Every finding on record at Twin Lakes

Based on review of personnel files, staff interview, and review of the facility policy, the facility failed to ensure Certified Nursing Assistants (CNAs) received 90-day performance evaluations. This had the potential to affect all of the residents. The facility census was 34 residents. Findings include: Review of the personnel file for CNA #500 revealed a hire date of 08/18/25 with no 90-day evaluation. Review of the personnel file for CNA #505 revealed a hire date of 11/24/25 with no 90-day evaluation. Interview on 05/27/26 at 4:00 P.M. with Regional Human Resource Manager #175 verified CNAs #500 and #505 did not receive 90-day evaluations. Review of the facility policy titled Personnel File Maintenance and Records Retention undated revealed the Human Resources Department was responsible for maintaining accurate personnel files for each associate in accordance with all applicable federal, state, and local regulations. Personnel files would include performance evaluations.

Based on observation, staff interview, and review of the facility policy, the facility failed to properly store foods in a safe and sanitary manner. This had the potential to affect all of the residents residing in the facility. The facility census was 34 residents. Findings include: Observation on 05/26/26 at 9:10 A.M. of main kitchen walk in refrigerator with Dietary Manager (DM) #201 revealed it contained a pan with pre-cooked undated meatloaf and an opened undated box of sausage patties. Interview on 05/26/26 at 9:10 A.M. with DM #301 confirmed the meatloaf and sausage patties were undated and should be discarded. Observation on 05/26/26 at 9:17 A.M. of main kitchen walk in freezer with DM #201 revealed it contained the following items: a bag of raw cookie dough which was undated and open to air, a bag of cooked ham with a discard ate of 12/22/25, an opened pan of frozen lasagna with a discard date of 05/04/26, an undated bag of frozen hamburger patties open to air, a container of catfish filets unsealed and open to air.Interview on 05/26/26 at 9:18 A.M. with DM #201 confirmed the walk-in freezer contained opened and undated items, expired items, and items left open to air.Review of facility policy titled Refrigerated Food Storage undated revealed all time and temperature control safety foods, including leftovers should be labeled, covered, and dated when stored in refrigerator.

Based on medical record review and staff interview, the facility failed to ensure a preadmission screening resident review (PASARR) screenings were completed accurately. This affected one (Resident #2) of three residents reviewed for PASARR screening. The facility census was 34 residents.Findings include: Review of the medical record revealed for Resident #2 revealed an admission date of 12/21/22 with diagnoses including cerebral infarction, vascular dementia, diabetes mellitus type two, atrial fibrillation, and hypertension. Review of the Minimum Data Set (MDS assessment for Resident #2 dated 02/14/26 revealed the resident had severe cognitive impairment and was dependent on staff assistance with activities of daily living (ADLs) Review of the diagnosis list for Resident #2 dated 05/27/26 revealed the resident had a diagnosis of psychotic disorder with hallucinations added to the medical record on 10/25/23. Review of the PASARR for Resident #2 dated 12/21/22 completed by the hospital revealed Resident #2 had no indications of serious mental illness (SMI). Review of the medical record for Resident #2 revealed the facility did not complete a PASARR for Resident #2 when the diagnosis of psychotic disorder with hallucinations due to known physiological condition was added on 10/25/23. Review of the PASARR for Resident #2 dated 05/08/25 completed by the prior Social Services Director (SSD)#199 due to a change in condition and decline revealed Resident #2 had no indications of SMI. Interview on 05/12/26 at 1:32 P.M. with SSD #125 verified the facility failed to complete a new PASARR for Resident #2 that accurately identified the resident's diagnosis of psychotic disorder with hallucinations which is designated as a SMI.

Based on observation, staff interview, and record review, the facility failed to properly store potentially hazardous chemicals in two of two satellite kitchens in the skilled nursing unit. This had the potential to affect three facility-identified cognitively impaired and independently mobile residents (Residents #3, #12, and #24) of 34 residents residing in the facility. The facility census was 34 residents. Findings include: 1. Observation on 05/26/26 at 9:49 A.M. of the community kitchenette on [NAME] Court nursing unit revealed there was a spray bottle of Kontrol Morning Fresh in an open cabinet under the sink. The label on the spray bottle indicated the contents were flammable and could cause skin irritation. Interview on 05/26/26 at 9:50 A.M. with Licensed Practical Nurse (LPN) #400 confirmed the Kontrol Morning Fresh spray bottle was in an unlocked cabinet and was easily accessible to residents. LPN #400 verified the bottle should be stored in a locked cabinet. Review of the Material Safety Data Sheet (MSDS) for Kontrol Morning Fresh revealed the product contained hazardous ingredients and was to be kept out of the reach of children. 2. Observation on 05/27/26 at 3:25 P.M. of the community kitchenette on [NAME] Court revealed there was a bottle of Clorox bleach germicidal spray and a bottle of Glance glass and multi-purpose cleaner in an unlocked cabinet under the sink. Interview on 05/27/26 at 3:26 P.M. with Registered Nurse (RN) #407 confirmed the Clorox spray and the Glance spray were in an unlocked cabinet which was easily accessible to residents. RN #407 verified the bottles should be stored in a locked cabinet. Review of MSDS sheet for Clorox bleach germicidal spray revealed exposure to the spray might cause irritation to respiratory tract, slight eye irritation, skin irritations and if swallowed could cause irritation to mucous membranes and gastrointestinal tract and might cause nausea, vomiting and diarrhea. Review of MSDS sheet for Glance glass and multi-purpose cleaner revealed it contained hazardous and corrosive ingredients which could cause permanent eye damage, including blindness, permanent skin damage, irritation to nose, throat and respiratory tract if inhaled and burns to mouth, nose, throat and stomach if ingested. A physician and poison control center should be contacted immediately if ingested. 3. Observation on 05/27/26 at 3:27 P.M. revealed there were two containers of Sani Wipes in two open cabinets just outside the community kitchenette on [NAME] Court. Interview on 05/27/26 at 3:28 P.M. with the Administrator confirmed the Sani Wipes were in an unlocked cabinet accessible to residents and should be secured. Review of MSDS sheet for Sani Wipes revealed exposure could cause serious eye irritation, drowsiness or dizziness. Sani Wipes contained a flammable liquid and vapor and should be stored in a locked cabinet. 4. Observation 05/27/26 at 3:29 P.M. of the [NAME] Court kitchenette revealed there was a spray bottle of multipurpose cleaner and a cannister of Oxivir wipes in an unlocked drawer. Interview on 05/27/26 at 3:30 P.M. with Certified Nursing Assistant (CNA) #409 confirmed the cleaning agents were not supposed to be in the kitchenette. Review of MSDS sheet for Oxivir Wipes revealed the container should be tightly closed and staff should wear protective gloves when using and should avoid breathing in substance on the wipes.

Based on medical record review, observation, staff interview, review of pharmacy guidelines, and review of the facility policy, the facility failed to ensure insulin vials were properly labeled and stored. This affected two (Residents #49 and #2) of 29 residents with medications stored in the [NAME] Nursing Unit-A and [NAME] Nursing Unit medication carts. The facility census was 34 residents. Findings include: 1. Review of the medical record for Resident #49 revealed an admission date of [DATE] with a diagnosis of diabetes mellitus type two. Review of the physician's orders for Resident #49 revealed an order dated [DATE] for Humalog insulin four units subcutaneously with breakfast and six units with dinner. Review of Medication Administration Record (MAR) for Resident #49 dated [DATE] revealed staff administered six doses of Humalog insulin to the resident from [DATE] to [DATE]. Observation on [DATE] at 8:49 A.M. of the [NAME] Nursing Unit -A medication cart. with Licensed Practical Nurse (LPN)#405 revealed there was an open vial of insulin for Resident #49 dated [DATE]. Interview on [DATE] at 8:49 A.M. with LPN #405 confirmed the Resident #49's insulin was expired and should have been discarded. 2. Review of the medical record for Resident #8 revealed an admission date of [DATE] with diagnoses of diabetes mellitus type one and type two. Review of the physician's orders for Resident #8 revealed an order dated [DATE] for Humalog insulin 10 units subcutaneously three times daily with meals. Review of the MAR for Resident #8 dated [DATE] revealed staff administered 17 doses of insulin to Resident #8 from [DATE] to [DATE]. Observation cart on [DATE] at 8:44 A.M. of the [NAME] Nursing Unit medication cart with LPN #400 revealed there was a Humalog insulin pen for Resident #8 dated as opened on [DATE]. Interview on [DATE] at 8:44 A.M. with LPN #400 verified Resident #8's insulin was expired and should have been discarded. Interview on [DATE] at 11:49 A.M. with the Director of Nursing (DON) verified Humalog (Lispro) insulin has an expiration date of 28 days after removal from refrigerated storage and placement on the medication cart. Review of pharmacy insulin expiration guidelines revealed Lispro (Humalog) vials and pen-injectors should be labeled with the date when opened, when taken from refrigerated storage, or placed in the medication cart. The expiration is described as the time from when the product was opened or removed from refrigeration and when the product should be removed from use. For Lispro (Humalog) insulin, the expiration period is 28 days. Review of the facility policy titled Medication Storage undated revealed it was the policy of the facility to store medications and biologicals safely, securely and properly. Outdated, contaminated or deteriorated medications were to be removed from inventory and disposed of according to medication disposal procedure.

Based on record review, staff interview, and policy review, the facility failed to notify the responsible party when a resident experienced a significant weight loss. This affected one (#32) of two residents reviewed for notification of change. The facility census was 38. Findings include: Review of the medical record of Resident #32 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medicare five-day Minimum Data Set (MDS) assessment, dated 06/17/21, revealed the resident had impaired cognition. Review of Resident #32's weights revealed: on 02/21/21, she weighed 144 pounds; on 03/01/21 at 140 pounds; on 04/06/21 at 127 pounds; on 04/19/21 at 125 pounds; and on 05/01/21 at 127 pounds. This revealed a 17 pound weight loss and a 11.8 percent significant weight loss in less than three months. Review of the progress notes dated 04/2020 through 06/01/2020 revealed no indication of family notification of weight loss. Interview on 07/08/21 at 9:54 A.M. with Registered Dietitian (RD) #350 stated she does not personally notify the responsible party of a resident's weight loss and the nurse does the notification when they call to notify of the new orders associated with the weight loss. RD #350 further verified the medical record of Resident #32 lacked evidence of notification of responsible party of weight loss. Interview on 07/08/21 at 11:48 A.M. with Licensed Practical Nurse (LPN) #287 stated the nurses notify the responsible party of weight loss when they call to notify of the new orders associated with the weight loss. LPN #287 further stated the notification was documented in the progress notes when the notification was completed. Review of the facility's undated policy titled, Notification and Reporting of Changes in Health Status, Illness, Injury, and Death of a Resident, revealed the appropriate associates will promptly inform the resident representative of a significant change in the resident's status, such as a deterioration in health and document the notification in the medical record.

Based on medical record review, family interview, staff interview, and policy review, the facility failed to include residents and resident representatives to participate in care planning. This affected one (#12) of 16 residents reviewed during the annual survey. The facility census was 38. Findings include: Review of the medical record for Resident #12 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/21/21, revealed the resident had severely impaired cognition. Review of the medical record revealed documentation of care conferences held on 04/21/20 and 12/16/19. There were no other documented care conferences held from 05/01/20 to 07/05/21. Interview on 07/06/21 at 1:45 P.M. with the daughter of Resident #12 stated the facility had not invited her to any care conferences since prior to the COVID-19 pandemic. Interview on 07/07/21 at 1:45 P.M. with the Director of Nursing (DON) verified the last care conference held for Resident #12 was 04/21/20. The DON stated she was unsure why additional care conferences were completed. Subsequent interview on 07/08/21 at 11:39 A.M. with the DON stated the expectation of a care conference was to be offered at least quarterly. Review of the facility's undated policy titled, Care Conference, revealed every resident and responsible party will be invited to a quarterly meeting that is held for the dual purpose of educating the resident about new issues that might impact his/her care and discussing his/her current physical, mental, and emotional status.

Based on medical record review, staff interview, and policy review, the facility failed to ensure resident's code status was accurate in the medical record. This affected three (#12, #22, and #32) of four residents reviewed for advanced directives. The facility census was 38. Findings include: 1. Review of the medical record for Resident #12 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/21/21, revealed the resident had severely impaired cognition. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the DNR Order Form revealed Resident #12 was a Do Not Resuscitate-Comfort Care (DNR-CC), signed by the physician on 11/08/18. 2. Review of the medical record for Resident #32 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medicare five-day MDS assessment, dated 06/17/21, revealed the resident had impaired cognition. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the DNR Order Form revealed Resident #32 was a DNR-CCA, signed by the physician on 05/25/21. 3. Review of the medical record for Resident #22 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment, dated 04/28/21, revealed the resident had severely impaired cognition. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the DNR Order Form revealed Resident #22 was a DNR-CCA, signed by the physician on 01/23/20. Interview on 07/06/21 at 3:30 P.M. with Registered Nurse (RN) #294 verified the code status orders did not match the signed DNR forms for Residents #12, #22, and #32. Review of the facility's undated policy titled Advance Directives, revealed all advance directive document copies will be obtained, filed in medical record and readily retrievable by associates.

Based on record review and interview the facility failed to ensure a resident kept a prescheduled appointment for an eye specialist. This affected one Resident (#3) of four residents reviewed for ancillary medical care Facility census was 40. Findings include: Review of the medical record for Resident #3 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was cognitively intact and required extensive assist of one staff for all activities of daily living except supervision only for eating. Review of the nurse's progress notes revealed episodes of confusion and forgetfulness. Review of progress note dated 10/12/18 at 2:15 P.M. revealed the resident's son called inquiring pickup times for appointments that were scheduled for 10/16/18 and 10/19/18 and was told the facility had no information about the appointments. A progress note dated 10/17/18 revealed a call was made to the eye specialist regarding the appointment for 10/18/18. The progress noted indicated because the resident was receiving skilled services, the appointment was rescheduled and the facility charge nurse would cancel transportation. Review of progress note dated 10/17/18 at 3:49 P.M. reported eye appointment discussed with the resident and a call was placed to the resident's son. The person who answered the phone confirmed the eye specialist appointment for an injection was rescheduled by the son. A phone interview on 11/05/18 at 12:43 P.M. with eye specialist clinic staff (CS) #300 reported she rescheduled Resident #3's appointment from 10/18/18 to 11/05/18 and Resident #3 received her eye injection 11/05/18. CS #300 stated the clinic did not initiate the rescheduling, and the clinic would not consider payment source when deciding care needed. She further reported an awareness of nursing facilities having appointments rescheduled when expensive medications were involved. CS #300 reported the injection for Resident #3 was Eyelera (medication to delay progression of [MEDICATION NAME] degeneration) and the facility would have to pay approximately $2000.00 for the injection. CS #300 checked the resident's medical file and questioned other clinic staff and indicated there was no complications to the resident due to the delay in the appointment. CS #300 indicated the resident's next appointment was in four months and had there been issues her next appointment would have been in a month. Phone interview on 11/05/18 at 3:20 P.M. with Registered Nurse (RN) #222 reported she become aware of Resident #3's ancillary medical appointments during the initial care conference with Resident # 3 and her family. She stated during the care conference a paper was handed to her with two or three appointments and she agreed to arrange transportation for the resident. RN #222 stated when she realized what the appointments were for she called Resident #3's son and told him to reschedule the appointments for after discharge from facility. She stated that unless the appointments were related to the cause for admission to the facility the appointments must be rescheduled. She denied any facility policy or regulation demanded that practice, and stated that was the way the facility always did it. She stated she discussed the appointment with the unit manager who conferred with her. RN #222 acknowledged awareness that the appointment was for an eye injection. She also admitted to not consulting anyone to question if postponing the injection could be problematic for Resident #3's vision. She stated when she called to cancel the eye appointment, the staff member who answered the phone did not indicate there was an issue canceling the appointment. RN #222 acknowledged she was unaware of the job duties or qualifications of the clinic staff who answered the phone. Interview on 11/05/18 at 4:00 P.M. with the Administrator reported the facility did not have any policies regarding ancillary medical appointments, that all efforts were made to ensure appointments were kept and transportation assistance was provided. This deficiency substantiates Complaint Number OH 843

Based on observations, record review, staff interview, and review of facility policy, the facility failed to ensure proper infection control practices were implemented during medication administration for eye drops. This affected one (#3) of five residents observed for medication administration. The facility census was 41. Findings include: Review of the record for Resident #3 revealed an admission to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #3 had mild to moderate cognitive deficits and required extensive assist with most activities of daily living, Observation on 06/05/18 at 9:08 A.M. with Licensed Practical Nurse (LPN) #30, revealed during medication administration, LPN #30 administered one drop of [MEDICATION NAME] to both eyes of Resident #3 without donning gloves prior to administration. Interview on 06/05/18 at 9:15 A.M. with LPN #30, verified she did not put on gloves and indicated she should have prior to administering the eye drops. Review of the undated facility policy titled, Eye Medication Administration, indicated staff were to perform hand hygiene and put on gloves prior to administering the eye drops. This deficiency substantiates Complaint Number OH 059.

Based on policy review, review of personnel files and staff interview, the facility failed to ensure the [DIAGNOSES REDACTED] Exposure Control Plan was followed. This involved two (STNA #23 and #25) of seven employee files reviewed and had the potential to affect 42 of 42 residents in the facility. Findings include: Review of personnel files revealed two employees hired in the past 12 months did not have documentation to show a two step TB was completed prior to State tested Nurse Aide (STNA) #23 and #25 providing care to residents. Review of the personnel file for STNA #23 revealed she was hired and began working in the facility on 11/10/15. Her personnel file contained no documentation of having a two step Mantoux testing prior to commencing duties in the facility. Review of the personnel file for STNA #25 revealed she was hired and began working in the facility on 09/04/15. Her personnel file contained no documentation of having a two step Mantoux testing prior to commencing duties in the facility. Human Resource Employee #189 stated all employees are required to have the 2-step Mantoux testing performed prior to commencing duties in the facility. Review of the facility's [DIAGNOSES REDACTED] (TB) Exposure Control Plan with an initiation date of May 2004, revised April 2015, revealed Employee Screening testing was to be administered upon employment and an annual TB screening questionnaire would be completed for all employees.

Based on observation, record review and staff interview, the facility failed to ensure one of three dishwashers were maintained to ensure the dishes were sanitized and failed to ensure food was held at a safe temperature level while on the steam table. This had the potential to affect 19 of 42 residents in the facility. Findings include: 1. On 01/15/16 at 9:45 A.M. the kitchen on the Walden Court unit was inspected. At the time of the inspection Food Service Employee (FSE) #146 was washing the breakfast dishes in the dishwasher on the unit and putting the washed dished away. The dishwasher wash and rinse temperatures were checked with with the assistance of Dietitian #190. Three wash cycles were run and each time the temperature was 177 degrees Fahrenheit (F). Dietitian #190 verified each observation. At 9:50 A.M. FSE #146 stated that she checked the temperature every morning and recorded it on a sheet located in the kitchen. Review of the sheet revealed she had the rinse temperature recorded at 178 degrees F. After the observation was verified, Dietitian #190 informed FSE #146 to take all the dishes to the main kitchen and re-wash the dishes. Interview with Dietitian #190 revealed only dishes for the 19 residents on the Walden unit where being washed in this dish washer. Review of the policy and procedure sheet revealed the policy stated, the minimum temperature as required by the manufacturer was 180 degrees F. 2. On 01/16/16 at 9:07 A.M. the temperature of the food items on the steam table in the Walden Kitchen were obtained with the assistance of FSE #146. The temperature of the ground sausage was 132 degrees F. FSE #146 verified the temperature. She stated she still had a resident to serve on the ground diet. Review of the diet list revealed two residents on the Walden unit were on a mechanical diet and one resident was on a puree diet. Review of the food service policy for Food Temperatures revealed it was the facility policy to hold the food at 135 degrees F or greater.

Based on resident and staff interview, and review of resident council meeting minutes, the facility failed to ensure the designated staff person responsible for providing assistance to the resident group, assisted the residents in scheduling and facilitating quarterly meetings as agreed upon by the resident group. This had the potential to affect all 42 residents of the facility. Findings include: An interview was conducted with the Director of Nursing (DON) on 09/05/13 at 9:30 A.M. to determine if the facility had an organized resident council, and if there were any residents designated as officers for the council. She reported the facility did have a resident council which was facilitated by Licensed Social Worker (LSW) #1, but there was no president or officers as none had volunteered to represent the resident group when asked. The DON communicated that many of the residents on the Shepherd unit were here for rehabilitation, were not at the facility for an extended time, and did not show much interest when asked to attend. She stated there were a few interviewable residents who had attended one or more council meetings and provided a short list of names. Residents who had attended at least one council meeting included Residents #41, #44, and #60. An attempt to interview Resident #44 regarding the facility's resident council group was made on 09/05/13 at 11:25 P.M. Resident #44 reported that she has attended council meeting in the past, but stated she really did not know much about it and did not feel that she could answer my questions accurately. An attempt to interview Resident #41 regarding the facility's resident council group was made on 09/05/13 at 11:34 P.M. Resident #41 denied having attended any resident group meetings recently and reported that "they" had asked her to be the president of the council but she did not want to. The resident then stated that she did not know much about the resident council but communicated she might like to attend again and requested information regarding when the next one was. An attempt to interview Resident #60 regarding the facility's resident council group was made on 09/05/13 at 1:55 P.M. Resident #60 stated that she had attended only one resident council meeting, she currently did not have any concerns, and shared that she did not know how often the resident council met. The facility's resident council meeting minutes were reviewed on 09/05/13, at 12:09 P.M., with LSW #1. LSW #1 communicated the facility had quarterly resident council meetings as agreed upon by the residents who attended the council meeting during the 04/26/12 council meeting. Further review of resident council meeting dates and minutes revealed that as of 09/05/13 there has been only one other resident council meeting since 04/26/12, which was facilitated by LSW #1 on 02/19/13. Nine residents including residents #41, #44, and #60 had all attended the 02/19/13 meeting. When queried as to why quarterly meetings had not been scheduled, organized, or facilitated since 02/19/13 she verbalized that she had missed scheduling a May 2013 meeting, and that a meeting had been scheduled in August of 2013 but there was a conflict with activities on that day and was no.

Based on review of facility notices provided to residents regarding Notice of Medicare Non-Coverage (NOMNC) and staff interview, the facility failed to provide Medicare beneficiaries an advanced completed copy of the NOMNC at least two days prior to termination of services. This involved three had the potential to affect three (#11, #16, #22) of three discharged residents sampled for review of Medicare benefits and notices. This had the potential to affect 12 of 43 residents receiving Medicare benefits for skilled nursing services at the facility. the time of survey. Findings include: The NOMNC, or CMS forms , were requested and reviewed for discharged residents #11, #16, and #22 on 09/05/13. Resident #11 was admitted to the facility on [DATE] for skilled nursing services, and was discharged on [DATE]. Review of the NOMNC provided to the Resident #11 revealed the resident was notified on 03/27/13 that coverage of her current skilled services would end on 03/27/13. The resident signed receipt of NOMNC on 03/27/13. There was no documentation evident in the medical record or on the NOMNC form to support the resident was given advanced notice of non-coverage. Resident #16 was admitted to the facility on [DATE] for skilled nursing services, and was discharged on [DATE]. Review of the NOMNC provided to the Resident #22 revealed the resident was notified on 04/02/13 that coverage of his current skilled services would end on 04/02/13. The resident signed receipt of NOMNC on 04/02/13. There was no documentation evident in the medical record or on the NOMNC form to support the resident was given advanced notice of non-coverage. Resident #22 was admitted to the facility on [DATE] for skilled nursing services, and was discharged on [DATE]. Review of the NOMNC provided to the Resident #22 revealed the resident was notified on 06/13/13 that coverage of her current skilled services would end on 06/13/13. The resident signed receipt of NOMNC on 06/13/13. There was no documentation evident in the medical record or on the NOMNC form to support the resident was given advanced notice of non-coverage. An interview was conducted with the DON on 09/05/13 at 11:45 A.M. regarding the procedure for notifying residents receiving skilled services of non-coverage of Medicare benefits. She reported that residents ' progress and projected discharge from skilled nursing and/or rehabilitative services was discussed at each resident ' s respective care conferences. However, the DON communicated and affirmed there was no documentation to support that residents receiving skilled Medicare services were given an advanced completed copy of the NOMNC at least two days prior to termination of services.

Based on record review, and interview, the facility failed to ensure one former resident's physical therapy was provided in accordance with the physician orders [REDACTED]. The facility identified eleven residents receiving therapy in the facility. The census was 40. Findings were: Review of the closed record for Resident #41 included [DIAGNOSES REDACTED]. The resident was admitted to the facility for rehabilitation and strengthening with the anticipation to return home after discharge. She was assessed on admission as alert and oriented, able to understand and follow directions, and make her needs known. Her continuity of care form from the hospital included PWB (partial weight bearing) x four weeks (till 9/26/11) 50% with brace. Brace may be off at night. Follow up appointment with the orthopedic surgeon post injury (approx 9/29/11) It was signed and dated 09/03/11. A physician's orders [REDACTED]. PT/PTA to see 5 x a week up to 90 days for therapeutic exercise, activity, normal gait. Her wellness pathway for falls dated 09/16/11 included the intervention the resident had a 50% weight bearing restriction, used a walker to assist with weight bearing support. Receiving physical therapy for gait training. The occupational therapy noted for 09/26/11 identifies the resident as weight bearing at times. The Plan included therapeutic exercise, activities, gait training and strengthening and 50% weight bearing until 09/26/11. A physical therapy note from 09/20/11 thru 09/26/11 documented on 09/24/11 the resident may be weight bearing as tolerated on 09/26/11. On 09/26/11 she was issued a rolling walker instead of the walker previously used. A therapy progress note dated 09/30/11 identified the resident's goal was to ambulate 150 feet, with a 5 point cane modified independence with weight bearing advanced. The physical therapy progress report from 10/01/11 thru 10/7/11 included the resident will decrease her weight bearing status to 20 %. On 10/20/11 at 11:30 A.M. physical therapist #5 was interviewed. She stated the resident used a knee brace that was on at all times, and was up in her room independently with her walker after being taught not to bear her full weight. She said the resident was able to understand the restriction. She said supervising therapist #6 told her after 09/26/11, Resident #41 was full weight bearing but she (physical therapist #5) did not see an order for [REDACTED]. She said the resident did not complain of pain. Physical therapist #5 stated she guessed it was not healing well when Resident #41 she returned from the surgeon's office because she was placed on a 20% restriction. At 12:15 P.M. PT #7 revealed after Resident #41 went to the surgeon an X-ray showed the leg was not healing well. She stated, it is not unusual for a client to have a non-healing fracture and exhibit no pain. PT#7 said Resident #41 was shown what 50% weight bearing was by putting her on a scale to understand how it feels to weight bear at 50%. She added, when residents are safe, and consistently maintaining their weight at 50% they are independent to walk with the walker. She said the therapy staff informed the nursing department what the residents walking status was. Therapist #7 reviewed the closed medical record and found no documentation the resident was independent with walking. She was stand by assist, which meant staff were close enough to assist is she lost her balance. Therapist #7 said with a standard walker the client would step and lift the walker to ambulate, and with a rolling walker it moved when being pushed During an interview with the Director of Nursing (DON) at 12:30 P.M. she stated Resident #41's surgeon was not well known to the facility, and there was no documentation the therapy staff called to review with the surgeon the residents progress, and if he wanted to advance her to a higher degree of weight bearing. At 12:45 P.M. occupational therapist assistant #8 was interviewed. She verified the resident was on 50% weight bearing until she was told by the supervising therapist #6 to begin a change in her weight bearing, to progress greater than 50%. She said she went by what the supervising therapist told her. At 2:30 P.M. supervising therapist #6 was spoken to via telephone. She left employment of the facility prior to 10/01/11. She recalled Resident #41, and was read the order dated 09/03/11. She said she would interpret it to mean the resident could be weight bearing as tolerated after 09/26/11. She added, she would usually call the physician to see what they wanted done, if they want to progress or not. She said she left the faciity on [DATE] and the new supervising therapist should have called. The procedure per the therapist would be to call the physician, and have them either call or fax an order to the facility for nursing to write. At 2:40 P.M. Registered Nurse (RN) #4 was interviewed. She said on 10/03/011 someone from the physician's office called the facility and she spoke with them. They wanted to know what the residents therapy order was. She read it to them, as written. She said the person on the phone said, " they have made a mistake," and make her less than 20%. weight bearing. When the resident returned she had new orders for weight bearing of less than 20%. Interview with RN supervisor # 3 at 2:45 P.M. after reviewing the order stated, both therapy and nursing are to co-ordinate the care. She verified there was no written order by the physician to change the residents' weight bearing status past 50%. A call placed to the orthopedic surgeon was not returned. This citation substantiated Complaint Number OH 729.

Based on funds review and interview, the facility failed to ensure receipts were obtained for funds released to a family member to ensure the money was for resident items. This affected one ( #32) of two residents funds held by the facility. Findings include: Resident # 32 , a Medicaid recipient, requested the facility to manage her monies. Review of the disbursement for funds for the resident, revealed there were 16 withdrawals of $50 dollars each between March 2010 and February 2011 from the residents account by the residents' family member. Review of the receipts revealed the facility had no receipts for the use of the money withdrawn and given to the family member. The facility had no verification, the monies disbursed were used for the resident. Interview with Staff Member #8 on 03/5/11 at 10:00 A.M. confirmed the facility did not have receipts and had no system to ensure the monies were used on the residents behalf.