Every finding on record at Wayne County Care Center

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEYBased on record review, Facility Reported Incident review, interview, and facility policy review the facility failed to ensure residents were free from staff to resident physical abuse. This deficient practice affected one resident (Resident #16) of three residents reviewed for physical abuse. The facility census was 44.|Findings Include: Review of Resident #16's medical record revealed admission date 04/09/26 with diagnoses including but not limited to traumatic hemorrhage of cerebrum, leukemia, depression, high blood pressure and anxiety.Review of Resident #16's admission Minimum Data Set (MDS) dated [DATE] revealed Resident #16 had severely impaired cognition with a Brief Interview of Mental Status (BIMS) score of five out of possible 15 and was dependent on staff for Activities of Daily Living (ADL) tasks.Review of the Facility Reporting Incident (FRI) Tracking Number 273607 dated 04/21/26 revealed Resident #16 reported Certified Nursing Assistant (CNA) #400 had slapped her hands when she was holding onto the siderail and stated, when we say no we mean no when CNA #400 was performing personal care during the night shift on 04/20/26. Resident #16 was able to identify CNA #16 from several pictures presented for her to identify the CNA she reported. The facility placed CNA #16 on administrative leave pending investigation results. Further review revealed CNA #400 received a disciplinary written warning dated 06/24/25 for violation of resident care related to resident complaints of leaving them on wet bed pads and unfriendly attitude towards residents when answering call lights.Interview on 05/13/25 at 2:35 P.M. with Resident #16 confirmed someone did slap her hands during care.Interview on 05/14/26 at 9:15 A.M. with the Director of Nursing (DON) revealed Resident #16's account of what had occurred during night shift personal care on 04/20/26 did not change during several interviews by other staff members. The DON stated during CNA #400's interview for the facility investigation, CNA #400 did not confirm or deny the allegation of physical abuse reported by Resident #16. The DON verified the CNA was terminated as a result of the investigation of physical abuse. Review of the facility's policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property dated 02/2005 revealed residents have the right to be free from abuse, neglect, exploitation, and misappropriation of resident property. This includes, but not limited to, freedom of corporal punishment, involuntary seclusion and any physical or chemical restraint that is not required to treat the resident's medical symptoms.The deficient practice was corrected on 04/22/26 when the facility implemented the following corrective actions: On 04/20/26 Resident #16 was assessed for any bruises or skin tears related to having her hands slapped during care - negative findings were documented.On 04/21/26 CNA #400 was placed on administrative leave pending outcome of the investigation. CNA #400 was terminated.On 04/21/26 residents were interviewed for any further abuse allegations - no further allegations were reported - weekly audits for eight weeks to be implemented.On 04/22/26 all staff were in-serviced on the facility's abuse policy and procedures.On 04/30/26 and 05/07/26 weekly audits completed with no negative findings This deficiency represents non-compliance investigated under Complaint Number 3004666.

Based on record review, Facility Reporting Incident review, interview and facility policy review the facility failed to prevent misappropriation of residents' medication. This deficient practice affected one resident (Resident #14) out of one resident reviewed for misappropriation. The facility census was 44.Findings Include:Review of Resident #14's medical record revealed admission date 12/27/22 with diagnoses including but not limited to unspecified dementia, cognitive communication deficit, anxiety, and depression.Review of Resident #14's physician orders revealed an order dated 07/21/25 for antianxiety medication Clonazepam oral tablet 0.5 milligram (MG) give 0.5 MG by mouth at bedtime.Review of Resident #14's Medication Administration Record (MAR) dated 08/01/25 to 08/30/25 revealed Clonazepam was marked as administered per order on 08/19/25.Review of Resident #14's narcotic count sheet for Clonazepam dated 07/22/25 revealed on 08/19/25 at 8:20 P.M. one tablet of Clonazepam was administered with eight tablets left in the medication card. Further review revealed on 08/20/25 at 6:00 A.M. the count sheet was adjusted to match the blister pack with one tablet being marked as removed and the count sheet reflecting seven tablets left, the entry was signed by Licensed Practical Nurse (LPN) #397 and LPN #401.Review of the Facility Reporting Incident (FRI) #264336 dated 08/20/25 revealed during narcotic count at morning shift change on 08/20/26 at 6:00 A.M. it was noted Resident #14's Clonazepam should have had eight tablets in the blister pack and there were only seven observed. At the time LPN #397 and LPN #401 made the decision to document one tablet being deducted from the count sheet to reflect the number of tablets left in the blister pack. Both LPN #397 and LPN #401 signed the entry on the narcotic count sheet for Resident #14's Clonazepam, without notifying the Director of Nursing about the discrepancy with Resident #14's Clonazepam. Neither LPN #397 nor LPN #401 had knowledge of the missing Clonazepam tablet. At 2:30 P.M. on 08/20/25 the DON was notified of the discrepancy with Resident #14's Clonazepam. The DON placed LPN #397 and LPN #401 on administrative leave and requested a urine drug test to be completed for LPN #397 and LPN #401. On 08/22/25 the county sheriff was notified of the narcotic discrepancy, and a report of loss was filed. On 08/25/25 at 8:00 A.M. urine drug results were received by the facility for LPN #397 with negative results reported for Clonazepam, LPN #401's urine drug results were still pending.Interview on 05/14/26 at 9:30 A.M. confirmed Resident #14's Clonazepam count was adjusted by LPN #397 and LPN #401 during the morning narcotic count on 08/20/25. The DON stated neither LPN #397 or LPN #401 knew what had happened with the missing Clonazepam tablet. LPN #397 and stated LPN #401 made the decision to deduct the tablet from the count sheet and had LPN #397 sign the count sheet. Review of the facility's policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property dated 02/2005 revealed residents have the right to be free from abuse, neglect, exploitation, and misappropriation of resident property. This includes, but not limited to, freedom of corporal punishment, involuntary seclusion and any physical or chemical restraint that is not required to treat the resident's medical symptoms.

Based on Facility Reporting Incident review, interview, and facility policy review the facility failed to report misappropriation of residents' pain medication Oxycodone. This deficient practice affected seven residents (Residents #6, #13, #14, #18, #24, #45, and #47) out of seven reviewed for use of pain medication Oxycodone. The facility's census was 44.Findings Include:Review of the Facility Reporting Incident (FRI) #264336 dated 08/20/25 and closed 08/25/25 revealed during the investigation Licensed Practical Nurse (LPN) #401 was required to complete a urine drug test for Clonazepam on 08/20/25. The facility received LPN #401's drug test results on 09/04/25 revealing LPN #401 tested positive for Oxycodone without an active prescription. LPN #401 resigned from employment at the facility on 09/19/25. The facility's investigation led to the Ohio Nursing Board being notified with action taken to suspend LPN #401's LPN license, local law enforcement investigated, Ohio Attorney General's office investigated, and the facility's pharmacy conducted an investigation and whole house audit of resident's ordered Oxycodone. The facility did not report this separate misappropriation incident, only continued to investigate under the original FRI #264336 for the misappropriation of Clonazepam.Interview on 05/14/26 at 10:00 A.M. with the Director of Nursing (DON) confirmed the facility did not initiate a new FRI once the drug results were received for LPN #401 showing the use of Oxycodone. The DON confirmed Residents #6, #13, #14, #18, #24, #45, and #47 had orders for Oxycodone and were identified affected.Review of the facility's policy titled, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property dated 12/2005 revealed facility staff should immediately report all such allegations to the Administrator and to the Ohio Department of Health in accordance with the procedures in this policy.

Based on record review, observation, interview and facility policy review the facility failed to ensure Enhanced Barrier Precautions were followed during indwelling urinary catheter care. This deficient practice affected one resident (Resident #11) of one resident reviewed for indwelling urinary catheter. The facility census was 44.Findings Include:Review of Resident #11's medical record revealed admission date 01/16/26 with diagnoses including but not limited to rectum cancer, high blood pressure, obstructive and reflux uropathy, and epilepsy.Review of Resident #11's discharge return anticipated [NAME] Data Set (MDS) dated [DATE] revealed Resident #11 had impaired cognition with a Brief Interview of Mental Status (BIMS) score of eight out of a possible 15 and had an indwelling urinary catheter.Review of Resident #11's physician orders revealed an order dated 03/26/26 for catheter size 18 French (FR) balloon size 10 cubic centimeter (CC) to continuous drainage due to wound healing every shift, and order dated 03/25/26 for catheter care every shift and as needed (PRN), and an order dated 04/07/26 for Enhanced Barrier Precautions to be maintained for high contact care related chronic wound every shift.Review of Resident #11's elimination care plan dated 04/14/26 revealed indwelling urinary catheter with catheter care per physician orders.Observation on 05/13/26 from 11:07 A.M. to 11:15 A.M. during Resident #11's indwelling urinary catheter care completed by Certified Nursing Assistants (CNAs) #254 and #373. There was a small rectangular magnet noted on the upper left-hand doorframe of Resident #11's room with EBP-2 in black print. Upon entering Resident #11's room, CNA #254 and #373 did not don a gown as part of their personal protective equipment (ppe) prior to initiating and completing Resident #11's indwelling urinary catheter care.Interview on 05/13/26 at 11:25 A.M. with CNA #254 confirmed neither CNA placed a gown on as part of their PPE prior to completing indwelling urinary catheter care for Resident #11. CNA #254 stated they should have put on gowns before they started her catheter care.Review of the facility's policy titled, Enhanced Barrier Precautions dated 12/2024 revealed enhanced barrier precautions are utilized to prevent the spread of multi-drug-resistant organisms to residents. Enhanced barrier precautions employ targeted gown and glove use in addition to standard precautions during high contact resident care activities for residents with indwelling medical devices or wounds.This deficiency represents non-compliance investigated under Complaint Number 2683752.

Based on interview and record review the facility failed to ensure residents who wanted the facility to manage resident funds had a signed authorization for the facility to manage their resident funds. This affected two residents (#19 and #37) out of 24 residents with resident funds. Findings Include: Review of the Resident Funds for Resident #19 revealed the current balance of $2,210.05 in the Resident funds account, There was no documentation that Resident #19 signed authorization for the facility to manage his resident funds. Review of the Resident Funds for Resident #37 revealed the currant balance of $3,716.61 in the Resident funds account. There was no documentation that Resident #37 signed authorization for the facility to manage his resident funds. Interview on 11/12/24 at 3:01 P.M. with Fiscal Specialist #300 verified there were no resident funds authorizations forms for Resident #19 and Resident #37.

Based on interview and record review the facility failed to ensure residents receive a spend down notice prior to reaching the maximum allowed limit for Medicaid benefits. This affected two residents (Resident #4 and #19) out of 24 residents with resident funds. Findings Include: Review of the Resident Funds for Resident #19 revealed a balance of $3,716.61 in the Resident Funds account. The facility is to notify the resident when their account reaches $200 below the allotted amount ($2000), which could cause the resident to lose their Medicaid benefits. Review of the Resident Funds for Resident #4 revealed a balance of $4,814.47 in the Resident Funds account. The facility is to notify the resident when their account reaches $200 below the allotted amount ($2000), which could cause the resident to lose their Medicaid benefits. Interview on 11/12/24 at 3:01 P.M. with Fiscal Specialist #300 verified Resident #4 and #19 did not receive written notification that their accounts were over the allotted amount and could affect residents Medicaid benefits. Residents are to be notified that they are getting close to the limit so that they can use their funds or the funds need to be returned to Medicaid.

Based on review of the medical record, review of therapy assessments, and staff interview, the facility failed to provide a Notice of Medicare Non-Coverage (NOMNC) to Resident #41. This affected one resident (#41) of two reviewed for beneficiary notification. The facility census was 37. Findings include: Review of the closed medical record for Resident #41 revealed an admitted [DATE] with diagnoses including cerebral infarction, hemiplegia and hemiparesis following non-traumatic intracerebral hemorrhage affecting non-dominant left side, muscle wasting and atrophy to bilateral lower extremities, and unspecified abnormalities of gait and mobility. Resident #41 was discharged on [DATE]. Review of the physician's orders for June 2024 identified orders for occupational therapy five to seven times per week for four weeks (ordered 05/08/24) and physical therapy five to seven times per week for four weeks (ordered 05/06/24). Review of the progress note, dated 05/10/24 at 1:08 P.M., revealed Social Services Designee (SSD) #245 met with Resident #41 and his daughter to discuss discharge planning, a discharge meeting was scheduled for 05/22/24, and Resident #41's therapy discharge date was set for 06/03/24. Review of the discharge Minimum Data Set (MDS) Assessment, dated 06/04/24, revealed Resident #41 had no cognitive impairment. The assessment indicated Resident #41 required partial or moderate assistance for showering, dressing, sit to stand, transfers, and walking, and supervision or touching assistance for oral hygiene, toileting hygiene, personal hygiene, and bed mobility. Resident #41 received 894 minutes of speech therapy over 24 days, 2,797 minutes of occupational therapy over 56 days, and 2,887 minutes of physical therapy over 57 days. Review of the physical therapy recertification assessment, dated 05/08/24, revealed Resident #41 was certified for physical therapy services through 06/01/24. Review of the occupational therapy recertification assessment, dated 05/08/24, revealed Resident #41 was certified for occupational therapy services through 06/03/24. On 11/13/24 at 2:56 P.M., an interview with SSD #245 confirmed a Notice of Medicare Non-Coverage (NOMNC) was not provided to Resident #41 because he was not managed care and it was not an involuntary discharge. SSD #245 was unaware that a NOMNC was supposed to be provided to individuals receiving skilled services covered under Medicare Part A. On 11/14/24 at 8:09 A.M., an interview with Certified Occupational Therapy Assistant (COTA) #303 confirmed the recertification dates for therapy services were the dates Resident #41 was approved for therapy services covered by insurance. On 11/14/24 at 9:00 A.M., an interview with the Director of Nursing (DON) verified the progress note dated 05/10/24 indicated Resident #41 would be discharged from therapy on 06/03/24 with a discharge planning meeting scheduled with Resident #41's family on 05/22/24. The DON stated a NOMNC should have been issued to Resident #41.

Based on observation, interview, and review of facility policy, the facility failed to change the oxygen tubing in a timely manner for Resident #8. This affected one resident (#8) of one reviewed for oxygen use. The facility census was 37. Findings include: Review of the medical record for Resident #8 revealed an admitted [DATE] with diagnoses including cerebral infarction, type two diabetes mellitus, anxiety, ovarian cancer, hypertension, depression, and hemiplegia and hemiparesis following cerebral infarction. Review of the respiratory care plan, revised 01/18/24, revealed Resident #8 had the potential for altered breathing patterns related to shortness of breath, anxiety, decreased energy, fatigue, and hypoxia. Interventions included administer oxygen via nasal cannula as per orders and observe effects (revised 07/05/23) and change oxygen tubing as per physician's orders (revised 07/05/23). Review of the significant change Minimum Data Set (MDS) Assessment, dated 10/02/24, revealed Resident #8 had severe cognitive impairment and utilized oxygen therapy. Review of the physician's orders for November 2024 identified orders for change oxygen tubing, bag and aerosol set-up every Saturday (ordered 06/10/23). Review of the treatment administration record (TAR) for November 2024 indicated Resident #8's oxygen tubing was changed on 11/09/24, signed as administered by Licensed Practical Nurse (LPN) #503. On 11/12/24 at 9:05 A.M., an observation of Resident #8 revealed she was laying in bed with eyes closed, not responsive to verbal stimuli, and was receiving oxygen via nasal cannula. The oxygen tubing was dated 11/02/24. On 11/12/24 at 9:10 A.M., an observation and interview with Certified Nurse Aide (CNA) #229 verified Resident #8's oxygen tubing was dated 11/02/24. On 11/12/24 at 3:11 P.M., an interview with the Director of Nursing (DON) stated the facility's policy was to change the oxygen tubing at least every seven days or as needed. On 11/13/24 at 9:17 A.M., an attempt to interview LPN #503 via phone was unsuccessful. Review of the facility's policy titled Departmental (Respiratory Therapy) - Prevention of Infection, dated November 2011, indicated the oxygen cannula and tubing would be changed every seven days or as needed.

Based on a Self-Reported Incident (SRI) review, record review, review of hospital records, facility investigation review, personnel file review, staff interviews, and facility policy review the facility failed to provide adequate staff assistance during resident care resulting in a fall with major injury. Actual harm occurred on 07/24/24 at 4:20 A.M. when State tested Nursing Assistant (STNA) #300 was providing incontinence care to Resident #6, who required two staff assistance with bed mobility, repositioned the resident onto her right side and Resident #6 kicked her left leg out and began sliding out of the bed and landed on her right side. The resident sustained bruising to her right hand, left eye, left shin, left index finger, right upper chest and right forearm, a skin tear to left hand third digit and pain to right leg and hip. An x-ray of the right hip and leg was completed on 07/25/24 at 9:21 A.M. and revealed a fracture to the right femoral neck. The resident was subsequently transferred to the hospital and had surgical repair of the right hip. This affected one resident (Resident #6) out of two residents reviewed for falls. The facility census was 40. Findings Include: A review of the medical record for Resident #6 revealed an admitted [DATE] with diagnoses including Alzheimer's dementia, stroke, high blood pressure, anxiety, contractures, and osteoporosis. A review of Resident #6's skin impairment risk care plan dated 07/05/22 and revised on 07/25/24 revealed a low air loss mattress to the bed for pressure reduction related to impaired mobility. A review of Resident #6's Activities of Daily Living (ADL) care plan revision date 04/13/24 revealed Resident #6 required total assist with all ADL and mobility tasks with one to two assists with incontinence care and toileting and two persons assist with bed mobility. Further review of Resident #6's care plan revealed fall care plan revised 08/11/22 revealed interventions including keep call light in easy reach, keep frequently used items in easy reach, observe Resident #6 has nonslip footwear in place, and observe Resident #6's glasses are kept in a safe place, assist with placement prior to transfers. A review of Resident #6 fall risk assessment dated [DATE] revealed Resident #6 was at high risk for falls related to muscle weakness, contractures and dementia. Review of the current physician orders revealed acetaminophen 650 milligrams orally every four hours as needed for pain- not to exceed 3,000 mg daily and Morphine Sulfate (concentrate) oral solution 10 mg per 0.5 milliliters (ml)- give 10 mg by mouth every two hours as needed for dyspnea (shortness of breath) both dated 05/24/24. A review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #6 had severely impaired cognition with a Brief Interview of Mental Status (BIMS) score of two out of a possible 15. Resident #6 was always incontinent of both urine and bowel requiring staff assistance with incontinence care. Resident #6 was non-ambulatory using a wheelchair for mobility and was dependent on staff for completion of all cares including transfers and bed mobility. A review of Resident #6's Kardex (information reference for State tested Nursing Assistants regarding resident specific needs to be able to provide the appropriate care) dated 07/24/24 revealed Resident #6 required one-to-two-person assistance with toileting and incontinence care and two persons assist with bed mobility. A review of Resident #6's progress notes revealed: On 07/24/24 at 7:06 A.M., authored by Licensed Practical Nurse (LPN) #224, revealed at 4:30 A.M. STNA #300 reported Resident #6 had rolled out of bed onto right side while providing care. Upon entering room Resident #6 was observed positioned on her back on the floor beside the bed with a pillow under her head. LPN #224 assessed Resident #6 with vital signs including blood pressure - 152/92 millimeters of mercury (mmHg) (normal blood pressure is 120/80 mmHg), pulse - 94 (beats per minute) (normal range 60-90), respirations (per minute) (normal range 12-20 breaths per minute) - 20, temperature - 97.6 (degrees Fahrenheit) and blood oxygen (saturation) level 93% (normal greater than 92%). On further exam there was a skin tear noted to (the resident's) left hand third digit and discoloration observed to (the) left index digit prior to transfer back into bed. Resident #6 was awake, and no pain or distress indications were observed by LPN #224. The physician and Director of Nursing was notified of the fall. On 07/24/24 at 7:30 A.M., authored by LPN #222, revealed STNAs (unidentified) reported Resident #6 required assistance in her room, upon entry LPN #222 observed Resident #6 was sitting in the wheelchair slouched forward and drooling. Resident #6 was difficult to arouse with a blood pressure reading at 89/50 (mmHg) and pulse at 90 (bpm), respirations were uneven and unlabored (no respiratory rate or additional assessment of the resident's respiratory status was documented). After approximately 90 seconds, Resident #6 returned to baseline level of alertness and orientation. Resident #6 was returned to bed by staff and the use of a mechanical lift. Resident #6's blood pressure reading was 120/58 (mmHg) and pulse was 89 (bpm). Resident #6 refused the breakfast meal and denied having pain. On 07/24/24 at 10:27 A.M., authored by Registered Nurse (RN) #320, revealed Resident #6's daughter was notified of the fall and a new order for diuretic medication Lasix related to increased edema to lower legs noted on 07/23/24. On 07/24/24 at 9:31 P.M., authored by RN #257, revealed an STNA (unidentified) alerted RN supervisor (RN #257), and staff LPN regarding Resident #6 was grimacing and yelling with movement of her right leg during evening care. Resident #6's right lower leg below the knee was observed discolored and swollen and presented as displaced (there was no further clarification indicated in the medical record) and RN #257 was not available for interview). The physician, Director of Nursing and wound nurse were notified. On 07/24/24 at 11:29 P.M., authored by RN #257, revealed a new order for a right femur two views X-ray, right tibia/fibula two view X-ray related to acute pain due to trauma/fall. The right leg presents displaced and Resident #6 grimacing and yelling out during care. On 07/25/24 at 12:58 P.M., authored by RN #315, revealed Resident #6's daughter was updated on (the resident's) current condition, pain management, pending X-ray results and ongoing fall investigation. On 07/25/24 at 2:27 P.M., authored by RN #315, revealed the physician and the Director of Nursing were notified of the X-ray results. Per the physician recommendation to call the family to see if they want the resident evaluated for an orthopedic consult for surgical intervention, Resident #6's daughter was notified and will speak with the rest of the family. On 07/25/24 at 3:15 P.M., authored by RN #257, revealed Resident #6's daughter notified the facility and requested Resident #6 be sent to the hospital for evaluation by an orthopedic physician. RN #257 updated the physician, and an order was received for Resident #6 to be transferred to the hospital. Transportation was requested and will be at the facility at 4:15 P.M. Resident #6's family was notified and will meet Resident #6 at the hospital. On 07/25/24 at 8:30 P.M., authored by LPN #312, revealed the hospital notified the facility Resident #6 was being admitted to the hospital for surgical repair of her right hip fracture. A review of Resident #6's Medication Administration Record (MAR) dated 07/01 /24 to 07/26/24 revealed the following entries for pain management: On 07/24/24 at 5:13 A.M. acetaminophen 650 milligrams (mg) orally (po) was administered for a pain level at three out of 10) on a scale of 0-10 with 0 being no pain and 10 indicating the worst pain). On 07/24/24 9:42 P.M. Morphine 10 mg/0.5 milliliter (ml) was administered by mouth for pain level at eight out of 10. On 07/25/24 at 8:10 A.M. Morphine 10 mg po was administered for pain level at six out of 10. On 07/25/24 at 12:11 P.M. Morphine 10 mg po for a pain level of three out of 10. On 07/25/24 at 4:00 P.M. Morphine 10 mg for a pain level at three out of 10. A review of Resident #6's X-ray results with service date 07/25/24 at 9:12 A.M. and report date 07/25/24 at 1:24 P.M. revealed the conclusion was a right femoral neck/intertrochanteric fracture and right periprosthetic supracondylar fracture with evidence of mild healing. A review of Resident #6's hospital documents dated 07/25/24 to 07/29/24 revealed Resident #6 received an open reduction and internal fixation (ORIF) surgery related to the right femoral neck fracture on 07/28/24 and was discharged back to the facility on [DATE]. Further review of the facility's fall investigation for Resident #6 dated 07/24/24 and 07/25/24 revealed a statement dated 07/24/24 at 6:30 A.M. authored by STNA #300 indicating Resident #6 was administered incontinence care and bed mobility by STNA #300 without assistance from other staff members. Resident #6 had been moving her legs during care and STNA #300 requested Resident #6 to stop moving her legs, but Resident #6 continued to move her legs. STNA #300 had repositioned Resident #6 onto her right side to continue incontinence care. STNA #300 stated Resident #6 moved her left leg over the edge of the bed and then continued to slide off the edge of the bed onto the floor. STNA #300 immediately moved onto the bed and lowered Resident #6's upper body onto the floor. STNA #300 ensured Resident #6 was safe and went to notify the floor nurse of the incident. A statement dated 07/26/24 authored by LPN #224 revealed LPN #224 had been Resident #6's nurse during the incident on 07/24/24 at 4:30 A.M. when LPN #224 was performing medication administration when STNA #300 advised her Resident #6 was on the floor beside the bed, lying on her right side. Resident was repositioned onto her back for LPN #224 to complete a head-to-toe assessment. LPN #224 assessed for range of motion to bilateral lower extremities, there was no range of motion observed due to contractures. There was no displacement and/or shortening of either leg prior to transferring Resident #6 back into bed by use of a mechanical lift. Review of Self-Reported Incident Tracking Number 250054 dated 07/25/24 revealed an allegation of physical abuse and neglect when Resident #6 fell out of bed on 07/24/24. An assessment was completed, and the resident showed no signs of pain or discomfort. Today (07/25/24), the resident showed signs of pain and discomfort. Through investigation, the Administrator identified Resident #6 required two-person assistance with bed mobility. The resident was limited with any mobility, required the use of a Hoyer (mechanical) lift from her chair to the bed. The resident is unable to stand or walk and has limited cognitive ability but recognizes familiar faces with a smile. Further review revealed STNA #300 provided a statement and explained what happened on 07/24/24. The STNA explained to the Administrator and others that she was providing incontinence care and rolled Resident #6 to herself on the left side (of the resident). She then rolled the resident over to her right side, when the resident's left leg jerked and she (the resident) started sliding out of bed. STNA #6 grabbed her on the right and crawled on the bed to get a better hold of Resident #6. STNA #300 could not hold the resident so she helped the resident to the floor. STNA #300 did move her head, putting a pillow under it and went to the hallway for help. The LPN then did evaluate the resident checking range of motion and vitals. The LPN then told the STNAs to get the Hoyer. They Hoyered her (the resident) back to bed. The facility unsubstantiated the allegation citing evidence was inconclusive, but abuse, neglect or misappropriation is suspected. In conclusion, statements did support STNA #300 was not following the resident's care Kardex. A review of STNA #300 employee file revealed a hire date of 02/08/21 and a resignation date of 08/01/24. STNA #300 had been suspended on 07/24/24 pending completion of the fall investigation for Resident #6. STNA #300 was scheduled for a pre-disciplinary conference on 08/01/24 at 1:00 P.M. STNA #300 had submitted a resignation letter dated 08/01/24 with resignation effective immediately and did not attend the scheduled conference. Attempts to reach LPN #224 and RN #320 were made during the survey however, unsuccessful. No return calls from either nurse were provided. An interview on 09/09/24 at 9:50 A.M. with the Administrator confirmed Resident #6's fall was caused when inappropriate assistance by STNA #300 during incontinence care on 07/24/24 at 4:20 A.M. The Administrator stated a facility investigation was initiated immediately with STNA #300 being suspended pending completion of the investigation. The facility had scheduled a pre-disciplinary conference with STNA #300 on 08/01/24 however, the STNA submitted her immediate resignation on 08/01/24 without reason provided. Observation on 09/09/24 at 1:15 P.M. revealed Resident #6 was sitting in a Broda wheelchair in the unit lounge watching television. Resident #6 was not observed in bed to watch bed mobility assist by staff. Review of the facility's policy titled, Falls and fall Risk, managing dated 03/18 revealed, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. This deficiency represents non-compliance investigated under Complaint Number OH00156843 and OH00156546.

Based on record review, facility policy and procedure review and interview the facility failed to ensure Resident #16's advance directive wishes were accurately documented and consistent throughout the medical record. This affected one resident (#16) of 16 residents whose records were reviewed for advance directives. Findings include: Review of Resident #16's medical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the electronic health record revealed a code status of Do Not Resuscitate Comfort Care-Arrest (DNRCC-A) (providers would treat resident as any other without a Do Not Resuscitate (DNR) order until the point of cardiac or respiratory arrest at which point all interventions would cease and the DNR Comfort Care (DNRCC) would be implemented). A sticker on the physical medical record indicated a DNRCC-A status but no corresponding form/order was able to be located. On 05/23/22 at 3:24 P.M., Licensed Practical Nurse (LPN) #112 was interviewed regarding the resident having no signed code status form in the medical record. LPN #112 reported she would notify the supervisor. On 05/24/22 Resident #16 was noted to have a form signed 02/13/15 in the medical record indicating her desired code status was DNRCC. The sticker was changed from DNRCCA to DNRCC. The code status in the electronic health record had been changed to DNRCC. On 05/24/22 at 1:35 P.M. interview with the Director of Nursing revealed Resident #16 used to reside in the residential care facility and had a signed DNRCC. No DNRCCA form was able to be located. Once she learned of the discrepancy in the medical record on 05/23/22 she educated Resident #16 on the difference between DNRCC and DNRCCA. Resident #16 indicated she desired a DNRCC code status and the sticker and electronic health record were changed. The signed DNRCC order from 2015 was placed in the resident's medical record. Review of the facility Advance Directives policy, revised December 2016 revealed prior to or upon admission of a resident, the social services director or designee would inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directive. Information about whether or not the resident had executed an advance directive should be displayed prominently in the medical record. The plan of care for each resident would be consistent with his or her documented treatment preferences and/or advance directive. Review of a paper titled Ohio's Do-Not -Resuscitate Law, provided by the facility, revealed with a DNRCC order a person received any care that eased pain and suffering but no resuscitative measures to save or sustain life from the moment the order was signed by the physician. With a DNRCC-Arrest order, a person received standard medical care that may include some components of resuscitation until he or she experienced a cardiac or respiratory arrest.

Based on record review and interview the facility failed to ensure timely provision of dental services for Resident #11. This affected one resident (#11) of three residents reviewed for dental services. Findings include: Review of Resident #11's medical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A plan of care, initiated 06/14/18 indicated Resident #11 had two dental implants and had all her own teeth. An intervention initiated 06/28/18 (revised 08/25/20) revealed staff were to assist with any dental appointments, transportation and paperwork needed as necessary. Review of a significant change Minimum Data Set (MDS) 3.0 assessment, dated 08/21/21 indicated Resident #11 had obvious or likely cavity or broken natural teeth. Review of a dental progress note and summary report, dated 01/20/22 revealed Resident #11 presented with tooth tenderness and slight puffiness at tooth #5 and a missing crown at tooth #7. Treatment planned for the next visit included extraction of tooth #5 and further evaluation of tooth #7 including radiography. No additional dental visit notes were located. On 05/25/22 at 3:13 P.M. interview with the Director of Nursing (DON) revealed the dentist provided documentation via email regarding visit notes. The DON stated once the dental notes were received, they were reviewed by social service, herself, and the MDS nurse. When a procedure was needed the dental provider sent consent forms for resident/family to consent and for the physician to give medical clearance. The DON revealed since the dentist had not sent the forms to be completed, Resident #11 was not seen by the dentist when they made their visit in February. The dental provider was notified today and the forms were provided. The facility called and obtained consent over the phone from Resident #11's grandson. The physician clearance papers had been placed in the physician's folder to be completed. On 05/25/22 at 3:18 P.M. interview with Social Service Director (SSD) #148 revealed since Resident #11's dental visit on 01/20/22 was an emergency visit the information from the dentist was emailed to the facility. SSD #148 stated once she received the paper work from the dentist she scanned the information into the record and provided a copy to the DON and MDS nurse. SSD #148 revealed she did not review the information since she was unable to contact families or residents to obtain consent for procedures. SSD #148 revealed the dental provider generally created a list of residents to be seen before each visit and she was able to add to the list. Someone must communicate to her that a resident needed dental services so she could add them to the list. If a resident had an emergency visit and needed a follow up the dental provider generally sent a consent to treat and physician clearance forms. Resident #11 was now on the list to be seen by the dentist on 05/31/22. On 05/25/22 at 3:31 P.M. interview with SSD #148 indicated she received the 01/20/22 dental notes for Resident #11 via email on 01/25/22. The next regular dental visit was on 02/07/22. SSD #148 revealed if she had been informed of the plan to extract teeth for Resident #11 she could have requested the necessary forms and added her to the list of residents to receive services on 02/07/22. Review of a contract with Mobile Medical, effective on 05/26/16 revealed dental services to be provided at the facility included dental examinations and [CONDITION(S)] screening, diagnostic x-ray examination, prophylaxis and denture cleaning, tooth surface restorations, simple extractions, removable prosthetic fabrication, relines and repairs. This deficiency substantiates Complaint Number OH 855.

Based on interview and record review, the facility failed to implement a plan to manage residents exposed to COVID-19 that was based on national standards developed to contain the spread of COVID-19. Specifically, a COVID-19 outbreak was identified in the facility on 08/13/20 when one staff tested positive for COVID-19. After this outbreak, staff failed to wear all recommended Personal Protective Equipment (PPE- i.e., gloves, gown, eye protection and respirator or facemask) when providing care for five (Resident (R) 1, R2, R3, R4, R5) of five residents reviewed for transmission-based precautions. This deficient practice had the potential to affect 23 residents residing on the units where the staff who tested positive for COVID-19 worked, out of a census of 37 residents. Findings include: Review of the Centers for Disease and Control and Prevention (CDC) guidance titled Responding to COVID-19, Considerations for the Public Health Response to COVID-19 in Nursing Homes, updated 04/30/20, revealed the following in the section titled, Response to Newly Identified [DIAGNOSES REDACTED]-CoV-2-infected HCP (Health Care Personnel) or Residents: HCP who worked with symptoms consistent with COVID-19 or in the 48 hours prior to symptom onset: .If the HCP is diagnosed with [REDACTED]. Review of the facility's policy from the Nursing Services Policy and Procedure Manual for Long-Term Care © MED-PASS titled, Coronavirus Disease (COVID-19) - Infection Prevention and Control Measures, revised April 2020, directed that If there are COVID-19 cases in the facility: Staff wear all recommended PPE (personal protective equipment) (i.e. gloves, gown, eye protection and respirator or facemask) for the care of all residents on the unit. The policy did not direct how to care for residents who were exposed to a HCP who became COVID positive. Review of the facility's undated document titled COVID-19 Tracking revealed State tested Nursing Assistant (STNA) 4 was tested for COVID-19 on 08/10/20 and the facility received a COVID positive result on 08/13/20. Review of the facility's Daily Staffing documents revealed STNA4 worked from 6:00 AM to 6:00 PM on 08/08/20, 08/09/20, and 08/11/20 on the B1 and B2 hall, working with two other STNAs. Review of the Daily Census report dated 08/11/20 revealed the facility census was 37 with 23 residents residing on the B1 and B2 Halls. Review of the Infection Control Preventionist (ICP) document revealed that R1, R2 and R3 were tested for COVID-19 on 08/20/20, R4 was tested on [DATE], and R5 was tested on [DATE]. a. Review of R1's Electronic Medical Record (EMR) revealed that on 08/20/20 at 3:00AM, a Nurse's Note documented that R1 was not feeling well and had a temperature of 100.8 degrees Fahrenheit (F). A nurse's note dated 08/20/20 at 12:05 PM in the Progress Notes tab of the EMR documented that a COVID test was obtained, and the resident was moved to the COVID Unit. Review of Lab Report dated 8/23/20 revealed that, based on the sample taken on 08/20/20, the resident had tested positive for COVID-19. Review of R1's Progress Notes tab revealed no information about use of PPE between 08/13/20, when the first COVID-19 outbreak occurred, and 08/20/20 when the resident developed symptoms and was transferred to the COVID-19 unit. b. Review of R2'S EMR revealed that on 08/20/20 at 4:14 AM, a Nurse's Note documented that R2 was not feeling well and had a temperature of 100.2 degrees F at 12:30 AM. A nurse's notes dated 08/20/20 at 7:50 AM revealed the resident was transferred to the COVID Unit due to presumptive COVID-19 and placed on droplet precautions. Review of a Lab Report dated 8/23/20 revealed that, based on a sample taken on 08/20/20, the resident had tested positive for COVID-19. Review of R2's Progress Notes tab revealed no information about use of PPE between 08/13/20, when the first COVID-19 outbreak occurred, and 08/20/20 when the resident developed symptoms and was transferred to the COVID-19 unit. c. Review of R3's EMR revealed that on 08/20/20 at 3:20 AM, a Nurse's Note in the Progress Notes tab documented that R3 had a temperature of 100.7 Degrees F and Tylenol had been administered at 12:20 AM. A nurse's note dated 08/20/20 at 7:50 AM revealed R3 was transferred to the COVID-19 Unit due to presumptive COVID-19 and placed on droplet precautions. Review of a Lab Report dated 8/23/20 revealed that, based on a sample taken on 08/20/20, R3 had tested positive for COVID-19. Review of R3's Progress Notes tab revealed no information about use of PPE between 08/13/20, when the first COVID-19 outbreak occurred, and 08/20/20 when the resident developed symptoms and was transferred to the COVID-19 unit. d. Review of R4's EMR revealed that on 08/22/20 at 10:20 PM, a Nurse's Note in the Progress Notes tab of the EMR documented that R4 had diarrhea and was placed on droplet precautions. Review of a Lab Report dated 08/25/20 revealed that, based on a sample taken on 08/23/20, R4 was positive for COVID-19. Review of R4's Progress Notes tab revealed no information about use of PPE from 08/13/20, when the first COVID-19 outbreak occurred through when the resident began displaying COVID-19 symptoms. e. Review of R5's EMR revealed that on 08/24/20 at 7:30 PM, a Nurse's Note in the Progress Notes tab documented that R5 had a cough and coarse rhonchi (abnormal lung sounds) and at 9:00 PM was moved into the COVID-19 Unit. Review of Lab Report dated 8/25/20 revealed that, based on a sample taken on 08/24/20, R5 was positive for COVID-19. Review of R5's Progress Notes tab revealed no information about use of PPE between 08/13/20, when the first COVID-19 outbreak occurred, and 08/24/20 when the resident developed symptoms and was transferred to the COVID-19 unit. Interview with STNA1 on 09/18/20 at 10:45 AM revealed that she routinely worked on the B1 and B2 Halls. STNA 1 stated that between the first staff outbreak on 08/13/20 and the first resident outbreak on 08/20/20, staff were following standard precautions, and the only PPE staff were using was wearing surgical masks when providing care for residents on these halls. During an interview on 09/18/20 at 1:40 PM, Registered Nurse (RN) 1 stated that she recalled STNA4 was the first COVID positive staff member and the first case of COVID in the facility. The immediate intervention for the residents on the units where STNA4 worked was to increase monitoring from daily to twice a day. RN 1 stated that staff were using a cloth mask, and no other PPE was used until the resident outbreak was identified and residents were moved to the COVID Unit. In the COVID Unit, RN1 stated full PPE, which included N95 masks, body suits, face shields and gloves, was used. During an interview on 09/18/20 at 2:44 PM, the Infection Control Preventionist (ICP) stated that on 08/13/20, the first positive case of COVID-19 was identified with STNA4. The residents and responsible parties were notified about the occurrence by the Administrator and she recalled staff were wearing cloth face masks. The ICP stated that staff working on the halls where STNA4 worked did not immediately begin wearing full PPE after the 08/13/20 outbreak. The ICP stated that she conferred with the Director of Nursing (DON) and Medical Director and she did not know about the CDC guidance for a COVID outbreak. The ICP stated she does monitor the CDC website and it was the intention of the facility to follow CDC guidelines. Further interview with the ICP revealed that if staff had used full PPE when providing care, it would be documented in the progress notes in the EMR. During an interview on 09/18/20 at 3:03 PM, the Medical Director stated that within a day of the outbreak, the facility had a meeting with the(NAME)County Health Department. He recalled the health department didn't think the facility needed to do anything; however, the facility ultimately tested the whole building. When asked what the facility was required to do in response to an outbreak, he stated There's been so many directives, it's very confusing and we have tried to keep on top of them. During an interview on 0918/20 at 3:15 PM, the Administrator stated that in response to the COVID-19 outbreak, she spoke with(NAME)County Health Department for guidance and the use of full PPE was not recommended. The Administrator stated she believed the facility policies provided guidance for an outbreak and she did not know about the guidance provided for new outbreaks by the CDC.

Based on observation and interview the facility failed to provide a clean and sanitary kitchen for food storage and preparation. This affected 46 out of 47 residents who received meals from the dietary department (Resident #36 did not receive meals prepared by dietary staff). Findings: 1. A tour of the kitchen was conducted with the Certified Dietary Manager (CDM) #102 at 8:43 [NAME]M. to 9:00 [NAME]M. on 09/03/19. During the tour, the vent behind the ice machine, the ceiling vent over the roll in cooler, and the wood fixture by the ice machine coming from the ceiling connected to the door magnet contained heavy dust build up. Observation of the kitchen on 09/03/19 at 11:30 [NAME]M. revealed Dietary Aide (DA) #101 came into the kitchen, reached into a small bin of cup lids and took one out. DA #101 shook the water off the lid and left the kitchen area and placed it on an unidentified resident's coffee cup. Observation of the bin containing the lids revealed a small amount of brown liquid fluid in the bottom of the bin. The observation was verified with Certified Dietary Manager (CDM) #102 on 09/03/19. 2. Kitchen observations were conducted between 11:00 [NAME]M. and 12:36 P.M. on 09/03/19. Dietary Cook #100 was preparing the residents' plates for lunch. During meal preparation, Dietary Cook #100 finished preparing a lunch plate then left the tray line to look for lids for soup bowls. Upon returning to the tray line, Dietary Cook #100 opened the lids and began preparing lunch meals without washing hands. Interview with the Certified Dietary Manager (CDM) #102 at 12:00 P.M. on 09/03/19 confirmed the finding.

Based on record review and interview, the facility failed to ensure Resident #42's bed was maintained in a low position while she was in bed. Harm occurred when staff failed to address Resident #42's behavior of putting her bed in the high position. Resident #42 raised the bed and fell out from the high position, resulting in a right [MEDICAL CONDITION] requiring hospitalization and surgical repair. This affected one of three residents reviewed for falls. Findings include: Resident #42 was admitted on [DATE] with [DIAGNOSES REDACTED].#42's quarterly Minimum Data Set (MDS) assessments dated 01/16/18 and 06/05/18 revealed Resident #42's cognition was severely impaired and she required extensive assistance with two staff for bed mobility, transfers, and toilet use. Resident #42 had a physician order [REDACTED]. Resident #42's current comprehensive care plan related to her being at risk for falls revealed an intervention on 03/27/17 for staff to keep Resident #42's bed in the lowest position when she was in bed. Review of Resident #42's fall reports revealed on 02/27/18 at 6:55 A.M., the resident was calling out for help and was found seated on the floor mat at her bedside leaning against the bed. No injuries were noted at the time, but Resident #42 complained of pain in her pelvis and hips. An X-ray was completed and revealed Resident #42 had a right [MEDICAL CONDITION]. The investigation outcome revealed Resident #42's bed was not in the low position at the time of the fall, and that Resident #42 had been seen by staff playing with the bed control. Review of the radiology report dated 02/27/18 confirmed Resident #42 had a right [MEDICAL CONDITION]. Since Resident #42 was on Hospice services, Hospice staff indicated they would evaluate her on 02/28/18. Resident #42's nurse's note dated 02/28/18 at 9:30 A.M. revealed Hospice orders were obtained for a possible surgery consult and emergency visit on 02/28/18. Resident #42 was determined to need surgery and was sent to the hospital on [DATE] for surgical repair of her [MEDICAL CONDITION] and was readmitted to the facility on [DATE]. Review of State tested Nursing Assistant (STNA) #46's witness statement revealed when she as providing care to Resident #42 at 5:30 A.M., prior to the fall on 02/27/18. Resident #42 had the bed controls in her hand pushing the buttons to raise the bed up. STNA #46's statement said the bed was lowered, but she did not address Resident #42's behavior of playing with the bed control buttons. Review of Licensed Practical Nurse (LPN) #30's witness statement revealed she last saw Resident #42 around 5:30 A.M. on 02/27/18 and her bed was in low position. LPN #30 said she had previously seen Resident #42 using the bed controller to her bed and she had her bed elevated in the higher position. Review of the facility investigation report for Resident #42's fall on 02/27/18 revealed STNA #41, STNA #46, STNA #84, LPN #73, and LPN #30 received discipline for Resident #27 not having her low bed intervention in place at the time of the fall, which created or contributed to unsatisfactory or unsafe conditions. Interview on 07/03/18 at 12:30 P.M. with the Director of Nursing (DON) confirmed staff had seen Resident #42 playing with the bed control remote prior to the fall on 02/27/18, but this behavior was not addressed prior to her falling. The DON confirmed all staff working with Resident #42 around the time of the fall received discipline since Resident #42's bed was not maintained in a low position at the time of the fall.

Based on observation, interview, and record review the facility failed to ensure the dishwasher rinse temperature was maintained at the appropriate temperature and failed to ensure clean dishes dried under sanitary conditions. This affected 46 out of 46 residents that consumed food from the kitchen (Resident #12 did not consume food by mouth). The facility census was 47. Findings include: 1. Observation on 07/01/18 at 9:30 A.M. of the dishwasher rinse cycle water temperature revealed it was a high temperature dish washer and the temperature gauge read 170 degrees Fahrenheit (F). Assistant Production Manager #18 joined the observation and after the dishwasher ran a second time, the temperature was observed to be 170 degrees F. Interview with Assistant Production Manager #18 confirmed the rinse cycle was 170 degrees F and revealed the temperature should be 180 degrees F. Review of Dishwasher Temperature Log for (MONTH) (YEAR) revealed the dishwasher rinse cycle temperature was recorded at each meal. The rinse temperature was below 180 degrees F on 06/02/8 at lunch, 06/03/8 at lunch and dinner, 06/10/18 at breakfast, 06/12/18 at dinner, 06/13/18 at dinner, 06/17/18 at lunch, 06/18/18 at lunch, 06/19/18 at dinner, 06/20/18 at dinner, 06/23/18 at lunch and dinner, 06/24/18 at all meals, 06/25/18 at all meals, 06/26/18 at all meals, 06/27/18 at all meals, 06/28/18 at lunch and dinner, 06/29/18 at lunch and dinner, and on 06/30/18 at lunch. 2. Observation on 07/01/18 at 9:37 A.M. with Assistant Production Manager #18 revealed a fan was blowing on clean dishes that just ran through the dishwasher. The fan had dust on the outside and on the blades. The Assistant Production Manager #18 verified this concern.

Based on medical record review, observation, and staff interview, the facility failed to follow physician ordered treatments for geriatric sleeves (geri-sleeves). This had the potential to affect one (Resident #19) of two residents reviewed for skin conditions. Findings include: A review of Resident #19's medical record revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. A review of Resident #19's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of six (scores of zero to seven indicate severe cognitive impairment). This assessment indicated Resident #19 required extensive assistance with one staff for transfers and locomotion. A physician order [REDACTED].#19 had the potential for skin impairment related to the progression of her disease process and was to have geri-sleeves to her arms at all times. This intervention was initiated on 05/01/18 on the care plan. An observation on 07/02/18 at 3:02 P.M. revealed Resident #19 was not wearing geri-sleeves on her arms. This concern was confirmed at the time of the observation with Licensed Practical Nurse (LPN) #10. An observation on 07/03/18 at 9:44 A.M. revealed Resident #19 was not wearing geri-sleeves on her arms. This concern was confirmed with LPN #9 at the time of the observation.

Based on record review, interview, and observation, the facility failed to ensure splint devices were available and applied to Resident #12's hands to maintain range of motion (ROM). This affected one of two residents reviewed for ROM. Findings include: Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of her annual Minimum Data Set (MDS) assessment from 06/20/18 revealed Resident #12 had severe cognitive impairment. Resident #12's most recent Occupational Therapy (OT) referral, dated 03/09/18, resulted in an assessment and treatment from 03/09/18 to 05/03/18 during which her range of motion (ROM) for her upper extremities was increased and her tolerance while wearing splints was also increased. OT referred Resident #12 to restorative nursing on 05/03/18 for ongoing treatment that included placement of a cone splint in her right hand and a palm protector in her left hand. Resident #12's physician order [REDACTED]. Resident #12's comprehensive care plan for Extremity Stiffness dated 07/14/17 directed staff to follow functional passive ROM and the splint/brace restorative program and for staff to refer to restorative documentation as needed. Review of the available restorative schedule in Resident #12's care plan, dated 10/23/17, revealed the splint/brace should be placed on the resident from 7:00 A.M. until 2:00 P.M., 3:00 P.M. until 8:00 P.M., 9:00 P.M. until 6 A.M. and off in between those times and for bathing. Observation of Resident #12 on 07/01/18 at 5:20 P.M. with Registered Nurse (RN) #77 revealed she did not have her hand splints placed as directed by the restorative care plan. Interview with RN #77 at this time confirmed the splint devices were not in place according to her care plan. Interview with restorative nurse, RN #40, on 07/01/18 at 5:32 P.M. revealed there was another restorative schedule for Resident #12. RN #40 reported it was the most current for Resident #12 which called for placement of a cone in her right hand and a palm protector on her left hand to be placed on second shift, with washcloths in her hands at all other times. Observation of Resident #12 on 07/01/18 at 5:32 P.M. with RN #40 revealed no cone in her hand and no cone available. A sign was taped to the wall behind Resident #12's bed, which said, please place cone in right hand and palm protector in left hand when up in wheelchair. Off when in bed. Thank you! Therapy. Interview with RN #40 at this time confirmed there was no cone in place for Resident #12 and confirmed placement of sign with with information which was not accurate. Observation of Resident #12 at 4:57 P.M. on 07/02/18 with LPN #10 revealed a cone in her left hand and a palm protector in her right hand. LPN #10 confirmed placement of each object. LPN #10 reviewed the restorative plan for placement of cone and palm protector and realized the splint placement was backwards. Interview with Occupational Therapist (OT) #105 on 07/03/18 at 11:10 A.M. revealed Resident #12 is often in therapy. OT #105 explained the plan for Resident #12's splint devices were to prevent her contractures from getting worse as the severity of her contractures prevent her from making gains. OT #105 also said the splint devices were also to help prevent skin breakdown.

Based on medical record review and staff interview, the facility failed to implement dietary recommendations for Med Pass nutritional supplement for Resident #19. This affected one out of two residents reviewed for nutrition. The facility census was 47. Findings include: A review of Resident #19's medical record revealed an admission date of [DATE] and the [DIAGNOSES REDACTED]. A review of Resident #19's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of six (scores of zero to seven indicates severe cognitive impairment). Record review revealed a dental visit on 01/11/18. Resident #19 had loose fitting dentures but refused to allow a realignment to the dentures. A care plan dated 03/19/15 revealed Resident #19 had the potential for an alteration in nutrition related to impaired cardiac function and had interventions to receive Med Pass (a high calorie supplement) per physician orders. Physician orders [REDACTED].#19 was to receive Med Pass four ounces (oz) twice a day. A nutritional note from 05/16/18 revealed Resident #19 previously had mouth sores due to loose dentures and she had a new recommendation for an increase in the Med Pass supplement from twice a day, to three times a day. No evidence of the new orders for the Med Pass for three times a day could be provided. A review of Resident #19's Medication Administration Record [REDACTED]. An interview on 07/02/18 at 9:57 A.M. with Dietician #21 confirmed she had ordered the Med Pass increase on 05/16/18, but the order had not been followed through with by nursing. She confirmed Resident #19 should be have been receiving the Med Pass three times a day.

Based on observation, interview, and record review, the facility failed to follow the pureed peanut butter and jelly sandwich recipe, to ensure Resident #27 received the proper pureed portion sized sandwich. This affected one (Resident #27) of one residents who received a pureed peanut butter and jelly sandwich on 07/04/18. Findings include: Observation on 07/04/18 at 10:40 A.M. of Assistant Production Manager #18 pureeing one serving of a peanut and butter jelly sandwich for Resident #27 revealed she shook bread mix out of a bread mix bucket into the blender, without measuring it. Assistant Production Manager #18 added a large spoon full of jelly and a large spoonful peanut butter, without measuring them, into the blender with the bread. Interview with Assistant Production Manager #18 at this time revealed she put a fourth of a cup of bread mix in the blender. Assistant Production Manager #18 shook what she estimated as a fourth of a cup into a measuring cup, and it did not equal one fourth of a cup. Assistant Production Manager #18 revealed it was about one eighth of a cup. Assistant Production Manager #18 reviewed the directions on the bread mix bucket, and revealed two slices of bread (one serving) required one third of a cup bread mix. Assistant Production Manager #18 confirmed there was not enough bread mix in the pureed peanut butter and jelly sandwich. Review of the Pureed PBJ sandwich procedure (undated) revealed the following steps to puree a peanut butter and jelly sandwich: 1. Using prep directions on container of Thick and Easy bread mix, prepare serving for two slices of bread. 2. Place bread mixture in molds and chill. 3. Mix four tablespoons of smooth peanut butter and two tablespoons of smooth jelly together until smooth and homogenous. 4. Remove puree bread from molds and assemble with above mixture as a sandwich on a plate.

Based on record review and interview the facility failed to ensure a thorough investigation was not completed on a Self-Reported Incident (SRI) # 0. This affected one resident, (Resident #42) out of the two SRI's reviewed for this survey. The facility census was 47. Findings include: Resident #42 was admitted to this facility on 03/09/13. Her admitting [DIAGNOSES REDACTED]. This resident's Minimum Data Set 3.0 ((MDS) dated [DATE] showed that this resident had severe cognitive impairment. Her functional assessment showed that this resident was totally dependent on staff for all activities of daily living except eating. For eating this resident needed extensive assistance. Review of SRI # 0 dated 08/26/16 revealed that at approximately 6:00 P.M. on this date a State tested Nurse Aide (STNA) was rude to a resident she was helping feed. Per the witness the aide was observed telling the resident to feed herself then and then shut up, then immediately corrected herself. Review of the facility's policy for Abuse, Neglect and Misappropriation revised 11/17/16 showed that the facility investigation included interviewing the resident, the accused and all witnesses. This policy further states that witnesses generally include anyone who came in close contact with the resident the day of the incident. The facility's investigation file of SRI # 0 included a witness statements and interview with the STNA in question. The investigation did not include other resident interviews or statements regarding their care they had received from this STNA. During an interview on 05/10/17 at 3:03 P.M. with the Administrator and the Director of Nursing (DON) confirmed that the facility's investigation did not include other resident interviews or statements. The DON stated that she did conduct this investigation and did not obtain other resident interviews and/or statements.