Hickory Creek Of Athens

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of on-call physician contact procedures, and staff interview, the facility failed to ensure a resident, who had a significant change in condition, received appropriate and timely consultation with the on-call advanced level provider for a transfer to the hospital for an evaluation. This affected one (Resident #36) of two residents reviewed for hospitalization. Actual Harm occurred when Resident #36 displayed a significant change in condition consistent with a cerebrovascular accident (CVA) and did not receive a timely transfer to the hospital for evaluation and treatment. Resident #36 suffered an ischemic stroke but could not be given tissue plasminogen activator (a medication used to break down blood clots) due to being outside the treatment window for optimal results. Resident #36 was hospitalized for several days before returning to the facility with residual effects from his stroke. The facility census was 78. Findings Include: Review of Resident #36's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included paranoid schizophrenia, chronic obstructive pulmonary disease, adult onset diabetes mellitus, congestive heart failure, and hypertension. Review of a quarterly Minimum Data Set (MDS) assessment, dated 03/03/25, revealed the resident had clear speech and minimal difficulty hearing. He was able to make himself understood and was able to understand others. His cognition was severely impaired. He was not known to have any functional limitations in his range of motion. Supervision or touching assistance was needed with bed mobility and transfers. Review of a physical therapy treatment encounter note dated 05/23/25 revealed Resident #36's physical therapy was focused on lifting a 10-pound kettlebell with a deadlift/ squat pattern to help increase his functional task performance. He had reports of increased fatigue in his bilateral lower extremities with deadlift/ squat activities requiring longer rest periods. They were also working on transfer training to improve reciprocal movement patterns. His functional status because of the skilled interventions indicated he was supervision or touching assistance for transfers. He was able to ambulate up to 10 feet with supervision or touching assistance and was able to wheel himself 50 feet with two turns only requiring supervision or touching assistance. He had reports of increased fatigue in his bilateral lower extremities with deadlift/ squat activities requiring longer rest periods but no mention of any weakness or limited mobility of his upper extremities. The therapy encounters notes did not indicate he had any problems with weakness or limited mobility of his upper extremities. Review of Resident #36's nursing progress notes revealed a nursing note dated 05/26/25 at 1:06 A.M. by Licensed Practical Nurse (LPN) #161 that documented the resident was up in his wheelchair and was assisted to the bathroom with the assistance of one staff. He had weakness in his right upper and lower extremities. The resident was unable to lift his right arm fully by himself. He was encouraged to elevate his right arm and not let it dangle while in his wheelchair. The resident was able to lift his right arm some without assistance but not more than halfway up the length of his body. He was able to stand on his right lower leg but when the staff were wheeling him in his wheelchair, he was dragging his right leg. The resident was offered snacks and was continued to be confused off and on, trying to suck ice cream out of a spoon like it was a straw. The on-call physician was paged at that time to update him on the resident's change in condition. Review of a neurological assessment flow sheet revealed the facility's nurses were obtaining neurological assessments on Resident #36 beginning on 05/25/25 at 6:45 P.M. At this time Resident #36 was alert and oriented times three (person, place, time) and had no abnormal findings noted. The neurological assessment that was completed on 05/26/25 at 1:30 A.M. revealed the resident remained alert and oriented times three but had some confusion and weakness to the right arm and leg. Review of a nursing note dated 05/26/25 at 1:34 A.M. documented LPN #161 paged the on-call physician again to update him on Resident #36's change in condition. Review of a nursing note dated 05/26/25 at 2:18 A.M. revealed LPN #161 left a message for Resident #36's legal guardian with instructions to call back into the facility to give an update on the resident's status. The nurse also attempted to contact the on-call physician again to update him of the resident's change in condition. Resident #36 continued to have weakness in his right upper arm. Review of a nursing note dated 05/26/25 at 2:32 A.M. documented LPN #161 received a return call from Resident #36's legal guardian and was able to update her on the resident's change in condition. The guardian requested the resident to be sent to the local emergency room (ER) for evaluation of his right sided weakness. The nurse discussed in detail the resident's history and code status (full code). Resident #36 was made aware of the guardian wanting him sent to the emergency room for an evaluation. 911 was called and report was called to the local emergency room (ER) regarding the resident's condition. Review of a nursing note dated 05/26/25 at 3:10 A.M. by LPN #161 revealed Emergency Medical Services (EMS) personnel were onsite to transport Resident #36 to the ER. The resident was transferred to the gurney with the assist of three and all paperwork was sent with resident at that time. Review of a nursing note dated 05/26/25 at 7:13 A.M. revealed LPN #161 called the ER at that time for an update. Resident #36 was being transported to the ER's main hospital for symptoms of a stroke. The resident was on a Heparin drip (medication given intravenously that acts like a blood thinner and was used to prevent or treat blood clots) at this time. The resident's legal guardian was updated at that time. Review of Resident #36's hospital records revealed an ER note dated 05/26/25 at 3:53 A.M. that documented the resident with multiple comorbidities presented to the ER via EMS from a skilled nursing facility for an evaluation of a fall and possible stroke. The resident was reported to have had an unwitnessed fall on 05/25/25 at around 6:00 P.M. The nursing report indicated the resident did strike his head and the nurses were continuing to do neurological exams. Around 1:00 A.M. they noticed the resident began having deficits. He complained of a headache and stated he had weakness in his right arm and leg. His physical exam in the ER showed he did have marked weakness in the right arm and leg. The nursing staff at the ER did reach out to the facility's nurse to further elaborate on the resident's last known well check. It was very unclear when the symptoms began. The initial report was 1:00 A.M. when they noticed the neurological deficit, however, a separate report indicated that he potentially was having issues at 11:00 P.M. with grasp of the right hand. The ER physician consulted with a stroke neurologist, who agreed with the current workup. It was recommended to transfer the resident, if a computed tomography angiography (CTA) was abnormal or admission to the hospital for further stroke workup. The CTA impression was that there was no acute intracranial abnormalities, no hemorrhage or mass effects, and no pathological enhancement. The intracranial and extracranial vessels demonstrated no flow-limiting stenosis, thromboses, dissection, or large vessel occlusion. If there was concern for an acute infarction (stroke), then Magnetic Resonance Imaging (MRI) imaging would be more sensitive. His disposition, after the ER visit, was to be admitted as an in-patient stay in the hospital. Review of Resident #36's hospital history and physical dated 05/26/25 at 1:13 P.M. revealed the resident had a past medical history of seizure disorder, hypertension, hyponatremia (low sodium level), schizophrenia, depression, insomnia, constipation, and dysphagia. He presented with right arm/ leg weakness, difficulty moving and walking, and chest pain. The resident was admitted for a cerebrovascular accident (CVA)/ transient ischemic attack (TIA) and not a candidate for tissue plasminogen activator (TPA) due to being outside the treatment window. He had a sudden onset of right arm weakness and difficulty moving and walking for greater than six hours prior to arrival at ER on [DATE]. The ER consulted with teleneurology and it was deemed he was not a candidate for TPA. A neuro-exam with the RUE and RLE revealed weakness (worse in the RUE). CTA of the brain showed no acute findings and a brain MRI was ordered. Review of a neurology consult completed on 05/27/25 at 9:35 A.M. revealed Resident #36 was referred to neurology for a stroke. He had an MRI of his brain completed on 05/26/25 that revealed an acute left corona radiata ischemic infarction (stroke). Ischemic stroke was listed as his acute problem. He started on Aspirin 81 milligrams (mg) daily for three weeks and Plavix 75 mg indefinitely for secondary stroke prevention. Review of Resident #36's MRI of his brain that was obtained on 05/26/25 revealed there was an abnormal hyperintense signal and diffusion restriction along the left corona radiata consistent with acute to subacute lacunar infarction measuring 9 millimeters (mm) in diameter. The impression of the MRI was that the resident had an acute to subacute lacunar infarction along the left corona radiata measuring 9 mm. Review of Resident #36's hospital Discharge summary dated [DATE] at 4:34 P.M. revealed he was being discharged back to the skilled nursing facility in stable condition following a hospital admission that began on 05/26/25 at 10:15 A.M. He was diagnosed with an ischemic stroke and his acute problems also included dysphagia (difficulty swallowing), dysarthria (slurred speech), and right hemiparesis (weakness of the right upper and lower extremities). He was to take Aspirin 81 mg daily for three weeks and was also started on Plavix (an anti-platelet) 75 mg by mouth daily. Review of a nursing note dated 05/28/25 at 6:55 P.M. revealed Resident #36 returned to the facility. He arrived via stretcher with two EMS personnel and was transferred into the bed in his room. During an interview on 08/07/25 at 9:47 A.M., Corporate Nurse #122 stated Resident #36's physician took his own off-hour calls. She denied they used an on-call service for any emergent needs from an advanced level provider off-hours. The physician had a physician's assistant that was also available to be on call. If the physician was going to be out of town or on vacation, he would inform the facility of the name of the physician covering for him in his absence. During an interview on 08/07/25 at 9:55 A.M., LPN #161 stated she was the nurse that worked the evening of 05/26/25, when Resident #36 had a change in condition, requiring a transfer to the hospital. She recalled she had sent him out to the hospital but was not clear on the exact date of that transfer. She confirmed Resident #36 did have a change in condition that night, and she attempted to notify the physician and the resident's legal guardian. She had a hard time getting the physician and guardian to answer. The resident's vital signs were stable, but with his change in condition she wanted to notify them. She stated Resident #36 had weakness in his right arm and was having difficulty being able to fully move his right arm. She felt, with the symptoms he was displaying, the resident may have had a stroke. She stated it could also have been a sign of him having had a heart attack, a urinary tract infection, or an unknown injury. The resident was lifting his right upper arm but not per his baseline. She stated the nurses had a number to contact Resident #36's physician during the off-hours. Prompts were given when calling that number to specify if the call was an urgent call or a non-urgent call. They then received another prompt to indicate who they were trying to contact (physician, physician assistant, or the nurse). She stated she identified the call as an urgent call and left her name and number in which to be reached. She called multiple times for the physician to call her back but never did get a response from him. The only call back that she received was the one she placed to the resident's guardian. She stated she has had a problem with reaching that physician during the evening hours in the past. There were some nights he would not bother to call back at all. She denied that she attempted to contact the physician's assistant with any follow-up calls despite not being able to reach the physician. She confirmed she could have reached out to the physician's assistant at that same number as she knew there was a prompt to indicate the urgent call was for him. She did not think of reaching out to the physician's assistant and just waited to hear back from the physician or the resident's guardian on what they wanted them to do. She further confirmed it was about 30 minutes, after she contacted 911, that the EMS arrived. They only used 911 when needing to send a resident out and the county's EMS service could be dispatched from several different locations. It was typical for it to take EMS 15 to 30 minutes to arrive when calling for transport. She followed up with the ER later that morning and was told that the resident had been transferred to the ER's main hospital and was being admitted . She denied the resident was complaining of chest pain when in the facility. Her assessment of the resident was negative other than the weakness he had in his RUE. He has had some weakness in the past but was not rebounding as he normally would. She denied the resident had slurred speech or facial drooping. It did cross her mind to go ahead and send the resident out when they could not reach the physician. She discussed it with the house supervisor and had the house supervisor assess the resident also. She wanted the house supervisor to assess the resident as her assessment was basically negative, with the exception of the weakness, and his weakness was not all the time. They decided since his assessment was relatively negative and his vital signs were stable, they would wait to hear back from the guardian and to follow what she wanted to do about the resident's change in condition. She reported the guardian was a little hesitant to send him out at first but then decided to go ahead and send him out just to be safe.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to provide proper justification for the use of medication for dementia. This affected one, (Resident #3) of five residents reviewed for unnecessary medications. The census was 78. Findings Include: Resident #3 was admitted to the facility on [DATE]. His diagnoses were acute kidney failure, chronic obstructive pulmonary disease (COPD), type II diabetes, morbid obesity, muscle weakness, chronic respiratory failure, dysphagia, congestive heart failure, schizoaffective disorder, atrial fibrillation, anemia, anxiety disorder, anemia, acute embolism and thrombosis, osteoarthritis, mild cognitive impairment, hyperlipidemia, peripheral vascular disease, and hernia. Review of his minimum data set (MDS) assessment, dated 06/30/25, revealed he was cognitively intact. Review of Resident #3's current physician orders found he was prescribed the following medications for dementia: Olanzapine (antipsychotic) 5 milligrams (mg) and Namenda (used to treat dementia)10 mg twice daily. Review of Resident #3's current diagnoses, dated 08/06/25, found he did not have a diagnosis of dementia. Review of Resident #3's psychological notes, dated 10/09/23, revealed during a dementia screening, he had dementia symptoms, but there was no diagnosis of dementia given. Review of Resident #3 psychological notes, dated 04/28/25, revealed no diagnosis of dementia. The notes listed he was prescribed Namenda for dementia, but there was no justification for the use of Namenda due to not having a diagnosis of dementia. Review of Resident #3's Pre-admission Screening and Resident Review (PASRR) documents, dated 04/10/25 and 08/06/25, revealed under section Section D: Medical Diagnoses, it indicated that Resident #3 did not have dementia. Review of Resident #3 current care plan, dated 08/05/25, revealed no care plan for dementia or dementia care. Interview with Corporate Nurse #122 on 08/07/25 at 2:00 P.M. confirmed they can not find when dementia was added to resident's diagnoses or his care. She confirmed Resident #3 has two medications for the diagnosis of dementia, but they can not provide documentation to support the justification for the use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, staff interview, and facility policy review, the facility failed to ensure indwelling urinary catheter care was provided in accordance with acceptable infection control practices to prevent infections. The facility also failed to ensure a resident's indwelling urinary catheter's collection bag was maintained off the floor to help prevent infection. This affected one, (Resident #5) of two residents reviewed for indwelling urinary catheters. The facility census was 78. Findings include: Review of Resident #5's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included neuromuscular dysfunction of the bladder, benign prostatic hyperplasia with lower urinary tract symptoms, and urinary retention.Review of Resident #5's physician's orders revealed he had an order in place for the use of an 18 French indwelling urinary catheter with 10 milliliter (ml) balloon related to obstructive uropathy. The orders also included the need to perform catheter care every shift. His antibiotic history report under the discontinued physician's orders revealed he had been on antibiotics as recent as 06/20/25 through 06/29/25, when he received Zerbaxa (Ceftolozane Sulfate-Tazobactam Sodium) Intravenous solution reconstituted 1.5 (1-0.5) Grams (GM) with directions to use 3 grams over 60 minutes intravenously every eight hours for sepsis, urinary tract infection (UTI), and bacteremia for a total of 20 administrations. Review of Resident #5's active care plans revealed he had a care plan in place for being at risk for an alteration in elimination related to a history of UTI's, use of an indwelling urinary catheter, and urinary retention. The care plan had been initiated on 06/28/23. The goal was for the resident to be clean, dry, and odor free. The interventions included the need to provide catheter care every shift and as needed (prn) and to monitor the resident for signs and symptoms of a UTI. It did not indicate to maintain the catheter's collection bag off the floor only to ensure it was maintained below the level of the bladder to prevent backflow. On 08/05/25 at 10:35 A.M., Resident #5 was observed lying in bed in a supine position with the head of bed elevated. He had his eyes closed. His indwelling urinary catheter's collection bag was lying on the floor next to the left side of his bed. It did not have a cover bag and only had a vinyl cover bag in front of the collection bag for dignity purposes. The back of the collection bag was in direct contact with the resident's tiled floor. 08/05/25 at 11:45 A.M., Resident #5 was observed sitting up on the side of his bed eating his lunch. His indwelling urinary catheter's collection bag was still resting on the floor, but was more underneath the bed than the side of the bed that it was observed to be at earlier. On 08/05/25 at 11:46 A.M., an interview with Resident #5, at the time of the observation, revealed he had not been up out of bed, since the prior observation was made on 08/05/25 at 10:35 A.M. He stated the last time he had been up and out of bed was about two hours ago. He confirmed staff had brought his lunch in to him (between the two observations made) and failed to secure his indwelling urinary catheter's collection bag to the side of the bed to maintain it off the floor. He confirmed he has had problems with UTI's in the past. On 08/05/25 at 11:55 A.M., an interview Licensed Practical Nurse (LPN) #145 confirmed Resident #5 did have the use of an indwelling urinary catheter and was known to have UTI's in the past. He was asked to go to the resident's room to verify his indwelling urinary catheter's collection bag was resting in direct contact with the floor. He responded to the room and noted the catheter's collection bag to be on the floor under the resident's bed. He stated it had clips on it and should be secured to the side of the bed hanging from the bed frame. He noted the resident's urine in the indwelling urinary catheter's tubing to be cloudy, which could be indicative of a UTI. He asked the resident if he was having any problems related to his catheter and he indicated he was having some pressure in his bladder area. He indicated he would have to update the physician to see if they wanted to check the resident for a UTI. He acknowledged the catheter's collection bag should be maintained off the floor for infection control purposes. He secured it to the bed frame using the clips raising it off the floor. He acknowledged a staff member had been in the resident's room to deliver the resident's lunch tray to him and did not raise the catheter's collection bag off the floor. On 08/05/25 at 2:35 P.M., catheter care was observed being provided to Resident #5, after consent was obtained from the resident permitting it to be observed. The catheter care was being provided by Certified Nursing Assistant (CNA) #203 and she was assisted by LPN #165. CNA #203 was the one who washed the resident's groin, penis, and catheter tubing before rinsing and drying those areas in the same fashion. She dropped the wash cloths that she was using to wash and rinse the resident's penis and catheter tubing directly onto his floor at the bedside. She did not have a plastic bag to place the used, soiled wash cloths in and simply turned away from the resident by twisting at the waist and dropping the soiled wash cloths from her gloved hands onto the tiled floor. Findings were confirmed with CNA #203. On 08/05/25 at 2:41 P.M., an interview with CNA #203 confirmed she did not set out any plastic bags to use to properly dispose of her used wash cloths and towel after use. She further confirmed she threw the used wash cloths and towel directly onto the floor, which was an infection control concern. She was asked if she was the aide that delivered Resident #5's lunch tray to him earlier that day and confirmed that she was. She reported she did observe Resident #5's indwelling urinary catheter's collection bag to be lying on his floor. She denied she attempted to secure it off the floor when she seen it lying on the floor. She was the only one passing trays at the time and did not want to stop passing the trays to the other residents to take care of Resident #5's catheter bag being on the floor. Review of the facility's policy on Use of Indwelling Urinary Catheters dated 03/07/15 revealed for a resident with an indwelling urinary catheter, the facility staff were to use appropriate infection control practices regarding hand washing, catheter care, tubing, and the collection bag. They were to identify potential evidence of symptomatic UTI's or other related changes in the urine condition, such as onset of bloody urine, cloudiness, or oliguria. Catheters must be anchored to avoid excessive tugging on the catheter during transfers and the delivery of care to prevent inadvertent catheter removal or tissue injury from a dislodged catheter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to provide continued mental health services and implement interventions for a resident at risk of suicide. This affected one resident (#24) of three residents reviewed for depression. The facility census was 74.
Findings include:
Record review revealed Resident #24 was admitted to the facility on [DATE] with diagnoses including dementia without behavioral disturbance, bipolar disorder, major depressive disorder, contracture of muscle to right lower leg, unspecified personality disorder, and bilateral osteoarthritis of knees. Additional diagnoses of anxiety disorder and brief psychotic disorder were added on 06/19/24.
Review of orders revealed Resident #24 had orders in place for Aricept tablet 10 milligrams (mg) one tablet by mouth (06/20/24); sensor bed alarm to alert staff of resident's desire to transfer and check placement every shift (06/20/24); low bed for safety (06/20/24); and lurasidone hci tablet 60 mg give one tablet by mouth once daily (08/02/24).
Review of a discharge minimum data set (MDS) completed on 06/17/24 revealed Resident #24's memory was OK and her ability to make decisions required modified independence, she had an acute onset of mental status change, had delusions, refused care daily, required maximum assistance for bed mobility, and was dependent for transfers.
Review of nursing note dated 06/19/24 at 9:39 P.M. revealed during an emergency telehealth visit with Psych360, Resident #24 was asked if she had suicidal thoughts and replied, yes, the voices are telling me do to it. They are saying I don't belong. When asked if she had a plan, Resident #24 stated, yes and was placed on one to one with staff at all times and charting every two hours until further orders received from physician and a Columbia Suicide Risk Assessment was completed per facility policy. Physician and Director of Nursing (DON) were made aware.
Review of a Columbia Suicide Risk assessment dated [DATE] at 9:39 P.M. revealed Resident #24 had thoughts of wishing she was dead, had suicidal thoughts, suicidal intent without a specific plan, and scored a 6 indicating moderate suicide risk.
Review of an additional nursing note dated 06/19/24 at 9:39 P.M. revealed Resident #24 received new orders to start Ativan 0.5 mg by mouth as needed for 14 days and risperidone 0.5 mg by mouth every 12 hours for bipolar disorder, then discontinue order once Latuda arrives from the pharmacy. Family and primary care physician (PCP) made aware.
Review of a note dated 06/19/24 at 10:39 P.M. revealed multiple purple colored bruising noted to bilateral upper extremities and a discontinued peripheral IV site on left arm. Tiny multiple red colored scattered scratch marks were noted to Resident #24's face, bilateral arms, and chest. Resident #24 voiced she is scratching her body as a result of being anxious. PCP and family made aware and a new order was received for lotion applied twice a day for dry skin.
Review of a nursing note dated 06/19/24 at 11:39 P.M. revealed Resident #24 continued one to one with staff and had no behaviors at this time.
Review of a provider note from Nurse Practitioner (NP) #121 revealed she received a call regarding Resident #24 having worsening symptoms of agitation and restlessness including clawing at her eyes and was not able to be redirected. A new order was given to send Resident #24 to the emergency room for psychiatric evaluation.
Review of nursing notes dated 06/20/24 at 1:39 A.M. and 3:39 A.M. revealed Resident #24 continued to be one to one with staff and had no behaviors at this time.
Review of a behavior note dated 06/20/24 at 4:16 A.M. revealed Resident #24 was attempted to scratch her right eye then attempted to gouge right eye and pull off her eyelid stating she was digging her own grave and knows the drug cartels and all the drugs Dr. [NAME] and all his drugs. Resident continued to have increased false beliefs and remained one to one with staff. Physician was made aware.
Review of an addendum to behaviors note dated 06/20/24 at 4:35 A.M. revealed Resident #24 was redirected by staff with success, with a cold wash clothe to wipe her face. Psych360 was made aware and gave an order to send Resident #24 to hospital for evaluation.
Review of a Transfer out of Facility Form dated 06/20/24 revealed Resident #24 transferred to the emergency room for self-harm, increased false beliefs, and increased hallucinations.
Review of a nursing note dated 06/20/24 at 2:40 P.M. revealed Resident #24 returned to the facility with no new orders, was placed on one to one with staff, and precautions. Resident #24 was refusing to speak to staff. PCP was made aware and gave an order to change Ativan 0.5 mg to every three hours as needed for 48 hours. Family aware.
Review of a social service note dated 06/20/24 at 3:13 P.M. revealed an attempt was made to complete the Columbian Suicide Risk Assessment, but Resident #24 kept her eyes closed and refused to speak.
Review of a social service note dated 06/20/24 at 3:15 P.M. revealed Resident #24 was one to one with staff for safety until the Columbian Suicide Risk Assessment could be completed over a period of time and no further concerns are reported.
Review of a social service note dated 06/20/24 at 4:24 P.M. revealed the Columbian Suicide Risk Assessment was completed and Resident #24 scored a 0 indicating no risk at this time.
Review of a nursing note dated 06/20/24 at 8:31 P.M. revealed Psych360 gave a new order to discontinue risperidone 0.5 mg due to Latuda being delivered and available.
Review of a social service note dated 06/21/24 at 4:01 P.M. revealed a Columbian Suicide Risk Assessment was completed and Resident #24 was pleasant, smiling, and stated she would never try to hurt herself in any way.
Review of a nursing note dated 08/02/24 at 8:56 A.M. revealed a new order was received from Psych360 to discontinue Aricept and increase Lurasidone to 60 mg at dinner. PCP was notified and gave an order not to discontinue Aricept, resident and family were notified.
Observation on 08/05/24 at 8:27 A.M. revealed Resident #24 was resting in bed with a slight lean to the left and the bed was not in a low position.
Observation on 08/05/24 at 10:59 A.M. revealed Resident #24 was resting in bed, but the bed was not in a low position.
Interview on 08/05/24 at 12:56 P.M. with Resident #24 revealed she struggles with depression, and she does have negative thoughts such as wanting to hurt herself. Resident #24 stated she does not know if the facility assists with managing depression well, she thinks she gets medications and she sees doctors and the social worker. During the interview, Resident #24's bed was not in a low position. At the end of the interview, a state tested nursing assistant (STNA) entered Resident #24's room and was made aware of her statements.
Interview on 08/05/24 at 1:03 P.M. with Social Worker (SW) #125 revealed Resident #24 had a sudden change overnight, was sent to the hospital, came back and was placed on one to one with staff, they traded her call light with a bell, served meals on paper plates and gave plastic silverware, family was notified and Pysch360 evaluated her. SW #125 revealed the facility used to have a counselor but she went on maternity leave and never came back. SW #125 stated the facility is switching psych companies in the next couple weeks. SW #125 stated Resident #24 had scored 0's on her suicide risk assessments for awhile but she could benefit from counseling services.
Interview on 08/05/24 at 2:15 P.M. with the Director of Nursing (DON) revealed Resident #24 has an order in place for a low bed because of her behaviors, they were worried she would throw herself out of bed. The DON confirmed Resident #24's bed was not in low position during observations. The DON stated she was not sure if Resident #24 received counseling services but thought counseling could help anybody.
Interview on 08/05/24 at 3:32 P.M. with Regional Nurse (RN #130) revealed Resident #24 was seen by psychiatric services, but not counseling services. RN #130 stated the psychiatric services reviewed Resident #24's medications but also provided behavioral health services because they asked how she was doing and if she had thoughts of harming herself. RN #130 confirmed counseling services were not provided because the facility wanted to make sure medications were effective prior to attempting another intervention. RN #130 did not express knowledge of benefits of therapeutic intervention versus pharmacologic intervention.
This deficiency represents non-compliance investigated under Complaint Number OH00155225.

**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 adequately review all medications for proper justification via pharmacy monthly reviews. This affected one (Resident #12) of five residents reviewed for medications. The census was 77.
Findings Include:
Record review revealed Resident #12 was admitted to the facility on [DATE]. Her diagnoses were type II diabetes, hemiplegia and hemiparesis, chronic bronchitis, COPD, epileptic seizures, allergic rhinitis, hypertension, personal history of traumatic brain injury, insomnia, obesity, age related nuclear cataract, macular degeneration, osteoarthritis of knee, presbyopia, hallux valgus, and dysphagia. Review of her minimum data set (MDS) assessment, dated 04/15/24, revealed she was cognitively intact.
Review of Resident #12's physician orders revealed she was prescribed and administered Rifaximin Tablet 550 milligrams (mg) twice daily for prevention. This order was originally put in place on 12/14/20.
Review of Resident #12's monthly pharmacy reviews and pharmacy recommendations, dated June 2023 to May 2024, revealed no documentation to support the pharmacist questions the diagnosis, the length of time, or any testing that was/was not being completed for her use of Rifaximin, which is an antibiotic.
Interview with Director of Nursing (DON) and Corporate Nurse #200 on 06/05/24 at 3:02 P.M. and 06/06/24 at 2:19 P.M. confirmed there was no documentation to support the pharmacy had questioned or made any recommendations regarding the use or, and length of time Resident #12 had been on Rifaximin.
Review of facility Antibiotic Stewardship Program, (dated 11/28/17), revealed the medical director, consultant pharmacist, and attending physicians support the program via participation in developing promoting, and implementing a facility-wide system for monitoring the use of antibiotics. Consultant pharmacist reviews antibiotics prescribed to residents during their medication regimen reviews and serves as resource for questions related to antibiotics.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, staff interview, and policy review, the facility failed to maintain an infection prevention and control program to prevent the development and transmission of diseases and infections. This affected one of nine residents on enhanced barrier precautions (Resident #11), one of two residents receiving glucometer checks on the Brookside wing (Resident #15), and one of two residents reviewed for indwelling catheters (Resident #18).
Findings include:
1. Review of the medical record for Resident #11 revealed an admission date of 05/10/24 and diagnoses including dementia, diabetes, and alcoholic cirrhosis. The resident also had gastrostomy tube for nutrition.
Observations of medication administration on 06/04/24 at 11:30 A.M. revealed Licensed Practical Nurse (LPN) #150 to administer medication through Resident #11's gastrostomy tube. Upon entering the room there was a sign on the door indicating the resident was on enhanced barrier precautions. LPN #150 did not apply a gown or gloves to administer the medications through the gastrostomy tube. The sign on the door stated staff must wear gloves and a gown for high-contact resident care activities including care or use of feeding tubes.
Review of the facility policy titled Standard and Transmission-based precautions (dated 05/05/17 and updated 03/24/24) revealed enhanced barrier precautions refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities.
Interview with LPN #150 on 06/04/24 at 11:40 A.M. confirmed he did not wear a gown or gloves to administer the medications through Resident #11's feeding tube and should have.
2. Review of the medical record for Resident #15 revealed an admission date of 05/10/24 and diagnoses including diabetes, chronic obstructive pulmonary disease, and neoplasm of the trachea/lung. The resident had a physician's order for insulin per sliding scale before meals and at bedtime.
Observations on 06/04/24 at 11:55 A.M. revealed LPN #147 to perform a blood glucose check for Resident #15 using a glucometer machine. After performing the blood sugar test, LPN #147 cleaned the glucometer machine with an alcohol prep pad and then placed it back into the basket containing the other blood sugar supplies (extra alcohol prep pads and lancets). LPN #147 stated the glucometer machine is used for any resident that requires their blood sugar to be taken. (Each resident does not have their own glucometer machine). The surveyor asked LPN #147 if the facility policy included the use of alcohol prep pads for cleaning glucometers. LPN #147 then stated she was supposed to use a bleach disinfectant wipe to clean the glucometer. She then quickly wiped off the glucometer with a bleach disinfectant wipe and let the machine set on the top of the medication cart to dry.
Review of the facility policy titled Cleaning and Disinfection of Capillary-blood sampling devices (i.e. Blood Glucose Meter) and dated 08/21/13 and revised 04/15 revealed staff were to cleanse the glucometer with a disinfectant wipe. Allow surfaces to remain wet based on the manufacturer guidelines.
Interview with Corporate RN #200 on 06/04/24 at 4:45 P.M. confirmed staff are to use a bleach disinfectant wipe to clean the glucometer and follow the instructions on the disinfectant wipe label.
Review of the bleach disinfectant wipe label revealed to wipe the surface to be disinfected. Use enough wipes for treated surface to be visibly wet for the contact time listed on the label. Then let air dry. The label stated 30 second contact time for HIV and one minute contact time for Hepatitis B. The longest time was three minutes for TB and Clostridium Difficile.
3. Review of Resident #18's medical record revealed the resident was admitted to the facility on [DATE]. His diagnoses included obstructive and reflux uropathy, benign prostatic hypertrophy (BPH) with lower urinary tract symptoms, and the need for assistance with personal care.
Review of Resident #18's physician's orders revealed he had the use of an indwelling urinary catheter to straight drain due to an enlarged prostate. The order had been in place since 09/16/23.
Review of Resident #18's care plans revealed he had a care plan in place for an alteration in elimination with use of a indwelling urinary catheter related to obstructive and reflux uropathy, BPH with obstruction, and the need for the catheter for effective emptying of his bladder. He was known to have urinary tract infections by history. The care plan was initiated on 08/04/21. The goal was for him to be free of complications related to appliance use. The interventions included the need to keep the indwelling urinary catheter bag below the level of the bladder to prevent backflow. That intervention had been in place since 08/04/21.
On 06/04/24 at 10:32 A.M., an observation of Resident #18 noted him to be sitting up in a recliner in his room with his feet elevated. His indwelling urinary catheter's collection bag was hanging off the side of the trash can that was sitting next to his recliner. The clip to the collection bag was overtop of the side of the trash can and the collection bag was on the outside of the trash can. The collection bag was also noted to be in direct contact with the floor.
On 06/04/24 at 11:05 A.M., an interview with LPN #147 revealed Resident #18 did have the use of an indwelling urinary catheter and also had a history of UTI's. She reported the catheter's collection bag should be maintained below the level of his bladder and should also be secured so it was not dragging on the floor. She was asked to accompany the surveyor to the resident's room. She verified his indwelling urinary catheter's collection bag was resting on the floor. She reported he normally had a taller trash can that was in his room and kept the collection bag off the floor when it was hung over the side of the larger trash can. She searched the room and could not find it. She obtained one from the area behind the nurses' station and returned it to the resident's room. She hung the clip at the top of the collection bag over the top of the larger trash can elevating it off the floor. She was not concerned with the trash can being used to hang the collection bag from as long at the catheter bag did not touch the floor. She acknowledged an increased risk of UTI's by allowing the catheter's collection bag to rest on the floor.
Review of the facility's policy on Use of Indwelling Urinary Catheters (dated 03/07/15) revealed for residents with an indwelling catheter they were to use appropriate infection control practices regarding hand washing, catheter care, tubing, and the collection bag.

**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 provide adequate justification and monitoring regarding the use of an antibiotic. This affected one (Resident #12) of five residents reviewed for medications. The census was 77.
Findings Include:
Record review revealed Resident #12 was admitted to the facility on [DATE]. Her diagnoses were type II diabetes, hemiplegia and hemiparesis, chronic bronchitis, COPD, epileptic seizures, allergic rhinitis, hypertension, personal history of traumatic brain injury, insomnia, obesity, age related nuclear cataract, macular degeneration, osteoarthritis of knee, presbyopia, hallux valgus, and dysphagia.
Review of her minimum data set (MDS) assessment, dated 04/15/24, revealed she was cognitively intact.
Review of Resident #12's physician orders revealed she was prescribed and administered Rifaximin (broad spectrum antibiotic) Tablet 550 milligrams (mg) twice daily for prevention. This order was originally put in place on 12/14/20. Also, there was no evidence of laboratory services ordered or completed to monitor the effectiveness and need for Rifaximin.
Review of Resident #12 progress notes, care plan, and diagnoses list found no evidence of justification for the use of Rifaximin.
Interview with Director of Nursing (DON) and Corporate Nurse #200 on 06/05/24 at 3:02 P.M. and 06/06/24 at 2:19 P.M. confirmed they got an order to add liver disease to Resident #12 diagnoses list to provide justification for the use of Rifaximin. But, they also confirmed there were no physician notes, physician orders, justification on the physician orders, and laboratory services orders to monitor and determine the justification for the use of the antibiotic. They confirmed there should have been proper orders and justification for the use of this medication.
Review of facility Antibiotic Stewardship Program, (dated 11/28/17), revealed the medical director, consultant pharmacist, and attending physicians support the program via participation in developing promoting, and implementing a facility-wide system for monitoring the use of antibiotics. Medical director serves as the primary medical point of contact for the program and serves as a liaison between the facility and other medical staff members. Licensed nurses participate in the program through assessment of residents and following protocols as established by the program. Prescriptions for antibiotics shall specify the dose, duration, and indication for use. Reassessment of empiric antibiotics is conducted for appropriateness and necessity, factoring in results of diagnostic tests, laboratory reports, and/or changes in the clinical status of the resident. Random audit of antibiotic prescriptions shall be performed to verify completeness and appropriateness (process measure). Attending physicians shall be provided feedback on his/her antibiotic use data.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure all resident Pre-admission Screening and Resident Review (PASRR) documents were accurate to resident current conditions and diagnoses. This affected two residents (Resident #45 and Resident #46) of three residents reviewed for PASRR documents. The census was 77.
Findings Include:
1. Record review revealed Resident #45 was admitted to the facility on [DATE]. Her diagnoses were COPD, congestive heart failure, muscle weakness, cognitive communication deficit, hypertension, depression, anxiety disorder, atherosclerotic heart disease, atrial fibrillation, and bipolar disorder. Review of her Minimum Data Set (MDS) assessment, dated 03/04/24, revealed she was cognitively intact.
Review of Resident #45's significant change PASRR document, dated 03/06/24, revealed under Section D, the diagnoses listed were mood disorder, panic or other severe anxiety disorder, other psychotic disorder, and bipolar disorder. But review of her diagnoses list, she did not have psychotic disorder listed in her diagnoses list, so it should not have been documented on her PASRR document.
2. Record review revealed Resident #46 was admitted to the facility on [DATE]. Her diagnoses were dementia, COPD, vitamin B12 deficiency, dysphagia, psychosis, peripheral vascular disease, Alzheimer's disease, constipation, hypertensive retinopathy, osteoarthritis, and onychogryphosis. Review of her Minimum Data Set (MDS) assessment, dated 03/11/24, revealed she had a severe cognitive impairment.
Review of Resident #46's significant change PASRR document, dated 07/19/23, revealed under Section D, the diagnoses listed were mood disorder, panic or other severe anxiety disorder, other psychotic disorder, psychosis, major depressive disorder, and anxiety disorder. But review of her diagnoses list, she did not have anxiety disorder, panic or other severe anxiety disorder, other psychotic disorder, and mood disorder/major depressive disorder listed in her diagnoses list, so it should not have been documented on her PASRR document.
Review of Resident #46's full diagnoses list since admission found the following diagnoses were removed and listed as being resolved: schizophrenia on 06/09/23, mental disorder on 12/12/23, major depressive disorder on 12/12/23, and schizoaffective disorder on 03/09/23.
Interview with Corporate Registered Nurse (RN) #200 on 06/05/24 at 9:48 A.M. confirmed the PASRR documents provided were the most up to date. She confirmed both residents had diagnoses that should not have been listed on PASRR documents and should have been removed to make the document the most accurate when there were significant changes. She confirmed both resident PASRR documents provided were completed as significant changes, but still did not accurately reflect their diagnoses.

Based on medical record review, resident interview, staff interview, and observations, the facility failed to conduct accurate assessments in the area of hearing status. This affected two of four residents reviewed for communication (Residents #3 and #37).
Findings include:
1. Review of the medical record for Resident #37 revealed an admission date of 01/08/17. The resident had a diagnosis on 01/27/23 of sensorineural hearing loss bilaterally (hearing loss caused by damage to the inner ear or the nerve from the ear to the brain).
The plan of care dated 05/08/23 stated the resident had sensorineural hearing loss and would participate in audiology services as needed.
Review of the annual Minimum Data Set (MDS) assessment completed 07/27/23 revealed the resident had moderate difficulty hearing and had no hearing aid. Review of MDS assessments completed 10/16/23 and 04/15/24 revealed the resident had adequate hearing and no hearing aide. The MDS assessment on 04/15/24 stated a brief interview for mental status score of 15, indicating intact cognition.
Observation and interview with Resident #37 on 06/03/24 at 2:21 P.M. revealed the resident to be very hard of hearing. The resident had her television volume turned up to 68.
Observation and interview with Resident #37 on 06/04/24 at 10:11 A.M. revealed her to be in bed with her television volume on 80. She stated she can't hear and it is getting worse.
Interview with Social Service Designee #102 on 06/04/24 at 3:35 P.M. confirmed Resident #37 was hard of hearing and needed hearing aids. She confirmed the MDS assessments 10/16/23 and 04/15/24 were not accurate for hearing.
2. Review of the medical record for Resident #3 revealed an admission date of 07/03/23.
Review of the plan of care dated 07/12/23 revealed the resident had trouble hearing and would be referred to audiology for evaluation.
Review of Minimum Data Set (MDS) assessments completed 07/06/23, 01/03/24, and 04/04/24 revealed the resident had adequate hearing and no hearing aides. The Minimum Data Set (MDS) assessment completed 04/04/24 documented a brief interview for mental status (BIMS) score of 15, indicating intact cognition.
Observation and interview with Resident #3 on 06/03/24 at 9:10 A.M. revealed he has difficulty hearing and has had pain in his right ear since he was admitted that he feels affects his hearing. He stated he has not had his hearing tested and feels nothing has been done about his pain and hearing issue, even though he had reported it to nursing staff. During the interview, the surveyor had to raise her voice so the resident could hear.
Observations on 06/04/24 at 9:44 A.M. Resident #3 was observed in his room with the television on and turned up very loud.
Interview with Licensed Practical Nurse (LPN) #143 on 06/05/24 at 9:57 A.M. revealed Resident #3 has had trouble hearing since he was admitted . She stated you have to adjust your tone of voice for him to hear. She stated he turns the television up loud so he can hear it. She stated she thinks a lot of the time he reads your lips and you might have to use gestures, like pointing, so he can understand things.
Interview with LPN #150 on 06/05/24 at 10:13 A.M. confirmed Resident #3 is hard of hearing and you have to raise your voice to speak to him. He also stated the resident turns up his television to very loud in order for him to hear it.
Interview with Social Service Designee #102 on 06/05/24 at 10:05 A.M. confirmed the MDS assessments were not accurate for hearing for Resident #3.

Based on medical record review, resident interview, staff interview, and observation, the facility failed to develop a comprehensive care plan in the area of hearing status. This affected one of four residents reviewed for communication (Resident #37).
Findings include:
Review of the medical record for Resident #37 revealed an admission date of 01/08/17. The resident had a diagnosis on 01/27/23 of sensorineural hearing loss bilaterally (hearing loss caused by damage to the inner ear or the nerve from the ear to the brain).
Review of the annual Minimum Data Set (MDS) assessment completed 07/27/23 revealed the resident had moderate difficulty hearing and had no hearing aid. Review of MDS assessments completed 10/16/23 and 04/15/24 revealed the resident had adequate hearing and no hearing aide. The MDS assessment on 04/15/24 stated a brief interview for mental status score of 15, indicating intact cognition.
Observation and interview with Resident #37 on 06/03/24 at 2:21 P.M. revealed the resident to be very hard of hearing. The resident had her television volume turned up to 68.
Observation and interview with Resident #37 on 06/04/24 at 10:11 A.M. revealed the resident to be in bed with her television volume on 80. She stated she can't hear and it is getting worse.
The plan of care dated 05/08/23 stated the resident had sensorineural hearing loss and would participate in audiology services as needed. Interventions included: adequate hearing, encourage non verbal communication with resident, provide reassurance and patience when communicating with resident. There were no further interventions listed related to hearing for the resident.
Interview with MDS Nurse #163 on 06/04/24 at 3:55 P.M. confirmed the plan of care does not include sufficient interventions for assisting staff in communicating with the resident related to hearing loss. She confirmed the words adequate hearing were not an intervention to assist staff in communicating with the resident. She stated she did not know what encouraging non verbal communication with the resident meant. She stated a communication board could be used but was not specified in the plan of care.

Based on medical record review, resident interview, staff interview, and observations, the facility failed to residents received proper treatment and assistive devices to maintain hearing abilities. This affected two of four residents reviewed for communication (Residents #3 and #37).
Findings include:
1. Review of the medical record for Resident #3 revealed an admission date of 07/03/23. A Minimum Data Set (MDS) assessment completed 04/04/24 documented a brief interview for mental status (BIMS) score of 15, indicating intact cognition.
Review of the plan of care dated 07/12/23 revealed the resident had trouble hearing and would be referred to audiology for evaluation.
Review of a consultation report revealed Resident #3 had an ear care exam on 12/06/23 by a nurse practitioner. The report stated the resident's tympanic membranes were visible in both ears. There was no evidence of a hearing evaluation and the fact that the resident had trouble hearing was not mentioned in the report.
Interview with Resident #3 on 06/03/24 at 9:10 A.M. revealed he has difficulty hearing and has had pain in his right ear since he was admitted that he feels affects his hearing. He stated he has not had his hearing tested and feels nothing has been done about his pain and hearing issue, even though he had reported it to nursing staff. During the interview, the surveyor had to raise her voice so the resident could hear.
Observations on 06/04/24 at 9:44 A.M. Resident #3 was observed in his room with the television on and turned up very loud.
Interview with Licensed Practical Nurse (LPN) #143 on 06/05/24 at 9:57 A.M. revealed Resident #3 has had trouble hearing since he was admitted . She stated you have to adjust your tone of voice for him to hear. She stated he turns the television up loud so he can hear it. She stated she thinks a lot of the time he reads your lips and you might have to use gestures, like pointing, so he can understand things.
Interview with LPN #150 on 06/05/24 at 10:13 A.M. confirmed Resident #3 is hard of hearing and you have to raise your voice to speak to him. He also stated the resident turns up his television to very loud in order for him to hear it.
Interview with Social Service Designee #102 on 06/05/24 at 10:05 A.M. revealed the consulting audiology company was aware in December 2023 of Resident #3 having hearing loss and possibly needing hearing aids. She confirmed the consultation report from 12/06/23 did not address hearing loss. She confirmed Resident #3's hearing loss had not been evaluated.
2. Review of the medical record for Resident #37 revealed an admission date of 01/08/17. The resident had a diagnosis on 01/27/23 of sensorineural hearing loss bilaterally (hearing loss caused by damage to the inner ear or the nerve from the ear to the brain).
The plan of care dated 05/08/23 stated the resident had sensorineural hearing loss and would participate in audiology services as needed.
Review of the annual Minimum Data Set (MDS) assessment completed 07/27/23 revealed the resident had moderate difficulty hearing and had no hearing aid. The care area assessment stated referral was not necessary but there was no further explanation. Review of MDS assessments completed 10/16/23 and 04/15/24 revealed the resident had adequate hearing and no hearing aide. The MDS assessment on 04/15/24 stated a brief interview for mental status score of 15, indicating intact cognition.
Observation and Interview with Resident #37 on 06/03/24 at 2:21 P.M. revealed the resident to be very hard of hearing. The resident had her television volume turned up to 68. The resident stated she had been seen by audiology but was still waiting on hearing aids.
Observation and interview with Resident #37 on 06/04/24 at 10:11 A.M. revealed her to be in bed with her television volume on 80. She stated she can't hear and it is getting worse.
Review of audiology consult reports revealed the following: 08/25/22 hearing difficulty per patient. Ear wax was removed. Report dated 01/27/23 revealed the patient would like time to think about hearing aid recommendation. Report dated 02/02/23 revealed the resident wants more time to think about hearing aides. Report dated 01/26/24 revealed impressions were taken for hearing aids. The hearing aids will be ordered pending insurance prior authorization. Hearing aid fitting in one month. Report dated 04/19/24 revealed pending hearing aides right and left per patient. Report dated 04/29/24 revealed still awaiting insurance approval.
Review of nursing notes revealed on 05/30/24 at 12:48 P.M. Social Service Designee #102 documented she had spoken to care coordinator for the audiology service. Insurance has denied the resident a set of hearing aides at this time.
Interview with Social Service Designee #102 on 06/04/24 at 3:35 P.M. revealed the facility had been working with their audiology consultants to get hearing aids for Resident #37. However, there had been issues with billing. She stated an HMO had been billed for the hearing aids and they were sending bills for $1900.00 and $400.00 in order for the resident to get hearing aids. She stated the resident was no longer under an HMO and was under Medicaid as of 04/01/24. She stated she did not know why Medicaid could not be billed for the hearing aids instead of the HMO. She stated the resident really needs hearing aids. She stated they should be covered by Medicaid. She stated she had gotten conflicting information from the audiology consultants on the status of the hearing aids. She stated on 04/29/24 she was notified by email by the audiology consulting company that the resident was getting the hearing aids that day. She stated the resident did not receive hearing aids and she was then later notified on 05/30/24 that insurance had denied the hearing aides.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, staff interview, and policy review, the facility failed to ensure residents, who were at risk for falls and had a history of falls, had fall prevention interventions implemented as per their plan of care. This affected two (Resident #18 and #28) of three residents reviewed for accidents.
Findings include:
1. Review of Resident #18's medical record revealed the resident was admitted to the facility on [DATE]. His diagnoses included adult onset diabetes mellitus, unspecified psychosis, psychotic disorder with hallucinations, unspecified dementia, Parkinson's disease, insomnia, muscle weakness, unsteadiness on feet, and need for assistance with personal care.
Review of Resident #18's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had clear speech. He was able to make himself understood and was usually able to understand others. His cognition was severely impaired and he was known to have other behaviors not directed at others. He also had a functional limitation in his range of motion of his bilateral lower extremities.
Review of Resident #18's care plans revealed he had a care plan in place for being at risk for falls related to Parkinson's disease, decreased strength, impaired balance, personal history of falls, use of psychotropic medications, requiring assist with all mobility needs, and dizziness. The care plan was revised on 08/07/22. The goal was to minimize potential risk factors related to falls. The interventions included the need for his bed to be in its lowest position. That intervention was added on 08/04/21.
On 06/03/24 at 9:45 A.M., an observation of Resident #18 noted him to be lying in bed. He was noted to have a fall mat on the floor on the left side of the bed towards the window. His bed was not noted to be in its lowest position.
On 06/05/24 at 8:15 A.M., an observation of Resident #18 noted him to be lying in bed in a supine position with his eyes closed. His fall mat was on the floor to the left side of the bed. Again, his bed was not noted to be in its lowest position as it was at the height of a standard bed.
On 06/05/24 at 8:20 A.M., an interview with Registered Nurse (RN) #142 revealed Resident #18 was considered to be at risk for falls. She was asked what fall prevention interventions were in place for the resident. She reported one of his fall prevention interventions was for his bed to be maintained in its lowest position. She verified the resident's bed was not in its lowest position. She noted the resident had the bed control in his right hand while he was sleeping in his bed. She stated she was not sure if the resident raised the bed or if it had been left up by someone else and his bed control was just left in his reach. She reported the bed control should be placed somewhere where the resident did not have access to so he could not raise the bed. She confirmed the resident had cognitive impairment and poor safety awareness.
2. Review of Resident #28's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included unspecified dementia with psychotic disturbance, unspecified psychosis, anxiety disorder, restlessness and agitation, and mild cognitive impairment.
Review of Resident #28's annual MDS assessment dated [DATE] revealed the resident did not have any communication issues and her cognition was moderately impaired. No behaviors or rejection of care was noted.
Review of Resident #28's care plans revealed she had a care plan in place for being at risk for falls and had a history of falls with potential for injury. Her fall risk was related to the use of medications that increased her risk for dizziness and sedation, being bed bound per her choice., and being wheelchair bound when she was out of bed. The care plan was last revised on 03/15/23. The goal was to minimize potential risk factors related to falls. The interventions included the use of a pressure sensitive alarm (PSA) alarm to her bed. They were to check the placement and the function of the PSA every shift. That intervention was added to the care plan on 11/24/23, after the resident had a fall while trying to get out of bed.
On 06/04/24 at 9:46 A.M., an observation of Resident #28 noted her to be lying in bed in a supine position with her head of bed elevated. Her eyes were closed but she was able to awaken without difficulty when spoken to. Her PSA was noted to not be plugged in to the alarm box making ineffective. The PSA pad was under her but the wire was not plugged into the alarm box that was sitting on her bedside chair. She did not have any other alarm boxes in the room and the wire was clearly not plugged into anything as it was wrapped around the assist bar on the side of the bed.
On 06/04/24 at 9:59 A.M., an interview with State Tested Nursing Assistant (STNA) #114 revealed Resident #28 was considered to be a fall risk. She reported the resident was on an alarm to prevent her from falling. She was asked to accompany the surveyor to the resident's room. She confirmed the PSA was not in working order as the wire was not plugged into the alarm box making the alarm ineffective. She denied she was the one that unplugged it and also denied the resident had been out of bed that day. She claimed she had checked on her earlier that day and the other STNA working had been in there and changed her. She connected the pressure sensitive alarm to the alarm box by plugging the wire into the alarm box. She was not sure how it got unplugged.
Review of the facility's policy on Fall Management (dated 10/17/16) revealed it was the intention of the facility to promote programs geared to improving mobility and reduce the risk of falls through a comprehensive, interdisciplinary process of assessment, care plan development, and implementation with ongoing monitoring and review. An interdisciplinary plan of care would be developed, implemented, reviewed, and updated as necessary to reflect each resident's current safety needs and fall reduction interventions.

**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 adequate indication of use for an antipsychotic medication and failed to ensure specific target behaviors were being appropriately monitored for residents receiving psychotropic medications. This affected four residents (#13, #44, #53 and #77) of five residents reviewed for unnecessary medications use.
Findings Include
1. A review of Resident #13's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including restlessness and agitation, vascular dementia with behavioral disturbances, psychosis, personality disorder, sexual dysfunction and major depressive disorder.
A review of Resident #13's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/01/22 revealed the resident did not have any communication issues and his cognition was severely impaired. Mood indicators were present and the resident was known to have verbal behaviors directed at others, other behaviors not directed at others and refusal of care.
A review of Resident #13's care plans revealed the resident had a care plan in place for an altered cognitive function related to his diagnoses of dementia, anxiety, psychosis, dementia, delirium, personality disorder, and restlessness and agitation. The care plan indicated the resident was known to express false beliefs, had visual hallucinations, and yelled out from his room and then would tell staff he did not need anything. The care plan did not include any intervention to monitor and document behaviors when they occurred.
Record review revealed the resident also had a care plan in place for alterations in his mood and/or behaviors as evidenced by being resistive to care, feeding down/ depressed/ hopeless, feeling tired or having little energy, having the diagnosis of depression, showing little interest/ pleasure in doing things, showing signs of verbal aggression, trouble falling/ staying asleep, hypersexual behaviors, and putting himself on the floor. This care plan as well did not include an intervention to monitor and document behaviors that occurred.
A review of Resident #13's active physician's orders revealed the resident was ordered to receive Risperdal (an antipsychotic) 2 milligrams (mg) by mouth twice a day for psychosis. The order had been in place since 08/03/22. He was also receiving Remeron (an antidepressant) 15 mg by mouth every night at bedtime for depression. The order originated on 08/22/22.
A review of Resident #13's medication administration record (MAR) for October 2022 revealed the resident was receiving Risperdal and Remeron on a scheduled basis as ordered. The MAR did not identify what resident specific targeted behaviors the medications were being used for only the diagnoses in which they were being given for.
A review of a POC Response History for Monitoring Behavior Symptoms under the task tab of the electronic health record (EHR) revealed the aides documented behaviors when noted on their shift. The behaviors being monitored were not resident specific and were the same generic behaviors that were monitored for with all residents.
On 10/03/22 at 3:55 P.M., an interview with the Director of Nursing (DON) confirmed the facility did not have resident specific target behaviors listed on their MAR for the psychotropic medications being used for each resident. The DON was asked what Resident #13 was receiving Risperdal for. He looked at the MAR and reported the resident was receiving it for psychosis. He acknowledged psychosis was a diagnosis and not a specific behavior in which the medication was being used for. He stated they used to have paper sheets in which they were able to record target behaviors on but when they went to an electronic MAR they quit using them. The DON reported the aides documented behaviors in the POC, under the task tab, but verified they were the same behaviors for all residents and were not resident specific target behaviors for a particular resident. The DON denied the nurses documented behaviors on a MAR and stated they would put any behaviors they noted in a progress note. He acknowledged the staff would be more likely to capture behaviors when they occurred, if they knew what specific behaviors they should be monitoring for. He acknowledged they should be identifying why the residents were receiving psychotropic medications and what behaviors they were being used for.
On 10/03/22 at 4:15 P.M., an interview with Registered Nurse (RN) #136 revealed Resident #13's behaviors included not wanting to do for himself. RN #136 revealed she tried to cue him to do as much for himself as possible and she assisted him as needed. The aides documented behaviors in the POC under the task tab. She confirmed the behaviors monitored for the resident were the same being monitored for all residents and not specific to Resident #13. She stated the nurses would only document a behavior in the progress note, if it was out of the norm for that resident. She was asked what the resident was receiving Risperdal for and replied she thought it was for anxiety and to help him sleep. She denied she was aware of what behavioral symptoms the resident was known to have in relation to his psychosis diagnosis. She stated she floated between units and was not familiar with all residents. When asked where she would go in the medical record for that information, she stated she would look at his history and physical (H&P). She denied the MAR identified what his target behaviors were but felt it would be helpful if it specified.
A review of the facility policy on Psychotropic Monitoring, effective 06/21/17 revealed each resident receiving a psychotropic agent was to be monitored for episodes of behaviors being treated.
2. A review of Resident #53's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including bipolar disorder, anxiety disorder, mood disorder, major depressive disorder, and schizo-affective disorder.
A review of Resident #53's Minimum Data Set (MDS) 3.0 assessment, dated 08/12/22 revealed the resident did not have any communication issues and his cognition was moderately impaired. Mood indicators were noted to be present but the resident was not indicated to have displayed any behaviors.
A review of Resident #53's care plans revealed he had care plans in place for an altered cognitive function, alteration in mood and behaviors, and having a history or diagnoses of bipolar disorder, anxiety and insomnia. The care plan noted the resident was known to have persistent anger at others, made repetitive anxious complaints, had repetitive questions, had a sad/anxious appearance, and unrealistic fears and anxiety. None of the care plans included the intervention to monitor for and record behaviors when they occurred.
A review of Resident #53's physician's orders revealed the resident had orders in place to receive Haldol (an antipsychotic) 5 mg by mouth two times a day and Zyprexa (an antipsychotic) 15 mg po every night at bedtime for schizo-affective disorder. The Haldol order had been in place since 07/29/20 and the Zyprexa had been in place since 05/26/22. He was also receiving Buspar (an anti-anxiety medication) 5 mg by mouth twice a day for anxiety disorder and Trazadone (an antidepressant) 75 mg by mouth every night at bedtime for insomnia. The Buspar had been in place since 07/29/20 and the Trazadone had been in place since 07/19/21.
A review of Resident #53's MAR for October 2022 revealed he was receiving the Haldol, Zyprexa, Buspar, and Trazadone as scheduled. The MAR only included the diagnoses in which the psychotropic medications were being used for and did not identify any targeted behaviors in which each medication was being used for. The MAR did not allow the nurses to document if any resident specific target behaviors occurred.
A review of a POC Response History for October 2022 that was under the task tab of the electronic health record (EHR) revealed the aides were monitoring the resident for behavior symptoms. The behaviors being monitored for were generic behaviors and were not resident specific target behaviors in which Resident #53 was receiving the psychotropic medications for.
On 10/04/22 at 8:30 A.M., an interview with the DON revealed staff were not monitoring Resident #53 for any resident specific target behaviors for which his psychotropic medications were being used for. The DON confirmed the nurses would document behaviors in the progress notes but the aides documented behaviors in the POC. He indicated the behaviors monitored for in the POC by the aides were the same for all residents and not specific to the resident or for why he was receiving psychotropic medications.
On 10/04/22 at 8:45 A.M., an interview with LPN #183 revealed she was not familiar with the psychoactive medications Resident #53 was receiving and had to refer to his physician's orders to see what he was on. She identified Haldol, Buspar and Zyprexa as psychotropic medications the resident was receiving. She stated the resident received Haldol and Zyprexa both for schizo-affective disorder. She was asked what behaviors he had that were related to his schizo-affective disorder. She reported when he first came he had to be sent out to a psychiatric hospital to get his medications adjusted. Since he returned to the facility, he had been perfectly fine. She thought the resident was having delusional behavior but was not really sure. When he first came, he was pulling his own teeth out and had a lot of anger. She also thought the resident had been known to hit staff when he resided on the secured unit. She denied he had any of those behaviors now since his return from the psychiatric hospital. She reported staff would ask him if he was having any problems. The LPN denied there was anything on the MAR to reflect what resident specific behaviors staff should be monitoring for. She was asked about the use of Buspar and indicated it was being used for anxiety disorder. She was asked what behaviors the resident displayed when anxious and replied he would pace in the halls. She denied he did that very often and indicated it was maybe once a month. She denied anything was communicated to staff to monitor the resident for pacing as part of his target behaviors. She reported the resident did also receive Trazadone for insomnia but staff were not recording on a behavior monitoring system how often insomnia was actually occurring for the resident. The LPN revealed the resident tended to sleep a lot during the day and was up at night. She confirmed the nurses were to document all behaviors in the progress notes if they occurred.
3. Review of the medial record for Resident #44 revealed an admission date of 03/07/22 with diagnoses including dementia with behavioral disturbances, anxiety, depression, and delusional disorders.
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/02/22 revealed Resident #44 was severely cognitively impaired with inattention, fluctuating disorganized thinking, delusions, hallucinations, physical and verbal behaviors directed towards others, rejection of care and wandering. Per the MDS assessment, Resident #44 received antipsychotic medications on a routine basis.
Review of the physician's orders dated 09/2022 revealed Resident #44 received Risperdal (antipsychotic) 0.5 milligram (mg) by mouth two times daily for delusional disorder and unspecified dementia and Lexapro (antidepressant) 10 mg by mouth daily for depression. There were not any target behaviors or symptoms listed related to depression, delusional disorder or unspecified dementia for Resident #44.
Review of the plan of care for adverse effects related to antipsychotic medication and psychoactive medications used for anxiety, delusional disorder, dementia with behaviors and depression revealed interventions that included assess behaviors for which drugs were being given and monitor and record the frequency of occurrence as needed. However, the facility did not provide any documentation of target behaviors for Resident #44.
Review of the point of care (POC) documentation by the State Tested Nursing Assistants (STNA) during the month of September 2022 revealed the documentation of behaviors was generic and the same for all residents. The facility did not provide any documentation of specific/individualized target behaviors for Resident #44.
An interview on 09/28/22 at 2:51 P.M. with Licensed Practical Nurse (LPN) #126 revealed resident behaviors were documented in the task section point of care by the STNA staff. LPN #126 also revealed each resident should have personalized triggers and interventions and nurses were to document acute behaviors in the nursing progress notes.
An interview on 10/03/22 at 3:59 P.M. with the DON confirmed the nurses did not routinely monitor or document personalized target behaviors for the residents, including Resident 44 in the medical record. The DON indicated nurses document acute behaviors only in the progress notes
The facility did not provide a policy regarding target behaviors.
4. Review of the medical record for Resident #77 revealed an admission date of 03/02/22 with diagnoses including Alzheimer's disease, dementia without behaviors, major depression, mood disorder, unspecified psychosis and anxiety.
Review of the significant change Minimum Data Set (MDS) 3.0 assessment, dated 09/22/22 revealed Resident #77 was severely cognitively impaired with inattention, disorganized thinking, delusions, physical and verbal symptoms that interfere with care, rejection of care and wandering. Per the MDS assessment, Resident #77 received antipsychotic, antianxiety and antidepressant medications on routine basis.
Review of the physician's orders for 09/2022 revealed Resident #77 received the following medications:
Risperdal (antipsychotic) 2 milligrams (mg) by mouth for mood disorder, Ativan 0.5 mg by mouth two times daily for anxiety, Buspirone hydrochloride 15 mg by mouth three times daily for anxiety, Fuvoxamine maleate 50 mg by mouth daily for depression, Trazadone hydrochloride 75 mg by mouth at hour of sleep for depression, and Sertraline hydrochloride 75 mg by mouth daily for depression. There were not any personalized target behaviors for the nurse to monitor and document while administering the medications.
Review of the pharmacy medication reviews for 03/2022, 04/2022, 05/2022, 06/2022, 07/2022, and 08/2022 revealed no recommendations addressing the antipsychotic, antidepressant or antianxiety medications for the resident.
Review of the nursing progress notes for September 2022 revealed the following documentation:
A nursing note dated 09/27/22 at 4:43 P.M. Resident #77 was noted to have increased agitation, anxiety and pain. The nurse contacted the Hospice agency who came in the facility to visit the resident. Hospice recommended increasing the pain medication Morphine to 0.5 milliliters (10 mg) by mouth every hour as needed for pain or shortness of breath, increase as needed Ativan to 1 mg by mouth every four hours as needed for agitation/anxiety, and increase Risperdal to 2 mg by mouth two times daily.
An interview on 10/03/22 at 3:59 P.M. with the DON confirmed the nurses did not routinely monitor or document personalized target behaviors for the residents, including Resident #77 in the medical record. The DON indicated the nurses document acute behaviors only in the progress notes. The DON also confirmed mood disorder was not a justified/proper diagnosis for the administration of Risperdal.
The facility did not provide a policy regarding target behaviors.

2. On 09/26/22 beginning at 11:35 A.M. observation of the lunch meal revealed residents were being served in the dining room and on the 200 and 400 hallways from the same meal cart.
At the time of the observation, Resident #62 was observed sitting at a table with two unidentified residents who had been served their meal. Resident #62 stated multiple times, Where is my plate? with no acknowledgement of the question by staff serving the meal. Further observation revealed Resident #62 did not receive his lunch meal until 11:42 A.M. well after the other residents at the table were eating.
At the time of the observation, interview with Licensed Practical Nurse (LPN) #127 verified Resident #62 had not been served his meal at the same time as the unidentified residents seated at the same table.
The facility had no policy on meal delivery stated the facility followed CMS guidelines and regulations.
This deficiency substantiates Complaint Number OH00133807.
Based on observation, record review and interview the facility failed to ensure meals were provided in a timely and dignified manner for Resident #62 and Resident #44. This affected two residents randomly observed for dining in two of three dining rooms observed.
Findings Include:
1. Review of the medical record for Resident #44 revealed an admission date of 03/07/22 with diagnoses including dementia with behavioral disturbances, anxiety, adult failure to thrive, depression, and delusional disorder.
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/02/22 revealed Resident #44 had severe cognitive impairment with inattention, fluctuating disorganized thinking, delusions, hallucinations, physical and verbal behaviors towards others, rejection of care and wandering. Resident #44 required supervision of set up with meals.
An observation on 09/29/22 at 12:15 P.M. of the lunch meal on the Renaissance unit revealed Resident #44 was seated at a table with Residents #21 and #56. The staff started serving lunch trays at 12:20 P.M. and provided a tray to Resident #21 and #56. Resident #44 received her lunch tray at 12:41 P.M. Resident #44 was observed at that time eating food from the tray of Resident #21 seated beside her.
An interview on 09/29/22 at 12:45 P.M. with State Tested Nursing Assistant (STNA) #208 confirmed Resident #44 did not receive her lunch tray at same time as the other residents seated at the table and was eating food from Resident #21's meal tray. STNA #208 revealed the meal/food trays were removed and served from the meal cart as they were placed on the cart, and there was not an updated seating chart for the dining room on the Renaissance unit.
The facility had no policy on meal delivery stated the facility followed CMS guidelines and regulations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure Resident #78's privacy was maintained in regard to the specific reason the resident was in isolation precautions. This affected one resident (#78) of one resident reviewed for COVID-19.
Findings Include:
A review of Resident #78's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including mild intellectual disabilities, unspecified dementia with behavioral disturbances, and schizophrenia.
A review of Resident #78's nursing progress notes revealed a nurse's note, dated 09/24/22 at 1:37 P.M. revealed the resident had a non-productive cough and rhonchi heard in her right and left upper lungs. The physician was notified and the resident was placed in droplet and contact isolation at that time.
A review of Resident #78's physician's orders, dated 09/24/22 confirmed the resident was placed in droplet and contact isolation precautions every shift for cough and congestion. An order was also noted to test the resident as needed for Covid-19.
A review of Resident #78's Covid-19 tests revealed she was tested for Covid-19 on 09/24/22 with an antigen test and found to be negative for COVID-19. A repeat antigen test for COVID-19 was performed on 09/26/22 and the resident was found to be positive for COVID-19 at that time.
A review of Resident #78's treatment administration record (TAR) for October 2022 revealed the resident continued to be in droplet and contact isolation precautions. The TAR indicated she had been in transmission based precautions since 09/24/22.
On 10/04/22 at 10:35 A.M., an observation of Resident #78's room revealed she resided on one of the facility's two secured units. The resident was in the room at the end of the hall and had her door closed. On her door was a note that identified the resident was COVID-19 positive and directed any staff/visitors to see the nurse. Findings were verified by Licensed Practical Nurse (LPN) #103.
On 10/04/22 at 10:42 A.M., an interview with LPN #103 revealed the facility had recently posted the sign on the outside of Resident #78's door that identified her as being COVID-19 positive. The LPN acknowledged posting such specific diagnostic information about the resident's medical condition in an area that could be seen by visitors was considered a privacy/dignity issue. She was informed the sign could have been posted to direct staff and visitors to report to the nurse before entering the resident's room without identifying her as being positive for COVID-19.
The facility did not have any policies in place for what signs should be posted when a resident was placed in transmission based precautions for COVID-19. Corporate Nurse #220 reported on 10/04/22 at 1:50 P.M. the facility followed the regulations and did not have policy specific to what signs should or should not be posted for residents' in transmission based precautions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure Preadmission Screening and Resident Reviews (PASARR) were submitted as required for Resident #53 and Resident #24. This affected two residents (#53 and #24) of two residents reviewed for PASARR.
Findings Include:
1. A review of Resident #53's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including bipolar disorder, anxiety disorder, mood disorder and major depressive disorder all present upon his admission.
A review of Resident #53's Preadmission Screening and Resident Review (PASARR) Identification Screen, dated [DATE] revealed the PASARR Identification Screen was being completed as there had been an expired time limit for a hospital exemption. The request was to seek approval for a nursing facility admission for an unspecified period of time. Section (D.) of the PASARR Identification Screen assessed the resident as having indications of a serious mental illness. The person completing the screen was to identify all mental disorders that were listed in that section. The resident was marked as having a mood disorder, severe anxiety disorder and another mental disorder other than mental retardation (MR) that may lead to a chronic disability. The resident was noted to have insomnia and bipolar disorder. Schizophrenia, delusional (paranoid) disorder, Somatoform disorder, personality disorder and other psychotic disorders were not marked as being one of the resident's known mental disorders he had. He was identified based on that screen completed to have indications of a serious mental illness. The review results for a Preadmission Screen (PAS) Determination indicated the resident did have indications of a serious mental illness and a referral had been made to Ohio PASARR/ Maximus for a Level II further review evaluation. The PAS Determination revealed the resident had been approved for nursing facility services. The resident required the level of services that were provided in the nursing facility to include wound care, rehabilitative services and hands on assistance with medication administration. No specialized services were required at that time.
A review of Resident #53's cumulative diagnoses list revealed a diagnosis of schizo-affective disorder was added to the resident's diagnoses on [DATE].
A review of Resident #53's annual Minimum Data Set (MDS) 3.0 assessment, dated [DATE] revealed the assessor indicated the resident was not currently considered by the state Level II PASARR process to have a serious mental illness and/ or intellectual disability or related condition despite findings noted with his PASARR Identification Screen and PAS Determination that had been previously completed on [DATE]. Section (I.) of the MDS identified the resident as having the diagnoses of anxiety disorder, depression, bipolar disorder and schizophrenia. Additional active diagnoses included schizo-affective disorder of the bipolar type.
Resident #53's medical record was absent for any documented evidence of a new PASARR Identification Screen being completed after [DATE], when it was known the resident had a new mental illness diagnosis of schizo-affective disorder being added on [DATE]. Findings were verified by the facility Administrator on [DATE] at 9:10 A.M.
On [DATE] at 9:11 A.M., an interview with the Administrator denied the facility had submitted a new PASARR after the resident received a new diagnosis of a schizo-affective disorder. She stated schizo-affective disorder was just a type of mood disorder and she did not feel it would have warranted a new PASARR. She acknowledged schizo-affective disorder was a mental health condition where symptoms of both psychotic and mood disorders were present together during one episode or within a two week period of each other. Schizo referred to psychotic symptoms (delusions/ hallucinations) and affective referred to mood symptoms (depression or mania). That diagnosis was different from the diagnoses that were present at the time his last PASARR screen was completed on [DATE].
2. Review of the medical record for Resident #24 revealed an admission date of [DATE] with a diagnosis including anxiety disorder. An additional diagnosis was added on [DATE] of major depressive disorder, on [DATE] of paranoid personality disorder and on [DATE] of schizophrenia.
Review of the PASARR for Resident #24, dated [DATE] did not include any diagnosis of paranoid personality disorder and schizophrenia.
Review of the annual Minimum Data Set, dated [DATE] revealed Resident #24 had severe cognitive impairment with inattention, delusions and other behavioral symptoms not directed towards others and wandering. Resident #24 received an antipsychotic medication, antianxiety medication, and antidepressant medication seven of seven days of the look back period.
An interview on [DATE] at 8:29 A.M. with Social Services #137 confirmed Resident #24 had additional diagnosis that warranted a new PASARR with referral for a Level II assessment that was not completed.
The facility did not provide a policy related to PASARR.

Based on observation, record review and interview the facility failed to ensure Resident #30, who required staff assistance with activities of daily living (ADL) care received adequate and timely oral and hair care to maintain proper hygiene. This affected one resident (#30) of four residents reviewed for activities of daily living (ADL) care.
Findings Include:
Review of Resident #30's medical record revealed an initial admission date of 01/20/21 with the latest readmission of 09/21/21. Resident #30 had diagnoses including schizophrenia, fracture of shaft of right humerus, morbid obesity, unsteadiness on feet, generalized muscle weakness, encephalopathy, mild cognitive impairment, impulse disorder, bipolar disorder, repeated falls, vitamin D deficiency, constipation, intentional self harm, chronic pain, acquired absence of right toes, insomnia, seizures, anxiety disorder, deaf, non speaking, adjustment disorder, osteoarthritis, dental caries, acute gingivitis plaque induced, dementia with behavioral disturbances and unspecified disorder of psychological development.
Review of the resident's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 09/17/22 revealed the resident had no speech and had a severe cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of zero (out of 15). The assessment revealed the resident required extensive assistance from two staff for personal hygiene.
On 09/27/22 at 9:28 A.M., observation of Resident #30 revealed her teeth had a large amount of white debris and her hair was unkempt.
On 09/28/22 at 3:48 P.M., observation of Resident #30 revealed the resident was sitting at nurse's station in a wheelchair. The resident's mouth was dry and lips were cracked. The resident's hair remained unkempt. At the time of the observation, Licensed Practical Nurse (LPN) #128 verified the resident's mouth was dry, lips were cracked and her hair was unkempt.
On 10/03/22 at 2:45 P.M., interview with the Director of Nursing (DON) revealed the facility had no specific policy for ADL but stated staff should follow the standards of practice.
This deficiency substantiates Complaint Number OH00133807.

Based on observation, record review and interview the facility failed to timely identify, assess and monitor Resident #9 related to bruising. This affected one resident (#9) of two residents reviewed for skin conditions.
Findings Include:
Review of Resident #9's medical record revealed an initial admission date of 10/27/21 with the latest readmission of 06/15/22. Resident #9 had diagnoses including chronic obstructive pulmonary disease, pancytopenia, anxiety disorder, schizophrenia, hypothyroidism, dementia with behavioral disturbances, vitamin D deficiency, seizures, peripheral vascular disease, obstructive sleep apnea, onychogryphosis, dependence on supplemental oxygen, peripheral venous insufficiency, personal history of COVID-19 and vitamin B12 deficiency and anemia.
Review of the plan of care dated 05/03/22 revealed the resident was at risk for alteration in skin integrity related to cognitive impairment, dementia, history of skin impairment, incontinence, mobility impairment, non-compliance with therapeutic skin regimen, peripheral vascular disease, dry skin, thick yellow crumbly toe nails and prone to bruising with lab draws. Interventions included body check weekly and as needed, geri-sleeves to arms every shift for prevention, notify physician and family of any changes, and provide skin care as needed.
Review of the resident's monthly physician's orders identified an order, dated 06/15/22 for a head to toe skin assessment weekly every Sunday and an order, dated 07/27/22 for geri-sleeves for protection.
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 09/20/22 revealed the resident had clear speech, understood others, made herself understood and had no cognitive impairment as indicated by a Brief Interview for Mental Status (BIMS) score of 14 (out of 15). Review of the mood and behavior section of the MDS revealed the resident had hallucinations, delusions, displayed verbal abuse, behaviors directed towards others and rejected care. The resident required extensive assistance of two staff for bed mobility, transfers and bathing. The assessment indicated the resident was at risk for skin breakdown and had and unstageable pressure ulcer that was present on admission. The facility implemented interventions of pressure reducing device in chair/bed, nutrition/hydration interventions to manage skin problems, pressure ulcer/injury care, application of ointments/medications other than feet and application of dressings to feet.
On 09/26/22 at 3:39 P.M., observation of the resident revealed the resident had a large dark purple bruise to the back of her right hand.
Review of the resident's medical record failed to provide any documented evidence the large dark purple bruise to the back of the resident's right hand had been previously identified or assessed.
On 09/28/22 at 3:44 P.M., interview/observation with Licensed Practical Nurse (LPN) #201 verified the large dark purple bruise to the back of the resident's hand had not been previously identified or assessed.
On 10/03/22 at 2:45 P.M., interview with the Director of Nursing (DON) revealed the facility had no specific policy for bruising but stated staff were to follow the standards of practice.
This deficiency substantiates Complaint Number OH00133807.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview and facility policy and procedure review, the facility failed to ensure Resident #9 was provided pressure ulcer treatment as ordered. This affected one resident (#9) of four residents reviewed for pressure ulcers.
Findings Include:
Review of Resident #9's medical record revealed an initial admission date of 10/27/21 with the latest readmission of 06/15/22. Resident #9 had diagnoses including chronic obstructive pulmonary disease, pancytopenia, anxiety disorder, schizophrenia, hypothyroidism, dementia with behavioral disturbances, vitamin D deficiency, seizures, peripheral vascular disease, obstructive sleep apnea, onychogryphosis, dependence on supplemental oxygen, peripheral venous insufficiency, personal history of COVID-19 and vitamin B12 deficiency and anemia.
Review of a skin admission/readmission assessment, dated 10/27/21 revealed the resident was admitted to the facility with an unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) pressure ulcer to the right heel measuring 3.0 centimeters (cm) in length by 2.5 cm width with an undetermined depth due to the ulcer being scabbed.
The facility completed wound assessments/skin grids for the area weekly.
Review of the monthly physician's orders revealed an order, initiated 06/15/22 to cleanse right heel with normal saline (NS), pat dry, paint with Betadine, pad with ABD pad, secure with Kerlix wrap every Monday, Wednesday and Friday and as needed. Orders were also noted to evaluate and assess pressure area to the right heel every shift with the special instructions to assess the status of the wound and the area surrounding the pressure ulcer/pressure injury, the presence of complications such as infection and pain as it pertains to the wound, encourage/assist resident to float heels off bed as tolerated, pressure reduction cushion to chair, apply house moisture cream to heels twice daily for preventative skin care, encourage/assist to turn and reposition as tolerated and apply skin prep to heels twice daily for preventative heel care.
Review of the weekly skin grid-pressure, dated 09/07/22 revealed the wound measured 1.5 cm by 1.5 cm with the wound being covered with eschar.
Review of the weekly skin grid-pressure, dated 09/14/22 revealed the wound measured 1.0 cm by 1.0 cm with the wound being covered with eschar.
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had clear speech, understood others, made herself understood and had no cognitive impairment as indicated by a Brief Interview for Mental Status (BIMS) score of 14 (out of 15). Review of the mood and behavior section of the MDS revealed the resident had hallucinations, delusions, displayed verbal abuse, behaviors directed towards others and rejected care. The resident required extensive assistance of two staff for bed mobility, transfers and bathing. The assessment indicated the resident was at risk for skin breakdown and had and unstageable pressure ulcer that was present on admission. The facility implemented the interventions of pressure reducing device in chair/bed, nutrition/hydration interventions to manage skin problems, pressure ulcer/injury care, application of ointments/medications other than feet and application of dressings to feet. The assessment indicated the resident required oxygen.
On 09/26/22 at 11:25 A.M. observation of the resident revealed no physician ordered treatment to the unstageable pressure ulcer to the right heel at this time.
On 09/27/22 at 9:27 A.M., observation of the resident revealed no physician ordered treatment to the unstageable pressure ulcer to the right heel at this time.
On 09/27/22 at 4:32 P.M., observation of the resident revealed she had no physician ordered treatment to the unstageable pressure ulcer to the right heel at this time. At the time of the observation, Licensed Practical Nurse (LPN) #127 verified the resident did not have a treatment in place to the right heel at this time.
However, review of the Treatment Administration Record (TAR) for September 2022 revealed the treatment record was initialed on 09/26/22 and 09/27/22 indicating treatments were completed to the unstageable pressure ulcer to the right heel as ordered on these dates.
Review of the resident's progress notes from 09/26/22 and 09/27/22 revealed no documented evidence of the resident refusing the administration of the physician ordered treatment to the unstageable pressure ulcer on right heel.
On 09/27/22 at 4:34 P.M. interview with LPN #163 verified the wound to the resident's right heel was an unstageable pressure ulcer and a dressing should be in place as ordered.
Review of the facility policy titled, Skin Assessment, revised 09/2017 revealed it was the policy of the facility to provide necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing.
This deficiency substantiates Complaint Number OH00133807.

**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 a fall was reported and investigated when it occurred and/or failed to ensure fall prevention interventions were implemented as ordered. This affected two residents (#13 and 64) of three residents reviewed for falls/accidents.
Findings Include:
1. A review of Resident #13's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including monoplegia (paralysis that affects one limb) of upper limb following a stroke affecting his right dominant side, unsteadiness on his feet, restlessness and agitation, epilepsy, hypertension, adult onset diabetes mellitus, vascular dementia with behavioral disturbances, psychosis, insomnia, and personality disorder.
A review of Resident #13's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/01/22 revealed the resident did not have any communication issues but his cognition was severely impaired. Hallucinations, delusions, verbal behaviors directed at others, other behaviors not directed at others, and refusal of care were indicated to have occurred daily. The assessment revealed the resident required an extensive assist of two staff for bed mobility, transfers, and ambulation. The MDS revealed the resident had not sustained any falls since his prior assessment (an admission MDS assessment completed on 06/07/22).
A review of Resident #13's care plans revealed a plan of care related to the resident's risk for falls related to debilitation, weakness, dementia, impaired balance, impaired cognition, a personal history of falls, non-compliance with safety measures, unsteady gait, and use of psychotropic medications. The goal of the care plan was to minimize the potential risk factors related to falls. Interventions included the use of a a low bed. The intervention for the low bed was implemented on 07/03/22.
a. A review of Resident #13's progress notes revealed a nurse's note, dated 07/03/22 at 6:47 A.M. that revealed the resident was found on the floor that morning at 6:05 A.M. by staff. He was sitting against the wall next to his bed and chair. The resident reported he fell trying to get out of bed. No injuries were noted as a result of that fall. The new interventions indicated to have been added as a result of that fall was the use of a low bed.
A review of Resident #13's fall investigation for the fall occurring on 07/03/22 at 6:05 A.M. confirmed the resident had a fall when trying to get out of bed. New fall interventions added as a result of that fall included the use of a low bed.
A review of Resident #13's active physician's orders revealed the resident was to have the use of a low bed. The order was written on 07/05/22.
On 09/27/22 at 3:41 P.M. Resident #13 was observed lying in bed in his room. He was not noted to be lying in a low bed that was initiated as a fall prevention intervention following the fall he had from bed on 07/03/22. The bed he was in was not in its' lowest position as the metal legs off the bed frame were not in contact with the floor.
On 09/28/22 at 10:30 A.M., further observation of Resident #13 revealed he was in his room with the door mostly closed. When opened, the resident was found sitting on the floor with his back to the door to the left side of his bed. His arm remained resting on the bed and was preventing his sensor alarm from sounding. The resident was calling out for help making unintelligible sounds that could barely be heard from the hall when the door was mostly closed. The bed was noted to be in its lowest position but remained approximately 18 inches off of the floor. Licensed Practical Nurse (LPN) #128 was notified of the resident being on the floor. He responded to the resident's room and assessed the resident before rendering the resident assistance back into his bed. He denied the bed the resident was in was a low bed but noted the bed he was in was in its lowest position.
On 09/28/22 at 11:33 A.M., an interview with LPN #123 confirmed Resident #13's plan of care indicated the resident was to be in a low bed. He verified again the bed in the resident's room was not a low bed as was being used for some of the other residents on that unit. He stated the bed was in its lowest position but confirmed it was still approximately 18 inches off the floor. He indicated he would have to have the resident's bed replaced with a low bed as ordered.
On 09/28/22 at 11:50 A.M., an interview with the Director of Nursing (DON) revealed Resident #13 should have had a low bed as per his plan of care. He acknowledged the bed the resident did have in his room was not a low bed.
b. On 09/26/22 at 11:00 A.M. Resident #13 was observed in his room with his door shut. When the door was opened, the resident was observed to be sitting on his knees on the floor calling out for help. State Tested Nursing Assistant (STNA) #205 was informed of the resident being on the floor. STNA #205 was noted to assist the resident up off the floor and helped him back into bed. She commented the resident was known to scoot himself off the bed and was also known to hang off the bed. She did not summon the nurse to assess the resident before she helped him back into bed.
A review of Resident #13's medical record revealed a nurse's note, dated 09/26/22 at 11:15 A.M. that indicated the STNA was notified by a visitor while she was walking down the hallway with a lunch tray that the resident was on the floor. The resident was reported to be sitting on the floor beside his bed. The STNA assisted the resident up into his wheelchair and taken out to the dining room for his lunch meal. The medical record was absent for any evidence of a fall investigation being completed following the known fall the resident had on 09/26/22 at 11:00 A.M.
On 09/28/22 at 11:50 A.M., an interview with the Director of Nursing (DON) revealed Resident #13 has had four falls he was aware of during the past four months. He stated they were still in the process of investigating the fall that occurred the morning of 09/28/22. He provided the fall investigations he had. However, they did not include an investigation for a fall occurring on 09/26/22. He denied he had been made aware of a fall occurring on 09/26/22, therefore an investigation had not been initiated/completed. He agreed, any time the resident was found on the floor that was unwitnessed, it should be considered a fall. He denied the STNA should have assisted the resident up off the floor without the resident being assessed by a nurse first, when it was an unwitnessed fall. The DON revealed the resident was known to sit himself on the floor but if not witnessed, then staff should treat it as a fall.
Review of the facility policy titled, Fall Management, dated 10/17/16 revealed each resident would be assessed throughout the course of treatment for different parameters that may contribute to fall risk. An interdisciplinary plan of care would be developed, implemented, reviewed and updated as necessary to reflect each resident's current safety needs and fall reduction interventions. Management of falls included- the charge nurse was notified when a resident had a fall, the resident was assessed for injuries, vital signs and provided with prompt medical attention as needed. The responsible party and physician were notified of the occurrence and the status of the resident. The charge nurse gathered and recorded as much pertinent data as possible related to the fall. The resident's care plan was updated as needed to reflect the resident's health status and safety needs and new fall reduction interventions are communicated to care givers as needed.
2. Review of Resident #64's medical record revealed an initial admission date of 05/08/15 with the latest readmission of 09/13/22. Resident #64 had diagnoses including fracture of nasal bones, chronic obstructive pulmonary disease, dementia with behavioral disturbances, schizoaffective disorder, bipolar type, schizophrenia, generalized muscle weakness, dysphagia, gastro-esophageal reflux disease, behavioral syndromes associated with physiological disturbances and physical factors, psychosis, peripheral vascular disease, constipation, seizures, major depressive disorder, generalized anxiety disorder, anemia, insomnia, macular degeneration, borderline personality disorder, psychotic disorder with hallucinations, hearing loss, delusional disorder, hypertension and bipolar disorder.
Review of the fall risk assessment dated [DATE] revealed score of 12.5 indicating the resident was at risk for falls.
Review of the resident's comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 09/11/22 revealed the resident had unclear speech, sometimes understood others, sometimes made herself understood and had a severe cognitive deficit. Review of the mood and behavior section of the MDS revealed the resident displayed hallucinations, delusions, verbal behaviors directed towards others, behaviors not directed towards others and wandered. The resident required extensive assistance of two staff for bed mobility, transfers and toilet use and limited assistance of one staff for eating. The assessment indicated the resident had one fall with major injury.
Review of the plan of care (initiated 01/30/19) and last revised on 09/28/22 revealed the resident was at risk for falls with the potential for injury related to history of falls, falls with injury, multiple fall risk fractures, dementia, impaired balance, medications, non-compliance with safety measures, poor decision making skills, psychiatric disorder, history of hip fracture with hip replacement, history of putting self on floor, wheelchair dependent, leans forward in chair with risk for falls out of chair and recent fall with nasal fracture. Interventions included anti-tippers to wheelchair, encourage periods of rest when tired and between meals, encourage resident to do desired activities to decrease resident from transferring without assistance, encourage to sit down an talk on phone, encourage resident to wear as needed oxygen every shift, have commonly used articles within easy reach, low bed as tolerated, maintain a clear pathway, mat at bedside, monitor for side effects of psychotropic medications, pillows for positioning, place in supervised area during restlessness, post sign in room to remind to ask for assistance, provide rest periods, remind to ask for assistance when resident needs to get objects off the floor and wear gripper socks while in bed.
Review of the monthly physician's orders for September 2022 revealed an order, dated 09/13/22 for rear anti-tip guards to wheelchair; check placement and function every shift.
On 09/26/22 at 3:51 P.M., observation of the resident revealed a piece of Dycem lying on floor under the head of the bed. The resident's wheelchair had no anti-tippers in place as physician ordered.
On 09/26/22 at 4:03 P.M., interview with Licensed Practical Nurse (LPN) #127 revealed the resident was in the wrong wheelchair and stated the resident had a wheelchair with anti-tippers and roll back bars on the back.
Review of the facility policy titled, Fall Management, dated 10/17/16 revealed each resident would be assessed throughout the course of treatment for different parameters that may contribute to fall risk. An interdisciplinary plan of care would be developed, implemented, reviewed and updated as necessary to reflect each resident's current safety needs and fall reduction interventions. Management of falls included- the charge nurse was notified when a resident had a fall, the resident was assessed for injuries, vital signs and provided with prompt medical attention as needed. The responsible party and physician were notified of the occurrence and the status of the resident. The charge nurse gathered and recorded as much pertinent data as possible related to the fall. The resident's care plan was updated as needed to reflect the resident's health status and safety needs and new fall reduction interventions are communicated to care givers as needed.
This deficiency substantiates Complaint Number OH00133807.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of current resident diet orders maintained by the facility kitchen, review of meal tickets and interview, the facility failed to ensure residents received fortified foods as ordered and/or failed to ensure fluids were readily available to maintain hydration. This affected three residents (#13, #50 and #64) of four residents reviewed for nutrition and one resident (#30) of one resident reviewed for hydration.
Findings Include:
1. A review of Resident #13's medical record revealed the resident was admitted to the facility on [DATE] with the diagnoses of monoplegia (paralysis of one side of a limb) of an upper limb following a stroke affecting his right dominant side, dysphagia (difficulty swallowing), vascular dementia with behavioral disturbances, major depressive disorder, and adult onset diabetes mellitus.
A review of Resident #13's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/01/22 revealed the resident did not have any communication issues but his cognition was severely impaired. The assessment revealed the resident required an extensive assist of one staff for eating. He was 64 inches tall and weighed 112 pounds. The resident was not noted to have had a significant weight loss in the past month or six months.
A review of Resident #13's care plans revealed the resident had a care plan in place for the potential for an alteration in nutrition. The resident was known to have had a weight loss of greater than 5% within 30 days prior to the resident's admission into the facility. He was also known to have a significant weight loss of 7.7% in one month between 08/07/22 and 09/01/22. The care plan identified the resident as being on a mechanically altered/ therapeutic diet with fortified foods. He was known to have suboptimal intakes and known to refuse meals at times. The interventions on the care plan included the use of fortified foods per orders.
A review of Resident #13's physician's orders revealed the resident's diet order was for a low concentrated sweets diet with mechanical soft texture with fortified foods for all meals. The diet order had been in place since 08/22/22.
A review of Resident #13's nutrition assessment, completed on 08/29/22 revealed the resident was ordered to receive fortified foods for all meals. His meal intakes varied between 0-100% and the resident was assessed to be a moderate risk for nutritional decline.
A review of the diet orders maintained by the kitchen for all residents revealed Resident #13 was to be on a mechanical soft low concentrated sweet diet. The diet order did not list fortified foods with all meals as was ordered and per his plan of care.
On 09/29/22 at 11:27 A.M., an observation of Resident #13 revealed he was served his meal tray while in his room. The tray was placed on the bedside table. The resident was resting with his eyes closed. The aide attempted to arouse the resident for his meal and left his room a couple minutes after bringing in the tray. While the aide was gone, the resident's meal ticket was checked which reflected the resident's diet as mechanical soft, low concentrated sweet diet. Fortified foods was listed under his food likes and not under the actual diet ordered. The resident was served buttered noodles, mechanical soft chicken parmesan, a roll, a magic cup, and a sliver of strawberry cream pie. It was not evident what food could have been fortified as ordered with all meals. The aide returned to the resident's room at 11:45 A.M. trying to get him aroused enough to eat his meal. She left the room and came back to his room at 11:51 A.M. when she began feeding the resident. During the observation, Licensed Practical Nurse (LPN) #128 was asked what food item served to the resident was fortified. The LPN revealed it was usually mashed potatoes and if the resident was not served masked potatoes, it would be in a vegetable. LPN #128 contacted the kitchen to inquire as to what food item served during the lunch meal was considered fortified. He was informed the fortified foods being sent out with that meal was pudding.
On 09/29/22 at 12:03 P.M., an interview with Dietary Supervisor #173 confirmed Resident #13 did not receive any fortified foods with his lunch meal served on 09/29/22. She stated the resident should have received a bowl of fortified pudding but verified the residents residing on the secured unit Resident #13 was on were not provided the fortified pudding despite it being ordered.
2. A review of Resident #50's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including morbid obesity. congestive heart failure, gastroparesis, and depression.
A review of Resident #50's Minimum Data Set (MDS) 3.0 assessment, dated 08/10/22 revealed the resident did not have any communication issues but his cognition was moderately impaired. The resident was known to have mood indicators that included a poor appetite. He required (staff) supervision with set up help for eating. His height was 64 inches and his weight was 190 pounds. The resident was noted to have had a significant weight loss while not on a physician prescribed weight loss program.
A review of Resident #50's care plans revealed he had a care plan in place for the potential for an alteration in nutrition. The care plan reflected the resident was known to have had a significant weight loss at one month and at three months between May 2022 and August 2022. Weight loss was also known to have occurred in September 2022. Goals included no unplanned significant weight loss. Interventions included providing the resident with fortified foods per orders. The date the intervention was initiated was on 08/12/22.
A review of Resident #50's nutrition assessment, dated 09/10/22 revealed the resident was on a low concentrated sweet diet. The resident was noted to be on fortified foods for all meals. His meal intakes varied between 25-100% with about 59% on average. The resident's weight at the time of the assessment was 181 pounds, which reflected a significant weight loss. Fortified foods provided with all meals and supplements given were providing additional calories and protein to the resident. The resident was assessed to be a high risk for nutritional decline. Nutritional diagnosis was indicated to be increased nutritional needs.
A review of Resident #50's active physician's orders revealed an order for a low concentrated sweet diet with regular textured food diet. Staff were to add fortified foods with all meals. The order had been initiated on 07/06/22.
A review of the diet orders maintained by the kitchen for all residents revealed Resident #50 was identified as being on regular, low concentrated sweet diet. The diet order did not identify him as being on fortified foods for all meals.
On 09/29/22 at 12:00 P.M. Laundry/Housekeeping Supervisor #180 was observed to obtain Resident #50's lunch meal from the food cart. In the process, she had spilled his juice on his tray. She placed the tray on the counter of the nurse's station and called to get the resident another tray. His first tray that was delivered on the food cart was noted to have fortified pudding in a bowl marked with an F on the top of the lid that covered the bowl. The resident was provided a second tray from the kitchen at 12:12 P.M. that was not noted to have any fortified pudding on it. The first tray was returned to the food cart after all trays had been served and the fortified pudding in a bowl was not pulled off the first tray and taken to the resident's room. The meal ticket on the first tray served was noted to identify the resident's regular low concentrated sweet diet. Fortified foods was listed under the resident's food likes and not part of his actual diet order. At the time of the observation, LPN #124 was asked if the resident was provided a fortified food with his lunch meal served. The LPN revealed she was not sure what food item being served to the resident was fortified and stated she would have to ask. She checked with LPN #103, who went to the resident's room to check. She confirmed the resident was not provided fortified pudding with the second tray served as it had not been taken from the first tray that had been prepared for the resident from the kitchen and was not included on the second/new tray provided.
3. Review of Resident #64's medical record revealed an initial admission date of 05/08/15 with the latest readmission of 09/13/22. Resident #64 had diagnoses including fracture of nasal bones, chronic obstructive pulmonary disease (COPD), dementia with behavioral disturbances, schizoaffective disorder, bipolar type, schizophrenia, generalized muscle weakness, dysphagia, gastro-esophageal reflux disease, behavioral syndromes associated with physiological disturbances and physical factors, psychosis, peripheral vascular disease, constipation, seizures, major depressive disorder, generalized anxiety disorder, anemia, insomnia, macular degeneration, borderline personality disorder, psychotic disorder with hallucinations, hearing loss, delusional disorder, hypertension and bipolar disorder.
Review of the plan of care, dated 02/01/19 revealed the resident had the potential for alteration in nutrition and hydration related to body mass index (BMI) greater than 30, obesity, schizoaffective disorder, schizophrenia, COPD, dementia, receiving a mechanically altered diet and a 5.2% weight loss since 09/01/22. Interventions included honor food preferences as able, invite resident to food related activities, medications as ordered, monitor consistency of diet served, provide diet as ordered, dietician referral as needed, snacks as needed, thickened liquids as ordered and weights as ordered.
Review of the resident's comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 09/11/22 revealed the resident had unclear speech, sometimes understood others, sometimes made herself understood and had a severe cognitive deficit.
Review of the physician's orders for September 2022 revealed an order for a low concentrated sweets diet, pureed texture, nectar consistency and fortified food with breakfast and lunch.
Review of the resident's weights revealed she weighed 192.2 pounds on 08/07/22, on 08/12/22 190.0 pounds, on 09/01/22 191.5 pounds, on 09/08/22 179 pounds, on 09/13/22 179.4 pounds and on 09/20/22 181.5 pounds indicating a significant weight loss 6.87% in 30 days.
On 09/29/22 at 11:30 A.M. observation of the lunch meal revealed the resident was served a pureed diet of chicken parmesan, noodles, roll, vegetable, pie, milk, and her own pepsi that was thickened. Further review revealed the resident received no fortified food as physician ordered during the meal.
On 09/29/22 at 11:58 A.M., interview with Licensed Practical Nurse (LPN) #128 verified the resident had not received the fortified food/pudding for the lunch meal.
4. Review of Resident #30's medical record revealed an initial admission date of 01/20/21 with the latest readmission of 09/21/21. Resident #30 had diagnoses including schizophrenia, fracture of shaft of right humerus, morbid obesity, unsteadiness on feet, generalized muscle weakness, encephalopathy, mild cognitive impairment, impulse disorder, bipolar disorder, repeated falls, vitamin D deficiency, constipation, intentional self harm, chronic pain, acquired absence of right toes, insomnia, seizures, anxiety disorder, deaf, non speaking, adjustment disorder, osteoarthritis, dental caries, acute gingivitis plaque induced, dementia with behavioral disturbances and unspecified disorder of psychological development.
Review of the resident's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 09/17/22 revealed the resident had no speech and had a severe cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of zero (out of 15). The assessment revealed the resident required extensive assistance from two staff for personal hygiene.
On 09/27/22 at 9:28 A.M., observation of Resident #30 revealed her mouth was dry and lips were cracked.
On 09/28/22 at 3:48 P.M., observation of Resident #30 revealed the resident was sitting at nurse's station in a wheelchair. The resident's mouth was dry and lips were cracked. Interview with LPN #128 at the time of the observation verified the resident's mouth was dry and lips were cracked.
On 09/29/22 at 11:17 A.M., observation and interview with State Tested Nursing Assistant (STNA) #216 revealed the resident had no water pitcher in her room but did have two four ounce partially filled cups sitting on her dresser from medication pass. The STNA said she preferred a cup pulled from the bottom drawer from her dresser that was empty.
On 09/29/22 at 11:25 A.M., interview with LPN #127 revealed residents with behaviors were not provided a water pitcher due to the possibility of hitting staff. There was no evidence the facility provided any other alternatives for the resident to obtain and consume beverages, including water at her own discretion.
This deficiency substantiates Complaint Number OH00133807.

Based on observation, record review and staff interview, the facility failed to ensure Resident #9 and Resident #64's oxygen cannula and nebulizer administration set were stored in a sanitary manner to prevent potential infection. This affected two residents (#9 and #64) of two residents reviewed for oxygen therapy.
Findings Include:
1. Review of Resident #9's medical record revealed an initial admission date of 10/27/21 with the latest readmission of 06/15/22. Resident #9 had diagnoses including chronic obstructive pulmonary disease (COPD), pancytopenia, anxiety disorder, schizophrenia, hypothyroidism, dementia with behavioral disturbances, vitamin D deficiency, seizures, peripheral vascular disease, obstructive sleep apnea, onychogryphosis, dependence on supplemental oxygen, peripheral venous insufficiency, personal history of COVID-19 and vitamin B12 deficiency and anemia.
Review of the plan of care dated 05/03/22 and last revised on 07/07/22 revealed the resident received oxygen, had COPD, respiratory failure, required the use of a Bipap machine, had obstructive sleep apnea and was non-compliant with oxygen. Interventions included administer oxygen as ordered, aerosol treatments as ordered, monitor lung sounds as ordered, monitor pulse oximetry as ordered, and observe for signs and symptoms of dyspnea.
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 09/20/22 revealed the resident had clear speech, understood others, made herself understood and had no cognitive impairment as indicated by a Brief Interview for Mental Status (BIMS) score of 14 (out of 15). The assessment indicated the resident required oxygen.
Review of the monthly physician's orders for September 2022 revealed an order (dated 06/15/22) for oxygen at seven liters via nasal cannula to maintain oxygen saturation above 90%, Bipap at bedtime and times of sleep every shift and for Albuterol Sulfate nebulizer solution 2.5 milligrams (mg)/3 milliliters (ml) 0.083% with the special instructions to inhale orally via nebulizer every four hours as needed for shortness of breath.
On 09/26/22 at 3:42 P.M., observation of the resident's respiratory equipment revealed the resident's nebulizer administration set was stored on top of the refrigerator without being contained or in a bag. Further observation revealed the resident's nasal cannula was laying on the floor next to her bed.
On 09/26/22 at 3:46 P.M. interview with Licensed Practical Nurse (LPN) #127 verified the resident's oxygen cannula and nebulizer administration equipment were not stored in a sanitary manner.
2. Review of Resident #64's medical record revealed an initial admission date of 05/08/15 with the latest readmission of 09/13/22. Resident #64 had diagnoses including fracture of nasal bones, chronic obstructive pulmonary disease, dementia with behavioral disturbances, schizoaffective disorder, bipolar type, schizophrenia, generalized muscle weakness, dysphagia, gastro-esophageal reflux disease, behavioral syndromes associated with physiological disturbances and physical factors, psychosis, peripheral vascular disease, constipation, seizures, major depressive disorder, generalized anxiety disorder, anemia, insomnia, macular degeneration, borderline personality disorder, psychotic disorder with hallucinations, hearing loss, delusional disorder, hypertension and bipolar disorder.
Review of the plan of care dated 10/27/21 revealed the resident had impaired respiratory status related to COPD, respiratory failure, allergies, history of pneumonia, requiring oxygen as needed and becoming short of breath at times. Interventions included administer oxygen as ordered, aerosol treatments as ordered, C-PAP and settings as ordered, encourage compliance with use of C-PAP, elevate head with extra pillows or raising head of bed to avoid shortness of breath due to lying flat, encourage oxygen per orders, medication as ordered, monitor lung sounds as ordered and monitor pulse saturation as ordered, observe for signs/symptoms of dyspnea.
Review of the resident's comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 09/11/22 revealed the resident had unclear speech, sometimes understood others, sometimes made herself understood and had a severe cognitive deficit. The assessment indicated the resident utilized oxygen.
Review of the monthly physician's orders for September 2022 revealed an order (dated 09/13/22) for oxygen at two to three liters per minute via nasal cannula to maintain oxygen saturation over 90% as needed and Albuterol Sulfate aerosol solution 2.5 mg/3 ml with the special instructions to inhale orally via nebulizer four times a day for shortness of breath and/or wheezing.
On 09/26/22 at 3:49 P.M., observation of the resident's respiratory equipment revealed the nebulizer administration equipment was laying not contained/not bagged on top of the resident's night stand and the resident's oxygen cannula was laying on the floor.
On 09/26/22 at 3:51 P.M., interview with LPN #127 verified the resident's oxygen equipment was not being stored in a sanitary manner.

Based on observation, record review and interview the facility failed to complete a comprehensive and complete assessment including documentation of the explanation of risks and benefits for the use of a side rail for Resident #77. This affected one resident (#77) of one resident reviewed for side rails.
Findings Include:
Review of the medical record for Resident #77 revealed an admission date of 03/02/22 with diagnoses including Alzheimer's disease, dementia without behaviors unsteady gait, major depression, mood disorder, unspecified psychosis and anxiety.
Review of the plan of care, dated 03/09/22 revealed Resident #77 required assistance with activities of daily living (ADL) related to decreased ADL self performance, cognitive impairment and being uncooperative with care. Interventions included Resident #77 required extensive assistance from two persons for bed mobility and transfers.
Review of the significant change in condition Minimum Data Set (MDS) 3.0 assessment, dated 09/22/22 revealed Resident #77 rarely understood or understands and had severe impaired cognition with inattention and disorganized thinking. Resident #77 also had delusions, physical and verbal symptoms directed towards others that interfered with care, rejection of care and wandering behaviors. The assessment revealed Resident #77 required extensive assistance from two staff for bed mobility, transfers, and toileting. Resident #77 required was total dependent on one person for locomotion and did not ambulate.
Review of the physician's orders for 09/2022 revealed an order (dated 09/28/22) for Resident #77 to have bilateral upper one half side rails.
Review of a restraint-enabler decision tree, dated 09/28/22 revealed the bilateral upper one half side rails did not limit or restrict freedom of movement and would increase the resident's self mobility while in bed.
Review of a nursing progress note, revealed the nurse documented on 09/28/22 at 8:05 P.M. Resident #77 was dependent for bed mobility and did not assist in bed mobility in any manner. Resident #77 received assistance of two persons for bed mobility.
An observation on 09/28/22 at 2:20 P.M. of wound care for Resident #77 revealed at no time did Resident #77 reach for the side rail or hold on to it for bed mobility. An additional observation on 09/29/22 at 7:55 A.M. revealed Resident #77 way laying in a low bed with bilateral one half side rails up and a pressure bed alarm to bed.
An interview on 10/03/22 at 9:04 A.M. with Licensed Practical Nurse (LPN) #103 revealed the enabler-restraint decision tree was the only assessment tool used for side rail use. LPN #103 revealed Resident #77's wife wanted the side rails up and stated the risks and benefits had been explained to the wife. However, there was no documentation or side rail assessment available/provided to support the risks and benefits were fully explained or to support the use of the side rails increased the resident's self mobility.
The facility did not provide a policy related to side rails or side rail use.

Based on record review and interview the facility failed to use the services of a registered nurse for at least eight consecutive hours a day, seven days a week as required. This had the potential to affect all 88 residents residing in the facility.
Findings Include:
Review of the nursing staff schedule for 09/2022 revealed on 09/24/22 and 09/25/22 there was not an RN working in the facility.
On 10/03/22 at 3:53 P.M. interview with the Director of Nursing (DON) confirmed there was not a RN working on 09/24/22 or 09/25/22 as required. The DON indicated the facility was working on hiring more RN staff.