Adams Lane Healthcare And Rehabilitation Center

Based on observations and staff interviews, the facility failed to ensure a safe homelike environment for the 22 (Residents #58, #59, #60, #61, #62, #62, #63, #64, #65, #68, #69, #70, #71, #72, #73, #74, #75, #76, #77, #78, #79, and #80) in the memory care unit when the unit was left with a black moldlike substance in the hallway, and there was a strong odor of urine noted throughout the unit. This affected 22 residents in memory care unit of 94 residents reviewed for environment. The facility census was 94.Findings include: Observations on 07/15/25 from 3:22 P.M.- to 4:05 P.M., a tour of the facility was completed. The facility had an East Unit that was comprised of 100 and 200 halls. They had a North Unit that included the 500, 600, and 700 halls. They had a secure memory care unit that included the 300 and 400 halls. No odors or evidence of residents not receiving proper incontinence care was noted when touring the East and the North Units. Those areas of the facility were free of any odors and none of the residents observed showed signs of incontinence as evidenced by saturated clothing. The memory care unit was toured last and once it was entered and the surveyor walked behind the closed double doors a strong odor of urine was prevalent. The memory care unit was entered at 3:42 P.M. There had been some new vinyl flooring installed throughout the memory care unit. The walls were in disrepair as there was evidence of some damaged walls, peeling wallpaper, and missing baseboards along the base of the wall throughout both hallsOn 07/15/25 at 3:50 P.M., an interview with Licensed Practical Nurse (LPN) #145 revealed the facility was going to have a maintenance party where all the maintenance men from surrounding sister facilities came in and helped with the remodeling on the unit. LPN #145 reported the floors had been replaced about six weeks ago and they had started to patch and sand the walls on the 400 hall. She denied much work, other than the floor, was done on the 300 hall. She indicated it was hit and miss when they were there to work on it. She denied they had any outside construction companies or other contractors to do the work. She reported there used to be carpet in most areas of the unit that had been torn up and replaced. The missing baseboards used to have about eight or nine inches of carpet that came up the base of the wall that had been removed. They had not replaced the baseboard yet and were working on prepping the walls before they painted over the wallpaper. She believed the plan was to paint them gray. She conObservation on 07/16/25 at 9:20 A.M. in the memory care unit (300 and 400 Halls) revealed a strong smell of ammonia with two housekeepers actively cleaning.Interview on 07/16/25 at 9:26 A.M. with Maintenance Director #118 confirmed the 300 /400 hall memory care unit is under renovation. There is a new floor, and the wall repair is in progress. Maintenance Director #118 was reluctant to state the extent of the flood damage or the timeline for fixing the cosmetic damage but confirmed the strong odors in the memory care area were from the cleaning products used to clean the walls this morning.Observation on 07/16/25 at 1:30 P.M. revealed a strong odor of urine in the memory care unit 400 hall. Most residents were in the common area. The strongest urine odor was down the hall away from the common area.Interview on 07/16/25 at 1:35 P.M. with Housekeeper #176 confirmed there was a strong odor of urine in the hallway, and she indicated there was a resident in this hallway that pulls at her urine bag and dumps urine everywhere. Housekeeper #176 stated she was working to get all the rooms clean to help eliminate the odor.Interview on 07/17/25 at 11:45 A.M. with the Director of Nursing (DON) confirmed the strong cleanser smell in the memory care unit on the morning of 07/16/25 was a result of the cleaner used to remove the mold noted on the wall in the hallways where the molding has not yet been replaced that was observed on the walls in the afternoon of 07/15/25.This deficiency represents noncompliance investigated under Complaint Number OH00166441 (1280566).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and review of the facility policies, the facility failed to maintain appropriate infection control and enhanced barrier precautions (EBP) for one (Resident # 87) out of 41 residents in EBP. The facility census was 94. Findings include: Review of the medical record for Resident #87 revealed an admission date of 06/26/25. Diagnoses included metabolic encephalopathy, hypertension, peripheral vascular disease, major depressive disorder, cirrhosis of liver, type two diabetes mellitus, bipolar disorder, and chronic pain syndrome. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of three out of 15, indicating Resident #87 had severe cognitive impairment. The resident was assessed to require partial/moderate assistance for meals/eating, and oral hygiene. Resident #87 was dependent on staff for toileting, shower/bathing, dressing, and personal hygiene. Resident #87 was admitted with one Stage III pressure ulcer (Full thickness tissue loss, subcutaneous fat may be visible but bone, tendon or muscle are not exposed, slough may be present but does not obscure the depth of tissue loss, may include undermining and tunneling). Review of the Care Plan revealed Resident #87 had an open wound on her coccyx/right buttock and her left lateral hip. Resident #87 required EBP related to wound care for skin openings and a history of multi-drug-resistant organism (MDRO). Resident #87 required EBP for dressing, bathing/showering, transferring, personal hygiene, changing linen, toileting, and peri-care. Observation on 07/16/25 at 10:10 A.M. of incontinence care for Resident #87 by Certified Nursing Assistants (CNAs) #207 and #224 revealed Resident#87 was noted to have a sign above her bed for EBP. Resident #87 was cleaned appropriately. Cleaning uncovered an open sore on the left buttock/hip area and reddened open area on right buttock. CNA #224 did the cleaning and removal of the old incontinence brief and then did not change her gloves prior to applying the new incontinence brief. The incontinence care was appropriately timed, and Resident #87 remained comfortable throughout the process. Interview on 07/16/25 at 10:20 A.M. with CNA #224 confirmed the resident had a sign for EBP, and by policy, staff were to wear gloves and a gown when the resident has a catheter, a known infection, or an open wound. CNA #224 indicated Resident #87 received Triad paste as a barrier cream, and Triad paste was considered a medication, so the nurse would need to come and apply it. CNA #87 did not apply a barrier cream, so she did not realize she needed to change her gloves before applying a clean incontinence brief. CNA #224 realized she should change gloves and did perform hand hygiene after Resident #87 was redressed and comfortable in bed. Interview on 07/17/25 at 11:45 A.M. with the Director of Nursing (DON) confirmed during the observed incontinence care for Resident #87, while CNA #224 was performing care she did not change her gloves and do hand hygiene between cleaning the resident and applying a clean incontinence brief as per the facility Incontinence Care Policy. The DON also confirmed that CNAs #204 and #224 did not wear gowns for EBP, they only wore gloves. Review of the facility policy titled Incontinence Care, dated 01/06/25, revealed gloves should be changed and hand hygiene performed after the staff member cleans the resident and before the staff member applies barrier creams to the resident and again before applying clean incontinence briefs and under pads. Gloves should be removed and hand hygiene performed before the staff member changes linen and clothing if needed. Gloves should be removed and hand hygiene performed when the process is complete. Review of the facility policy titled Enhanced Barrier Precautions, dated 01/2025, revealed EBP is used in conjunction with standard precautions when the resident has an infection or colonization with a center for disease control (CDC) - targeted multi drug resistant organism (MDRO) when contact precautions do not otherwise apply; or when the resident has wounds and/or an indwelling medical device even if the resident is not known to be infected or colonized with a MDRO. For residents for whom EBP are indicated, EBP is employed when performing the following hi-contact resident care activities: Dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, during device care, and providing wound care.This deficiency represents noncompliance investigated under Complaint Number OH00166441 (1280566) and Complaint Number OH00166153 (1280565).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on record review, review of a facility self-reporting incident (SRI), review of the facility's related investigation, staff interview, resident interview, family interview, and review of the facility's Abuse Policy, the facility failed to protect Resident #14's right to be free from sexual abuse by Resident #97. This resulted in Immediate Jeopardy and actual harm beginning on 07/08/25 at 7:20 P.M. when Certified Nursing Assistant (CNA) #119 observed Resident #97, who had a history of sexually inappropriate behaviors engaged in non-consensual sexual intercourse with Resident #14, a cognitively impaired and non-interviewable female resident, who lacked the cognitive ability to provide consent to sexual activity. CNA #119 observed Resident #97 lying on top of Resident #14 with his shorts pulled down to his ankles and Resident #14 was noted to be completely naked. Resident #14 was transferred to the emergency room for an evaluation including a SANE exam and a rape kit. Blood work was completed to rule out sexually transmitted diseases (Hepatitis/HIV) and Resident #14 received prophylaxis treatment. Resident #14's immediate reaction at the time of the incident included she was tearful, had scared facial expressions, and reported he hurt me. This affected one resident (#14) of two residents reviewed for sexual abuse. The facility census was 94. On 07/17/25 at 1:12 P.M., the Director of Nursing (DON), Assistant Director of Nursing (ADON), Regional Nurse, Regional Administrator, and Administrator in Training (AIT) were notified Immediate Jeopardy began on 07/08/25 at 7:20 P.M. when the facility failed to protect Resident #14's right to be free from sexual abuse by Resident #97. The Immediate Jeopardy was removed on 07/09/25 and subsequently corrected on 07/10/25 when the facility implemented the following corrective actions:On 07/08/25 at 7:20 P.M. the CNA observed Resident #14 and Resident #97 in Resident #14's bed. Resident #14 was completely naked, and Resident #97 had his shorts pulled down to his ankles lying on top of Resident #14. The CNA immediately intervened and stopped the sexual abuse from occurring separating the two residents. Resident #97 was placed on one-on-one staff supervision to ensure he remained separated from Resident #14, and Resident #14 remained free of further sexual abuse. On 07/08/25 at 7:25 P.M. the Licensed Practical Nurse (LPN) on duty called the facility DON and notified her of the incident between Resident #14 and Resident #97. The DON in turn notified the Executive Director (ED). On 07/08/25 at 7:35 P.M. the DON initiated the facility's investigation of the alleged sexual abuse of Resident #14 and interviewed all on-duty staff at the time of the incident that included four LPNs and four CNAs. On 07/08/25 at 7:45 P.M. the DON and the two LPNs on-duty initiated resident interviews and/or head-to-toe skin assessments on all current residents, excluding the residents residing on the facility's secured dementia unit. All other residents were interviewed and skin assessment completed with no negative findings. On 07/08/25 at 7:49 P.M. the DON completed a head-to-toe assessment on Resident #14. On 07/08/25 at 8:00 P.M., the Executive Director submitted the initial self-reported incident (SRI) of alleged sexual abuse of Resident #14 by Resident #97 to the Ohio Department of Health (ODH) via ODH Application Gateway. On 07/08/25 at 8:04 P.M. the DON called 911 to report the sexual abuse of Resident #14 to local law enforcement and local emergency medical service (EMS). On 07/08/25 at 8:09 P.M. the DON notified Resident #14 and Resident #97's responsible parties and medical providers of the incident that occurred between Resident #14 and Resident #97. On 07/08/25 at 8:20 P.M. the local law enforcement and EMS arrived at the facility. Resident #14 left the facility with EMS to be evaluated in the emergency room of a local hospital. On 07/08/25 at 8:35 P.M. Resident #97 left the facility with law enforcement. Resident #97 remained on one-on-one supervision the entire time from incident to exiting the facility. On 07/08/25 at 9:00 P.M. the DON completed staff interviews with all nursing staff who worked the 500-hall unit that day (4 LPNs and 4 CNAs). On 07/08/25 at 10:15 P.M. the DON completed 72 resident interviews and/or head-to-the-skin assessments to identify any other residents that had potentially been abused. Those residents who could not be interviewed, had a head-to-toe skin assessments completed. On 07/09/25 at 12:20 A.M., Resident #14 returned to the facility. The LPN on duty completed a head-to-toe skin assessment. On 07/09/25 at 12:20 A.M., the LPN on duty updated Resident #14's family on her return and her condition. On 07/09/25 at 8:00 A.M, the DON/ED initiated education with all staff regarding the facility's Abuse Policy with focus on the definition and signs of sexual abuse. On 07/09/25 9:00 A.M., a whole house audit was conducted of all 72 residents residing in the facility to identify any other residents displaying inappropriate sexual behaviors and/or entering other residents' room inappropriately. On 07/09/25 at 10:30 A.M, facility Root Cause Analysis was completed by the [NAME] President (VP) of Clinical and Regional Clinical Support nurse. Facility Root Cause Analysis determined that lack of supervision of Resident #97, who had a history of sexually inappropriate behaviors, lead to the occurrence of an incident. Resident #97 does have a history of sexual behaviors and Tagamet (H2-receptor antagonist) was ordered on 03/05/25. All facility staff were educated on the Abuse Policy with emphasis on sexual abuse. On 07/09/25 at 10:30 A.M., Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was held with the DON, ED, ADON/Infection Preventionist, Medical Director, Regional Clinical Support and VP Clinical Support. The purpose of the meeting was to discuss the incident with the Medical Director to review, develop, and implement corrective actions. On 07/09/25 at 12:10 P.M., the ED notified the State's local Ombudsman of the incident of sexual abuse of Resident #14 by Resident #97. On 07/09/25 at 12:30 P.M., the ED issued an immediate discharge to Resident #97 and his guardian. Resident # 97 remained in custody of local law enforcement at this time. On 07/09/25 at 2:38 P.M the DON and ED completed education with all staff regarding the facility's Abuse Policy with focus on the definition and signs of sexual abuse. Staff educated include ED (1), AIT (1), DON (1), ADON (1), Registered Nurses (RNs) (5), LPNs (29), CNAs (43), Dietary staff (12), Laundry and Housekeeping Staff (15), Activities (3), Therapy (4), Social Services Director (1), Receptionists (2). The facility implemented a plan for the DON or designee to complete ongoing audits by resident interview to ensure there have not been any concerns or allegations of abuse. The audit would be completed with 10 random residents twice weekly for four weeks beginning on 07/08/25, then as determined necessary thereafter. Audit results will be reviewed in QAPI. The facility implemented a plan for the DON or designee to complete ongoing audits by staff interview to ensure they understand the abuse policy and what to do if they have any concerns or allegations of abuse. The audits would be completed with 10 random staff members of any discipline, twice weekly for four weeks beginning 07/08/25, then as determined necessary. Audit results would be reviewed in QAPI. The facility implemented a plan for the DON or designee to complete an observation audit of the residents' environment to ensure no residents were displaying inappropriate sexual behaviors and/or entering other residents' rooms inappropriately. Audits would be completed twice weekly for four weeks beginning 07/08/25, then as determined necessary. Results of audits would be reviewed in QAPI. On 07/10/25 at 3:00 P.M., the facility submitted conclusion of SRI to the ODH via ODH Application Gateway substantiating allegation of sexual abuse of Resident #14 by Resident #97. Findings include: Review of Resident #14's medical record revealed the resident was admitted to the facility on [DATE] with the diagnoses including memory deficit following a cerebral infarction, encephalopathy (group of conditions that cause brain dysfunction that can appear as confusion, memory loss, and personality changes), anxiety disorder, depression, and post-traumatic stress disorder (PTSD). The resident's most current weight listed was 110 pounds. Review of Resident #14's active care plans revealed a plan of care initiated 08/12/24 related to PTSD. The care plan identified the resident as having PTSD and was a known rape survivor. The care plan indicated the resident had been physically and sexually assaulted by a guy. The resident's triggers included yelling, loud noises, and approaching her in a fast manner. The goal was for the resident to have a decreased effect from her triggers daily. The interventions included offering the resident empathy, compassion, and support as needed. Review of Resident #14's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had adequate hearing without the use of a hearing aid and clear speech. She was able to make herself understood and was usually able to understand others (misses some part/ intent of message but comprehends most of the conversation). The resident's vision was adequate with the use of corrective lenses. The assessment revealed the resident's cognition was severely impaired, and she was known to have physical behavioral symptoms directed towards others that occurred one to three days of the seven-day assessment period. The resident was not known to reject care. She did not have any functional limitation in her range of motion and used a wheelchair as a mobility device. The resident was dependent on staff for upper and lower body dressing and required substantial/ maximum assistance for transfers. Review of Resident #14's progress note revealed a nurse's note by the facility DON dated 07/08/25 at 7:20 P.M. that indicated Resident #14 had an observed resident interaction with a male resident. The staff were indicated to have intervened and separated. Resident #14 was assessed without negative effects. The resident's physician and resident representative were notified. A nurse's progress note by the DON on 07/08/25 at 8:20 P.M. revealed the resident was transferred out of the facility via EMS to a local emergency room (ER) for an evaluation. She returned to the facility on [DATE] at 12:20 A.M. in stable condition. Review of the resident's medical record revealed no nursing progress was entered by LPN #215, the nurse on duty at the time of the incident and who was assigned to care for Resident #14. The DON, who authored the progress note above, was not present in the facility at the time of the incident. The DON arrived to the facility 30-45 minutes after she was called and informed of the incident. The DON documented the effective date and time in the note she authored in the resident's medical record. Further review of Resident #14's progress notes revealed a nurse practitioner (NP) note dated 07/09/25 (untimed) that indicated the resident was being seen for a hospital follow up on a sexual assault. The resident was seen in the ER on [DATE]- 07/09/25 after a sexual assault. She was evaluated by the Sexual Assault Nurse Examiner (SANE) nurse. There were no signs of trauma or penetration to the oral cavity, rectum, or vagina. The resident was treated with prophylactic antibiotics, and a referral was placed to infectious disease. A Hepatitis panel and HIV test obtained at the hospital were unremarkable/ negative. The NP indicated she was unable to obtain a full review of systems due to the resident's cognitive impairment. Review of Resident #14's ER notes for her ER visit on 07/08/25- 07/09/25 (3 hours) revealed the resident had been seen for a reported sexual assault. She was diagnosed with a sexual assault of an adult, treated with prophylactics (Metronidazole 2000 milligrams (mg), Azithromycin 500 mg, and Rocephin 500 mg with Lidocaine intramuscularly) and discharged back to the nursing facility. A Hepatitis panel and HIV tests were administered at the hospital and found to be non-reactive at the time. The resident was to follow up with the infectious disease clinic. Review of Resident #97's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including major depressive disorder, severe, recurrent and without psychotic features, adjustment disorder with depressed mood, morbid obesity (severe), and antisocial personality disorder. The resident's most recent weight was 462 pounds.Review of Resident #97's progress notes revealed a nurse's note dated 03/04/25 at 10:07 P.M. by the DON that indicated the on-call physician service was updated on the resident entering another resident's room. Review of a social service note dated 03/05/25 at 8:13 A.M. revealed a referral had been made to a sister facility for Resident #97 to be transferred to their behavioral unit. The social worker indicated she would follow up and assist as needed. Review of a nurse's note dated 03/05/25 at 10:40 P.M. revealed the nurse manager for Resident #97's unit spoke with both the house NP and the psychiatric NP with a new order being given for Tagamet 200 mg po twice daily (BID) on a scheduled basis. The note indicated the resident was to remain on one-on-one supervision until 3:00 P.M. that day and then he was to be on every 15-minute checks for the next 72 hours. Review of Resident #97's active care plans revealed a plan of care initiated 03/05/25 indicating the resident had sexually oriented behaviors. The resident exhibited sexually inappropriate behavioral symptoms due to severe mental illness as evidenced by physical touching and grabbing. The goal was for the resident to comply with staff redirection and behave in a safe and respectful manner. Interventions included conducting an evaluation of the sexually oriented behavioral symptoms to determine what the resident was communicating through the behavior (e.g. need to feel in control, feeling inadequate, feeling angry/ hostile and disrespectful towards himself, and projecting those feelings onto others). The care plan also included the need to intervene and redirect when any inappropriate behavior was observed, communicate assertively the resident must exercise control over his impulses and behaviors, remind the resident to refrain from inappropriate touching, and refer the resident for a psychiatric evaluation and utilize psychoactive medications as warranted. Review of Resident #97's most recent quarterly MDS assessment dated [DATE] revealed the resident did not have any communication issues. The resident was able to make himself understood and was able to understand others. The assessment revealed the resident was cognitively intact and not known to display any behaviors during the seven-day assessment period. The resident did not have any functional limitations to his range of motion and did not require the use of any assistive devices for mobility. The assessment revealed the resident required supervision or touching assistance for transfers and ambulation. Review of a facility self-reported incident, tracking number 262557 dated 07/08/25 revealed the facility reported an allegation of sexual abuse involving Resident #97 and another female resident (Resident #14). Resident #97 was the alleged perpetrator and Resident #14 was the involved resident/ victim. The SRI revealed neither of the residents were able to provide any meaningful information when interviewed. Witnesses to the sexual abuse were identified as CNA #112, CNA #119, and LPN #215. The date/ time/ location of the occurrence was on 07/08/25 at 7:20 P.M. in Resident #14's room. The narrative summary of the incident revealed a CNA entered the room of Resident #14 and saw Resident #97 lying on top of Resident #14 in bed. Neither resident had clothes on. Both residents were immediately separated, and Resident #97 was placed on one-on-one supervision. Local law enforcement was notified. Resident #97 left the facility with the local law enforcement, and he was on one-on-one supervision from the time of the incident until he left with law enforcement. Resident #14 was sent to the ER for an evaluation and returned to the facility later that same night. The SRI included a head-to-toe skin assessment was completed on Resident #14 (after the incident) with no negative findings, signs of trauma, or injuries. The facility substantiated the allegation of sexual abuse based on their investigation. The facility DON was identified as the investigator of the allegation. Review of the facility's related investigation revealed personal witness statements were obtained from the two involved residents, Resident #14's roommate, and the three staff members identified as witnesses to the sexual abuse. Review of Resident #14's personal witness statement revealed a verbal statement was obtained from the resident by the DON regarding the incident that took place on 07/08/25 at 7:20 P.M. The statement was obtained on 07/08/25, without a time indicated. The resident was asked a series of four questions. She was asked if he (Resident #97) touched her and she replied yes. She was asked if he touched her with his hands and she replied yes. She was asked if he touched her with his penis and she said yes. She was then asked if she had any pain and responded no.Review of Resident #97's personal witness statement revealed a verbal statement was obtained from the resident by the DON regarding the incident that took place on 07/08/25 at 7:20 P.M. The statement was obtained on 07/08/25, but no time was indicated for when the statement was obtained. Resident #97 was asked what he was doing? He did not answer at first, but then finally stated I was just in visiting. Review of a personal witness statement obtained from Resident #15 (roommate of Resident #14) by LPN #215 on 07/08/25 at 8:35 P.M. regarding the incident occurring on 07/08/25 (time of incident not specified) revealed she did not see anyone enter the room. She did see him close the curtain. She could hear her roommate (Resident #14) asking for help. She started to yell and stopped. She then heard the aide open the door and tell him to get out. After that, the nurse came in. She thought the other male resident was in the room for about 10 minutes. Review of a personal witness statement from CNA #119 for the incident dated 07/08/25 at 7:20 P.M. revealed she and CNA #112 were looking for a dog toy when they were told Resident #14 was the one who had it last. When she went to Resident #14's room, knocked, and entered she saw Resident #14 and Resident #97 on the bed. Resident #14 was naked with her head on the pillow and her hands clasped together over her chest. Resident #97 had his shirt on and his shorts were down between her (Resident #14's) legs with what looked like his penis in her vagina. She told him (Resident #97) that this wasn't going to be happening. Resident #97 stood up grunting, pulled his shorts up, and then balled his fist while walking towards her. She told him he did not want to do this, and he then walked out the door. She shut the door and went to the bed and noticed Resident #14's depend (incontinent brief) was on her bedside table. Her shoes were beside the wall on the bed. She asked Resident #14 if she was okay and if it was consensual. Resident #14 replied no, he hurt me. CNA #14 then reported she started to put Resident #14's hospital gown on her so she would be covered up. CNA #112 then walked in and the aide told her to go get the nurse and also told the other aide what had happened. LPN #215 came in and she told her what she had seen. LPN #215 contacted the supervisors while she and the other aide stayed outside Resident #97's room until the local law enforcement arrived. She indicated in her statement that she had just seen Resident #14 approximately 20 minutes prior and the resident was in her wheelchair in the lobby playing with a staff member's puppy. Review of a personal witness statement from CNA #112 for the incident occurring on 07/08/25 at 7:20 P.M. given on 07/08/25 (no time indicated) revealed she walked into Resident #14's room and saw that she was naked. The aide that she was training (CNA #119) told her Resident #97 was on her (Resident #14) while she was naked and Resident #97 was naked from the waist down. CNA #119 told her Resident #97's penis was inside of Resident #14 and that he was touching her also. CNA #119 then told Resident #97 to get up. He got up, dressed, and left the room. She confirmed they had just seen Resident #14 20 minutes prior out in the lobby playing with a staff member's puppy while up in her wheelchair. Review of a personal witness statement from LPN #215 for the incident occurring on 07/08/25 at 7:20 P.M. given on 07/08/25 (no time indicated) revealed she was alerted by a CNA that a resident (Resident #97) was found on top of another resident (Resident #14) with his pants around his ankles and he was seen having intercourse. Upon entering the room, both residents were immediately separated. Vital signs were collected, and skin was assessed. She then notified appropriate staff. Both residents were placed on one-on-one supervision until EMS/ local law enforcement arrived. On 07/16/25 at 10:25 A.M., an interview with CNA #119 revealed it was her first day working at the facility when the incident between Resident #14 and Resident #97 occurred on 07/08/25. She stated she had been a CNA for 20 years in the past but had taken a different job outside of healthcare in the past five years. She confirmed she was one of the day shift aides working from 7:00 A.M. to 7:00 P.M. weekend. She further confirmed she was the staff member who found the two residents (#14 and #97) in bed and naked. The incident occurred at 7:20 P.M. She stated she was still there at the time as her relief was running late. She was being trained by CNA #112. She reported she and CNA #112 were looking for a dog toy and had been told Resident #14 was the last one known to have it. She went to Resident #14's room, knocked on the door, and entered finding Resident #14 in bed with her gown off and her incontinence brief lying across the bedside table. Resident #14's shoes were on her bed by the wall. Resident #14 had been in a hospital gown that evening. Resident #97 was lying on top of Resident #14 with his short pulled down. Resident #97 was thrusting his hips into Resident #14 and was making grunting noises. It looked as if his penis was inside of Resident #14. When Resident #97 stood up, he had some kind of liquid on his erect penis. She described the liquid as like fluids but was not sure if they were Resident #97's or Resident #14's. She was also not sure if the fluid was semen or urine. She stated, it just appeared like they were having sex. Resident #14 had her hands clenched in a fist and next to each other over her breast. She denied Resident #14 was making any sounds and did not hear Resident #14 say anything. She stated she saw a tear coming down the side of Resident #14's face and she had a scared look on her face. She had seen Resident #14 minutes prior to that incident in the lobby petting a dog. She was up in her wheelchair at the time and dressed in a gown. She had an incontinence brief on and was wearing shoes, as she was ready for bed. With the way Resident #14 went around in her wheelchair, she did not feel Resident #14 would have been able to transfer herself from the wheelchair to bed. She stated when she walked in and found them, she said oh no, we are not doing this. She then told Resident #97 he needed to get out of Resident #14's room. Resident #97 then started to get up, pulled his pants up, and made a growling noise. She was not sure at the time if Resident #97 was non-verbal or not. He balled his fist at her as he passed her by when leaving the room. After Resident #97 left the room, she went to Resident #14 and asked her if she was okay. Resident #14 replied no, he hurt me. She then put Resident #14's gown on her as she was trying to cover up her breasts. The other aide (CNA #112) peeked in the room at that time, and she told the other aide to go get the nurse as she believed Resident #14 had been raped. The other aide got the nurse (LPN #215) and the nurse came right in. She then informed LPN #215 what she walked in on, and the nurse notified the ADON and the DON. Another aide then came to sit with Resident #14 while she and CNA #112 sat outside the room of Resident #97. They sat outside his room to ensure the two residents remained separated from one another until the local law enforcement and EMS arrived. Resident #97 just sat in his room on his bed moving his hands up and down his leg while tapping his feet on the floor. She was not familiar with Resident #97 at the time to know if he was cognitively intact or not. Resident #97 resided on the same hall as the SR and his room was catty-corner from hers. They remained with Resident #97 until the police arrived. She then went to the shower room twice with the law enforcement officer to give them an account of what had happened. The second time she went to the shower room was so the law enforcement officer could ask her if she had cleaned Resident #14 after the incident. She informed the law enforcement officer that she had not and put the same gown on her that she had on prior to the incident. She remained in the facility until all the interviews were done and all the evidence was bagged. The Law enforcement officer then walked Resident #97 out of the building. She filled out an incident report for the DON before she left the facility around 10:00 P.M. that night. She confirmed what she filled out was the personal witness statement and further confirmed the statement in the facility's investigation was what she had written. She reported she had just come from the county courthouse earlier that morning (prior to her interview) where she had to give testimony to the Grand Jury. She stated the Prosecutor had indicated they were debating on whether the charges against Resident #97 would include any federal charges. If convicted for what they were wanting to charge him with, he could get between 66 and 88 years. On 07/16/25 at 3:05 P.M., an interview with CNA #112 confirmed she was working on 07/08/25 when the incident occurred between Resident #14 and #97. She recalled it was sometime around shift change and thought it was probably 7:25 P.M. to 7:30 P.M. when it happened. She only seen the aftermath of what had happened. She walked into Resident #14's room to check on her coworker (CNA #119) who she was training. Her coworker was the one that had seen what happened and separated the two residents. She suspected she went to check on CNA #119 about five to 10 minutes after CNA #119 went to Resident #14's room. By the time she arrived at Resident #14's room, Resident #14 was still undressed, and CNA #119 was in the process of redressing the resident. She was told what had happened and then she left the room to get the nurse. She confirmed LPN #215 was the nurse working who she went to get. Resident #97 was already in his room when she arrived at Resident #14's room, which was catty-corner from Resident #14's room. She was familiar with the two residents involved prior to the incident, as she would often help the aides on the 500 hall. Resident #14 was normally up in the lobby area by the nurses' station on the North unit. She denied she had any prior interactions with Resident #97 before that incident. She was a little bit familiar with him. She reported that Resident #14 needed help transferring in and out of bed. She described Resident #14 as a two-person assist that needed substantial to maximum assistance for transfers. Resident #14 was non-ambulatory and had the use of a wheelchair. She was only able to stand and pivot when transferred. She reported that Resident #14 was able to undress herself at times but normally needed help doing so. She denied she had ever noted Resident #14 to remove her own clothing herself. She was usually dressed in a T-shirt or long-sleeved shirt and sweatpants. When she went to bed or on shower days, she had a gown on. When she saw Resident 14, the resident had always been dressed in clothes. She reported Resident #14 was normally confused but the level of confusion depended on the day. She was able to talk in short sentences but could not carry a conversation on with you. She had heard Resident #14 say please help or the resident would tell her thank you. Resident #14 could also get agitated, anxious, and restless at times but for the most part was relaxed. She described Resident #97 as being independently ambulatory. He was typically in his room, in the dining room, or outside to smoke. He was known to visit other residents (naming a male resident he visited on the 700 hall) but denied knowledge of Resident #97 visiting any female residents prior to that incident. She then recalled there was one time when Resident #97 did go into one female resident's room a while back. She identified that female resident as Resident #68, who used to reside on the 600 hall. That female resident had since been moved to the facility's memory care unit and was currently out of the facility in the hospital. She reported Resident #97 seemed like he was okay. She was not aware of him having any behaviors. She denied she was aware of him displaying any prior sexually inappropriate behaviors. She then recalled hearing something about Resident #97 cornering an aide in the shower room but wasn't sure of any details. That occurred about a month two ago and she identified CNA #192 as the aide involved. She did not think that Resident #97 touched the aide, he just had her cornered. She reported the nurse (LPN #215) responded to the incident between Resident #14 and #97 immediately. LPN #215 assessed Resident #14 and then had her (CNA #112) call the ADON. The ADON then called the DON. The DON came into the facility. She confirmed she sat with Resident #97 until the DON and the local law enforcement arrived. The DON was on scene before the local law enforcement arrived. She was not interviewed by law enforcement but did give a written statement to the DON. She was not sure how Resident #14 got into bed that night when she was found in bed with Resident #97 on top of her. They normally had to put her in bed, and no one had put her in bed that night. She denied there would be any other aides (other than her and the trainee) that would have put Resident #14 to bed. She believed Resident #97 had put Resident #14 in bed. She felt he would have been capable of lifting Resident #14 from her wheelchair into bed. She confirmed Resident #14 had a roommate who was present when the incident took place. She identified the roommate as Resident #15. She reported Resident #15 was alert and oriented and should be able to answer questions regarding the incident. She believed the roommate was asked to provide information regarding the incident to the facility as part of their investigation. Resident #14 resided in the bed by the door and Resident #15 was in bed by the window. On 07/16/25 at 4:40 P.M., an interview with Resident #15 revealed she recalled the incident that occurred on 07/08/25 and confirmed she was lying in her bed at the time the incident took place. She denied that she had seen anything. The resident stated he (Resident #97) pulled the curtain when he came in. She stated she got a quick look and only saw part of his face. She was not sure at the time if it was an employee or a resident. She just thought someone came in to get her roommate (Resident #14) ready for bed. She could not recall the time of the incident and was not sure if it occurred before or after dinner. She denied that she heard the male say anything. She reported her roommate was just carrying on. She heard her roommate say, get out. She denied she heard any other noises until the staff came in. The staff came in about 15 minutes after Resident #97 was there. They started yelling quite loudly at R[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, resident interview, vendor staff interview, and facility policy review, the facility failed to provide medically necessary social services regarding discharge processes. This affected one (Resident #11) of three residents reviewed for discharge. The census was 108.
Findings Include:
Resident #11 was admitted to the facility on [DATE]. Her diagnoses were congestive heart failure, chronic respiratory failure with hypoxia, hypo-osmolality and hyponatremia, atrial fibrillation, gout, anemia, hypertension, anxiety disorder, glaucoma, bipolar disorder, fibromyalgia, COPD, and depression. Review of her minimum data set (MDS) assessment, dated 03/14/25, revealed she was cognitively intact.
Review of Resident #11's quarterly care conference notes, dated 11/04/24, 01/27/25, and 04/21/25 revealed the facility addressed on-going discharge questions. It stated, she was undecided as to whether she wanted to discharge, but she wanted to be asked at each care conference if she still wanted to be discharged from the facility.
Review of Resident #11's current care plan revealed a care area of, discharge plan: uncertain resident/family have not confirmed a discharge plan at this time. Interventions included staff will assist resident/family with all available information/resources for decision, and staff will assist to meet all needs.
Review of Resident #11 entirety of medical/discharge records, dated 04/21/25 to 05/20/25, revealed no records about assisting the resident with a discharge plan/process. There was no documentation about her selling an already owned house, there was no documentation about her visiting another apartment with the intent of discharging, there was no documentation about her desire to purchase a new home with the intent of discharging, and there was no documentation about the facility assisting her with any of the discharge process.
Interview with Social Services #101 on 05/20/25 at 11:45 A.M. and 3:15 P.M. revealed she spoke with Resident #11 on a quarterly basis about her discharge status and desires. Confirmed each quarterly meeting, from November 2024 to April 2025, revealed she was undecided but wanted to continue to discuss it. She confirmed she knew about the resident setting up appointments with a home health agency to visit apartments within the last three to four weeks. She confirmed she has not spoke to Resident #11 about finding other apartments or the process of purchasing a house. She confirmed that her signing an apartment application and attempting to find a house to purchase would indicate a resident was actively looking to discharge.
Interview with Resident #11 on 05/20/25 at 12:10 P.M. revealed she was looking to purchase a new house after selling hers and paying off old debt. She confirmed she made appointments to see an apartment and had a home health agency staff take her to see it. She confirmed she has taken the lead on all actions related to purchasing a new house. She stated she had thought about the cost of home health and the cost of a new home, and she feels she could afford it. She confirmed the facility had not discussed the process or finances with her; they had told her she could not afford both without going through the details with her. She confirmed the facility had not done anything to help her move out of the facility, even though she has an active desire to move out.
Interview with Director of Nursing (DON) and Administrator on 05/20/25 at 1:15 P.M. and 3:40 P.M. confirmed there was no documentation to support the facility had provided any help with Resident #11's active desire for discharge. She confirmed there should have been documentation about any discussion or actions/inactions that Resident #11 would allow. They knew that after she declined the apartment about three to four weeks ago, she was actively looking to discharge from the facility but there was nothing to support they were assisting her with the discharge process.
Review of facility Transfer or Discharge Policy, dated March 2025, revealed when a resident is on therapeutic leave, transferred, discharged , or transferred to a hospital, details of the transfer/discharge will be documented in the medical record and appropriate information will be communicated to the receiving facility or provider.
This is an incidental finding related to complaint number OH00165631.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure written information prior to transfer to the hospital of the bed hold notice. This affected three residents (#61, #71 and #106) of three residents reviewed for hospitalization. The census was 108.
Findings included:
1. Review of Resident #71's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included diabetes, encephalopathy, Down's syndrome, dysphagia, chronic kidney disease, and high blood pressure. Review of the quarterly minimum data set assessment (MDS) dated [DATE] revealed his cognition was not intact (BIM's-3). He required setup or clean-up assistance with oral hygiene, is dependent upon staff for toileting, dressing and personal hygiene and substantial/maximal assistance for shower bathing. The resident has an indwelling urinary catheter and is frequently incontinent of bowel.
Review of the nursing progress notes revealed on 12/26/24 at 11:54 P.M. Resident #71 was mouth breathing, and an oxygen face mask was put on the resident. Monitored oxygen, it was at 70% again. Increased oxygen to 4 liters (L), and his oxygen would not go above 88% on 4L. Resident #71 was sent to the hospital and admitted on [DATE]. On 12/29/24 at 1:39 P.M. Resident #71 was readmitted to the facility from the hospital.
Further review revealed Resident #71 has a Guardian/Resident Representative.
Review of the bed hold notice revealed it was was not signed until after Resident #71 returned to the facility on [DATE]. This was verified during interview with the Director of Nursing on 02/18/25 at 3:38 P.M.
2. Review of Resident #61's medical record revealed an admission date of 03/09/21 and a reentry date of 12/02/24. Further review revealed diagnoses including chronic obstructive pulmonary disease, diabetes, obstructive uropathy, anxiety, paranoid schizophrenia, major depressive disorder, and extrapyramidal and movement disorder.
Review of the annual minimum data set (MDS) dated [DATE] revealed Resident #61 had a brief interview for mental status (BIMS) score of 13 indicating the resident was cognitively intact. Further review of the MDS revealed Resident #61 wore a hearing aide, was able to understand person to person communication and was able to make himself understood during person to person communication.
Review of Resident # 61's progress note dated 11/28/24 at 1:17 PM revealed Resident #61 was having pain and swelling to his lower extremities. Further review of Resident #61's progress notes on 11/28/24 at 2:28 PM revealed Resident #61 requested to go to the emergency room because of the pain. Review of Resident #61's progress note dated 12/02/24 at 3:07 PM revealed Resident #61 returned to the facility after completing his hospital course of treatment.
Review of the facility Notice of Bed Hold Policy revealed the notice, given to the resident to allow him to decide if he wanted to hold his bed so that he could return from the hospital to the same room and bed, was to cover Resident #61's hospital stay that started on 11/28/24 and ended on 12/02/24. Further review of the Notice of Bed Hold Policy revealed it was signed by Resident #61 on 12/03/24.
In an interview on 02/18/25 at 3:38 P.M. the Director of Nursing (DON) verified the Notice of Bed Hold Policy was signed on 12/03/24 after Resident #61's return to the facility.
Review of the Notice of Bed Hold Policy (undated) revealed it was to be signed by the resident upon discharge to the hospital or if the resident was unable to sign verbal notification from the resident or resident's representative was to be documented.
3. Review of the medical record for Resident #106 revealed an admission date of 09/12/24. Diagnoses include acute on chronic respiratory failure, chronic diastolic heart failure, chronic obstructive pulmonary disease, bacterial pneumonia, depression, diabetes mellitus, type two, diabetic peripheral neuropathy, acute on chronic anemia and Upper GI bleed.
Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 14 out of 15 indicating intact cognition. The resident required minimal assistance for all activities of daily living.
Review of the transfer form dated 11/06/24 revealed Resident #106 had a change in condition and was sent to the hospital.
Review of the notice of bed hold letter revealed the letter was not signed by the resident until 11/19/24 on her return to facility.
On 02/19/25 at 7:40 A.M., interview with Assistant Director of Nursing (ADON) #283 verified the bed hold letter dated 11/06/24 was not signed by the resident until 11/19/24. Further interview verified the letters are to be signed acknowledging the facility bed hold policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure pre-admission screening and resident reviews (PASSAR) were accurately completed. This affected one resident (#43) of two review for PASSAR accuracy. The census was 108.
Findings include:
Review of Resident #43's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included Ogilvie syndrome ( acute colonic pseudo-obstruction, is the acute dilatation of the colon in the absence of any mechanical obstruction), colostomy, gastrostomy, nausea and vomiting, schizoaffective disorder , depression and anxiety.
Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed his cognition was intact. He required partial/moderate assistance for oral hygiene, personal hygiene, and turning and repositioning, dependent for toileting and substantial/maximal assist for showers/bathing, lower body dressing and application of footwear. Resident #43 had an indwelling catheter and a colostomy. Receives antipsychotic's and antidepressants.
Review of the PASSAR dated 07/28/24 failed to identify Schizoaffective disorder, depression and anxiety. Mood disorder was the only thing identified under indication of serious mental illness.
On 02/13/25 3:26 P.M. interview with Social Worker Designee #311 verified the depression, schizoaffective disorder and anxiety were not included on the PASSAR and a new one had not been completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to develop and implement a comprehensive person centered care plan for diuretic medication for Resident #60. This affected one resident (#60) of five residents sampled for unnecessary medications. The facility census was 108.
Findings include:
Review of Resident #60's medical record revealed an admission date of 10/03/20 and a reentry date of 01/13/22. Further review revealed diagnoses including malignant neoplasm of overlapping sites of rectum, anus and anal canal, secondary malignant neoplasm of large intestine and rectum, diabetes, chronic respiratory failure, morbid obesity, heart failure, and hypertension.
Review of Resident #60's quarterly minimum data set (MDS) dated [DATE] revealed the resident had a brief interview for mental status (BIMS) score of 15 indicating that she is cognitively intact. Further review of the MDS revealed Resident #60 was receiving diuretic medication.
Review of Resident #60's physician's orders revealed an order with a start date of 04/02/24 for furosemide 40 mg give one tablet in the morning for heart failure.
Review of Resident #60's plan of care revealed no care plan for diuretic medication.
In an interview on 02/18/25 at 4:34 P.M. MDS nurse Licensed Practical Nurse (LPN) #350 verified there was not a diuretic medication care plan in Resident #60's plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and review of facility policy and procedure, the facility failed to ensure medications were locked against unauthorized access. This had the potential to affect one resident (#97) of 10 residents on the 200 hallway identified as cognitively impaired and independently mobile. The census was 108.
Findings include:
Observation on 02/12/25 at 10:39 A.M. revealed the medication cart in the hallway unlocked outside of room [ROOM NUMBER]-A with the door closed and no nurse in attendance of the cart. At 10:41 A.M. Registered Nurse #251 came out from the room and verified during interview she had left the medication cart unlocked and unattended in the hallway.
Review of the facility Medication Storage policy and procedure (dated 04/18 and updated 01/03/25) revealed compartment (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts and boxes) containing drugs and biological's shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview the facility failed to maintain infection control with urinary catheters. This affected one resident (#3) of four residents reviewed for urinary catheters. The census was 108.
Findings include
Review of Resident #3's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included metabolic encephalopathy, morbid obesity, heart failure, diabetes, atrial fibrillation, major depression, chronic kidney disease and anxiety.
Review of the admission minimum data set (MDS) dated [DATE] revealed her cognition was intact. She required set up or clean-up assistance for eating, oral hygiene, is dependent for toileting, and substantial/maximal assistance with shower/bathing, partial/moderate assistance for personal hygiene, dressing and turning and repositioning. The resident had a urinary catheter and was frequently incontinent of bowel.
On 02/11/25 at 11:47 A.M. observation revealed the urinary catheter tubing was observed on the floor. At 12:05 P.M. the urinary catheter tubing remained on the floor. At 12:07 P.M. interview with Registered Nurse (RN) #251 verified the urinary catheter tubing was on the floor. On 02/11/25 at 12:41 P.M. Licensed Practical Nurse (LPN) Supervisor #277 revealed she had changed the resident's urinary catheter bag and tubing.
On 02/12/25 at 10:38 A.M. observation revealed Resident #3 revealed she was up in the wheelchair with therapy staff in her room. The resident's urinary catheter tubing was observed on floor and the bag was in a wash basin.
On 02/13/25 at 2:57 P.M. Resident #3 was observed up in her wheelchair, with her urinary catheter tubing on the floor, red colored sediment in tubing . On 02/13/25 at 3:03 P.M. interview with LPN #233 verified the urinary catheter tubing was on the floor

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, staff and resident interviews, the facility failed to provide a safe, clean, comfortable and homelike environment for two residents which allowed them to use their personal belongings to the extent possible This affected three residents (#33, #40, #75) of 108 residents residing in the facility. The census was 108.
Findings Include:
1. Record review revealed Resident #40 had an admission date of 03/30/18 with diagnoses including: Cerebral infarction, dysphagia, influenza, chronic obstructive pulmonary disease, morbid obesity, diverticulosis, muscle wasting and atrophy, intervertebral disc degeneration of the lumbar region, type two diabetes mellitus, chronic respiratory failure with hypoxia, major depressive disorder, cardiac pacemaker, voice and resonance disorder, low back pain, abnormalities of gait and mobility, anemia, hyperlipidemia, anxiety disorder, left bundle branch block, constipation, gastroesophageal reflux disease, difficulty in walking, history of covid-19, urge incontinence, venous thrombosis and embolism, hypertension, abnormal posture, and unsteadiness on feet.
Observation on 02/11/25 at 9:26 A.M. revealed the following items on the bathroom sink: Mouthwash, shampoo, toothbrush, toothpaste, shave cream, surgical mask, comb, disposable razors, denture cup, and denture adhesive. None of the items were labeled for ownership.
Interview with Resident #40 on 02/11/25 at 9:26 A.M. confirmed that the bathroom is shared between three residents and the sink was always a big mess. Resident #40 confirmed that she didn't store or use her personal toiletries in the bathroom, she used her toiletries at her bedside table each day because the sink was not clean.
Interview on 02/11/25 at 9:59 A.M. with Certified Nurse Aide (CNA) #295 confirmed the bathroom is shared between two resident rooms or three residents, and that the items on the bathroom sink were unlabeled for ownership and should not be laying out on the bathroom sink. CNA #295 was unable to confirm which items belonged to which of the three residents who shared the bathroom.
2. Record review revealed Resident #75 had an admission date of 09/13/24 with diagnoses including: Chronic Kidney Disease stage three, sacrolitis, major depressive disorder, exudative age-related macular degeneration left eye, atherosclerosis of aorta, spondylosis without myelopathy or radiculopathy, pruritus, hypertension, anxiety disorder, osteoporosis, hypercholesterolemia, bilateral primary osteoarthritis of knee, and neuralgia and neuritis unspecified.
Observation on 02/11/25 at 10:21 A.M. revealed the following items on the bathroom sink: Body wash, lotion, a basin with a toothbrush, toothpaste, a loose toothbrush, dentures in a cup covered with water and without a lid, body spray, deodorant, an electric toothbrush (uncovered) and plugged in. None of the items were labeled for ownership. A pair of pants and a pair of underwear with a soiled incontinence pad in them were on the bathroom floor, and the pants appeared to be wet. Also on the floor was a bag of incontinence briefs unlabeled for ownership with another pair of pants sitting on top of it.
Interview on 02/11/25 at 10:21 A.M. with Resident #75 confirmed the bathroom was shared between two resident rooms, for a total of four residents and stated the other residents in the next room were disrespectful for leaving their things on the sink. Resident #75 confirmed that she kept her personal toiletries in a basket and used the toiletries in her room because the bathroom and the bathroom sink were not clean.
Interview on 02/11/25 at 10:40 A.M. with Licensed Practical Nurse (LPN) #270 confirmed that the bathroom was shared between two resident rooms, or four residents and that soiled clothing shouldn't be on the bathroom floor, and unlabeled items shouldn't be on the bathroom sink. LPN #270 was unable to confirm which items on the sink belonged to which of the four residents who shared the bathroom.
3. Review of Resident #33's medical record revealed an admission date of 11/04/21 and diagnoses including chronic obstructive pulmonary disease, diabetes, peripheral vascular disease, and hypertension. Review of Resident #33's quarterly minimum data set (MDS) dated [DATE] revealed a brief interview for mental status (BIMS) score of 13, indicating the resident was cognitively intact. further review of the MDS revealed Resident #33 was independent with toileting tasks and was occasionally incontinent of urine.
An observation made on 02/11/25 at 11:29 A.M. revealed Resident #33's bathroom had a strong odor and dirty linen was noted to be on the floor around the front of the toilet. A second observation made on 02/13/25 at 4:20 P.M. revealed the odor continued and a towel was on the floor in front of the toilet.
In an interview on 02/13/25 at 4:20 P.M. Licensed Practical Nurse (LPN) #206 verified there was an odor in the bathroom and removed the towel from the floor in front of the toilet. LPN #206 stated the Certified Nurses Aides had put the towel down to soak up urine from the floor but the should have removed the towel after the task was completed.

Based on observation, staff and resident interviews, and record review the facility failed to provide reasonable accommodation of needs and preferences when a bedside chair, a bedside nightstand, and a call light were not within reach. This affected one of 108 residents (#26). The facility census was 108.
Findings Include:
Record review revealed Resident #26 had an admission date of 05/19/23 with diagnoses including: Type two diabetes, displaced intertrochanteric fracture of left femur, cervical disc degeneration, coronary artery bypass graft without angina, chronic atrial fibrillation, systolic congestive heart failure, muscle wasting multiple sites, posthemorrhagic anemia, Alzheimer's disease, major depressive disorder, dementia without behavioral disturbance, unsteadiness on feet, abnormalities of gait and mobility, hyperlipidemia, hypertension, venous insufficiency, cognitive communication deficit, wrist drop left wrist, lymphedema, hypertension, urinary tract infection, full incontinence of feces, urinary incontinence, retention of urine, cardiac pacemaker, and history of covid-19.
Interview and observation on 02/10/25 at 7:39 P.M. with Resident #26 confirmed that he would prefer to get out of bed and sit in a chair to watch television, and would like to be able to access his personal belongings without requiring staff assistance to do so. At the time of the interview, observation revealed no bedside chair or bedside nightstand in the room for Resident #26. A bedside table was observed on the wall opposite of the foot of the bed and out of reach. Personal belongings were on the floor beside the bed stored in shopping bags and were out of reach.
Observation on 02/11/25 at 9:13 A.M. revealed the call light for Resident #26 hanging off the right side of the bed out of his reach. Resident #26 attempted to retrieve the call light unassisted and was unable to do so.
Interview on 02/11/25 at 9:18 A.M. with Licensed Practical Nurse (LPN) #280 confirmed that the call light for Resident #26 was hanging off the right side of the bed out of reach. LPN #280 confirmed that Resident #26 was unable to retrieve the call light, and required staff assistance to do so.
Interview on 02/13/25 at 8:37 A.M. with Staff #305 confirmed that the facility did not provide bedside chairs for residents and if residents wanted a bedside chair, resident's families were responsible to provide them.
Interview on 02/18/25 at 9:16 A.M. with Activities Staff #246 confirmed that Resident #26 enjoyed watching television in his room and in the common areas as one of his independent activities. Activities Staff #246 confirmed that Resident #26 did not have access to a bedside chair in his room.
Review of the activities care plan for Resident #26 with a revision date of 02/11/24 revealed Resident #26 enjoyed Independent, self- directed leisure time activities, and functioned at an independent level in his leisure pursuits. Resident #26 was alert and oriented and able to express his needs, desires and opinions, and frequently engaged in the following leisure pursuits: Watching TV, listening to music, reading magazines, and visits with staff and other residents.
Review of the activities of daily living (ADL) care plan for Resident #26 with a revision date of 02/11/24 revealed the resident requires extensive to total assist for most all care due to impaired mobility, impaired cognition, impaired balance and overall decline in functional status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and facility policy review, the facility failed to ensure antibiotic stewardship guidelines were followed prior to antibiotic use. This affected one (Resident #299) of one resident reviewed for antibiotic stewardship. The census was 100.
Findings Include:
Resident #299 was admitted to the facility on [DATE]. Her diagnoses were sepsis, rectal abscess, difficulty walking, type II diabetes, muscle weakness, chest pain, obesity, anemia, vitamin D deficiency, tobacco use, hypertension, major depressive disorder, osteoarthritis, fibromyalgia, and headache. Review of her Minimum Data Set (MDS) assessment, dated 08/14/23, revealed she was cognitively intact.
Review of Resident #299 physician orders revealed she was prescribed Doxycycline Hyclate Oral Tablet 100 milligrams, twice daily for seven days. Initially, this medication justification was for infection, but then it was clarified to be for an abscess to her buttocks.
Review of Resident #299 medication administration record (MAR), dated August 2023, confirmed she was administered the Doxycycline twice daily as ordered.
Review of Resident #299 and facility infection control documentation and progress notes, dated 08/25/23 to 08/29/23, revealed Resident #299 had a McGeer's assessment completed on 08/29/23. According to facility documentation, she did not meet criteria for an antibiotic, which was relayed to the nurse practitioner on that same day. The nurse practitioner decided to keep her on this medication for the remainder of the order. There was no documentation prior to 08/29/23 to determine if or what type of antibiotic should be used for her infection.
Interview with Regional Nurse #206 and Regional Nurse #207 on 08/30/23 at 9:35 A.M. both stated they have to follow the antibiotic stewardship policy prior to ordering/administering an antibiotic. They both agreed that doxycycline was ordered prior to McGeer's assessment being completed for Resident #299.
Interview with Registered Nurse (RN) #160 on 08/30/23 at 11:13 A.M. confirmed McGeer's was not completed prior to the ordered/administering of Doxycycline for Resident #299. She confirmed she is the person who does the McGeer's assessment and was not in the building during the time it was initially ordered/administered.
Review of facility Antibiotic Stewardship policy, dated December 2017, revealed the CDC has reported that antibiotic resistance is one of the major threats to human health, especially because some bacteria have developed resistance to all known classes of antibiotics. The antibiotic stewardship team will review infections and monitor antibiotic usage patterns on a quarterly basis, obtain and review various reports from pharmacy for institutional trends, monitor antibiotic resistance patterns and report on number of antibiotics prescribed and the number of residents treated each month. Facility will evaluate and communicate clinical signs and symptoms when a resident is first suspected of having an infection. Use of diagnostic testing to optimize tracking and treatment of infections. A method of flagging residents with multidrug-resistant organisms will be instituted by the laboratory.
Review of facility Antibiotic Stewardship Plan, dated 10/19/18, revealed standardized practices to address care for suspected infections and the use of standardized definitions and criteria. This facility will utilize McGeer's criteria for monitoring, and reporting infections for surveillance and treatment.

Based on medical record review and staff interview, the facility failed to ensure advance directive orders and documents were consistent in the medical record and reflective of the resident/resident representative wishes. This affected one (Resident #348) of 24 residents reviewed for advance directives. The facility census was 100.
Findings include:
Review of Resident #348's medical record revealed an admission date of 08/08/23 with diagnoses that included Alzheimer's disease with dementia, congestive heart failure and atherosclerotic heart disease.
Further review of Resident #348's physician's orders revealed the resident's code status was full code (cardiopulmonary resuscitation).
Review of the paper chart revealed an advance directive form which indicated do not resuscitate comfort care (DNR-CC) measures (comfort measures in the event of cardiac/respiratory arrest) chosen by Resident #348's responsible party and signed by the physician on 08/09/23. The paper chart also contained a full code paper which indicated to staff the resident was a full code in case of emergency.
Interview with Licensed Practical Nurse (LPN) #171 on 08/28/23 at 11:23 A.M. revealed the electronic medical record and the full code form contained in the paper chart were not accurate and did not reflect Resident #348's advance directive form which indicated a DNR-CC status.

Based on medical record review and interview, the facility failed to ensure a significant change assessment was initiated when a resident was admitted to hospice services. This affected one (Resident #91) of 21 residents who were reviewed regarding requirements for significant change assessments. The census was 100.
Findings include:
Review of Resident #91's medical record revealed diagnoses including malignant neoplasm of the prostate, secondary malignant neoplasm of the bone, abnormal weight loss, and depression. Review of hospice notes revealed an initial visit was made on 08/02/23. On 08/03/23 an order was written to admit Resident #91 to hospice. There was no evidence the facility initiated a significant change Minimum Data Set (MDS) assessment.
On 08/29/23 at 8:57 A.M., Regional Nurse #206 verified Resident #91 had an order admitting him to hospice dated 08/03/23 and a significant change MDS had not been initiated but should have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.
Based on closed medical record review, review of an emergency medical services (EMS) report, interviews with facility staff and review of facility Code Status policy the facility failed to immediately initiate cardiopulmonary resuscitation (CPR) for Resident #94. This resulted in Immediate Jeopardy and the actual serious life-threatening harm and death on [DATE] beginning at 5:22 A.M. when Resident #94, who had advance directives for cardiopulmonary resuscitation/full code status, was found unresponsive, without a pulse, and was not provided CPR. The facility notified EMS for hospital transport without completing a comprehensive assessment of the resident ' s status. Resident #94 was assessed to be deceased by EMS without evidence of having received life saving measures. This affected one resident (#94) of two residents reviewed for an emergent change in condition and death. The facility identified 51 residents with a full code status. The facility census was 100.
On [DATE] at 3:50 P.M., the Administrator, Regional Director of Clinical Operations #300, Regional Registered Nurses (RN) (#206, #207, and #208), and the Director of Nursing (DON) were notified Immediate Jeopardy began on [DATE] at 5:22 A.M. when State Tested Nursing Assistant (STNA) #100 found Resident #94 unresponsive. STNA #100 notified Licensed Practical Nurse (LPN) #101 of the resident ' s status, however LPN #101 failed to complete a comprehensive assessment of the resident and failed to immediately initiate CPR despite the resident ' s wishes for a full code status. LPN #101 notified EMS of the need to transport the resident to the hospital however the resident was pronounced deceased upon EMS arrival (exact time unknown but EMS arrived at the facility at 5:38 A.M.).
The Immediate Jeopardy was removed, and the deficiency corrected on [DATE] when the facility implemented the following corrective actions.
•
On [DATE], Resident #94 expired in the facility.
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On [DATE] at 6:25 A.M., the DON immediately educated Licensed Practical Nurse (LPN) #101 on the facility's Code Status Policy.
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On [DATE] at 10:00 A.M., Human Resources Manager #194 audited employee files for all licensed nurses to ensure they had valid, active CPR certification.
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On [DATE] at 11:17 A.M., the facility completed an ad hoc Quality Assurance and Performance Improvement (QAPI) plan related to the abatement. The Administrator, Medical Director #301, and the DON were in attendance. The plan was approved by the committee including ongoing compliance.
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On [DATE] at 12:00 P.M., the DON, RN #160 and LPNs (#115 and #171) audited all hard copies of advanced directives in current resident's medical records to ensure they were present, appropriately signed and had a physician's order in place.
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On [DATE] from 8:30 A.M. to 4:33 P.M., the DON educated all 31 licensed nursing staff on the facility CPR policy and steps to take when finding a resident without vital signs.
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Beginning [DATE] the facility implemented a plan for the DON/designee to ensure nursing staff understood the Code Status Policy and when finding a resident without vitals to ensure adherence to Code Status Policy. Audits were completed three times per week for two weeks, then two times per week for two weeks, and then weekly for two weeks, then as determined necessary. Audits were completed ongoing every two weeks since original schedule completion.
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Between [DATE] and [DATE] no additional resident concerns were identified related to CPR.
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On [DATE] between 10:45 A.M. and 11:20 A.M. interviews with the Administrator, DON, RN (#160 and #304), LPN (#124, #171, #191, and #192), STNA (#122, #190, and #209) verified they were educated on the facility CPR policy.
Findings include:
Review of Resident #94's closed medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including anxiety disorder, dementia, fibromyalgia, osteoarthritis, muscle weakness, and repeated falls.
Review of a physician order, dated [DATE], revealed Resident #94 was a full code.
Review of Resident #94's medical record from [DATE] through [DATE] revealed no documentation of Resident #94 or Resident #94's physician changing Resident #94's code status from a full code.
Review of Resident #94 ' s care plan, dated [DATE], revealed Resident #94 desired to be a full code with cardiopulmonary resuscitation (CPR) initiated with the absence of pulse, respirations, and/or blood pressure. Interventions included supporting Resident #94/family with their decision and to honor their preference.
Review of Resident #94's quarterly Minimum Data Set (MDS) 3.0 assessment, dated [DATE], revealed the resident had severe cognitive impairment. The assessment revealed the resident required extensive, one-person physical assistance from staff for bed mobility. The resident required supervision from staff for eating, transfers, toileting, and personal hygiene.
Review of Resident #94 ' s nursing progress note, dated [DATE] at 5:22 A.M. and authored by LPN #101, revealed State Tested Nursing Assistant (STNA) #100 called LPN #101 into Resident #94 ' s room, the resident was without vital signs by verification of two nurses (identified as LPN #101 and LPN #102) (the progress note did not provide additional details regarding how this was verified). The progress note indicated EMS was notified. EMS arrived and the resident was with vital signs on electrocardiogram (EKG). The deputy was called due to the inability to reach the medical doctor. Resident #94 ' s sister was notified by the deputy. The note also indicated the coroner ' s office would be en route after the notification.
Review of an emergency medical services (EMS) report, dated [DATE], revealed EMS were dispatched to the facility on [DATE] at 5:26 A.M., were reroute at 5:31 A.M., and at the scene at 5:38 A.M. Upon arrival, Resident #94 was found lying in bed, unresponsive and apneic (not breathing). The resident was cold to the touch with lividity and the initial stages of rigor. Facility nurse stated the resident was a full code, was found this way just prior to the call to EMS, and CPR was not performed due to the resident ' s obvious death. The resident was last seen approximately two hours prior. The facility was unable to reach their medical director. An EKG was obtained and revealed asystole (cessation of electrical activity of the heart) in three leads. The communication center notified the county sheriff ' s office and a deputy arrived on scene, took over, and contacted the coroner.
Review of Resident #94's nursing progress note, dated [DATE] at 7:40 A.M. and authored by the Director of Nursing (DON), revealed there was an order to release the body to the funeral home as requested by the family.
Review of LPN #101's witness statement, dated [DATE], revealed her last rounds were at 3:00 A.M. At 5:20 A.M., STNA #100 called her to the memory care unit for a resident without vital signs. EMS was called at 5:22 A.M. A second nurse, (identified as LPN #102), verified there were no vital signs.
Review of STNA #100 ' s witness statement, dated [DATE], revealed Resident #94 went to bed at 10:45 P.M. During rounds, STNA #100 checked on the resident at 1:00 A.M. and observed her in bed, lying on her side and sleeping. STNA #100 checked on the resident again at 3:05 A.M. and the resident was still on her side and sleeping. During STNA #100 ' s last round at 5:15 A.M., the resident was lying on her back in bed. STNA #100 attempted to wake the resident with no response and notified the nurse (identified as LPN #101).
During interview on [DATE] at 11:24 A.M., LPN #101 stated she was working on Hallway 100 or 200 (on [DATE]) when STNA #100 alerted her that Resident #94 was cold and unresponsive. LPN #101 stated she tapped on the resident ' s shoulder and called her name and there was no response. LPN #101 stated the only vital sign that she obtained was a radial pulse, which was absent, she then left the resident ' s room to get help and called EMS from the nursing station. During this time, LPN #101 stated she asked LPN #102 to check on Resident #94 to verify there was no pulse. LPN #101 stated she did not administer oxygen or start CPR because as soon as she started back into the room, EMS had arrived. LPN #101 stated that she was unsure of how many minutes passed from the time she was notified by STNA #100 of Resident #94 being unresponsive until EMS arrived, but that it felt like a matter of minutes. LPN #101 verified Resident #94 was a full code and CPR should have been administered. An additional interview on [DATE] at 2:23 P.M. with LPN #101 verified her nursing progress note, dated [DATE] at 5:22 A.M., contained a documentation error. LPN #101 indicated Resident #94 did not have any vital signs on EKG as indicated in the progress note.
During interview on [DATE] at 11:51 A.M., STNA #100 stated she was doing her morning rounds and getting residents up when she noticed, from the doorway, that Resident #94 was uncovered. STNA #100 stated she walked into the room to check on the resident and noticed the resident was not moving, and her hand was cold. STNA #100 attempted to contact LPN #101 on her handheld, two-way radio, without success, and then went to get her on the 100 Hallway. STNA #100 revealed she did not return to Resident #94 ' s room because she stayed at the door awaiting EMS.
During interview on [DATE] at 12:18 P.M., Regional RN #207 revealed the facility knew this incident was an issue and stated they identified it immediately after CPR was not initiated on Resident #94 who was a full code.
During interview on [DATE] at 6:08 P.M., LPN #102 stated Resident #94 was not provided CPR and that she did not obtain any vital signs because the resident was unresponsive and cold. This surveyor asked LPN #102 if CPR should have been initiated for Resident #94 after being found unresponsive and without a pulse. LPN #102 stated yes, CPR should have been started and that she knows that now, after receiving the facility in-service education on CPR.
During interview on [DATE] at 11:22 A.M., Physician #301 stated that although he was unsure if Resident #94 would have survived CPR efforts, it was unfortunate the staff did not follow the resident's advanced directive order.
Review of the facility undated policy titled, Code Status, revealed in accordance with the State of Ohio Do Not Resuscitate (DNR) Comfort Care Protocol the facility would ensure a resident ' s wishes were carried out as they desire. Every effort to maintain a resident ' s wishes and dignity would be carried out as requested by the resident/or resident representative or family. Full Code was when a resident was identified as a full code and the facility staff would provide emergent measures in attempt to resuscitate the patient. This may involve chest compressions, electric shocks, and emergency medications that act to temporarily keep blood moving to essential organs such as the brain. All measures would be attempted to maintain the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, financial record review, and staff interview, the facility failed to provide an adequate plan to spend down resident finances when funds were above the Medicaid allowable limit. This affected three (Residents #19, #23, and #37) of six resident financial information reviewed. The census was 100.
Findings Include:
1. Resident #19 was admitted to the facility on [DATE]. Her diagnoses included atherosclerotic heart disease, major depressive disorder, anxiety disorder, and cognitive communication deficit. Review of her Minimum Data Set (MDS) assessment, dated 07/16/23, revealed she had a significant cognitive impairment.
Review of Resident #19's quarterly financial statements, dated 07/01/22 to 06/30/23, revealed her total amount in her resident account varied between $2986.96 and $7191.37; it was never below $2000.
Review of Resident #19's medical records, which included progress notes, social service notes, and care plans, revealed no documentation to support the facility had a plan in place to assist Resident #19 with spending her money in hopes of not losing her Medicaid insurance benefits, due to her resident financial account being more than $2000.
Review of Resident #19's spend down notices revealed the facility sent notices to Resident #39 on 08/25/22, 09/26/22, 10/27/22, 11/29/22, 12/28/22, 01/24/23, 03/29/23, 04/45/23, 05/22/23, and 06/27/23. On each spend down notice, it stated, this letter is to notify you that your current Resident Fund balance is within $200 or exceeding what is allowable under Medical Assistance. Please contact your social worker within the next seven days to discuss ways to assure continuance of Medicaid benefits. There was no evidence the facility followed up to create a spend down plan.
2. Resident #23 was admitted to the facility on [DATE]. His diagnoses included atherosclerotic heart disease, atrial fibrillation, major depression, cognitive communication deficit, psychosis, and hypertension. Review of his MDS Assessment, dated 05/23/23, revealed he was cognitively intact.
Review of Resident #23's quarterly financial statements, dated 10/01/22 to 03/31/23, revealed his total amount in his resident account varied between $3419.47 and $8141.47; it was never below $2000.
Review of Resident #23's medical records, which included progress notes, social service notes, and care plans, revealed no documentation to support the facility had a plan in place to assist Resident #23 with spending his money in hopes of not losing his Medicaid insurance benefits, due to his resident financial account being more than $2000.
Review of Resident #23 spend down notices revealed the facility drafted the notice form for Resident #23 on 08/25/22, 09/26/22, 10/27/22, 11/29/22, 12/28/22, and 03/29/23. On each spend down notice, it stated, this letter is to notify you that your current Resident Fund balance is within $200 or exceeding what is allowable under Medical Assistance. Please contact your social worker within the next seven days to discuss ways to assure continuance of Medicaid benefits. There was no evidence the facility followed up to create a spend down plan.
3. Resident #37 was admitted to the facility on [DATE]. His diagnoses included chronic obstructive pulmonary disease, peripheral vascular disease, cerebral infarction, hypertension, and anxiety disorder. Review of his MDS assessment, dated 08/01/23, revealed he was cognitively intact.
Review of Resident #37's quarterly financial statements, dated 07/01/22 to 06/30/23, revealed his total amount in his resident account varied between $3971.83 and $9574.78; it was never below $2000.
Review of Resident #37's medical records, which included progress notes, social service notes, and care plans, revealed no documentation to support the facility had a plan in place to assist Resident #37 with spending his money in hopes of not losing his Medicaid insurance benefits, due to his resident financial account being more than $2000.
Review of Resident #37 spend down notices revealed the facility drafted the notice form for Resident #37 on 08/25/22, 09/26/22, 10/27/22, 11/29/22, 12/28/22, 03/29/23, 04/24/23, 05/22/23, 06/27/23, and 07/20/23. On each spend down notice, it stated, this letter is to notify you that your current Resident Fund balance is within $200 or exceeding what is allowable under Medical Assistance. Please contact your social worker within the next seven days to discuss ways to assure continuance of Medicaid benefits. There was no evidence the facility followed up to create a spend down plan.
Interview with Social Worker Designee #174 on 08/30/23 at 12:20 P.M. confirmed she was not aware that she was to help with a spend down plan until not long ago when a family member called her and asked what to do. She has helped residents and families look through magazines and web sites to spend money as needed, but she was not aware she was the primary person to help with spend downs.
Interview with Regional Nurse #206, Regional Nurse #207, and Regional Nurse #208 on 08/30/23 at 12:24 P.M. confirmed they are not completely sure what the policy/procedures are for spending down resident finances. They also confirmed resident finances should not be above $2000 when the resident utilized Medicaid.
Interview with Administrator on 08/30/23 at 12:46 P.M. confirmed all three residents had a personal funds account that was above $2000. She confirmed they will be enforcing their policy of having the social work designee take lead on developing a plan and implementing a spend down process for any resident having more than $2000 in their funds account.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, policy review, review of drug reference information and interview, the facility failed to ensure medications were appropriately labeled and stored. This affected six residents (Resident #21, #29, #65, #67, #89 and #93) of 100 residents residing in the facility.
Findings include:
1. On [DATE] at 8:54 A.M., Licensed Practical Nurse (LPN) #124 was observed preparing and administering medication to Resident #67. There was no expiration date on the bottle of enteric coated aspirin 81 milligram (mg) dose.
LPN #124 verified she was unable to locate an expiration date on the aspirin bottle at the time of preparation/administration.
2. On [DATE] at 10:16 A.M., observation of the 400 hall medication cart revealed there was an open/used insulin pen for Resident #65 which was not dated. There was a box with an open vial of Humulin 70/30 insulin which was undated with no name.
On [DATE] at 10:16 A.M., LPN #157 verified Resident #65's insulin pen did not contain a date when it was opened. LPN #157 stated the Humulin 70/30 was being used for Resident #21, stating his name must have gotten torn off the box. LPN #157 verified the Humulin 70/30 vial did not contain information regarding the date it was opened.
3. On [DATE] at 10:25 A.M., observation of 200 hall medication cart revealed Resident #93 had an opened insulin glargine dated [DATE]. Resident #89 had an open vial of insulin glargine with two dates on it ([DATE] and [DATE]) and an open vial of insulin aspart dated [DATE]. Resident #29 had insulin glargine and novolog pens which were not dated and had expired and had an open lantus pen with no date indicating the date it was opened.
On [DATE] at 10:25 A.M., Registered Nurse (RN) #156 verified the dates Resident #89's and #93's insulin was opened and verified Resident #29 had two insulin pens which were not dated but expired and one insulin pen without the date indicating when it was opened.
Review of the Medscape web site revealed the insulin could be stored for a maximum of 28 days at room temperature when opened or unrefrigerated.
Review of the facility's Storage of Medications policy, dated [DATE], revealed the facility should not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs should be returned to the dispensing pharmacy or destroyed.

Based on observation, record review, and interview, the facility failed to ensure resident fall safety measures were in place as ordered. This affected two (Residents #30 and #65) of three residents reviewed for falls.
Findings include:
1. Review of Resident #65's medical record revealed a 06/06/23 admission with diagnoses including encephalopathy, acute kidney failure, diverticulitis, severe morbid obesity, altered mental state, paroxysmal atrial fibrillation, protein calorie malnutrition, essential tremor, depressive disorder, anxiety disorder, bipolar disorder, dementia, and hypertension.
Review of a 06/06/23 admission fall assessment revealed the resident was assessed as a high fall risk with one to two falls in the last three months, inadequate vision, sometimes forgetful, frequently incontinent, confined to a chair and oriented, unable to independently come to a standing position, exhibits loss of balance while standing, strays off the straight path of walking, requires hands-on assistance to move from place to place and agitated behavior daily.
Resident #65 had a risk for falls plan of care that indicated the resident was a moderate risk for falls related to gait/balance problems, incontinence, psychoactive drug use, and unaware of safety needs. Interventions included dycem to bed and chair.
Review of the 06/26/23 quarterly Minimum Data Set Assessment (MDS) included the resident was severely impaired for daily decision making, required limited assist of one for bed mobility, extensive assist of one for transfers, supervision for walking in room and hall and toileting. The resident had occasional incontinence and no behaviors. The resident had one fall without injury.
Review of the physician orders included an order dated 07/02/23 for dycem to side of bed and an order dated 07/03/23 for dycem to recliner.
Review of the resident record revealed the resident had three falls since admission.
Review of the medical record revealed on 06/22/23 at 7:00 A.M. Resident #65 was found to be lying on the floor in the middle of her room in the prone position. The resident was noted without non-skid shoes or socks on and stated, I slid out of bed and then just rolled and rolled and laid here because it's hard to get up. Resident #65 was assisted up to a standing position with two staff and transferred to a recliner. A new intervention was implemented for a bright colored sign hung on the resident's walker to remind resident to wear slipper socks or proper footwear.
Review of a nurse note dated 06/29/23 at 7:41 P.M. revealed Resident #65 was found on floor sitting with her back against the foot of the chair. Resident #65 stated, I just slid out of my chair and ended up on the floor. Resident #65 was assisted up off the floor by three staff members. A new intervention was implemented to put dycem on the resident's recliner.
Review of the medical record revealed on 07/01/23 at 11:30 P.M. Resident #65 was found laying on her back on the middle of the floor. Neurological tests were started due to the resident slid out of bed. The new intervention was dycem to bed.
Observation on 07/12/23 at 6:15 P.M. with the Director of Nursing (DON) revealed Resident #65 was sitting in her recliner. The resident stood up with assist of the DON and holding onto the walker handles. There was no dycem on her recliner. The DON lifted the blanket that was on the recliner. There was no dycem under the blanket. The DON checked the resident's bed. There was no dycem on the fitted mattress sheet, under the fitted mattress, under the waffle padding on the top of the mattress nor on either side of the mattress. There was one blue dycem in the closet. The DON verified the dycem was not in place as ordered.
2. Review of Resident #30's medical record revealed a 06/02/23 admission with diagnoses including Parkinson's disease, type 2 diabetes, hallucinations, mild protein calorie malnutrition, paroxysmal atrial fibrillation, ,atherosclerotic heart disease, myocardial infarction, bipolar disorder, depression, Alzheimer's disease, muscle weakness, dementia with psychotic disturbance, malignant neoplasm of prostate, hypertension, repeated falls, transient ischemic attack and obstructive sleep apnea.
Review of the medical record revealed the resident had a high risk for falls plan of care on admission related to deconditioning, gait/balance problems, incontinence, and unaware of safety needs. Interventions included Dycem to wheelchair seat when occupied.
Review of the 06/08/23 admission MDS included the resident was independent for daily decision making with no behaviors. The resident required extensive assist of two for bed mobility, transfers, toileting, limited assist of one for walking in room, always incontinent of urine and frequently incontinent of bowel movement.
Review of the resident record revealed the resident had three falls since admission.
Review of a 6/20/23 at 12:10 A.M. progress note included when making rounds the resident was found sitting on the floor beside his bed. Resident #30 state, I slid off. New interventions included to move bed against wall and get a physical therapy evaluation.
Review of the medical record revealed on 06/27/23 at 6:31 P.M. Resident #30 was heard yelling out, found sitting on floor in between bed and wheelchair. Resident #30 stated he forgot to lock his wheelchair brakes before sitting. Staff reminded the resident to ask for assistance and put brightly colored sign within view to remind resident to pull call light for assistance.
Review of the record revealed on 07/05/23 at 3:30 P.M. Resident #30 was noted laying on the floor in front of his wheelchair beside his recliner chair. Resident #30 stated he was getting up. A new order was implemented for dycem to wheelchair seat.
Review of the physician orders revealed an order dated 07/06/23 for dycem to wheelchair when occupied.
Observation on 07/12/23 at 6:23 P.M. with the DON revealed Resident #30 was sitting in his wheelchair at the dining table in the common area. The resident stood up with the assist of the DON. There was no dycem on his wheelchair seat above or under the pressure reducing cushion. The DON and Licensed Practical Nurse (LPN) #221 verified there was no dycem on the wheelchair as ordered.
This deficiency represents non-compliance investigated under Complaint Number OH00144345

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview and policy review the facility failed to ensure residents were provided a dignified dining experience and failed to ensure urinary catheter drainage bags were discreet to promote resident dignity. This affected two residents (Resident #53 and #67) of eight residents reviewed for dignity. The census was 96.
Findings include:
1. Review of Resident #67's medical record revealed an admission date of 06/16/23. Diagnoses included sepsis, encephalopathy, diabetes, Alzheimer's dementia, and mild protein calorie malnutrition. Review of the five-day Minimum Data Set 3.0 assessment dated [DATE] revealed the resident was not cognitively intact. She required extensive assistance to being dependent of two staff members for activities of daily living.
On 06/27/23 at 11:05 A.M. an observation of the lunch meal revealed State Tested Nursing Assistant (STNA) #322 was standing at Resident #67's bedside, feeding the resident her lunch meal. The STNA was not at eye level with the resident but was standing over the resident while assisting her with the meal.
On 06/27/23 at 11:09 A.M. interview with STNA #322 verified she was standing while feeding Resident #67 her lunch meal and she should be seated, placing herself at eye level, with the resident.
Review of the facility policy and procedure Dignity, Respect and Privacy not dated revealed to provide care to residents while maintaining their dignity and privacy staff should be at eye level.
2. Review of Resident #53's medical record revealed he was admitted to the facility on [DATE] with diagnoses including type two diabetes mellitus without complications, muscle wasting and atrophy, Down syndrome, chronic kidney disease, obstructive and reflux uropathy, and bladder disorder, unspecified.
Review of Resident #53's physician order, dated 09/20/22, identified he was to have a #18 French Foley catheter to straight drain due to obstructive uropathy and the facility may change it as needed if encrustation occurs.
Review of Resident #53's quarterly Minimum Data Set (MDS) 3.0 Assessment, dated 06/20/23 revealed he was cognitively impaired and had an indwelling catheter.
Observation on 06/27/23 at 8:05 A.M. and at 8:24 A.M. of Resident #53's urinary catheter bag revealed the bag was not covered exposing the urine collected in the drainage bag and this was visible from the resident's doorway.
Interview on 06/27/23 at 8:24 A.M. with Registered Nurse (RN) #261 verified the urine in Resident #53's urinary catheter bag was visible from the doorway. She verified the urine in the urinary catheter bag should not be visible for the respect and dignity of Resident #53.
Review of the facility policy titled, Dignity, Respect, & Privacy, undated, revealed the facility was to provide care to residents while maintaining their dignity and privacy. Residents are to always be treated with respect and cared for in a manner that protects their privacy.
This deficiency represents non-compliance investigated under Complaint Number OH00143590 and OH00143268.

Based on observation and interview the facility failed to ensure a safe environment for the residents, staff and the public. This had the potential to affect all 13 ambulatory residents (#8, #15, #19, #22, #24, #35, #50, #52, #56, #83, #88, #89, and #100) identified by the facility. The facility census was 96.
Findings included:
1. Observation on 06/27/23 at 7:55 A.M. of a large hole in the asphalt in the visitor parking lot. There was a drain noted in the center of the hole. On the lowest corner of the drain was an orange safety cone which had been flattened, cracked, and was lying flat in the hole. Resident #15 was walking around the visitor parking lot at the time of the observation.
Interview on 06/27/23 at 3:30 P.M. with Receptionist #228 revealed the large hole has been present since she started working in the facility September 2022.
Observation on 06/27/23 at 3:40 P.M. with the Maintenance Supervisor #214 revealed the large hole in the visitor parking lot measured four feet by three-and-one-half feet by six inches deep. The asphalt at the edge of the hole was crumbly and in the center was a drain. An interview at the time with Maintenance Supervisor #214 revealed the drain had been sinking for a long time but was unable to specifically recall when it began. He verified the area was a driving and walking hazard.
2. Observation on 06/27/23 at 3:15 P.M. of a metal cap in the floor at the beginning of the 200- hall moving and spinning as this surveyor walked on it. This surveyor tripped due to the unstable metal cap. STNA #317 verified it was a safety hazard and didn't know how long the cap had been loose. The unit was the skilled rehabilitation unit where residents had therapy to prepare to return home.
Observation on 06/27/23 at 3:27 P.M. revealed Maintenance Supervisor #214 was leaning over the drain with the drain cap in his hand. He had a drill and screws to secure the cap to the floor. An interview at the time revealed the screws were taken out of the drain cap around 11:30 A.M. on 06/27/23 because he needed to put chemicals down the drain. He reported he got busy and didn't come back to put the screws back in. Further interview verified the cap not being properly secured was a safety issue.
This deficiency is an incidental finding during investigation of Master Complaint Number OH00144114, Complaint Number OH00143590 and OH00143268.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, observation and facility policy and procedure, the facility failed to follow proper infection control procedure related to indwelling catheter care and medication administration. This affected one resident (Resident #67) of three residents reviewed for urinary catheters and one resident (Resident #88) of three residents observed for medication administration. The census was 96.
Findings include:
1. Review of Resident #67's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included sepsis, encephalopathy, diabetes, Alzheimer's dementia, and mild protein calorie malnutrition. Review of the five-day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed her cognition was not intact. She required extensive assistance of two or more staff members for bed mobility, total dependence of two or more staff members for transfers, dressing, and toilet use.
On 06/27/23 at 11:10 A.M. observation revealed State Tested Nursing Assistant (STNA) #242 applied gloves, closed the window blind and explained to Resident #67 the care to be provided. STNA #242 closed the curtain around the resident's bed, removed her gloves and applied a new pair of gloves without washing her hands. STNA #242 then removed the old catheter anchor that was on the resident's right leg. The STNA then removed her gloves and applied a new pair without washing her hands. STNA #242 removed her gloves, applied new gloves without washing her hands. STNA #242 washed the resident's buttocks and then removed her gloves and applied new gloves without washing her hands.
On 06/27/23 at 11:35 A.M. interview with STNA #242 verified she had not washed her hands between glove changes
2. On 06/28/23 at 7:50 A.M. during observation of medication administration for Resident #88 by Licensed Practical Nurse (LPN) #230 revealed Resident #88 dropped a pill in her bed and LPN #230 picked up the pill with her ungloved hand and gave the pill to Resident #88 to take. Then LPN #230 placed the resident's hearing aides into both ears, exited the resident's room and went back to the medication cart without washing her hands. LPN #230 then began to prepare medications for the next resident.
On 06/28/23 at 8:20 A.M. interview with LPN #230 verified she had not washed her hands after providing resident care and returning to the medication cart to prepare medications
Review of the policy and procedure for Hand washing dated 03/19 revealed hands should be washed after touching a resident or handling his/her belongings.
This deficiency represents non-compliance investigated under Complaint Number OH00143268.

Based on record review, interview and facility policy and procedure review the facility failed to ensure resident funds were appropriately managed. This affected one resident (Resident #70) of three residents reviewed for funds. The facility census was 96.
Findings included:
Review of Resident #70's medical record revealed an admission date of 12/08/20 with diagnoses including type II diabetes mellitus with other specified complications, chronic obstructive pulmonary disease with acute exacerbation, morbid (severe) obesity due to excessive calories, and generalized muscle weakness.
Review of Resident #70's Resident Fund Manager Service form revealed she authorized the facility to manage her funds on 01/19/21 and she would receive a $50.00 monthly allowance after her care costs were paid to the facility (directly transferred from her account to the facility).
Review of Resident #70 quarterly Minimum Data Set (MDS) 3.0 assessment, dated 06/06/23, revealed the resident was cognitively intact.
Review of Resident #70's financial statements, dated 02/03/21 to 06/07/23, revealed she had 14 monthly deductions starting 04/04/23 for insurance premiums. A monthly deposit from Social Security of $519.00, a monthly deduction of $264.00 for care costs and a monthly deduction of $255.00 for insurance premium, totaled $519.00. Further review of the statements revealed starting 10/12/22 through 06/07/23, Resident #70 had a monthly balance of one dollar and 33 cents. Record review revealed no evidence the resident was receiving a monthly allowance ($50.00 per month) to use for needed personal purposes.
Interview on 06/27/23 at 3:05 P.M. with Resident #70 revealed the facility was taking all of her money for ancillary services insurance premiums and she would like to have her money back. She verified she was a Medicaid recipient and would like to have the $50.00 per month she was permitted to have for personal purposes.
Interview on 06/28/23 at 9:40 A.M. with Receptionist #228 revealed residents who receive Medicaid were to get anywhere from $30.00 to $50.00 per month, depending on the resident. She reported the money was for residents to purchase personal items needed. Receptionist #228 reported she was directed by former Business Office Manager #341 to take the insurance premium for ancillary services out of residents' accounts who signed up for ancillary services. She reported Corporate Accounts Receivable Director (CARD) #337 was now her supervisor and overseeing the resident accounts.
Telephone interview on 06/29/23 at 11:08 A.M. with CARD #337 revealed upon review of Resident #70's account, there was a deduction taken out of her funds by Social Security. Since the facility was not the resident's representative payee, the Social Security office would not release any information to the corporation regarding the reason for the Social Security deduction. CARD #337 indicated Resident #70 did not permit the facility to be the representative payee and therefore, the resident needed to contact the Social Security office to inquire about the garnishing of her monies.
Interview on 06/29/23 at 11:30 A.M. with Receptionist #228 verified Resident #70 has had 14 deductions from her account for Insurance Premiums (for ancillary care) starting on 04/04/22.
Telephone interview on 06/29/23 at 11:39 A.M. with CARD #337 revealed she had spoken to her supervisor and the resident would be provided back pay with interest. She reported she would look at Resident #70's account and calculate since the insurance premiums started being taken out, 04/04/22, and when Social Security started garnishing her monies, what her interest would be. She verified Resident #70 should have been left with $50.00 monthly in her account for personal purposes and that the additional deductions should not have been taken.
Interview on 06/29/23 at 1:00 P.M. with the Administrator revealed she had been attempting to correct Resident #70's funds concern since 04/11/23 and would be upset if she had a banking error that was not resolved timely.
Review of the facility policy titled, Managing Resident Personal Funds, revised 01/20/21, revealed nursing homes residents supported by Medicaid were entitled to maintain a small personal funds account, to be used for personal preference items. A Medicaid resident had the right to a small personal allowance each month, usually from his/her Social Security income, to use for personal purposes. The resident may entrust the funds to the facility but was not required to do so. The facility was required to accept and serve as fiduciary for those residents.
This deficiency is an incidental finding during investigation of Master Complaint Number OH00144114, Complaint Number OH00143590 and OH00143268.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Self-Reported Incident (SRI) review, medical record review, interview and facility policy review the facility failed to prevent misappropriation of narcotics. This affected one resident (Resident #73) of three residents reviewed for abuse/neglect/misappropriation. The facility census was 96.
Findings included:
Review of Resident #73's medical record revealed diagnosis including fibromyalgia. Review of the resident's medication orders revealed the resident had an order for Norco 5-325 milligrams (mg) four times a day.
Review of facility self-reported incident (SRI), tracking number 234072 revealed on 04/15/23 at 3:34 A.M. the outside pharmacy delivered medications to the facility. Per Licensed Practical Nurse (LPN) #300's statement, she checked the medications in and then gave three narcotic medications (each contained in a medication card, unit dose for 30 tablets) to Registered Nurse (RN) #339 which included a 30 count card of Norco (narcotic pain medication) 5-325 milligrams (mg), Ativan (anti-anxiety medication) and tramadol (pain medication). Per LPN #340's statement, when RN #339 delivered the medications to LPN #340, only two narcotic medication cards were provided to him for the hall he was working which did not include the Norco for Resident #73. During the day shift medication administration, it was identified the Norco was missing when the last Norco was used from the previous card (for Resident #73). Pharmacy was contacted to have the medication refilled and confirmed the medication had been delivered on 04/15/23 at 3:34 A.M. and signed as received by LPN #300. Statements were obtained from LPN #300 and #340 and RN #339. RN #339 stated she believed there were only two cards of medication given to her and she gave them to LPN #340. The facility determined the allegation of misappropriation was inconclusive as they were unable to determine if medications were misappropriated by the alleged perpetrator (RN #339). It was suspected but the facility was unable to make the determination that this had occurred through witness statements. Not only was the (narcotic) card missing but also the sheet (used to sign each dose removed from the medication card) that goes with the card.
Review of the investigation file revealed the facility became aware of the missing controlled narcotic (Norco) during day shift on 04/15/23 when the floor nurse (current Director of Nursing (DON)) was using the last of Resident #73's narcotic medication and reached out to the pharmacy to send the next card. Per the current DON's signed statement, the pharmacy reported the medication was delivered during night shift on 04/15/23 at 3:40 A.M. There were three nurses working and on the schedule during the time of the delivery. LPN #300, Registered Nurse (RN) #339 and LPN #340. Review of the statements revealed LPN #300 signed for Resident #73's controlled narcotic (Norco), with two other controlled substances (Ativan and tramadol) and then handed them off to RN #339 who then handed the medications off to LPN #340. RN #339's statement by telephone revealed she believed she was only handed the Ativan and tramadol by LPN #300. LPN #340's statement by email revealed he was only handed the Ativan and tramadol by RN #339.
Interview on 06/29/23 at 1:42 P.M. with the DON revealed she was the nurse on duty who was working and discovered Resident #73's controlled narcotic (Norco) was missing. She reported she reached out to the pharmacy to send the next card of Norco for Resident #73 because she was using the last dose in the current card of medication. The pharmacy reported to her the Norco was delivered to the facility at 3:40 A.M. on 04/15/23. The DON and Licensed Practical Nurse (LPN) Supervisor #99 completed a whole house audit of controlled substances and Resident #73's controlled narcotic (Norco) was not found.
Review of the investigation file revealed LPN #300 was urine tested on [DATE] and the results were negative, RN #339 was urine tested on [DATE] and the results were positive for cannabinoids on 04/27/23, and LPN #340 was urine tested on [DATE] and the results were negative. RN #339 was terminated on 05/02/23 related to her urine drug screen results.
On 06/29/23 at 4:10 P.M. interview with the DON and Administrator verified the Norco was delivered to the facility on [DATE] and the facility was unable to locate the Norco for Resident #73.
Review of the facility policy titled, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, dated 10/2022, revealed misappropriation of resident property was the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent.
This deficiency represents non-compliance investigated under Complaint Number OH00143268.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview and facility policy and procedure review, the facility failed to ensure oxygen tubing was dated and stored properly. This affected one resident (Resident #87) of seven residents reviewed for oxygen use. The census was 96
Findings include:
Review of Resident #87's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, diabetes, and mild protein calorie malnutrition. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed his cognition was intact. He required extensive assistance of two or more staff members for bed mobility, transfers and extensive assistance of one staff member for dressing, toilet use and personal hygiene.
Review of the physicians orders for June 2023 revealed orders for oxygen two to four liters by nasal cannula at night time and Xopenex (a bronchodilator) every four hours via nebulizer for shortness of breath. Review of the treatment record for June 2023 revealed to change oxygen supplies every week on Sunday.
On 06/27/23 at 3:00 P.M. and 3:25 P.M. observation revealed Resident #87's oxygen tubing was dated 06/18/23 and the nasal cannula was tied to the resident's bed rail. The resident's nebulizer tubing was also not dated and the nebulizer mouthpiece was laying on a chair in the resident's room, not covered or stored to prevent possible contamination.
Review of the policy and procedure Oxygen Handling revised 01/21 revealed Oxygen tubing and other equipment will be changed routinely.
This deficiency is an incidental finding during investigation of Master Complaint Number OH00144114, Complaint Number OH00143590 and OH00143268.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and staff interview, the facility failed to identify and treat potential incidents of pain and implement a comprehensive and individualized pain management plan for Resident #67 who was observed to experience discomfort/possible pain during care. This affected one resident Resident (Resident #67) of three residents reviewed for urinary catheters. The census was 96.
Findings include:
Review of Resident #67's medical record revealed she was admitted to the facility on [DATE] with diagnoses including sepsis, encephalopathy, diabetes, Alzheimer's dementia, and mild protein calorie malnutrition.
Review of the pain assessment dated [DATE] revealed the no evidence staff identified the resident had any type of pain. The resident did not have a care plan for pain.
Review of the admission physician orders revealed a #16 French indwelling urinary catheter with the balloon inflated to 10 milliliters due to a neurogenic bladder, catheter care every shift, and monitor for pain (with numerical scale of 1-10) every shift. There was no order for scheduled or as needed (PRN) pain medication.
Review of the five-day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively impaired. The assessment revealed the resident required extensive assistance from two or more staff members for bed mobility and total dependence from two or more staff members for transfers, dressing, and toilet use.
On 06/27/23 at 11:10 A.M. State Tested Nursing Assistant (STNA) #242 was observed providing urinary catheter care to the resident. The STNA closed the blind and explained to Resident #67 she was going to provide the resident with catheter care. At this time, Resident #67 was heard stating, no-no-no-no. The STNA proceeded to provide care and told the resident, I know it hurts (while lowering the head of the resident's bed) but we have to lower it so care can be completed. STNA #242 provided the resident catheter care and then turned Resident #67 onto her left side at which time the resident moaned and called out. The STNA continued with the resident's care, washing the resident's buttocks, and changing the disposable incontinence pad that was underneath the resident. While replacing the pad underneath the resident and turning the resident, she again yelled out and appeared to be in pain. STNA #242 explained the need to replace the resident's bed linens. The STNA then placed a pillow between the resident's legs and the resident again moaned and yelled out; the resident appeared to be in distress during the procedure.
On 06/27/23 at 11:35 A.M. interview with STNA #242 revealed she was unaware whether the resident received anything for pain.
Following the surveyor's observation, review of a progress note, dated 06/27/23 at 12:09 P.M. revealed the nurse practitioner was updated of the resident yelling out during peri-care and at times throughout the shift. A new order was given for Tylenol 650 milligrams (mg) for general pain/discomfort.
Review of the physician's orders revealed an order for Tylenol 650 mg every four hours as needed for general discomfort.
On 06/27/23 at 2:30 PM. interview with the Director of Nursing (DON) and the Administrator revealed staff had reported the resident had been moaning and calling out with care but they were told this was a behavior when staff touched the resident and not necessarily pain related. The DON stated a new pain assessment had since been completed and the resident's primary care provider ordered Tylenol 650 milligrams (mg) every four hours as needed for pain.
Review of the June 2023 Medication Administration Record and progress notes revealed on 06/27/23 at 12:12 P.M. the resident received Tylenol 650 milligrams (mg) for a pain rating of five on a 0-10 pain scale (with ten being the most severe pain) and the medication was determined to be effective; on 06/28/23 at 8:00 A.M. the resident received Tylenol 650 mg (no pain rating provided) and the medication was determined to be effective; on 06/29/23 at 5:37 A.M. the resident received Tylenol 650 mg for a pain rating of 8 on a 0-10 scale and the medication was determined to be effective.
On 06/29/23 at 1:24 P.M. interview with STNA #242 revealed she felt Resident #67 had been more comfortable with positioning since 06/27/23 when the Tylenol order was added and stated if the resident doesn't feel good, she called out in pain. STNA #242 reported if a resident was having pain or complains of pain, she was to stop whatever she was doing with that resident and report the resident's complaints to the nurse. She reported if the resident had pain medications ordered, the nurse could administer the medication. The STNA stated she had noticed that if Resident #67 called out, it could be time for her pain medication.
On 06/29/23 at 1:24 P.M. interview with Registered Nurse (RN) #309 revealed she felt Resident #67's pain management plan was currently effective. She reported she worked with Resident #67 last week and noted she winced in pain in her shoulder. RN #309 reported she notified the physician, and an x-ray was ordered, but the physician did not want to order any pain medications until he knew what the cause was of the pain. RN #309 reported the x-ray was negative, and the physician still did not order any pain medication because he wanted to assess her for a rotator cuff injury. RN #309 reported she knows when a cognitively impaired resident is experiencing pain by signs (of pain). She reported she looks for guarding, wincing, or other facial expressions. RN #309 reported sometimes it was very difficult to determine if a resident was having pain or if it was a behavior but in these cases you do right by the resident and notify the physician of your findings. RN #309 reported the physician makes the ultimate decision of whether a resident's presentation was pain or behavioral. She reported the nurse on duty needed to provide the physician with his or her findings. The RN verified the resident currently had an order for Tylenol for pain management.
The facility did not have a policy regarding pain management.
This deficiency represents non-compliance investigated under Complaint Number OH00143268.

Based on observation, interview, record review and policy review the facility failed to store and prepare food in a sanitary manner. This has the potential to affect 95 residents in the facility. The facility identified one resident (Resident #63) did not receive food by mouth from the kitchen The facility census was 96.
Findings included:
1. Review of food temperature logs for May 2023 revealed food temperatures were not taken during preparation, and during holding for the dinner meal hot items on 05/09/23, breakfast meal and lunch meal cold items on 05/13/23, lunch meal hot items on 05/13/23, dinner meal hot items on 05/18/23, lunch meal cold items on 05/25/23, dinner meal cold items on 05/27/23, dinner meal cold items on 05/28/23, breakfast, lunch and dinner meal hot items on 05/30/23, and dinner cold items on 06/07/23.
Interview on 06/27/23 at 9:25 A.M. with Dietary Manger #251 verified there was missing documentation to verify food temperatures were obtained.
2. Observation on 06/27/23 at 10:15 A.M. of the prep refrigerator revealed a partially used bag of spinach which was left open to air. An interview at the time of the observation with Dietary [NAME] #287 verified items in the refrigerator should be closed to keep food protected.
3. Observation on 06/27/23 at 10:51 A.M. of Dietary [NAME] #284 pulling tongs from overhead storage and entering the walk-in cooler to obtain hotdogs and sausage to cook for residents. Dietary [NAME] #284 placed seven hotdogs from a container in the refrigerator into a container in her hand. Observation revealed the tongs had a dried, crusty, white substance inside the arm and serving part of the tong. The Dietary [NAME] #284 verified the substance and stated, These are dirty. She then left the walk-in cooler to obtain another tong which were clean. Dietary [NAME] #284 then reentered the walk-in cooler and obtained a sausage and placed it in the container with the hotdogs.
Interview on 06/27/23 at 12:15 P.M. with Dietary [NAME] #284 verified she cooked one of the hotdogs she obtained with the dirty tongs for Resident #64 and the sausage for Resident #91.
Interview on 06/27/23 at 12:20 P.M. with Regional Culinary Director #333 verified the hotdogs should have been discarded after being handled with the dirty tongs and if he had known they had been touched by the dirty tongs, he would have had Dietary [NAME] #284 discard them.
4. Observation on 06/27/23 at 10:52 A.M. of Speech Therapist #302 walking into the kitchen near a food preparation table with her hair not properly contained in a hair net. She had her hair in a loose ponytail and only the upper part of her hair was contained inside a hair net. An interview at the time with Regional Culinary Director #333 verified Speech Therapist #302 was not wearing her hair net appropriately and her hair was not contained in it.
5. Observation on 06/27/23 at 10:54 A.M. of the bench can opener (large can opener attached to a counter) blade with dark, crusted substance. An interview at the time with Regional Culinary Director #333 verified the can opener was dirty.
Interview on 06/27/23 at 12:30 P.M. with Dietary Manager #251 verified the bench can opener was dirty, and the dirt did not appear to be from use of the can opener today.
Review of the facility policy titled, Cleaning Bench Can Opener, created and revised 09/08/21, revealed the bench can opener will be cleaned and sanitized after each use and as needed.
Review of the facility policy titled, General Cleaning of Equipment, created 10/01/21 and revised 10/01/21, revealed basic cleaning equipment will be maintained in a clean and sanitary condition after every yes to ensure food safety.
This deficiency represents non-compliance investigated under Complaint Number OH00143268.

Based on record review and interview the facility failed to ensure the dietary manager was qualified to perform the job duties of the manager. This had the potential to affect all 95 residents residing in the facility.
Findings include:
Review of Dietary Manager #315's personnel file revealed on 02/23/2020 she was promoted to the position of Dietary Manager. Review of the employee's personnel file revealed no evidence Dietary Manager #315 was a certified dietary manager, certified food service manager, had similar national certification for food service management and safety from a national certifying body or had an associate's or higher degree in food service management or in hospitality, if the course study included food service or restaurant management, from an accredited institution of higher learning.
On 09/23/21 at 2:49 P.M. interview with Dietary Manager #315 revealed she had not completed a Certified Dietary Manager certification training course as of this date.
On 09/23/21 at 3:24 P.M. interview with the Administrator verified Dietary Manager #315 did not met the education/training requirements of a Dietary Manager.

Based on observation, medical record review and interview the facility failed to ensure Resident #89 was provided a dignified dining experience during the lunch meal on 09/20/21. This affected one resident (#89) of two residents reviewed for dignity.
Findings include:
Review of the medical record for Resident #89 revealed an admission date of 11/21/19 with diagnoses including Alzheimer's disease, anxiety disorder, depression, repeated falls, cognitive communication disorder and dementia with behavioral disturbance.
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 09/07/21 revealed the resident was rarely or never understood and required extensive assistance from one staff for eating.
Review of the care plan, dated 09/10/21 revealed Resident #89 was at risk for malnutrition and dehydration related to diagnoses, need for mechanically altered diet, being overweight, using psychoactive medication, and being totally dependent (from staff) at meals. Interventions included providing assistance with meals as needed, honoring food preferences, providing diet as ordered, monitoring for any decrease in appetite and weighing according to facility policy.
On 09/20/21 at 11:35 A.M. State Tested Nursing Assistant (STNA) #335 was observed beginning to feed Resident #89. Immediately upon sitting down STNA #335 mixed the resident's meat and mashed potatoes. She was observed feeding Resident #89 bites of mixed meat and mashed potatoes at 11:38 A.M., 11:40 A.M., 11:42 A.M., and 11:44 A.M. She fed her a spoonful of mixed meat, mashed potatoes, and green beans at 11:43 A.M., and a bite of mixed green beans and mashed potatoes at 11:45 A.M. During the lunch meal starting at 11:42 A.M. STNA #335 was observed using the spoon to wipe food off Resident #89's lips and chin and putting the spoon back in her mouth three bites in a row.
On 09/20/21 at 12:19 P.M. interview with STNA #335 confirmed the above observations. She reported Resident #89 liked her food mixed and that using the spoon in that manner was habit for her.
Review of the policy titled Feeding a Resident, dated October 2018 revealed residents should be fed in a dignified manner that promotes independence, self-esteem and a sense of well-being.

Based on record review, facility policy and procedure review and interview the facility failed to ensure all staff were checked against the Nurse Aide Registry to ensure no staff member had a finding entered into the State Nurse Aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property. This had the potential to affect all 95 residents residing in the facility.
Findings include:
Review of the facility personnel files on 09/22/21 revealed no evidence any of the facility contracted rehabilitation staff were checked against the Nurse Aide Registry to ensure no staff member had a finding entered into the State Nurse Aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property. This included Rehab Director #390, Physical Therapist #391, Physical Therapy Assistant (PTA) #392, PTA #393, PTA#394, Certified Occupational Therapy Assistant (COTA) #395, COTA #396, Occupational Therapist #397 and Speech-Language Pathologist #398.
On 09/22/21 at 1:30 P.M. interview with the Administrator confirmed the facility was not checking contracted staff against the Nurse Aide Registry.
On 09/22/21 at 2:36 P.M. interview with Human Resource Manger #363 revealed the facility does not check any of their contracted employees, which included the above therapy staff against the Nurse Aide Registry prior to working in the facility.
For purposes of the guidance related to this Centers for Medicare and Medicaid (CMS) requirement staff includes employees, the medical director, consultants, contractors and volunteers. In addition to the facility not checking these contracted staff against the Nurse Aide Registry prior to working in the facility, there was no evidence the employees had been checked by the contracted company who they were hired by.
Review of the facility policy titled Abuse, Neglect, Exploitation, and Misappropriation, dated 09/2020 revealed all employees were to be checked against the Nurse Aide Registry.

Based on closed record review and interview the facility failed to complete a discharge summary including a recapitulation of the resident's stay for Resident #95. This affected one resident (#95) of two residents reviewed for discharge.
Findings include:
Review of the closed medical record for Resident #95 revealed an admission date of 06/24/21 and discharge date of 07/01/21. The resident had diagnoses including malignant neoplasm of the brain, severe protein calorie malnutrition, failure to thrive and seizure disorder.
Record review revealed the resident was cognitively impaired and required limited to extensive assistance from one staff for activities of daily living.
Review of the progress note, dated 07/01/21 at 2:41 P.M. revealed Resident #95 went for a follow up visit with the surgeon who indicated the resident could be discharged home from the facility on this date. The facility physician gave the verbal order for the resident to discharge home with family.
Record review revealed the facility failed to complete a discharge summary that included a recapitulation of the resident's stay.
On 09/22/21 at 1:50 P.M. interview with the Social Service Designee confirmed there was not a recapitulation of stay completed for Resident #95 following the resident's discharge from the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #22's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, type two diabetes with neuropathy, chronic kidney disease, severe protein calorie malnutrition, history of COVID-19, anxiety disorder, traumatic amputation at knee left lower leg, dementia without behavioral disturbance, peripheral vascular disease and hypothyroidism.
Review of Resident #22's annual Minimum Data Set (MDS) 3.0 assessment, dated 07/20/21 revealed the resident's speech was clear, she made herself understood, she understands others and her cognition was intact. The assessment revealed the resident had no behaviors and did not reject care. Resident #22 required extensive assistance of one staff for bed mobility, was totally dependent on two staff to transfers, required extensive assistance of one staff for personal hygiene. The resident had had limited range of motion of both lower extremities and used a wheelchair. The MDS assessment revealed it was somewhat important for the resident to choose between a tub bath, bed bath and shower.
Review of Resident # 22's plan of care revealed she preferred showers in the morning, but on 03/07/19 Resident #22 changed her mind and now preferred showers in the evening.
Review of Resident #22's shower documentation revealed between 09/01/2021 and 09/21/2021 staff documented two showers were provided. On 09/17/2021 Resident #22 refused a shower due to not feeling well, she was diagnosed and treated for pneumonia.
On 09/20/21 at 11:18 A.M. interview with Resident #22 revealed concerns she did not receive showers twice a week as she wanted. During the interview the resident revealed she was not sure when she had last received a shower. Resident #22 revealed she preferred a morning shower, but since she was not getting one in the morning regularly she changed her preference to evenings.
On 09/22/21 at 8:16 A.M. interview with State Tested Nursing Assistant (STNA) #353 revealed Resident #22 preferred a shower twice a week.
On 09/22/21 at 2:54 P.M. interview with the DON revealed Resident #22 had not received any showers from 09/01/2021 to 09/20/2021 and that staff were completing bed baths instead. The DON revealed there was no reason why Resident #22 received bed baths and not showers as per the resident's plan and preference.
Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure residents, who required staff assistance for personal care/showers and/or meals received adequate and timely assistance to maintain proper hygiene and oral intake. This affected two residents (#11 and #22) of four residents reviewed for shower/bathing and two residents (#89 and #92) of seven residents observed for dining.
Findings include:
1. Record review revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including need for assistance with personal care, epilepsy, pain in right wrist and hand, unsteadiness on feet, abnormal posture, muscle weakness, chronic pain and neurofibromatosis.
Review of Resident #11's Minimal Data Set (MDS) 3.0 assessment, dated 07/02/21 revealed Resident #11 required physical help from one staff for bathing.
A current plan of care revealed the resident was at risk for decline in activities of daily living (ADL) function related to impaired mobility, mild intellectual and developmental disabilities. Interventions indicated the resident preferred to shower in the evening and preferred female staff to provide personal care.
A plan of care related to fall risk revealed staff were to use lower seating shower chair for showers.
On 09/20/21 at 2:51 P.M. interview with Resident #11 revealed concerns related to showers. The resident revealed she was unable to shower by herself and required staff to assist her with showers. The resident revealed she was supposed to be offered a shower every night, however she had not been receiving or being offered showers and staff were refusing to help her.
Review of Resident #11's electronic medical records/staff TASK documentation revealed the resident was to receive a shower on night shift. Review of the electronic shower records from 08/24/21 to 09/22/21 revealed no evidence the resident was provided or refused a shower on 08/30/21, 08/31/21, 09/01/21, 09/03/21, 09/09/21, 09/11/21, 09/16/21 or 09/19/21.
On 09/23/21 at 10:40 A.M. interview with the Director of Nursing (DON) verified the resident was to receive a shower every night on night shift. Initially, the DON indicated she believed staff had just forgotten to document the showers in the electronic medical record and indicated there could be paper shower sheets completed. However, the DON was only able to find one paper shower sheet, dated 09/06/21 that indicated the resident received a shower. The DON verified there was no documented evidence the resident received a shower on 08/30/21, 08/31/21, 09/01/21, 09/03/21, 09/09/21, 09/11/21, 09/16/21 or 09/19/21 as planned and per the resident's preference.
3. Review of the medical record for Resident #92 revealed an admission date of 05/18/21 with diagnoses including encephalopathy, unspecified severe protein-calorie malnutrition, anxiety disorder, dementia without behavioral disturbance, hypothyroidism and major depressive disorder.
Review of the plan of care, dated 09/06/21 revealed Resident #92 was at risk for malnutrition and dehydration related to need for supplementation, psychoactive medications, requiring assistance at meals, history of severely poor intakes, and diagnoses including anxiety, depression and dementia. Interventions included using adaptive equipment as ordered, providing medications as ordered, offering meal alternates when the resident refused, providing the diet as ordered, and providing assistance with meals and snacks as needed.
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was rarely or never understood and required extensive assistance from one person for eating.
On 09/20/21 from 11:03 A.M. to 12:15 P.M. observation of the lunch meal revealed the first lunch cart arrived to the unit at 11:03 A.M. and the second arrived at 11:05 A.M. Resident #92 was observed sitting on the couch in the living room from 11:03 A.M. until 11:35 A.M. when staff brought her to the dining room. Resident #92's meal was set up and the staff walked away from her. The resident had meatloaf, mashed potatoes, french fries and green beans. Resident #92 was not observed touching her tray until 11:50 A.M. when she put her fingers in the mashed potatoes and licked it off. She was again observed doing this at 11:58 A.M. and 12:00 P.M. At 12:11 P.M. State Tested Nursing Assistant (STNA) #335 approached the resident and put her sandwich in her hand to prompt her to eat. She additionally fed her a bite of food and walked away at 12:14 P.M. At 12:15 P.M. an STNA sat down finished assisting the resident with her meal.
On 09/20/21 at 12:19 P.M. interview with STNA #335 revealed she believed Resident #92 was able to feed herself. The STNA confirmed the resident had stuck her fingers in the mashed potatoes but stated Resident #92 was able to feed herself finger foods. STNA #335 revealed they usually gave the resident time to feed herself and then provided assistance. The STNA confirmed it had been over an hour since the meal had arrived to the unit when staff began to assist the resident and the resident had not consumed much of the meal independently in that time period.
Review of the policy titled Feeding a Resident, dated October 2018 revealed it was the responsibility of nursing staff to provide assistance to residents who were not able to feed themselves. Residents should be fed in a manner that promoted independence, self-esteem and a sense of well being.
4. Review of the medical record for Resident #89 revealed an admission date of 11/21/19 and diagnoses including Alzheimer's disease, anxiety disorder, depression, repeated falls, cognitive communication disorder and dementia with behavioral disturbance
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 09/07/21 revealed the resident was rarely or never understood and required extensive assistance from one staff for eating.
Review of the care plan, dated 09/10/21 revealed Resident #89 was at risk for malnutrition and dehydration related to diagnoses, need for mechanically altered diet, being overweight, using psychoactive medication and being totally dependent (on staff) for meals. Interventions included providing assistance with meals as needed, honoring food preferences, providing diet as ordered, monitoring for any decrease in appetite and weighing according to facility policy.
On 09/20/21 at 4:00 P.M. observation of the dinner meal revealed the trays arrived on the unit. At that time, Resident #89 was observed sitting at the same table as another resident. At 4:22 P.M. an STNA began feeding the second resident at the table. Resident #89 sat at the table until 4:43 P.M. when Housekeeping Supervisor #360 asked the STNA if Resident #89 had eaten. Upon receiving a negative response Housekeeping Supervisor #360 warmed up the resident's food and began feeding her at 4:46 P.M.
On 09/20/21 at 4:33 P.M. interview with Housekeeping Supervisor #360 revealed she was an STNA and was helping to feed the residents on the memory care unit. The supervisor revealed there was only one nurse and one STNA on the unit and she knew they had a lot of residents to feed.
On 09/20/21 at 4:50 P.M. interview with Licensed Practical Nurse (LPN) #379 confirmed Resident #89 had been waiting 45 minutes after the meal had been brought to the unit to eat. She additionally confirmed she had been sitting at the table while another resident was fed.
Review of the policy titled Feeding a Resident, dated October 2018 revealed it was the responsibility of nursing staff to provide assistance to residents who were not able to feed themselves. Residents should be fed in a manner that promoted independence, self-esteem and a sense of well being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy and procedure review and interview the facility failed to provide timely and adequate treatment for Resident #75 following a fall with injury.
Actual harm occurred on 07/02/21 when Resident #75, who was severely cognitively impaired and required staff assistance for bed mobility and transfers, sustained a fall which resulted in bruising and swelling to her hip but was not immediately sent to the hospital for evaluation/treatment. From 07/02/21 to 07/09/21 the resident exhibited increased pain and agitation, yelling out for help and rated her pain up to a nine on a scale of one to 10 (with 10 being the worst pain). The resident was transferred to the hospital on [DATE] (seven days after the fall) and diagnosed with an acute closed communicated displaced right femoral interochanteric fracture requiring surgical repair and a severe displaced subacute fracture of left hemipelvis. The resident was hospitalized from [DATE] to 07/12/21.
This affected one resident (#75) of four residents reviewed for falls.
Findings include:
Review of the medical record for Resident #75 revealed an admission date of 02/26/21 with diagnoses including Alzheimer's disease, chronic obstructive pulmonary disease, fracture of unspecified part of neck of right femur, anxiety disorder, gastro-esophageal reflux disease, depression and hypertension.
Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 07/19/21 revealed Resident #75 had severely impaired cognition. The assessment revealed the resident required extensive assistance from two staff members for bed mobility and was totally dependent on staff for transfers.
Review of a progress note, revealed on 07/02/21 at 1:30 P.M. Resident #75 was found lying on the floor beside her bed. Range of motion was completed for all four extremities and found to be at baseline. The resident reported discomfort in her legs and feet, which the nurse noted was the resident's baseline for transfers and turning. Notifications occurred appropriately.
On 07/02/21 at 1:44 P.M. the resident was given Morphine for generalized discomfort, at 3:00 P.M. Following the administration of pain medication, the resident's pain decreased to a two on a scale of one to 10.
On 07/02/21 at 4:41 P.M. the resident was administered Buspirone for increased anxiety and at 4:44 P.M. she was given Ultram for pain to bilateral legs and feet, the note indicated staff were unable to rate her pain at that time due to her cognitive impairment.
On 07/02/21 at 5:53 P.M. the resident was administered Morphine as the Tramadol (Ultram) was ineffective and the resident was noted to have more pain than baseline. The resident was assessed to have pink and purple bruising to the top anterior right thigh with slight swelling, however, the note indicated range of motion remained at baseline. The physician was notified of the new findings. The physician indicated to continue with as needed pain meds and stated the resident would be seen on Monday 07/05/21. The physician advised staff to call for increased pain or pain medication being ineffective.
Review of Certified Nurse Practitioner #422's notes, with a date of service on 07/02/21 and signed 07/05/21 revealed nothing related to the resident's fall, pain or injury.
Further review of the progress notes revealed on 07/05/21 the resident received Ultram at 8:05 A.M. for generalized pain and pain in buttocks, she received Morphine at 10:20 A.M. after yelling out about pain all over, and at 3:33 P.M. she received Morphine for generalized discomfort.
Review of the hospice nurse's note, dated 07/07/21 revealed the hospice aide reported the resident had a new bruise on her right thing. When discussed with the nurse it was indicated this was the result a recent fall in the previous week and the nurse reported the resident's pain and anxiety mediations were adequate at the time. In an addendum dated 07/13/21 the hospice nurse documented the hospice aide reported the fall was on 07/05/21 and not the previous week. Review of the hospice nurse's notes dated 07/08/21 revealed the resident was experiencing severe pain intermittently in her right leg, she stated the duration was unable to be determined and the pain was assessed using the Face, Legs, Activity, Cry, Consolability (FLACC) tool.
On 07/08/21 at 12:23 P.M. the resident was assessed to have continued purple and yellow bruising to the right hip, thigh, and lower leg into the ankle which was noted from her previous fall. On 07/08/21 at 1:32 P.M. the resident was administered Ultram for generalized and bilateral leg pain, she was also given Morphine at that time. In addition, the note revealed the facility called Buckeye Hospice to update them on the resident's bruising. Hospice staff indicated a nurse would be sent to see the resident.
On 07/08/21 at 3:40 P.M. the Hospice nurse arrived to see the resident regarding her right lower extremity and increased pain. New orders from hospice were received to increase Morphine dose and the POA was updated. The resident received Morphine at 4:33 P.M. for generalized discomfort.
On 07/09/21 at 11:44 A.M. the CNP assessed the resident and recommended an x-ray of the right leg. X-ray staff arrived at 4:58 P.M. The progress note on 07/09/21 at 6:00 P.M. indicated the resident was ordered an x-ray to the right hip due to increased bruising to her right lower extremity on that day, and it was discovered she had a right hip fracture. Hospice and Physician #424 were notified and the physician gave an order to send the resident to the emergency room. A note on 07/09/21 at 6:03 P.M. revealed Hospice Registered Nurse #427 notified the facility and the resident's power of attorney (POA) agreed to the resident being sent to the hospital.
Review of CNP #423's note, dated 07/09/21 revealed Resident #75 was seen for swelling an ecchymosis to the right leg. The nurse documented the resident fell on [DATE], ecchymosis and worsening edema to right hip and leg. CNP #423 documented the resident denied pain upon examination. An x-ray of the right leg was ordered. However, review of the Medication Administration Record (MAR) revealed the resident was administered Morphine Sulfate for pain on 07/09/21 at 1:00 P.M. for pain rated a nine out of 10, at 3:10 P.M. for a pain rated a seven out of 10 and at 6:30 P.M. for a pain rated an eight out of 10.
Review of the hospice nurse's note, dated 07/09/21 revealed the floor nurse notified hospice the bruise and knot on the resident's right leg from a fall on Monday had progressed to bruising and swelling of the whole right leg. A visit was made to the facility to evaluate and the floor nurse stated the resident was just put into bed and was difficult to get settled due to pain. The hospice physician was consulted and Morphine was increased. An addendum dated 07/13/21 revealed the hospice nurse had asked the facility nurse if an x-ray had been performed following the fall. The facility nurse revealed one had not been done as the resident was a hospice patient and had originally admitted with a fractured pelvis and comfort care. The hospice nurse's note, dated 07/10/21 revealed the facility called to notify them an x-ray was performed and the resident had a fractured hip. The physician had recommended the resident be sent to the hospital. The resident's power of attorney was notified of the results of the x-ray and asked if he wanted to send her to the hospital, he agreed
Review of the hospice aide note, dated 07/09/21 revealed the resident had been complaining of leg and bottom pain, her right leg was very swollen and bruised. The hospice aide said the facility aides reported they had kept the resident in the recliner because they were afraid to put her in bed.
Review of the Medication Administration Record for June 2021 revealed the resident received Tramadol HCl 50 milligrams (mg) three times a day for pain. Further review revealed she received Morphine Sulfate Solution 20 mg per milliliter (ml) for pain as needed eight times throughout the month (once on 06/08/21, twice on 06/16/21, twice on 06/19/21, once on 06/24/21, once on 06/29/21, and once on 06/30/21). Additionally, Resident #75 received Ultram 50 mg as needed for pain rated six to ten on seven occasions in June (once on 06/01/21, twice on 06/06/21, once on 06/09/21, once on 06/10/21, once on 06/16/21, and once on 06/22/21).
Review of the Medication Administration Record (MAR) for July 2021 revealed the resident received Tramadol Hcl 50 mg three times a day for pain, she did not receive Tylenol Tablet 325 mg as needed for general discomfort rated one to five. She received Morphine sulfate 20 mg/ml on 07/02/21 at 1:44 P.M. and 5:53 P.M. for a pain level of four, 07/03/21 at 10:30 A.M. for a pain of eight, 07/04/21 at 2:04 P.M. for a pain of nine and at 6:41 P.M. for a pain of nine, 07/05/21 at 10:20 A.M. for a pain of five and at 3:33 P.M. for a pain of three, 07/06/21 at 10:00 P.M. for a pain of five, 07/07/21 at 10:20 A.M. for a pain of nine and at 2:45 P.M. for a pain of seven, 07/08/21 at 9:32 A.M. for a pain of four, 1:32 P.M., for a pain of five and 4:33 P.M. for a pain of three, and on 07/09/21 at 1:00 P.M. for a pain of nine, 3:10 P.M. for a pain of seven, and 6:30 P.M. for a pain of eight. The resident received Ultram 50 mg on: 07/02/21 at 4:44 P.M. for a pain of five, on 07/05/21 at 8:05 A.M. for a pain of three, on 07/06/21 at 1:58 P.M. for a pain of six, and on 07/08/21 at 1:32 P.M. for a pain of five.
Review of the care of plan, updated 07/22/21 revealed the resident was at risk for alteration in comfort related to fracture of the superior rim pubis and right femur fracture. Interventions included providing medications as ordered to manage pain, monitoring for adverse effects of pain medications, monitoring the effectiveness of interventions, monitoring for increased pain and notifying the physician as needed and repositioning the resident for comfort.
Review of the physician progress note, dated 07/29/21 revealed Resident #75 was admitted to the hospital from [DATE] to 07/12/21 after her fall. She was found to have an acute closed communicated displaced right femoral interochanteric fracture, she had an open reduction and internal fixation (ORIF) surgical repair. Additionally, the resident was assessed to have a severe displaced subacute fracture of left hemipelvis with no surgical intervention provided. The physician note documented the resident was found to have a right hip fracture shortly after her fall. The physician documented the resident had little pain initially that increased after several days and she developed ecchymosis.
On 09/22/21 at 3:07 P.M. interview with Buckeye Hospice Registered Nurse (RN) #388 revealed she had been unaware of Resident #75's fall until a hospice aide notified her of a bruise. Buckeye Hospice RN #388 said hospice was not made aware of the fall when it occurred, and stated the facility was not great at notifying them of changes. She was under the impression the fall occurred on 07/05/21. Buckeye Hospice RN #388 said she saw the resident once a week but went in to evaluate the resident after learning of the bruise. Upon visiting the facility, she was informed of the fall, she stated on her original visit the facility had not reported a concern with pain. Buckeye Hospice RN #388 said she had asked the facility about an x-ray, but they said they did not get one because she was hospice. Buckeye Hospice RN #388 reported she told them that was not an appropriate reason not to get an x-ray and the facility then stated there were not enough signs to order one.
On 09/21/21 at 3:41 P.M. an attempted interview with Resident #75 revealed the resident said she hurt. However, the resident was unable to identify where or how much she hurt and was quickly distracted. Before the end of the conversation the resident again began saying she hurt.
On 09/21/21 at 3:43 P.M. interview with Licensed Practical Nurse (LPN) #382 revealed Resident #75 was unable to tell staff where her pain was at or how severe it was. LPN #382 revealed staff use observations to assess when the resident was in pain such as yelling out, and then used a pain scale (FLACC) from the electronic medical record to number her pain based on the signs. LPN #382 reported she had recently given Resident #75 some pain medications because she had been yelling out.
On 09/22/21 at 4:10 P.M. interview with the Director of Nursing (DON) verified Resident #75 had sustained a fall on 07/02/21. The DON agreed the resident's as needed pain medications were used more from 07/02/21 to 07/09/21 when comparing her use in June 2021. She stated she knew Resident #75 must have been in pain and that was why she had been advocating for the CNP to see her. In further interviews with the DON on 09/23/21 at 10:43 A.M. and 2:10 P.M. she reported the resident reported pain of eight and nine multiple times in June, so she did not think there was really an increase following her fall. However, she agreed the resident received Tramadol three times a day in June and July and seemingly needed less Morphine and Ultram in June to cover this pain. The DON then stated the increase in as needed: pain medications were because they were being used as a preventative measure, as staff figured the resident would be in pain from her fall. The DON confirmed the progress note on 07/02/21 revealed Physician #424 wanted to be notified if the resident experienced increased pain. She additionally confirmed the hospice nurse saw Resident #75 on 07/08/21 for increased pain and there was nothing to indicate the physician was notified. The DON indicated that due to the new Morphine order, the hospice nurse would have notified the hospice physician. She confirmed there was nothing to indicate the resident's physician, Physician #424, was notified.
On 09/22/21 at 4:47 P.M. interview with Physician #424 revealed he had been on vacation when he was initially notified of Resident #75's fall. He stated he originally planned on seeing her the Monday after the fall (07/05/21) but did not realize he would still be on vacation. He would have expected the facility to ask one of the CNP's to see the resident when she started bruising. Physician #424 denied knowing the resident experienced bruising and swelling beginning hours after the fall. He stated if he had been aware of that he would have ordered an x-ray immediately. The physician thought that this case had been an example of poor communication with the involved parties. Physician #424 stated on 07/09/21 the nurses told him the resident began complaining of pain in the middle of the week. He stated Resident #75 had been receiving Morphine, so she probably had not been in too much pain until the fracture displaced. The physician denied ever speaking to the resident's family.
On 09/21/21 at 5:21 P.M. interview with Resident #75's POA revealed he was notified of the fall originally and was called a few days later about getting an x-ray. The POA reported when the results came back, he agreed to send the resident to the hospital.
Review of the FLACC scoring table revealed resident's behaviors are scored based on the severity to determine a pain score. Behaviors included breathing, negative vocalization, facial expression, body language, and consolability.
Review of the policy undated Status Change in Resident Condition- Notification policy revealed the facility nurse was to notify the resident's attending physician when there was a significant change in resident's physical, mental, or psychosocial status, when there was a need to alter the resident's treatment significantly, or when deemed necessary or appropriate in the best interest of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure pressure relieving devices were in place as planned and failed to include documentation of interventions for Resident #75 who developed a pressure ulcer to the right knee. This affected one resident (#75) of two residents reviewed for pressure ulcers.
Findings include:
Review of the medical record for Resident #75 revealed an admission date of 02/26/21 with diagnoses including Alzheimer's disease, chronic obstructive pulmonary disease, fracture of unspecified part of neck of right femur, anxiety disorder, gastro-esophageal reflux disease, depression and hypertension. Record review revealed the resident received Hospice services.
Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 07/19/21 revealed the resident had severely impaired cognition and required the extensive assistance of two staff for bed mobility.
Record review revealed the resident was at risk for skin breakdown with a care plan and interventions in place for skin assessments, a pressure relieving mattress, turing and repositioning and to be up in the chair often. The plan of care was updated on 08/06/21 when Resident #75 was assessed to have a pressure injury to her right inner knee. A new intervention at that time included encouraging the resident to allow staff to place a pillow between her knees while in bed, routine wound rounds with the nurse practitioner and monitoring for changes.
Review of the progress note, dated 08/06/21 revealed the resident had a new area to her left knee, it was reported as being circular. A skin assessment was done, the area was cleansed and a border foam dressing was applied. A pillow was put between the resident's knees to keep pressure off the area at that time. An additional note on 08/06/21 revealed the area was actually to the resident's right knee measuring 1.5 centimeters (cm) by 1.5 cm with no depth documented. The intervention to use a pillow between the legs was deemed appropriate to continue and treatment ordered (skin prep to right inner knee every shift). A further note indicated the power of attorney was notified of the new order for skin prep to the right inner knee every shift and to encourage a pillow between the resident's knees.
Review of an unavoidable pressure injury assessment document, dated 08/06/21 revealed an intervention to place a pillow between the resident's legs in relation to Resident #75's pressure area was noted.
Review of wound assessments revealed from 08/06/21 through 09/21/21 the area to the right knee continued to show signs of improvement/healing.
Review of the physician's orders and treatment administration record (TAR) for August and September 2021 revealed no evidence of staff applying or monitoring the use of a pillow between the resident's knees.
Observations on 09/21/21 at 3:41 P.M., 4:08 P.M. and 4:17 P.M. revealed Resident #75 was in bed lying on her left side with her legs curled up with the right leg on top of the left. It was apparent based on the location of her knees under the blanket there was nothing keeping them apart (no pillow in place). At 4:17 P.M. State Tested Nursing Assistant (STNA) #334 lifted the resident's blanket and confirmed her right knee was resting on top of her left knee with no pillow or wedge observed. At the time of the observation, interview with STNA #334 revealed she was unsure if there was supposed to be something in place.
On 09/21/21 at 4:48 P.M. interview with Licensed Practical Nurse (LPN) #383 revealed Resident #75 repositioned herself onto her lift side often. LPN #383 reported Resident #75 had a cushion to go between her knees and indicated it must have moved when the resident repositioned. During the interview, LPN #383 reported there was not a location to document this intervention being implemented and stated it was just something nurses usually did when a resident had a similar area.
On 09/22/21 at 3:07 P.M. interview with Buckeye Hospice Registered Nurse (RN) #388 revealed there should have been an order in place for offloading pressure to the resident's knees.
On 09/23/21 at 2:10 P.M. interview with the Director of Nursing (DON) and Regional Quality Assurance Nurse #426 revealed there was not a location in the medical record where nurses or STNA staff would document a pillow/wedge being in place between Resident #75's legs. Regional Quality Assurance Nurse #426 revealed the intervention was included in the [NAME] for the nurses to see. The DON reported the resident did not move around a lot and indicated the STNA staff should be checking and changing the resident every two hours at which time they should ensure a pillow/wedge was in place and felt this was sufficient for the resident.
Review of the policy titled Pressure Ulcer Prevention and Risk Identification revealed interventions for pressure areas were to be implemented as indicated by the physician and as determined by the interdisciplinary team.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy and procedure review and interview the facility failed to ensure Resident #57 received restorative therapy and splinting/brace use per plan of care and therapy recommendations. This affected one resident (#57) of two residents reviewed for range of motion.
Findings include:
Record review revealed Resident #57 was admitted to the facility on [DATE] with diagnoses including quadriplegia, multiple sclerosis, muscle weakness, diplopia and muscle spasms.
Review of Resident #57's restorative order from therapy dated 07/22/21 revealed the State Tested Nursing Assistants (STNA) were trained and instructed on passive range of motion (PROM). A recommendation for PROM to bilateral lower extremities times 30 reps in all directions and planes was provided at that time.
Review of Resident #57's electronic TASK documentation revealed the resident was to receive PROM daily for 15 minutes including 15 reps' times two to all four extremities and for staff to assist with applying a splint to right elbow for up to eight hours during the night as tolerated. The documentation also included provisions for removal and monitoring the resident's skin related to the splint.
Review of the TASK documentation revealed no evidence restorative PROM had been performed in the last 30 days and the splint had only been applied for five minutes once in the last 30 days.
Resident #57 had a plan of care that identified the resident was at risk for further contractures related to multiple sclerosis (MS), impaired mobility, no voluntary movement in the bilateral lower extremity and quadriplegia. The goal developed was for the resident to maintain or have no decline in functional range of motion and tolerate program. Interventions included restorative aides would provide passive range of motion (PROM) daily for 15 minutes to 15 reps times two to all four extremities. Further review of Resident #57's plan of care revealed no evidence of a plan of care for splint/brace devices.
Review of Resident #57's Minimum Data Set (MDS) 3.0 assessment, dated 09/10/21 revealed the resident was dependent on staff for all activities daily of living (ADL). Further review of the assessment revealed the resident was not receiving any type of restorative nursing program or splint or brace assistance.
On 09/20/21 at 10:43 A.M. and on 09/23/21 at 10:50 A.M. interview with Resident #57 revealed staff had not offered or been performing restorative services or applying his splint/brace. The resident reported he believed he had experienced a decline in range of motion in his hands.
On 09/23/21 at 10:37 A.M. interview with Registered Nurse (RN) #403 confirmed there was no documented evidence the resident received PROM per plan of care and therapy recommendation in the past 30 days. The RN also confirmed staff had only applied the splint once in the last 30 days.
Review of the facility undated policy titled Restorative Nursing Program revealed the facility strived toward achieving the resident's highest functional level and maintained communication between nursing, restorative nursing and therapy. Referrals were received after discontinuation of rehabilitation services. Documentation of care was performed daily and as needed. A progress note would be documented at minimum quarterly by a registered nurse. A licensed registered nurse would evaluate the process and continued need of services quarterly.

Based on record review and interview the facility failed to ensure fall interventions were implemented for Resident #49 and failed to monitor the delivery/effectiveness of interventions to prevent additional falls. This affected one resident (#49) of four residents reviewed for falls.
Findings include:
Review of the medical record for Resident #49 revealed an admission date of 07/23/17 with diagnoses including dementia, type two diabetes mellitus with neuropathy, bipolar disorder, major depression, metabolic encephalopathy, delusional disorders and epilepsy.
Review of the plan of care (initiated 02/08/19) and updated 08/08/21 revealed Resident #49 was at risk for falls and potential injury related to dementia, psychoactive medications, seizures, unsteady gait, recent decline in activities of daily living and recent falls. Interventions included keeping the call light in reach, using bright colored sign on walker to visually remind resident to take walker with her, encouraging the resident to use non-skid shoes or socks when up, a low bed, motion sensor when in bed, non-skid strips on floor to side of bed, toileting and assisting to bed after dinner.
Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 08/10/21 revealed the resident had significantly impaired cognition. The resident required extensive assistance of two staff for bed mobility and transfers and was dependent on two staff for locomotion on and off the unit. The resident had two falls since admission or prior assessment, with one fall resulting in injury.
Review of the resident fall history revealed the following:
Review of the progress note, dated 07/25/21 at 1:38 P.M. revealed the nurse was brought to Resident #49's hallway where the resident was found lying on her back in the hallway. Assessments for range of motion, skin, and pain were all done appropriately. However, there was nothing to indicate what fall interventions were in place at the time of the fall. A fall investigation, dated 07/25/21 revealed Resident #49 fell while carrying her purse and using rotary rollator. No additional fall interventions were documented as having been in place at the time of the fall.
Review of the progress note, dated 09/09/21 at 2:45 P.M. revealed the resident was found lying beside a bed in a room that was not hers. She stated she was trying to get into bed. Assessments for range of motion and pain were done appropriately. However, there was nothing to indicate what fall interventions were in place at the time of the fall.
A fall investigation, dated 09/09/21 revealed the resident fell while trying to get into bed. No additional fall interventions were documented as having been in place at the time of the fall.
Review of the progress note, dated 09/10/21 at 6:30 P.M. revealed the resident was found lying on her back in her room with her head towards the toilet and her feet towards her bed. Assessments for range of motion, skin, and pain were all done appropriately. The note indicated the resident did not have non-skid socks on at the time of the fall, a new intervention to toilet the resident between 6:00 P.M. and 7:00 P.M. was implemented following this fall. A fall investigation, dated 09/10/21 revealed the resident fell while trying to go to the bathroom.
Review of the bladder continence task, the bowel continence task, and the restorative toileting program documentation, dated 09/10/21, revealed the resident was taken to the toilet at 10:15 P.M. There was no documentation to indicate she had been taken to the bathroom after her dinner.
Review of the progress note, dated 09/13/21 revealed a falls team meeting was held and the immediate intervention of toileting the resident between 6:00 P.M. and 7:00 P.M. was deemed appropriate. The note indicated the resident was to be toileted often throughout the shift and staff education for proper footwear was to occur.
Review of the progress note, dated 09/19/21 at 2:32 A.M. revealed the aide called the nurse to the room due to a fall. The resident was found laying on the floor with her legs extended. Assessments for range of motion, pain, and skin, were done appropriately. However, there was nothing to indicate what fall interventions were in place at the time of the fall. A fall investigation, dated 09/19/21 revealed the resident fell while going to the restroom. No additional fall interventions were documented as having been in place at the time of the fall.
Review of the medical record revealed no evidence that staff monitored or documented the use of non-skid shoes or socks for the resident.
On 09/22/21 at 4:10 P.M. interview with the Director of Nursing (DON) confirmed fall interventions were not documented as having been in place for the above falls. The DON revealed this was a consistent problem with the nurses that did not seem to change with education. The DON revealed it was likely related to the nurses not really getting into the care plans, out of fear of messing them up and not knowing what interventions to document. She confirmed fall interventions were something the nurses should be aware of. The DON additionally confirmed there was no documentation to indicate Resident #49 was taken to the toilet on 09/10/21 after the dinner meal, despite this being a care planned fall intervention. She stated non-skid socks were difficult to keep on the residents in the memory care unit in general as they frequently took them off. She stated the interventions were to encourage them to be in place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #63's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including type two diabetes mellitus, morbid obesity, history of COVID-19, essential hypertension, anxiety disorder, depressive episodes, schizophrenia, dysphagia, psychosis, hyperlipidemia, osteoarthritis and mild intellectual disabilities.
Review of Resident #63's monthly physician orders revealed an order for consistent carbohydrate no added salt diet, with two oranges daily and a house pudding supplement in the evening.
Review of Resident #63's annual MDS 3.0 assessment, dated 01/05/2021 revealed the resident's speech was clear, she made herself understood, understands others, her vision was adequate with corrective lens and her cognition was intact. Resident #63 had minimal depression, no indicators of psychosis or behaviors and did not reject care. Resident #63 was assessed to require supervision with set up assistance from staff for meals. The assessment revealed the resident was 63 inches tall, weighed 220 pounds, had no weight changes and was not on a planned diet for weight change.
Review of Resident #63's weight record revealed on 01/05/2021 she weighed 219.6 pounds. On 02/03/2021 she weighed 211.9 pounds. On 03/02/2021 she weighed 208 pounds. On 04/06/2021 the resident's weight was 198 and there was no re-weight obtained, following a 10 pound weight loss in one month.
Review of Resident #63's current plan of care for nutrition revealed Resident #63 was at risk for malnutrition and/or dehydration. Resident #63 was obese, received superfoods, was on a therapeutic diet and received insulin. The care plan revealed on 04/08/21 Resident #63 has a significant weight loss in the past three to six months and superfoods were added.
Continued review of the resident's weights revealed on 05/03/2021 she weighed 201 pounds. On 06/01/2021 she weighed 203.2 pounds and on 07/02/2021 her weight was 197.3 with no evidence a re-weight was obtained. On 08/02/2021 the resident weighed 187.4 and no re-weight was obtained. On 08/02/21 the resident's plan of care was updated to reflect the resident had again experienced a significant weight loss in the past one and six months.
Review of Resident #63's nutritional assessment, dated 08/02/2021 revealed Resident #63 had an unplanned weight loss. The note indicated with the resident's intake and nutritional supplement her weight should stabilize and no recommendations were made at that time.
Review of Resident #63's quarterly MDS 3.0 assessment, dated 08/20/2021 revealed the resident had an unplanned weight loss and weighed 187 pounds.
On 09/08/2021 Resident #63 weighed 195.4 pounds, which was an eight pound weight gain since August 2021. No re-weight was obtained to verify the accuracy of the weight or identify actual weight changes for the resident.
On 09/22/21 at 10:49 A.M. interview with the Director of Nursing (DON) revealed Resident #63 wanted to lose weight and had lost about 30 pounds. However, this was not reflected in the resident's plan of care or dietary notes. The DON revealed Resident #63 would only eat one chicken strip as the resident was very concerned about her blood sugars.
On 09/22/21 at 11:39 A.M. interview with RDN #389 revealed she was not notified (dates not provided) that Resident #63 wanted to lose weight and was trying to lose weight. RDN #389 confirmed there was no evidence Resident #63 had re-weights obtained when she gained or lost five pounds or more. In addition, RDN #389 was unable to provide evidence Resident #63 had received education about safe weight loss and balanced diets.
Review of the facility undated Weight Policy revealed re-weights would be completed on any weight change of five pounds or more. Re-weights would be done immediately (within 72 hours).
Based on observation, record review, facility policy and procedure review and interview the facility failed to implement individualized and comprehensive nutritional interventions to ensure residents maintained acceptable parameters of nutrition, failed to ensure re-weights were obtained to identify actual weight changes and/or failed to ensure nutritional supplements were provided as ordered.
Actual harm occurred when Resident #73, who had diagnoses of Parkinson's disease and dementia sustained an unplanned weight loss of 18.8 pounds/10% over three months and 29.8 pound/15.88% severe weight loss from admission [DATE]) through 09/07/21 (less than a six month time period) related to inadequate intakes without evidence of individualized and comprehensive interventions to prevent the weight loss and/or promote weight gain for the resident.
This affected three residents (#73, #63 and #29) of five residents reviewed for weight loss and nutrition.
Findings include:
1. Review of the medical record for Resident #73 revealed an admission date of 04/15/21 with diagnosis including Parkinson's disease, unspecified dementia, severe protein calorie malnutrition and type two diabetes mellitus. Record review revealed the resident was on a regular diet with regular texture and thin liquids.
Review of the weight record for Resident #73 revealed on 04/15/21 (admission) the resident weighed 187.6 pounds. On 07/07/21 the resident weighed 173.8 pounds, on 08/10/21 the resident weighed 170.6 pounds, on 08/17/21 the resident weighed 163.8 pounds which demonstrated a continued weight loss following admission. On 08/30/21 the resident weighed 167.8 pounds.
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/30/21 revealed Resident #73 was cognitively impaired and required supervision and set up assistance from staff for meals. The assessment revealed the resident had weight loss and no problems with teeth, chewing or swallowing.
Review of the progress note, dated 09/01/21 at 2:17 P.M. by Registered Dietitian Nutritionist (RDN) #389 revealed Resident #73's current body weight was 161.8 pounds indicating a continued undesired weight loss of six pounds or three percent in one week related to inadequate oral intake. Resident #73's intake was 0-100% with refused meals noted. The note indicated the resident was accepting current supplement. The dietitian recommended the physician consider adding the medication Mirtazapine (anti-depressant medication also used for appetite stimulant) for augmentation of appetite. There was no evidence the physician was aware or addressed the recommendation for appetite stimulant at this time.
On 09/02/21 the resident weighed 162.4 pounds and on 09/07/21 the resident weighed 157.8 pounds. Resident #73 sustained a 29.8 pound/15.88% severe weight loss from admission through 09/07/21.
Review of the progress note, dated 09/06/21 at 2:20 P.M. by RDN #389 revealed Resident #73 had a significant weight change. The current body weight was 162.4 pounds on 09/02/21, 165.6 pounds on 08/04/21 and 181.2 pounds on 06/02/21 indicating a significant unplanned weight loss of 18.8 pounds or 10 percent over three months related to inadequate intakes. At this time the resident was on a house supplement of 237 milliliter (ml) two times daily. Current meal intake was 0-100% but noted the resident was taking 100% of the supplement and adequate fluids. The dietitian recommended an appetite stimulant and noted the physician was aware of the weight loss and recommendations. However, there was no evidence the physician addressed the recommendation for the appetite stimulant.
Record review revealed on 09/16/21 supplements for weight loss and nutrition included eight ounces of super coffee every evening with dinner and 237 milliliters (ml) of house supplement three times daily were ordered.
Review of the progress note, dated 09/16/21 at 8:00 A.M. revealed the physician was notified of a significant weekly weight change of eight pounds. A note by Registered Dietitian Nutritionist (RDN) #389, dated 09/15/21 at 3:28 P.M. revealed the resident's current body weight on 09/15/21 was 149.8 pounds indicating a continued, significant and unplanned weight loss of eight pounds or five percent in one week related to poor oral intake. The note indicated the resident continued to have agitation at meals and refusals but was taking house supplement decently well. The dietitian recommended an appetite stimulant, super coffee at breakfast, and to increase the house supplement plus 237 ml to three times daily to augment intake. The note revealed to continue to monitor weight weekly. There was no evidence the physician addressed the recommendation for the appetite stimulant.
Review of the progress notes from 08/01/21 through 09/22/21 revealed no IDT note addressing Resident #73 significant weight loss, continued weight loss or evidence of the implementation of individualized and comprehensive interventions to prevent additional weight loss and/or to promote weight gain for the resident.
Review of the physician progress notes, dated 06/21/21, 08/06/21 and 08/12/21 revealed no documentation addressing weight loss or dietitian recommendations for adding an appetite stimulant.
Review of the resident's meal intakes from 08/24/21 through 09/22/21 revealed intakes were recorded by State Tested Nursing Assistant (STNA) staff. The intake records revealed the resident's intakes varied from 0-100% with multiple refusals for an average of less than 50% of meals eaten.
Observations made from 09/20/21 through 09/24/21 of meal times revealed Resident #73 was not up in the dining room for breakfast on any date and was observed only up for lunch on 09/23/21 and 09/24/21. During the meal observations, the resident was observed to only pick at his food and not eat. There was no evidence of staff supervision being provided for the duration of each meal observed.
On 09/22/21 at 8:17 A.M. interview with STNA #331 revealed the resident was not a morning person and rarely ate breakfast. The STNA revealed the resident was usually up out of bed between 10:30 A.M. and 11:00 A.M. but was not offered a breakfast meal at that time as lunch was at 11:00 A.M.
On 09/22/21 at 11:22 A.M. interview with RDN #389 revealed nutritional recommendations were written and given to the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) and then the ADON contacted the physician to get orders for the recommendation(s) and documents any changes. RDN #289 confirmed there was no documentation the physician addressed the appetite stimulant recommendation and no evidence of comprehensive and individualized nutritional interventions to prevent additional weight loss for Resident #73 and/or to promote weight gain. In addition, RDN #389 revealed she had not spoken with Resident #73's family in regards to nutritional interventions or alternative methods of feeding to address the resident's continued unplanned severe weight loss.
On 09/22/21 at 3:43 P.M. interview with STNA #340 revealed Resident #73 ate depending on his mood. The STNA indicated in her opinion the resident had not been eating well since his wife had not been in the facility to visit.
On 09/23/21 at 2:33 P.M. interview with the ADON confirmed the physician did not address the recommendation for an appetite stimulant as recommended by RDN #389 in September 2021. In addition, there was no evidence the physician provided any other individualized interventions to prevent additional weight loss for the resident and/or to promote weight gain.
3. Review of Resident #29's medical record revealed an admission date of 12/19/2018 with diagnoses including end stage renal disease, severe protein calorie malnutrition and dementia.
Review of Resident #29's September 2021 physician's orders revealed an order for a house supplement to be given four times a day as a renal supplement.
On 09/21/21 at 4:00 P.M. Resident #29 was observed to return from dialysis. The resident did not received the house supplement as ordered at that time.
Review of Resident #29's September 2021 medication administration record revealed every Tuesday, Thursday and Saturday Resident #29's noon house supplement was not given as ordered. The supplement was not given as ordered on 09/02/21, 09/04/21, 09/07/21, 09/09/21, 09/11/21, 09/14/21, 09/16/21, 09/18/21 or 09/21/21.
On 09/22/21 at 9:31 A.M. interview with Licensed Practical Nurse (LPN) #383 revealed Resident #29 does not receive her noon nutritional supplement on Tuesdays, Thursdays or Saturdays when she goes to dialysis.
On 09/22/21 at 11:32 A.M. interview with RDN #389 revealed she was not aware Resident #29 was not receiving her noon nutritional supplement on Tuesdays, Thursdays or Saturdays. RDN #389 confirmed the resident should still be receiving the nutritional supplement four times a day even on the days she received dialysis.
On 09/22/21 at 11:41 A.M. interview with the Director of Nursing confirmed the facility was not giving Resident #29 the nutritional supplement as it was ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to implement an individualized and comprehensive treatment plan, including the delivery of anti-depressant medication as ordered for Resident #17 to assist the resident to maintain her highest practicable mental and psychosocial well-being. This affected one resident (#17) of three residents observed during medication administration.
Findings include:
Record review revealed Resident #17 was admitted to the facility on [DATE] with a diagnoses including major depressive disorder.
Review of Resident #17's Minimum Data Set (MDS) 3.0 assessment, dated 07/08/21 revealed the resident had little pleasure, had trouble falling or staying asleep, poor appetite and felt bad about herself 7-11 times a day in the previous 14 days. The assessment revealed the resident felt down, depressed of hopeless 12-14 times in the previous 14 days.
A plan of care revealed the resident had an alteration in mood due to diagnoses of stroke, major depression and sleep disorder. The resident was referred for weekly counseling.
Record review revealed on 09/15/21 the resident's order for the anti-depressant medication, Celexa was decreased from 40 milligrams (mg) to 30 mg. The medication was ordered to be administered by mouth once a day in the morning.
Review of Resident #17's Medication Administration Records (MAR) for 09/2021 revealed the resident was ordered Celexa 40 mg one tablet in the morning for depression. Target behaviors for the medication were lack of pleasure, lack of interest, hopelessness, tearfulness and sadness. Review of the MAR revealed the medication was discontinued 09/15/21. However, the MAR did not include in the new order for Celexa 30 mg that was obtained on 09/15/21. The new order was not entered in the electronic medical record or recorded on the MAR for continued administration as ordered.
On 09/22/21 at 8:27 A.M. observation of medication administration for Resident #17 revealed the nurse did not administer Celexa to the resident.
On 09/22/21 on 8:44 A.M. interview with Licensed Practical Nurse (LPN) #381 and LPN #400 revealed staff had canceled the order for Celexa 40 mg on 09/15/21 but did not enter the new order for Celexa 30 mg at that time. The LPN staff verified the resident had not received the Celexa medication since it 09/15/21 as ordered.
On 09/22/21 at 9:43 A.M. interview with Resident #17 with LPN #400 present revealed the resident reported she was currently having symptoms and depression including sadness and anxiety.
On 09/22/21 at 10:01 A.M. interview with Registered Nurse (RN) #358 revealed she had contacted the physician and received a new order to restart the Celexa at 30 mg on this date.

Based on observation, facility policy and procedure review and interview the facility failed to ensure contingency narcotics were reconciled every shift and failed to ensure an accurate accounting of narcotics were maintained. This affected two residents (#69 and #298) and had the potential to affect all 95 residents residing in the facility.
Findings include:
On 09/23/21 at 3:15 P.M. observation of 100 unit medication cart with Registered Nurse (RN) #387 revealed the facility contingency narcotic box was locked in bottom of the 100 medication cart. The narcotic box was a plastic box that had four green zip ties with a different number on each corner of the box. The RN reported during shift change the nurses usually verify the numbers on the box with a reconciliation sheet that was in the binder. However, the nurse was not able to find a current reconciliation sheet in the binder. The last sheet available for review was dated 07/02/2021. The RN reported she knew there was a more recent sheet because she worked Sunday and verified the number, however a new box had been delivered since she worked on Sunday. RN #387 verified she did not reconcile the narcotic box with the previous shift nurse on this date to ensure the numbers were accurate.
Further observation of the medication cart revealed Resident #69's Lyrica 75 milligrams (mg) count did not match the reconciliation sheet. The blister card had 25 capsules in the package, however the reconciliation sheet indicated there was 26. Resident #298's as needed Hydrocodone/APAP 5/325 mg blister card was empty, however the reconciliation sheet indicated there should have been one remaining pill.
During the observation RN #387 confirmed Resident #69's and #298's narcotic counts did not match the reconciliation sheets. The RN reported she had given both medications this morning around 8:00 A.M. and she must have forgotten to sign them out when she had administered them.
On 09/23/21 at an unknown time the facility had pharmacy fax over of the emergency box delivery slip dated 09/02/21 to confirm the numbers on the narcotic contingency box. The RN reported the facility had run out of the reconciliation sheets and no one started a new sheet when the box was delivered on 09/20/21. The facility was not able to locate the reconciliation sheets from July 2021 to present.
Review of the undated contingency narcotic box medication list revealed the box contained 120 controlled narcotics.
On 09/23/21 at 3:38 P.M. interview with Licensed Practical Nurse (LPN) #337 revealed narcotics were to be signed out upon administration of the medication.
Review of the facility policy titled Control Substance, dated 07/2016 revealed nursing staff must count controlled drugs at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing.
Review of the facility policy titled Medication Administration, dated 2007 revealed the individual who administers the mediation dose, records the administration immediately following the medication being given.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure medications were stored in original packaging, insulin was stored at appropriate temperatures and dated upon opening and controlled drugs were stored in a fixed compartment in the refrigerator. This affected three residents (#1, #49, and #60) identified as receiving insulin on 300, 400 and 600 units, one resident (#34) of one resident who had a narcotic stored in the refrigerator on the 500/600 unit, one resident (#13) who had narcotics stored in the top of the 600 medication cart and had the potential to affect all 95 residents residing in the facility.
Findings include:
1. Record review revealed Resident #13 was admitted to the facility on [DATE] with a diagnosis including diarrhea.
Review of Resident #13's orders and medication administration records dated 08/2021 to 09/22/21 revealed the resident was ordered Lomotil 2.5-0.025 milligrams (mg) give two tablets by mouth every six hours as needed for diarrhea from 08/04/21 until it was discontinued on 08/19/21.
Observation of narcotic reconciliation count of the top of 600 cart on 09/22/21 at 7:26 A.M., with Licensed Practical Nurses (LPN's) #369 and #372 revealed Resident #13 had 20 Lomotil tablets in a blister packaging still in the narcotic box in the medication cart. Further observation revealed the foil backing on pill 20 had been broken and a piece of clear tape had been placed over the back of the foil to keep the pill in the blister packaging. LPN #369 and #372 confirmed findings during observation. LPN #372 reported once the foil backing had been broken and the pill was not administered the pill should have been destroyed and not placed back into the package and taped.
2. Record review revealed Resident #34 was admitted to the facility on [DATE] with diagnoses including respiratory failure, fracture of right femur, severe protein-calorie malnutrition, malignant neoplasm of the upper lobe of lung, anemia, cerebral infarction, hemiplegia, pain in leg and uterus disorder.
Review of Resident #34's orders revealed an order for Marinol (a control narcotic) 2.5 milligrams (mg) twice daily.
Observation of the 500 and 600 medication storage room on 09/23/21 at 3:47 P.M. with the Director of Nursing (DON) revealed Resident #34's Marinol blister packet containing one Marinol was stored in a non-fixed plastic box that was able to be easily removable from the dorm size refrigerator. The DON confirmed findings and reported the plastic boxes used to be glued inside the refrigerators the plastic box could not be removed.
3. Observation of 700 medication cart on 09/23/21 at 3:50 P.M. with Registered Nurse (RN) #385 revealed there were 14 loose, unpackaged and unidentifiable pills noted throughout the cart. RN #385 confirmed findings during the observation.
Review of the facility policy titled Medication Storage, dated 2007 revealed medications were to be stored properly, following manufacturer or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. Schedule II mediation and preparation must be stored in a separately locked permanently fixed compartment. Outdated, contaminated, discontinued, or deteriorated medication and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy, if a current order exists.
Review of the facility policy titled Medication Administration, dated 2007 revealed drugs were dispensed in the manufacturer's original container with the labeled manufacturer's expiration date. Once a medication was removed from the package/container, unused medication doses shall be disposed of according to the nursing care centers policy.
4. Review of the medical record revealed Resident #1 admitted on [DATE] with a diagnosis including diabetes mellitus.
Review of the physician's orders for September 2021 revealed Resident #1 was ordered Novolog Solution 100 units per milliliter (ml) to be administered five units before meals and according to a sliding scale before meals and at bedtime. Additional review revealed an order for Tresiba Solution 100 units per ml, 36 units to be injected in the morning.
Observation on 09/23/21 at 3:43 P.M. with RN #425 revealed one opened vial of Novolog Solution and one open vial of Tresiba Solution for Resident #1. Neither bottle was labeled with an open date. Interview with RN #405 at the time of the observation revealed insulin was usually good for 28 days after opening. The RN confirmed the two vials of insulin had been used and there was nothing to indicate what day they had been opened.
Review of the instructions for Novolog, provided by the facility revealed Novolog vials were good for 28 days after first use.
Review of the instructions for Tresiba revealed it could be stored for 56 days after being opened.
5. Review of the medical record revealed Resident #49 was admitted on [DATE] with a diagnosis including type two diabetes mellitus. Review of Resident #49's physician's orders for September 2021 revealed orders for Basaglar KwikPen Solution Pen-Injector 100 units per ml with 30 ml to be injected in the morning, Novolog Solution 100 units per ml to be injected according to a sliding scale four times a day, and Trulicity 1.5 mg per 0.5 ml to be injected every Saturday morning.
Review of the medical record revealed Resident #60 was admitted on [DATE] with a diagnosis including type two diabetes. Review of Resident #60's physician's orders for September 2021 revealed an order for Insulin Novolog FlexPen to be injected according to a sliding scale four times a day.
Observation on 09/23/21 at 4:00 P.M. of the refrigerator in the medication room of the memory care unit (hall 300 and 400) with Licensed Practical Nurse (LPN) #372 revealed two thermometers indicating a temperature of 20 degrees Fahrenheit. The refrigerator contained:one vial of tuberculosis solution with packaging information that recommended temperature for storage was between 36 and 46 degrees Fahrenheit, three Novolog pens for Resident #60, two Basaglar KwikPens, two vials of Novolog and three Trulicity pens with packaging information indicating the medications should be stored between 36 to 46 degrees for Resident #49.
Additional review of the temperature log for September 2021 revealed there were 26 occasions from 09/01/21 to the morning of 09/23/21 the refrigerators temperature had been below 36 degrees Fahrenheit. These observations were confirmed by LPN #372, who agreed the refrigerator was below the temperature requirements listed on the two boxes, and confirmed it was likely the rest of the medication required a similar temperature range.
Review of the instructions for the Basaglar KwikPen, provided by the facility revealed unused pens were to be kept between 36 and 46 degrees Fahrenheit.
Review of the instructions for Novolog pens and vials, provided by the facility revealed unopened refrigerated vials should be kept between 36 and 46 degrees Fahrenheit.
Review of the facility policy titled Medication Storage, dated 2007 revealed medications were to be stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. Medication requiring refrigeration or temperatures between 36 degrees Fahrenheit(F) (2 degrees Celsius (C)) and 46 F (8 C) were kept in a refrigerator with a thermometer to allow temperatures monitoring. Insulin products should be stored in the refrigerator until opened. The date should be noted on the label for insulin vials and pens when first used. The opened insulin vial may be stored in refrigerator or at room temperature. Opened insulin pens must be stored at room temperatures. Insulin should not be frozen and if frozen do not use. Outdated, contaminated, discontinued, or deteriorated medication and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy, if a current order exists.
Review of the facility policy titled Medication Administration, dated 2007 revealed drugs were dispensed in the manufacturer's original container with the labeled manufacturer's expiration date. The nurse shall place a date opened sticker on the mediation if one was not provided by the dispensing pharmacy and enter the date opened. Once a medication was removed form the package/container, unused medications doses shall be disposed of accruing to the nursing care centers policy.

Based on observation, staff interview and facility policy and procedure review the facility failed to store and distribute food under sanitary conditions to prevent contamination, spoilage and/or food borne illness. The affected 92 of 92 residents residing in the facility who received meal trays from the kitchen. The facility identified three residents (#39, #294 and #65) who received nothing by mouth. The facility census was 95.
Findings include:
On 09/22/21 at 3:10 P.M. observation of the kitchen during tray line revealed the following:
a. The tray line service area had dried food debris on the food serving line and dried pieces of food on the line. Observation of three food carts, with food to be served, tray cards and beverages for the evening meal on them had dried food on them and were soiled with dried food debris.
The sprinkler heads over the fryer and the grill were covered with grease encrusted dust.
Two additional meal carts had dried food debris on them.
The reach in refrigerator had dried food debris on the outside of it.
The reach in freezer had dried strawberry ice cream on it.
The pellet and plate warmer had dried food on them.
On 09/22/21 at 3:45 P.M. interview with Dietary Manager #315 confirmed the above observations.
b. On 09/23/21 at 10:29 A.M. observation of the kitchen revealed the steam table controls and surrounding area had dried food on it. Observation of the floor under the fryer revealed there was grease buildup and under the griddle there was dried food debris under it. In excess of 10 pans were observed stored wet and/or dirty at the time of the observation.
Interview with Dietary Manager #315 at the time of the observations confirmed the above findings.
c. On 09/23/21 at 11:11 A.M. observation of the 500 unit resident refrigerator revealed an open avocado dip with no date as to when it was opened and a container of opened undated cottage cheese with no resident name on it. Tartar Sauce was observed in a takeout container with no date on it. An open potato salad container was observed with no resident name and no date when opened.
Interview with Licensed Practical Nurse (LPN) #337 at the time of the observations confirmed the above findings.
Review of the facility Storage of Food Brought in by Outside Sources for Residents, dated 11/2016 revealed any perishable food brought in by an outside source which was not to be eaten right away shall be stored a clean, sealed container. The container shall be labeled, dated and placed in an appropriate non-dietary refrigerator. all items lacking proper labeling would be discarded. All resident foods stored in non-dietary refrigerators shall be discarded after three days.

Based on record review and interview the facility failed to establish an infection prevention and control program (IPCP) that included a comprehensive tracking system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents. This had the potential to affect all 95 residents residing in the facility.
Findings include:
Review of the facility infection control logs from July 2021 to September 2021 revealed the log was not comprehensive and was incomplete.
Review of the infection control log, dated 07/2021 revealed a total of 18 documented infections. There were six urinary tract infections (UTI), two of which had no identified organism and one that did not meet antibiotic criteria. There was one pneumonia and one upper respiratory infection (URI) that did not meet criteria. Of the three identified wound infections, one did not have an identified organism and did not meet criteria. The blood/sepsis infection had no identified organism. The infection identified as other did not meet criteria. There were two prophylactic antibiotics prescribed with no reason why. The facility mapping was not completed for tracking trends or patterns and did not include all organisms causing the infections.
Review of the infection control log, dated 08/2021 revealed a total of 16 documented infections. There were two URIs, one with no identified organism and did not meet criteria. There were three UTIs, all three had no identified organism and one did not meet criteria. The two blood/sepsis infections did not have identified organisms. Of the three wound infections two did not meet criteria. The one prophylactic antibiotic prescribed had no reason why. The facility mapping was not completed for tracking trends or patterns and did not include the organisms causing the infections.
Review of the infection control log, dated 09/2021 revealed three documented infections, however the facility identified six total infections in September 2021. The infection control log had one skin infection with no identified organism and criteria not met, one UTI with no identified organism, and one pneumonia. The undocumented infections included two UTIs and one blood infection with no identified organisms. The facility mapping was not completed for tracking trends or patterns and did not include the organism causing the infections.
An interview on 09/23/21 at 3:05 P.M. with the Assistant Director of Nursing (ADON) who was also the Infection Control Preventionist confirmed the infection control logs for 07/2021, 08/2021 and 09/2021 were not comprehensive and complete. The ADON revealed she was training another nurse how to complete the logs and that nurse was not present in the facility or available during the survey.
Review of the facility policy titled Infection Control, dated 11/23/16 and Antibiotic Stewardship Program, dated 11/2016 revealed infection control logs should be completed to track, record and analyze infections.

Based on observation, interview and facility policy and procedure review the facility failed to provide a clean resident environment. The carpet throughout the facility was observed soiled with large brown and black stains. This had the potential to affect all 95 residents residing in the facility.
Findings include:
On 09/20/21, 09/21/21 and 09/22/21 observations conducted during the annual survey revealed the carpeting throughout the facility had large brown and black stains in multiple areas of the building.
On 09/21/21 at 2:57 P.M. interview with Maintenance Director #310 confirmed the carpet was soiled throughout the facility with large brown and black stains and needed cleaned.
Review of the facility policy titled Infection Control-housekeeping, dated 12/28/13 revealed the workplace would be maintained in a clean and sanitary condition.