse. A telephone interview with NA #61 conducted on 03/02/24 at 7:58 PM until 8:12 PM revealed NA #61 confirmed her statement as read to her. When asked what the difference was in her first and second statement, she stated that she was nervous and scared when she made first statement of having left hipsters and pants half way down the residents legs. Stated that she changed Resident #42 around 3-4 AM and her hipsters were wet and changed. As the resident was fighting being changed, the pants were not put on. NA #61 stated that she placed the pants on the end of the bed. NA # 91 NA #91 made the following statement on 03/02/24 (typed as written) When I came up the hall I saw (resident name redacted) legs up in the air. Another CNA #129 was already in the room I walked in to see if she needed help and I notices (resident first name redacted) hipsters were down to her knees I walked on side of the bed to help the CNA try to get (resident first name redacted) dressed when I looked down at (resident first name redacted) I noticed a big bruise on side of her head. CNA # 129 went and got nurse immediately we than stalted [sic] dressing (resident name redacted) and saw blood on her arm from skin tear After taking off her shirt we saw a big Bruise on her shoulder [sic] me and (CNA first name redacted) #62 help (resident first name redacted) up into her wheelchair We notice she couldn ' t[sic] stand good. A telephone interview with NA #91 conducted on 03/02/24 at 11:14 PM revealed NA #91 confirmed her statement as read to her. She stated that Resident #24 was agitated and wanted to get up. When ask if she thought the resident could get herself up said I don't know. She comment that her pants were folded up at the foot of the bed which she though was strange as the resident always complains about being cold and had on no pants. NA #62 NA #62 made the following statement on 03/02/24 (typed as written) Was taking a resident up hall when CNA #91 yelled at me for help resident was unable to stand I went in to help and me (NA #62) and CNA discovered bruise on side (right) of head and found bruise on shoulder (right) and discovered blood on sheets and found skin tear on right elbow. Then the nurse came in. A telephone interview with NA #62 conducted on 03/02/24 at 11:08 PM revealed NA #62 confirmed her statement as read to her. In addition she stated she was standing on the other side of the bed and the resident was in no pain. She did not notice any red marks on hips. NA #129 NA #129 made the following statement on 03/02/24 (typed as written). I was in a resident room when I heard (resident name redacted) call out for help. I went into (resident name redacted) room, and was standing at foot of bed; and asked her what she needed about that time (CNA name redacted) #91 walked to (resident's name redacted) bedside and noticed a bruise on (resident first name redacted) head. I left to go get the nurse on duty. When we the nurse and I returned CNA first name redacted) #91 noticed blood on (residents name redacted) sheet, her hipsters was at her knees. We found a pair of pants and shirt lying on floor in front of her closet. A telephone interview with NA #129 conducted on 03/02/24 at 7:58 PM revealed NA #26 confirmed her statement as read to her. Timeline from facility On March 2, 2024 - Nurse was notified by incoming day shift CNA's on residents condition - All parties at this time as made aware and paper work initiated to turned into APS, OHFLAC, and Ombudsman immediately. - Administrator watched the cameras that day with nothing suspicious noted or reported at that time. 6:46 AM CNA (#129 an #91) in the room this is the original finding of injuries 6:48 AM CNA #129 went to get the nurse 6:49 AM Nurse (LPN #11) enters the room 6:53 AM Nurse (LPN #85)s enters the room 7:20 AM Paper work initiated 7:50 AM Ambulance arrives On March 6, 2024 in person interviews with CNA's #91, #62, and #129 was completed by the Administrator, Social Worker, Medical Records, LPN, Assistant Director of Nursing (ADON) and the interim Director of Nursing (DON). Statements were received by CNA's #61 and #26. Discovered at this time that the hipsters and pants were left down around the residents knees. Social Worker turned in immediately to CNA Board, APS, OHFLAC and Ombudsman. On 03/06/24 education on the importance of hipster use and all protective devices began and disciplinary action taken by the CNA Supervisor for CNA's #61 and #26. The education included all NA's except one (1). No information was available as to who conducted the inservice. An additional education on hipsters on the evening of 03/06/24 was held by the DON, and the Administrator on the importance of these (hipsters) being in place. Because we had not received the statements until this time, we had no reason to believe that this was an abuse or neglect situation. On 03/06/24 monitoring of all aides began by supervisors. As of 03/06/24 audits began on residents with hipsters. Spot checks performed on both day and night shift by the supervisor on shift. Audits remain ongoing at this time . Abuse and Neglect In Service conducted by Social Worker for CNA's #61 and #26 on 03/06/24. The facility provided evidence of an inservice on abuse and neglect given by the NHA and DON on 02/07/24 for all employees. In addition, an inservice regarding reporting of alleged violations was held on 02/26/24 by the NHA and DON which was attended by all staff from all departments. On March 6, 2024 - Five day followup turned in. - At this time it was substantiated as neglect due to reviewing the statements. - Spoke with the two (2) aides #61 and #26 letting the know that it had been substantiated and was turned into appropriate agencies. - Counseled again and informed them that the monitoring by supervisor would continue and any further finding would result in termination. On March 13, 2024 - CNA #61 will be terminated today. Facility Investigation findings for Resident #42 Incident Occurring on 03/02/24 Resident investigation noted that resident had a shower on 02/28/24 and was scheduled for a shower on 03/02/24 but had not actually had one on this day due to time of incident. Also noted that cameras were observed that shows resident door had been left open for the night and into the morning of incident. Cameras also show no outside entry of anyone other than staff for care provision into residents room and also adjoining room. Room mate is bed bound as are the 2 neighboring residents in adjoining room. When asked all residents in room and neighboring room deny hearing any type of noises that night. One neighboring resident did say that she ha heard the bathroom door shut before but on this night. Resident was shown on camera in wheelchair awaiting for ambulance transfer eating and tapping right foot on the floor with no obvious signs of pain when sitting. Was not able to bear weight when being placed on the gurney for transport which also was observed on the camera. Staff are being interviewed for recount of the shifts working on 03/01/24 and 03/02/24 and oncoming staff for shift change. Resident alarms were reordered upon re-entry due to psychotropic meds ordered. Resident alarms were discontinued on 03/28/24 due to residents behavior had been disagreeable with use and carrying on her lap instead of leaving in place causing her to become upset with use and with staff attempting to place. Resident was also noted to be receiving PT and restorative services. Wheelchair was her primary mode of locomotion daily. Dycem to wheelchair and hipsters remained ordered for safety. Hipsters were noted to be half way down on thigh area above knees when oncoming staff went in to do their bed check and to get resident up for breakfast and this is when injuries were found and unwitnessed accounts of how they were sustained. This was immediately reported to OHFLAC, APS, Ombudsman and physician was notified for immediate transport orders for evaluation due to injuries following observation by LPN on duty. Resident did remain alert and verbal without loss of consciousness or changes to mental or communicative status. (Name of local hospital) reported that resident did have a right hip fracture but did not perform a head CT due to resident having aggressive behavior per nurse report. Was transported to (name of medical center) and found to have an active subdural hemorrhage. Were making arrangements for surgery to right hip for repair per nursing report when calling to find out status of resident. Noted to have surgical repair to right hip while at name of medical center when they were called to check the status of resident. Also was noted that the subdural hemorrhage had ceased prior to surgery on hip without intervention. Resident had reportedly done well for the surgical process, however, had passed away while aftercare was being done. Compiled by the facility Social Worker. Plan of Correction The facility submitted the following plan of correction on 03/3/24: Element 1: On March 2, 2024 Nurse was notified by incoming day shift CNA's on resident's condition. The residents (family member), the facility Administrator, DON, Director of Social Services were notified of the incident, and the required reporting documents were completed and reported to APS, OHFLAC, Ombudsman immediately. The facility Risk Manager and Social Services Director began investigating the incident on this date. Element 2: Because this has the potential to impact all residents, on March 6, 2024 two (2) employee statements indicated the potential for neglect on there behalf. The two (2) employees received disciplinary action and education on abuse and neglect and the importance of hipsters and protective devices on this date. All other facility employees were in-serviced on the proper reporting procedures of allegations of Abuse and Neglect on this date as well. The Social Services Director reported the potential for neglect for both employees to the CNA Registry on this date as well. On 03/06/24 the facility began an audit on residents with hipsters. Spot checks are performed on all shifts by the CNA shift supervisor. Element 3: The CNA Supervisor developed a monitoring log on 03/06/24 to ensure all residents with an order for hipsters have them in place as ordered. The on-shift CNA Supervisor will complete the log on each shift daily for 90 days, every other day for two weeks, then randomly thereafter. The DON will review the logs on a monthly basis for accuracy and completeness. Audits will be re-evaluated at the quarterly Quality Assurance Meeting to ensure continued compliance. To ensure all residents are free from abuse and neglect the Social Services Director will continue to complete a Abuse and Neglect Log to monitor the potential abuse and neglect that a resident may receive. To continue compliance the Social Services Director will complete a Quarterly Abuse and Neglect Log to turn in at our quarterly Quality Assurance Meeting to ensure continued compliance. All accusations of abuse and neglect will be investigated and reported and the accusative will be properly disciplined. Interviews were conducted on 03/12/24 with the following staff members regarding the education of reporting abuse and neglect and the use of hipsters: LPN #19 at 1:20 PM Answered questions correctly regarding reporting of abuse and neglect and the use of hipsters. Housekeeping Aide #52. Answered question correctly regarding reporting of abuse and neglect. HA #52 stated that she knows nothing regarding hipsters that that is not her job. NA #60 at 1:30 PM. Answered questions correctly regarding reporting of abuse and neglect and the use of hipsters. NA #32 at 1:33 PM. Answered questions correctly regarding reporting of abuse and neglect and the use of hipsters. NA/Restorative #5 at 1:40 PM. Answered questions correctly regarding reporting of abuse and neglect and the use of hipsters. NA #71 at 1:43 PM. Answered questions correctly regarding reporting of abuse and neglect and the use of hipsters. RN #109 and LPN #70 at 2:55 PM. Answered questions correctly regarding reporting of abuse and neglect and the use of hipsters. RN #109 stated that we are monitoring all residents who are ordered hipsters every shift to see that they are appropriately applied. Interviewed the DON and LPN #59 at 2:58 PM Answered questions correctly regarding reporting of abuse and neglect and the use of hipsters. NA # 129 at 3:00 PM. Answered questions correctly regarding reporting of abuse and neglect and the use of hipsters. The Hipster Monitoring log was reviewed and found the monitoring started on 03/06/24 and was ongoing during the complaint investigation. The following residents were being monitored for ordered hipsters: Resident # 300, #307, #62, #46 and #303. Random observations during the complaint investigation (03/12-13/24) of each resident found the hipsters were applied correctly. On 03/13/24 at 10:39 AM a survey team member reported the following interviews: NA #123 an interview on 03/13/24 at 9:56 AM with NA #123 stated that everything must be reported. If she sees anything suspicious she is to remove/protect the resident and immediately report it to her nurse. NA #123 also states administration goes over this stuff with us and so does the nurses. At 10:02AM NA #98 stated that he would report any abuse or neglect to his nurse but would also make sure the resident was removed or safe first then report NA # 98 also states he is inserviced on abuse and neglect reporting regularly/yearly. At 10:10 AM Activity Assistant (AA) #117 stated that she would make sure the resident is safe and free from abuse and immediately call for the nurse/ person in charge . AA #117 stated I would report anything and everything I may think is abuse or neglect, because even if it aint it still needs to be looked into. LPN #58 at 10:21 AM stated that there is a book behind the nurses stations on how to report. After the resident is safe, you must report within two (2) hours to all agencies and investigate.

Based on record review and staff interview the facility failed to complete a new pre-admission screening and resident review (PASARR) when four (4) of five (5) reviewed for the care area of PASARR received a new diagnosis of a serious mental disorder. Resident identifiers: 66, 10, 62, 24. Facility Census: 77. Findings included: a) Resident #66 On 01/02/24 at approximately 01:45 PM, record review indicates that Resident #66 was admitted to the facility with a PASARR indicating no diagnosis of Major Depressive Disorder. Resident #66 was diagnosed with Major Depressive Disorder, Single Episode, on 04/14/23 and the PASARR was not updated to reflect the diagnosis. On 01/03/24 at approximately 09:56 AM, the Director of Nursing (DON) #23 presented copies of Resident #66's diagnoses, care plan, and PASARR. The DON #23 acknowledged the diagnosis of Major Depressive Disorder, the missing on the most recent PASARR, and acknowledged there was no updated PASARR to reflect the diagnosis. b) Resident #10 On 01/02/24 at approximately 02:00 PM, record review indicates that Resident #10 was admitted to the facility on [DATE] with a PASARR that indicated no diagnosis of Major Depressive Disorder. Upon admission, Resident #10 was diagnosed with Major Depressive Disorder. The PASARR was not updated to reflect the diagnosis of Major Depressive Disorder. 01/03/24 09:56 AM Director of Nursing (DON) #23 presented copies of Resident #10's diagnoses, care plan, and PASARR. The DON #23 acknowledged the diagnosis of Major Depressive Disorder, was missing on the PASARR, and acknowledged there was no updated PASARR to reflect the diagnosis. c) Resident #62 During a medical record review on 01/02/24, revealed Resident #62 had a new psychiatric diagnosis of major depressive disorder on 10/01/23. There was no new PASARR completed with the new psychiatric diagnosis. In an interview with the Director of Nursing (DON) on 01/02/24 at 4:30 PM, she verified the new diagnosis of major depressive disorder for Resident #62 on 10/01/22 had no new PASARR completed to update the new diagnosis of major depressive disorder. d) Resident #24 During a medical record review on 01/02/24, revealed Resident #24 had a diagnosis of schizoaffective disorder on 04/06/23. The PASARR completed on 08/16/23 did not include the psychiatric diagnosis of schizoaffective disorder. In an interview with the Director of Nursing (DON) on 01/02/24 at 4:30 PM, she verified the diagnosis of schizoaffective disorder for Resident #24 had not been included on the PASARR completed on 08/16/23. 49467

Based on record review and staff interview the facility failed to ensure one (1) of one (1) Resident reviewed for the care area of death received medications as ordered by the physician. Resident identifier: 80. Facility census: 77. Findings included: a) Resident #80 Record review found the resident was admitted to the facility on [DATE]. The Resident expired at the facility on [DATE]. Review of the Medication Administration Record (MAR) found an order for Lisinopril, oral tablet, 5 milligrams (mg's) give 1 tablet by mouth, one time a day, The start date of the Lisinopril was [DATE]. HOLD if systolic Blood pressure is less than 120 or if heart rate is less than 60 beats per minute (BPM) and Notify MD (doctor.) The medication was ordered to be given at 9:00 AM. The diagnosis for use of this medication was, Essential Hypertension. Review of the MAR found the following days when the medication was administered, but should have been held according to the physician's order because the systolic blood pressure was lower than 120 and/or the heart rate was lower than 60 BPM: [DATE] Blood Pressure (BP) ,d+[DATE], [DATE] BP ,d+[DATE] [DATE] BP ,d+[DATE] [DATE] BP ,d+[DATE] [DATE] BP ,d+[DATE] [DATE] BP ,d+[DATE] [DATE] BP ,d+[DATE], heart rate: 56 [DATE] BP ,d+[DATE] [DATE] BP ,d+[DATE] [DATE] BP ,d+[DATE], Heart rate: 57 [DATE] BP ,d+[DATE], Heart rate: 57 [DATE] BP ,d+[DATE] [DATE] BP ,d+[DATE] [DATE] BP ,d+[DATE] [DATE] BP ,d+[DATE] [DATE] BP ,d+[DATE] [DATE] BP ,d+[DATE] [DATE] BP ,d+[DATE] [DATE] BP ,d+[DATE] [DATE] BP ,d+[DATE] [DATE] BP ,d+[DATE] In addition the Resident had an order to receive Coreg Oral Tablet 6.25 mg., give 1 tablet by mouth two (2) times a day at 9:00 AM and 9:00 PM for a diagnosis of Unspecified Diastolic Congestive Heart Failure. HOLD if systolic Blood pressure is less than 120 or if heart rate is less than 60 beats per minute (BPM) and Notify MD (doctor.) The start date of the medication was [DATE]. The start date was [DATE]. On the following days at 9:00 AM the medication was given outside the ordered physician's parameters: [DATE] Blood Pressure (BP) ,d+[DATE], [DATE] BP ,d+[DATE] [DATE] BP ,d+[DATE] [DATE] BP ,d+[DATE] [DATE] BP ,d+[DATE] [DATE] BP ,d+[DATE] [DATE] BP ,d+[DATE], heart rate: 56 [DATE] BP ,d+[DATE] [DATE] BP ,d+[DATE] [DATE] BP ,d+[DATE], Heart rate: 57 [DATE] BP ,d+[DATE], Heart rate: 57 [DATE] BP ,d+[DATE] [DATE] BP ,d+[DATE] [DATE] BP ,d+[DATE] [DATE] BP ,d+[DATE] [DATE] BP ,d+[DATE] [DATE] BP ,d+[DATE] [DATE] BP ,d+[DATE] [DATE] BP ,d+[DATE] [DATE] BP ,d+[DATE] [DATE] BP ,d+[DATE] On the following days the 9:00 PM dosage was administered outside the physician's parameters: [DATE] BP ,d+[DATE] [DATE] BP ,d+[DATE] [DATE] BP ,d+[DATE] [DATE] BP ,d+[DATE] [DATE] BP ,d+[DATE] [DATE] BP ,d+[DATE] [DATE] BP ,d+[DATE] [DATE] BP ,d+[DATE] [DATE] BP ,d+[DATE] [DATE] BP ,d+[DATE] [DATE] BP ,d+[DATE] [DATE] BP ,d+[DATE] [DATE] BP ,d+[DATE] [DATE] BP ,d+[DATE] [DATE] BP ,d+[DATE] [DATE] BP ,d+[DATE] [DATE] BP ,d+[DATE] [DATE] BP ,d+[DATE] [DATE] BP ,d+[DATE] [DATE] BP ,d+[DATE] [DATE] BP ,d+[DATE] [DATE] BP ,d+[DATE] [DATE] BP ,d+[DATE] On [DATE] at 11:53 AM, the Director of Nursing (DON) said the order says to contact the physician so most likely the physician was contacted and the physician ordered the medications to be given. The DON said she would look for evidence the physician was contacted. On [DATE] at 1:14 PM, the DON said she could not find any evidence the physician was contacted. The DON confirmed the medication should not have been given on 61 occasions during 30 days in November and 8 days in December, 2023. At 11:10 AM on [DATE], the DON was asked if she could explain why the Resident's blood pressure was ,d+[DATE] on [DATE] and ,d+[DATE] on [DATE] as recorded on the MAR? Both readings would have been considered critically low. The DON provided information indicating these recordings were made in error. Nurses document on paper and then enter the numbers on the MAR. On [DATE] the hand written information indicated the BP was ,d+[DATE] and on [DATE] the BP was ,d+[DATE]. The DON said on both occasions the medication should have been held.

Based on observation and staff interview the facility failed to ensure food was stored in accordance with professional standards for food service safety. This deficient practice had the potential to affect any resident receiving nourishment from the kitchen. Facility census: 77. Findings included: a) Kitchen tour During the kitchen tour on 01/02/24 at 11:15 AM, it was discovered the drip pan had a large accumulation of grease build up. In the walk-in cooler a bin holding four (4) ounce orange juice cups had two (2) cups that had been crushed and the orange juice had poured out over the other juice cups and accumulated in the bottom of the bin. There was a used paper towel and a strip of cardboard lying on top of the orange juice cups. An interview with the Dietary Manager (DM) on 01/02/24 at 11:15 AM, verified the grease drip pan needed to be cleaned and the two (2) damaged orange juice cups had contaminated the other orange juice cups.

Based on observation, resident interview, and staff interview, the facility failed to provide a safe, clean, comfortable and homelike environment. This was a random opportunity for discovery. Resident Identifier: 4. Facility Census: 77. Findings included: a) Resident #4 On 01/02/24 at approximately 12:47 PM, Resident #4 ' s room was observed to have a strong urine odor. There were multiple wet spots in the floor in Resident # 4's room along with dirty wheelchair tracks streaked through the liquid in the floor. Resident #4 stated he/she had soiled their clothes and changed themselves. Soiled clothes were observed laying on the bathroom floor with wet spots leading out into Resident #4's bedroom. Resident #4 stated in the interview he/she had soiled their clothes, and got a pack of underwear from the aides so I could change myself. Resident #4 indicated he/she had changed their clothes and left them on the bathroom floor. On 01/02/24 at 12:50 PM, Housekeeper #100 entered the room and acknowledged the smell, wet spots, dirt spots, and soiled clothes on the floor.

Based on record review and staff interview, the facility failed to ensure a facility initiated thirty day notice of discharge contained the date the discharge notice was issued and the effective discharge date . This was true for one (1) out of two (2) Residents reviewed for discharges. Resident identifier: #29. Facility census: 77. Findings included: a) Resident #29 Record review found resident #29 had multiple physical and verbal altercations with staff and residents. The facility implemented numerous interventions when behaviors occurred with no success. The facility issued a 30 day discharge notice, stating the Resident was a danger to self and other Residents. With no placement being found for Resident #29, he currently remains at the facility. On 01/03/24 at 1:00 PM, record review found the 30 day discharge notice for Resident # 29 did not contain the date the discharge was initiated or the effective discharge date on the letter issued to the responsible party and the required State authorities. On 01/03/24 at 1:54 PM, the administrator confirmed the notice was not dated as to when it was provided and the effective date of the discharge was not included on the 30 day discharge notice.

Based on recorded review, resident interview, and staff interview the facility failed to have an assessment that accurately reflected the resident's status. This was true for one (1) out of four (4) Residents reviewed for the care area of falls. Resident identifier: Resident # 32. Facility census 77. Findings included: a) Resident # 32 During a review of the Minimum Data Set (MDS), it was documented that Resident #32 had a fall with a major injury. On 01/02/24 at 2:23 PM, Resident # 32 was asked about the fall and the major injury. Resident #32 stated he fell out of his chair last summer, but he did not get hurt. On 01/03/24 at 10:28 AM medical records Clerk #103 stated Resident #32 only had one fall on 07/31/23 with no injuries. On 01/03/24 at 1:46 PM, the Director of Nursing (DON) confirmed Resident #32's fall with injury was coded incorrectly by the MDS nurse. The DON said the major injury was from a resident-to-resident altercation on 09/14/23, not from a fall.

Based on observation and staff interview the facility failed to ensure garbage storage area was maintained in a sanitary condition to prevent the harborage and feeding of pests. It was discovered the dumpster's were full and overflowing with several garbage bags lying on each of the dumpster's. Facility census: 77. Findings included: a) Garbage storage area During an observation of the garbage storage area on 01/03/24 at 10:45 AM, it was discovered the three (3) dumpster's were full and had several garbage bags lying on top of the lids of the dumpster's. An interview with the Nursing Home Administrator (NHA) the on 01/02/24 at 12:30 PM, verified the area trash disposal company was to deliver an extra dumpster for the holidays. He reported they had not provided an extra dumpster for Christmas or New Years Day. He also reported he had not contacted the company regarding the non delivery of the extra dumpster's.

Based on observation and staff interview, the facility failed to maintain a safe, clean, comfortable and homelike environment. This failed practice has the potential to affect more than a limited number of residents and was discovered during a complaint investigation. Facility census 85. Findings included: a) Observation on 08/29/23 at approximately 9:44 a.m., revealed the shared restroom for Resident Rooms 313/315 had a strong sewer smell and the floor was stained with a brown/watery substance. b) Observation on 08/29/23 at approximately 9:56 a.m., revealed the shared restroom for Resident Rooms 208/210 had strong sewer smell and the toilet appeared shifted / unsecured to the floor and would not flush and appeared to be stopped up. c) Observation on 08/29/23 at approximately 10:03 a.m., revealed the toilet appeared shifted / unsecured to the floor and the sealant at the base of the toilet appeared to be stained with a mold/mildew substance in the shared restroom for Resident Rooms 204/206. d) Observation on 08/29/23 at approximately 10:09 a.m., revealed damaged door trim and scuffed paint/exposed drywall in the shared restroom of Resident Rooms 404/406. e) Observation on 08/29/23 at approximately 10:13 a.m., revealed cobwebs in the upper right hand corner of the room near the resident bed and a missing floor transition at the entrance door to the room in Resident room [ROOM NUMBER]. f) Observation on 08/29/23 at approximately 10:16 a.m., revealed the base of the toilet appeared to be stained with a mold/mildew substance in the shared restroom for Resident Rooms 401/403. g) Observation on 08/29/23 at approximately 10:27 a.m., revealed base trim that was missing paint and appeared worn throughout the room and scuffed/peeling paint on the wall near the window in Resident room [ROOM NUMBER]. h) Observation on 08/29/23 at approximately 11:56 a.m., revealed vegetation growing in the gutters and wooden garden planters that were broken/disrepair in the Non-Smoking Courtyard. i) Observation on 08/29/23 at approximately 1:48 p.m., revealed the ceiling vents throughout the Kitchen appeared stained and loaded with dust/debris. j) Observation on 08/29/23 at approximately 1:53 p.m., revealed the floor to the Walk-In Cooler in the Kitchen appeared rusty and unsealed. k) Interview on 08/29/23 at approximately 1:54 p.m. with the Maintenance/Housekeeping/Laundry Supervisor verified these findings. These findings were also acknowledged by the Administrator at the exit interview on 08/29/23 at approximately 4:15 p.m.

Based on observation, facility documentation and staff interview the facility failed to have completed temperature logs for the refrigerators, freezer and dishwasher. The facility failed to complete and document food temperatures of food before serving on 11/01/22 for breakfast and lunch. This was a random opportunity for discover. The failed practice had the potential to affect more than a limited number of residents. Facility census: 77. Findings included: a) Refrigerators/Freezer Temps An observation during the initial kitchen tour on 10/31/22 8:45 AM, showed incomplete temperature logs for the refrigerators and freezer as followed: 1. Refrigerator (Walk-In)Temperature Log: 10/02/22- Morning (AM) and Evening (PM) temperatures missing 10/20/22- PM temperature missing 10/31/22- AM temperature missing 2. Refrigerator (Kitchen) Temperature Log 10/02/22- PM temperature missing 10/18/22- PM temperature missing 10/20/22- PM temperature missing 10/22/22- PM temperature missing 10/23/22- PM temperature missing 10/26/22- PM temperature missing 10/31/22- AM temperature missing 3. Freezer Temperature Log 10/02/22- AM temperature missing 10/08/22- PM temperature missing 10/20/22- PM temperature missing 20/21/22- PM temperature missing 10/31/22- AM temperature missing During an interview on 10/31/22 at 8:50 AM, Cook #4 stated usually the temperatures are taking in the morning however staff did not get the temperature logs completed this morning due to being busy. b) Dish Washer Log An observation on 10/31/22 at 8:55 AM, showed no dish washer temperature log available. During an interview on 10/31/22 at 8:55 AM, Dietary Staff (DS) #95 stated that the kitchen was short staffed today and dish washing was not a normal work assignment. DS #95 stated she did not know where the dish temperature log was located. There was no dietary staff that could locate where the dish washer temperature log was kept. c) Food Temperature Checks An observation on 11/01/22 at 11:52 AM , showed there was no completed food temperature log dated for 11/01/22. The food temperature log binder ended with the date of 10/31/22. During an interview on 11/01/22 at 11:30 AM, Cook #4 stated, I guess we don't have the food temperatures documented for 11/01/22 yet. Cook #4 stated that dietary staff were busy with the food tray line, making the lunch trays to go out to be served to residents.

Based on observation, resident interview, and staff interview the facility failed to Resident #23 had a call system within reach. The bathrooms in rooms 405, 407, 404, and 406 did not a cord to activate the call system to contact staff. These observations were a random opportunity for discovery. Facility census 77. Findings included: a) Resident #23 During an interview on 10/31/22 at 9:30 AM, Resident #23 was in a wheelchair, located between the two beds in the Resident's room. Resident #23 was asked if she could reach her call light. Resident #23 stated she did not know where it was, but if she needed something she would wheel down to the nurse's station. On 10/31/22 at 9:45 AM, Nurse Aide #45 was asked if she could find the call light for Resident #23. NA #45 located the call light which was on the floor behind the nightstand and was tied to the bed not occupied by Resident #23. On 10/31/22 at 9:50 AM, Resident #23 confirmed she slept in the bed next to the door of the room. The call light was tied to the bed next to the window. b) Bathroom call lights On 10/31/22 at 9:52 AM, NA #45 was asked about the call light in Resident #23's bathroom. NA #45 pointed out a white switch, located behind the grab bar on the wall. The switch looked like a regular light switch, that can be flipped up and down. There was not a pull-cord of any type attached to the switch to enable the resident to activate the call system if the resident fell and was lying in the floor. Observation with Licensed Practical Nurse (LPN) #58 on 11/02/22 at 9:15 AM, confirmed there was no pull-cord on the call lights in the bathrooms for rooms: 405, 407, 404, and 406. LPN #58 stated she would let someone know about the missing cords.

Based on facility documentation and staff interview the facility failed to include direct staffing levels / direct overall number of staff for the resident acuity in the facility assessment. This has the potential to affect all resident in the facility. The Facility census 77. Findings included: a) Facility Assessment Review of the facility assessment on 11/02/22 at 4:21 PM, found a lack of information provided for nursing staff and nurse aides providing resident care. Position: --Registered Nursing. Job Description & Qualifications: --Individuals who have successfully completed a state approved training and competency evaluation program and required testing. Standard Deployment Plan: --Licensed Practical Nurse (LPN) see PBJ reports. Average Hours a Day. --Eight (8) to 12 per Registered Nursing Aide (RNA) During an Interview with the Administrator and the Assistant Director of Nursing (ADON) on 11/02/22 at 5:13 PM the ADON verified that the Direct Care Staff needed by the facility was incomplete and the Facility Assessment was not correct without the information.

Based on resident interview, record review and staff interview the facility failed to ensure a Resident was free from neglect. The failed practice was true for one (1) of three (3) Residents reviewed for abuse. Resident identifier: #20. Facility census: 77. Findings included: a) Resident #20 During an interview on 10/31/22 at 10:20 AM, Resident #20 stated that she wished the facility would get her a wheelchair so she could get out of bed. An observation on 10/31/22 at 10:20 AM, showed Resident #20 lying in bed with no available wheelchair located in Resident # 20's room. During an interview on 11/01/22 at 3:25 PM, Resident # 20 stated she was not able to get out of bed yesterday and had not been out of bed today. Resident # 20 stated she asked her Nurse Aides (NA) to get up out of bed earlier today and was told they did not have time to get her up and out of bed today. Resident # 20 stated she would love a wheelchair so she could wheel around the facility. An observation on 11/01/22 at 3:25 PM, showed Resident #20 lying in bed and there was no available wheelchair located in Resident # 20's room. During an interview on 11/01/22 at 3:50 PM, Licensed Practical Nurse (LPN) #7 stated if Resident # 20 wanted to get out of bed she may do so. An observation on 11/01/22 at 3:51 PM, found LPN #7 went to Resident # 20's room to discuss the desire to get out of bed. Resident # 20 stated to LPN #7 and the Surveyor that she would like to get up and enjoy the company of others. Resident # 20 stated it had been a long time since she was able to get out of bed. LPN #7 asked Resident # 20, did you ask someone to get up today? Resident #20 replied, I did, I asked the NA earlier but was told they didn't have time to get me up. LPN #7 replied anytime a NA says they don't have time to get you up and you want to up; press the call light and talk to your nurse about getting up. LPN #7 went to look for the assigned NAs to assist Resident #20 out of bed. Resident #20's assigned NAs were not seen in the hallway and LPN #7 could not find them. LPN # 7 stated the next step would be to report the incident to her supervisor, talk with the NAs and assist Resident # 20 in getting up to attend activities. An observation on 11/01/22 at 4:10 PM, showed Resident # 20 sat in a geriatric chair and was attending activities. Resident #20 was assisted out of bed after surveyor intervention. During an interview on 11/01/22 at 4:20 PM, Resident # 20 stated that she was very happy she was able to get up out of bed and attend activities. Resident # 20 stated it was lonely in her room alone all the time and she enjoyed being out with others. Resident # 20 stated it felt good to get out of bed and be around others as she had not been out of bed for a long time. Review of Resident #20's medical record showed the last activity assessment completed on Resident #20 was dated 07/20/22. The activity assessment stated Resident #20's mobility should be with a wheelchair and required assistance. The activity assessment stated Resident preferred own room activities which contradicted interview findings with Resident #20. The care plan stated that resident #20 mainly was a loner and preferred to do her own room activities that also contradicted Resident 20 interview findings. Further review of Resident # 20's medical record showed, multiple progress notes: A progress note dated 10/27/22 at 1:29 PM, stated, Resident noted in geri chair watching television in east side lounge. A progress note dated 10/27/22 at 7:00 PM, stated, Resident in bed at this time finishing dinner tray. A progress note dated 10/30/2022 at 11:59 AM, stated, Resident in bed at this time with HOB raised using her tablet. Resident took all medications per MAR with ease including lokelma pkt. Resident requested PRN pain medication during AM med pass stating her bottom was hurting and rated pain 7/10. PRN pain medication administered. A progress note dated 11/01/22 at 4:41 PM, stated, Resident up in geri chair sitting in dining room at this time. During an interview on 11/02/22 at 11:25 AM, LPN #7 stated that that incident with Resident #20 was reported to the Assistant Director of Nursing (ADON) on 11/01/22. During an interview on 11/02/22 at 11:47 AM, the ADON stated that LPN #7 did report an incident about Resident #20 and ADON followed up with NAs. The ADON stated that the NAs were already in the process of getting Resident #20 out of bed. The ADON stated that Resident # 20 was perfectly capable of letting her needs be known. ADON stated that she was unaware and was not informed by LPN #7 that the NAs were not available on the floor when Resident #20 made the allegation of neglect. ADON stated that all she could do was say I'm sorry and would provide an in-service to all staff regarding providing care and when Residents ask for care, staff need to listen and complete resident care. During an interview on 11/02/22 at 1:55 PM, the ADON stated that an allegation of NAs not providing care to residents would be considered an allegation of neglect. The ADON stated, I am going to be honest; I did not report the incident with Resident #20 yesterday. The ADON stated that an allegation of neglect should have already been reported by now and was not reported in a timely manner.