Ohio Valley Manor Nursing And Rehabilitation

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to immediately notify hospice services of a significant change in a resident's physical, mental, social, or emotional status for 1 (Resident #129) of 1 resident reviewed for hospice services. Specifically, Resident #129 fell due to a seizure on 07/27/2025, and the facility did not notify hospice until 07/28/2025. Findings included: An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/28/2025, revealed Resident #129 was admitted to the facility on [DATE] and most recently readmitted to the facility on [DATE]. The MDS indicated the resident had a medical history that included diagnoses of non-traumatic brain dysfunction and diabetes mellitus. Resident #129 had a short- and long-term memory problem and severely impaired cognitive skills for daily decision-making per a Staff Assessment of Mental Status (SAMS). The MDS indicated Resident #129 received hospice services while a resident of the facility. Resident #129's Order Summary Report, listing active orders as of 08/21/2025, revealed an order dated 09/03/2024 to admit the resident to hospice services.Resident #129's Care Plan Report included a focus area, initiated 09/27/2024, that indicated the resident had potential for or a decline in condition and the resident received hospice services. An intervention initiated 09/27/2024 directed staff to keep family and hospice informed.During an interview on 08/21/2025 at 2:14 PM, the Hospice Case Manager stated Resident #129 was admitted to hospice services on 09/03/2024. The Hospice Case Manager stated an incident occurred on Sunday, 07/27/2025, that resulted in a shoulder injury to the resident. The Hospice Case Manager stated the facility did not notify hospice about the incident until the next day on Monday, 07/28/2025. The Hospice Case Manager stated hospice had a 24-hour phone contact, and the expectation was that the facility would have reported the incident immediately. The Hospice Case Manager stated that following this incident, she reminded Licensed Practical Nurse (LPN) #2 that hospice had a 24-hour contact number. During an interview on 08/21/2025 at 10:40 PM, LPN #19 stated Resident #129 experienced a seizure on 07/27/2025 and fell on their right shoulder, causing a shoulder injury. LPN #19 stated she was performing a medication pass, and when she noticed Resident #129 was having a seizure, she dropped what she was doing to assist the resident. LPN #19 stated she notified the physician, family, and the unit manager, but did not notify the hospice provider, because she was not aware at the time that the resident received hospice services. LPN #19 stated her main concern at that moment was to provide care to Resident #129 to stabilize the resident. LPN #19 stated she knew the hospice provider should have been notified, and she believed the unit manager notified the hospice provider the next morning.During an interview on 08/22/2025 at 10:33 AM, the Director of Nursing (DON) stated she did not think the attending nurse, LPN #19, was aware Resident #129 was admitted to hospice. The DON stated the electronic medical record (EMR) was unavailable at the time due to a change in the facility's ownership, and nursing staff were working from the resident's paper charts, which had limited documentation. The DON stated the expectation would have been to notify the hospice provider immediately after the resident was stable. The DON stated the unit manager brought it to her attention that hospice was not notified until the following day.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure hand hygiene occurred between glove changes for 1 (Resident #32) of 1 residents observed during wound care and the facility failed to store oxygen equipment appropriately when not in use for 1 (Resident #61) of 5 residents reviewed for respiratory services. Findings included: A facility policy titled, Handwashing/Hand Hygiene Policy Interpretation and Implementation, dated 04/28/2025, did not address hand hygiene between glove changes. An admission Record indicated the facility admitted Resident #32 on 05/13/2025. According to the admission Record, the resident had a medical history that included diagnoses of obesity and chronic pain syndrome. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/20/2025, revealed Resident #32 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated Resident #32 had one stage 2 pressure ulcer that was present upon admission. Resident #32's Care Plan Report included a focus area, revised 05/20/2025, that indicated the resident had impaired skin integrity. Interventions directed staff to use enhanced barrier precautions related to wounds and to monitor for signs and symptoms of infection. On 08/19/2025 at 2:26 PM, observations of wound care for Resident #32 revealed that Licensed Practical Nurse (LPN) #2 entered the resident's room with gloves on then put another pair of gloves over top of the first pair. The observation revealed LPN #2 cleansed Resident #32's wound with normal saline, patted the wound dry, and applied a skin-protectant and packing material to the wound. The observation revealed that when LPN #2 removed her gloves both pairs of gloves came off. The observation revealed LPN #2 got another pair of gloves and put them on without doing hand hygiene. The observation revealed after applying a dressing to the wound, LPN #2 removed her gloves again and put on new gloves without doing hand hygiene. The observation revealed LPN #2 removed all the supplies, threw the supplies away with her gloves on, and then washed her hands. During an interview on 08/19/2025 at 2:40 PM, LPN #2 stated she used hand sanitizer before she entered the room, and she put on two pairs of gloves. LPN #2 stated when both pairs of gloves came off, she did not do hand hygiene prior to putting on more gloves, but she should have. LPN #2 stated she should have done hand hygiene between each glove change. During an interview on 08/22/2025 at 10:34 AM, the Director of Nursing (DON) stated hand hygiene should occur after staff touched a dirty area, and staff should take off their gloves, perform hand hygiene, and then put on new gloves. The DON stated gloves should be changed anytime they were soiled and hand hygiene should occur in between all glove changes. During an interview on 08/22/2025 at 11:12 AM, the Administrator stated hand hygiene should be done in between glove changes for infection control reasons

Based on observation, interview, record review, and facility policy review, the facility failed to follow physician's orders for supplemental oxygen administration for 1 (Resident #41) of 5 residents reviewed for oxygen use. Findings included:A facility policy titled, Policy and Procedure for the Administration of Oxygen Therapy, reviewed 11/2024, revealed, Procedure 1. Oxygen will be administered in accordance with physician's order. 2. Nurse should verify order prior to administering oxygen. An admission Record revealed the facility admitted Resident #41 on 03/27/2019. According to the admission Record, the resident had a medical history that included diagnoses of heart disease, mild intermittent asthma, and personal history of COVID-19. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/09/2025, revealed Resident #41 had a short- and long-term memory problem and severely impaired cognitive skills for daily decision-making per a Staff Assessment of Mental Status (SAMS). The MDS revealed Resident #41 received supplemental oxygen therapy while a resident of the facility. Resident #41's Care Plan Report included a problem statement, initiated 05/10/2023, that indicated the resident had a potential for altered respiratory status related to allergic rhinitis and asthma. An intervention initiated on 05/10/2023 directed staff to administer supplemental oxygen per medical doctor (MD) orders. Resident #41's Medication Review Report, dated 08/21/2025, included an order started on 06/03/2024 to administer supplemental oxygen at two liters per minute (LPM) per nasal canula (flexible tubing fitted in the nostrils), routinely every day and night shift for cough and congestion. An observation on 08/18/2025 at 12:33 PM revealed Resident #41 was in bed receiving supplemental oxygen by way of a nasal canula at a rate of 1.5 LPM. An observation on 08/19/2025 at 11:13 AM revealed Resident #41 was in bed receiving supplemental oxygen by way of a nasal canula at a rate of 1.5 LPM. An observation on 08/20/2025 at 8:00 AM revealed Resident #41 was in bed receiving supplemental oxygen by way of a nasal canula at a rate of 1.5 LPM. During an interview on 08/18/2025 at 12:33 PM, Registered Nurse (RN) #13 reviewed Resident #41's electronic medical record (EMR) and stated the resident should be on continuous supplemental oxygen at a rate of 2 LPM. During a concurrent observation and interview on 08/20/2025 at 8:06 AM, State Tested Nurse Aide (STNA) #15 looked at Resident #41's oxygen concentrator and stated, Right now it [the oxygen concentrator] is on at 1.5 LPM. The observation revealed STNA #15 exited the resident's room and did not tell the nurse about Resident #41's oxygen flow rate. During a concurrent observation and interview on 08/20/2025 at 8:59 AM, Licensed Practical Nurse (LPN) #14 checked Resident #41's oxygen concentrator and stated the setting was below 2 LPM but above 1.5 LPM. During an interview on 08/21/2025 at 4:01 PM, the Administrator stated she expected staff to follow orders for oxygen administration.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure dented cans were discarded, food items were dated and labeled, and kitchen staff washed their hands utilizing proper technique. These failures had the potential to affect all residents who received meals from the dietary department. Findings included:A facility policy titled, Food Storage, revised 11/2024, indicated, Policy Statement- Food shall be received and stored in a manner that complies with safe food handling practices. The section titled, Policy Interpretation and Implementation revealed, 5. Dry foods will be labeled and dated. Such foods will be rotated using first in - first out system. 6. All foods stored in the refrigerator and freezer will be covered, labeled and dated. a. Refrigerated, ready to eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or date by which the food shall be consumed or discarded when held at 41 degrees F [Fahrenheit] for a maximum of 7 days. The date of preparation counted as day 1. b. Refrigerated, ready to eat, time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held over 24 hours, to indicate the date or date by which the food shall be consumed or discarded when held at 41 degrees F for a maximum of 7 days. The date of preparation shall be counted as day one and date marked may not exceed a manufacturer's use by date if the manufacture determined the use by date based on food safety. A facility policy titled, Handwashing/Hand Hygiene Policy Interpretation and Implementation, reviewed 04/28/2025, indicated, Washing Hands 1. Wet hands first with water, then apply an amount of product recommended by the manufacturer to hands. 2. Rub hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers. 3. Rinse hands with water and dry thoroughly with a disposable towel. 4. Use a towel to turn off the faucet. A concurrent observation and interview on 08/18/2025 at 9:25 AM, revealed the Dietary Supervisor washed her hands for about eight seconds prior to entering the dry pantry. The Dietary Supervisor stated she did not know why she washed her hands in haste, she was just in a hurry, and she knew better. The Dietary Supervisor stated the expectation was to wash hands for at least 15 seconds. The Dietary Supervisor stated the risk to residents was foodborne illness. A concurrent observation and interview on 08/18/2025 at 9:27 AM revealed two 50-ounce tomato soup cans in the dry pantry area. One 50-ounce tomato soup can was dented and the other was dented and breached. The Dietary Supervisor stated the spillage from the breached can looked like mold. A concurrent observation and interview on 08/18/2025 at 9:33 AM revealed six meat patties stored in an unlabeled foam container in a refrigerator. The Dietary Supervisor stated the meat patties may have been leftovers from a meal served, the facility held leftovers for seven days, and the expectation was to count the day of opening as day one. The observation also revealed a clear plastic bag with white onion slices and a use by date of 08/20/2025, but no preparation date. A concurrent observation and interview on 08/18/2025 at 9:38 AM revealed an opened, unsealed box of frozen pizza slices; an unsealed clear plastic bag containing five pounds of garlic bread sticks that were not labeled and not dated; and egg patties that were not dated or labeled. The Dietary Supervisor stated the expectation was that all food items be sealed with open and use-by dates. A concurrent observation and interview on 08/20/2025 at 9:26 AM revealed [NAME] #17 did not wash with soap for at least 15 seconds. [NAME] #17 stated she got nervous, and she was supposed to turn on the water, use soap, scrub for 20 seconds, rinse thoroughly, grab a paper towel, dry her hands, and use the paper towel to shut off the water. [NAME] #17 stated not washing hands properly could make residents sick. A concurrent observation and interview on 08/20/2025 at 9:28 AM revealed Dietary Aide #16 washed her hands, shut off the water with her hands, and grabbed a paper towel to dry her hands. Dietary Aide #16 stated she was supposed to leave the water running and use a paper towel to shut off the water after drying her hands. Dietary Aide #16 stated she did not know why she did not use paper towels to shut off the water. She further stated not washing hands properly could make residents sick. During an interview on 08/20/2025 at 2:10 PM, the Administrator stated the expectation for food labeling and storage for the kitchen staff was that they followed regulations and that all food was stored and labeled according to regulations and guidelines. The Administrator stated all kitchen staff were responsible for the proper labeling and storage of food items. The Administrator stated it was important to label and store food items properly to ensure palatability and food safety, and, if food was not labeled and stored properly, there may be potential for foodborne illness. The Administrator stated the expectation for kitchen staff when washing hands was that they should turn the water on, use hot water, use soap, scrub for 20 seconds, rinse thoroughly, dry hands with a clean paper towel, and use a clean dry paper towel to turn off faucets. The Administrator stated she did not know why kitchen staff did not properly wash their hands during the survey, and it was important for staff to wash hands properly to avoid illness. The Administrator stated she expected dented cans to be properly disposed. The Administrator further stated that dented cans were kept in the manager's office until the damaged items could be returned to their vendor.

Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure residents were free of significant medication errors. This affected one resident (Resident #150) of three reviewed for medication errors. The facility census was 130 residents.
Findings include
Review of the medical record for Resident #150 revealed an admission date of 04/09/25 with diagnoses including atrial fibrillation, protein calorie malnutrition, dementia, depression, and transient ischemic attacks.
Review of the care plan for Resident #150 initiated on 04/09/25 revealed the resident had a potential for cardiac complications related to atrial fibrillation with interventions including to administer medications per orders.
Review of the Minimum Data Set (MDS) assessment for Resident #50 dated 04/15/25 revealed the resident had minimal cognitive impairment and required supervision and assistance from staff with activities of daily living (ADLs)
Review of the physician's orders for Resident #150 revealed as order dated 04/24/25 per the resident's primary care provider for Diltiazem 180 milligrams (mg) one tablet by mouth every day.
Review of physician's orders for Resident #150 transcribed by facility staff on 04/24/25 revealed an order for Dilantin 180 mg one tablet by mouth every day.
Review of the Medication Administration Record (MAR) for Resident #150 dated 04/25/25 revealed the resident received Dilantin 180 mg one tablet by mouth on 04/25/25
Review of the Medication Error Form for Resident #150 revealed the resident received Dilantin instead of Diltiazem due to an error in transcription by the facility staff.
Interview on 06/13/25 at 1:00 P.M. with the Director of Nursing (DON) confirmed there was a medication error involving Resident #150 which occurred on 04/25/25. Resident #150 was supposed to received Diltiazem 180 mg but instead got Dilantin 180 mg due to a transcription error. The facility provided education to Licensed Practical Nurse (LPN) #840, the nurse involved with the error for Resident #150, regarding the importance of properly transcribing medications following any changes by the physician.
Review of the facility policy titled Administering Medications Policy revised 2022 revealed medications were to be administered in a safe and timely manner and as prescribed.
This deficiency represents noncompliance investigated under Complaint Number OH00165207.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews, review of facility Self Reported Incidents (SRIs), and review of facility policy, the facility failed to ensure a SRI was filed with the State Agency following an allegation of sexual abuse. This affected one resident (#83) out of the three residents reviewed for abuse. The facility census was 136.
Findings include:
Record review for Resident #83 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included bipolar disorder, anxiety disorder, and dementia.
Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/29/15, revealed the resident was assessed by staff to have a long term memory problem.
Review of the physicians order, dated 12/30/24, revealed the resident was to be referred to a gynecologist related to vaginal bleeding.
Review of the gynecologist visit note, dated 01/28/25, revealed resident in with acute bleeding for one month duration status post complete hysterectomy and Computed Tomography (CT) scan showed no uterus. emergency room (ER) reported on 01/16/25 speculum was full of blood and cleaned once, filled up with blood again. Patient has dementia and reported being sexually active with husband and bleeding started after sex. Physical exam revealed no blood in vagina, intact cuff, urethral meatus normal, external genitalia normal. Assessment/plan- no active vaginal bleeding, concern for prior vaginal laceration based on ER report from 01/16/25. Laceration likely has healed, vaginal cuff intact. The potential of an acute vaginal laceration raises concern for potential sexual assault. Unable to fully assess patient due to mobility issues. Visualization was poor but confident no longer actively bleeding from the vagina. Unable to visualize if possible prior laceration.
Review of the SRI's filed by the facility revealed no SRI was filed with the State Agency related to the potential sexual assault alleged by the physician at the gynecologist office.
Interview with the Administrator on 02/24/25 at 2:45 P.M. confirmed there had not been an SRI filed with the State Agency following the documented allegation of sexual assault from the gynecologist office.
Review of the facility policy titled, Abuse, Neglect, Exploitation, and Misappropriation of Resident Property, implemented on 09/15/21, revealed if the event that caused the allegation involves abuse or serious bodily injury, it should be reported to the State Agency immediately, but no later than two hours after the allegation was made.
This deficiency represents non-compliance investigated under Complaint Number OH00162528.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the facility investigation, staff interview, and review of the facility handbook, the facility failed to ensure the resident environment was free of potentially hazardous substances/prescription medications. This affected one (Resident #130) of three residents reviewed for accidents and accident hazards. The facility census was 130.
Findings include:
Review of the medical record for Resident #130 revealed an admission date of 04/04/23 with diagnoses including frontotemporal neurocognitive disorder, diabetes mellitus type two, rhabdomyolysis, dementia, anxiety, dehydration, falls, hematuria, and polyosteoarthritis.
Review of the quarterly Minimum Data Set (MDS) assessment for Resident #130 dated 04/15/24 revealed the resident had severely impaired cognition.
Review of the progress note for Resident #130 dated 05/24/24 timed at 10:35 A.M. revealed the resident was sent to the hospital for evaluation and possible treatment for ingestion of medications not prescribed for the resident.
Review of facility investigation revealed on 05/02/24 staff found Resident #130 in his room with two medications that belonged to State Tested Nursing Assistant (STNA) #30 in the resident's possession. The resident had found medication bottles containing Wellbutrin (an antidepressant) and Adderall ER (a stimulant medication and a controlled substance) in STNA #30's purse which had been left unattended in the resident dining room. Resident #130 had the bottles of Wellbutrin and Adderall in his possession with one bottle opened and the other remaining closed. Interview with STNA #30 confirmed she could not recall or verify how many individual medications were in either bottle, or how many were taken. STNA #30 further confirmed she had left her purse on the table in the resident dining room while she took her lunch break. A visiting family member had informed staff that Resident #130 was looking through the purse when no staff was around. Two staff members went searching for the resident and found him in his room with both medicine bottles.
Review of facility transfer report revealed Resident #130 was sent to the hospital on [DATE] after possible ingestion of two medications that were not prescribed to him.
Review of hospital records for Resident #130 dated 05/02/24 revealed the hospital conducted blood tests to determine if the resident had ingested Wellbutrin or Adderall and determined the resident's blood was negative for both substances. The resident returned to the facility with no new orders.
Interview on 05/24/24 at 11:00 A.M. with the Director of Nursing (DON) and Administrator confirmed STNA #30 acknowledged she did not properly secure her personal belongings on 05/02/24 when she left her purse containing bottles of Wellbutrin and Adderall unattended in the resident dining area. Further interview confirmed Resident #130 was found in his room with STNA #30's purse and the bottles of Wellbutrin and Adderall in his possession with one pill bottle open.
Interview on 05/24/24 at 12:15 P.M with Registered Nurse (RN) #10 confirmed she responded to the room of Resident #130 on 05/02/24 when staff reported the resident had taken two bottles of medication from a staff members' personal belongings.
Review of the employee handbook undated under the section titled Personal Property on page 25 revealed all employees were responsible for securing/storing their own personal property.
This deficiency represents noncompliance investigated under Complaint Number OH00153629.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to ensure a resident's mental health diagnoses were accurately coded on the Pre-admission Screening and Resident Review (PASARR). This affected two (#44, #96) of four residents reviewed for PASARR. The facility census was 134.
Findings include:
1. Record review revealed Resident #44 was admitted to the facility on [DATE] diagnoses included depression, lung disease, anxiety, unspecified dementia with behaviors, and heart failure.
Review of Resident #44 quarterly Minimum Data Sets (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired and required extensive assistance with bed mobility, transfer, dressing and toileting.
Review of Resident # 44's PASARR dated 08/31/20 revealed Resident #44 did not have any mental health diagnoses.
Review of Resident #44's face sheet dated 09/02/20 revealed Resident #44 admitted to the facility with diagnoses of depressive disorder and anxiety.
Interview with the Social Worker (SW) # 204 on 09/01/22 at 10:11 A.M. verified Resident #44's mental health diagnoses including mood disorder, anxiety, and unspecified dementia with behavioral disturbance were not listed on Resident #44's 08/31/20 PASARR. SW #204 noted another PASSAR was not completed to reflect these changes.
2. Review of the medical record for Resident #96 revealed an admission date of 10/11/19 with diagnoses including unspecified dementia with behaviors (11/22/19), major depressive disorder (03/23/20), anxiety (11/22/19), and psychotic disorder with delusions (04/16/20).
Review of the annual MDS dated [DATE] revealed Resident #96 had severe cognitive impairment with delusions, and physical and verbal behaviors directed towards others. The MDS indicated Resident #96 was not considered by state level II PASRR process to have a serious mental illness or related condition.
Review of the PASRR dated 10/11/19 indicated Resident #96 had no indications of serious mental illness.
An interview on 09/01/22 at 10:08 A.M. with Social Services #204 and #216 confirmed the PASRR for Resident #96 was not updated with new diagnoses of major depressive disorder and psychotic disorder with delusions added in 2020.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure Resident #96 received appropriate nail care. This affected one of four residents reviewed for activities of daily living. The facility census was 134.
Findings include:
Review of the medical record for Resident #96 revealed an admission date of 10/11/19 with diagnoses including unspecified dementia with behaviors, psychotic disorder with delusions, depression, anxiety and congestive heart failure.
Review of the quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #96 had severe cognitive impairment with delusions, physical and verbal behaviors directed towards others. Resident #96 required extensive assistance of two persons for personal hygiene and was totally dependent on two persons for bathing.
Review of the plan of care revealed Resident #96 needed staff assistance to complete activities of daily living.
Review of the shower sheets for Resident #96 from 07/04/22 through 08/29/22 revealed the nurses signature ensured the resident had been provided nail care with the shower.
Observations on 08/30/22 at 9:33 A.M. and at 3:22 P.M. and on 08/31/22 at 9:55 A.M. revealed Resident #96 to have long, jagged fingernails with a brown and black substance underneath the fingernails.
An interview on 08/31/22 at 10:05 A.M. with State Tested Nursing Assistant (STNA) #8 confirmed Resident #96 fingernails were long and jagged with a brown and black substance underneath the fingernails. STNA #8 stated nail care would be provided with showers and as needed.

Based on record review, observation and interview, the facility failed to prepare and serve the puree diet as planned by a Registered Dietitian for Residents #40, #28, # 22, #75, #68, #23, #2, and #20. The facility census was 134.
Findings Include:
Record review for Resident # 40 revealed admission date of 06/01/22, medical diagnosis of Alzheimer's disease and No Added Salt puree diet order.
Record review for Resident #28 revealed admission date of 12/05/17, medical diagnosis of dementia with behavioral disturbance and Regular puree diet order.
Record review for Resident # 22 revealed admission date of 10/03/19, medical diagnosis of Alzheimer's Disease and Regular, puree, nectar consistency diet order.
Record review for Resident # 75 revealed admission date of 04/01/22, medical diagnosis of Atrial Fibrillation and No Added Salt, No Concentrated Carbohydrate and puree consistency diet order.
Record review for Resident #68 revealed admission date of 03/08/22, medical diagnosis of unspecified convulsions and No Added Salt puree diet order.
Record review for Resident #23 revealed admission date of 10/24/19, medical diagnosis of Alzheimer's Disease and Regular, nectar consistency, puree diet order.
Record review for Resident #2 revealed admission date of 11/03/21, medical diagnosis of dementia with behavioral disturbance and No Concentrated Sweets, honey consistency and puree diet order.
Record review for Resident #20 revealed admission date of 11/23/20, medical diagnosis of chronic congestive heart failure and No Added Salt, No Concentrated Sugar, nectar consistency and puree diet order.
Review of lunch menu spreadsheet dated 08/31/22 revealed the puree diet was to consist of six ounces of puree lasagna with two ounces sauce, a number eight scoop serving size of puree green beans and a number 12 serving size of puree roll.
Observation on 8/31/22 at 9:35 A.M. revealed [NAME] #260 pureed the roll/bread with the green beans in the blender. There was no separate serving of roll/bread.
Interview on 08/31/22 at 9:40 A.M., [NAME] #260 verified she had pureed the green beans with the bread. She stated she purees the vegetable with the bread because it dries out on the steam table during serving time.
Interview on 08/31/22 at 11:35 the Registered Dietitian, (RD) #90 verified the puree roll/bread should have been pureed separately and served separately from the green beans.
Review of the Puree Recipe Guidelines, undated, revealed directions to follow the spreadsheet when preparing puree foods.

Based on observation and interview, the facility failed to store foods, discard expired foods and monitor refrigerator temperatures. This had the potential to affect 133 residents who received food from the kitchen. The facility census was 134.
Findings include:
Observation on 08/29/22 at 10:05 A.M. revealed following sanitation violations in the main kitchen:
1. Open container of syrup dated 08/13/21 with no open or use by date in the dry storage area.
2. In the reach in refrigerator, six containers of liquid, identified as juice, with no label or date
3. Three reach-in refrigerators temperature monitoring logs not completed of random dates totaling 85 missing temperature entries.
Observation on 08/29/22 at 10:30 A.M. revealed following sanitation violations in Parkview satellite kitchen:
1. In the reach in refrigerator, three containers of liquid, identified as juice, with no label or date.
2. One reach in refrigerator temperature monitoring log not completed of random dates totaling 54 missing temperature entries.
Observation on 08/29/22 at 10:40 A.M. revealed following sanitation violations in the Birch satellite kitchen:
1. One reach in refrigerator temperature monitoring log not completed of random dates totaling 48 missing temperature entries.
2. In the dry storage area, an open loaf of bread with no open or use by date.
3. In the reach in refrigerator, six containers of liquid, identified as juice, with no label or date.
4. Opened, unlabeled bag of darkened, browned green vegetable, identified as lettuce, with no open or
use by date.
Interview on 08/29/22 at 10:40 Diet Manager Assistant, #98 verified the foods should have been labeled and dated, including the containers of juices, the lettuce and bread loaf. The refrigerator temperature monitoring logs should have been completed. She verified the skilled facility residents receive foods from the main kitchen, Parkview satellite and Birch satellite kitchens.
Review of the facility policy, Food Storage, dated 01/20/22, revealed dry food will be labeled and dated. All foods stored in the refrigerator will be covered, labeled, and dated. Refrigerated food will indicate the date the food shall be consumed or discarded for a maximum of seven days. Functioning of the refrigeration will be monitored at designated intervals throughout the day.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident and staff interview, the facility failed to notify the a resident of a change in medications. This affected one resident (#85) of one reviewed for care planning. The facility census was 135.
Findings include:
Medical record review revealed Resident #85 was admitted to the facility on [DATE] with diagnoses including displaced fracture of right femur, type 2 diabetes, cirrhosis of liver, and major depressive disorder.
Record review of the Minimum Data Set (MDS) assessment completed on 10/10/19 revealed Resident #85 was cognitively intact.
Review of physician orders dated 11/06/19 for Resident #85 revealed the resident had a change from Ensure nutritional supplement to Glucerna nutritional supplement, before meals and at bedtime. The resident also had a change in Calcium Citrate 950 milligrams (mg) every morning, from Calcium Citrate 975 mg every morning. There was no documentation the resident was notified of the change.
Interview with Resident #85 on 12/03/19 at 10:16 A.M. revealed he was not notified of the medication changes. care.
Interview with the Director of Nursing (DON) on 12/05/19 at 1:44 P.M. verified there was no notification to Resident #85 of the changes in medication and the supplement.

Based on observation, staff interview, facility policy review, and review of manufacture's guidelines, the facility failed to date open vials of medications. This had potential to affect one Resident (#231) identified by facility as a new admission. The facility further failed to remove expired medications out of active medication use, this had the potential to affect one Resident (#67) for who it was prescribed for. The facility census 135.
Findings include:
1. Observation on 12/03/19 at 4:43 P.M. with Licensed Practical Nurse (LPN) #100 of the medication room on Unit One revealed there was an opened vial of Tuberculin Protein Derivative Diluted Aplisol (TB) with no date when it was opened.
Interview on 12/03/19 at 4:45 P.M. with LPN #100 verified the vial of Tuberculin Protein Derivative Diluted Aplisol was opened and not dated.
Review of the manufacturers recommendations for storage for Tuberculin Protein Derivative Diluted Aplisol, revealed vials in use for more than 30 days should be discarded due to possible oxidation and degradation which may affect potency.
2. Observation on 12/03/19 at 5:24 P.M. with the Director of Nursing (DON) of the Maple Unit medication room revealed a bottle of Lorazepam (anti-anxiety) Oral Concentrate two milligrams (mg) per milliliter (ml) was opened with the only dose given date 07/26/19. The medication had a 90-day shelf life after opened.
Review of the Controlled Drug Record for Resident #67 revealed the only dose of Lorazepam Oral Concentrate 2 mg/ml was given on 07/26/19.
Interview on 12/03/19 at 5:26 P.M. with the DON verified the Lorazepam Oral Concentrate 2 mg/ml was opened with the only dose given on 07/26/19.
Review of the Lorazepam Oral Concentrate 2 mg/ml manufacturing guidelines revealed to discard opened bottle after 90 days.
Review of the facility policy titled, Storage of Medications, dated 11/27/19 revealed the facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed, some drugs have a shelf life that is different than the expiration date after opening. These drugs shall be labeled with the date opened to ensure that no outdated or deteriorated drugs are stored.