Every finding on record at Willows at Bellevue

Based on observation, staff interview, and review of the facility policies, the facility failed to ensure food items stored in unit refrigerators were labeled and dated and further failed to ensure unit refrigerators did not contain expired food items. This had the potential to affect all 57 residents who received food from the kitchen. The facility census was 57. Findings include: Observation beginning on [DATE] at approximately 5:38 P.M. of the unit refrigerator located centrally between all resident units hallways with Registered Nurse (RN) #396 revealed the following concerns: In the refrigerator, there was one plastic container containing prunes which was dated [DATE], one plastic container containing potato soup which was dated [DATE], one plastic container containing grapefruit which was labeled [DATE], one container of prunes which was dated [DATE], one undated disposable container from a restaurant which contained fried chicken, two containers of pudding which expired in [DATE], and one unlabeled and undated container of cottage cheese which had been opened. Interview at the time of observation, with RN #396, confirmed the areas of concern. Additional observation and interview on [DATE] at 5:52 P.M. with Dietary Manager #344 further verified the areas of concern. Dietary Manager #344 verified prepared items should be disposed of within three days of being placed in the refrigerator. Review of the facility policy titled Food Brought Into Facility, dated [DATE], revealed the purpose of the policy was storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. The policy stated food brought in by family members, friends or gusts must be inspected by a staff member, properly labeled and dated, and stored and discarded in conjunction with the facility's Date [NAME] and Labeling policy and procedure. Review of the facility policy titled Food Safety and Handling, not dated, revealed prepared leftover food items must be discarded within three days and ready-to-eat potentially hazardous foods must be marked with the date of preparation and consumed or discarded within seven days (including he day of preparation).

Based on medical record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to ensure Resident #205 received oxygen at the correct rate as prescribed by the physician. This affected one (Resident #205) of one resident reviewed for respiratory care. The facility census was 57. Findings include: Review of the medical record revealed Resident #205 was admitted to the facility on [DATE]. Diagnoses included acute respiratory failure with hypoxia, acute kidney failure, heart failure, chronic kidney disease, chronic venous insufficiency (peripheral), type II diabetes mellitus, obstructive sleep apnea, dyspnea, hypoxemia, and weakness. Review of the admission Minimum Data Set assessment dated [DATE] identified Resident #205 was cognitively intact. The resident required some level of staff assistance for all activities of daily living and also received oxygen therapy. Review of the active physician orders for April 2025 identified an order dated 03/27/25 for continuous oxygen at two liters per nasal cannula. Review of the plan of care dated 03/27/25 revealed Resident #205 had the potential for complications, functional and cognitive status decline. Interventions included administering oxygen per orders. Review of the vital sign record for 03/27/25 through 04/06/25 revealed Resident #205 was receiving oxygen at three liters on 03/29/25 at 4:00 A.M., 04/01/25 at 4:03 A.M., 04/01/25 at 4:17 P.M., 04/02/25 at 7:38 A.M., 04/02/25 at 1:33 P.M., 04/02/25 at 3:43 P.M., 04/03/25 at 7:57 A.M., 04/03/25 at 7:59 A.M., 04/04/25 at 11:37 P.M., 04/06/25 at 6:31 A.M., 04/06/25 at 6:32 A.M., 04/06/25 at 9:13 A.M., and 04/06/25 at 10:53 A.M. During an observation on 04/07/25 at 10:40 A.M., Resident #205's oxygen concentrator was running at three liters per minute while Resident #205 was receiving the oxygen via nasal cannula. During an interview at the time of observation, Resident #205 reported they were supposed to receive two liters of oxygen per minute. During a follow-up observation on 04/07/25 at 11:28 A.M., Resident #205's oxygen concentrator was running at three liters per minute while Resident #205 was receiving the oxygen via nasal cannula. An interview on 04/10/25 at 8:23 A.M. with the Director of Nursing confirmed Resident #205 had a physician order for two liters of oxygen and did not have an order for three liters of oxygen. The Director of Nursing verified the oxygen for Resident #205 was being administered at three liters per minute via nasal cannula. Review of the facility policy titled Administration of Oxygen, dated May 2018, revealed physician orders would be verified when oxygen was administered.

Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to ensure call lights were within reach. This affected two (#11 and #33) of two residents reviewed for call lights. The facility census was 57. Findings include: 1. Review of the medical record for Resident #11 revealed diagnoses including encephalopathy, myocardial infarction, stage four chronic kidney disease, venous insufficiency, anxiety, bipolar disorder, depression, schizoaffective disorder, left knee effusion, history of falling, chronic pain, weakness, lymphedema, cardiac pacemaker, atrial fibrillation, communication deficit, and mild cognitive impairment. Review of the quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] for Resident #11 revealed she was a fall risk, had mild cognitive impairment, used a wheelchair, required supervision with transfers, and required assistance with toileting. Observation on 04/07/25 at 9:46 A.M. of Resident #11's room revealed she was unable to see or reach her call light. Resident #11 was sitting in her recliner next to her bed and the call light was tangled around the back of the bed handle. Subsequent interview with Graduate Resident Care Associate (GRCA) #406 confirmed Resident #11 could not see or reach her call light. 2. Review of the medical record for Resident #33 revealed diagnoses including congestive heart failure, heart disease, hypertension, disorientation, fall on the same level, and unsteady gait. Review of the quarterly MDS assessment dated [DATE] revealed Resident #33 was cognitively intact, used a manual wheelchair and required moderate assistance with transfers, bathing, and toileting. Observation on 04/07/25 at 9:42 A.M. of Resident #33's room revealed Resident #33 was sitting in her wheelchair in the center of her room. The bed was against the wall and the call light was tied to the bed handle on the wall side of the bed, out of her reach of the resident. Subsequent interview with Floor Technician #405 confirmed Resident #33 was not able to reach her call light. Observation on 04/09/25 at 10:07 A.M. of Resident #33's room revealed Resident #33 was sitting in her wheelchair at the side of her bed. The bed was against the wall and the call light was tied to the bed handle on the wall side of the bed, opposite the resident and out of the resident's reach. Subsequent interview with GRCA #409 confirmed Resident #33 was not able to reach her call light. Review of facility policy titled Guidelines for Answering Call Lights dated 12/17/24 indicated call lights would be placed within reach of residents.

Based on medical record review and resident and staff interview, the facility failed to ensure a resident's bathing preference was reasonably met. This affected one (Resident #20) of three residents reviewed for reasonable accommodations of shower preferences. The facility census was 54. Findings include: Review of Resident #20's medical record revealed an admission to the facility occurred on 12/20/22. Diagnoses included stroke, chronic obstructive pulmonary disease (COPD), and diabetes mellitus. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 was cognitively intact and was dependent on staff for bathing. The MDS assessment dated [DATE] revealed Resident #20's preferences for choosing bathing/shower was listed as very important to the resident. Review of Resident #20's shower/bathing records was completed from 05/12/23 through 06/01/23. Resident #20 was documented as receiving a shower on 05/19/23 and 05/29/23. The documentation revealed there were no other showers given to Resident #20 in the 20 days. Resident #20 did receive bed baths during this time frame but no other showers were given. Interview with Resident #20 on 06/01/23 at 3:08 P.M. confirmed she has been getting bed baths instead of showers frequently. Resident #20 confirmed she was scheduled for showers twice a week and was getting them about once a week. Resident #20 confirmed she wants her showers twice a week as scheduled. Resident #20 confirmed she received a shower on Monday (05/29/23) however it had been quite a while before that. Interview with the Director of Nursing (DON) on 06/01/23 at 5:52 P.M. confirmed there was a lack of documented showers for Resident #20. The DON confirmed Resident #20 has been receiving bed baths instead of showers on several occasions in the past three weeks. This deficiency represents non-compliance investigated under Complaint Number OH00143054.

Based on medical record review, staff interview, and review of facility policy, the facility failed to provide timely physician and resident representative notification of changes in condition. This affected one (#31) of two residents reviewed for notification of change. The facility census was 53. Findings include: 1. Review of Resident #31's medical record revealed an admitted [DATE]. Diagnoses included type II diabetes, dementia, hypertensive chronic kidney disease, atrial fibrillation, other symptoms and signs concerning food and fluid intake, weakness and metabolic encephalopathy. Review of the annual Minimum Data Set (MDS) assessment, dated 01/12/23, revealed Resident #31 was moderately cognitively impaired, required limited assistance with activities of daily living (ADLs), supervision for eating and experienced a significant weight loss and was not on physician prescribed weight loss program. Review of a plan of care focus area, initiated 01/13/23, revealed Resident #31 experienced a significant weight loss. Interventions included provide diet, supplements, medications, adaptive equipment and snacks as ordered, offer encouragement and assistance with eating as needed and weigh as ordered. Review of current physician orders revealed Resident #31 was ordered a regular, mechanical soft, ground meat diet. In addition, Resident #31 was ordered Ensure pudding one time daily, Glucerna supplement two times daily and three snacks daily. Review of Resident #31's weights revealed on 07/01/2022, the resident weighed 106.6 pounds (lbs.). Resident #31's weights revealed on 12/03/2022, the resident weighed 97.4 lbs. On 01/09/2023, the resident weighed 92.4 pounds, indicating a 5.13% significant weight loss in one month and a significant weight loss of 13.32% in six months. Review of progress notes from 01/09/23 through 01/30/23 revealed no evidence Resident #31's physician or representative were notified of the resident's significant weight loss. Interview on 02/02/23 at 7:33 A.M. with the Director of Nursing (DON) revealed the typical process for weight loss was to document all residents with weight loss on a log which the physician reviewed each Tuesday when he visited the facility. The DON stated a facility event document, which was part of the facility's risk management program, was sometimes created for significant weight loss and notifications were documented on the event document. The DON confirmed an event document was not created following Resident #31's significant weight loss on 01/09/23. The DON verified there was no evidence Resident #31's physician was notified of the resident's significant weight loss until 01/31/23 and there was no evidence the resident's representative was notified of the weight loss. Review of facility policy titled Guidelines for Weight Tracking, reviewed 03/16/22, revealed residents who had a weight that seemed out of normal range would be re-weighed to determine accuracy of the original weight. In addition, the physician, resident representative and dietitian shall be notified of a weight variance of 5% in 30 days, 7.5% in 90 days and 10% in 180 days days.

Based on observations and staff interviews, the facility failed to ensure furniture in living quarters was maintained in good condition. This affected one (#9) of one resident reviewed. The facility census was 53. Findings include: Observations on 01/30/23 at 09:29 A.M. of Resident #9's room revealed the left door of the wardrobe had the wood grain laminate peeling off the door down the entire left side and hanging loosely from the door Interview with State tested Nursing Assistant (STNA) #386 on 02/01/23 at 04:17 P.M. verified the wardrobe for Resident #9 had the laminate peeling off the door.

Based on observation, staff interview, and medical record review, the facility failed to ensure residents were provided adaptive equipment during meals. This affected one (#34) of five residents observed eating meals in their room on the 100 Hall. The facility identified six residents in the facility with orders for adaptive eating equipment. The census was 53. Findings include: Review of Resident #34's medical record revealed an admitted [DATE]. Diagnoses including anemia in chronic kidney disease, unspecified protein-calorie malnutrition, unspecified dementia, chronic kidney disease, facial weakness following cerebral infarction, and hemiplagia and hemiparesis. Review of the Minimum Data Set (MDS) assessment completed on 11/21/22 revealed Resident #34 was assessed with severely impaired cognitive skills for daily decision making and required limited assistance with eating. Review of a care plan dated 07/26/21 revealed a nutritional risk care plan with an intervention to provide diet, supplements, medications, and adaptive equipment as ordered. Review of a physician order dated 11/16/22 revealed Resident #34 was to have a plate guard for all meals on the right side of the plate for increased self feeding and decreased spillage. Observation on 01/31/22 at 12:25 P.M. revealed Resident #34 in her bed on the 100 Hall sitting up and awaiting lunch. Further observation revealed Resident #34 received her lunch tray from staff and was assisted with tray set up. Resident #34's plate contained beef brisket and french fries and no plate guard in place on Resident #34's plate. Observation on 01/31/22 at 12:32 P.M. revealed Resident #34 fed herself and ate her lunch with no plate guard in place. Interview on 01/31/22 at 12:40 P.M. with Stated tested Nurse Aide (STNA) #313 stated she never saw Resident #34 with a plate guard to her meal plate and was not aware one was needed. Observation on 01/31/22 at 12:40 P.M. of Resident #34 eating in her room with STNA #313 verified Resident #34 did not have a plate guard in place and she was eating lunch in her room. Interview on 01/31/22 at 12:42 P.M. with Licensed Practical Nurse (LPN) #315 verified Resident #34 had a physician order for a plate guard for all meals, but stated she did not consistently work on Resident #34's hall so she was not aware how often, if ever, Resident #34 was given a plate guard. Observation on 01/31/22 at 12:45 P.M. with LPN #315 confirmed Resident #34 was eating in her room with no plate guard in place. Interview on 01/31/22 at 1:10 P.M. with Cook #341 stated the kitchen staff are made aware of all residents with order for adaptive eating equipment and keep a paper in the kitchen with what each resident required with meals. Cook #341 stated she knew Resident #34 was to have a plate guard in place for all meals. Cook #341 stated the plate guard for Resident #34's plate was not put in place in the kitchen because Resident #34 ate in her room and the plate cover used for the hall trays would not fit over the plate if a plate guard was applied. Cook #341 stated Resident #34's plate guard should be applied after she was served her meal tray in her room. Review of a facility policy titled Meal Service, revised January 2023, revealed adaptive equipment is provided as ordered to aid an individual in feeding self when necessary. Items are included in the tray set up or during dining room service. Nursing will make final arrangement of the devices as part of the presentation. Dining service staff will deliver tray carts to each nurse's station and nursing staff will deliver and collect trays from individuals.

Based on observation, resident and staff interview, medical record review, review of pharmacy delivery slips, and review of a facility policy, the facility failed to ensure the pharmacy sent resident medications to the facility as ordered. This affected one (#7) of five residents reviewed for unnecessary medications. The census was 53. Findings include: Review of Resident #7's medical record revealed an admitted [DATE]. Diagnoses included diabetes mellitus type II, anemia, hypokalemia, peripheral vascular disease, altered mental status, acute pulmonary edema, and COVID-19. Review of the most recently completed Minimum Data Set (MDS) assessment, dated 01/12/23, revealed Resident #7 was assessed with moderately impaired cognition. Review of a nursing progress note dated 12/31/22 revealed Resident #7 tested positive for COVID-19 with no abnormal lung sounds or shortness of breath exhibited. Review of a subsequent nursing progress note dated 12/31/22 revealed a new order was given for Resident #7 to receive the medication to treat COVID-19, Paxlovid. Review of a physician order dated 12/31/22 revealed Resident #7 was ordered Paxlovid 300 milligrams (mg)-100 mg three tablets twice daily. Review of the December 2022 medication administration record (MAR) revealed Resident #7 did not receive the ordered Paxlovid on 12/31/22 with a note documented on 12/31/22 at 8:48 P.M. stating the medication was not available. Review of the January 2023 MAR revealed Resident #7 did not receive Paxlovid as ordered on 01/02/23, on 01/03/23 in evening, or on 01/04/23 in the morning. Nurses documented in the comments on 01/02/23 at 9:03 A.M. and at 8:56 P.M., on 01/03/23 at 10:16 A.M., and on 01/04/23 at 8:39 A.M. that the medication was not available. Review of pharmacy delivery sheets dated 12/31/22 and 01/03/23 revealed no evidence of Resident #7's Paxlovid being sent to the facility. Review of nursing progress notes between 12/31/22 and 01/04/23 revealed Resident #7 remained asymptomatic of COVID-19 symptoms. Review of a nursing progress note dated 01/04/23 at 5:33 P.M. revealed Resident #7's Paxlovid was discontinued due to the medication not received from the pharmacy and Resident #7 was five days out from her positive COVID-19 test. Interview on 01/31/23 at 2:48 P.M. with Resident #7 stated when she had COVID-19 in the beginning of January 2023 she did not have any symptoms other than an occasional cough. Resident #7 stated she did not feel tired or experience any changes in her respiratory status. Resident #7 stated she felt she recovered from her COVID-19 infection and had no lasting effects from it. Interview on 02/03/23 at 12:22 P.M. with Regional Clinical Support (RCS) #416 stated the pharmacy indicated Resident #7's Paxlovid was sent to the facility sometime between 12/31/22 and 01/04/23 but they did not have any delivery slips confirming that. RCS #416 stated the pharmacy received the order for Paxlovid on 12/31/22 and it should have been received in the facility the following day. RCS #416 stated the facility had pharmacy delivery slips from 12/31/22 and 01/03/22 and Resident #7's Paxlovid was not delivered on either of those days. Interview on 02/03/23 at 1:20 P.M. with Director of Nursing (DON) #332 stated the pharmacy told her Resident #7's Paxlovid was delivered to the facility on [DATE], but the facility did not have any record of it. DON #332 stated she reviewed the 12/31/22 pharmacy delivery slip and verified Resident #7's Paxlovid was not on the list. DON #332 confirmed the facility did not have any other pharmacy delivery slips between 12/31/22 and 01/04/23 other than what was provided. Review of a facility policy titled, Medication Ordering and Receiving from Pharmacy, revised November 2018, revealed medication orders are written on a medication order form provided by the pharmacy, written in the chart by the physician, electronic order, or written on a transfer order form and transmitted to the pharmacy. A licensed nurse or certified technician as permitted receives the medications delivered to the facility and documents that the delivery was received and verifies medications received with the medication order form.

Based on observations, staff interview, and review of facility policy, the facility failed to properly store oxygen tubing and follow their policy to date oxygen tubing when put into use. This affected one (#13) of one resident reviewed for oxygen administration. The facility identified 10 residents who had orders for oxygen. The facility census was 53. Findings include: Review of the medical record revealed Resident #13 admitted to the facility on [DATE]. Diagnoses included acute respiratory failure with hypoxia and unspecified asthma. Review of the Minimum Data Set (MDS) assessment, dated 01/02/23, revealed Resident #13 had severe cognitive impairment. Review of current physician's orders revealed orders for oxygen as needed for shortness of breath every four hours, change oxygen tubing monthly, and assess respiratory status twice daily. Observations on 01/30/23 at 12:19 P.M. revealed Resident #13's oxygen tubing was not dated and oxygen tubing draped across bed. Observations on 01/31/23 at 7:49 A.M. and 11:33 A.M. Resident #13 oxygen tubing noted to be undated and laying on the floor. Observations on 01/31/23 at 11:33 A.M. Resident #13 oxygen tubing noted to be undated and laying on Resident # 13's bed. Review of the facility policy titled Administration of Oxygen, dated 12/22, revealed oxygen tubing was to be changed monthly and dated. Interview with Licensed Practical Nurse (LPN) # 411 verified Resident #13 oxygen tubing was undated and not stored appropriately. LPN #411 verified the facility policy was to date tubing and and stored in a plastic bag attached to the oxygen concentrator.

Based on medical record review, resident and staff interview, and review of facility policy, the facility failed to ensure the physician followed up timely on dietitian recommendations for a resident with a significant weight loss. This affected one (#31) of one residents reviewed for nutrition. The facility census was 53. Findings include: Review of Resident #31's medical record revealed an admitted [DATE]. Diagnoses included type II diabetes, dementia, hypertensive chronic kidney disease, atrial fibrillation, other symptoms and signs concerning food and fluid intake, weakness and metabolic encephalopathy. Review of the annual Minimum Data Set (MDS) assessment, dated 01/12/23, revealed Resident #31 was moderately cognitively impaired, required supervision for eating, experienced a significant weight loss, and was not on physician prescribed weight loss program. Review of a plan of care focus area, initiated 01/13/23, revealed Resident #31 experienced a significant weight loss. Interventions included provide diet, supplements, medications, adaptive equipment and snacks as ordered, offer encouragement and assistance with eating as needed and weigh as ordered. Review of current physician orders revealed Resident #31 was ordered a regular, mechanical soft, ground meat diet. In addition, Resident #31 was ordered Ensure pudding one time daily, Glucerna supplement two times daily and three snacks daily. Review of Resident #31's weights revealed on 07/01/2022, the resident weighed 106.6 pounds (lbs.). Resident #31's weights revealed on 12/03/2022, the resident weighed 97.4 lbs. On 01/09/2023, the resident weighed 92.4 pounds, indicating a 5.13% significant weight loss in one month and a significant weight loss of 13.32% in six months. Review of the Nutritional Quarterly/Re-admission Observation, dated 01/13/23, revealed Resident #31 screened for malnutrition with advanced age, multiple medications, low body mass index (BMI), dementia and dysphagia. Resident #31's intakes were documented as good at 75% or more for 90% of meals, was on three supplements and three snacks daily and noted to accept those well also. It was recommended for Resident #31's diabetes medications to be evaluated to potentially reduce effects of weight loss. Review of a nursing progress note dated 01/16/23 revealed dietitian recommendations were printed and sent to the physician. Further review of progress notes from 01/16/23 through 01/30/23 revealed no evidence Resident #31's physician evaluated the resident's diabetes medications as recommended by the dietitian. Interview on 02/01/23 at 8:56 A.M. of the Director of Nursing (DON) revealed she discussed the dietitian's recommendations, made on 01/13/23, with Resident #31's physician on 01/31/23. The DON stated the physician was hesitant to make any changes to Resident #31's diabetes medications due to unstable blood sugar levels. Interview on 02/02/23 at 10:28 A.M. of Medical Director (MD) #415 confirmed he did not address the dietitian recommendation to review Resident #31's diabetes medications until 01/31/23. MD #415 stated the problem was the recommendation was made but the facility did not send a list of Resident #31's medications for him to review. MD#415 stated he did not have access to or know how to access the resident's medications via the electronic medical record (EMR) and stated he had weekly meetings with the Administrator and would be discussing with her how to ensure he received needed information to follow up on recommendations timely. MD #415 stated he typically followed the dietitian recommendations and, while he was uncertain it would have an impact on the resident's weight, he was looking at making changes to one of Resident #31's diabetes medications. Interview on 02/02/23 at 11:38 A.M. of Resident #31 confirmed she was aware she had lost weight. Resident #31 stated she was provided enough to eat, consumed two nutritional supplements daily, had an ensure pudding each day and was provided multiple snacks daily, including peanut butter and jelly sandwiches, fruit, peanut butter crackers. Resident #31 attributed her weight loss to being retired and not being as active as she once was. Review of facility policy titled Nutritional Recommendation Guideline, reviewed 12/01/21, revealed the suggested discipline follows up on recommendation(s) in a timely manner.

Based on observations, medical record review, staff interview, and review of facility policy, the facility failed to implement fall interventions as care planned and per physician orders. This affected one (Resident #9) of two residents reviewed for falls. The facility census was 53. Findings include: Review of the medical record revealed Resident #9 admitted to the facility on [DATE]. Diagnoses included memory deficit following cerebral infarct, vascular dementia, psychotic disturbance, mood disturbance, anxiety disorder, disorientation, weakness, altered mental status, cognitive communication deficit, and hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side. Review of Minimum Data Set assessment (MDS) dated [DATE] revealed Resident #9 could not complete the assessment of cognitive functioning. Resident #9 was dependent on staff for bed mobility, toileting, activities of daily living, bathing, locomotion, and dressing. Resident #9 required extensive assistance for transferring. Review of the care plan dated 01/10/23 revealed Resident #9 was at risk for falls due to decreased strength, mobility, high risk medications, and cognition. Interventions included the use of a fall mat next to the bed while the resident was laying down. Review of the fall risk assessment dated [DATE] revealed Resident #9 was at moderate risk for falls. Review of the current physician orders revealed orders for a fall mat next to the bed while the resident was laying in bed. Observations on 01/30/23 at 2:34 P.M. revealed Resident #9 was laying in bed without a fall mat in place to the floor. Observations on 01/31/23 at 7:52 A.M., 11:35 A.M., 2:36 P.M., and 2:44 P.M. revealed Resident #9 was laying in bed without a fall mat in place to the floor. Interview with Licensed Practical Nurse (LPN) #316 on 01/31/23 at 03:48 P.M. verified a fall mat was not in place while Resident #9 was in bed. Review of facility policy titled Fall Management Program Guidelines, dated 03/22, revealed to carry out any orders prescribed by the physician.

Based on observation, medical record review, family interview and staff interview, the facility failed to ensure dependent residents were provided assistance with shaving. This affected one (#16) of four residents reviewed for activities of daily living (ADLs). The facility census was 53. Findings include: Review of Resident #16's medical record revealed an admitted [DATE]. Diagnoses included vascular dementia, type II diabetes, chronic kidney disease, macular degeneration, hypertension, depressive disorder and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/01/23, revealed Resident #16 was severely cognitively impaired and required limited one person assistance with personal hygiene. Review of a plan of care focus area, reviewed 01/05/23, revealed Resident #16 required staff assistance to complete activities of daily living (ADLs) completely and safely related to cerebrovascular disease, dementia, vision, medications and weakness and Resident #16 would have ADLs met safely by staff assistance. Observation on 01/30/23 at 11:28 A.M. revealed Resident #16 was assisted back to the 100 Hall, after having her hair done. Resident #16 was noted to have significant hair on her chin. Interview on 01/30/23 at 1:35 P.M. with Resident #16's family member revealed family visited over the weekend and noticed the resident had hair on her chin. The family member stated he believed staff assisted Resident #16 with shaving on the days she had her hair done. Observation on 01/31/23 at 11:25 A.M. revealed Resident #16 sitting in the common area of the 100 Hall unit. Resident #16 was observed to have multiple hairs on her chin. Observation on 02/01/23 at 7:50 A.M. revealed Resident #16 was eating breakfast in the dining room. Resident #16 was observed to still have significant hair on her chin. Interview on 02/01/23 at 8:44 A.M. with State tested Nurse Aide (STNA) #313 revealed Resident #16 required extensive assistance with ADLs, including grooming and hygiene. STNA #313 stated the resident typically had her hair done weekly by the beautician and did not refuse care. While assistance with shaving could be done anytime it was needed, STNA #313 confirmed Resident #16's shower days were Tuesdays and Thursdays and assistance with shaving should have been completed on those days. STNA #313 stated she would take care of it today.

Based on observations, medical record review, staff interview and review of facility policy, the facility failed to complete an assessment for self-medication administration for one (#28) of one resident reviewed for self-administration of medication. The facility census was 53. Findings include: Review of the medical record revealed Resident #28 admitted to facility on 06/15/22. Diagnoses included dry eye syndrome of unspecified lacrimal gland. Review of Minimum Data Set assessment (MDS) dated [DATE] revealed Resident #28 had moderately impaired cognition. Review of the current physician orders revealed Resident #28's medications included Gen Teal Tears moderate artificial tear over the counter eye drop to be used twice daily in the morning and evening. There was no order for the resident to self administer any medications. Observations on 01/31/23 at 2:00 P.M. revealed two green boxes that contained over the counter lubricating eye drops at the Resident #28's bedside. Interview with Resident #28 on 01/31/23 at 2:55 P.M. revealed Resident #28 prefers to have the eye drops at bedside to give right at bedtime and first thing in the morning. Interview with Licensed Practical Nurse (LPN) #316 on 01/31/23 at 3:52 P.M. verified the two green boxes containing over the counter lubricating eye drops were at Resident #28's bedside. LPN #316 was unaware of a self-medication assessment. Interview with Director of Nursing (DON) on 02/01/23 at 4:09 P.M. verified no self-medication assessment had been completed for Resident #28. Review of facility policy titled Guidelines for Self-Administration of Medications, reviewed 12/01/21, revealed residents requesting to self-medicate shall be assessed and the results of the assessment would be presented to the physician for evaluation and an order for self-administration.

Based on resident record review, staff interviews, review of Exit Seeking Event, review of facility Self-Reported Incidents (SRIs), and review of facility policy, the facility failed to report an allegation of neglect to the State Survey Agency when one resident left the facility unsupervised. This affected one (#1) of three residents reviewed for elopement. The facility census was 45. Findings include: Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] and discharged on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment, dated 02/07/22, revealed the resident was moderately cognitively impaired and wandering had occurred in the last three days. Review of Exit Seeking Event, dated 02/04/22, revealed Resident #1 had exited the facility unsupervised and was found on the property by a contracted snow removal crew member at 4:00 P.M. Resident #1 had no injuries noted upon assessment. Review of the facility SRI revealed the facility had not filed a SRI with the State Survey Agency regrding Resident #1's elopement incident. Interview on 02/10/22 at 2:30 P.M. with Clinical Support Registered Nurse #400 verified a SRI was not completed when Resident #1 left the building unsupervised. Review of facility policy titled Abuse and Neglect Procedural Guide, dated 08/29/19, revealed all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property are reported to the administrator of the facility and other officials, including the state survey agency. This is an incidental citation discovered during the complaint investigation.

Based on observation, staff interview, medical record review, and review of a facility policy, the facility failed to ensure a resident's urinary catheter collection bag was kept off the ground. This affected one (#48) of one residents reviewed for urinary catheters. The facility identified two residents in the facility with urinary catheters. The census was 51. Findings include: Review of Resident #48's medical record revealed and admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS) assessment, dated 12/04/19, revealed Resident #48 was assessed with [REDACTED]. Review of a care plan dated 12/10/19 for Resident #48's urinary catheter, revealed an intervention to maintain a closed system with the urinary collection bag below the resident's bladder and keep the bag covered. Observation on 12/26/19 at 01:27 PM revealed Resident #48 sitting in a wheelchair in the dining room with his urinary catheter collection bag suspended from under his wheelchair and the bag resting on the floor. Subsequent observations on 12/27/19 at 10:20 [NAME]M. and 5:26 P.M., revealed Resident #48's urinary catheter collection bag remained suspended from under his wheelchair with the bag resting on the floor. Observations on 12/27/19 at 10:26 [NAME]M. and 12:49 P.M., revealed Resident #48 was propelling himself in his wheelchair and his urinary catheter collection bag could be heard and seen dragging on the floor as Resident #48 moved down the hallway. Observation on 12/28/19 at 7:56 [NAME]M., revealed Resident #48 sitting in his wheelchair in his room with his urinary catheter collection bag resting on the floor. Interview on 12/28/19 at 8:00 [NAME]M., Licensed Practical Nurse (LPN) #480 verified Resident #48's urinary catheter collection bag was on the floor and stated it should not be touching the ground at anytime. LPN #480 stated Resident #480 would not be able to reach under his wheelchair and move the placement of his urinary catheter collection bag on his own. Resident #48 was observed once again on 12/28/19 at 11:34 [NAME]M. sitting in the dining room with his urinary catheter collection bag suspended from underneath his wheelchair and resting on the floor. Review of a facility policy titled Urinary Catheter Care, dated 05/11/16, revealed staff should be sure the catheter tubing and drainage bag are kept off the floor.

Based on observation, staff interview, and review of a facility policy, the facility failed to ensure medications were secured from unauthorized access when a medication cart was left unlocked and unattended by staff. This affected one (#50) resident the facility identified as the only independently mobile and cognitively impaired resident residing on the 300 Hall. The census was 51. Findings include: Observation on 12/27/19 at approximately 3:30 P.M. revealed Registered Nurse (RN) #375 administering medications to residents on the 300 Hall from the 300 Hall medication cart. At 3:38 P.M., RN #375 removed medications from the 300 Hall medication cart, prepared them for administration, and walked away from the medication cart without locking it. RN #375 walked down the 300 Hall and entered a resident's room to administer the medications, leaving the unlocked medication cart out of her sight. At 3:42 P.M., RN #375 walked back to the 300 Hall medication cart, prepared another resident's medications for administration, and again, walked away from the medication cart without locking it. RN #375 walked down the 300 Hall and entered another resident's room to administer the medications, leaving the unlocked medication cart out of her sight. Interview on 12/27/19 at 3:47 P.M. with RN #375 verified she did not lock the 300 Hall medication cart for two different resident medication administrations in a row. RN #375 stated the medication cart should be locked every time a nurse steps away from the cart. Review of a facility policy titled Medication Storage in the Facility, revised (MONTH) 2014, revealed medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. Only licensed nurses, pharmacy personnel and those lawfully authorized to administer medications (such as medication aides) are permitted to access medications. Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access. The facility identified Resident #50 as the only resident residing on the 300 Hall who was cognitively impaired and independently mobile.

Based on observation, resident interview, and staff interview, the facility failed to provide access to the remote control to change position of an electric recliner chair for one for one (#200) of one resident reviewed for accommodation of needs. The facility census was 51. Findings include: Review of the medical record for Resident #200 revealed the resident was admitted on [DATE]. [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 09/27/19, revealed the resident had no cognitive issues. The resident required extensive assistance with bed mobility, transfer, locomotion, dressing, toilet use, and personal hygiene. Interview on 12/26/19 at 9:36 [NAME]M., Resident #200 revealed she was not able to access the remote control to her electric recliner chair. Resident #200 stated the facility does not want her to get out of her chair without assistance. Observation on 12/26/19 at 9:38 [NAME]M. revealed Resident #200 was reclined in the electric recliner chair in the resident's room. The recliner chair had a remote control, which was attached to a cord, and located in the side pocket of the recliner chair. The remote controlled the back and foot rest. On the remote was taped a handwritten note reading Remote to stay in side pocket. Resident #200 was unable to access the remote to make adjustments to the chair for comfort. Additional observations on 12/27/19 at 9:26 [NAME]M. and 3:29 P.M. revealed the remote control to the recliner was located in the side pocket of the recliner. Interview on 12/26/19 at 11:45 [NAME]M., State tested Nurse Aide (STNA) #600 verified Resident #200 was unable to reach the remote control to the recliner. STNA #600 stated about three to four weeks ago there was a note to keep the remote control in the side pocket of the recliner. Resident #200 was to use the call light when needed. Interview on 12/27/19 at 10:56 [NAME]M., STNA #650 verified Resident #200 was not to have access to the remote control for the recliner and the remote was to be kept in the side pocket. STNA #650 stated the resident was to use the call light when needed. Review of facility policy titled Resident Rights Guidelines, revised (MONTH) (YEAR), verified the residents have the right to be given the information to participate in decisions which affect them both individually and corporately.

Based on medical record review, staff interview, and review of a facility policy, the facility failed to ensure non-pharmacological interventions were attempted prior to the administration of [MEDICAL CONDITION] medications. The facility further failed to assess residents taking anti-psychotic medications for irreversible neurological side effects of antipsychotic medication. This affected one resident (#154) of five reviewed for unnecessary medications. The facility census was 54. Findings include: Medical record review revealed Resident #154 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #154's physician orders [REDACTED]. The order further directed staff to record prior interventions attempted. Further review revealed an order for [REDACTED]. Review of the most recent plan of care revealed Resident #154 was at risk for adverse consequences related to receiving anti-anxiety medication. Interventions included to attempt non-pharmacological interventions prior to administering as needed anti-anxiety medication, provide the lowest dose possible and attempt a gradual dose reduction when appropriate. Further review revealed the was also at risk for adverse consequences related to receiving antipsychotic medication. Interventions included to provide the lowest dose possible, attempt a gradual dose reduction when appropriate, and implement the Abnormal Involuntary Movement Scale (AIMS) assessment (a scale that measure involuntary movements known as Tardive Dyskinesia which is a side effect of antipsychotic medications that affects the nervous system and causes involuntary movements of the tongue, lips, face, trunk, and extremities). Further review of Resident #154's medical record revealed no evidence the resident received an AIMS assessment. Review of Resident #154's Medication Administration Record [REDACTED]. There were no non-pharmacological intervention attempts documented for seven of the 12 administrations. Interview on 10/31/18 at 9:00 A.M., with the Director of Health Services (DHS) revealed staff were to attempt non-pharmacological interventions prior to administering as needed anti-anxiety medications. The DHS revealed staff were to document those attempts in the residents medical record. The DHS verified there were no non-pharmacological intervention attempts documented for seven of the 12 doses of the Alazopram administered to the resident between 10/19/18 and 10/29/18. Interview on 11/01/18 at 8:30 A.M., Registered Nurse (RN) #202 revealed an AIMS assessment was to be completed for all resident's taking an antipsychotic medication. RN #202 verified an AIMS assessment was not completed for Resident #154. Review of a facility policy titled, Guidelines for: Abnormal Involuntary Movement Scale, dated 05/22/18, revealed residents who were prescribed antipsychotic medication would be assessed with [REDACTED]. The residents were to be assessed at the earliest possible time after admission, with dosage changes, and/or when a new order for an antipsychotic was obtained. Review of a facility policy titled, [MEDICAL CONDITION] Medication Usage and Gradual Dose Reductions, dated 10/09/17, revealed residents would receive [MEDICAL CONDITION] medications only if designated medically necessary and/or with appropriate documentation to support its usage. Further review revealed as needed medications would be documented in the MAR indicated [REDACTED].

Based on medical record review, staff interview, and facility policy review, the facility failed to ensure a resident was seen by a physician every 60 days. This affected one resident (#20) of 32 residents reviewed for physicians visits. The facility census was 54. Findings include: Medical record review revealed Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further record review revealed the last documented physician visit was 05/18/18. Interview with Director of Nursing (DON) on 10/30/18 at 3:24 P.M., confirmed the last visit with a physician Resident #20 had was on 05/18/18. Review of facility policy titled, Guidelines for Physician Services, revealed Physician visits, frequency of visits, emergency care of residents, etc., are provided in accordance with current OBRA regulations and campus policy.

Based on medical record review, observation, staff interview, and review of a facility policy, the facility failed to ensure oxygen supplies were dated when initiated. This affected two residents (#153 and #154) of two reviewed for oxygen therapy. The facility census was 54. Findings include: 1. Medical record review revealed Resident #153 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of an order dated 10/17/18, revealed Resident #153 required staff to administer continuous supplemental oxygen. Further review revealed staff were to change the oxygen tubing weekly on Sundays. The order further instructed staff to label the oxygen tubing with the date the tubing was initiated. Observation on 10/29/18 at 9:58 A.M., revealed oxygen was administered to Resident #153 by use of oxygen tubing and a nasal cannula (device used to deliver supplemental oxygen). No date was visible on the oxygen tubing and/or the nasal cannula. A second observation on 10/30/18 at 8:40 A.M. revealed the same. Interview on 10/30/18 at 8:40 A.M., with Licensed Practical Nurse (LPN) #210 revealed all oxygen supplies were changed weekly on Sundays. LPN #210 revealed staff were to date all supplies, including oxygen tubing and nasal cannula's with the date they were initiated. LPN #210 verified Resident #153's oxygen tubing and nasal cannula were not dated. 2. Medical record review revealed Resident #154 admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of an order dated 10/18/18, revealed Resident #154 required staff to administer continuous supplemental oxygen. Further review revealed staff were to change the oxygen tubing weekly on Sundays. The order further instructed staff to label the oxygen tubing with the date the tubing was initiated. Observation on 10/29/18 at 10:07 A.M., revealed oxygen was administered to Resident #154 by use of oxygen tubing and a nasal cannula. No date was visible on the oxygen tubing and/or the nasal cannula. A second observation on 10/30/18 at 8:73 A.M. revealed the same. Interview on 10/30/18 at 8:37 A.M., LPN #210 verified Resident #154's oxygen tubing and nasal cannula were not dated. Review of a facility policy titled, Guidelines for the Administration of Oxygen, dated 05/2018, revealed staff were to date oxygen tubing for the date it was initiated.

Based on surveyor observation, medical record review, staff interview, and review of facility policy, it was determined the facility failed to prevent an avoidable pressure ulcer to the heel of one of one resident (#31) identified with a facility acquired pressure ulcer. This resulted in actual harm when the resident was found with a necrotic and unstageable pressure ulcer on the left heel. Additionally, the facility failed to perform the correct physician ordered treatment on one (#26) of five sampled residents from the six identified by the facility with pressure ulcers. The total sample was 12 from the facility census of 46. Findings include: 1. Review of the medical record for Resident #31 revealed the resident was admitted to the facility on [DATE] free of pressure ulcers. The resident's [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessments dated 02/25/10 and 05/18/10 identified the resident as requiring extensive assistance with transfer, bed mobility, ambulation, dressing, and hygiene. Both MDS assessments indicated that no pressure ulcers were present. A plan of care for pressure ulcer prevention was developed 03/11/10. Risk factors identified were immobility, incontinence, and weakness. Interventions included assessment of the skin and reporting to the physician, discuss non-compliance, education, administer medications per order, provide nutritional support, provide and monitor effectiveness of pressure relieving devices (mattress), and incontinent care. Review of the "Pressure Ulcer Assessment" form, dated 05/19/10, revealed Resident #31 had a pressure ulcer on the left heel, described as eschar "black" in color, measuring 2.5 centimeters (cm) in length by 2.2 cm in width. Review of the form entitled "Skin Impairment Circumstance, Assessment, and Intervention", dated 05/19/10, revealed the resident had known behaviors of digging her heels into the wheelchair foot rests and had worn holes in her slippers toward the heels. The medical record review did not identify clinical conditions that would demonstrate that the pressure ulcer was unavoidable. The resident's weight was stable and within ideal body requirements. The podiatry notes on 05/24/10 did indicate a [MEDICAL CONDITION] [DIAGNOSES REDACTED]. A laboratory test for [MEDICATION NAME] levels on 06/28/10 indicated normal results. The Pre-[MEDICATION NAME] (indicating protein stores) on 06/28/10 indicated the result was slightly below normal at 17.4 milligrams per deciliter (mg/dL), with normal being 18. The MDS, nurses notes, and care plan did not document any resistance of care by the resident. Interview with the Director of Nurses (DON), on 08/25/10 at 2:45 P.M., revealed that the resident had worn holes in the slippers from the constant friction of rubbing her feet back and forth. She verified that no interventions were added to the preventive plan of care regarding padding the wheelchair foot rests, replacing the slippers, or attempts to protect the heels from friction. A physician's orders [REDACTED]. The resident was observed not to have the PRAFO boots applied for pressure reduction on 08/23/10 at 7:15 P.M., 08/24/10 at 1:50 P.M., 3:00 P.M. and 4:00 P.M., and on 08/25/10 at 7:50 A.M., 10:15 A.M., 1:30 P.M., and 3:30 P.M. On 08/25/10 at 2:45 P.M. the DON was unable to state why the PRAFO boots were not applied as ordered. She did observe and confirm the boots were available in the resident's room. The DON verified the preventative plan of care was not implemented regarding assessment of the skin or providing pressure reducing devices. Further review revealed that an acute plan of care was developed on 05/19/10 to address care of the left heel ulcer. It identified the possible cause as "slipper". Interventions included wound assessment per schedule, examine skin daily, pressure reducing mattress, nutritional supplementation to increase protein stores and healing, education for non-compliance (no behaviors listed), and keeping the heels floated. The plan of care did not address padding the wheelchair foot rests or interventions regarding "slippers". The DON verified the failure to address the resident's individualized behaviors and potential causes of the pressure ulcer on the plan of care, on 08/25/10 at 2:45 P.M.. On 08/24/10 at 10:45 A.M., Licensed Practical Nurse (LPN) #1 was observed during the treatment procedure to the left heel. LPN #1 failed to wash her hands prior to initiating the treatment to the open wound, failed to sanitize the scissors used during the procedure, and failed to wash her hands between the dirty and clean portion of the dressing procedure. LPN #1 verified these breaches of infection control issues on 08/24/10 at 11:15 A.M. During the treatment procedure, the surveyor observed the wound to have a yellow scab-like texture, and measured 0.7 cm in length by 0.4 cm in width, by 0.1 cm in depth. LPN #1 was observed to cleanse the wound area with saline, pat it dry, apply skin preparation solution to the surrounding area, and apply moistened [MEDICATION NAME] Blue dressing with a wrap to hold securely. Review of the current treatment orders, dated 08/18/10 from the Wound Clinic, revealed the resident was to have Santyl ointment applied before applying the [MEDICATION NAME] Blue dressing. The failure to apply the correct physician ordered treatment was verified with LPN #1 at 1:00 P.M. on 08/24/10. Further review of the medical record revealed Resident #31 had been diagnosed and treated for [REDACTED]. During the treatment procedure on 08/24/10, LPN #1 commented that Resident #31 was being treated for [REDACTED]. LPN #1 stated it was not and no special precautions were in place. LPN #1 was observed to bag the soiled dressing in a regular plastic bag and dispose of it in the regular trash bin in the soiled utility. Review of the laboratory testing and orders for Resident #31 revealed the physician ordered a culture and sensitivity test on drainage from the left heel wound 08/09/10. Results were found in the laboratory reports indicating the culture was positive [MEDICAL CONDITION]. Interview with the DON at 2:45 P.M. on 08/25/10 revealed she had not been made aware of [MEDICAL CONDITION] infection. She verified the laboratory report of 08/09/10 and 08/11/10 stating the resident was positive [MEDICAL CONDITION]. The DON and surveyor were unable to locate any evidence that the staff had been made aware of the infection or that precautions had been in place. Review of the policy entitled "Pressure Prevention Guidelines", not dated, revealed "care plan interventions shall be implemented based on risk factors identified in the nursing assessment. Interventions may include but not be limited to: inspecting the skin daily during care for signs of breakdown or changes to the skin, float heels as needed, place on pressure reduction support surfaces, and use assistive devices to reduce friction". Review of the policy entitled "Skin-Wound Program", not dated, revealed the facility is to strive to ensure that residents entering the facility without pressure ulcers do not develop pressure ulcers unless the individual's clinical condition demonstrates they were unavoidable. Those residents assessed at risk for breakdown were to be provided preventative interventions for the specific factors placing them at risk. Staff were instructed to protect the resident against adverse effects of external mechanical forces such as pressure, shear, and friction. Risk factors are to be identified on the plan of care. The policy stated a resident with pressure ulcers is to receive treatments and services to promote healing and prevent infection. The facility failed to follow the purpose and procedures of these policies resulting in an avoidable necrotic pressure sore [MEDICAL CONDITION] infection. 2. Review of the medical record for Resident #26 revealed the resident was admitted [DATE] with [DIAGNOSES REDACTED]. The resident was hospitalized [DATE] and readmitted [DATE] with a Stage I pressure ulcer (a persistent area of skin redness that does not disappear after pressure is relieved) of the right heel. By 05/17/10 the heel wound was described as having black eschar. On 07/13/10, Santyl, a [MEDICATION NAME] agent, was initiated for treatment of [REDACTED]. On 08/24/10 at 1:00 P.M., observation of the treatment procedure was done with LPN #1. The nurse was observed to apply the Santyl ointment to the wound bed. Review of the physician orders [REDACTED]. The current order documented cleansing of the heel wound, and application of a moistened [MEDICATION NAME] Blue dressing. The Santyl order was discontinued on the Treatment Administration Record (TAR) on 08/16/10. The new order was documented on the TAR as initiated on 08/07/10. Failure to apply the current physician ordered treatment was verified with LPN #1 on 08/24/10 at 1:30 P.M. She verified she had applied the [MEDICATION NAME] ointment without physician orders. Review of the wound assessment measurements revealed the wound was getting smaller. On 08/18/10, the wound measured 1.5 cm in length by 1.4 cm in width, by 0.1 cm. in depth. On 08/25/10, the wound measured 0.8 cm in length by 0.8 cm in width, by 0.1 cm in depth.