Every finding on record at Worthington Christian Village

THIS IS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on record review, staff interview, facility investigation report review, and policy review, the facility failed to provide adequate physical assistance with bed mobility. This resulted in Actual Harm to Resident #43 when one staff person was changing the bed sheets and rolled Resident #43 out of bed onto the floor, resulting in a leg fracture. Resident #43 required the assistance of two staff for bed mobility. This affected one (Resident #43) of two residents reviewed for falls. The census was 32.Findings Include:Resident #43 was admitted to the facility on [DATE]. Pertinent diagnoses included Parkinson's disease, hereditary and idiopathic neuropathy, cerebrovascular disease, spondylosis, degenerative disease of nervous system, and fibromyalgia.Review of Resident #43's minimum data set (MDS) assessment, dated 08/14/24, revealed she was cognitively intact, and required substantial/maximal assistance for rolling left and right in the bed, and returning to lying in bed. Review of Resident #43's fall risk assessment, dated 08/14/25, revealed she was at moderate risk for falling.Review of Resident #43's care plan, dated 05/26/22, revealed she was at risk for activities of daily living (ADL) decline related to impaired mobility. Interventions included the assistance of two people with all bed mobility, turning and repositioning for comfort.Review of Resident #43 Investigation Summary, dated 09/20/25, documented Registered Nurse (RN) #150 was called to Resident #43's room by Certified Nursing Assistant (CNA) #200 after Resident #43 fell from the bed. RN #150 assessed Resident #43 and she was in pain. The physician was contacted as Resident #43 had requested to go to the hospital and the physician agreed to send Resident #43 to the hospital. The investigation did not include a description of the injuries Resident #43 suffered from the fall.Review of CNA#200's written statement dated 09/20/25 revealed she was changing Resident #43's bed sheet by herself while Resident #43 was in bed. She rolled Resident #43 to the left side of the bed, away from herself to assist with changing the sheet. CNA #200 looked up after starting to change the sheet and saw Resident #43 holding on to the bed rail, and she continued changing the bed sheet. Then, CNA #200 stated she saw Resident #43 fall from the bed. CNA #200 reported the bed was in a high position while she was changing the bed sheet and Resident #43 fell.During an interview on 01/21/26 at 2:55 P.M., the Director of Nursing (DON) confirmed the facility did an investigation after the fall and confirmed CNA #200 was in Resident #43's room by herself, changing the bed sheet. Resident #43 was supposed to have two staff in the room when bed mobility tasks were being performed. She stated she was not given specific details about the nature of Resident #43's injury, only that she had fractured her leg because of the fall.During an interview on 01/22/25 at 10:28 A.M., RN #150 stated she was called to Resident #43's room by CNA #200, after Resident #43 fell from her bed. RN #150 stated the resident was in pain and did not want an X-ray performed at the facility. RN #150 stated she sent Resident #43 to the hospital after Resident #43 requested it, and after she spoke with the primary care physician. She confirmed CNA #200 was the only staff person in Resident #43's room at the time of the fall.On 01/21/26 at 1:56 P.M. an attempt was made to interview CNA#200 via telephone. The number was disconnected and CNA #200 was no longer employed at the facility. Review of facility Fall Prevention Program, dated 01/28/25, revealed the facility will protect residents from injury by falls. If the admission Fall Assessment indicates a risk for falls, the unit nurse will immediately initiate an acute care plan for fall prevention.The deficiency was corrected on 09/22/25 when the facility implemented the following corrective action:On 09/20/25, Resident #43's attending physician, hospice nursing staff, and resident representatives were notified immediately after the fall occurred.On 09/20/25, Resident #43 was sent to the hospital for further assessment of potential injuries. It was deemed she had a fracture to her leg (specifics were not available other than a leg fracture.)On 09/20/25, facility maintenance staff audited and physically checked mobility bars on all residents' beds to ensure they were secure and safe; no issues were found.On 09/20/25, the facility added bolsters to Resident #43's bed/mattress for safety if she returned to the facility.From 09/20/25 to 09/22/25, Director of Nursing (DON) and Assistant Director of Nursing (ADON) completed an assessment of all residents to determine which residents needed the assistance of two people. No new residents were found to need two-person assistance.From 09/20/25 to 09/22/25, the DON or designee provided all CNAs education on the residents who needed the assistance of two people for bed mobility and where to find that information in the electronic medical records.From 09/20/25 to 09/22/25, all CNAs completed a competency, observed by DON or designee, to ensure proper procedures were followed for changing bed sheets and care for residents who required two-person assistance for bed mobility.Starting 09/22/25, the DON or designee will audit all resident Kardex/tasks on electronic medical records to ensure accuracy, five times a week for four weeks, and then weekly for two months.Starting 09/22/25, the DON or designee will complete random certified nursing aides (CNA) performance/safety audits of bed mobility and resident care five times per week for four weeks, and then monthly after for two months.Results of the audits were presented to the Quality Assurance Performance Indicators (QAPI) on 10/29/25 to review the plan of correction; no changes or issues were noted.This deficiency represents non-compliance investigated under Complaint Number 2628187.

Based on record review, interview, and facility policy review, the facility failed to ensure blood pressure and pain medications were administered within the ordered parameters. This affected one resident (#17) of two reviewed for pain management. The facility census was 32.Findings include: Review of Resident #17's medical record revealed an admission date of 12/24/25 with diagnoses including, but not limited to, spinal stenosis, essential hypertension, alcohol dependence, and hyperlipidemia. Review of Resident #17's admission Minimum Data Set (MDS) 3.0 completed 12/31/25 revealed no cognitive deficit.Review of Resident #17's physician order dated 12/24/25 revealed an order for Carvedilol (used to lower heart rate and blood pressure) oral tablet 25 milligrams (mg) one tablet by mouth two times a day related to primary hypertension, with parameters to hold the medication if the systolic blood pressure (SBP) is less than 110 millimeters per mercury (mmHg) or the pulse is less than 60 and to notify the physician or nurse practitioner (NP). Review of Resident #17's physician order dated 12/25/25 revealed an order for Hydrochlorothiazide (diuretic) oral tablet 25 mg one tablet by mouth one time a day related to essential primary hypertension, with parameters to hold if the SBP is less than 110 mmHg and to notify the physician or NP. Review of Resident #17's physician order dated 12/25/25 revealed an order for Lisinopril (used to lower blood pressure) oral tablet 40 mg one tablet by mouth one time a day related to primary hypertension with parameters to hold if the SBP is less than 110 mmHg and to notify the physician or NP.Review of Resident #17's physician order dated 01/09/26 revealed an order for Oxycodone HCl (opioid) oral tablet five mg give one tablet by mouth every four hours as needed for mild to moderate pain (pain levels one to five). Review of the Resident #17's Medication Administration Record (MAR) 01/01/26 to 01/20/26 revealed Carvedilol, Hydrochlorothiazide, and Lisinopril were administered on 01/05/26 with a documented SBP of 108 mmHg. Additional review of the MAR for Resident #17 revealed Oxycodone was administered on 01/13/26 with a documented pain level of zero.Review of the progress notes for Resident #17 on 01/05/26 revealed no documentation of physician or nurse practitioner notification. Interview with Director of Nursing (DON) 01/22/26 at 8:45 A.M. revealed if a resident's blood pressure falls outside of parameters it should not be given unless the physician gives an order to administer the medication, in which case it should be documented in the medical record. The DON confirmed the resident was given all three blood pressure medications outside of parameters on 01/05/26. Continued interview with DON revealed as needed pain medications should only be administered within the parameters given by the physician or documented if the physician ordered them outside of parameters. The DON confirmed the resident should not have been given Oxycodone on 01/13/26 if reporting a pain level of zero. Review of the facility policy titled Medication Administration, effective January 2025, revealed the Unit Nurse will check special instruction and contradictions, including checking what vital signs should be monitored or other assessments, prior to the medication being given. Further review of the policy revealed when an as needed medication is administered the Unit Nurse must document in the MAR and resident chart why the medication was given. This represents noncompliance investigated under complaint 2568645.

Based on interview, medical record review, and review of facility policies the facility failed to document on a new skin area for Resident #9 and provide documented justification for the start of an antibiotic. This affected one resident (#9) of two residents reviewed for skin conditions. The facility census was 32.Findings include: Review of Resident #9's medical record revealed an admission date of 03/04/24 with diagnoses including chronic obstructive pulmonary disease, metabolic encephalopathy, dysphagia, unspecified mood disorder, major depressive disorder, anxiety disorder, and sialoadenitis.Review of Resident #9's quarterly Minimum Data Set (MDS) 3.0 assessment revealed moderately impaired cognition.Review of Resident #9's physician order dated 01/19/26 to 01/24/26 revealed an order for Mupirocin External Ointment (topical antibiotic ointment used to treat skin infections) 2% three times a day for five days for mouth lesion.Review of Resident #9's progress notes and assessments on 01/21/26 at 8:00 A.M. revealed there was no documentation in Resident #9's medical record indicating the reason for the ointment or a description of the mouth lesion.Interview on 01/21/26 at 2:25 P.M. and 3:13 P.M. with the Director of Nursing (DON) verified there had been no documentation to describe the mouth lesions and why they required an ointment. The DON stated the areas were about an inch above her mouth. She reported the physician was to evaluate them when he came in next.Review of the 'skin policy' dated 1/1/26, revealed the facility was committed to ensuring timely identification and documentation of any skin changes. Daily skin checks were to be performed by Certified Nursing Assistants (CNA) every day, and any changes were to be documented and reported to the nurse.

Based on medical record review and staff interview, the facility failed to ensure pharmacy recommendations were completed in two separate quarters within the first year of admission. This affected one (Resident #32) of five residents reviewed for pharmacy recommendations. The census was 32.Findings Include: Resident #32 was admitted to the facility on [DATE]. Her diagnoses were cerebral infarction, muscle wasting and atrophy, dysphagia, cognitive communication deficit, wedge compression fracture of first lumbar vertebra, hypertension, Alzheimer's disease, heart failure, atrial fibrillation, anxiety disorder, depression, mood disorder, and vascular dementia. Review of her minimum data set (MDS) assessment, dated 01/08/26, revealed she had a severe cognitive impairment.Review of Resident #32's physician orders revealed the following psychotropic medications: Buspirone HCl (anxiolytic) five milligrams (mg) one tablet twice daily for anxiety, which was started on 04/17/25, and Citalopram Hydrobromide (antidepressant) 20 mg one tablet daily for depression, which was started on 04/03/25.Review of Resident #32 monthly pharmacy reviews, dated April 2025 to December 2025, revealed her medications were properly reviewed each month by the pharmacist.Review of Resident #32 pharmacy recommendations, dated April 2025 to December 2025, revealed only one pharmacy recommendation made regarding a lipid panel that was being recommended to be completed. There were no recommendations for a gradual dose reduction (or any recommendation at all) regarding the use of Citalopram or Buspirone.Interview with Director of Nursing on 01/22/26 at 8:45 A.M. and 11:07 A.M. confirmed there were no pharmacy recommendations, including gradual dose reduction recommendations (GDR), for Resident #32 since admission in April 2025. She confirmed she reached out to the pharmacist about the pharmacy recommendations for Resident #32, and they were not going to attempt a GDR until April 2026. Review of email response from Pharmacist #201 on 01/22/26 at 9:13 A.M. revealed the following response, Here is my progress note from April 2025 and this month. I have her GDR on a schedule for 4/26 per my progress note.

Based on record review, interview, review of hospice provider contract, and facility policy review, the facility failed to ensure hospice documentation was reviewed and consistent with facility orders and plan of care for a resident. This affected one resident (#6) reviewed for hospice. The facility census was 32.Findings include:Review of Resident #6's medical record revealed an admission date of 12/20/24 with diagnoses including but not limited to cerebral atherosclerosis, vascular dementia, anxiety disorder, hypertension, and bipolar disorder.Review of Resident #6's annual Minimum Data Set (MDS) dated [DATE] revealed severe cognitive impairment. Review of MDS revealed the resident held food in their mouth/cheeks and/or had residual food in mouth after meals and complained of difficulty or pain when swallowing.Review of Resident #6's physician orders revealed a diet order dated 12/20/24 for a regular diet, mechanical soft texture and honey thick liquids.Review of quarterly nutrition reviews dated 06/30/25, 10/20/25, and 12/29/25 revealed the resident held food in their mouth/cheeks or residual food in mouth after meals and was coughing or choking during meals or when swallowing medications.Review of Resident #6's hospice reports dated 12/24/24, 12/26/25, and 12/27/25 revealed documentation of the residents' diet to be soft/puree and honey thick liquids.Interview on 01/21/26 at 1:09 P.M. with Hospice Nurse #202 revealed the orders hospice had on file for diet were soft/puree texture and honey thick liquids.Interview on 01/22/26 at 8:45 A.M. with the Director of Nursing (DON) revealed when hospice records are sent to the facility the medical records department reviews them.Interview on 01/22/26 at 8:50 A.M. with Medical Records (MR) #145, with DON present, confirmed their department receives the records and orders from hospice and uploads them into the documentation system, however they do not review the contents of the documents.Further interview on 01/22/26 at 9:16 A.M. with the DON confirmed the medical record department was not reviewing the records from hospice and was unable to confirm whether someone has been reviewing them.Interview on 01/22/26 at 10:20 A.M. with the DON revealed hospice verified they were documenting the incorrect diet and confirmed the resident was on a mechanical soft, honey thick liquid diet.Review of the hospice agreement between the facility and hospice, signed 12/19/24 and 12/20/24, revealed both facility and hospice will provide each other with plans of care and make any necessary modifications to it for the consistency of the hospice plan of care and facility plan of care.Review of the facility's hospice policy, revised 1/28/25, revealed the facility will collaborate with hospice to ensure the most recent hospice plan of care specific to each patient and will ensure the facility communicates with the hospice regarding the residents' plan of care.

Based on interview and medical record review the facility failed to ensure Resident #2 and #28's care plans accurately reflected the resident's prescribed medications. This affected two residents (#2 and #28) of five residents reviewed for unnecessary medications. The facility census was 32.Findings include:1.Review of Resident #28's medical record revealed an admission date of 07/25/16 with diagnoses including dementia, heart failure, dysphagia, hypertension, low back pain, anorexia, major depressive disorder, anxiety disorder, and hallucinations.Review of Resident #28's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed moderately impaired cognition. She received diuretics during the lookback period.Review of Resident #28's physician order dated 10/15/25 revealed an order for Lasix (diuretic) 20 milligrams (mg) one tablet by mouth one time a day for chronic heart failure.Review of Resident #28's plan of care on 01/21/26 revealed diuretic use was not addressed.Interview on 01/22/26 at 8:52 A.M. with MDS Coordinator #136 verified she did not have a care plan in place for her diuretic use. 2.Review of Resident #2's medical record revealed an admission date of 11/03/25 with diagnoses including cerebral infarction due to unspecified occlusion or stenosis of left anterior cerebral artery, hypertension, anxiety disorder, history of malignant neoplasm of bladder, and osteoarthritis.Review of Resident #2's Comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed severely impaired cognition.Review of Resident #2's physician order dated 11/14/25 revealed an order for Acetaminophen (analgesic) 500 milligrams (mg) one tablet by mouth every eight hours as needed for pain.Review of Resident #2's physician order dated 01/12/26 revealed an order for Acetaminophen 500 mg one tablet by mouth three times a day for pain.Review of Resident #2's care plan revealed his pain medication use was not addressed.Interview on 01/22/26 at 8:52 A.M. with MDS Coordinator #136 verified she did not have a care plan in place for his pain medication use.

Based on observation, staff interview, review of the dietary spreadsheets, and facility policy review, the facility failed to ensure residents received appropriate portion sizes during a lunch meal. This had the potential to affect all 32 residents who received food from the kitchen. Findings include: Observation of lunch meal service on 03/20/24 at 12:00 P.M. with Server #30 revealed a medium sized metal container was filled with various serving scoops, ladles, and spoons in it. Server #30 did not have a dietary spreadsheet to use for reference when he placed the serving utensils in each food item. Interview on 03/20/24 at 12:08 P.M. with Server #30 confirmed the following serving utensils were used for the following food items: Breakfast Casserole: #10 scoop (half a cup) Regular beef stroganoff: #8 scoop (three eights of a cup) Regular green beans: a large slotted spoon without a portion size Regular buttered noodles: large spoon without any slots and without a portion size indicated Pureed green beans: #10 scoop Pureed noodles: #16 scoop (one-fourth cup) Pureed broccoli: #16 scoop Pureed pears: #16 scoop Review of the dietary spreadsheets for the lunch meal on 03/20/24 revealed the following discrepancies on what was actually served to the residents and what should have been served: The residents were to receive breakfast casserole with a #8 scoop (but received #10 scoop) Regular beef stroganoff: #10 scoop (but received #8 scoop) Regular green beans: #8 scoop (but a slotted spoon was utilized) Regular buttered noodles: #8 scoop (but a slotted spoon was utilized) Pureed green beans: #8 scoop (but received #10 scoop) Pureed noodles: #8 scoop (but received #16 scoop) Pureed pears: #8 scoop: (but received #16 scoop) Interview on 03/20/24 at 12:35 P.M. with Dining Director (DD) #108 confirmed the large spoons (slotted and unslotted) were not to be used for portion control and should not have been used to serve the meal unless it was specifically indicated on the dietary spreadsheet. DD #108 confirmed the appropriate portions and scoops were not used during the meal service. Review of the facility's undated policy titled Portion Control revealed the menu should list the specific portion size for each food item. Menus should be posted on the tray line so staff can refer to the proper portions for each diet. Food should be served with ladles, scoops, spoodles, and spoons of standard sizes. Portions that are too small result in the individual not receiving the nutrients needed. Portions that are too large increase food as well as providing the individual with more food than needed. Review of the facility's undated policy titled Accuracy and Quality of Tray Line revealed the menu extensions (food items and amounts for each regular or therapeutic diet) should be displayed where the tray line staff can easily see them. The meal will be checked against the therapeutic diet spreadsheets to assure that foods are served as listed on the menu. Each meal tray will be checked for: accuracy of following the therapeutic diet extension and proper portion sizes.

Based on observations, staff interviews, and facility policy review, the facility failed to properly store and date food items in the freezer area of the kitchen and failed to utilize appropriate hand hygiene during lunch meal service. This had the potential to affect all 32 residents who received food from the kitchen. Findings include: During the initial tour of the kitchen on 03/19/24 at 10:32 A.M. with Dining Director (DD) #108, the following food items were found to be stored inappropriately and not dated in the freezer: a large plastic bag of chili lime tilapia which had been opened with no date, a plastic bag of chicken fingers which had been opened with no date, a plastic bag of popcorn shrimp which had been opened with no date, a bag of Texas Toast which had been opened and was missing four pieces of toast did not have a date, a bag of frozen sub buns in a blue plastic bag which had been torn open, exposing the buns directly to the cold air, and did not have a date on it, and a bag of egg rolls which had been opened with no date. DD #108 confirmed all of the above findings. Review of the facility policy titled Food Storage, dated 03/2023, revealed under frozen foods: all foods should be covered, labeled, and dated. 2. Observation of the lunch meal service on 03/20/24 at 12:00 P.M. with Server #30 revealed the server first checked all of the food temperatures using napkins and alcohol wipes to clean the thermometer in between foods. After food temperatures were completed, Server #30 transitioned to tray line. Server #30 did not wash his hands between taking the food temperatures and donning clean gloves to start the lunch tray service. Continuous observation of Server #30 revealed the server touching resident's plates and bowls with the potentially contaminated gloves. Server #30 did not change his gloves or wash his hands during the duration of the meal service observation. Interview on 03/20/24 at 12:35 P.M. with Dining Director (DD) #108 confirmed Server #30 should have washed his hands with soap and water prior to donning clean gloves. Review of the facility policy titled Hand Washing, dated 2023, revealed when to wash hands: before donning disposable gloves for working with food and after gloves are removed.

Based on record review and staff interview, the facility failed to ensure the residents received ongoing monitoring of medication side effects for psychotropic and antianxiety medication. This affected two (Residents #8 and #19) of five residents reviewed for unnecessary medications. The facility census was 32. Finding include: 1. Review of Resident #8's medical record revealed an admitted [DATE] with diagnoses of depression and anxiety. Review of the most recent quarterly Minimum Data Set (MDS) assessment completed on 01/08/24 revealed the resident was cognitively impaired and receiving antipsychotics on a routine basis. Review of the care plan completed on 12/20/23 for Resident #8 revealed staff should administer medications as ordered and monitor and document for side effects. Review of Resident #8's current physician orders for 03/2024 revealed an order where the staff were required to monitor for adverse side effects of antipsychotics, initiated on 08/10/23. If side effects are noted, staff should indicate in the Medication Administration Record (MAR) with a N, and document side effects in nurse's notes. Orders for medication administrations for Resident #8 revealed an order for Rexulti (Antipsychotic) with a start date of 02/28/24 for dementia and behavioral disturbance. Review of the medication administration record (MAR) for Resident #8 between 03/01/24 and 03/20/24 revealed adverse side effects were noted seven times on the following dates and time: on 03/05/24 on day and night shift, on 03/15/24 during day shift, on 03/17/24 during day shift, on 03/18/24 during night shift, and on 03/19/24 during day and night shift. The MAR did not describe the side effects Resident #8 exhibited. Resident #8 received daily administration of Rexulti between 03/01/24 to 03/20/24. Review of the progress notes for Resident #8 revealed there was no documentation of the side effects Resident #8 exhibited on 03/05/24 on day and night shift, on 03/15/24 during day shift, on 03/17/24 during day shift, on 03/18/24 during night shift, and on 03/19/24 during day and night shift. Interview on 03/20/24 at 3:24 P.M. with the Director of Nursing (DON) confirmed the staff were required to document observed side effects in the progress notes. The DON confirmed the documentation was not in Resident #8's progress notes for the seven times Resident #8 exhibited side effects noted in the MAR in March 2024. 2. Review of Resident #19's medical record revealed an admitted [DATE] with diagnoses of dementia, depression, and anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired. Review of Resident #19's physician orders dated 01/21/24 revealed an order where staff are required to monitor and document side effects of antianxiety medications in the progress notes. Resident #19 had an order for Ativan (antianxiety medication) with a start date of 02/29/24 for anxiety and restlessness. Review of the medication administration record (MAR) for Resident #19 revealed identified side effects were noted on 03/05/24 during the day and night shift. The MAR did not describe the side effects Resident #19 exhibited. Resident #19 received Ativan on 03/04/24 at 12:56 P.M. and 03/05/24 at 2:00 P.M. Review of the progress notes from 03/05/24 to 03/06/24 for Resident #19 revealed there was no documentation of the side effects Resident #19 exhibited on 03/05/24 during the day and night shift. Interview on 03/20/24 at 3:24 P.M. with the Director of Nursing (DON) confirmed the staff were required to document observed side effects in the progress notes. The DON confirmed the documentation was not in Resident #19's progress notes for the times Resident #19 exhibited side effects noted in the MAR in March 2024.

Based on record review, staff interview, and facility policy review, the facility failed to timely follow up on a pharmacy recommendations and implement the physician's response to the pharmacy recommendations. This affected two residents (Residents #10 and #178) of five residents reviewed for unnecessary medications. The facility census was 32. Findings include: 1. Review of the medical record for Resident #10 revealed a readmitted on 01/06/24. Diagnoses included metabolic encephalopathy and heart disease. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #10 had mild impaired cognition. Review of the pharmacy recommendation dated 05/19/23 revealed the pharmacist recommended to recheck Resident #10's thyroid-stimulating hormone (TSH) (measures how much of this hormone is in your blood) and thyroxine test (free T4) (measures the level of T4 in your blood) due to a dosage increase in Synthroid. The physician agreed and ordered to have TSH and free T4 labs completed every three months. The physician signed the recommendation and dated it 05/23/23. There was no physician order or labs drawn for TSH and free T4 tests from 05/23/23 to 06/13/23. Review of the pharmacy recommendation for Resident #10 dated 06/14/23 revealed the physician agreed to have a repeat thyroid lab (TSH and free T4) per progress note on 05/23/23. However, there was not a new order or any new lab results received. Review of the laboratory test results for Resident #10 revealed there was no TSH or free T4 tests completed from 05/23/23 to 07/09/23. The TSH and free T4 lab tests were not completed until 07/10/23. The resident's TSH level was high at 34.769 with a normal range being 0.340-5.500 ulU/mL. The next TSH lab drawn was five months later on 12/14/23 and it was low at 0.253 and there was no free T4 lab drawn. The follow TSH lab drawn was on 02/15/24 and the TSH was high again at 7.506 and there was no free T4 lab drawn. Review of the physician orders for Resident #10 dated March 2024 revealed there was not an order for TSH and free T4 labs to be drawn every three months. Interview on 03/20/24 at 4:02 P.M. with the Director of Nursing (DON) confirmed the pharmacy recommendations and the physician response were not implemented timely and there was no physician order to have a TSH and free T4 lab drawn every three months. The DON also confirmed the free T4 levels have not be drawn since 07/10/23. 49039 2. Review of Resident #178's medical record revealed an admitted [DATE]. Diagnoses included Alzheimer's disease, insomnia, and depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #178 was severely cognitively impaired and received antidepressants. Review of the pharmacy recommendations completed on 07/14/23 for Resident #178 revealed a request to decrease Trazodone (antidepressant) from 37.5 milligrams (mg) to 25 mg. The physician responded on 07/20/23 to decrease Trazodone from 37.5 mg to 25 mg. There was no physician order written on 07/20/23. The progress note dated 07/25/23 for Resident #178 revealed the pharmacist was at bedside and suggested reduction of Trazodone from 37.5 mg to 25 mg. The physician reviewed and agreed. There was no physician order written on 07/25/23. Review of the Medication Administration Record (MAR) for 07/2023, 08/2023 and 09/2023 revealed Resident #178 was receiving 37.5 mg of Trazodone one time a day. Review of the pharmacy recommendations completed on 10/11/23 for Resident #178 revealed a request to decrease Trazodone from 37.5 mg to 25 mg. The physician responded on 10/12/23 with agreement to decrease dosage. On 10/19/23, a physician order was written to decrease Trazodone to 25 mg. Interview on 03/21/24 at 11:48 A.M. with the Director of Nursing (DON) confirmed Trazodone was not decreased after pharmacist recommendation and physician agreement on 07/20/23 or 07/25/23. The DON confirmed Trazodone dosage was decreased after an additional recommendation was conducted from the pharmacist on 10/11/23. The DON confirmed Resident #178 received Trazodone 37.5 mg until 10/19/23. Review of the facility's undated policy titled Pharmacy Review Policy, revealed the pharmacist will report any irregularities found in the monthly review to the attending physician, the facility medical director, and director of nursing. Irregularities include, but are not limited to, any drug that meets the criteria of an unnecessary medication. Documentation will be in the resident's medical record by the attending physician that the finding has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record.

Based on record review, review of the facility policy, and staff interview the facility failed to ensure residents were free from unnecessary medications. This affected three (Resident #2, #9, and #10) of five residents reviewed for unnecessary medication use. The facility census was 32. Findings include: 1. Review of Resident #9's medical record revealed an admitted [DATE]. Diagnoses included altered mental status, urinary incontinence, and urinary tract infection (UTI). Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/13/24, revealed the resident had impaired cognition and was taking an antibiotic. Review of Resident #9's urine culture and sensitivity collected on 03/11/24 with a report date of 03/14/24 revealed Resident #9 had a UTI with Serratia Marcescens and Enterococcus Faecium present. The report stated Resident #9 should be treated for Enterococcus Faecium bacteria. Review of the antibiotics effective to treat Enterococcus Faecium showed nitrofurantoin, tetracycline, and vancomycin. Review of the antibiotics resistant to the bacteria revealed the penicillin class. Review of the infectious disease progress note for Resident #9 completed on 03/14/24 at 1:06 P.M. revealed a urine culture was obtained showing Enterococcus and Serratia. During this appointment, an order to start Amoxicillin-Clavulanate (Penicillin antibiotic) for 10 days was placed. Review of Resident #9's physician orders revealed an order for Amoxicillin- Pot Clavulanate with a start date of 03/15/24 for treatment of UTI. Review of the fax transmittal dated 03/21/24 from Columbus infectious disease (CID) specialist revealed Resident #9 was started on Amoxicillin-Clavulanate because Enterococcus Faecium was traditionally sensitive to penicillins. Review of Resident #9's progress notes between 03/14/24 and 03/21/24 revealed the infectious disease doctor was not notified of the culture and sensitivity result. Review of Resident #9's physician orders revealed an order for Doxycycline Hyclate (Tetracycline antibiotic) for treatment of UTI with a start date of 03/21/24. Interview on 03/21/24 at 5:22 P.M. with the Director of Nursing (DON) confirmed CID specialists were not notified of Resident #9's culture and sensitivity. DON #9 confirmed Amoxicillin Pot Clavulanate (Penicillin) was resistant to Enterococcus Faecium, stated CID specialists were notified on 03/21/24 of the results, and started the resident on the proper antibiotic to treat the infection. 41266 2. Review of the medical record for Resident #2 revealed an admitted on 10/06/23. Diagnoses included retention of urine, urinary incontinence, and sepsis. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #2 had impaired cognition. Review of the progress notes revealed on 12/19/23 at 3:14 P.M., Registered Nurse (RN) #85 contacted Resident #2's community urologist's office and discussed the resident's long-term use of antibiotics for UTI. Resident #2 had a history of chronic infections and the urologist started Resident #2 on a prophylactic antibiotic. The resident's family agreed with the therapy due to no negative impact on the resident. Review of the physician orders for Resident #2 revealed the resident had the following orders: Cephalexin (Keflex-an antibiotic) 250 milligrams (mg) daily for prophylactic dated 01/24/24 and discontinued 02/20/24, Contact isolation for extended-spectrum beta-lactamase (ESBL) dated 01/26/24 and discontinued 01/31/24, Straight cath for a urinalysis (UA) and culture if needed dated 02/09/24 and discontinued on 02/13/24. Review of the Society for Healthcare Epidemiology of America ([NAME]) infection criteria for surveillance of infections dated 02/09/24 for Resident #2 revealed the resident did not meet the criteria for a UTI. The criteria for a resident without an indwelling criteria indicated both criteria #1 and #2 must be present. Resident #2 met criteria #2 only. There was a hand written note that stated, Zero true infection at the top of the sheet. (Resident #2 continued on Cephalexin) Review of the UA with culture laboratory test dated 02/14/24 and reported 02/17/24 revealed Resident #2 had a positive culture with an identified organism of Enterococcus Faecium. Vancomycin was the only susceptible antibiotic listed. Other antibiotics were listed as resistant. Review of the physician order dated 02/20/24 revealed an order for Vancomycin Hydrochloride (HCl) Oral Solution Reconstituted (an antibiotic) 25 mg/milliliter (mL) give 10 mL twice daily for UTI. The Vancoycin was discontinued on 02/26/24. On 02/27/24, an order for Cephalexin 250 mg daily for prophylactic use and it was discontinued on 03/12/24. On 03/11/24, an order was to collect UA and culture due to increase in behavior and on 03/12/24, an order for Bactrim DS Oral Tablet 800-160 mg twice daily for UTI for five days and discontinued 03/17/24. On 03/15/24, the results of the UA culture revealed Resident #2 had a positive urine culture with the same identified organism, Enterococcus Faecium. Macrobid was a susceptible antibiotic, however, the change did not occur for three additional days after results were reported to the facility. Nitrofurantoin and vancomycin were the only two susceptible antibiotics listed for the organism.Macrobid oral capsule 100 mg every 12 hours for UTI for seven days dated 03/18/24 and was scheduled to end on 03/25/24 Review of the [NAME] infection criteria for surveillance of infections dated 03/11/24 revealed there were not any specific symptoms or criteria marked on the surveillance form for a UTI but indicated Resident #2 met appropriate surveillance criteria for an infection. Resident #2 started on Bactrim antibiotic on 03/12/24. Review of the Medication Administration Records (MARs) dated February and March 2024 revealed Resident #2 received antibiotics as physician ordered. Interview on 03/21/24 at 4:27 P.M. with the Director of Nursing (DON) confirmed Resident #2 was on a long-term antibiotic use therapy as a prophylactic for chronic UTIs that was ordered by an outside urologist prior to the Resident #2's admission to the facility. The DON confirmed Resident #2 had continued to show positive results for UTIs despite the prophylactic antibiotic use. The DON confirmed Resident #2 did not have any of the symptoms listed on the infection criteria sheet such as fever, blood in her urine, pain, or increased urgency, frequency, or incontinence. The DON stated Resident #2 displayed increased behaviors such as yelling out and refused care. The DON confirmed neither of these symptoms were listed on the infection surveillance sheet. The DON confirmed there was no evidence in Resident #2's medical record that prophylactic antibiotic had been reevaluated for appropriateness or effectiveness and had not been discussed with the outside urologist since December (three months ago). The DON confirmed he had not provided any education to Resident #2's family since the resident's urine culture showed ESBL (an antibiotic resistant bacteria). 3. Review of the medical record for Resident #10 revealed a readmitted on 01/06/24. Diagnoses included urinary tract infection (UTI) and seizures. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #10 had mildly impaired cognition. Review of the physician orders dated March 2024 revealed Resident #10 had the following orders: urinalysis with culture and sensitivity (UA C & S) for abnormal behavior dated 03/04/24 and Cipro oral tablet (an antibiotic) 250 milligrams (mg) twice daily for seven days for UTI prevention dated 03/05/24 and ended on 03/12/24. Review of the progress notes revealed on 03/03/24 at 4:39 P.M., a nurse noted she attempted to straight catheterize Resident #10 for urine collection but was unsuccessful due to the resident fighting and kicking at the nurse. On 03/05/24 at 2:31 P.M., the physician was updated that staff were not able to obtain a urine sample after making several attempts. The physician ordered to start Cipro 250 mg twice daily for seven days for possible UTI. On 03/05/24 and 03/06/24, Resident #10 was noted to refuse medications. Review of the [NAME] infection surveillance criteria dated 03/03/24 revealed there was no symptoms indicated on the sheet for a UTI. Resident #2 was noted to have increased behaviors. Resident #2 received Cipro antibiotic for twice daily for seven days. A urine culture was not completed due to inability to obtain. Review of the Medication Administration Record (MAR) dated March 2024 revealed Resident #10 refused the antibiotic on 03/06/24 in the morning and was sleeping on 03/10/24. Resident #10 received all other scheduled doses of the antibiotic. Interview on 03/21/24 at 4:27 P.M. with the Director of Nursing (DON) confirmed Resident #2 received an antibiotic without meeting the appropriate criteria for a UTI and a urine culture was not able to be obtained to confirm an infection and organism. Review of the facility's undated policy titled Antibiotic Stewardship revealed antibiotic treatment will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. The purpose is to define and identify infections and adopt the [NAME] definitions of infection as standardized definitions of infection for use in surveillance. The following conditions apply to all of the definitions: all symptoms must be new or acutely worse, many residents have chronic symptoms, such as cough or urinary urgency, which are not associated with infection. Identification of infection should not be based on a single piece of evidence. Physician diagnosis should be accompanied by compatible signs and symptoms of infection. Antibiotic use will be monitored.

Based on review of the facility policy, staff interview, observation, and record review, the facility failed to ensure staff sanitized their hands after glove changes during a suprapubic indwelling catheter dressing change. This affected one (Resident #21) of three residents reviewed for urinary catheter or urinary tract infection. The facility identified three residents with urinary catheters. The facility census was 32. Findings include: Record review of Resident #21 revealed an admitted [DATE]. Diagnoses included obstructive and reflux uropathy and urinary retention. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 was moderately cognitively impaired and had an indwelling urinary catheter. Review of the physician's order dated 03/13/24 revealed an order to cleanse super pubic cath stoma (insertion site) with normal saline, gauze, pad dry . Apply chamosyn cream to super pubic catheter stoma for redness daily. Every day shift for redness. Observation of Resident #21's suprapubic indwelling catheter dressing change on 03/20/24 at 2:48 P.M. revealed Registered Nurse (RN) #74 gathered her supplies and she washed her hands with soap and water and put on clean gloves. RN #74 removed the old dressing surrounding the suprapubic catheter insertion site. RN #74 washed her hands and changed gloves then cleaned the site with body wash. She took off her soiled gloves and put on new gloves. RN #74 did not wash hands or use hand sanitizer after removing her soiled gloves and before putting on gloves. RN #74 used normal saline nd gauze to clean the site. She then put chamosyn cream on the site and placed the gauze around the site then took off her soiled gloves. RN #74 did not wash her hands or use hand sanitizer and then put on clean gloves and placed tape around the dressing while holding the dressing down with her gloves. Interview with RN #74 on 03/20/24 at 3:03 P.M. verified she did not wash hands or use hand sanitizer after removing her soiled gloves two different times during Resident #21's dressing change. Review of the undated handwashing policy revealed appropriate 20 seconds hand washing with antimicrobial or non-antimicrobial soap and water must be performed under the following conditions: after handling items potentially contaminated with blood, body fluids, or secretions; after patient/resident care; if hands are not visibly soiled, an alcohol-based hand rub, can be utilized for no more than three-fourths of the times, or following manufactures guidelines. But always wash hands if water and sink are available. Gel to be used only if hand washing tools not available. Under the following conditions: after removing gloves.

Based on record review, staff interviews, and facility policy review, the facility failed to implement their antibiotic stewardship program to ensure infections and antibiotics were monitored. This affected two (Residents #2 and #10) of three residents reviewed for antibiotic use. The facility census was 32. Findings include: 1. Review of the medical record for Resident #2 revealed an admitted on 10/06/23. Diagnoses included retention of urine, urinary incontinence, and sepsis. Review of the physician orders for Resident #2 revealed the resident had the following orders: Cephalexin (Keflex-an antibiotic) 250 milligrams (mg) daily for prophylactic dated 01/24/24 and discontinued 02/20/24. Review of the Society for Healthcare Epidemiology of America ([NAME]) infection criteria for surveillance of infections dated 02/09/24 for Resident #2 revealed the resident did not meet the criteria for a UTI. The criteria for a resident without an indwelling criteria indicated both criteria #1 and #2 must be present. Resident #2 met criteria #2 only. There was a hand written note that stated, Zero true infection at the top of the sheet. (Resident #2 continued on Cephalexin.) On 03/11/24, an order was to collect UA and culture due to increase in behavior and on 03/12/24, an order for Bactrim DS Oral Tablet 800-160 mg twice daily for UTI for five days and discontinued 03/17/24. Review of the [NAME] infection criteria for surveillance of infections dated 03/11/24 revealed there were not any specific symptoms or criteria marked on the surveillance form for a UTI but indicated Resident #2 met appropriate surveillance criteria for an infection. Resident #2 started on Bactrim antibiotic on 03/12/24. Interview on 03/21/24 at 4:27 P.M. with the Director of Nursing (DON) confirmed Resident #2 was on a long-term antibiotic use therapy as a prophylactic for chronic UTIs that was ordered by an outside urologist prior to the Resident #2's admission to the facility. The DON confirmed Resident #2 had continued to show positive results for UTIs despite the prophylactic antibiotic use. The DON confirmed Resident #2 did not have any of the symptoms listed on the infection criteria sheet such as fever, blood in her urine, pain, or increased urgency, frequency, or incontinence. The DON stated Resident #2 displayed increased behaviors such as yelling out and refused care. The DON confirmed neither of these symptoms were listed on the infection surveillance sheet. The DON confirmed there was no evidence in Resident #2's medical record that prophylactic antibiotic had been reevaluated for appropriateness or effectiveness and had not been discussed with the outside urologist since December (three months ago). 2. Review of the medical record for Resident #10 revealed a readmitted on 01/06/24. Diagnoses included urinary tract infection (UTI) and seizures. Review of the physician orders dated March 2024 revealed Resident #10 had the following orders: urinalysis with culture and sensitivity (UA C & S) for abnormal behavior dated 03/04/24 and Cipro oral tablet (an antibiotic) 250 milligrams (mg) twice daily for seven days for UTI prevention dated 03/05/24 and ended on 03/12/24. Review of the [NAME] infection surveillance criteria dated 03/03/24 revealed there was no symptoms indicated on the sheet for a UTI. Resident #2 was noted to have increased behaviors. Resident #2 received Cipro antibiotic for twice daily for seven days. A urine culture was not completed due to inability to obtain. Interview on 03/21/24 at 4:27 P.M. with the Director of Nursing (DON) confirmed Resident #2 received an antibiotic without meeting the appropriate criteria for a UTI and a urine culture was not able to be obtained to confirm an infection and organism. Review of the facility's undated policy titled Antibiotic Stewardship revealed antibiotic treatment will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. The purpose is to define and identify infections and adopt the [NAME] definitions of infection as standardized definitions of infection for use in surveillance. The following conditions apply to all of the definitions: all symptoms must be new or acutely worse, many residents have chronic symptoms, such as cough or urinary urgency, which are not associated with infection. Identification of infection should not be based on a single piece of evidence. Physician diagnosis should be accompanied by compatible signs and symptoms of infection. Antibiotic use will be monitored.

Based on observation and staff interview, the facility failed to ensure a safe environment when staff propped open a fire door. This had the potential to affect all 23 residents residing in the facility. Facility census was 23. Findings include: Observation on 09/07/21 at 9:18 A.M. revealed the fire door leading to the kitchen to a hallway propped open with a plastic dish rack. Interview on 09/07/21 at 9:18 A.M., Director of Dining Services (DDS) #72 verified the door was propped with a plastic dish rack. DDS #72 further confirmed the door was a fire door and should not be propped.

Based on observation and staff interview, the facility failed to ensure a sanitary environment for food preparation. This had the potential to affect all 23 residents residing in the facility. Facility census was 23. Findings include: 1. Observation on 09/07/21 at 9:22 A.M. revealed a fan, approximately 18 inches in diameter, attached to the wall in the dishroom. The fan was observed on and faced toward clean dishes within the dish room and had a black, sticky, and furry substance all over the front and back of the fan. Interview on 09/07/21 at 9:22 A.M., Director of Dining Services (DDS) #72 verified the fan in the dish room had a black, sticky, and furry substance on the front and back surfaces. 2. Observation on 09/08/21 at 10:35 A.M. revealed the DDS #72 in the kitchen wearing a hairnet with her bangs uncovered. DDS #73 prepared pureed deviled eggs, ham salad, and carrots with a blender. Interview on 09/08/21 at 10:50 A.M., DDS #72 verified the hairnet did not fully cover her hair and further stated, it keeps falling off. DDS #72 removed the hairnet and placed it in the trash. Observation on 09/08/21 at 10:52 A.M. revealed DDS #72 remained in the kitchen not wearing a hairnet. DDS #72 was observed checking temperatures of foods on the steam table and entered the the walk-in refrigerator. Interview on 09/08/21 at 10:58 A.M., DDS #72 verified she was not wearing a hairnet and stated she forgot to put on a new hairnet when she removed the previous hairnet. 3. Observation on 09/08/21 at 10:45 A.M. revealed a large trash can uncovered near the food preparation area and a large trash can in the food preparation area, which was partially covered, and a large trash can in the dish room, which was not covered. Interview on 09/08/21 at 10:50 A.M. DDS #72 verified the trash cans in the food preparation area and dish room were not covered. The lid for the trash can in the food preparation area was located behind a storage rack and the lid for the trash can in the dish room was located beside the sink 4. Observation on 09/08/21 at 10:51 A.M. revealed DDS #72 washed and dried her hands with a paper towel, lifted the lid to the trash can with her bare hand, and placed the paper towel in the trash can. Concurrent interview on 09/08/21 at 10:51 A.M., DDS #72 verified she touched a contaminated surface immediately after washing her hands. The facility confirmed all 23 residents receive meals from the kitchen.

Based on medical record review and staff interviews, the facility failed to ensure residents were free from unnecessary [CONDITION(S)] drugs when the facility failed to ensure as needed orders for anti-anxiety medications (Lorazepam) was limited to 14 days. This affected three (#21, #5 and #15) out of five residents reviewed for unnecessary medications. Facility census was 23. Findings include: 1. Review of medical record for Resident #21 revealed an admission on 08/03/21 with cognitive deficits. Diagnoses include [CONDITION(S)], cardiac arrhythmia, heart failure, type two diabetes mellitus, and hypertension. Review Resident #21's minimum data set (MDS) assessment, dated 08/10/21 revealed resident requires one person assist with activities of daily living. A care plan relative to psychological and medical needs revealed individualized interventions with measurable goals. Review of the Medications Administration Record (MAR) dated 09/01/21 revealed Resident #21 receives Lorazepam tablet 0.5 milligrams (mg) one tablet by mouth every four hours as needed for Anxiety. Review of the Physician summary order report revealed on 08/03/21 Resident #21 was ordered Lorazepam Tablet 0.5 mg one tablet by mouth every four hours as needed for Anxiety. Review of the physician progress notes revealed no documentation to indicate review of the medication or the reason to continue the medication as needed. On 09/08/21, at 11:40 A.M. interview with Registered Nurse (RN) #27 verified the physician had not reviewed or documented on the use of Lorazepam for Resident #21 every 14 days and there was no stop date for the Lorazepam. 2. Resident #5 admitted on [DATE] with diagnoses that included but were not limited to end stage [CONDITION(S)], hypo-osmolality and [CONDITION(S)], acidosis, [CONDITION(S)], hypertensive heart failure, and acute pulmonary [CONDITION(S)]. Review of most recent MDS assessment dated [DATE] revealed Resident #5 had moderately impaired cognition, had no behaviors, did not wander, and did not reject care. The resident was a two-person physical assist, and required extensive assistance with bed mobility, dressing, eating, toileting, and personal hygiene, and total assistance with transfers and locomotion. Review of care plan dated 06/18/2021 revealed Resident #5 admitted to hospice services due to terminal disease presence. She is prescribed Anxiolytic medications to ease breathing and to decrease Anxiety. Interventions included administer anti-anxiety medications as ordered and monitor for side effects/effectiveness, educate resident/family to risks versus benefits, monitor for target behavior symptoms. Further review of care plan revealed the resident was at risk for changes in mood/behaviors related to chronic pain, cognitive communication deficit, and history of [CONDITION(S)]. Resident #5 had history of expressing feeling down and having trouble sleeping, history of having low energy and feeling bad about self, history of telling staff she gets a bed bath then reporting she wasn't bathed, and history of declining medications, insulin, preventative interventions, and false allegations due to forgetfulness. Interventions included arrange for psych consult/follow-up as needed, individualized activities program, encourage the resident to express feelings, offer intervention/distraction as needed for behaviors (TV, religious music, talking), encourage meds and treatments as ordered, report signs and symptoms of depression, and offer adequate rest periods. Review of the medical record revealed Resident #5 had physician orders dated 08/18/21 for [MEDICATION(S)] Tablet 0.5 mg tablet by mouth every four hours as needed for anxiety for 90 days. 3. Record review revealed Resident #15 admitted on [DATE] with diagnoses that included but were not limited to chronic diastolic heart failure, unspecified dementia, and hypertension. Review of most recent MDS assessment dated [DATE] revealed the resident had severely impaired cognition, had verbal behaviors, did not wander, and did not reject care. The resident was a two-person physical assist and required extensive assistance with transfers, eating, toileting, and personal hygiene, and total dependence with transfers and locomotion. Review of physician orders revealed Resident #15 had orders on 12/23/20 for [MEDICATION(S)] tablet 0.5 mg by mouth as needed for anxiety during the night (last ordered 04/30/21). Interview on 09/09/2021 at 9:03 A.M. Administrator verified Resident #15's as needed [MEDICATION(S)] was continued beyond 14 days. Attempt to interview House Physician #9 via telephone on 09/09/2021 at 3:19 P.M. was unsuccessful.

Based on observations, Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] . This had the potential to affect all 23 residents residing in the facility. The census was 23. Findings include: On 09/09/21 at 11:37 A.M. observations and review of the the Report of Nursing Staff directly Responsible for Resident Care Sheets from 09/05/21 to 09/09/21 revealed 09/05/21, 09/06/21, 09/07/21 and 09/09/21 did not indicate total hours worked. On 09/08/21 the total hours of nursing staff did not match with the Nursing Full Time Equivalents (FTEs) indicated. On 09/09/21 at 11:37 A.M. interview and review of the staff posting with the Administrator confirmed the Report of Nursing Staff directly Responsible for Resident Care Sheets were inaccurate and incomplete.

Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to complete a thorough investigation for Resident who had a fall. This affected one Resident (#110) of three reviewed for falls. The facility census was 31. Findings include: Medical record review revealed Resident #110 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The resident had severe cognitive deficits. She required a two person assist for turning in the bed, utilized a wheelchair for locomotion and required one person assist for activities of daily living (ADLs). Review of Resident #110's care plan, last updated on 01/02/20, revealed Resident #110 was to have a low bed, against the wall, with a perimeter mattress, and her call light within reach. Review of nurse's notes dated 01/30/20, revealed State tested Nursing Assistant (STNA) #80 walked into Resident #110's room and found her on the floor, beside her bed. It was reported to Registered Nurse (RN) #70 who completed an incident report at 2:31 A.M. Resident #110 could not explain what had happened. Nurse #70 and STNA #80 presumed Resident #110 fell out of her bed. Review of the incident report and nurses' progress notes dated 01/30/20, revealed Resident #110 was found on the floor beside her bed. The incident report did not contain any additional information to determine if fall precautions were in place when she was found on the floor. Furthermore, there was no witness statement completed by STNA #80. On 09/29/20, at 4:00 P.M. interview with the Director of Nursing (DON) revealed the only documentation they had of Resident #110's fall was the incident report RN #70 completed, and the documentation of the incident in Resident #110's nurses' progress notes. The DON confirmed it was unknown and not included in the incident report or the resident's nursing notes if the bed was in low position, against the wall, with a perimeter mattress. The DON confirmed STNA #80 did not complete a witness statement or submit a report regarding the resident's fall. RN #70 was off and out of state and could not be contacted for an interview. STNA #80 was no longer employed with the facility and could not be contacted for an interview. Review of the facility's policy titled, Accidents Policy, dated 05/2013 revealed nursing staff should document accidents in the clinical record. A report of this accident will be generated. In the case of a fall, an STNA report will also be completed. A designated committee will review the incident in a timely manner and try to determine the cause or contributing factors when the accident occurred. Documentation, including the STNA Fall Report, Accident Report, and the Committee Review of Accident form will be maintained. This deficiency substantiates Complaint Number OH 845

Based on observation, taste test, staff interviews, review of residents prescribed a pureed diet and policy review the facility failed to ensure the correct consistency for a puree food. This had the potential to affect seven Residents (#7, #10, #11, 23, #31, #32, and #39) identified by the faciliy who received pureed foods. The census was 42 residents. Findings include: During an observation and interview on 07/31/18 at 12:08 P.M., Dietary Cook #107 revealed the dinner menu was(NAME)Shrimp, Jasmine Rice and Bell Pepper Blend. The alternative menu consisted of ham and Swiss croissant and mashed potatoes. The dessert of choice was bananas with strawberry glaze or apple pie. Dietary Cook #107 proceeded to puree the ham and cheese croissants. She placed eight servings of the sandwich in the robot coupe with three cups of water and blended the mixture to a liquid state and added food thickener to obtain a pudding like consistency. The sandwich mixture was a soup like consistency when covered and placed in the refrigerator. When asked to see the recipe she followed to puree the food, Dietary Cook #107 indicated they did not have recipes for their food items. On 07/31/18 at 2:16 P.M. interview with Director of Dining Services #59 and Dietician #52 revealed they did not have standardized menus with recipes. They indicated they created the menus by following the Federal Regulations for nutritional value. On 07/31/18 at 2:20 P.M., observation of Dietary Cook #107 pureeing the curry shrimp for dinner revealed eight servings of the shrimp curry were placed in the robot coupe and mixed to a runny consistency. Dietary Cook #107 covered the shrimp curry and placed it in the steamer. At the time of the observation, Dietary Cook #107 explained the shrimp curry would thicken prior to serving. On 07/31/18 at 5:15 P.M., observation of the serving line revealed pureed curry shrimp, ham and cheese croissants, peppers and onions, bananas with strawberry glaze and apple pie. Dietary server #100 was asked to scoop one serving of each pureed item and pour it back into its bin. The shrimp did not hold a pudding or potato like consistency, and the apple pie was a soup like consistency. The dietician revealed the items were a little runny as they should be a pudding like consistency. To confirm the consistency of the puree foods, Director of Dinning Services #59 provided the pureed curry shrimp, ham and cheese croissant and apple pie on an eight-inch plate. The soup like apple pie and liquid from the curry shrimp covered the entire eight-inch plate causing the foods to run together. At the time of observation the food was tested for palpability and revealed there were rice size pieces of shrimp in the puree curry shrimp. This was confirmed by Director of Dinning Services #59. Review of a list of residents who received a pureed diet revealed seven Residents (#7, #10, #11, 23, #31, #32, and #39) were identified by the facility. Review of the Dysphagia Level 1 Diet Policy dated 05/2018 revealed the consistency should be smooth and similar in consistency to that of pudding or mashed potatoes.

Based on review of liability notices and staff interview the facility failed to ensure residents were issued a Centers for Medicare and Medicaid Services (CMS)- , denial notice when skilled nursing services were discontinued. This affected one Resident (#29) out of three residents reviewed for discontinuation of skilled services. The facility census was 42. Findings include: Medical record review for Resident #29 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) (a test to determine your cognitive functioning) of 14 (little to no impairment). During review of the liability notices for discharged residents revealed, Resident #29 had skilled nursing services discontinued on 04/09/18. In addition, there was no evidence a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN)/CMS- was provided to inform the resident of their right to a demand bill. The resident resided in the facility at that time. On 07/31/18 at 3:23 P.M. an interview with Licensed Social Worker #51 confirmed Resident #29 was not given a SNF ABN/CMS- upon a facility initiated discharge from Medicare Part A Services on 04/09/18. The resident remained in the facility.