Every finding on record at Wadsworth Pointe

Based on observation and staff interviews, the facility failed to ensure its kitchen area was maintained in a clean and sanitary condition. This had the potential to affect all 48 residents residing in the facility. Findings include:Observation of the kitchen area with Dietary Aide #223 on 07/13/26 beginning at 9:15 A.M. revealed the walk-in freezer had one bag of chicken patties and two bags of sausage patties unlabeled and undated. Review of the general kitchen area revealed it was sticky around the can opener, the microwave was dirty, the areas around the sinks and by the dish machine needed wiped down, and the floor needed a deep clean. Dietary Aide #223 verified the findings at the time of the observation. Regional Dietitian #290 verified the findings again around 10:00 A.M.Continued observation of the kitchen on 07/14/26 starting at 12:25 P.M. revealed cracked floor tiles, grout coming out between the floor tiles, the grid around the ceiling vent was rusty, and multiple light panels had dust, debris, and what appeared to be dead bugs in them. The findings were verified by Regional Dietitian #290 at the time of the observations.

Based on record review and staff interview, the facility failed to ensure the service of a Registered Nurse (RN) for at least eight hours a day, seven days a week as required. This had the potential to affect all residents. The facility census was 48.Findings include:Review of the staffing schedule and posted nursing staff information for 07/11/26 revealed the facility did not have eight consecutive hours of RN coverage as required. Review of the staffing tool from 07/06/26 through 07/12/26 revealed there was no RN scheduled to work in the facility on 07/11/26. During an interview on 07/16/26 at 10:27 A.M., the Director of Nursing (DON) verified there were no RNs at the facility on 07/11/26 after night shift left.This deficiency represents non-compliance investigated under Complaint Numbers 2987514, 2807579, and 2616372.

Based on record review, interview and policy review, the facility failed to ensure residents were notified to spend down their balance. This affected one resident (#56) of five residents reviewed for resident funds. The facility census was 48. Findings include: Record review revealed Resident #56 was admitted on [DATE] with diagnoses of anxiety disorder, type II diabetes, depression, dementia and cerebral infarction. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively impaired. Record review revealed a Resident #56 had an account balance of $10,771.93 upon discharge on [DATE].During an interview with Regional Business Office Manager #295 on 07/15/26 at 3:15 P.M. confirmed spend-down notifications were not sent to Resident #56's Power of Attorney (POA), only the quarterly statement. Regional Business Office Manager #295 confirmed Resident #56 had an account balance of $10,771.93 upon discharge on [DATE]. Regional Business Office Manager #295 stated Resident Fund Management Services mails out the quarterly statements and mails the facility a copy of them as well.Review of the facility policy titled RFMS-Resident Fund Management, revised on 03/11/26, revealed the community must notify all Medicaid residents/responsible parties once their account balance is within $200.00 of the state specific asset limit. This deficiency represents non-compliance investigated under Master Complaint Number 3078476.

Based on interview, record review, and facility policy review, the facility failed to submit an accurate Preadmission Screening and Resident Review (PASRR) Level I for one (Resident #7) of three sampled residents reviewed for PASRR requirements. Specifically, Resident #7's PASRR Level I did not reflect the presence of diagnosed mental illness or the use of psychotropic medications. Findings included: Review of the facility policy titled, Ohio Non-Licensed PASRR Designation Process, revised 01/12/2022, indicated, 3. He/She [individual responsible for completing PASRRs] will complete the PASRR screenings in accordance with OAC [Ohio Administrative Code] 5160-3-15.1 and 15.2. Review of the Resident Face Sheet indicated the facility admitted Resident #7 on 07/30/2024. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of Parkinson's disease; bipolar disorder (BPD), unspecified; major depressive disorder (MDD) single episode, unspecified; and alcohol abuse, uncomplicated. Review of Resident #7's Preadmission Screening and Resident Review (PASRR) Identification Screen, signed by the Social Services Designee (SSD) on 07/31/2024, revealed the screening type was a Resident Review due to Expiring Hospital Exemption. Section E: Indications of Serious Mental Illness indicated the resident did not have mental illness diagnoses of schizophrenia, mood disorders, delusional disorders, panic or severe anxiety disorders, somatic symptom disorders, personality disorders, other psychotic disorders, or another mental disorder that may lead to a chronic disability. The resident's diagnoses of BPD, MDD, and alcohol abuse were not reflected. The PASRR Identification Screen also indicated Resident #7 had not received psychotropic medications, including antidepressant and anti-psychotic medications, in the past six months and had no indicators of serious mental illness. Review of the Preadmission Screening and Resident Review Result Notice, dated 07/31/2024, indicated there were no indicators of serious mental illness and/or developmental disability for Resident #7, so a Level II evaluation was not required. Review of an admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/06/2024, revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated Resident #7 had active diagnoses including depression and BPD. The MDS indicated Resident #7 received antipsychotic and antidepressant medications during the seven-day assessment look-back period. During an interview on 01/23/2025 at 1:22 P.M., the social service designee (SSD) stated she had been with the facility since 2022 as a state trained nurse aide and had accepted the social services position six months prior. The SSD stated she completed PASSRs in the facility if they were not completed at the hospital. The SSD stated that when she was completing a PASRR she reviewed diagnoses, medications, and would contact the family. The SSD stated the mental health section of the PASRR form asked about mental illness history, the illness's effect on the resident's life and personal care, psychiatric medications, and addiction history. The SSD reviewed Resident #7's PASRR, dated 07/31/2024, confirmed she completed it, and stated she saw no indication of serious mental illness reflected on the PASRR. The SSD stated Resident #7 received psychotropic medications, including antidepressant and antipsychotic medications, and had diagnoses of BPD, MDD, and alcohol abuse that were present upon admission and should have been reflected on the resident's PASRR. The SSD stated she must have overlooked those diagnoses while completing Resident #7's initial PASRR. During an interview on 01/23/2025 at 3:27 P.M., the Interim Administrator reviewed Resident #7's diagnoses list and their PASRR Level I. The Interim Administrator stated the resident's diagnoses of BPD and MDD should have been reflected.

Based on observation, medical record review, staff interview, review of a facility policy, and review of the Centers for Disease Control and Prevention (CDC) website, the facility failed to ensure urinary catheters were maintained in a manner to prevent infection. This affected one (#49) of two residents reviewed for urinary catheters. The census was 56. Findings include: Review of the medical record for Resident #49 revealed an admitted [DATE]. Diagnoses included severe intellectual disabilities, acute kidney failure, retention of urine, chronic obstructive pyelonephritis, unspecified hydronephrosis, and benign prostatic hyperplasia with lower urinary tract symptoms. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #49 was assessed with moderately impaired cognition and used a manual wheelchair for mobility around the facility. Review of the plan of care dated 08/16/23, last reviewed 12/04/23, revealed Resident #49 required an external catheter and nephron tube due to acute kidney failure and urinary retention. Review of a progress note dated 10/11/23 revealed Resident #49's a urinary catheter (Foley) that was intact and draining clear yellow. The resident also had a right nephrostomy tube with a dressing that was clean, dry, intact, and draining clear yellow. Observation on 01/02/24 at 8:23 A.M. revealed Resident #49 sitting in the dining room awaiting breakfast. The resident's Foley catheter bag was hooked on the cross bar under his manual wheelchair and there was not enough space for the Foley catheter bag to be up off the floor. Further observation revealed approximately one-third of the Foley bag was resting directly on the floor uncovered. Interview with State tested Nurse Aide (STNA) #135 and STNA #140 at 8:35 A.M. on 01/02/24 stated Resident #49 could transfer himself and also could reach where the Foley bag was hooked on the wheelchair. STNA #135 and STNA #140 verified Resident #49's Foley bag was resting on the floor uncovered, and the resident dragged the bag around the facility under the wheelchair and in and out of the elevator when the resident to different floors of the facility. Review of the infection control policy, dated 08/19/20, revealed employees are to support resident safety by adhering to all policies and procedures related to infection prevention. Review of the CDC website at, https://www.cdc.gov/infectioncontrol/guidelines/cauti/index.html, last reviewed 11/05/15, and titled, Catheter-Associated Urinary Tract Infections (CAUTI), revealed under proper techniques for urinary catheter maintenance to keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor. This deficiency represents non-compliance investigated under Complaint Number OH00149334.

Based on observation, staff interview, and medical record review, the facility failed to ensure urinary catheter bags were covered to maintain resident dignity. This affected one (#49) of two residents reviewed for urinary catheters. The census was 56. Findings include: Review of the medical record for Resident #49 revealed an admitted [DATE]. Diagnoses included severe intellectual disabilities, acute kidney failure, retention of urine, chronic obstructive pyelonephritis, unspecified hydronephrosis, and benign prostatic hyperplasia with lower urinary tract symptoms. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #49 was assessed with moderately impaired cognition. Observation on 01/02/24 at 8:23 A.M. revealed Resident #49 was sitting in the common dining room awaiting breakfast and his urinary catheter (Foley) bag was not covered. Interview with State tested Nurse Aide (STNA) #135 and STNA #140 verified Resident #49's urinary privacy bag was not covered in the common dining area. This deficiency represents an incidental finding investigated under Complaint Number OH00149334.

Based on record review and interview, the facility failed to reconcile controlled narcotics to ensure medications were accounted for. This finding had the potential to affect four residents (Residents #29, #45, #58 and #59) of four residents who reside on the 2nd floor and receive narcotic medications. Findings include: Review of an email from Registered Nurse (RN) #913 to the Director of Nursing (DON) on 11/17/23 at 6:49 P.M. indicated the nurse decided to amend the original resignation letter because of the medication count issue that occurred during the week. The resignation date was to be effective immediately on 11/17/23. Interview on 12/12/23 at 7:40 A.M. with Human Resources (HR) Director #712 indicated RN #913 reported to her that she had a doctor's appointment on 11/14/23 and the DON refused to conduct a narcotic count with her when handing over the narcotic medication keys to the second floor drug administration cart. Interview on 12/12/23 at 8:11 A.M. with the DON indicated RN #913 worked the second floor on 11/14/23 and she worked on a cart on the third floor on dayshift. The DON stated she was passing medications around 10:30 A.M. to 11:00 A.M. when RN #913 asked her to count the narcotics drawer on the second floor so she could leave for a doctor's appointment. The DON confirmed she did not count the narcotic's drawer with the nurse but did accept the narcotic keys because RN #913 left the building. The DON confirmed the second floor medication administration cart and narcotic count was not completed with two nursing staff to ensure misappropriation of narcotics did not occur. The facility identified four residents who received narcotics from the locked narcotic drawer in the second floor medication administration cart including Residents #29, #45, #58 and #59. Review of the undated Narcotic Documentation Overview policy indicated the lack of appropriate documentation of narcotics can lead to suspicion of drug diversion, Drug Enforcement Agency (DEA) investigations and/or disciplinary action against the nursing license. This deficiency represents non-compliance investigated under Complaint Number OH00148527.

Based on review of the medical record, review of facility policy, observation and interview with staff, the facility failed to ensure staff appropriately donned personal protective equipment (PPE)while providing care to Resident #2 who was in isolation for COVID-19 precautions. This had the potential to affect all residents residing in the facility. The facility census was 57. Findings included: Review of the medical record revealed Resident#2 was admitted to the facility on [DATE]. Diagnoses included dementia, thyrotoxicosis, chronic obstructive pulmonary disease, COVID-19, hypertension, Crohn's disease, obstructive sleep apnea, and diabetes. Review of the quarterly Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #2 had moderately impaired cognition. Review of the physician's order revealed Resident #2 had an order to maintain combined droplet/contact precautions and isolation per transmission-based precautions (TBP). All care and services are provided in the resident's room. Do not discontinue isolation until resident has met the criteria for discontinuation of isolation per Centers for Disease Control guidelines using either symptom-based or testing based strategy dated 04/26/23 with an end date of 05/06/23. Review of the progress note dated 04/25/23 at 1:30 P.M. revealed the resident was notified her roommate had teste positive for COVID-19, resident and husband voiced their understanding. The resident will stay in the same room and be placed on precautions due to exposure. Review of the progress note dated 04/28/23 at 1:42 P.M. revealed Resident #2 was in contact/droplet isolation due to being in close proximity to individual who tested positive for COVID. A rapid COVID test was done at bedside and the results were negative. Observations on 04/29/23 at 10:58 A.M. Certified Occupational Therapist Assistant #200 went into room [ROOM NUMBER] with only a surgical mask on to perform occupation therapy exercises on Resident #2 who was in droplet isolation for close contact with her roommate who tested positive for COVID-19. He left the door open to the room so he could be seen in the room without personal protective equipment (PPE) on. At 11:00 A.M. COTA #200 came out of the room of Resident #2 without washing his hands. He verified he had not donned all required (gown, gloves, mask and eye protection) PPE while he was in the room or washed his hands before he exited the room of Resident #2. He stated he was not aware Resident #2 was on isolation. He verified at this time Resident #2 had signage on her door and an isolation cart outside her room indicating she was on isolation. He proceeded to don PPE in the hallway, walk down the hallway to the linen closet, retrieve towels and washcloths out of the linen closet with his PPE on. At 11:05 A.M. Marketing Director #201 approached him in the hallway and explained to him he could not have PPE on in the hallways and he needed to remove it and discard it immediately. Review of the facility policy titled, Transmission-Based Precautions(TBP), revision date of 02/03/23 revealed TBP would be used when a route of transmission was not completely interrupted using standard precautions alone. Droplet precautions were intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions. Because these pathogens do not remain infectious over long distances, special air handling and ventilation are not required to prevent droplet transmission. A single room was preferred, a mask was worn for close contact with infectious residents, gloves, gown and eye protection were worn adhering to standard precaution guidelines. This deficiency resulted from incidental findings during the investigation of Complaint Number OH00142174.

Based on observation and interview, the facility failed to ensure all resident meals were served according to resident preferences. This affected one (Resident #50) of three resident's review for dietary preferences. The facility census was 59. Findings include: Review of the medical record for the Resident #50 revealed an admitted [DATE] with diagnoses including diabetes mellitus, heart failure, and difficulty walking. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 09/04/21, revealed the resident had intact cognition and was independent for all activities of daily living (ADL). Review of the plan of care dated 09/06/19 with a revision date of 03/24/21 revealed Resident #50 had increased nutritional needs related to diagnoses and multiple food preferences that changed frequently. Interventions included: provide diet as ordered, respect dietary choices, review preferences per routine and as needed, and monitor weights and labs. Review of the dietary note dated 9/29/21 at 2:00 P.M. revealed Resident #50 at usual weight, current appetite was good, and food preferences were updated. Review of the physician orders for October 2021 reveal Resident #50 was ordered a low concentrated sweets and no added salt diet. Observation and interview on 10/15/21 at 8:30 A.M., Resident #50 stated he gets dehydrated because his [MEDICATION(S)] (diuretic) was increased, and he needed milk. Resident #50 stated milk would keep him from being dehydrated and calcium was good for his bones. Resident #50 stated he does not receive food preference as requested and as ordered, like no sugary cereals and milk on breakfast trays. Resident #50 stated he continually gets sugary cereal and no milk on his morning tray. Observation at this time, Resident #50 showed multiple bowls of sugary cereal in his room. Interviews on 10/25/21 from 7:51 A.M. to 8:10 A.M. with State tested Nurses Assistants (STNA's) #303, #327 and #328 verified Resident #50 did not receive items on his meal tray as requested, stating a lot of the time he received sugary cereal like Froot Loops and Frosted Flakes and no milk. STNA's #303, #327 and #328 verified this continued to occur and happened as recent as last week. This deficiency substantiates Complaint Number OH 437.

Based on interview, observation and review of maintenance logs, the facility failed to maintain adequate and comfortable lighting resident rooms. This affected eight (Residents #29, #30, #32, #36, #39, #42, #45 and #49) of 51 residents currently residing in the facility. Findings include: Tour of the third floor was conducted with State tested Nurse Aide (STNA) #121 on 08/11/21 beginning at 9:22 A.M. STNA #121 was requested to activate the lighting features in each resident room and bathroom. The lights did not function when activated for eight residents (#29, #30, #32, #36, #39, #42, #45 and #49) of 51 residents in the facility. Resident #29's lamp did not have a light bulb and Resident #32's living room three-way bulb light did not function. Interview with Resident #29 on 08/10/21 at 10:30 A.M. reported it was very dark at night in her room because she nor her roommate's wall lights worked and she had no bulb in her lamp. Interview with Maintenance Director (MD) #124 on 08/10/21 at 10:33 A.M. reported staff put in maintenance requests and he addressed the requests as soon as able. He was not aware of the number of lights that did not function indicating if he was not told he would not be aware a repair or replacement was needed. Review of maintenance logs revealed on 06/17/21 it was reported the light was not working in room 316. It was completed on 06/17/21. This deficiency substantiates complaint number OH 538.

Based on observation, interview and procedure review the facility failed to ensure staff consistently implemented the use of personal protective equipment related to COVID 19. This affected three residents (#20, #35 and #36) with the potential to affect all 51 residents in the facility. Findings include: Observations on 08/10/21 beginning at 9:22 A.M. revealed two residents on the third floor (#35 and #36) were on droplet precautions. A three tiered cart was outside the room with KN95 and surgical masks, gloves and gowns. To enter the second floor there was signage indicating to wear a KN95 mask and eye protection in the common areas and in resident rooms. These residents were newly admitted to the facility and had been vaccinated. There was one resident (#20) on droplet isolation on the second floor. There was a three tiered cart containing masks, gloves and gowns. Licensed Practical Nurse (LPN) #120 was working on the second floor and not wearing eye protection. On 08/10/21 at 10:17 A.M. Laundry Aide (LA) #123 was observed delivering laundry to Residents #35 and #36. LA #123 was wearing a mask and eye protection. She did not gown or glove when entering the room and upon exiting the room she did not cleanse her eye protection or change her mask. State tested Nurse Aide (STNA) #121 was present and educated LA #123 on what personal protective equipment (PPE) must be worn when entering the room. LA #123 said she did not see the droplet precaution sign nor the three tiered cart prior to entering the room. STNA #121 was wearing a KN95 mask and goggles then donned a gown and gloves prior to entering the room. Upon exiting the room she removed the gown and gloves. Interview with STNA #121 on 08/10/21 at 10:20 A.M. revealed she was unaware of what other steps she needed to take. STNA #122 who was in ear shot, reviewed the doffing procedure that was laminated and posted outside of the room. STNA #121 then used alcohol hand sanitizer to cleanse her hands but nothing else. Review of the doffing procedure with STNAs #121 and #122 revealed the eye protection should have been cleansed and her mask should have been changed. On 08/10/21 at 10:50 A.M. Maintenance Director (MD) #124 donned a gown and gloves in addition to his mask and goggles when entering Resident #20's room who was on droplet isolation. Upon exiting the room he removed the gown and gloves. He did not know what other steps to take despite the posted laminated donning and doffing of PPE guides. The Director of Nursing (DON) was present and obtained a box of alcohol prep pads and instructed him to cleanse his goggles and change his mask. Interview with the Assistant Director of Nursing (ADON) who was the Infection Control Preventionist for the facility on 08/10/21 at 2:16 P.M. verified masks and eye protection needed to be worn in the common areas of the facility because the facility was in outbreak testing status for COVID 19. She reported educating all staff on the appropriate donning and doffing of PPE. The ADON was informed of the breeches in donning and doffing of PPE and conducted staff education. This deficiency substantiates Complaint Number OH 538.

Based on interview and record review the facility failed to ensure bed hold notices were provided to all residents regardless of payment source. This affected one (Resident #55) of two residents reviewed for hospitalization s. Findings include: Review of Resident #55's closed medical record revealed an admission date of [DATE] and discharged date of 07/02/19. [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition and required total dependence of two staff for toilet use and transfers, extensive assistance of two staff for bed mobility, received oxygen and was on [MEDICAL TREATMENT]. Review of the nursing notes dated 07/02/19 at 6:30 [NAME]M. revealed at 5:55 [NAME]M. a state tested nurse aide yelled down the hall to the nurse that the resident was unresponsive. The nurse responded immediately with crash cart. Emergency Medical Services (EMS) was called. EMS arrived and transported the resident to the emergency room (ER). The resident's Power of Attorney was updated. Report was called in to the ER. The resident's physician was updated. Review of a nursing note dated 07/02/19 at 10:05 [NAME]M. revealed Resident #55 was transferred to the local hospital for admission. Further review of the medical record revealed no evidence the resident or representative was provided with a bed-hold notice. Interview on 10/02/19 at 12:31 P.M. with the Administrator and Corporate Director of Nursing #501 revealed Resident #55 did not get a bed hold notice because he was not on Medicaid. The Administrator stated they only gave bed hold notices to residents that received Medicaid but everyone received the policy in their admission packet. Review of the facility policy titled Bed Hold Letter Policy (Ohio) revised (MONTH) (YEAR) revealed it was the policy of the facility to track Medicaid bed hold days and notify appropriate parties via the Medicaid Bed Hold Letter.

Based on interview, policy review and record review, the facility failed to safeguard and account for the personal funds of residents residing in the facility. This affected one (Residents #9) of four residents reviewed for resident funds. Findings include: Review of the facility's policy and procedure for Resident Fund Management, updated January 2016, revealed segregation of duties was to be maintained within the facility. The person that disbursed funds could not be the same person posting the funds and reconciling the accounts. Numbered receipts records (separate receipt books) were to be used when receiving and disbursing resident funds. The receipts number log must be maintained at all times and saved on network drive in the facility's account receivable folder. Receipts for disbursing resident funds must be signed by the resident/responsible party and wee to be signed/initialed by the facility employee that disbursed the money and must be witnessed by another party. All funds received and disbursed were to be recorded on the resident's account in the Resident Funds Management System (RFMS). All checks written from the RFMS petty cash account must be approved by the Administrator. A daily count was to be completed and logged at the start and end of each business day and was to be completed by two people. A copy of this log was to be maintained in the RFMS closed file for each month. The Administrator, BOM or their Designee were responsible to account for all resident funds during reconciliation. Requests for funds over $50.00 should have a 24 hour advance notice, and preferred disbursement would be by check. Review of Resident #9's financial records, including bank statements dated 01/01/16 through 04/14/16 for the use of a debit card and facility banking transactions, revealed the debit card was used to purchase a chair, clothing and miscellaneous items from a discount stores. The facility had receipts for the chair and clothing but did not have receipts for multiple other purchases made on 03/10/16, 03/14/16 and 03/16/16 totaling $445.74 at discount stores. Review of the electronic conversation on the computer between Resident #9, the bank representative and Business Office Manager (BOM) #95 printed and dated 04/21/16 confirmed the following withdrawals from Resident #9's account with the use of a debit card: 03/07/16 - discount store- $73.19 03/10/16 - discount store- $92.48 03/14/16 - discount store- $134.31 03/16/16 - discount store- $152.60 03/18/16 - discount store (in a different city) $66.35 04/06/16 - cash - $120.00 (from a bank office in a different city) There were no receipts for any of these purchases or the cash withdrawal. Interview with Resident #9 on 04/25/16 at 1:00 P.M. revealed she had been employed as a bookkeeping for [AGE] years and knew she was to have receipts for her purchases. Resident #9 insisted she was not provided receipts for the purchases from the discount stores. Resident #9 stated former BOM #100 showed her only the receipts for the recliner, bedspread and clothes. Interview with the Corporate Director of Nursing (CDON) on 04/26/16 at 1:30 P.M. revealed former BOM #100 had been terminated from the facility due to Resident #9's missing receipts. BOM #100 was terminated prior to the completion date of the facility's self reported incident (SRI) report on 04/20/16. Purchases were made but receipts were not provided. The CDON stated former BOM #100 told the administrative staff she gave the receipts to Resident #9 and the resident put the receipts in a bag and lost them. The CDON stated when she interviewed Resident #9, the resident insisted she was not provided any receipts and had no idea what was purchased except for a recliner chair, clothing and a bedspread with two pillows. The CDON verified she did not have receipts to verify what purchases were made with Resident #9's money, which was withdrawn from her account. Interview with current BOM #95 on 04/26/16 at 6:00 P.M. revealed Resident #9 came to her office with a banking statement. She said there were some charges that she did not make or authorize. The BOM indicated Resident #9 was alert and kept constant track of her money and her banking activities. She said Resident #9's normal purchase amount at the city's discount store was around $25.00 and she always required a receipt. Resident #9's receipts were to be turned into the business office. Resident #9 did not want to keep the receipts and relied upon the business office to keep the receipts. BOM #95 stated both she and Resident #9 went through her banking statement and discovered the unauthorized purchases without receipts. This deficiency substantiates Complaint Number OH 854.

Based on interview, policy review and record review, the facility failed to prevent misappropriation of personal funds of residents. This affected one of four residents, Resident #9, reviewed for resident funds. Findings include: Review of the facility's policy and procedure for Resident Fund Management, updated January 2016, revealed segregation of duties was to be maintained within the facility. The person that was disbursing funds could not be the same person posting the funds and reconciling the accounts. Numbered receipts records (separate receipt books) were to be used when receiving and disbursing resident funds. The receipts number log must be maintained at all times and saved on the network drive in the facility's account receivable folder. Receipts for disbursing resident funds must be signed by the resident/responsible party and were to be signed/initialed by the facility employee that disbursed the money and must be witnessed by another party. All funds received and disbursed were to be recorded on the resident's account in the Resident Funds Management System (RFMS). All checks written from the RFMS petty cash account must be approved by the Administrator. A daily count was to be completed and logged at the start and end of each business day and was to be completed by two people. A copy of this log was to be maintained in the RFMS closed file for each month. The Administrator, Business Office Manager (BOM) or their Designee were responsible to account for all resident funds during reconciliation. Requests for funds over $50.00 should have a 24 hour advance notice, and preferred disbursement would be by check. Review of the facility Resident Abuse Policy dated May 2008 revealed the facility would not tolerate resident abuse or misappropriation. The facility would investigate all allegations of misappropriation of resident property and this was the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a residents belongings without the resident's consent. Review of Resident #9's record revealed the resident was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 assessment dated [DATE] revealed she was alert but had occasional confusion. Review of Resident #9's plan of care (POC) dated 03/18/16 revealed the resident displayed signs of depression/anxiety related to her [DIAGNOSES REDACTED]. Interventions included encouraging her involvement in activities and to remain involved in decision making as able. Review of Resident #9's financial records, including bank statements dated 01/01/16 through 04/14/16 for the use of a debit card and facility banking transactions, revealed the debit card was used to purchase a chair, clothing and miscellaneous items from discount stores. The facility had receipts for the chair and clothing but did not have receipts for multiple other purchases made on 03/10/16, 03/14/16 and 03/16/16 totaling $445.74 from discount stores. Review of the electronic conversation on the computer between Resident #9, the bank representative and the current BOM #95, was printed and dated 04/21/16. This document confirmed the following withdrawals from Resident #9's account with the use of a debit card: 03/07/16 - discount store- $73.19 03/10/16 - discount store- $92.48 03/14/16 - discount store- $134.31 03/16/16 - discount store- $152.60 03/18/16 - discount store (in a different city) $66.35 04/06/16 - cash - $120.00 (from a bank office in a different city) There were no receipts for any of these purchases or the cash withdrawal. Review of security alerts sent from the bank to Resident #9 revealed on 03/31/16 between 1:09 P.M. and 1:21 P.M., passwords and online security questions and answers were changed by former BOM #100. Review of an Online Banking Change of Profile dated 04/21/16 revealed Resident #9's debit card's email address and security questions were changed by former BOM #100 for all correspondence to come to her email address. On 04/14/16 the facility submitted a self reported incident investigating misappropriation of funds from Resident #9. This investigation indicated the current BOM #95 reported to the Administrator that Resident #9's debit card was missing and the last withdrawal on 04/06/16 for $120.00 was missing. The current BOM, #95, thought that former BOM, #100, was responsible. Former BOM #100 was employed at a sister facility. The Administrator of the sister facility had suspended BOM #100 pending investigation. The Administrator called BOM #100 and she said she forgot she had the $120.00 she withdrew and she was unsure if she had Resident #9's debit card. Former BOM #100 said she would look for the debit card and return the $120.00 to Resident #9. The Administrator called the attorney in charge of Resident #9's financial affairs and inquired about the debit card. On 04/14/16, the Attorney sent the facility a letter indicating he had not authorized an ATM card, he only authorized the purchase of a recliner and some clothing. On 04/26/16, the attorney for Resident #9 indicated that neither he nor the family had authorized the issuance of a ATM/debit card on her checking account. The Administrator checked Resident #9's room for receipts based on withdrawals made but no receipts were found. The Administrator called former BOM #100 and she reported she found Resident #9's debit card and was planning on coming into the facility in the afternoon to drop off the debit card, which she did. She also wrote a personal check for $120.00 and mailed it to RFMS to post to Resident #9's account to replace what she had withdrawn. The Administrator called the attorney and informed him of the return of the debit card and that the $120.00 would be replenished. This check, from former BOM #100, was deposited into Resident #9's account on 04/15/16. The attorney asked the Administrator to cut up the debit card. A statement was provided from former BOM #100 and she indicated she opened the account because Resident #9 had to spend down her money due to her high balance and being on Medicaid. She said Resident #9 helped her identify those items that she wanted purchased and she gave all the items bought with receipts. She told the Administrator the attorney approved the debit card issuance. This was denied by the attorney. On 04/14/16 the $120.00 was replaced into Resident #9's account with a personal check (check #102) from former BOM #100. Interview with Resident #9 on 04/25/16 at 1:00 P.M. revealed she had been employed as a bookkeeping for [AGE] years and knew she was to have receipts for her purchases. Resident #9 insisted she was not provided receipts for the purchases from the discount stores. Resident #9 stated former BOM #100 showed her only the receipts for the recliner, bedspread and clothes. Interview with the Corporate Director of Nursing (CDON) on 04/26/16 at 1:30 P.M. revealed former BOM #100 had been terminated from the facility due to Resident #9's missing receipts. BOM #100 was terminated prior to the completion date of the facility's self reported incident (SRI) report on 04/20/16. Purchases were made but receipts were not provided. The CDON stated former BOM #100 told the administrative staff she gave the receipts to Resident #9 and the resident put the receipts in a bag and lost them. The CDON stated when she interviewed Resident #9, the resident insisted she was not provided any receipts and had no idea what was purchased except for a recliner chair, clothing and a bedspread with two pillows. The CDON verified she did not have receipts to verify what purchases were made with Resident #9's money which was withdrawn from her account. Interview with current BOM #95 on 04/26/16 at 6:00 P.M. revealed Resident #9 came to her office with a banking statement. She said there were some charges that she did not make or authorize. The BOM indicated Resident #9 was alert and kept constant track of her money and her banking activities. She said Resident #9's normal purchase amount at the city's discount store was around $25.00 and she always required a receipt. Resident #9's receipts were to be turned into the business office. Resident #9 did not want to keep the receipts and relied upon the business office to keep the receipts. BOM #95 stated both she and Resident #9 went through her banking statement and discovered the unauthorized purchases without receipts. This deficiency substantiates Complaint Number OH 854.

Based on resident and staff interview, review of policy and procedures, resident handbook and the facility admission packet, the facility failed to ensure Resident #15 had the right to reasonable access to the use of a telephone without calls being overheard. This affected one of 29 residents residing on the third floor. Findings include: Interview with the family of Resident #15 on 04/28/15 at 11:50 A.M. revealed Resident #15 was able to communicate on the telephone but was not able to do so without being overheard by staff because staff remained in the office where the resident used the telephone. Interview with Resident #15 on 04/29/15 at 1:49 P.M. indicated her relatives were out of state and called her on occasion. She indicated when she received a phone call, someone would take her to an office and remain in the office while she spoke to her family on the telephone. Resident #15 stated she had to speak in Spanish to her family to keep her conversation private. Interview with Licensed Practical Nurse (LPN) #5 on 04/29/15 at 2:01 P.M. revealed residents were brought to the nursing office to take or make a call. She stated if the resident requested she leave the office she would leave, otherwise she would remain in the office and do charting. She stated they used to have a portable telephone but it has not worked in over a year. Review of the policy and procedure entitled resident's privacy dated April, 2015 indicated protecting the resident's privacy was a very important aspect of resident care and a right guaranteed by the residents bill of rights. Review of the admission packet's resident handbook indicated a telephone may be provided in resident rooms as part of the services of the facility. Where phones were not provided, a resident may have a phone installed in their room, with advance facility approval, and all charges for installation and monthly usage would be the sole responsibility of the resident. Phones were also available to the resident for use in the facility. It was the policy of the facility that all residents have regular access to the private use of a telephone. Review of resident rights in the admission packet indicated the resident had a right to reasonable access to the private use of a telephone.

Based on observation, interview and record review, the facility failed to develop a coordinated plan of care with the Hospice provider for one resident (Resident #96). This effected one of ten residents sampled for plans of care. The facility census was 61. Findings include: Review of the medical record revealed Resident #96 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission assessment dated [DATE] indicated Resident #96 was admitted for Hospice services. A plan of care related to terminal care was initiated by Licensed Practical Nurse (LPN) #11 was on 04/23/15. The interventions included advanced directives, comfort measures, Hospice consult, medications as ordered, one on one visits and pain management. Review of the medical record lacked any documentation from the Hospice provider. Interview with State tested Nurse Aide (STNA) #13 on 04/30/15 at 8:38 A.M. indicated she was aware Resident #96 received Hospice services. She reported seeing two Hospice staff in the day before but was not sure what services they provided to the resident. She stated usually there was documentation in the record regarding the services. The administrator provided a stack of documents from Hospice on 04/30/15 at 8:58 A.M. and indicated she had yet to place them in the medical record. Review of the Hospice records revealed Resident #96 entered into Hospice services on 04/22/15 for [MEDICAL CONDITION]. Interview with the director of nursing on 04/30/15 at 9:17 A.M. confirmed there was no integrated or coordinated plan of care in the clinical record. On 04/30/15 at 11:00 A.M. the administrator provided the Hospice plan of care faxed to the facility with a faxed stamp dated 04/30/15 at 10:20 A.M. Review of Hospice contract dated 11/25/13 indicated a plan of care would be provided within two working days that identified the care and services needed and specifically identify which provider was responsible for performing the respective functions that had been agreed upon ensuring coordination of services.

Based on observation, resident and staff interview and record and policy review, the facility failed to follow through on recommended dental services for one resident (Resident #25). This affected one of three residents reviewed for dental status. Twenty-six residents were interviewed related to dental status. Findings include: Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set 3.0 ((MDS) dated [DATE] and 03/04/15 indicated Resident #25 was alert and oriented, did not display behaviors and did not have any dental or oral concerns. Review of the nutrition risk plan of care authored by former Dietitian #9 on 01/13/15 indicated Resident #25 chose not to wear her new dentures and required a mechanically altered diet. The intervention included encouraging the resident to wear dentures at each meal. A note was found in the medical record related to dental services dated 10/31/13 identified Resident #25 as edentulous and had dentures that were approximately three years old. The note indicated the resident reported the upper denture fit fine but the lower denture did not fit and had to use dental adhesive. The dental note indicated Resident #25 needed a realignment on the lower denture. "Will need to put in for reline". Review of the consent form dated 02/22/13 and an undated consent form indicated Resident #25 desired dental services. The consent indicated extractions, dentures and partials required a consent and prior approval from Medicaid. Review of the social service note authored by Licensed Social Worker (LSW) #7 dated 07/07/14 indicated follow up with ancillary dental services regarding therapy's concern with ill-fitting dentures. Awaiting return call/message from ancillary dental services. Interview with Resident #25 on 04/28/15 at 9:29 A.M. revealed the resident had denture problems. Resident #25 reported not being able to wear her dentures because they did not stay in. Interview with Licensed Practical Nurse (LPN) #10 and State tested Nurse Aide (STNA) #11 on 04/29/15 at 2:24 P.M. indicated Resident #25 had dentures but refused to wear them because they flop around and she did not like the denture adhesive. Interview with LSW #7 on 04/29/15 at 1:23 P.M. indicated a consent for dental services was obtained upon admission. Interview with LSW #7 on 04/29/15 at 2:58 P.M. revealed Resident #25 recently agreed to dental services so she was put on the schedule to see the dentist in June, 2015. She stated prior to then she had declined ancillary dental services. LSW #7 verified there was not dental follow through with Resident #25's identified concerns related to her ill-fitting dentures from 2013.. Review of the routine dental care policy and procedure revised April, 2006 indicated nursing staff would conduct ongoing oral health assessments to assure that each resident received adequate oral hygiene, the physician would be notified of a residents need for dental treatment and order dental consultation as appropriate. Routine dental care included but not limited to an initial evaluation of the residents dental needs, consultation with the resident, staff and dental consultant, daily dental and oral hygiene plan of care, in service education and preventive care and treatment.

Based on observation and interview the facility failed to ensure that proper hand hygiene was maintained during meal pass. This affected four residents (Resident #10, Resident #23, Resident #26 and Resident #39) out of 23 residents receiving their meal in the main dining room. Findings Include: Observation of the main dining room on 04/28/15 at 12:00 P.M. for the lunch meal revealed Dietary Aide # 3 removed a resident's plate from the kitchen counter and placed the plate on the cart. Dietary Aide #3 proceeded to rub her forehead and hair with her left hand. Dietary Aide #3 then removed another plate from the counter and placed it on the cart without washing her hands after touching her face. On 04/28/15 at 12:30 P.M. interview with Dietary Aide #3 verified she touched her face and proceeded to place resident plates on the cart without washing her hands.

Based on observation and staff interview, the facility failed to maintain the emergency power to the exit signs installed to show the way out for residents using the beauty shop or vending machines. This had the potential to affect any resident using the beauty or vending area. The facility census was 55. Findings include: On 02/10/14 at 11:00 A.M. the surveyor and Administrator observed the exit sign by the vending machines and beauty shop was not internally illuminated under normal power. The battery back up bulbs did work when tested . The findings were verified by the Administrator at the time of discovery. This deficiency substantiates complaint number OH 425.

Based on record review, observation and interview, the facility failed to implement care planned interventions to prevent falls. This resulted in actual harm for one resident (Resident #40)who sustained a fractured wrist. The deficient practice affected two (Resident #40 and #7) residents of three residents reviewed for falls. The facility census was 52. Findings include: 1. Resident #40 was admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #40's clinical record revealed an Medical Data Set (MDS) 3.0 assessment dated 01/01/14. The MDS 3.0 indicated in the Care Area Assessment (CAA) section, a care plan should be initiated addressing Resident #40's high risk of falling. The MDS 3.0 indicated Resident #40 was not steady with moving from a seated to a standing position, walking, turning around and facing the opposite direction, and transferring from surface to surface. Resident #40 needed assistance with all mobility needs. A plan of care was initiated on 03/26/12 addressing Resident #40's high risk of falling related to poor coordination, unsteady gait, impaired cognition and poor safety awareness. Interventions included a Dycem above and below the cushion on Resident #40's wheelchair to prevent sliding and to place nonskid strips on the floor in Resident #40's bathroom. Review of Resident #40's Resident Care Card (undated) indicated one state tested nursing assistant (STNA) was needed for transfers and toileting, and a Dycem (nonskid pad) was to be maintained on Resident #40's wheelchair, under and on top of the cushion. Resident #40 was to wear gripper socks or nonskid shoes at all times and an alarming seatbelt was to be maintained while Resident #40 was up in the wheelchair. Resident #40 was interviewed and observed on 01/21/13 at 11:35 A.M.. Resident #40 stated she fell at the facility, in the bathroom and fractured her right wrist a few weeks ago. Resident #40 had a blue cast immobilizing the right wrist. Review of a facility Incident Report - Investigation Summary dated 01/05/14 revealed Resident #40 had a fall in the bathroom. Resident #40's roommate notified the staff that Resident #40 fell in her bathroom. The nurse immediately went into Resident #40's bathroom and observed her sitting on the floor, in front of the toilet. Resident #40's wheelchair was noted in front of her with the brakes observed in the unlocked position. Resident #40 complained of pain in the right wrist. The Incident Report - Investigation Summary revealed Resident #40 had attempted to transfer from the wheelchair to the toilet without assistance. Resident #40 lost her balance and fell on the floor. The physician was notified of the fall and Resident #40's pain in the wrist. An X-Ray was ordered of the right wrist. The results of the X-Ray indicated Resident #40 had fractured the right wrist. The report indicated Resident #40 was wearing shoes and the floor was dry and room clutter free. However; there was no documentation on the report indicating the nonskid strips were present on the floor in the bathroom at the time of the fall or that a Dycem was present on the seat of the wheelchair. Observation of Resident #40's room on 01/22/14 at 1:54 P.M. revealed Resident #40 was seated in a wheelchair and had a cast immobilizing her right wrist. There were no nonskid strips on the floor in the bathroom. Resident #40's wheelchair did not have a Dycem present on the seat of the wheelchair. On 01/22/14 at 2:01 P.M. Licensed Practical Nurse #4 verified the above findings. 2. Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A fall risk assessment dated [DATE] revealed Resident #7 was at high risk for falls. A care plan for being at risk for falls was initiated on 09/26/13 with multiple interventions including ensuring the resident was wearing non-skid foot wear when out of bed. Nurses notes dated 11/04/13 at 11:15 P.M. revealed staff responded to Resident #7's call light. Upon entering the room staff observed the resident sitting on her buttocks wedged between her chair and walker. The walker was preventing the resident from getting up. The resident had a slipper on her right foot and only a sock to her left foot. Nurses notes dated 12/19/13 at 2:01 P.M. revealed Resident #7 was observed tipping over her walker and falling to the floor. Resident #7 was not wearing shoes, just regular socks on feet. An Investigation Summary dated 11/04/13 revealed Resident #7 was observed sitting on her buttocks in her room wedged between her chair and walker. Resident #7 had a slipper on her right foot and only a sock to the other foot. Resident #7 was attempting to get out of her chair, lost her balance and got wedged between her walker and chair. An Investigation Summary dated 12/19/13 revealed Resident #7 was walking with her walker while holding a coffee cup in her left hand. Resident #7 had regular socks without shoes on her feet. The resident lost her balance while holding onto the cup and was unable to regain her balance due to not having proper traction on her feet. Interview with the director of nursing (DON) on 01/23/14 at 8:35 A.M. confirmed when Resident #7 fell on [DATE] and 12/19/13 she was not wearing non-skin foot wear. The DON said the facility had not re-educated staff regarding the importance of ensuring care planned interventions were implemented.