Every finding on record at Westerwood Rehabilitation

Based on observations, interviews, and record review, the facility failed to ensure Resident (#35) received the proper treatment and assistive devices to maintain hearing abilities. This affected one resident (#35) of the one resident reviewed for communication and sensory. The facility census was 55.Findings include:Review of the medical record revealed an admission date of 10/01/25 with diagnoses to include but not limited to Parkinson's disease, hypertensive chronic kidney disease, atrial fibrillation, depression, gastro-esophageal reflux disease, glaucoma, anxiety disorder, cardiac defibrillator, and anemia.Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11 which indicated moderate cognitive impairment. Additionally, the MDS revealed Resident #35 required substantial to maximum assistance with upper and lower body dressing to include personal hygiene.Review of an order dated 10/01/25 hearing aid- assist to place in ear(s) every morning (AM) and remove at night (HS), place on cart for storage.Review of an order dated 10/03/25 revealed place hearing aids in ears in AM and out at HS place right hearing aid in charger at night two times a day.Review of the care plan interventions dated 10/09/25 revealed one assist with placing hearing aids in ears in AM and out at HS (place right hearing aid in charger at night).Observation on 02/10/26 at 9:33 A.M. of Resident #35 who had her right hearing aid in her right ear and no hearing aid in her left ear. Resident #35 stated that her left hearing aid was missing and had been missing for a couple of months. Resident #35 stated she moved to the facility in October of 2025, and she had both her right and left hearing aids at that time.Interview on 02/10/26 at 9:35 A.M. with Registered Nurse (RN) #142 who confirmed Resident #35 had no left hearing aid in her left ear at that time.Interview on 02/11/26 at 11:43 A.M. with Resident #35's daughter who stated Resident #35 had both right and left hearing aids when she moved into the facility on [DATE]. Resident #35's daughter stated the left hearing aid went missing in late October 2025 or early November 2025. Resident #35's daughter stated she had told the aides on the hallway, the nurse on the hallway, and the Assistant Director of Nursing (ADON) #188 about the left hearing aid being missing. Resident #35's daughter stated the hearing aids are critical for Resident #35 to be able to stay connected.Interview on 02/11/26 at 12:17 P.M. with Registered Nurse (RN) # 267 who stated Resident #35 came to the facility with two hearing aids, but one hearing aid has been gone for a long time.Interview on 02/11/26 at 3:42 P.M. with ADON #188 who stated he could not remember the date that Resident #35's daughter had told him one of the hearing aids was missing but stated the staff did search for the missing hearing aid. ADON #188 stated he was not aware of the hearing aid being found. ADON #188 stated the missing hearing aid is a concern for Resident #35 to be connected and and able to communicate.On 02/11/26 at 4:10 P.M. the surveyor requested missing item report for Resident #35's hearing aid and did not receive it.Review on 02/12/26 at 7:30 A.M. of the missing items log revealed Resident #35's missing hearing aid was not on the missing items log dated 10/01/25 to 01/19/26.Interview on 02/12/26 at 11:39 A.M. with the Administrator who stated she was not aware of Resident #35's missing hearing aid.Review of the facility policy Missing Items undated revealed it is the policy of the facility to assist all resident in safe guarding and tracking of lost items. If an article is determined to be missing the attached form (missing item report) will be completed. The form will be routed to the list of individuals on the form or to the Administrator for searching and follow-up. Additionally, the resident/resident representative will be updated as to the status of the item(s).

Based on observation, review of physician orders, observations, and interviews, the facility failed to ensure residents were provided the correct diet texture. This affected one resident (#52) of four residents who were ordered a pureed diet. The facility census was 55. Findings include:Record review revealed Resident #52 was admitted to the facility on [DATE] with diagnoses including hypertensive chronic kidney disease, dysphagia, and muscle weakness. Review of a care plan dated 12/02/25 revealed Resident #52 had potential for nutrition and/or hydration issues related to obesity, history of edema, atherosclerotic heart disease, chronic kidney disease, hyperlipidemia, gastro-esophageal reflux disease, cognitive communication deficit, hypertension; dysphagia requiring a pureed diet. The goal was to maintain adequate nutritional status. Interventions included but were not limited to regular diet with pureed texture and nectar thickened liquids. Review of a physician's order dated 07/24/25 revealed Resident #52 required a regular diet with pureed texture and nectar-thick liquids. Resident #52 should receive extra gravy. Review of a minimum data set (MDS) assessment dated [DATE] revealed Resident #52's cognition was intact, he had no behaviors, he required moderate assistance for eating, and he was receiving a mechanically altered diet. Observation on 02/10/26 at 7:56 A.M. revealed Resident #52 was seated in his wheelchair with breakfast in front of him. The breakfast included mechanical soft turkey bacon. Observation on 02/11/26 at 7:52 A.M. revealed resident #52's breakfast was on the bedside table with the lid on while he rested in bed. Certified Nursing Assistant (CNA) #260 entered the room and removed the lid, revealed mechanical soft appearing sausage, along with pureed toast and eggs. CNA #260 stated the diet appeared to be mechanical soft. Observation on 02/11/26 at 7:56 A.M. of the tray line in the kitchen revealed multiple kitchen staff. When asked to see the pureed sausage, a cook showed a container of mechanical soft sausage, using a spoon to mix it, taking a spoonful and then pouring it back in, in lumps. When asked if that was the correct texture, another worker who was not part of the conversation (Cook #240) entered the tray line area and grabbed the container of mechanical soft sausage and walked away without a word. After following [NAME] #240, she was observed to have placed the mechanical sausage into the food processor. [NAME] #240 was asked to stop and grab two spoons. When tasted, the sausage was mechanical soft texture, gritty and chunky. When asked her opinion on the texture, [NAME] #240 stated it was pureed but because they used a different sausage than normal, it was slightly different. When asked what a pureed texture was, [NAME] #240 stated completely smooth. The dietary manager entered the area and stated it appeared the sausage had been through the processor. Requested Dietary Manager tried the sausage and he stated it was mechanical soft texture. Dietary Manager retrieved Resident #52's tray from his room to correct it. When asked how many residents were served the wrong diet, Dietary Manager stated two. Observation on 02/12/26 at 7:48 A.M. with Licensed Practical Nurse (LPN) #218 revealed Resident #52 had a bowl of oatmeal on his breakfast tray. When asked, LPN #218 stated a pureed texture is supposed to be easy to swallow and smooth. LPN #219 was not sure if the oatmeal would be considered pureed but did state it would not be smooth. Interview on 02/12/26 at 8 A.M. with Assistant Director of Nursing (ADON) #216 stated pureed food should be smooth like pudding. ADON #216 confirmed Resident #52 had regular oatmeal on his breakfast tray. When asked if oatmeal was considered pureed, and she asked to look it up. ADON #216 then stated oatmeal is not pureed. At 8:06 A.M. ADON #188 entered the office, and when asked if oatmeal was considered pureed, he stated he had never been asked that and was unsure. Review of a policy titled Puree dated 07/01/23 revealed pureeing food was blending cooked, moist foods into a smooth, lump-free, pudding-like consistency to ensure safe swallowing and easy digestion.

Based on record review and interview the facility failed to maintain an accurate medical record. This affected one resident (#75) of two residents reviewed for hospitalization. The facility census was 55. Findings include: Review of Resident #75's medical record revealed an admission date of 01/12/26, a discharge to the hospital date of 01/22/26 and diagnoses including stage 4 adenocarcinoma of the gastroesophageal junction with metastasis, moderate protein-calorie malnutrition, acute respiratory failure with hypoxia, diabetes, major depressive disorder, generalized anxiety disorder, and hypertension. Review of Resident #75's admission Minimum Data Set (MDS) dated [DATE] revealed a brief interview for mental status score of 15 indicating the resident was cognitively intact. Further review of Resident #75's MDS revealed the resident required a walker and wheelchair for mobility, partial/moderate assistance with toileting hygiene, substantial/maximal assistance with bathing/showering, transfers and bed mobility, was occasionally incontinent of bladder and bowel, and had no skin issues. Review of Resident #75's nursing progress notes dated 01/22/26 at 8:19 A.M. written by Licensed Practical Nurse (LPN) #219 revealed a note stating resident with brown (colored) emesis (vomiting)(that) guaiac(ed) positive(hidden blood was detected in the emesis, indicating bleeding somewhere in the digestive tract) CNP (Certified Nurse Practitioner) (was) notifiedReview of Resident #75's nursing progress notes dated 01/22/26 at 12:00 P.M. written by Registered Nurse (RN) #153 revealed a note stating Resident transported to MCSA (Mount Carmel Saint Ann's Hospital) via Critical Care (ambulance). Report (was) called to (the) hospital. (The) family (was) notified.Review of Resident #75's nursing progress notes dated 01/30/26 at 12:38 P.M. written by LPN #144 revealed a head-to-toe skin evaluation was completed. Skin is warm to touch. Skin appears dry. No new area (of skin impairment was) noted during (the) skin evaluation.Review of Resident #75's nursing progress notes dated 02/06/26 at 9:46 A.M. written by LPN #144 revealed a head-to-toe skin evaluation was completed. Skin is warm to touch. Skin appears dry. No new area (of skin impairment was) noted during (the) skin evaluation.In an interview on 02/12/26 at 1:30 P.M. the Assistant Director of Nursing (ADON) confirmed Resident #75 had not returned from the hospital at the time of the interview and that skin assessments were charted on 01/30/26 and 02/06/26 while the resident was in the hospital.

Based on observation, review of physician orders, and interviews, the facility failed to ensure alternating air mattresses were on the ordered settings. This affected one resident (#72) of three residents reviewed for risk of pressure ulcer. The facility census was 55.Findings include:Record review revealed Resident #72 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease, spinal stenosis if the lumbar region, and monoplegia of right lower limb. Review of a minimum data set (MDS) assessment completed 11/25/25 revealed Resident #72 had moderately impaired cognition, no behaviors, was at risk for developing pressure ulcers, and had a pressure reducing device in place for her bed. Review of a care plan dated 12/25/24 revealed Resident #72 was at risk for skin breakdown related to weakness, decreased mobility, bowel and bladder incontinence, use of a wheelchair, and diagnoses of chronic venous insufficiency, chronic kidney disease, hypertension, anemia, monoplegia, and urine incontinence. The goal was to have no new skin breakdown. Interventions included but were not limited to an air mattress with built up perimeter and check placement and function each shift; bed linens clean, dry, and wrinkle-free; and encourage to turn and reposition frequently. Review of a physician order dated 09/18/25 revealed Resident #72 required an air mattress with built up perimeter and to check placement and function every shift and setting to 125. Observation on 02/10/26 at 7:48 A.M. revealed Resident #72 was resting in bed and her alternating air mattress was set to 260. Observation and Interview on 02/10/26 at 3:13 P.M. with Certified Nursing Assistant (CNA) #273 revealed Resident #72's air mattress was set to 150. CNA #273 confirmed the settings. Observation on 02/11/26 at 11:11 A.M. revealed Resident #72 was resting in bed and her air mattress was set to 150.

Based on observation, interviews, and record review, the facility failed to ensure a Resident (#10) was assessed and monitored for bruising, Resident (#35) had on compression stockings for edema. This affected two residents (#10, #35) of the four residents reviewed for quality of care. The facility census was 55.Findings include:1.Review of Resident #35's medical record revealed an admission date of 10/01/25 with diagnoses to include but not limited to Parkinson's disease, hypertensive chronic kidney disease, atrial fibrillation, depression, gastro-esophageal reflux disease, glaucoma, anxiety disorder, cardiac defibrillator, and anemia. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11 which indicated moderate cognitive impairment. Additionally, the MDS revealed Resident #35 required substantial to maximum assistance with upper and lower body dressing to include personal hygiene. Review of the care plan dated 10/09/25 revealed a focus of the resident has an activity of daily living (ADL) deficit related to wears thrombo-embolic deterrent (TED) hose (specialized, high-compression, white stockings designed for non-ambulatory (bedridden) or post-surgical patients to prevent deep vein thrombosis and blood clots. They apply graduated pressure, strongest at the ankle, to promote blood flow and reduce venous pooling.) with interventions to include TED hose on in the morning and off at bedtime, assist with placement and removal as needed. Review of an order dated 10/01/25 revealed TED hose on in morning, off at night two times a day. Observation on 02/10/26 at 9:26 A.M. of Resident #35 who had non-skid socks on and black shoes with no compression stockings on. Interview on 02/10/26 at 9:35 A.M. with Registered Nurse (RN) #142 who confirmed that Resident #35 had no TED hose on and her legs were not elevated while Resident #35 was sitting in the chair. Interview on 02/11/26 at 11:30 A.M. with the Administrator who stated there is no facility policy on edema or TED hose application. Interview on 02/11/26 at 11:43 A.M. interview with Resident #35's daughter who stated she had not seen Resident #35 wearing TED hose since Resident #35 had been in the facility. Interview on 02/11/26 at 2:24 P.M. with Certified Nursing Assistant (CNA) #164 who stated Resident #35 wears non-skid socks only. Interview on 02/11/26 at 12:20 P.M. with Licensed Practical Nurse (LPN) #267 who stated she had not seen an order for TED hose for Resident #35 and Resident #35 only wears non-skid socks. Interview on 02/11/26 at 3:54 P.M. with Assistant Director of Nursing (ADON) #188 who stated the CNA's are typically responsible for putting TED hose on the residents and the nurses should verify the TED hose are on the resident before the document on the treatment administration record (TAR). Review of the facility policy Resident Care Plan revised date 08/10/17 which stated it is the policy of the facility to develop and implement an individualized, interdisciplinary plan of care for each resident, that includes the instructions needed to provide effective person-centered care, and meets professional standards of quality care. 2.Record review revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including hypertension, hyperlipidemia, and type II diabetes. Observation on 02/09/26 at 8:01 P.M. revealed Resident #10 was resting in her bed and had a purple bruise the size of a quarter to her left posterior forearm. Review of a skin assessment completed on 02/11/26 at 10:53 A.M. by Licensed Practical Nurse (LPN) #283 revealed Resident #10 had a head-to-toe skin evaluation completed. The skin was warm to touch, intact and had no discoloration. Interview on 02/11/26 at 3:02 P.M. with Certified Nursing Assistant (CNA) #260 revealed she was unsure where the bruise on Resident #10's left forearm came from. Interview on 02/12/26 at 7:45 A.M. with LPN #219 confirmed there was a bruise on Resident #10's left forearm but he was not sure when she got the bruise. At this time, the bruise was observed to be fading purple and yellow. Interview and observation on 02/12/26 at 7:56 A.M. with Assistant Director of Nursing (ADON) #216 confirmed there was a bruise to Resident #10's left forearm. ADON #216 did not know when Resident #10 got the bruise and she would have to review documentation to see where it came from. Interview on 02/12/26 at 10:43 A.M. with ADON #188 confirmed Resident #10's skin assessment completed on 02/11/26 by LPN #283 was inaccurate as it did not contain the information about the bruise to Resident #10's left forearm. ADON #188 stated he was still interviewing his staff to determine when the bruising started.

Based on record review, staff interviews, and policy review, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurately coded for skin conditions. This affected one resident (#4) of two residents reviewed for skin assessment accuracy. The facility census was 55.Findings include:Review of the medical record for Resident #4 revealed an admission date of 08/02/21 with diagnoses including Alzheimer's disease, type II diabetes, and stage III chronic kidney disease. Review of the quarterly Minimum Data Set (MDS) assessment completed on 01/20/26 revealed a Brief Interview for Mental Status score of 09, indicating moderate cognitive impairment. Resident #4 was dependent on facility staff for all care including eating, personal care and hygiene, turning and positioning, and with transfers and mobility.Further review of the medical record revealed Resident #4 had a facility-acquired skin tear to his left shoulder. The skin tear was identified on 12/16/25. The skin tear remained active through the duration of the survey.Review of the quarterly Minimum Data Set (MDS) assessment, Section M - Skin Conditions, assessment reference date of 01/08/26 and lookback period of seven days prior, revealed no current pressure ulcers, venous and arterial ulcers, or other ulcers, wounds, or skin problems.Interview on 02/12/26 at 2:10 P.M. with the Administrator confirmed the inaccuracy in Resident #4's MDS assessment.Review of the policy titled, MDS: Conducting an Accurate Resident Assessment, undated, all residents will receive an accurate assessment that is reflective of the resident's status at the time of the assessment. The policy stated the appropriate qualified health professional will correctly document the resident's medical, functional, and psychosocial problems.

Based on record review and interview, the facility failed to ensure residents were made aware of which skilled services were ending. This affected three residents (#84, #85, and #86) of three residents reviewed for advanced beneficiary notices. The facility census was 55. Findings include:1.Record review revealed Resident #84 was admitted to the facility on [DATE] with diagnoses including acute cystitis, cognitive communication deficit, and muscle weakness. Review of a Notice of Medicare Non-Coverage dated 10/10/25 revealed Resident #84's skilled nursing services would end on 10/10/25 but did not specify which services. 2.Record review revealed Resident #85 was admitted to the facility on [DATE] with diagnoses of left femur fracture, need for assistance with personal care, and muscle weakness. Review of a Notice of Medicare Non-Coverage revealed Resident #85's skilled nursing services would end on 12/19/25 but did not specify which services. 3.Record review revealed Resident #86 was admitted to the facility on [DATE] with diagnoses including hypertensive heart disease with heart failure, takotsubo syndrome, and malnutrition. Review of a Notice of Medicare Non-Covered revealed Resident #86's skilled nursing services would end on 08/11/25 but did not specify which services. Interview on 02/10/26 at 2:48 P.M. with Licensed Social Worker (LSW) #217 revealed the Notice of Medicare Non-Coverage (NOMNC) does not have to specify which services are ending and just needs to say skilled nursing services for Residents #84, #85, and #86. Interview on 02/10/26 at 2:58 P.M. with Discharge Planner (DP) #192 revealed the NOMNCs stated skilled services which can include physical therapy, occupational therapy, speech therapy, and nursing services. DP #192 confirmed Residents #84, #85, and #86 were in the facility for therapy services. Interview on 02/11/26 at 7:28 A.M. with the Administrator revealed Residents #84, #85, and #86 received skilled services for speech, physical, and occupational therapy and did not have a skill-able nursing service.

Based on interview, record review and facility policy, the facility failed to have a treatment order in place for a burn abrasion for one resident (#10) out of three residents reviewed for treatment orders for skin alterations on admission. The facility census was 61. Findings include: Review of the medical record for Resident #10, revealed an admission date of 04/19/25 and a transfer to the hospital date of 05/03/25. Diagnoses included but were not limited to inflammatory polyarthropathy, muscle weakness, need for assistance with personal care, adult failure to thrive, lower back pain and burn of unspecified degree of upper back, subsequent encounter. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 14. The resident was assessed to require supervision or touching assistance with toilet hygiene, partial/moderate assistance with shower/bathe self, and transfers with independent with bed mobility. Review of the plan of care dated 04/21/25 for Resident #10 revealed the resident to have impaired skin integrity due to a burn with an intervention including but not limited to perform and document skin treatments as ordered. Review of the admission skin assessment dated [DATE] for Resident #10 revealed a left scapula open area abrasion. Review of the wound rounds summary dated 04/20/25 for Resident #10 revealed an upper left back active abrasion measured 9 centimeters (cm) x 4 cm x 0 with scant serosanguinous drainage. Review of the physician orders from 04/19/25 to 04/21/25 at 12:26 P.M. for Resident #10 revealed no treatment order for the burn abrasion on the left back/scapula area. Interview on 05/30/25 at 11:54 A.M. with the Assistant Director of Nursing verified Resident #10 did not have an order for treatment for the burn abrasion on the left back/scapula area from 04/19/25 until 04/21/25 at 12:26 P.M. when he entered the order. Also verified the nurse who admitted the resident should have obtained an order for a treatment as the resident was admitted over a weekend. Review of the facility policy titled Skin Integrity at Risk Program no date, revealed residents receive care and necessary treatments to promote healing and a physician is notified of a skin alteration and treatment is initiated as ordered. This deficiency represents non-compliance investigated under Complaint Number OH00165558.

Based on medical record review, interview and facility policy review, the facility failed to ensure Resident #10 was transferred in a safe manner and as per the resident's plan of care and facility policy with two staff via a mechanical (Hoyer) lift to prevent a potential accident. This affected one resident (#10) of four residents reviewed for accident hazards. The facility census was 59. Findings include: Review of the medical record for Resident #10 revealed an admitted [DATE] with diagnoses including chronic obstructive pulmonary disease, spinal stenosis lumbar region, and dementia. Review of the plan of care dated 07/26/2023 revealed Resident #10 had an activity of daily living (ADL), self-care performance deficit related to decreased mobility, weakness, memory loss/confusion, and required assistance for ADLs and mobility needs. Interventions included providing two staff assist with transfers using a Hoyer (mechanical) lift. Review of Resident #10's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 08 out of 15 indicating a moderately impaired cognition for daily decision-making abilities. Resident #10 was noted to be free from bilateral upper and/or lower extremity impairment and required a wheelchair for mobility. The assessment noted the resident was dependent on staff with all transfers. Review of the Fall Risk Assessment completed for Resident #10 dated 04/28/2024 revealed resident was alert only with one to two falls in the past three months. Resident #10 was noted to be chair bound and was noted to require the use of assistive devices for gait and balance. Interview on 05/08/2024 at 2:00 P.M. with the Administrator revealed there was a staff member, State tested Nursing Assistant (STNA) #335 who was still in training who transferred Resident #10 (on 05/06/24) by himself with the use of a mechanical lift. The Administrator revealed the management team was made aware of the incident by Resident #8's daughter. Interview on 05/08/24 at 4:30 P.M. with the daughter of Resident #8 revealed she was concerned an STNA (STNA #335) was transferring Resident #10 via a Hoyer lift by himself, without a second person present on 05/06/24. The daughter indicated she asked the STNA if he needed a spotter since she stated she was aware he was a new employee. The daughter indicated the STNA replied to her he had [AGE] years experience, knew what he was doing, was very strong and didn't need help. The daughter indicated the STNA also reported everyone was busy right now. The daughter indicated she reported the situation to staff but continued to have concerns related to the safety of the resident without a second staff person present for the transfer with the Hoyer lift. Attempts to reach STNA #335 during the investigation on 05/08/24 at 3:10 P.M. and 05/20/24 at 11:40 A.M. were unsuccessful. Record review/review of Resident #10's medical record revealed no written documentation of the incident/transfer on 05/06/24. There was no written statement from STNA #335 available or provided to review during the survey. Review of an undated facility policy titled Hoyer (Sling) Lift Transfer, revealed at least two staff members were needed when using a mechanical lift. The deficiency was corrected on 05/07/24 when the facility implemented the following corrective actions: Review of requested documents related to education and corrective action taken by the facility related to this incident revealed the facility provided a Hoyer (Sling) Lift Transfer policy and procedure and a re-training document (dated 05/07/24) for STNA #335 and all staff related to the incident that occurred on 05/06/2024. The facility implemented a plan to audit resident transfers to ensure residents who required a Hoyer lift were transferred with two staff. Following this incident on 05/06/24, no additional incidents had occurred related to a staff member completing a single mechanical lift transfer. This deficiency represents non-compliance investigated under Complaint Number OH00153624.

Based on medical record review, observation, and staff interview, the facility failed to obtain a physician order for a right arm sling prior to use. This affected one (Resident #116) out of two residents reviewed for limited mobility. The facility census was 62. Findings include: Review of the medical record for Resident #116 revealed an initial admitted [DATE] and a readmitted [DATE]. Resident #116's medical diagnoses included fracture of shaft of right humerus, laceration of part of head, difficulty in walking, lack of coordination, cognitive communication deficit, and history of falling. Review of the Admission Minimum Data Set 3.0 assessment, dated 03/26/24, revealed Resident #116 had intact cognition and scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #116 had an impairment on one side of her upper extremity (shoulder, elbow, wrist, hand). Resident #116 required setup or clean-up assistance with eating and hygiene, and required partial to substantial assistance from staff to complete all other activities of daily living. Resident #116's active diagnoses included fractures and other multiple trauma. Review of Resident #116's physician orders dated April 2024 revealed there was no order for a right arm sling. Observation on 04/01/24 at 3:00 P.M. revealed Resident #116 was in her room, laying in bed, wearing a sling on her right arm. Interview on 04/02/24 at 2:45 P.M. with the Assistant Director of Nursing (ADON) #229 confirmed there was no a physician order in place for Resident #116's right arm sling and stated there should be an order for it. ADON #229 stated Resident #116 fractured her right humerus bone and was wearing the sling while the bone healed.

Based on medical record review, review of a lunch tray ticket, observation, and staff interview, the facility failed to ensure was provided meals as preferred. This affected one resident (#4) of five residents reviewed for nutrition. The facility census was 62. Findings include: Review of the medical record for Resident #4 revealed an admitted [DATE] with diagnoses including Alzheimer's disease, Parkinson's disease, severe protein-calorie malnutrition, vascular dementia, acquired absence of right and left leg above knee, type two diabetes mellitus, unspecified mood disorder, dysphagia, adult failure to thrive, and constipation. Review of Resident #4's Plan of Care, dated 02/07/24, revealed Resident #4 had the potential for nutrition or hydration issues related to her diagnoses, need for mechanically altered diet, dysphagia, pocketing food, severe protein calorie malnutrition, being underweight, and increased nutrient needs related to her wound. Interventions included a consistent carbohydrate and pureed diet, offering alternates if intake is poor, assisting with meals, providing supplements as ordered, encouraging intake of meals and fluids, and per the resident's preference and daughters request the resident was to be given a bite of food with or dipped in frozen nutritional treat. Review of Resident #4's quarterly Minimum Data Set (MDS) assessment, dated 03/21/24, revealed Resident #4 had severely impaired cognition. Resident #4 weighed 72 pounds, had no significant weight changes, and was on a mechanically altered and therapeutic diet. Review of Resident #4's physician order, dated 04/02/24, revealed Resident #4 was to receive a frozen nutritional treat with meals. Review of the lunch tray ticket, dated 04/04/24, revealed Resident #4 was to receive pureed cornflake chicken breast, pureed squash, carrots, and green beans, and a vanilla frozen nutritional treat. Observation on 04/04/24 from 1:00 P.M. to 1:15 P.M. revealed STNA #77 was assisting Resident #4 with her meal. There was a plate which included two pureed foods and no supplements on Resident #4's bedside table. STNA #77 was observed feeding Resident #4 bites of pureed food and the bites of pureed food were not mixed with or dipped in frozen nutritional treat as indicated on Resident #4's care plan. The observation further revealed there was a refrigerator in Resident #4's room which contained one frozen nutritional treat and two house shakes. STNA #77 indicated he would call the kitchen to find out if Resident #4 was supposed to receive a nutritional supplement. STNA #77 verified with the kitchen that Resident #4 was supposed to receive a frozen nutritional treat with the lunch meal and the kitchen staff agreed to deliver a nutritional treat to the residents room. STNA #77 did not mix any bites of pureed food with a nutritional treat or dip the bites in a nutritional treat at any point prior to the kitchen staff bringing the nutritional treat to Resident #4's room. Interview on 04/04/24 from 1:00 P.M. to 1:15 P.M. with STNA #77 verified there was no nutritional treat on Resident #4's bedside table or with Resident #4's meal tray. He additionally reported Resident #4 had not eaten a nutritional treat or supplement prior to the beginning of the observation and he was unsure what supplements Resident #4 was supposed to be receiving as she had just returned to the facility. STNA #77 verified the tray ticket indicated Resident #4 was to receive a frozen nutritional treat and he called the kitchen to ensure one was sent to the room. STNA #77 reported the facility staff was not supposed to take things from the refrigerator in the residents room. This deficiency represents non-compliance investigated under Master Complaint Number OH00152690 and Complaint Number OH00152366.

Based on medical record review, resident and staff interviews, and facility policy review, the facility failed to ensure residents were provided with timely dental services. This affected one (Resident #116) out of one resident reviewed for dental services. The facility census was 62. Findings include: Review of the medical record for Resident #116 revealed an initial admitted [DATE] and a readmitted [DATE]. Resident #116's medical diagnoses included fracture of shaft of right humerus, laceration of part of head, difficulty in walking, lack of coordination, cognitive communication deficit, and history of falling. Review of a progress note, dated 03/06/24 at 8:00 A.M., revealed Resident #116 had a Medicare payer source. Review of the Admission Evaluation, dated 03/19/24, revealed Resident #116 had broken or loosely fitting full or partial denture (chipped, cracked, uncleanable, or loose). Review of Resident #116's plan of care, dated 03/20/24, revealed there were no dental or denture concerns addressed in the resident's care plan. Review of the Admission Minimum Data Set 3.0 assessment, dated 03/26/24, revealed Resident #116 had intact cognition and scored a 15 out of 15 on the Brief Interview for Mental Status assessment. The assessment did not note any dental issues. Review of Resident #116's physician orders, dated April 2024, revealed Resident #116 had an order for a regular, mechanical soft diet per the resident's request. The order was dated 03/28/24 at 2:24 P.M. Review of a dietary progress note, dated 03/28/24 at 2:26 P.M., by Dietitian #327 revealed an oral exam showed Resident #116 had broken or loosely fitting full or partial dentures (chipped, cracked, uncleanable, or loose). The note stated, dentures do not fit. Furthermore, Resident #116 reported the dentures have caused a sore and that it is effecting her ability to eat with dentures in. Resident #116 agreed to downgrade her diet to mechanical soft until the sore healed. The diet change would allow Resident #116 to eat without dentures in at meal time and allow the gums to heal. Review of the list of residents seen by the dentist, dated 03/28/24, revealed Resident #116 had not been seen by the dentist. Review of a progress note, dated 03/29/24 at 6:57 A.M., by Assistant Director of Nursing (ADON) #229 revealed a new order was implemented for a mechanical soft diet per Resident #116's request related to a sore from Resident #116's dentures. The start date of the new diet was 03/28/24. Interviews on 04/02/23 at 11:18 A.M. and on 04/03/24 at 4:40 P.M. with Resident #116 revealed the resident reported her dentures did not fit and she had sore gums. Resident #116 stated she had a canker sore on her right upper gum. The resident attempted to raise her upper lip to show the sore to this surveyor but stated, I don't think you can see it. Resident #116 placed her finger on the outside of her upper lip just under her right nostril and stated, it's right there. Resident #116 stated when she had to bite into harder foods her upper denture rubbed against the canker sore and caused pain so she had been leaving her dentures out during meals. This surveyor observed both her upper and lower dentures to be sitting on the bed side table next to the resident's bed. Resident #116 stated she had an appointment with an outside dentist scheduled in June 2024 but would like to be seen by a dentist sooner. Resident #116 stated she had not been informed of an in-facility dentist or any dental services offered by the facility. Interview on 04/03/24 at 6:08 P.M. with Ancillary Specialist (AS) #141 revealed the facility did offer dental services to residents. The services were offered to both Medicare and Medicaid residents. AS #141 stated when a resident was admitted to the facility, ancillary services were part of the admission packet that was reviewed with the resident. A consent form was reviewed with the resident and the resident signed the form indicating whether the resident wanted to accept or decline ancillary services. AS #141 reviewed the admission packets and notified providers of the residents who wished to receive services. AS #141 confirmed the dentist visited the facility on 03/28/24 and Resident #116 was not seen at that time. AS #141 reviewed Resident #116's admission packet and ancillary services consent form and confirmed neither had been completed. AS #141 stated Dietitian #327 informed her of Resident #116's ill-fitting dentures after the dentist's visit to the facility. AS #141 stated she had not been told Resident #116 was experiencing any pain. Interview on 04/03/24 at 6:27 P.M. with Admissions Coordinator (AC) #319 revealed he reviewed admission packets and ancillary services consent forms with new admissions to the facility. AC #319 stated the admission packet and consent forms should be completed within 72 hours of admission. AC #319 confirmed the admissions packet or ancillary services consent form for Resident #116 had not been completed yet. AC #319 stated he had not been able to connect with the resident yet in order to complete the paperwork. Review of the facility policy titled Dental Services, undated, revealed the policy stated, it was the policy of the facility to assist residents in obtaining routine (to the extent covered under the State plan) and emergency dental care. The dental needs of each resident are identified through the physical assessment and MDS assessment processes, and are addressed in each resident's plan of care. Referrals to dietitian, speech therapist, physician, or dental provider shall be made as appropriate. In the case of an acute dental condition, the facility will take measures to ensure residents are still able to eat and drink while awaiting dental services including: notifying physician of pain or other needs, modifying diet consistency, referring to dietitian for food preferences during the interim, and referral to speech therapist for chewing or swallowing problems.

Based on medical record review, review of hospital records, observation, staff interview, facility policy review, and review of Centers for Disease Control and Prevention guidance, the facility failed to staff practiced proper infection control practices while assisting residents with meals. This affected one (Resident #4) out of three residents reviewed for transmission based precautions. The facility census was 62. Findings include: Review of Resident #4's medical record revealed an initial admitted [DATE] and a readmitted [DATE]. Resident #4's diagnoses included but were not limited to Alzheimer's disease, Parkinson's disease without dyskinesia (uncontrolled, involuntary muscle movement), severe protein-calorie malnutrition, adult failure to thrive, type two diabetes mellitus, and colonized clostridium difficile (C. Diff) colitis. Review of the quarterly Minimum Data Set 3.0 assessment, dated 03/21/24, revealed Resident #4 had severely impaired cognition and was unable to complete the Brief Interview for Mental Status assessment. Resident #4 required total dependence on staff to complete all activities of daily living. Review of Resident #4's census revealed the resident was hospitalized from 03/22/24 to 04/02/24. Review of hospital records, dated 04/02/24, revealed Resident #4 tested positive for Clostridium difficile (C. Diff) at the hospital on 03/23/24. However, the hospital records indicated the second step of the test was negative which was indicative of a colonized infection and not an active infection. Resident #4 was noted to have watery stool on 03/28/24 and was placed under contact transmission-based precautions (TBP) during her hospitalization . Review of a progress note dated 04/02/24 at 9:36 A.M., revealed Resident #4 ' s daughter was contacted to inform her Resident #4 ' s discharge date and time had been confirmed as today at 2:00 P.M. Resident #4's daughter was informed that Resident #4 would be readmitted to a private room due to isolation needs. Observation on 04/04/24 from 12:45 P.M. to 1:12 P.M. of Resident #4 during lunch meal service with State-tested Nurse Aide (STNA) #77 revealed Resident #4 was in a private room and was under contact TBP. STNA #77 was observed in the room wearing an isolation gown and gloves. Resident #4's meal tray was observed on the bedside table on the right side of the resident's bed. The resident's meal ticket was observed laying on the floor next to the bedside table. There was no nutritional supplement observed on Resident #4's meal tray and STNA #77 stated he would call the kitchen to find out if Resident #4 was supposed to receive a nutritional supplement because prior to the resident's hospitalization , she did receive a frozen nutritional treat with meals. STNA #77 walked over to corded phone in room that was sitting on the floor and picked it up with gloves on and called the kitchen. STNA #77 verified with the kitchen Resident #4 was supposed to receive a frozen nutritional treat with the resident's lunch meal and agreed to deliver one to the resident's room. STNA #77 hung up the phone and placed it back onto the floor. STNA #77 walked back over to Resident #4's bedside table where Resident #4's meal tray was sitting, picked up the spoon (with the same gloves on) and began attempting to feed the resident again. STNA #77 put the spoon up to Resident #4's lips and encouraged the resident to open her mouth. Resident #4 opened her mouth slightly and took a very small amount of food into her mouth before shutting it again. STNA #77 looked down at the floor and noticed the resident's meal ticket was laying on the floor. STNA #77 picked up the resident's meal ticket from the floor with the same gloves on and handed it to this surveyor. STNA #77 did not change gloves or complete any hand hygiene. STNA #77 walked back over to Resident #4 and lifted the resident's covers to reveal the resident's abdominal binder with his gloved hands. STNA #77 replaced the resident's covers with the same gloves on. Kitchen staff arrived at Resident #4's room with a frozen nutritional treat. STNA #77 answered the knock at the door with the same gloves on and accepted the nutritional treat from the kitchen staff. STNA #77 did not change gloves or complete any hand hygiene. STNA #77 returned to the resident's bed side table and opened the frozen nutritional treat with the same gloves in place, picked up the resident's spoon again and began mixing the nutritional treat with the resident's pureed foods. STNA #77 again put the spoon to Resident #4's lips and encouraged her to open her mouth. Resident #4 opened her mouth and accepted bites of food. STNA #77 continued feeding Resident #4 without changing his gloves or completing any hand hygiene during the observation. Interview on 04/04/24 at 2:05 P.M. with STNA #77 confirmed the above observations. STNA #77 confirmed he had not changed his gloves or completed any hand hygiene after picking up items from the floor or answering the resident's door with gloves on and continued feeding Resident #4. STNA #77 stated Resident #4 ate approximately 25 percent of her meal at lunch and drank approximately 120 milliliters (mL) of fluids. STNA #77 stated he was not told why Resident #4 was under contact TBP and he did not ask anyone. STNA #77 stated he was not aware Resident #4 had colonized C. Diff with possible symptoms (water stools) of an active C. Diff infection. Review of the facility policy titled Handwashing/Hand Hygiene Policy, undated, revealed the facility policy stated, it was the policy of the facility that hand washing/hand hygiene be regarded as the single most important means of preventative measures in the spread of infectious disease. When to wash hands: before serving food, before and after the use of gloves, gowns, and masks, before and after caring for a resident in an isolation area, after contact with work surfaces potentially contaminated with a resident's blood, excretions, or secretions, and when in doubt, wash. The use of gloves does not replace hand washing. Review of the Centers for Disease Control and Prevention guidance titled Your Risk of C. diff, last reviewed 06/27/22, revealed the guidance under the section, What is Colonization? stated, someone who is colonized has no signs or symptoms. If you are colonized with C. diff, you can spread the infection to others. Once your body is colonized with C. diff, you can remain colonized for several months. It is more common to become infected with C. diff in healthcare settings, such as hospitals and nursing homes. In a healthcare setting, while caring for you and other patients with C. diff, healthcare professionals will use certain precautions, such as wearing a gown and gloves, to prevent the spread of C. diff to themselves and to other patients. In addition to Standard Precautions, use Transmission-Based Precautions for patients with documented or suspected infection or colonization with highly transmissible or epidemiologically-important pathogens for which additional precautions are needed to prevent transmission. This deficiency represents non-compliance investigated under Complaint Number OH00152366.

Based on medical record review, resident and staff interview, and observation, the facility failed to ensure residents were provided with activities to meet their needs. This affected one resident (Resident #32) of four residents reviewed for activities. The facility census was 62. Findings include: Review of medical record for Resident #32 revealed an admitted [DATE] with diagnoses which included nuerolyptic parkinsonism, dementia, depression, bipolar II disorder, anxiety disorder, benign prostatic hyperplasia, cognitive communication deficit, drug induced movement disorder, and dorsalgia (back pain). Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/18/24, revealed Resident #32 had intact cognition and scored a 15 out of 15 on the Brief Interview for Mental Status assessment. Resident #32 required a varied amount of assistance which ranged from minimal to total dependence on staff to complete Activities of Daily Living. Review of Resident #32's Activities Assessment, dated 02/09/24, revealed the resident enjoys watching the news, watching Cleveland Browns football on television, spending time with family, spending time outside hiking, ham radio, reading, and listening to music. Resident #32 liked to do research and activity staff have been giving him a tablet to work on. Resident #32 was to receive one-to-one visits. Review of Resident #32's Activities Log from 02/01/24 to 03/31/24 revealed the activities that were documented as having been completed for Resident #32 included reading on 20 out of 60 days, watching television on 45 out of 60 days, This Day in History & Puzzles on 40 out of 60 days, catholic communion and other religious activities on 02/06/24, 02/13/24, 02/20/24, 03/03/24, 03/05/24, 03/10/24, 03/12/24 and 03/19/24, family or friends visits on 02/06/24, 02/14/24, 02/26/24, and 03/01/24 and electronics use (Kindle which is a mobile reading device) on 13 out of 60 days. The activities log documented one to one visits occurred on 02/07/24, 02/20/24, 02/23/24, 02/25/24, 02/26/24, 03/04/24, 03/07/24, 03/11/24, 03/13/24, 03/18/24, 03/22/24, 03/24/24, and 03/27/24 with documentation which indicated the one on one visits consisted of dropping off a Kindle to Resident #32. Review of Resident #32's Care Plan, completed on 03/26/24, revealed Resident #32 needed to maintain social interaction and stimulation, and his interests included watching the news, watching Cleveland Browns football on television, spending time with family, spending time outside hiking, ham radio, reading, and listening to music. Interventions for Resident #32 included assessing Resident #32 for response to activities and adjusting the plan, assisting the resident to the activity area per his choice, introducing Resident #32 to peers, and providing an activity calendar. Interview on 04/01/24 at 11:03 A.M. with Resident #32 revealed he does not like to participate in group activities. Resident #32 stated he has a hard time speaking and was tired all the time. Resident #32 stated he does not really watch television and would like more things to do. Interview on 04/02/24 at 3:25 P.M. with Resident #32 revealed he does not watch television and wished he had his computer but it was a desktop computer and he had nowhere to put it. Resident #32 stated he liked listening to music too but did not have a radio. Observations on 04/01/24 at 3:09 P.M., on 04/02/24 at 3:25 P.M. and on 04/03/24 at 10:42 A.M., revealed Resident #32 was sitting up in his chair with no reading materials, no music, and the television was off. Resident #32 was not actively engaged in any activities. Interview on 04/04/24 at 11:42 A.M. with State tested Nurse Aide (STNA) #217 revealed Resident #32 liked to stay in his room and read, visit with family or listen to music. STNA #217 confirmed there was no radio or reading materials in Resident #32's room. Interview on 04/04/24 at 1:47 P.M. with Community Life Coordinator (CLC) #192 confirmed CLC #192 was aware of Resident #32's preferred activities which included reading and listening to music. CLC #192 confirmed Resident #32 did not have a radio or reading device in his room and stated Resident #32 would be provided a radio or Kindle, but it was expected that he ask for it. CLC #192 indicated Resident #32 used to have a radio however it broke and the facility did not have enough radios available to give each resident their own radio. CLC #192 stated staff are supposed to check in every morning to ask if residents want anything but do not document requests or refusals. CLC #192 indicated the actitivity titled This Day in History & Puzzles on the activity log meant staff dropped off a packet to the resident.

Based on record review, resident representative and staff interviews, review of the hospice contract, and facility policy review, the facility failed to ensure hospice communication notes were available and a part of the medical record for one resident (Resident #59). The facility also failed to timely notify the hospice provider of medication changes for one resident (Resident #59). This affected one resident (Resident #59) of three reviewed for hospice services. The facility census was 61. Findings Include: Review of the closed medical record for Resident #59 revealed an admitted on [DATE] and a discharge date on [DATE] due to the resident passing away. Medical diagnoses included Parkinson's Disease with dyskinesia (uncontrolled, involuntary muscle movement), dementia with psychotic disturbance and anxiety, epilepsy (seizures), anxiety disorder, supraventricular tachycardia (a faster than normal heart rate beginning above the heart's two lower chambers), cognitive communication deficit, presence of neurotransmitter, and dystonia (involuntary muscle contractions that cause repetitive or twisting movements). Review of Resident #59's census revealed the resident was admitted under a hospice payer. Review of the Patient Information Report from the hospice provider date [DATE] revealed Resident #59 was admitted to hospice on [DATE] (prior to the resident's admission to the facility). Review of the physician orders for Resident #59 revealed the resident had the following orders: Hospice-Transitions Hospice (dated [DATE] and discontinued [DATE]), Hospice-Transitions Hospice (dated [DATE] and discontinued [DATE] with reason to add a diagnosis), Hospice-Transitions Hospice with diagnosis Parkinson's Disease (dated [DATE] and discontinued [DATE] with no reason indicated), Hospice-Transitions Hospice with diagnosis Parkinson's Disease (dated [DATE] and discontinued [DATE]), and Hospice-Transitions Hospice with diagnosis Parkinson's Disease (dated [DATE] and discontinued [DATE] due to the resident being deceased ). Further review of the physician orders for Resident #59 revealed the resident had the following medication orders: Quetiapine Fumarate (Seroquel) (an antipsychotic medication) 50 milligrams (mg) with instructions to give one tablet every eight hours as needed for severe agitation dated [DATE] and discontinued [DATE], Quetiapine Fumarate 50 mg with instructions to give one tablet twice a day (BID) dated [DATE] and discontinued [DATE], Seroquel 50 mg with instructions to give one tablet in the evening for dementia with behaviors dated [DATE] and discontinued [DATE], Seroquel 100 mg with instructions to give one tablet daily for dementia with behaviors dated [DATE] and discontinued [DATE], Quetiapine Fumarate 25 mg with instructions to give one tablet in the evening for one week dated [DATE] and discontinued [DATE], Quetiapine Fumarate 50 mg with instructions to give one tablet in the morning for one week dated [DATE] and discontinued [DATE], and Quetiapine Fumarate 25 mg with instructions to give one tablet in the morning dated [DATE] and discontinued [DATE] due to hospice. Additionally, Resident #59 had an order for Trazodone Hydrochloride (HCl) 50 mg with instructions to give 25 mg by mouth at bedtime for insomnia dated [DATE] and discontinued [DATE] per the hospice Certified Nurse Practitioner (CNP). Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #59 had severely impaired cognition and scored a zero out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #59 was dependent on facility staff to complete Activities of Daily Living (ADLs). Review of the progress notes dated from [DATE] to [DATE] revealed on [DATE] at 4:41 P.M., Resident #59 admitted to the facility and was transported by the family. Vital signs were within normal limits. There was no indication of the resident receiving hospice services upon admission. The first progress note which mentioned contact with hospice was dated [DATE] (seven days after admission) at 7:32 P.M., Certified Nurse Practitioner (CNP) was notified of x-ray results. The nurse also left a voicemail with hospice. No new orders at this time. Resident denied pain. Power of Attorney (POA) aware. Further review of the progress notes dated from [DATE] to [DATE] revealed on [DATE] at 11:02 A.M. and 11:03 A.M., notification of order change notes stated Resident #59 and the resident's representative were updated on new orders. Risk/Benefits were explained for Trazodone HCl 50 mg with instructions to give 25 mg by mouth at bedtime for insomnia, Seroquel tablet 100 mg with instructions to give one tablet by mouth daily, and Seroquel 50 mg with instructions to give one tablet in the evening for dementia with behaviors. The start dates for the medication were [DATE] and [DATE]. Resident #59 and the resident's Power of Attorney (POA) were made aware. There was no indication the resident's hospice provider was notified of the medication changes. Review of the care plan dated [DATE] revealed Resident #59 had a terminal prognosis related to hospice services for Parkinson's Disease with declines in condition expected. Interventions included Capital City Hospice, all care must be preauthorized: all new medications-call before contacting contracted company, all new treatments-medical equipment, labs, diagnostic tests, x-rays, transport from the facility, condition change, hospice will call the resident's physician unless other arrangements are made with hospice staff. The interventions were resolved on [DATE]. On [DATE], interventions included Transitions Hospice was initiated. Additional intervention included coordinate all care with hospice and work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met (dated [DATE]). Review of the Encounter Summary-Progress Note completed by the facility's Certified Nurse Practitioner (CNP), CNP #150, dated [DATE] at 1:47 P.M. revealed Resident #59 was seen for an acute visit due to behaviors including restlessness, impulsivity, yelling out during the day and night, and difficulty with redirecting the resident. CNP #150 planned to increase Seroquel to 100 mg daily at bedtime and add Trazodone 25 mg daily at bedtime to address dementia with psychotic disturbances. The resident's instructions included the same and to continue to follow with hospice. There was no indication the hospice provider was notified of the medication changes. Review of Plan of Care Conference, dated [DATE] (nine days after medication changes), revealed Resident #59's POA/spouse, the resident's daughter and son-in-law, Hospice Executive Director ([NAME]) #105, Licensed Social Worker (LSW) #112, and the Director of Nursing (DON) attended the care conference. Nursing Services noted the current plan of care, behaviors, falls, and interventions were reviewed. Nursing agreed with the current plan and medication education was provided. Resident #59's family reported medication tweaks and environmental adjustments were still occurring. The care conference did not indicate what medications were reviewed or what medications the resident's family received educated about. Further review of the medical record for Resident #59 revealed there were not any hospice communication notes included in the medical record. Interview on [DATE] at 1:08 P.M. via telephone with CNP #103 revealed she was the on-call CNP for Resident #59's hospice provider. CNP #103 stated the facility's CNP (CNP #150) increased Resident #59's Seroquel shortly after the resident was admitted and thinks CNP #150 also adjusted or added some other medication as well that she was not notified of until she attended a care conference via telephone to discuss Resident #59 on [DATE] and reviewed Resident #59's medications. CNP #103 recommended Resident #59's antipsychotic medication be reduced again at that time. CNP #150 stated she did not attend a care conference on [DATE] for Resident #59. Interview on [DATE] at 10:21 A.M. via telephone with [NAME] #105 revealed the facility's CNP (CNP #150) adjusted Resident #59's medications, including Seroquel, without notifying the hospice provider/hospice CNP (CNP #103). [NAME] #105 stated CNP #103 became aware of the medication adjustments/changes on [DATE] when CNP #103 attended a care conference via telephone to discuss Resident #59 and she reviewed the resident's medications. CNP #103 requested to have the medications reduced again at the time of the care conference. [NAME] #105 denied medications were discussed during the care conference held on [DATE]. Interview on [DATE] at 11:12 A.M. with the DON confirmed there were some communication issues between the facility and the hospice provider for Resident #59. The DON stated the facility conducted two care conferences for Resident #59 during her stay at the facility. The DON stated one was completed in November and the other was completed in [DATE]. The DON stated a hospice representative attended both care conferences and the resident's medications would have been reviewed at each care conference. The DON confirmed there was no documentation the hospice provider was notified of any medication changes for Resident #59 prior to [DATE] (nine days later). Further interview on [DATE] at 11:52 A.M. with the Director of Nursing (DON) confirmed Resident #59's medical record only included plans of care from the hospice provider and did not include any progress/visit notes from the hospice provider. Interview on [DATE] at 2:10 P.M. with LSW #112 confirmed a care conference was completed on [DATE] for Resident #59 (nine days after the medication changes). LSW #112 stated she was not able to remember exactly what was discussed during the care conference but the resident's medications would have been reviewed as that was standard procedure for all care conferences. LSW #112 confirmed [NAME] #105 attended the care conference on [DATE] via telephone but CNP #103 did not attend. LSW #112 stated there was a family meeting held on [DATE] per the family's request as well but she was not able to attend that meeting and was not aware what occurred during that meeting. Review of the facility policy, Hospice Program, undated, revealed the policy stated, The hospice agency retains overall professional management responsibility for directing the implementation of the plan of care related to the terminal illness and related conditions. All hospice services are provided under contractual arrangement. Complete details outlining the responsibilities of the facility and the hospice agency are contained in this agreement. Review of the hospice contract, dated [DATE], revealed the contract stated, Nursing Facility and Transitions will each maintain and make available to each other for inspection and copying, detailed clinical records concerning each Transitions Hospice Patient in accordance with good professional practice, federal and state laws and regulations, and applicable Medicare and Medicaid guidelines. The contract also revealed 3.3 Notification Agreement. The facility will immediately notify the hospice about the following: significant change in the patient's physical, mental, social, or emotional status. Clinical complications that suggest a need to alter the plan of care. This deficiency represents non-compliance investigated under Complaint Number OH00149558.

Based on record review, staff interviews, review of the hospice contract, and facility policy review, the facility failed to follow the hospice agreement in place for one resident's (Resident #59) hospice provider. This affected one (Resident #59) of three residents reviewed for hospice services. The facility census was 61. Findings Include: Review of the closed medical record for Resident #59 revealed an admitted on [DATE] and a discharge date on [DATE] due to the resident passing away. Medical diagnoses included Parkinson's Disease with dyskinesia (uncontrolled, involuntary muscle movement), dementia with psychotic disturbance and anxiety, epilepsy (seizures), anxiety disorder, supraventricular tachycardia (a faster than normal heart rate beginning above the heart's two lower chambers), cognitive communication deficit, presence of neurotransmitter, and dystonia (involuntary muscle contractions that cause repetitive or twisting movements). Review of Resident #59's census revealed the resident was admitted under a hospice payer. Review of the Patient Information Report from the hospice provider date [DATE] revealed Resident #59 was admitted to hospice on [DATE] (prior to the resident's admission to the facility). Review of the physician orders for Resident #59 revealed the resident had the following hospice orders: Hospice-Transitions Hospice (dated [DATE] and discontinued [DATE]), Hospice-Transitions Hospice (dated [DATE] and discontinued [DATE] with reason to add a diagnosis), Hospice-Transitions Hospice with diagnosis Parkinson's Disease (dated [DATE] and discontinued [DATE] with no reason indicated), Hospice-Transitions Hospice with diagnosis Parkinson's Disease (dated [DATE] and discontinued [DATE]), and Hospice-Transitions Hospice with diagnosis Parkinson's Disease (dated [DATE] and discontinued [DATE] due to the resident being deceased ). Review of the physician orders for Resident #59 revealed the resident had the following medication orders: Quetiapine Fumarate (Seroquel) (an antipsychotic medication) 50 milligrams (mg) with instructions to give one tablet every eight hours as needed for severe agitation dated [DATE] and discontinued [DATE], Quetiapine Fumarate 50 mg with instructions to give one tablet twice a day (BID) dated [DATE] and discontinued [DATE], Seroquel 50 mg with instructions to give one tablet in the evening for dementia with behaviors dated [DATE] and discontinued [DATE], Seroquel 100 mg with instructions to give one tablet daily for dementia with behaviors dated [DATE] and discontinued [DATE], Quetiapine Fumarate 25 mg with instructions to give one tablet in the evening for one week dated [DATE] and discontinued [DATE], Quetiapine Fumarate 50 mg with instructions to give one tablet in the morning for one week dated [DATE] and discontinued [DATE], and Quetiapine Fumarate 25 mg with instructions to give one tablet in the morning dated [DATE] and discontinued [DATE] due to hospice. Additionally, Resident #59 had an order for Trazodone Hydrochloride (HCl) 50 mg with instructions to give 25 mg by mouth at bedtime for insomnia dated [DATE] and discontinued [DATE] per the hospice Certified Nurse Practitioner (CNP). Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #59 had severely impaired cognition and scored a zero out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #59 was dependent on facility staff to complete Activities of Daily Living (ADLs). Review of the progress notes dated from [DATE] to [DATE] revealed on [DATE] at 11:02 A.M. and 11:03 A.M., notification of order change notes stated Resident #59 and the resident's representative were updated on new orders. Risk/Benefits were explained for Trazodone HCl 50 mg with instructions to give 25 mg by mouth at bedtime for insomnia, Seroquel tablet 100 mg with instructions to give one tablet by mouth daily, and Seroquel 50 mg with instructions to give one tablet in the evening for dementia with behaviors . The start dates for the medication were [DATE] and [DATE]. Resident #59 and the resident's Power of Attorney (POA) were made aware. There was no indication the resident's hospice provider was notified of the medication changes. Review of the care plan dated [DATE] revealed Resident #59 had a terminal prognosis related to hospice services for Parkinson's Disease with declines in condition expected. Interventions included Capital City Hospice, all care must be preauthorized: all new medications-call before contacting contracted company, all new treatments-medical equipment, labs, diagnostic tests, x-rays, transport from the facility, condition change, hospice will call the resident's physician unless other arrangements are made with hospice staff. The interventions were resolved on [DATE]. On [DATE], interventions included Transitions Hospice was initiated. Additional intervention included coordinate all care with hospice and work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met (dated [DATE]). Review of the Encounter Summary-Progress Note completed by the facility's Certified Nurse Practitioner (CNP), CNP #150, dated [DATE] at 1:47 P.M. revealed Resident #59 was seen for an acute visit due to behaviors including restlessness, impulsivity, yelling out during the day and night, and difficulty with redirecting the resident. CNP #150 planned to increase Seroquel to 100 mg daily at bedtime and add Trazodone 25 mg daily at bedtime to address dementia with psychotic disturbances. The resident's instructions included the same and to continue to follow with hospice. There was no indication the hospice provider was notified of the medication changes. Review of Plan of Care Conference, dated [DATE] (nine days after medication changes), revealed Resident #59's POA/spouse, the resident's daughter and son-in-law, Hospice Executive Director ([NAME]) #105, Licensed Social Worker (LSW) #112, and the Director of Nursing (DON) attended the care conference. Nursing Services noted the current plan of care, behaviors, falls, and interventions were reviewed. Nursing agreed with the current plan and medication education was provided. Resident #59's family reported medication tweaks and environmental adjustments were still occurring. The care conference did not indicate what medications were reviewed or what medications the resident's family were educated on. Interview on [DATE] at 1:08 P.M. via telephone with CNP #103 revealed she was the on-call CNP for Resident #59's hospice provider. CNP #103 stated the facility's CNP (CNP #150) increased Resident #59's Seroquel shortly after the resident was admitted and thinks CNP #150 also adjusted or added some other medication as well that she was not notified of until she attended a care conference via telephone to discuss Resident #59 on [DATE] and reviewed Resident #59's medications. CNP #103 recommended Resident #59's antipsychotic medication be reduced again at that time. CNP #150 stated she did not attend a care conference on [DATE] for Resident #59. Interview on [DATE] at 10:21 A.M. via telephone with [NAME] #105 revealed the facility's CNP (CNP #150) adjusted Resident #59's medications, including Seroquel, without notifying the hospice provider/hospice CNP (CNP #103). [NAME] #105 stated CNP #103 became aware of the medication adjustments/changes on [DATE] when CNP #103 attended a care conference via telephone to discuss Resident #59 and she reviewed the resident's medications. CNP #103 requested to have the medications reduced again at the time of the care conference. [NAME] #105 denied medications were discussed during the care conference held on [DATE]. Interview on [DATE] at 11:12 A.M. with the DON confirmed there were some communication issues between the facility and the hospice provider for Resident #59. The DON stated the facility conducted two care conferences for Resident #59 during her stay at the facility. The DON stated one was completed in November and the other was completed in [DATE]. The DON stated a hospice representative attended both care conferences and the resident's medications would have been reviewed at each care conference. The DON confirmed there was no documentation the hospice provider was notified of any medication changes for Resident #59 prior to [DATE] (nine days later). Interview on [DATE] at 2:10 P.M. with Licensed Social Worker (LSW) #112 confirmed a care conference was completed on [DATE] for Resident #59 (nine days after the medication changes). LSW #112 stated she was not able to remember exactly what was discussed during the care conference but the resident's medications would have been reviewed as that was standard procedure for all care conferences. LSW #112 confirmed [NAME] #105 attended the care conference on [DATE] via telephone but CNP #103 did not attend. LSW #112 stated there was a family meeting held on [DATE] per the family's request as well but she was not able to attend that meeting and was not aware what occurred during that meeting. Review of the facility policy, Hospice Program, undated, revealed the policy stated, The hospice agency retains overall professional management responsibility for directing the implementation of the plan of care related to the terminal illness and related conditions. All hospice services are provided under contractual arrangement. Complete details outlining the responsibilities of the facility and the hospice agency are contained in this agreement. Review of the hospice contract, dated [DATE], revealed the contract stated, 3.3 Notification Agreement. The facility will immediately notify the hospice about the following: significant change in the patient's physical, mental, social, or emotional status. Clinical complications that suggest a need to alter the plan of care. This deficiency revealed non-compliance during the investigation of Complaint Number OH00149558.

Based on medical record review, interview, and facility policy review, the facility failed to report an allegation of abuse to the state agency as required for one resident (#65). This affected one (Resident #65) of one resident reviewed for abuse. The facility census was 63. Findings Include: Review of the medical record for the Resident #65 revealed an initial admitted [DATE] with diagnoses including fracture of shaft of humerus, left arm, anemia, chronic kidney disease, obstructive sleep apnea, diabetes mellitus, hypertension, hyperlipidemia, gastro-esophageal reflux disease, dysphagia, generalized muscle weakness, history of falling, pain and secondary hyperparathyroidism of renal origin. The resident discharged against medical advice (AMA) on 11/11/23. Review of the resident's discharge Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition was not assessed. Review of the mood and behavior revealed the resident displayed verbal behaviors directed towards others and rejected care. The resident was dependent on toileting and required substantial assistance with bed mobility, bathing, and personal hygiene. Review of the progress note dated 11/11/23 at 2:13 A.M. revealed the resident was heard yelling and the nurse went into his room to find out what was going on. Two aides were in the room trying to change the pads under the resident but the resident was verbally abusive. The nurse instructed the aides to leave the room and the resident reported he wet himself because a urinal was placed between his legs with the lid on. The nurse explained spills do occur while using a urinal in bed and offered to change the resident and also provide care for him the rest of the night. The resident refused to be changed and called his family to come and get him. The resident's family arrived at the facility at 1:30 A.M. An AMA form was given to the family to sign but they refused to sign and wrote complaints on the form. The resident and his family left the facility at 1:45 A.M. The Certified Nurse Practitioner (CNP) was notified as well as the on call nurse manager. Review of the resident's AMA Form dated 11/11/23 revealed the resident's signature and a hand written note stating Leaving due to patient abuse. Would not come when light was on to urinate, put urinal on didn't take the lid off, urinated in bed. Insulted with smart comments and was made fun of. Two nights of abuse, had enough. Review of the facility's Self-Reported Incidents (SRI) revealed no incident related to the allegation of abuse. On 12/05/23 at 2:00 P.M., interview with the Director of Nursing (DON) verified no SRI was filed for the allegation of abuse documented by Resident #65 on the AMA form. Review of the facility policy titled, Abuse Prevention Policy, dated 08/16/21 revealed an initial investigation will be conducted and submitted to the Ohio Department of Health (ODH) immediately.

Based on observation, facility policy and procedure review and interview the facility failed to ensure altered textured food items were prepared in accordance with professional standards for food service safety to prevent contamination and/or food borne illness. This affected 16 residents (#2, #4, #5, #9, #21, #23, #28, #30, #31, #32, #36, #40, #44, #51, #115 and #210) of 16 residents identified to receive altered textured diets in the facility. The facility census was 56. Findings include: On 04/06/22 from 10:00 A.M. to 10:10 A.M. Cook #142 was observed during preparation of the lunch meal. Cook #142 was observed preparing altered texture food items. The cook was wearing gloves and placed turkey ala king into the blender. After blending one pan to a puree texture and three pans to a ground texture, Cook #142 gave the blender container to Dining Services Director #263 to be washed. Cook #142 then grabbed the sanitizing bucket, put her hand in the sanitizer to grab a wash cloth, wiped the blender base with the sanitizing cloth, threw a piece of turkey from the counter into the trash can, and changed the page on the food preparation manual. This was all done wearing the same gloves. Cook #142 did not change gloves or perform any hand hygiene during this process. Dining Services Director #263 then brought the blender container back to Cook #142 to prepare pureed texture minestrone soup. Wearing the same gloves as above, Cook #142 placed the soup in the blender, prepared it to the proper texture and poured it into a clean pan. While pouring the pureed soup into the clean plan, she placed a gloved hand on the top of the blending blade. After pouring all the soup into the clean pan, she cleaned the blender base with the sanitizing cloth. After doing this, Cook #142 then removed her gloves. On 04/06/22 at 10:13 A.M. interview with Cook #142 confirmed she did not change her gloves between preparing the altered food texture of the turkey ala king and minestrone soup. Cook #142 revealed staff typically do not change their gloves when preparing food textures until they change food types; so she did not change her gloves (perform hand hygiene) between the turkey ala king and minestrone soup because both foods contained turkey in them even though they were completely different food items. Cook #142 confirmed she did use the sanitizing cloth, threw a piece of turkey in the trash, touched the top of the blending blade, and changed pages in the food preparation manual prior to starting the process of blending the minestrone soup wearing the same gloves. The facility identified 16 residents, Resident #2, #4, #5, #9, #21, #23, #28, #30, #31, #32, #36, #40, #44, #51, #115 and #210 who received altered textured diets in the facility. Review of the undated facility Kitchen Hand Hygiene Policy revealed dietary employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils and unwrapped single service and single use articles and also in the following situations: after hands had touched anything unsanitary, after handling chemicals and before beginning to work with food, while preparing food, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks, before applying (donning) gloves for working with food and after removing gloves. The policy indicated for use of gloves- gloves should be changed when handling soiled trays and dishes, during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks and anytime a contaminated surface was touched.

Based on observation, facility policy and procedure review, facility Infection Control Program review and interview the facility failed to maintain adequate infection control practices when checking resident blood sugars using a shared glucose meter (glucometer) including proper handwashing and disinfecting of the glucometer to prevent the spread of infection. This affected one resident (#31) and had the potential to affect one additional resident (#18) who received blood glucose monitoring using the shared glucometer on the unit. Findings include: On 04/06/22 at 11:40 A.M. Licensed Practical Nurse (LPN) #141 was observed checking Resident #31's blood sugar using a shared glucometer. LPN #141 applied gloves and gathered the necessary equipment. After repositioning Resident #31 in the chair, the LPN removed her gloves and applied new gloves without first washing her hands. LPN #141 then obtained a blood sample and removed her gloves. However, the LPN had to obtain a new test strip for the glucometer as the first test did not register. LPN #141 applied a new pair of gloves without first washing her hands/performing hand hygiene and obtained another blood specimen from the resident. Following the procedure, LPN #141 was observed to place the glucometer in a cup that contained a disinfectant wipe but failed to properly clean the meter. On 04/06/22 at 11:57 A.M. interview with LPN #141 verified she had not washed her hands between glove changes and verified she had not properly disinfected the glucometer after use with Resident #31. The facility identified two residents, Resident #18 and Resident #31 who resided on the unit who required blood glucose monitoring using the shared glucometer. Review of the Glucometer Disinfection policy, dated 09/07/17 revealed all external surfaces of the glucometer must be cleaned and disinfected with the facility validated disinfectant after each patient use, whenever it was visibly soiled or contaminated and prior to docking. Staff were to reapply gloves, retrieve disinfectant wipe from the container and cleanse the glucometer with a disinfectant wipe by ensuring a four minute dwell time. Review of the facility Infection Prevention and Control Program, dated 08/2017 revealed the hand hygiene protocol included staff to use hand hygiene when coming on duty, between resident contacts, after handling contaminated objects, after personal protective equipment (PPE) removal, before/after eating, before/after toileting and before going off duty. Staff should use hand hygiene before and after performing resident care procedures and hands shall be washed in accordance with the facilities established hand washing procedure.

Based on record review and staff interview the facility failed to ensure accurate weights were obtained to ensure significant weight changes were addressed and accurate. This affected two residents (#30 and #57) of three residents reviewed for nutrition. The facility identified 11 residents who had significant weight loss or gain in the last six months. Findings include: 1. Review of the medical record for Resident #30 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the care plan, dated 02/05/21 revealed the resident had potential for nutrition and/or hydration issues related to chronic disease. Care plan interventions included to monitor weights and notify the physician of any changes. Review of the weight record revealed Resident #30 weighed 153.6 pounds (lbs) on admitted . On 02/26/21 the resident weighed 166.6 lbs and on 02/27/21 the resident weighed 142.2 lbs This represented a 14.6% weight loss in one day. Review of the progress notes and weights did not reveal any reassessment of weight and the record was silent for any dietary assessment following the weight loss. There was no evidence the physician or dietitian were notified of the weight loss. From 02/28/21 to 03/01/21 Resident #30's weight remained 142.2 lbs. On 03/02/21 Resident #30's weight was documented as 171.8 lbs. Review of the nurse's progress note, dated 03/02/21 revealed the nurse requested the aide to re-weigh the resident due to the significant gain of 29.6 lbs in one day. However, there was no evidence in the medical record the resident was re-weighed. There was no evidence the physician or dietitian was notified of the weight gain. Review of the dietary assessments and progress notes from 02/17/21 to 03/01/21 revealed the resident's significant weight changes were not addressed. Interview on 03/11/21 at 9:11 A.M. with the dietitian revealed she monitored the resident's weight and if she feels a weight accuracy was in question, she would ask for the resident to be re-weighed. During an interview with Director of Nursing (DON) on 03/15/21 at 11:04 A.M. she revealed the facility had four scales and a company who serviced and calibrated them regularly. The DON revealed the company was at the facility on 06/18/20, 02/19/21 and 03/02/21 to provide service on malfunctioning scales. The DON further revealed if staff noticed a scale was not functioning properly, they were supposed to set the scale aside, with a sign on it and inform management. The staff should then re-weigh the resident with another scale. The DON confirmed the weight changes indicated in Resident #30's medical record were questionably inaccurate and there was no documentation in the medical record the weight was taken again or further investigated. Interview with the Administrator on 03/15/21 at 12:45 P.M. confirmed the weight changes in Resident #30's medical record were questionably inaccurate. The Administrator further revealed there were no investigations completed for the weight changes and nothing was reported to the Quality Assurance Committee regarding possibly inaccurate scales. Review of the facility policy titled Nutrition Risk-Weight Loss Management, dated 2012 revealed systems to monitor for accurate weights, including re-weights being done as needed and the Registered Dietitian ensuring accurate, timely, weights were documented in the medical record. 2. Review of the closed medical record for Resident #57 revealed the resident was admitted to the facility on [DATE] and was discharged from the facility on 06/15/20. The resident had [DIAGNOSES REDACTED]. Review of the physician's orders, dated May 2020 revealed to obtain the resident's weight daily and notify the physician of two pounds (lbs) weight gain in 24 hours or five lbs in a week. Review of the care plan, dated 05/28/20 revealed the resident had the potential for altered cardiovascular status related to [MEDICAL CONDITION]. Care plan interventions included to weigh the resident daily and notify the physician of changes. Review of Resident #57's weights for May and June 2020 revealed the resident weighed 202 lbs on admission. On 06/08/20 the resident's weight was documented to be 198.2 lbs. On 06/09/21 the resident's weight was entered as 217 lbs. This indicated a weight gain of 9.4% in one day. The resident's weight remained steady until discharge on [DATE], at which time the weight was documented to be 218.6 lbs. Interview on 03/11/21 at 9:11 A.M. with the Dietitian revealed she monitored the resident's weight and if she feels a weight accuracy was in question, she would ask for the resident to be re-weighed. During an interview with Director of Nursing (DON) on 03/15/21 at 11:04 A.M. she revealed the facility had four scales and a company who serviced and calibrated them regularly. The DON revealed the company was at the facility on 06/18/20, 02/19/21 and 03/02/21 to provide service on malfunctioning scales. The DON further revealed if staff noticed a scale was not functioning properly, they were supposed to set the scale aside, with a sign on it and inform management. The staff should then re-weigh the resident with another scale. The DON confirmed the weight changes indicated in Resident #57's medical record were questionably inaccurate and there was no documentation in the medical record the weight was taken again or further investigated. Interview with the Administrator on 03/15/21 at 12:45 P.M. confirmed the weight changes in Resident #57's medical record were questionably inaccurate. The Administrator further revealed there were no investigations completed for the weight changes and nothing was reported to the Quality Assurance Committee regarding possibly inaccurate scales. Review of the facility policy titled Nutrition Risk-Weight Loss Management, dated 2012 revealed systems to monitor for accurate weights, including re-weights being done as needed and the Registered Dietitian ensuring accurate, timely, weights were documented in the medical record. This deficiency substantiates Complaint Number OH 733.

Based on observation, record review and staff interview the facility failed to ensure fall interventions were in place for Resident #6, who had a history of [REDACTED]. The facility also failed to ensure comprehensive and thorough fall investigations were completed. Actual harm occurred when Resident #6 sustained a fall resulting in a right ankle fracture with lack of evidence that interventions were in place at the time of the fall. This affected one resident (Resident #6) of three residents reviewed for accidents. Findings include: Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the fall risk assessments dated 10/26/15, 11/09/15, and 11/10/15 revealed the resident was not at high risk for falls. A plan of care (POC), initiated 11/06/15 revealed the resident was at risk for falls related to decreased mobility, weakness, pain and edema on bilateral lower extremities. The plan of care also reflected the resident required assistance for activities of daily living and mobility needs, medication use, had bowel and bladder incontinence, history of falls, and wore glasses. The goal was for the resident to be free of minor injury. Interventions included to anticipate the resident's needs, be sure the call light was within reach and encourage resident to use it for assistance, encourage the resident to wear non-skid footwear. Review of the Resident #6's progress notes, dated 11/08/15 revealed the resident was found on the floor beside her bed and was complaining of back pain. The note indicated a new intervention was to add a chair alarm. On 11/09/15, the resident was sent to the emergency room due to increased pain in the back and chest. The resident returned from the hospital on [DATE] with [DIAGNOSES REDACTED]. Interview with the Director of Nursing (DON) on 02/23/16 at 10:50 A.M. revealed the DON was unsure if the resident had fallen from her wheelchair or bed but thought it would be her wheelchair since the facility implemented a chair alarm following the fall. On 11/10/15, the progress notes revealed a registered nurse (RN) knocked on the resident's door to find the resident lying on the floor behind the door and had to get a slim state tested nursing assistant (STNA) to get into the room and move the resident slightly so the RN could gain entrance into the room. The resident stated she was returning to her bed after using the bathroom. The resident was noted to have one non-skid sock on and the other one was in the bathroom. The resident was complaining of pain and indicated it was due to the previous rib fracture. New fall interventions noted were for a bed alarm and a floor mat next to the bed. Interview with the DON on 02/23/16 at 10:50 A.M. confirmed the facility's quality assurance fall investigation did not address if the resident was assisted by staff to the bathroom prior to the fall and whether the resident's call light was was within reach and/or activated prior to the fall. The POC interventions were revised on 11/11/15 to include the use of a bed alarm while the resident was in bed and the use of a floor mat to the right side of bed. On 12/09/15 new fall interventions were implemented including a chair alarm, low bed and perimeter mattress as ordered. Review of progress notes, revealed on 12/04/15, the resident's alarm was sounding and a RN found the resident sitting on the floor by her chair. The resident's call light was observed to be in reach at that time. Record review revealed no new safety interventions were implemented at that time. Interview with the DON on 02/23/16 at 1:20 P.M. confirmed there were no new fall interventions implemented following this fall. Review of progress notes revealed on 12/05/15, the resident was found lying on the floor. Upon examination it was noted that the resident had what appeared to be a fractured ankle. The resident was assisted back to her chair and was prepared for transportation to the hospital. Interview with the DON on 12/05/16 at 1:20 P.M. confirmed the medical record and the facility's quality assurance fall investigation did not include if the resident's chair alarm was in place and sounding at the time the resident was found on the floor. The DON stated she called the nurse after talking with the surveyor and the nurse said the alarm was sounding but could not be heard until the nurse made it onto the unit. Review of hospital records revealed the resident was hospitalized from [DATE] through 12/09/15 with [DIAGNOSES REDACTED]. The resident had surgical intervention of an open reduction internal fixation of her right ankle. Review of progress notes revealed on 12/17/15, the resident phoned the desk to report that she was on the floor and a RN went to find the resident sitting on the floor. The resident said she slipped out of her wheelchair while trying to get something. Her cast to her right ankle was noted to be intact and there were no noted injuries. Interview with the DON on 02/23/16 at 10:50 A.M. confirmed the medical record did not state if the call light was within reach and whether the resident's chair alarm was in place and sounding at the time of the fall. The DON stated following this fall, a new intervention was implemented to place a non-stick mat (Dycem) in the wheelchair. Observation of Resident #6 on 02/23/16 at 7:56 A.M. revealed the resident was lying in bed eating her breakfast with her bed alarm in place. However, the resident's bed was not in low position and there was no mat placed next to the bed. No staff were observed in the resident's room at the time of the observation. Additional observation of the resident on 02/23/16 at 10:14 A.M. revealed the resident was sitting in her wheelchair in her room. The resident had a chair alarm in place, however it was not turned on. Interview with STNA #52 on 02/23/16 at 10:14 A.M. confirmed the chair alarm was not turned on, confirmed the resident's bed was not in low position while the resident was eating breakfast and also confirmed there was not mat to the floor. The STNA stated Resident #6 no longer required a mat to the floor because she does not try to get out of bed. STNA #52 also stated staff usually put her in her chair to eat her meals. She said there was a new staff person working and that staff member must not have known that. Review of the facility's policy and procedure on fall prevention and management revised on 07/13/12 revealed it was the facility policy to ensure a safe environment with least restrictive measures while promoting the highest possible level of independence. The purpose of the policy was to provide a safe environment for resident of the health care facility. This program was designed to identify residents at risk of falls; define interventions for the prevention of falls; implement Quality Assurance measures to monitor progress; and provide ongoing staff education. This deficiency substantiates Complaint Number OH 601.

Based on medical record review, review of the facility self-reported incident investigation, review of the facility abuse policy and procedure, and staff and resident interview, the facility failed to ensure Resident #50 was free from sexual abuse. This affected one resident (#50) of two residents reviewed for abuse. The facility census was 77. The Administrator and Director of Nursing (DON) were notified on 06/03/15 at 4:00 P.M. that Immediate Jeopardy began on 05/05/15 when Resident #50's mother reported an allegation of potential sexual abuse. There was no evidence the facility completed a thorough investigation of the allegation at that time. On 05/15/15, the Administrator asked the DON to talk with Resident #50 again as she felt there was more the resident was not telling administrative staff. Resident #50 then disclosed to the DON that State-tested Nurse Aide (STNA) #10 had inappropriately touched her breast and kissed her using his tongue. Although the resident did not provide a date as to when this particular incident had occurred, Resident #50 stated the sexual encounters had been occurring over the past six months. STNA #10 was terminated on 05/07/15 for reportedly unrelated performance concerns, however Resident #50 stated she was fearful STNA #10 would come back to the facility and she was a sitting duck. The Immediate Jeopardy was removed on 05/15/15 when the facility completed the following corrective actions: · On 05/07/15, STNA #10 was terminated from the facility. There was no evidence STNA #10 had been in the facility since terminated on 05/07/15. · On 05/15/15, the facility assisted Resident #50 with filing a police report with the local police department and a picture of STNA #10 was distributed to campus security and the facility receptionists due to Resident #50's fear of retaliation by STNA #10. · On 05/15/15 the DON re-educated all 35 current licensed nurses and STNA staff regarding the facility abuse policy and procedure. Although the Immediate Jeopardy was removed on 05/15/15 when the facility initiated staff training, the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of providing education to all staff related to abuse prohibition and was reassessing all residents for potential sexual abuse. Findings Include: Review of Resident #50's medical record revealed an original admission date of [DATE] with the latest re-admission on 05/11/15 with admitting [DIAGNOSES REDACTED]. Record review revealed the resident had been hospitalized from [DATE] through 05/11/15 due to an acute medical change in medical condition. Review of the most recent quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/14/15 revealed the resident was cognitively intact, able to make her needs known and understands others. She was assessed to require extensive assistance from staff for bed mobility, transfers, toileting, dressing and grooming. Record review revealed the resident was dependent on staff for bathing and had an indwelling urinary catheter. However, her mother also provided hands on care, including assistance with personal care/bathing at times. Review of a facility Self-Reported Incident (SRI), dated 05/05/15 revealed Resident #50's mother reported to Registered Nurse (RN) #11 she felt the resident was sexually abused because her vaginal areas were reddened. The resident's mother named STNA #10 as the alleged abuser. The facility initiated an investigation at which time the Assistant Director of Nursing (ADON) interviewed the resident who denied being touched inappropriately at that time. The SRI further reported STNA #10 as not assigned to the unit the resident resided on and the nurse on duty confirmed she had not seen him on the hallway during the shift. The facility did not substantiate the allegation of abuse due to the resident denying the allegation occurred. No physical examination of the resident was completed and no further investigation was conducted. The investigation failed to provide any evidence of interviews with other residents, STNA #10 or other staff members related to the allegations made at that time. Review of a SRI, dated 05/15/15 revealed Resident #50 reported to the DON, STNA #10 had touched her breasts and kissed her with his tongue. The SRI indicated STNA #10 was no longer employed with the facility due to unrelated performance concerns. The facility conducted an investigation and the based on the investigation, the allegation of sexual abuse was substantiated. The report indicated Certified Nurse Practitioner (CNP) #30 was notified of the incident, however there was no documentation from CNP #30 contained in the resident's medical regarding the incident. There was no evidence any physician was notified. The facility assisted Resident #50 in filing a police report with the local police department. The SRI also indicated a picture of STNA #10 was distributed to campus security and the receptionists due to Resident #50's fear of retaliation. On 05/15/15 (no time indicated) the DON interviewed Resident #50 per the request of the Administrator regarding the previous allegation of sexual abuse reported to the facility by the resident's mother on 05/05/15. The statement documented STNA #10 had touched the resident's breasts and had kissed her on the mouth using his tongue. The statement documented some staff teasing the resident about STNA #10 being her boyfriend and it would embarrass her so the resident started saying no, he is yours to them. The DON was able to determine the resident had confided in STNA #12 (date unknown) about the inappropriate touching of her breasts and STNA #12 shared the information with STNA #10. The resident reported STNA #10 confronted Resident #50 about what she told STNA #12 and told her their conversations were private and should not be told to anyone. The DON documented at that time she excused herself, located STNA #12 who was currently working a shift at the facility and STNA #12 was suspended pending the conclusion of the investigation. Upon the DONs return to complete the interview, Resident #50 reported STNA #10 did call her during her hospital stay from 05/05/15 to 05/11/15 but she did not talk to him. The resident stated she felt someone had told STNA #10 what her mother reported and he was trying to talk to her about it. This was confirmed during an interview with Resident #50 on 06/01/15 at 10:05 A.M. The DON documented the resident's concern that staff would find out and tell STNA #10 or that his co-workers would retaliate and wished the investigation be kept as private as possible. On 05/15/15 (no time indicated) STNA #12 was interviewed by the Administrator and the DON related to her being named during the investigation. The interview with STNA #12 revealed STNA #12 knew STNA #10 spent a lot of time in Resident #50's room with the door shut. The statement documented STNA #12 acknowledged that she did not report the inappropriate relationship between STNA #10 and Resident #50 to anyone at the facility for further investigation, but did tell STNA #10 he needed to stop. The interview also documented STNA #12 talked with STNA #10 about trying to touch other employee's breasts and being too close in people's personal space. Review of STNA #12's notice of disciplinary action form, dated 05/15/15, revealed she was suspended on that day pending the completion of the investigation. STNA #12 was terminated on 05/19/15 after knowingly admitting to being aware that Resident #50 and STNA #10 were having a potentially inappropriate relationship and admitted to not reporting it for investigation but instead telling STNA #10 he needed to stop. As part of the facility investigation, on 05/15/15 (no time indicated) the Administrator and the DON interviewed STNA #13. STNA #13 reported she had heard from STNA #12, that Resident #50 and STNA #10 were boyfriend and girlfriend. STNA #13 reported STNA #12 had told her about it and confirmed she had not reported the information to administrative staff. On 06/01/15 at 10:05 A.M. interview with Resident #50 revealed STNA #10 had been touching her inappropriately on the breasts and only kissed her one time on the mouth using his tongue. She said STNA #10 would beg her to let him touch her breasts. She said she told him they were just friends and friends didn't do things like that. She said even after the kissing situation was over he would still come back and try to touch her breasts. The resident said she felt uncomfortable when STNA #10 came into her room. She said she never reported the incident to anyone at the facility. She said her mother came to the facility to assist her with a shower and noted she was really red around her vaginal area and buttocks. She said her mother told the facility that something had happened to her and she had told her mom that STNA #10 was creepy. When her mother said something to RN #11, she mentioned STNA #10's name as a concern. She said the Assistant Director of Nursing (ADON) then came to talk with her and it all came out in the open. Resident #50 stated the other employees would joke all the time and say there's your boyfriend. On 06/01/15 at 12:20 P.M. interview with the DON revealed the allegation of sexual abuse was brought to RN #11's attention on 05/05/15 by Resident #50's mother. The DON said an investigation was initiated but the resident denied the incident occurred therefore the allegation was unsubstantiated. The DON stated on 05/15/15 however, the resident admitted the allegation had occurred. She said the nursing staff was educated on abuse on 05/15/15 following the incident. On 06/01/15 abuse in-service re-education was initiated by the Administrator for all staff in all other departments. On 06/01/15 at 9:10 A.M. interview with the Administrator revealed the incident was isolated to the nursing department therefore the entire staff was not educated on abuse. She said there was only one other resident in the facility who was at potential risk for sexual abuse (due to the resident's age) and verified no other resident had been assessed after the allegation of abuse was substantiated. On 06/03/15 at 3:30 P.M. interview with CNP #30 revealed she had been notified on an incident of possible sexual abuse involving Resident #50 on 05/26/15. CNP #30 indicated she had not yet examined the resident or followed up regarding the incident, but failed to explain why. Review of the facility's abuse prevention policy and procedure, last revised on 02/13/12, revealed the facility had a zero tolerance for abuse, neglect and misappropriation of resident property. All reports of resident abuse, neglect, injuries of an unknown source shall be promptly and thoroughly investigated by the facility management. Sexual abuse was identified as sexual harassment, sexual coercion and sexual assault. All employees will be in-serviced and trained during orientation regarding identification, prevention, and reporting abuse and the Abuse Elder Act. On-going education and training for employees will include appropriate intervention for behavioral episodes, how to report, and clear definitions of abuse. Any allegation of abuse needs to be reported to a supervisor, DON or Administrator. Facility employees need to protect the resident if they suspect abuse. The DON or designee shall be responsible for the investigation of the alleged incident. The investigation will consist of, an interview with the person reporting the incident, interview with the witnesses and resident, review of the medical record and notification of investigation made to physician and responsible party, interview staff members having contact with resident during period of alleged incident, interview with other residents, and review of all circumstances surrounding the incident. An assessment will be completed on the resident to determine any medical course of action needed. The resident will be protected from any harm during the investigation. Any staff member in the allegation will be suspended. If abuse is determined to occur the staff member would be terminated and notification to the licensing agency and the Attorney General's office would occur. This deficiency substantiates Self Reported Incident Control Number OH 155.