Every finding on record at Woodward Skilled Nursing and Therapy

Based on observation, record review, and interview, the facility failed to ensure sufficient staffing was available:a. to turn and reposition residents at risk for pressure ulcers for 1 (#3); andb. to prevent dependent residents from being taken to the dining room one hour before meals for 1 (#9) of 3 sampled residents reviewed for staffing. The DON identified 15 dependent residents resided in the facility.Findings: 1. On 07/14/26 from 8:49 a.m. to 11:39 a.m., during continuous observation, Resident #3 was observed lying on their right side in bed throughout the observation period. Staff was not observed to check on Resident #3 or reposition the resident during the continuous observation.An admission assessment for Resident #3, dated 06/16/26, showed the resident's cognition was severely impaired with a BIMS score of 0. The assessment showed the resident was at risk for developing pressure ulcers.A care plan for Resident #3, dated 06/12/26, showed the resident was to be turned every two hours, heels offloaded with pillows, and required assistance with turning and repositioning frequently.On 07/16/26 at 12:35 p.m., CNA #4 stated they had set a reminder on their phone to reposition Resident #3 every two hours. CNA #4 stated Resident #3 remained in the same position because they did not have enough time to reposition every two hours while Resident #3 was in bed, as they were the only staff member assigned to that hall.On 07/16/26 at 3:16 p.m., the DON stated it was not acceptable to keep a resident in the same position for more than two hours if they were unable to reposition.2. On 07/14/26 at 10:59 a.m., Resident #9 was observed in the main dining room drinking coffee and tea. The resident was observed without any food.On 07/14/26 at 11:51 a.m., food was served to Resident #9 sitting in the dining room.A significant change assessment for Resident #9, dated 06/12/26, showed the resident's cognition was intact with a BIMS score of 14. The assessment showed Resident #9 was dependent on staff for activities of daily living, which included transfers and use of a manual wheelchair. The assessment showed Resident #9's diagnoses included stroke and hemiplegia.On 07/14/26 at 11:31 a.m., Resident #9 stated I don't like sitting in the dining room for so long; it hurts my butt sitting here waiting on my food.On 07/14/26 at 1:47 p.m., dietary worker #1 stated staff start to bring the residents to the dining room for lunch at 10:30 a.m. They stated lunch was scheduled to be served at 11:30 a.m., so dietary staff would serve residents something to drink.On 07/14/26 at 2:06 p.m., CNA #1 stated they were told to have dependent residents in the dining room at 10:30 a.m. On 07/16/26 at 11:28 a.m., LPN #1 stated residents were taken to the dining room starting at 10:30 a.m. because it took a long time to get dependent residents up when there was only one aide on the hall.On 07/16/26 at 11:34 a.m., the DON stated they had never told staff to get dependent residents up and to the dining room starting at 10:30 a.m. The DON stated staff should get residents up in their wheelchairs and leave them in their room with the call light instead of taking them to the dining room about 10:45 a.m.On 07/16/26 at 12:51 p.m., the administrator stated there was currently one CNA on each hall working, but they could request help from them or any other nursing staff to assist them as needed.On 07/16/26 at 12:56 p.m., the administrator stated they tried to over-schedule staff on weekends because they had so many staff call-ins. The administrator stated they did not use agency staff to fill in.

Based on record review and interview, the facility failed to ensure annual nurse aide skill reviews was conducted for 2 (CNA #2 and CNA #3) of 2 nurse aides sampled for employee training review. The administrator identified 35 residents resided in the facility. Findings: 1. CNA #2's employee file showed they had a hire date of 10/16/24. There was no documentation to show CNA #2 had an annual skills review completed in or after 10/2025. 2. CNA #3's employee file showed they had a hire date of 01/08/25. There was no documentation to show CNA #3 had an annual skills review in or after 01/2026. On 07/16/26 at 12:51 p.m., the administrator stated the required annual skills review for CNA #2 and CNA#3 were not conducted.

Based on observation and interview, the facility failed to maintain an effective pest control program to ensure the facility remained free of pests.The administrator identified 35 residents resided in the facility. Findings:On 07/14/26 at 10:57 a.m., during an observation of the lunch meal service, three flies were observed on the dining table while residents drank coffee.On 07/14/26 at 11:34 a.m., during an observation of the lunch meal service, eight flies landed on top of the steam table while food was being prepared and served from the steam table.On 07/14/26 at 11:36 a.m., during an observation of the lunch meal, there was a blue light hung in the dining room on the wall.On 07/14/26 at 11:56 a.m., during an observation of the lunch meal service, flies were observed landing on residents' plates containing food.On 07/16/26 at 9:57 a.m., during a wound care observation, multiple flies were observed landing on the clean wound care supplies.A policy titled Pest Control, dated 10/2008, read in part, It's the policy of this facility to maintain an effective pest control program so that the facility is free of pest and rodents.On 07/14/26 at 9:45 a.m., the maintenance supervisor stated they had tried fly bait and fly spray and had requested an indoor solution from their supervisor. On 07/15/26 at 11:38 a.m., LPN #1 stated room [ROOM NUMBER] had a lot of flies and that corporate did not allow sticky traps to be hung. LPN #1 stated the facility used the blue lights for the flies.On 07/16/26 at 10:05 a.m., LPN # 2 stated the flies were terrible in the facility.

Based on observation, record review, and interview, the facility failed to ensure an allegation of physical abuse was reported to the State Agency within the two hour required timeframe for 1 (#3) of 3 sampled residents reviewed for abuse.The administrator identified 35 residents resided in the facility Findings:On 07/14/26 at 1:18p.m., Resident #3 was observed sitting in a wheelchair with four round purple and yellow areas of circular bruising on their left upper arm.A policy titled Resident Abuse, Neglect and Misappropriation of Property, dated 07/2018, read in part, All allegations and incidents of abuse, neglect or misappropriation of residents' property, must be reported to Quality Assurance Performance Improvement committee, appropriate Federal and State Agencies including OSDH and investigated to establish a reasonable conclusion about the validity of the allegation .Immediately but not later than 2 hours if the alleged violation involves abuse or results in serious bodily injury.An admission assessment for Resident #3, dated 06/16/26, showed the resident had a BIMS score of 0 which indicated severe impairment in cognition. The assessment showed the use of anticoagulant medication.On 07/14/26 at 1:12 p.m., Resident #3's family member stated on 07/10/26, they showed the DON Resident #3's bruising on the upper left arm.On 07/14/26 at 4:00 p.m., the administrator stated they followed OSDH guidance on reporting abuse.On 07/16/26 at 4:02 p.m., the DON stated Resident #3's family member showed them the bruised area on the resident's left upper arm. The DON stated they both discussed that the bruising appeared to resemble fingerprints and acknowledged that Resident #3 was receiving Eliquis (a blood thinner medication). On 07/16/26 at 5:07 p.m., the administrator stated more than two hours had elapsed between the allegation and sending the initial report to the OSDH.

Based on observation, record review, and interview, the facility failed to ensure a resident received pressure ulcer prevention interventions to include repositioning every two hours for 1 (#3) of 2 sampled residents reviewed for pressure ulcers.The DON identified three residents with pressure ulcers. Findings:On 07/14/26 from 8:49 a.m. to 11:39 a.m. during continuous observation, Resident #3 was observed lying on their right side in bed throughout the observation period. Staff was not observed to check on resident.A policy titled Skin Integrity/ Wound Care, revised 07/2024, read in part, To promote healing of pressure ulcers.Use Proper positioning, transferring, and turning techniques.A Braden Scale for Resident #3, dated 06/10/26, showed:mobility (ability to change and control body position) as very limited, andfriction and shear (require moderate to maximum assistance in moving).A care plan for Resident #3, dated 06/12/26, showed an intervention to turn the resident every two hours, offload heels with pillows, and assist with turning and repositioning frequently. An admission assessment for Resident #3, dated 06/16/26, showed an admission date of 06/10/26. The admission assessment showed a BIMS score of 0 which indicated the resident was severely impaired in cognition for daily decision making. The assessment showed the resident was at risk for developing pressure ulcers.A progress note for Resident #3, dated 06/16/26, showed they had a left heel unstageable pressure ulcer that was acquired.A document titled Wound Dynamics, dated 06/16/26, showed Resident #3's wound to the left heel was a stage two. The document showed the wound measured 4 cm in length, 4.2 cm in width, and no measurable depth with an area of 16.8 square cm.A document titled Wound Dynamics, dated 06/23/26, showed Resident #3's wound to the left heel was a stage 2. The document showed the wound measured 4 cm in length, 4.2 cm in width, and no measurable depth with an area of 16.8 square cm.A document titled Wound Dynamics, dated 07/07/26, showed Resident #3's wound to the left heel was a stage two. The document showed the wound measured 4 cm in length, 5 cm in width, and no measurable depth with an area of 20 square cm.On 07/16/26 at 12:35 p.m., CNA #4 stated they had set a reminder on their phone to reposition Resident #3 every two hours. CNA #4 stated Resident #3 remained in the same position because they did not have enough time to reposition every two hours while Resident #3 was in bed, as they were the only staff member assigned to that hall.On 07/16/26 at 3:16 p.m., the DON stated it was not acceptable to keep a resident in the same position for more than two hours if they were unable to reposition.

Based on observation, record review, and interview, the facility failed to ensure urinary catheter bags were not placed on trash cans or allowed to touch the floor for 1 (#7) of 1 sampled resident reviewed for urinary catheters.The DON identified two residents with urinary catheters resided in the facility.Findings: On 07/15/26 at 8:52 a.m., Resident #7 was observed in their room sitting in their recliner. Resident #7's urinary catheter bag was observed hanging on a small trash can beside the recliner and touching the floor. On 07/16/26 at 9:53 a.m., Resident #7's urinary catheter bag was observed hanging on a small trash can beside their recliner and touching the floor. A policy titled Catheter Care Guideline, dated 03/01/25, read in part, Ensure care aligns with safe and effective management of urinary catheters and reduce the risk of infection and promote resident comfort and dignity. A physician's order for Resident #7, dated 07/02/26, showed catheter care every shift and as needed. A significant change assessment for Resident #7, dated 07/04/26, showed the resident's cognition was severely impaired with a BIMS score of 2. The assessments showed the resident had a diagnosis of renal disease. A care plan for Resident #7, dated 07/09/26, read in part, The resident has an indwelling urinary catheter; position the catheter bag and tubing below the level of the bladder. On 07/16/26 at 9:56 a.m., CNA #1 stated they always hung the catheter bag on the trash can when a resident was in their recliner. On 07/16/26 at 9:58 a.m., LPN #1 stated the catheter bag was always hung on the trash can when a resident sat in their recliner, but it should not touch the floor. On 07/16/26 at 10:08 a.m., the DON stated staff was encouraged not to hang the urinary catheter bag on the trash can, and it should not touch the floor. On 07/16/26 at 10:10 a.m., the regional nurse consultant stated a urinary catheter bag that was hung on the trash can and was allowed to touch the floor caused a concern for infection control.

Based on observation, record review and interview, the facility failed to ensure a 2 person transfer was completed per the care plan for 1 (#1) of 3 sampled residents reviewed for accident hazards. The DON identified 43 residents resided in the facility and 17 residents required two staff members to transfer. Findings: On 04/22/25 at 3:08 p.m., Resident #1 was observed in their room, sitting in their recliner, with a mechanical lift sheet under them. Resident #1 did not answer questions appropriately or would answer, I don't know. On 04/23/25 at 12:52 p.m., CNA #4 and CNA #5 were observed to use a mechanical lift and transfer Resident #1 from their wheelchair to their recliner. Resident #1's Care Plan, dated 06/21/22, read in part, assist x 2 for transfers. Resident #1's Quarterly Assessment, dated 10/23/24, showed Resident #1's BIMS score was a 4, which indicated the resident's cognition was severely impaired. The assessment showed Resident #1 did not have an impairment in their upper extremities. An Incident Report, dated 12/07/24, showed while repositioning a resident, the staff member heard a pop sound and Resident #1 complained of pain to their right arm. The report showed the physician was notified and gave an order to obtain x-rays of the right shoulder. The report showed the results indicated the resident had a broken right humerus. An inservice sheet, dated 12/08/24, showed staff were educated on transferring residents and using a gait belt. Transfer/Gait Belt Competency check off documents, dated 12/08/24 and 12/09/24, showed staff demonstrated adequate staff were available to assist the resident per the care plan. A Final state report, dated 12/11/24, read in part, During reposition [with a] resident, staff member heard a pop sound. Resident c/o [complaints of] pain to right arm. PCP [primary care physician] notified .Resident is a X2 [times 2] assist with transfers .N/O [new order] received to obtain 2 view x-ray of right shoulder. X-ray obtained and results received and sent to [name withheld]. [Name withheld] stated that resident has a broken right humerus and to put a sling on it .After investigating nurse aide [name withheld] admitted to lifting and repositioning resident under [their] arms with no assist. [CNA #6] admits that [they are] aware [Resident #1] is a two person lift and assist and that [CNA #6] is to use a gate [sic] belt which [they] did not do either, employee terminated on 12/10/24 for failure to follow policy and procedures that resulted in injury to the resident. Resident #1's Quarterly Assessment, dated 12/11/24, showed Resident #1's BIMS score was a 3, which indicated the resident's cognition was severely impaired. The assessment showed Resident #1 did have an impairment in their upper extremities on one side. Compliance Rounds, dated 12/09/24 through 12/13/24, 12/18/24, 12/29/24, and 01/08/25 were completed. The compliance rounds consisted of asking staff how to find what level of care the resident required and watching to see if residents were transferred and positioned properly. A policy titled Stand Assist Lift Guideline, dated 02/2025, read in part, Specific methods of transferring and lifting will be designated for each resident. The designated method for the transfer type will be accessible to all staff who perform lifting and transferring and is contained in the care plan. On 04/25/25 at 10:20 a.m., the DON was asked to describe the incident that occurred with Resident #1. The DON stated CNA #6 did not follow the policy and that was how Resident #1's arm was broken. The DON stated, after the incident, the facility inserviced staff, had staff complete transfer/gait belt competency check offs, and compliance rounds had been completed.

Based on record review and interview, the facility failed to complete a significant change assessment for one (#37) of 12 sampled residents reviewed for assessments. The Long Term Care Application, dated 10/01/24, documented 46 residents resided in the facility. Findings: A RAI manual, dated October 2023, read in part, .Significant change MDS completion date must be no later than 14 days from the ARD and no later than 14 days after the determination that the criteria for an SCSA were met . Resident #37 had diagnoses which included depression with psychotic features, anxiety, and diabetes mellitus. A significant change assessment, dated 09/15/24, was not completed by the ARD date. On 10/04/24 at 8:22 a.m., the MDS coordinator was asked what was the policy for completing a MDS in a timely manner. They stated there was no policy and they referred back to the RAI manual for instructions. They were tasked to review the significant change assessment dated [DATE]. They were asked if the significant change had been completed by the ARD date. They stated, No.

Based on record review and interview, the facility failed to ensure resident assessments were accurately coded for one (#11) of 12 sampled residents reviewed for assessments. The Long-Term Care Facility Application, dated 10/01/24, documented 45 residents resided in the facility. Findings: 1. Resident #11 had diagnoses which included coronary artery bypass, heart disease with heart failure, and congestive heart failure. A physician's order, dated 10/04/24, documented clopidogrel bisulfate (Plavix) (antiplatelet medication). A significant change assessment, dated 07/10/24, doucmented Plavix as a anticoagulant and not as a antiplatelet. On 10/04/24 at 11:40 a.m., the MDS coordinator was asked what was the facility policy on accuracy of assessments. They stated they followed physician orders. They were asked to review the significant change assessment dated [DATE]. They were asked if Resident #11 was on a anticoagulant or a antiplatelet medication and if the medication coding was correct on the significant change assessment. They stated they marked Plavix as a anticoagulant in error.

Based on record review and interview, the facility failed to ensure the care plan was revised and updated for one (#36) of 12 sampled residents reviewed for care plans. The Long-Term Care Facility Application, dated 10/01/24, documented 45 residents resided at the facility. Findings: Resident #36 had diagnoses which included insomnia, anxiety, acute kidney, urethritis, chronic urinary tract infection, and history of urinary retention. A care plan, dated 12/23/23, documented the resident would not have a decline in functional status. The care plan did not document any further updates for a decline in ADL status. A quarterly assessment, dated 07/26/24, documented staff assistant with ADLs was supervision to moderate assist. A significant change assessment, dated 08/23/24, doucmented the resident required maximum assist with ADLs. No revision or update to the ADL careplan was noted on current care plan. On 10/03/24 at 12:29 p.m., Corporate Nurse Consultant #1 was asked the facility policy for revising and updating care plans. They stated they would have to look at the RAI manual to be certain. They were asked to review the care plan for Resident #36 and then asked was the care plan updated or revised for an ADL decline. They stated it was not.

Based on record review and interview, the facility failed to ensure medications were given as ordered for one (#5) of five sampled residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents report, dated 08/08/23, documented 47 residents resided in the facility. Findings: A Medication Administration-General Guidelines policy, effective January 2022, read in part, .For residents not in their rooms or otherwise unavailable to receive medication on the pass .After completing the medication pass, the nurse returns to the missed resident to administer the medication . Resident #5 was scheduled to receive the following medications during the 7 a.m.-11 a.m. time slot: Aspirin Low Dose 81 mg, Pantoprazole Sodium 40 mg, Polyethylene Glycol 3350 Powder 17 gm, Docusate Sodium 100 mg, Ipratropium Bromide Solution 0.06% 2 sprays in both nostrils, Metoprolol Tartrate 25 mg, Mucinex ER 600 mg, Propranolol HCL 10 mg , Seroquel 50 mg, and Hydrocodone-Acetaminophen 5-325 mg. The June 2023 MAR for Resident #5 documented medications scheduled to be given during the 7 a.m.-11 a.m. time slot were not given on the following days: 06/01 through 06/04, 06/11, 06/14, 06/15, 06/19, 06/21 through 06/24, 06/26, and 06/28 through 06/30/23. The CMA documented Resident #5 was asleep. The July 2023 MAR for Resident #5 documented medications scheduled to be given during the 7 a.m.-11 a.m. time slot were not given on the following days: 07/02 through 07/04, 07/06 through 07/08, 07/10 through 07/13, 07/15 through 07/19, and 07/21/23. The CMA documented Resident #5 was asleep. On 08/11/23 at 9:50 a.m., the DON was asked what was the facility policy on administering medication to residents if they were asleep. The DON stated, Most medication times have a four hour window. You can come back at a time when they are awake. The DON was asked if Resident #5 had a physician's order to hold medication if they were asleep. She reviewed Resident #5's orders and said no. The DON was asked to review Resident #5's June and July MAR's. They acknowledged the 7 a.m.-11 a.m. medications were not given as ordered.

Based on observation, record review, and interview, the facility failed to prevent the use of a chair alarm to prevent falls from becoming a restraint for one (#45) of nine sampled residents reviewed for restraints. The Resident Census and Conditions of Residents report, dated 08/08/23, documented 47 residents resided in the facility. The Regional Nurse Consultant reported there were 9 residents with chair alarms. Findings: A Restraint and Non-Restraint Devices policy, revised 12/14/22, read in parts, .Non-restraint devices are devices that do not restrict the resident's freedom of movement .A Monthly Restraint/non-restraint Assessment .will be completed .to determine the continued need for the use of the restraint/non-restraint . Resident #45 had diagnoses that included history of falling, syncope and collapse, unspecified dementia of unspecified severity, with anxiety. A quarterly assessment, dated 05/24/23, documented Resident #45 was cognitively intact and required extensive assistance of 2 people for positioning, transfers, and ambulation. A Restorative Note, dated 06/26/23, documented Resident #45 actively participated in walking 100-300 feet two to five times per week with limited assistance of one staff. A Restorative Note, dated 07/31/23, documented Resident #45 actively participated in walking 150-300 feet two to five times per week with a walker and assistance of one staff for supervision/cueing. A nursing progress note, dated 07/20/23, read in part, .resident deactivated alarm and was ambulating in the hall on own, resident states i dont know why i cant just walk around my own resident reminded of ambulatory limitations and stated i dont care about that [expletive]! resident assisted back into wheelchair and alarm reattached . A nursing progress note, dated 07/21/23, read in parts, .resident in family room using the couches to ambulate without assistance, resident urged to return to wheelchair .resident became angry .while stating get the .away from me .i will walk if i want .i took that .off cuz i dont wanna hear it. On 08/08/23 at 3:46 p.m., Resident #45 was observed sitting in their room in a recliner with a chair alarm in place. A bed alarm was noted across the resident's bed. When asked how it felt having the alarms, Resident #45 reported they did not like them because they kept them from being able to get up and walk to regain their strength. Resident #45 stated, When I get up, they all come running and yelling Sit down! Sit down! So I just sit down. On 08/10/23 at 9:56 a.m., the DON was asked what was the facility policy on restraints. She reported there were no restraints used in the facility, but they did use grab bars (side rails) and chair/bed alarms for fall prevention. The DON was asked what would be considered a restraint. She stated it would be something a resident could not take off completely and transfer themselves or get free. The DON was asked when a chair/bed alarm would be considered a restraint. She stated if a resident had one that talked and it said Sit down then they would feel like they couldn't get up; or, if the resident felt it restricted their movement. The DON was asked what would be the facility's response if a resident felt their chair/bed alarm was restrictive. The DON stated at that point they would look at the resident's recent falls, restorative reports, and reassess the resident's need. The DON was asked to review the quarterly assessment for Resident #45 dated 05/24/23 and the restorative notes for Resident #45 dated 06/26/23 and 07/31/23. The DON was asked if Resident #45's need for the use of the chair alarm had been reassessed at any time. She stated it had not. The DON was asked if any other interventions to prevent falls had been attempted for Resident #45 besides the use of the chair alarm. She stated, No. The DON was asked to review the nursing progress notes for Resident #45 dated 07/20/23 and 07/21/23. The DON acknowledged Resident #45's statements to the staff indicated they felt like they could not get up or were restricted in their movement because of the chair alarm.

Based on record review and interview, the facility failed to monitor food holding temperatures to ensure safe temperatures were maintained on the steam tables during meal services. The Resident Census and Conditions of Residents, dated 03/14/23, documented the facility census to be 54, and all residents received meal service from the kitchen. Findings: The weekly Daily Hot Food Table Temperature Chart, forms, dated 01/03/23 through 03/11/23, contained no entry or incomplete entries of food holding temperatures as follows: a. the breakfast meal contained no or incomplete temperatures for four of 70 breakfast meals served, b. the lunch meal contained no or incomplete temperatures for seven of 70 lunch meals served, and c. the dinner meal contained no or incomplete temperatures for 34 of 70 dinner meals served. On 03/15/23 at 2:30 p.m., the DM was asked how the facility ensured foods are served at palatable and safe temperatures. The DM stated staff are supposed to check the holding temperatures of the food. The DM was asked if the temperature logs were completed for the holding temperatures. The DM stated the staff continue to have issues with not documenting the holding temperatures. The DM was asked if there were ever complaints from the residents that foods were not served hot. They stated there had been resident complaints several months ago and they are working on correcting the issues.

Based on record review and interview the facility failed to: a. ensure aspiration precautions and the use of a straw with fluids was implemented as ordered by the physician for one (#4) of three sampled residents reviewed for following physician's orders, and b. administer breathing treatments as ordered by the physician for one (#4) of three sampled residents reviewed for medication administration. The Resident Census and Conditions Report, dated 03/14/23, documented 54 residents resided in the facility. The DON identified one resident received thickened liquids. Findings: A MEDICATION ADMINISTRATION-GENERAL GUIDELINES policy, dated January 2022, read in parts, .Administration .Medications are administered in accordance with written orders of the prescriber . Resident #4 had diagnoses which included, dementia, asthma, dysphagia, and pneumonia due to other specified infectious organism. A Physician Order, dated 01/05/23, read in part, .Regular diet Regular Texture, Regular - Thin liquids consistency .Albuterol Sulfate Nebulization Solution (2.5 MG/ML) 0.083% 1 vial orally via nebulizer four times a day related to COVID-19 . A Treatment Administration Record, dated 01/05/23 to 01/31/23, documented Resident #4's Albuterol breathing treatment had not been administered at 11:00 p.m., for eleven of twenty seven doses. A Physician Progress Note, dated 01/10/23, read in parts, .resident with persisting cough, hypoxia and fatigue .was recently started on doxycycline as chest x-ray shows probable right lower lobe infiltrate .Nursing does report occasional choking with meals or drinks .possible aspiration pneumonia or post COVID secondary bacterial pneumonia .Speech therapy evaluation/swallow evaluation .aspiration precautions . A Physician Order, dated 01/10/23, read in part, .Aspiration Precautions .No straws .Practice chin tuck with swallowing .sit upright when eating or drinking and remain in upright position for at least 1 hour following meals . A Modified Barium Swallow Evaluation Report, dated 01/24/23, read in parts, .RECOMMENDATIONS .Diet level recommended regular Liquid level thin with a straw .No skilled Speech Pathology services are recommended at this time:allow patient plenty of time to eat and keep [them] upright at 90 degrees for at least 30 minutes following each meal; recommend alternating solids and liquids and to use a straw with liquids . A Physician Progress Note, dated 01/24/23, read in parts, .Cough is improved. [The resident] had a swallow evaluation and apparently did better with a straw during [their] evaluation .Formal report pending . A Treatment Administration Record, dated 01/25/23, documented to discontinue aspiration precautions. A Treatment Administration Record, dated 02/01/23 to 02/28/23, documented Resident #4's Albuterol breathing treatment had not been administered at 11:00 p.m., for fourteen of twenty eight doses. A Physician Progress Note, dated 02/21/23, read in parts, .Chief Complaint .fatigue/pneumonia .No worsening shortness of breath Dementia is stable. Appetite is okay .Plan .speech therapy .continue aspiration precautions; liquids with a straw . A dietary Table Card, dated 02/21/23, read in parts, .Type: Regular .Texture: regular .Fluid Cons:Regular - Thin liquids The dietary table card did not document any aspiration precautions or to use a straw with liquids. A Treatment Administration Record, dated 03/01/23 to 03/14/23, documented Resident #4's Albuterol breathing treatment had not been administered at 11:00 p.m., for eight of fourteen doses. On 03/15/23 at 4:40 p.m., Resident #4 was observed sitting at the dining table. A grey coffee cup with a lid and straw and an empty clear cup without a straw was observed in front of the resident. On 03/15/23 at 4:55 p.m., the DON was shown Resident #4's January, February and March TAR's and asked what did 7 indicate on documentation for the evening dose of albuterol. The DON reviewed the TAR, and stated sleeping. They were asked if there is a physician order to hold if the resident is sleeping. They stated, No. The DON was asked if the medication should have been held without physician orders. They stated, No. On 03/15/23 at 5:19 p.m., the DM was asked if any residents were on aspiration precautions. The DM stated there was one resident on thickened liquids. The DM was asked if there are any diet changes how would they know. They stated, they would get that information from the nurses. The DM was asked if they had received any dietary changes for Resident #4. They were shown the table card and stated the last change was on 02/21/23. The dietary card did not document the current physician diet orders. The physician ordered aspiration precautions; liquids with a straw on 02/21/23. On 03/15/23 at 5:28 p.m., feeding assistant #1 was asked what diet Resident #4 was on. They stated, a regular diet. They were asked if Resident #4 can use a straw. They stated, they were unsure. They were asked if Resident #4 was on aspiration precautions. They stated, No. On 03/15/23 at 6:14 p.m., the DON was asked if the resident was on aspiration precautions prior to survey. The DON stated, We were doing the sitting upright and no straws. The DON was asked if Resident #4's diet order, dated 02/21/23 (aspiration precautions; liquids with a straw) should have been clarified. They stated, Yes.

Based on record review, observation, and interview, the facility failed to provide adequate assistance for residents who required set up assistance for meals for one (#1) of three sampled residents reviewed for meal set-up and assistance. The Resident Census and Conditions of Residents, dated 03/14/23, documented four residents required assistance and two residents were dependent for eating. The form documented the facility census of 54 residents. Findings: Resident #1 had diagnoses to include Diabetes Mellitus-type 2, COPD, pressure wounds, non-pressure wounds, CHF, depression, and anxiety. A Physician Order, dated 01/06/23, documented Resident #1 was to be served a regular diet with low concentrated sweets. A Quarterly Assessment, dated 02/23/23, documented Resident #1 required set up assistance for eating. A Care Plan, dated 03/13/23, read in parts, .has had a decline in ADL performance .Eating: set up .has terminal prognosis of CHF .Adjust provision of ADLS to compensate for resident's changing abilities . On 03/14/23 at 4:45 p.m., observations of meal service was conducted on the west hall. Staff were going room to room to pick up the empty trays to return to the kitchen. Resident #1 was seated in a wheelchair in their room. A plate of food was next to the resident on an over bed table. The plate of food had been untouched, and the plastic wrap remained secured over the plate. On 03/14/23 at 4:50 p.m., CNA #1 entered Resident #1's room and asked Resident #1 if they were finished eating. CNA #1 then asked Resident #1 if they wanted help to unwrap the plate of food. The resident responded yes, and the CNA unwrapped the plate of food for the resident to begin eating. On 03/15/23 at 4:20 p.m., the DON was asked if Resident #1 required assistance with meals. They stated staff open everything for the resident. The DON was informed of the observations on 03/14/23 and was asked if staff should have provided set up assistance with the meal at the time the meal was served. The DON stated, Yes.

Based on record review and interview, the facility failed to report an alleged violation of verbal abuse and neglect for two (#5 and #11) of three sampled residents reviewed for abuse allegations. The Resident Census and Conditions of Residents report, dated 06/22/22, documented 48 residents resided in the facility. Findings: A policy and procedure titled, Resident Abuse, Neglect and Misappropriation of Property, dated September 2016, read in part, .The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion . Identification/Reporting/Protection .The licensed nurse in charge should then assess the resident for evidence of harm related to the allegation .The nurse should take immediate steps to protect the resident from further incident during this time .The licensed nurse .shall then complete an incident report reflecting any and all findings from the assessment of the resident following the incident . Resident #5 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #11 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An OSDH incident report, dated 01/17/22, read in part, .Part B The following employees [LPN #4] and [LPN #5] have been suspended pending investigation for allegations of Verbal abuse and neglect. Facility has initiated investigation . There was no documentation an initial report had been reported to OSDH. On 06/23/22 at 12:45 p.m., the QM was asked to verify there was no documentation the incident on 01/17/22 had been filed with OSDH. The QM stated, Yes.

Based on record review and interview, the facility failed to investigate allegations of abuse for one (#10) of three sampled residents reviewed for abuse. The Resident Census and Conditions of Residents report, dated 06/22/22, documented 48 residents resided in the facility. Findings: A policy and procedure titled, Resident Abuse, Neglect and Misappropriation of Property, dated September 2016, read in part, .The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion . Investigation .A member of the administrative staff will then conduct a thorough investigation of the incident/allegation to obtain information about the incident and complete ODH-283 .The preliminary report .shall at the minimum, include: who, what, when and where; and measures taken to protect the resident(s) during the investigation .preliminary information .preliminary findings of the investigation . Resident #10 was admitted with [CONDITION(S)], depressive disorder, and [CONDITION(S)]. An OSDH incident report, dated 05/10/21, read in part, Part B .[Resident] had approached a nurse stating that .arm was broken 04/16/21 Nurse brought this administrator the physician notes 05/11/21 at 11am [a.m.] reflecting an allegation of abuse .Initially [Resident] had stated that the staff had adjusted [Resident] in bed correctly using the pad to pull .up in bed in .conversation with the QM nurse on 04/19/21. At the orthopedic physician appointment [resident] stated that [Resident] was jerked by an aide when [Resident] felt a pop in her shoulder .Part C .At the time of the initial interview with [Resident] .stated that the aides had used the bed pad to adjust [resident] in bed. [Resident] now states the aides pulled [Resident] up by [Resident] arms, when asked who [Resident] stated .did not know their names. Investigation has begun . The facility did not provide any documenation an investigation had been completed. On 06/23/22 at 12:45 p.m., the QM was asked if the incident on 05/10/21 had been investigated. The QM stated, No.

Based on record review and interview, the facility failed to complete a significant change assessment for one (#11) of two sampled residents reviewed for PASRR's. The Resident Census and Conditions of Residents report, dated 06/22/22, documented 48 residents resided in the facility. Findings: Resident #11 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission assessment, dated 10/04/21, documented Resident #11 required limited assistance with transfers, dressing, and personal hygiene. A quarterly assessment, dated 01/11/22, documented Resident #11 required extensive assistance with transfers, dressing, and personal hygiene. On 06/23/22 at 12:05 p.m., the case manager was asked to review Resident #11's admission and quarterly assessments. They were asked if the resident had a decline in two or more care areas, what should have been done. They stated, a significant change.

Based on record review and interview, the facility failed to notify the state authority of new mental health diagnoses for one (#36) of two sampled residents reviewed for PASRR's. The Resident Census and Conditions of Residents report, dated 06/22/22, documented 48 residents resided in the facility. Findings: A level I PASRR screen, dated 07/01/19, documented Resident #36 was screened and a level I was completed. It was documented there were no indicators for a level II PASRR. Resident #36 was admitted to the facility on [DATE] with no diagnoses which included a serious mental illness. On 06/18/21, the resident had a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/02/21, the resident had a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] There was documentation the state authority had been notified of the resident's new diagnoses to see if a level II PASRR was required. On 06/23/22 at 4:25 p.m., the case manager was shown Resident #36's level I PASRR where no indicators for a level II were required. They were asked what the process was if a resident had a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . They were informed the resident had new diagnoses of unspecified [CONDITION(S)] not due to a substance or known physiological condition and generalized anxiety in 2021. They were asked if the state authority had been notified to see if a level II PASRR was needed. They stated they didn't think so, but would check. On 06/24/22 at 9:50 a.m., the case manager was asked if the state authority had been notified. They stated they checked and they did not notify them.

Based on observation, interview and record review the facility failed to assist with meal set up for two (#5 and #8) of three sampled residents dependent on staff for set up of their meal. The facility identified 54 residents resided in the facility. Findings: Resident #5 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #5's care plan documented, Focus .Resident has an ADL Self Care Performance Deficit, 04/30/2021 .Interventions: Eating: resident is able to feed self independently requires setup help from staff . Resident #5's Quarterly assessment, dated 07/17/2021, documented .resident needed supervision and set-up help with eating . The residents cognition was moderately impaired. Resident #8's five day assessment, dated 08/03/2021, documented, .needed set up assist for eating . On 09/14/2021 at 11:34 a.m., staff were observed delivering hall trays to 100/200 hall. At 11:35 a.m., resident #5 was observed in her recliner with the meal tray on her bed side table. The meal tray was observed between the recliner and the bed out of reach of the resident. At 11:40 a.m., staff was observed on the phone, sitting at center desk between 100/200 halls. At 11:45 a.m., resident #8 was observed resting in her recliner with the meal tray on the bedside table out of reach of the resident. At 12:15 p.m., resident #5's meal observed to be untouched. At 12:25 p.m., resident #8 was observed with an untouched meal tray. At 12:30 p.m., LPN#1 was made aware of the above observations about staff not providing assistance with meal set up. LPN #1 stated, It should have been addressed. She then acknowledged both residents required set up assistance with their meal trays.