Momentous Health At Franklin

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review, the facility failed to ensure medical records were complete and accurate. This affected one (#3) of 23 residents reviewed medical record accuracy. The facility census was 66.Findings include: Review of the medical record of Resident #3 revealed an admission date of 05/21/25. Diagnoses included end-stage renal disease (ESRD) with dependence on renal dialysis, and heart failure. Review of Resident #3's physician orders revealed orders dated 05/22/25 and 05/24/25 for Resident #3 to attend dialysis on Tuesday, Thursday, and Saturday with pickup at 5:30 A.M. On 05/27/25, there was an order to send Resident #3 to the emergency room for evaluation. Review of a progress note dated 05/27/25 at 7:23 A.M. revealed Registered Nurse (RN) #128 was notified Resident #3 was not picked up for transport for dialysis that morning (05/27/25) and may have missed dialysis on Saturday (05/24/25) due to transport. NP #301 was notified and an order was received to send the resident to the hospital for evaluation and treatment due to missing dialysis treatments. There was no evidence in the medical record of the physician being notified of Resident #3 missing dialysis treatments on 05/22/25 nor 05/24/25. There was no documentation the physician recommended Resident #3 going to the hospital on [DATE] and 05/24/25 and Resident #3 refusing to go to the hospital. Interview on 09/15/25 at 3:42 P.M., Physician #502 stated he was notified of Resident #3 missing dialysis treatments on 05/22/25 and 05/24/25. Physician #502 stated he suggested Resident #3 go to the hospital, however the resident refused to go to the hospital. Interview on 09/11/25 at 9:38 A.M., the Director of Nursing (DON) verified there was no documentation acknowledging Resident #3 had missed dialysis until 05/27/25. The DON verified any missed dialysis treatments and physician notification should be documented. Interview on 09/15/25 at 3:15 P.M., Chief Operating Officer (COO) #210 verified Resident #3's medical record was silent for physician notification of missing dialysis treatments on 05/22/25 and 05/24/25. Review of the facility policy titled Change in Condition Monitoring dated 05/01/22 revealed the nurse will record in the resident's medical record information relative to changes in the residents' medical condition or status.

Based on review of the facility's quality assurance performance improvement (QAPI) meeting sign-in sheets, review of the facility's QAPI meetings policy, and staff interview, the facility failed to ensure required QAPI team member were present at meetings. The had the ability to affect all 66 residents residing in the facility. Findings include: Review of the facilities' QAPI/Quality Assessment and Assurance (QAA) meeting sign in sheets revealed the following: The Director of Nursing (DON) and Medical Director (MD) were not present at a meeting 10/23/24. No designees for the DON or MD were listed.The DON and MD were not present at a meeting dated 02/10/25. No designees for the DON or MD were listed. No staff identified as the infection preventionist (IP) or designee was present. No designee for the IP listed.The DON was not present at a meeting dated 04/22/25. No designee for the DON was listed.The IP was not present at a meeting dated 08/26/25. No designee for the IP listed. Review of the facility's QAPI meetings policy dated 08/01/23 revealed the facility Quality Assurance and Quality Improvement (QA/QI) Committee members include but are not limited to the DON, MD or physician, Administrator, Director of Housekeeping/Laundry, Director of Therapeutic Recreation, Director of Social Work, Director of Food Services, Director of Rehabilitation, QA Nurse, Director of Maintenance, and other designated facility staff. The QA/QI Committee will meet at least quarterly to identify QA/QI issues and to develop appropriate plans of action needed to correct the issues. The Committee monitors the effect of the implemented changes and makes any revisions necessary to the plan of action. Further review revealed the IP was not listed as a required team member. Interview with the Administrator on 09/10/25 at 3:09 P.M. confirmed QAPI meetings dated 10/23/24, 02/10/25, 04/22/25, and 08/26/25 did not have the required members attending. The Administrator confirmed the IP was not listed as a required member in the facility's policy. Interview with Chief Operating Officer #210 on 09/10/25 at 3:17 P.M. confirmed QAPI meetings dated 10/23/24, 02/10/25, 04/22/25, and 08/26/25 did not have the required members attending. The Administrator confirmed the IP was not listed as a required member in the facility's policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, observations, and resident and staff interviews, the facility failed to ensure all residents were provided with a safe, clean and homelike environment. This affected two (#13 and #25) of two residents reviewed for homelike environment. The facility census was 66.Findings included:
1. Observation on 09/08/25 at 8:47 A.M. revealed Resident #25's bathroom smelled of urine. There was a yellow substance surrounding the base of the toilet, and an area measuring approximately eight inches (in) by 8 in of a similarly appearing yellow substance. There were several brown marks throughout the floor of the bathroom.
Interview on 09/08/25 at 8:47 A.M., Resident #25 stated his bathroom floor was dirty, and the bathroom smelled like urine. Resident #25 stated his bathroom did not get cleaned very often.
Interview on 09/08/25 at 9:00 A.M., Certified Nursing Assistant (CNA) #129 verified Resident #25's bathroom had yellow stains around the base of the toilet, brown marks throughout the floor, and a strong urine odor. CNA #129 stated there hadn't been a housekeeper assigned to the 100 hall in over a month.
2. Review of the medical record of Resident #13 revealed an admission dated of 12/14/11. Diagnoses included cerebrovascular disease and obsessive-compulsive disorder.
Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 was cognitively intact and dependent on staff with ambulating.
Observation on 09/08/25 at 8:54 A.M. revealed the floor tile, in Resident #13's room, had multiple pieces of tile missing. The floor tile with missing pieces was in front of Resident #13's table and was located in middle of the floor.
Interview on 09/08/25 at 10:22 A.M. with Licensed Practical Nurse (LPN) #114 confirmed Resident #13's room had one floor tile in his room that has multiple pieces of tile missing. LPN #114 confirmed the floor tile was located in the walkway to the door. LPN #114 confirmed Resident #13 has two other floor tiles in his room that has one small piece missing. LPN #114 stated Resident #13 utilized a walker at times to ambulate.
Review of the facilities Homelike Environment policy dated 10/27/21 revealed residents are provided with a safe, clean, comfortable and homelike environment.
This deficiency represents non-compliance investigated under Complaint Number 2605044, Complaint Number 1260835, Complaint Number OH00164419 (1260832), Complaint Number OH00164929 (1260832), and Complaint Number OH00166722 (1260778).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, review of Self-Reported Incidents (SRI), and facility policy review, the facility failed to ensure all alleged violations of staff-to-resident physical abuse were reported timely to administration and the State Survey Agency. This affected one (#40) of five residents reviewed abuse. The facility census was 66.Findings include: Review of the medical record for Resident #40 revealed an admission date of 06/09/25. Diagnoses included cerebral infarction with left-sided hemiplegia, chronic obstructive pulmonary disease, hypertension, anxiety, and chronic respiratory failure with hypoxia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #40 had moderately impaired cognition. Review of the progress notes dated 07/01/25 at 6:05 A.M. revealed Licensed Practical Nurse (LPN) #160 entered Resident #40's room and heard Resident #40 yelling profanities and get off of me directed at an unknown certified nurse aide (CNA). The progress note revealed the unknown CNA was providing personal care for Resident #40. LPN #160 documented Resident #40 hit the unknown CNA twice. LPN #160 asked Resident #40 what happened, but Resident #40 would not provide an answer. According to the progress notes, approximately 20 minutes after the incident, Resident #40 apologized for her actions stating she was in her sleep. Review of the facility's SRI dated 07/01/25 to 09/10/25 revealed there were no allegations of physical abuse involving Resident #40 reported to the State Survey Agency. Interview with the Administrator on 09/09/25 at 8:49 A.M. confirmed she was not aware of the allegation of physical abuse by Resident #40 and did not report this to the State Survey Agency. Interview on 09/11/25 at 8:00 AM with LPN #160 revealed she could not remember who the CNA was during the incident that occurred on 07/01/25 but recalls that she asked the CNA to leave Resident #40's room. LPN #160 confirmed she did not report the incident on 07/01/25 to a member of administration. Review of the facility policy titled Abuse Prevention dated 08/20/21 revealed it is the facility's policy to investigate all alleged violations involving abuse, neglect, exploitation, mistreatment of a resident, or misappropriation of resident property, including injuries of unknown source, in accordance with this policy. Staff should report all incident/allegations immediately to the administrator or designee. This deficiency represents non-compliance investigated under Complaint Number 2574888.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure admission comprehensive Minimum Data Set (MDS) assessments were completed within the required timeframes. This affected three (#3, #25, and #39) of three residents reviewed for resident assessment. The facility census was 66.Findings include: 1. Review of the medical record of Resident #39 revealed an admission date of 07/14/25. Diagnoses included major depressive disorder, anxiety disorder, suicidal ideations, hypertension, and morbid obesity. Review of the admission comprehensive MDS assessment dated [DATE] revealed the resident had a severe cognitive impairment. The assessment was not locked as completed until 08/18/25. Interview on 09/09/25 at 4:26 P.M., MDS Nurse #172 verified Resident #39's admission comprehensive MDS assessment was not locked as completed until 08/18/25. MDS Nurse #172 verified Resident #39's admission comprehensive MDS assessment should have been completed within 14 days of admission by 07/27/25. 2. Review of the medical record of Resident #25 revealed an admission date of 06/19/25. Diagnoses included dementia, anxiety, and depression. Review of the admission comprehensive MDS assessment dated [DATE] revealed the resident had severely impaired cognition. The assessment was not locked as completed until 07/08/25. Interview on 09/09/25 at 4:26 P.M., MDS Nurse #172 verified Resident #25's admission comprehensive MDS assessment was not locked as completed until 07/08/25. MDS Nurse #172 verified Resident #25's admission comprehensive MDS assessment should have been completed by 07/02/25. 3. Review of the medical record of Resident #3 revealed an admission date of 05/21/25. Diagnoses included cellulitis, depression, viral hepatitis C, end-stage renal disease with dependence on renal dialysis, anxiety, gastroesophageal reflux disease, and heart failure. The resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE]. Review of Resident #3's admission comprehensive MDS assessment dated [DATE] revealed the assessment was not completed until 06/16/25. Interview on 09/09/25 at 4:26 P.M., MDS Nurse #172 verified Resident #3's admission comprehensive MDS assessment was not completed within 14 days of Resident #3's admission. MDS LPN #172 verified Resident #3's admission comprehensive MDS assessment should have been completed by 06/15/25.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to ensure resident care plans were complete and specific to each resident. This affected two (#3 and #55) of six residents reviewed for care planning. The facility census was 66. Findings included:
1. Review of the medical record of Resident #3 revealed an admission date of 05/21/25. Diagnoses included cellulitis, depression, type II diabetes mellitus, history of nontraumatic intracerebral hemorrhage, end-stage renal disease with dependence on renal dialysis, anxiety, gastroesophageal reflux disease, and heart failure. The resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE].
Review of the plan of care dated 05/29/25 revealed there was no care plan to address Resident #3's ability to carry out his activities of daily living (ADLs). There was no dental care plan to address Resident #3's edentulism.
Review of the quarterly MDS assessment dated [DATE] revealed the resident had moderately impaired cognition. Resident #3 was independent or required supervision for all ADLs. Resident #3 required supervision and touching assistance with walking up to 50 feet.
Interview on 09/09/25 at 4:26 P.M., MDS Nurse #178 verified Resident #3's care plan was incomplete. MDS Nurse #178 verified Resident #3's care plan did not address ADLS or Resident #3's edentulism.
2. Review of the medical record for Resident #55 revealed an admission date of 06/13/24. Diagnoses included traumatic subdural hemorrhage without loss of consciousness and major depressive disorder.
Review of the physician orders revealed an order dated 11/12/24 for Mirtazapine (psychotropic) oral tablet 7.5 milligrams (mg) give one tablet by mouth at bedtime related to major depressive disorder; an order dated 11/19/25 for Celexa (psychotropic) oral tablet 10 mg give one tablet by mouth at bedtime related to major depressive disorder; and an order dated 12/15/24 for Eliquis (anticoagulant) oral tablet five mg give one tablet by mouth two times a day related to acute embolism and thrombosis of deep vein of left lower extremity.
Review of Resident #55's care plans revealed there were not a care plans for the medication use of anticoagulants or psychotropic medications.
Interview on 09/15/25 at 8:43 A.M. with Minimum Data Set (MDS) Nurse #172 confirmed Resident #55 did not have a care plan for anticoagulants or psychotropic medications.
Review of the facility policy titled Resident Care Plans dated 05/01/22 revealed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to ensure care plans were updated timely to reflect new diagnoses, new sexual behaviors, and medications to treat the new diagnoses and behaviors. This affected two (#45 and #57) of six residents reviewed for care planning. The facility census was 66. Findings include: 1. Record review for Resident #57 revealed an admissions date of 04/18/22 with diagnoses including cerebral infraction, dementia, and major depressive disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #57 was cognitively impaired. Review of the medical laboratory records dated 08/19/25 revealed Resident #57 was positive for Herpes Simplex 1. Review of the physician's orders dated 08/24/25 revealed Resident #57 had a new order of Valtrex (treats Herpes) 500 milligrams (mg). Review of Resident #57's care plan on 09/10/25 revealed that the new diagnoses and medication was not included in the care plan. Interview on 09/10/25 at 3:40 P.M. with Director of Nursing verified Resident #57's care plan was not updated timely and it should include the new diagnosis of Herpes Simplex 1 and the new medication to treat it. 2. Record review for Resident #45 revealed an admissions date of 01/28/25 with diagnoses including alcohol dependence with alcohol induced persisting dementia. Review of the nursing progress notes revealed Resident #45 had increased sexual behaviors on 08/31/25 and 09/07/25. Review of the physician orders revealed Resident #45 was ordered medroxyprogesterone acetate five milligrams (mg) on 09/02/25 for increased sexual behaviors. Review of Resident #45's care plan revealed the care plan was not updated timely and it did not include Resident #45's sexual behaviors and the new medication to treat the behavior. Interview on 09/10/25 at 3:40 P.M. with Director of Nursing verified Resident #45's care plan was not timely updated and it should have been to include new behaviors and medications used to treat behaviors. Review of the facility policy titled Resident Care Plans dated 05/01/22 revealed assessments are ongoing and care plans are revised as information about the resident and residents' conditions change.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, resident interview, staff interview, and policy review, the facility failed to ensure residents who required assistance with activities of daily living received adequate assistance with nail care. This affected one (#22) of two residents reviewed for ADLs. The facility census was 66. Findings include: Review of the medical record for Resident #22 revealed an admission date of 01/25/24. Diagnoses included acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, major depressive disorder, dementia, muscle weakness, and need for assistance with personal care. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 had intact cognition. The resident was independent with personal hygiene, required setup/cleanup assistance with dressing, and required supervision or touching assistance with bathing. Review of the plan of care dated 08/06/24 revealed Resident #22 was independent/supervision for ADLs except for bathing. Interventions included to monitor for any decline and report immediately, and to setup supplies for the resident as needed. Review of task documentation dated 08/12/25 through 09/10/25 revealed Resident #22 required setup, supervision or limited assistance of one person with personal hygiene tasks and supervision and setup for bathing. Review of shower sheets dated 07/02/25 through 09/10/25 revealed Resident #22's nails were last cleaned and clipped on 08/16/25. Observation and interview on 09/08/25 at 9:51 A.M. revealed Resident #22 had several fingernails which were long, extending approximately one inch or more beyond the finger tip. Resident #22's fingernails had chipped fingernail polish and were curling and jagged around the edges. Resident #22 stated, despite her requests, staff had not assisted her with cutting her fingernails in a long time. Resident #22 stated she had carpal tunnel syndrome and was unable to cut her fingernails on her own. Resident #22 stated her fingernails were splitting and getting caught on clothing and bedding and stated she wished staff would help her cut them. Interview on 09/08/25 at 10:00 A.M., Admissions #162 verified Resident #22's fingernails were long, jagged, and curling around the edges and the resident was in need of nail care. Review of the facility policy titled Resident ADL Care, dated 07/01/23, revealed when autonomy and independence are no longer possible or feasible, facility staff will provide the necessary support in all ADL functioning. Resident nails are expected to be trimmed and kept neat to prevent skin tears, scratches, or injuries. Nail care will be provided as needed to the resident. This deficiency represents non-compliance investigated under Complaint Number 2605044, Complaint Number 2574888, Complaint Number OH00166722 (1260778), Complaint Number OH00165869 (126837), Complaint Number OH00164929 (1260835), Complaint Number OH00164419 (1260832), and Complaint Number OH00163480 (1260830).

Based on record review, observation, resident and staff interviews, and policy review, the facility failed to ensure activities met the needs and preferences of the residents. This affected one (Resident #77) of two residents reviewed for activities. The facility census was 66.Findings included:
Review of the medical record for Resident #77 revealed an admission date of 09/02/25 with diagnoses of paraplegia, schizophrenia, anxiety disorder, and bipolar disorder. There was no Minimum Data Set (MDS) assessment available to review due to recent admission.
Interview on 09/08/25 at 12:04 P.M. with Resident #77 revealed there were no activities.
Observation on 09/11/25 at 8:26 A.M. revealed the schedule of activities for September 2025 had no activities scheduled for the residents after the 2:00 P.M. everyday of the month, except for every other Tuesday when church services were scheduled at 6:00 P.M.
Interview on 09/11/25 at 8:38 A.M. with Activities Director #104 confirmed there were no activities scheduled for the residents after the 2:00 P.M. scheduled activity is completed, except for every other Tuesday when church services were held at 6:00 P.M. Activities Director #104 stated there was not enough help in the activities department and she was trying to find help.
Review of the activities policy dated 05/01/22 revealed activities will be scheduled periodically during the day, as well as during the evenings, weekends, and holidays.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, resident and staff interviews, review of U.S. Food and Drug Administration (FDA) guidance, and policy review, the facility failed to ensure residents vaped in the facility's designated smoking area. This affected one (Resident #11) of two residents reviewed for supervision. The facility census was 66.Findings include: Review of the medical record for Resident #11 revealed an admission date of 07/29/24 with diagnoses including centrilobular emphysema and Alzheimer's disease. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed Resident #11 had moderate cognitive impairment, rejected care at times and was independent with ambulation. Review of the Smoking assessment dated [DATE] revealed Resident #11 required supervision while smoking. There was no documentation that Resident #11 was non-compliant with the facility's smoking policy. Observation and interview on 09/08/25 at 10:15 A.M. revealed Resident #11 with a cloud of smoke above her knees and a vape machine in her left hand while lying in the bed. Resident #11 reported it was nothing. Licensed Practical Nurse (LPN) #114 confirmed at time of observation that Resident #11 had the vape in her room and was not allowed to have a vape in her room. The Director of Nursing (DON) went to the resident's room and spoke with the resident and removed the vape. Interview on 09/08/25 at 10:21 A.M. with Certified Nursing Assistant (CNA) #116 stated Resident #11 was always vaping in her room. Review of the facilities smoking policy dated 08/01/23 revealed the facility shall establish and maintain safe resident smoking practices, allowing residents who wish to the ability to smoke, while also doing in safe manner. Designated smoking area signs shall be prominently displayed where smoking is allowed. Smoking restrictions shall be strictly enforced in all nonsmoking areas. The facility may check periodically to determine if residents have any smoking articles in violation of their smoking policies. Review of the FDA's guidance titled E-Cigarettes, Vapes, and other Electronic Nicotine Delivery Systems (ENDS) dated 07/17/25 and found at https://www.fda.gov/tobacco-products/products-ingredients-components/e-cigarettes-vapes-and-other-electronic-nicotine-delivery-systems-ends#Are%20You%20Looking%20for%20General%20Health%20Information%20about%20ENDS%20Products? revealed there are no safe tobacco products, including ENDS. FDA has received reports from the public about safety problems associated with vaping products including overheating, fires, and explosions. These problems can seriously hurt the person using the ENDS product and others around them.

Based on observation, staff interviews, and policy review the facility failed to ensure the medication error rate did not exceed five percent (%). There were two observed errors out of 34 opportunities that resulted in a medication error rate of 5.88%. This affected one (Resident #42) out of four residents reviewed for medication administration. The facility census was 66. Findings include: Review of the medical record for Resident #42 revealed an admission date of 12/20/21. Review of the physician orders revealed an order dated 01/09/24 for Calcium plus Vitamin D3 Oral Tablet 500-5 milligrams (mg)- microgram (mcg) give one tablet by mouth one time a day for supplement. There was an order dated 07/17/25 for Duloxetine HCl oral capsule delayed release sprinkle 30 mg give one capsule by mouth one time a day for schizophrenia. Observations on 09/10/25 from 8:00 A.M. through 8:30 A.M. with Licensed Practical Nurse (LPN) #151 revealed LPN #155 administered 33 medications to three residents. Resident #42 was administered the following medications in error, Calcium + Vitamin D3 Oral Tablet 600-10 mg-mcg one tablet by mouth and Duloxetine HCl Oral Capsule Delayed Release Sprinkle 20 mg one capsule by mouth. Interview on 09/10/25 at 11:17 A.M. with LPN #151 confirmed she administered the wrong doses of medications to Resident #42. LPN #151 confirmed she Calcium + Vitamin D3 Oral Tablet 600-10 mg-mcg one tablet by mouth and confirmed the physician order was for Calcium + Vitamin D3 Oral Tablet 500-5 mg-mcg give one tablet by mouth. LPN #151 confirmed she administered Duloxetine HCl oral capsule delayed release sprinkle 20 mg one capsule by mouth to Resident #42 and confirmed the physician order was for Duloxetine HCl oral capsule delayed release sprinkle 30 mg give one capsule by mouth. LPN #151 stated she administered the wrong dose because that was what was available in the medication cart and she did not know what to do to get the correct dosage. Review of the medication administration policy dated 05/01/22 revealed medications will be administered as prescribed with the correct dosage. This deficiency represents non-compliance investigated under Complaint Number OH00164691 (1260834).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, resident and staff interviews, review of dietary spreadsheets, review of guidelines for pureeing food, and policy review, the facility failed to ensure residents received enough food to meet their needs and preferences, serve portions sizes as planned on the menu, ensure pureed food was prepared in a manner to maintain the nutritive value of the food, and ensure posted menus were updated for the residents to view what meals they were having for the day. This affected Resident #3 and had the potential to affect 65 of 66 residents. The facility identified one resident (#9) who did not receive food from the kitchen. The facility census was 66. Findings include:
1. Review of the medical record for Resident #3 revealed an admission date of 05/21/25. Diagnoses included type II diabetes mellitus, end-stage renal disease (ESRD) with dependence on renal dialysis, and gastroesophageal reflux disease.
Review of the nutrition care plan dated 05/23/25 revealed Resident #3 was on a restricted diet due to ESRD with interventions of provide diet as ordered and communicate with the renal registered dietician (RD) as needed. There was no interventions listed to address Resident #3 not receiving enough food and addressing Resident #3's behavior to eat off other resident's used food trays.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 had moderately impaired cognition.
Interview on 09/08/25 at 12:05 P.M., Resident #3 stated he was supposed to receive a renal diet and sometimes he does not get enough food to eat. Resident #3 stated he was supposed to get double portions.
Observation on 09/10/25 at 8:22 A.M. revealed Resident #3 was pulling food off of used food trays on the food services cart. Resident #3 was eating the food items pulled off the cart.
Interview on 09/09/25 at 8:24 A.M. with Licensed Practical Nurse (LPN) #151 confirmed Resident #3 was pulling and eating food off the used breakfast trays located on the food services cart. LPN #151 stated Resident #3 pulls food off the dirty food trays on the food services cart all the time and eats it. LPN #151 confirmed the facility hasn't stopped Resident #03 from eating food off the dirty trays stating you can't stop him we just let him do it.
Review of the Meal Delivery policy dated 05/01/22 revealed nursing staff collects all the trays from the resident's rooms and places them back into the mobile trucks after mealtime, then the cart is returned to the Dietary Department.
2. Review of the dietary spreadsheet, dated 09/09/25 revealed two beef tacos, each containing a #16 (2 ounce) scoop of meat in each, were to be served.
Observation on 09/09/25 from 11:53 A.M. to 12:29 P.M. of tray line for the lunch meal revealed [NAME] #166 placed one taco (one flour tortilla containing 2 ounces of taco meat) on each plate. Continued observation revealed [NAME] #166 provided two tacos for residents who were supposed to receive double portions. At 12:03 P.M., a cart containing trays for the dining room left the kitchen. At 12:14 P.M., a cart containing trays for the 100 hall left the kitchen. At 12:28 P.M., a cart containing trays for the 300 hall left the kitchen.
Interview on 09/09/25 at 11:53 A.M., [NAME] #166 stated residents who received the standard menu were served one taco and residents on double portions were served two tacos.
Interview on 09/09/25 at 12:29 P.M. Dietary Supervisor #168 verified the portion size for the tacos was supposed to be two tacos and residents on double portions should have received four tacos.
Review of the facility policy titled Portion Control dated 2010 revealed residents would receive the appropriate portions of food as planned on the menu.
3. Observation on 09/09/25 at 10:43 A.M., [NAME] #166 stated there were five residents on pureed diets. [NAME] #166 added five scoops of taco meat to the food processor, then added approximately 6 ounces of beef broth. [NAME] #166 then started the food processor and added approximately half cup of bread crumbs and continued pulsing. [NAME] #166 turned the food processor off and checked the consistency of the mixture, and stated it was more runny than he preferred, added more bread crumbs, and started the food processor again.
Interview on 09/09/25 at 10:58 A.M., [NAME] #166 verified he added liquid to the processor before assessing the need to add liquid. When queried regarding the use of a recipe for making pureed food, [NAME] #166 stated, that's how I make it. That's my recipe.
Interview on 09/09/25 at 1:18 P.M., DS #168 verified the guidelines for making pureed food indicated the appropriate procedure was to place the food in the food processor, puree, and then assess the need to add more water or thickening agent.
Review of the facility policy titled Pureed Food Preparation dated 2009 revealed food should be placed in the processor bowl, drained of liquid, and pureed well. The addition of fluid may not be necessary, depending on product composition.
4. Observation on 09/08/25 at 9:09 A.M. revealed the menu posted in the 200 hall was for Friday, 09/05/25.
Observation on 09/08/25 at 9:10 A.M., Resident #39 looked at the posted menu on the 200 hall and stated, that doesn't do me any good. That's from several days ago.
Interview on 09/08/25 at 9:10 A.M., Certified Nursing Assistant (CNA) #116 verified the menu posted on the 200 hall was from 09/05/25, three days prior.
Interview on 09/11/25 at approximately 8:00 A.M., Dietary Supervisor (DS) #168 stated she or the cook is responsible for posting the daily menus. DS #168 stated she was unable to get menus printed over the weekend and was not able to update the posted menu until Monday morning.
The facility identified Resident #9 did not receive food from the kitchen.

Based on observation, resident and resident representative interviews, and staff interview, the facility failed to ensure residents received foods that were palatable. This had the potential to affect 65 of 66 residents. The facility identified one resident (#9) who did not receive food from the kitchen. The facility census was 66. Findings include: Review of a test tray on 09/09/25 at 12:52 P.M. with Dietary Supervisor (DS) #168, revealed the taco, refried beans, and rice and beans were luke warm and not palatable. DS #168 verified the taco, refried beans, and rice and beans were not served at a suitable temperature and were not palatable. Interview on 09/09/25 at 1:07 P.M., Resident #39 stated the food he was served for lunch was cold. Interview on 09/09/25 at 1:11 P.M., Resident #20 stated the food she was served for lunch was cold, like it always is. The resident described the food as hog slop. Interview on 09/08/25 at 9:10 A.M., Resident #77 complained of the food being cold. Interview on 09/08/25 at 10:03 A.M., Resident #24's responsible party stated Resident #24 often complained about the food being cold. The facility identified Resident #9 did not receive food from the kitchen. This deficiency represents non-compliance investigated under Complaint Number OH00165869 (1260837).

Based on observation, staff interview, and policy review, the facility failed to ensure food was stored in a manner to protect against the potential spread of foodborne illness. The facility also failed to ensure staff wore hair restraints in the kitchen. The facility also failed to ensure the kitchen was maintained in a clean and sanitary manner. This had the potential to affect 65 of 66 residents in the facility. The facility identified one resident (#09) who did not receive food from the kitchen. The facility census was 66. Findings include: Observation and interview on 09/08/25 at 7:50 A.M. of the kitchen's reach-in refrigerators with Dietary Supervisor (DS) #168 revealed a reusable plastic bag of cheese slices that was unsealed, and a package of bologna slices not dated or sealed. There was also a box containing two bags of sausage and one of the bags was not sealed and did not have a date. DS #168 verified the cheese was not sealed and the bologna and sausage were not sealed or dated. DS #168 verified all food should be sealed and dated. Observation and interview on 09/08/25 at 8:00 A.M. with DS #168 revealed a bag of cookie dough which was not sealed and two plastic disposable cups containing an unidentified food, which were not sealed, labeled, nor dated. DS #168 verified the cookie dough was not sealed and the two plastic cups were not sealed, labeled, or dated. Observation and interview on 09/09/25 at 10:43 A.M. revealed [NAME] #166 preparing pureed taco meat. [NAME] #166 had facial hair, measuring approximately one-fourth inch, and was not wearing any type of restraint for his facial hair. At 11:09 A.M., [NAME] #166 verified he was not wearing a hair restraint for his facial hair. Observation and interview on 09/09/25 at 11:03 A.M. with DS #168 revealed there was a round vent on the ceiling above the steam table. The vent was coated in light brown debris and there were black specs on the ceiling in the surrounding four foot area which were flapping in the breeze from the vent. The support beam for the steam table, which extended to the ceiling of the kitchen revealed the top-most portion, measuring approximately two feet, was coated in a brown and grey fuzzy substance. DS #168 verified the vent was coated in light brown debris and black specs surrounded the four foot area around the vent. DS #168 verified the support beam was coated in a brown and grey fuzzy substance. DS #168 verified the areas needed to be cleaned and stated she was unable to reach the areas. DS #168 was standing next to [NAME] #166 while [NAME] #166 was preparing food for the lunch meal. DS #168 was wearing a hair net, however her hair was not fully covered, and approximately three inches of hair was sticking out from under the hair net around the head. DS #168 verified her hair was not fully contained by the hairnet. Review of the facility's undated policy titled Food Safety and Sanitation revealed hair restraints are required and should cover all hair on the head and beard nets are required when facial hair is visible. Food should be protected from contamination (including dust). All time and temperature control for safety (TCS) foods should be labeled, covered, and dated when stored. When a food package is opened, the food item should be marked to indicate the open date, which is used to determine when to discard the food.

Based on record review, observation, staff interview, policy review, and review of Centers for Disease Control and Prevention (CDC) guidance, the facility failed to follow physician orders for contact isolation precautions for Residents #57 and #13. This affected Residents #57 and #13 and had the potential to affect the residents residing on their units, 100 and 200 halls. The facility census was 66.
Findings include:
1. Review of the medical record for Resident #13 revealed an admission dated of 12/14/11. Diagnoses included cerebrovascular disease, obsessive-compulsive disorder, and hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side.
Review of the physician orders dated 09/09/25 revealed an order for contact isolation precautions every shift for shingles until resolved.
Observation on 09/09/25 at 11:16 A.M. revealed Resident #13 sitting in the dining room, leaning on a dining room table, with ten other residents and one Certified Nursing Assistant (CNA) present.
Interview on 09/09/25 11:20 A.M. with Licensed Practical Nurse (LPN) #114 confirmed Resident #13 was positive for shingles infection as of 09/09/25, Resident #13 had open and moist blisters, and should be in contact isolation. LPN #114 confirmed Resident #13 should not be in the dining room with other residents due to a diagnosis of active shingles.
Interview on 09/09/25 at 11:23 A.M. with Activities Personnel #130 stated she was not aware of Resident #13 was required to be in contact isolation, and that was not communicated to her.
Review of the Transmission Based Precautions policy dated 05/01/22 revealed contact precautions are required for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with the resident. If the resident is transported to another area in the facility, the facility will notify the unit of the type of precautions the resident needs.
Review of CDC guidance titled Preventing FZV (Varicella-Zoster Virus) Transmission in Healthcare Settings dated 04/19/24 and found at https://www.cdc.gov/shingles/hcp/infection-control/index.html revealed facilities should use the table [Found at website] to determine if any additional infection control precautions are required. Infection control precautions are based on the patient's immune status and rash localization.
2. Record review for Resident #57 revealed an admissions date of 04/18/22 with diagnoses including cerebral infraction and dementia.
Review of the physician orders dated 08/21/25 revealed Resident #57 had an order for contact isolation precautions due to wounds from the herpes simplex virus.
Observation on 09/08/25 at 9:19 A.M. revealed Resident #57's room did not have a sign stating to use contact precautions prior to entering or a personal protective equipment (PPE) supply cart outside the room.
Interview on 09/08/25 at 9:31 A.M. with Licensed Practical Nurse (LPN) #148 verified Resident #57 did not have contact isolation precaution signage or PPE stored outside the room.
Interview on 09/08/25 at 9:36 A.M. with Certified Nursing Assistant (CNA) #129 verified she was recently alerted of Resident #57's contact isolation precautions order. CNA #129 stated that while she was performing care for Resident #57 that morning, the only PPE she used was gloves.
Review of the facility policy titled Transmission Based Precautions dated 05/01/22, revealed when a resident has orders for contact precautions, a gown should be worn when entering the room and the facility will implement a system to alert staff to the type of precautions for the resident.

Based on observation, policy review, resident interview, and staff interview, the facility failed to maintain a clean, sanitary, and safe environment for all residents. This affected Residents #4 and #31 and had the potential to affect all 66 residents residing in the facility.Findings include:
1. Observations on 09/08/25 between 9:00 A.M. and 10:00 A.M. revealed the floors of the 200 and 300 halls contained numerous areas of dark grey and black shoe (foot) prints, dark grey and black wheelchair trail marks, and dark grey and black marks suggestive of dried liquid drips. There was dirt, grime, and dust throughout both halls.
Interview on 09/08/25 at 10:02 A.M., Resident #31 described the facility cleanliness as “nasty” and stated all of the housekeepers but one were recently fired.
Interview on 09/08/25 at 11:21 A.M., Resident #4 complained the floors in the common area were not very clean and further stated he thought the floors were dirty because there was only one person in housekeeping for the entire building.
Interview on 09/08/25 at 10:12 A.M., Housekeeper #109 verified the 200 and 300 halls contained numerous areas of foot prints, wheelchair marks, dried liquid, dirt, grime, and dust. Housekeeper #109 stated she was upset at the condition of the hallways when she arrived to begin her shift that morning and further stated the halls had not been cleaned over the weekend because the majority of the housekeeping staff had recently been fired.
2. Observations on 09/11/25 at 1:22 P.M. revealed a build up in the lint trap of all three dryers in the laundry room.
Interview on 09/11/25 at 1:25 P.M. with Housekeeper #126 verified that the amount of lint in the trap would be from a couple loads. Housekeeper #126 stated she arrived to work at 1:00 P.M. and was doing her first load of laundry for the day. Housekeeper #126 verified the lint traps should be cleaned regularly to prevent a build up of lint.
Review of the facility policy titled “Infection Control – Housekeeping”, dated 10/27/21 revealed the facility procedure is to provide a safe and septic handling, washing, and storage of linens.
This deficiency represents non-compliance investigated under Complaint Number 2605044, Complaint Number 2574888, Complaint Number OH00164929 (1260835), Complaint Number OH00164419 (1260832), and Complaint Number OH00166722 (1260778).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, staff and resident interviews and policy review, the facility failed to ensure medications were stored securely. This affected five (#18, #29, #32, #55 and #56) out of five residents reviewed for medication storage. This had the potential to affect four (#29, #48, #10 and #57) residents that the facility identified as cognitively impaired and independently mobile. The facility census was 61.
Findings include:
1. Medical record review for Resident #18 revealed an admission on [DATE] with diagnoses including but not limited to schizophrenia, left female breast cancer, anxiety disorder, impaired cognition and bipolar disorder.
Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] for Resident #18 revealed an intact cognition. Resident #18 was independent for eating and supervised toileting, bed mobility, and transfers. Resident #18 was incontinent of bowel and bladder. Resident #18 was receiving hospice services.
Review of the plan of care for Resident #18 revealed resident remains at risk for skin breakdown due to medical conditions. Previously closed area on coccyx has reopened and nurse practitioner will follow and as needed. Interventions include body audits as scheduled, monitor labs, monitor pain symptoms, reposition every two hours, and wound nurse weekly.
Review of the active physician orders for [DATE] for Resident #18 revealed an order dated [DATE] for a low air loss mattress to bed, an order dated [DATE] to cleanse coccyx with normal saline. Pat dry. Apply triad cream three times a week and as needed. Hospice to perform two times a week and facility staff to perform one time a week and as needed. Hospice to perform care on Monday and Wednesday.
Review of the discontinued physician orders for Resident #18 revealed an order dated [DATE] and discontinued on [DATE] for cleanse open area to coccyx with normal saline, pat day, pack with calcium alginate and cover with silicone sterile adhesive dressing.
Observation on [DATE] at 4:13 P.M. of Resident #18 bedside stand revealed one spray bottle of Integrity wound cleaner with a warning on the label if swallowed seek medical attention, a second wound cleanser bottle, a box of comfort foam dressings, an open package of calcium alginate wound dressing and a hydrophilic wound dressing unsupervised.
Interview on [DATE] at 4:19 P.M. with Assistant Director of Nursing (ADON) #69 verified the observation and stated the wound cleansing products should not be in the room.
2. Medical record review for Resident #29 revealed an admission on [DATE] with diagnoses including but not limited to hemiplegia and hemiparesis following a stroke, peripheral vascular disease, dementia, convulsions, major depression disorder, hypothyroidism, vascular dementia, and hypertension.
Review of the quarterly MDS assessment dated [DATE] for Resident #29 revealed was unable to complete the brief interview for mental status with staff interview revealing modified independence. Resident #29 was coded as independent with eating. Resident #29 required maximum assistance for toileting, bed mobility and transfers.
Review of the active physician orders for Resident #29 revealed an order dated [DATE] for Norco oral tablet 5-325 mg one tablet every 12 hours for pain related to headache and an order dated [DATE] for Senna 8.8 mg two tablets every 12 hours for constipation.
Observation on [DATE] at 8:42 A.M. of Resident #29 revealed a bottle of nystatin powder on bedside in resident's room. Further observation of the pharmacy label revealed it was ordered for Resident #30.
Interview on [DATE] at the time of observation with LPN #36 verified that the bottle of nystatin powder was for Resident #30 and should not be in the room.
3. Medical record review for Resident #32 revealed an admission dated on [DATE] with diagnoses including but not limited to encephalopathy, epilepsy atherosclerotic heart disease of native coronary artery, hemiplegia and hemiparesis following a stroke affecting the left non dominant side, major depressive disorder, retention, hypertension and pain.
Review of the admission MDS assessment dated [DATE] revealed resident #32 had intact cognition. Resident #32 was coded as independent with eating, maximal assistance with toileting, supervision for bed mobility and moderate assistance with transfers.
Observation on [DATE] at 9:06 A.M. revealed LPN #36 prepared the oral medication for Resident #32. Medication including Baclofen 20 mg one tablet, Eliquis tab 5 mg one tablet, Aspirin 81 chewable one tablet, Atenolol 25 mg one tablet, Famotidine 20 mg one tablet, Folic acid 1 mg one tablet, Gabapentin 300 mg one tablet, Levetiracetam 1000 mg one tablet, Omeprazole 40 mg tab one tablet and Vitamin B12 100 mg one tablet. LPN #36 carried the medication into the room and set it on the bedside table in front of Resident #32. LPN #36 then left the room to ensure there was not any blood pressure parameters related to scheduled medication.
Additional observation on [DATE] at 9:16 A.M. of Resident #32's bedside table revealed two large tubes of Voltaren topical ointment. Further observation revealed one tube did not have a label and the other tube had a label from the hospital prior to admission.
Interview on [DATE] at 9:16 A.M. with Resident #32 stated the hospital gave one tube to him and he brought it with him when he transferred and has been on that table since arrival.
Interview on [DATE] at 9:25 A.M. with LPN #36 verified she left the prepared medication in the residents 'room unsupervised and should not have. LPN #36 verified that Resident #32 did not have orders for the Voltaren topical ointment and stated it should not have been in his room.
4. Medical record review for Resident #55 revealed an admission on [DATE] with diagnoses including but not limited to heart disease, ventricular tachycardia, extended spectrum Beta Lactamase resistance, chronic kidney disease stage three, hypertension, chest pain, chronic embolism and thrombosis, spinal stenosis.
Review of the quarterly MDS assessment dated [DATE] for Resident #55 revealed an intact cognition. Resident #55 is independent for eating and bed mobility. Resident #55 requires supervision for transfers and toileting.
Observation on [DATE] at 9:40 A.M. of Resident #55 bedside table revealed two bottles of Nasal spray oxymetazoline hydrochloride 0.05% with expired dates of 04/2022 and 07/2023.
Interview on [DATE] at 9:48 A.M. with LPN #55 verified Resident #55 did not have orders for the medications and stated they should not be in his room unsupervised.
5. Medical record review for Resident #56 revealed an admission on [DATE] with diagnoses including but not limited to heart disease, chronic kidney disease, hypertension and major depressive disorder.
Review of the comprehensive MDS assessment dated [DATE] for Resident #56 revealed an intact cognition. Resident #56 was coded as independent for eating, bed mobility, transfers. Resident #56 required moderate assistance with toileting.
Observation on [DATE] at 10:00 A.M. from the hallway into Resident #56's room revealed a bookshelf with three bottles on it. Further observation with LPN #55 revealed one opened bottle of hydrogen peroxide, a nasal spray bottle (oxymetazoline hydrochloride 0.05%) and an opened bottle of acetone fingernail polish removed. The bottles of hydrogen peroxide and the acetone both had warning labels to contact medical services if ingested.
Interview on [DATE] at the time of the observation with LPN #55 verified the items noted should not be in the residents' room and removed them.
6. Observation on [DATE] at 10:35 A.M. of the four-drawer treatment cart located on the 300 hundred hall was unlocked and unsupervised.
Observation on [DATE] at 10:35 A.M. with LPN #55 and the Administrator verified the cart contained treatment supplies, topical creams and ointments and bottles of hydrogen peroxide and dyna hex with label to contact poison control if ingested.
Interview on [DATE] at 10:35 A.M. with LPN #55 and the Administrator verified the treatment cart contained medical supplies with warning labels to contact the poison control center if ingested and should have not been unlocked and unsupervised. The facility confirmed there were four (#29, #48, #10 and #57) residents that are cognitive impaired and independently mobile that could access unsecured medications.
Review of the facility policy titled Medication Storage dated [DATE] states the facility shall store all drugs and biological's in a safe, secure and orderly manner. Number 7 states compartments including but not limited to drawers, cabinets, room, carts containing drugs ad biological shall be locked when not in use and shall not be left unattended.
This deficiency is based on incidental findings discovered during the course of this complaint investigation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, staff interviews and policy review, the facility failed to ensure staff completed hand hygiene during during incontinence care. This affected one (#06) out of three residents reviewed for incontinent care. The facility census was 61.
Findings include
Medical record review for Resident #06's revealed resident was admitted to the facility on [DATE] with diagnoses including unspecified dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, hyperlipidemia, retention of urine, hypertension, anxiety disorder, peripheral vascular disease, muscle weakness and dysphagia.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #06 revealed the resident had severe cognitive impairment. Resident #06 required supervision with eating and rolling left and right. Resident #06 required moderate assistance with toileting, personal hygiene, and maximal assistance with toileting. Resident #06 was coded as being incontinent of bladder and bowel.
Observation on 07/09/24 at 3:34 P.M. with State Tested Nursing Assistant (STNA) #40 and #87 providing incontinent care for Resident #06. Resident #06 was assisted into the shower room. STNA #40 applied gloves to both hands and assisted the resident to pull down his sweatpants. Resident #06 was sitting on the commode when STNA #40 removed his incontinent brief that was saturated with urine. STNA #40 folded the brief up and placed it into the trash container. STNA #40 then removed his sweatpants and pulled up his gripper socks up. STNA #40 placed each leg into the new sweatpants and the applied the tabbed brief to Resident #06 around his upper thighs. Resident #06 stated he was done with the toileting and STNA #40 pulled an incontinent wipe from a package. Resident #06 was assisted to a standing position utilizing the garb bar. STNA #40 used one wipe to complete four passes to the perineal area without using a separate area for each stroke from front of the perineal to the back of the perineal area and then discarded the wipe into the trach container. STNA #40 then pulled up the incontinent brief and then the sweatpants. Resident #06 was assisted back into the wheelchair. STNA #40 then moved the wheelchair out of the bathroom using the handle grips with gloved hands and positioned him into the shower area. STNA #40 removed the package of wipes from the bathroom and placed them on a cabinet in the shower area. STNA #40 then went into the bathroom, removed her gloves and placed them in the trash container. STNA #40 then exited the bathroom, placed her hands on the wheelchair handles and pushed the resident out into the hallway.
Interview on 07/10/24 at 3:45 P.M. STNA #40 verified she did not wash her hands after removing the urine-soaked brief and should have. STNA #40 verified she used the contaminated gloves to push the resident into the shower area. Additionally, STNA #40 verified when she did remove the gloves she did not complete hand hygiene, handling the wheelchair handle grips, the package of wipes and the doorknob to get out of the shower room.
Interview on 07/11/24 at 4:15 P.M. with the Corporate Registered Nurse (RN) #800 verified the staff should be washing her hands when she removes her gloves each time during incontinent care.
Review of the facility's policy titled Peri Care, dated 05/01/22, states under #11 to use a clean area of cloth for each area cleaned, Number 13 states remove gloves and perform hand hygiene and apply clean gloves to apply clean brief and reapply clothing.
This deficiency is based on incidental findings discovered during the course of this complaint investigation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interviews, the facility failed to ensure a resident's admission assessments were timely completed in the electronic health record. This affected one (#300) out of three residents reviewed for medical record accuracy and completeness. The facility census was 61.
Findings include:
Medical record review for Resident #300's chart revealed resident admitted to the facility on [DATE] with diagnoses including chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, emphysema, congestive heart failure, chronic kidney disease and hypertension. Resident #300 discharged from the facility on 05/23/24 at approximately 9:49 A.M.
Review of Resident #300's discharge Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Resident #300 was independent with eating. Resident #300 required maximal assistance with toileting, showering, lower body dressing, sitting to lying, lying to sitting, sitting to standing, chair transfers, toilet transfers, tub transfers, and walking ten feet. Resident #300 required moderate assistance with upper body dressing, personal hygiene, rolling left and right. Resident #300 was coded as always incontinent of bladder and occasionally incontinent of bowel. Resident #300 had two stage two pressure ulcers that were present on admission.
Review of the plan of care for Resident #300 revealed the document was not completed.
Review of the Nursing admission Assessment with Care Plan for Resident #300 revealed the assessment was opened in the electronic health record on 05/16/24 but wasn't marked as completed until 05/23/24 at 11:59 A.M. which was after the resident was discharged . The assessment was completed by the Administrator/Licensed Practical Nurse (LPN) #100. Further review of the assessment revealed the two pressure ulcers were not documented on the skin assessment only bruising on both right and left hands.
Review of the Bowel and Bladder Assessment for Resident #300 revealed the assessment was opened on 05/17/24 and completed on 05/23/24 at 10:55 A.M. after the resident was discharged by Registered Nurse (RN) #804.
Review of the Braden scale for Resident #300 revealed the assessment was opened on 05/17/24 at 10:56 A.M. and completed on 05/23/24 at 10:57 A.M. after the resident was discharged by RN #804.
Review of the dental oral evaluation for Resident #300 revealed the assessment was opened on 05/17/24 at 10:58 P.M. and completed on 05/23/24 at 10:59 A.M. after the resident was discharged by RN #804.
Review of the pain tool for Resident #300 revealed the assessment was opened on 05/17/24 at 11:02 A.M. and closed on 05/23/24 at 11:09 A.M. after the resident was discharged by RN #804.
Review of the weekly Head to Toe assessment for Resident #300 revealed the assessment was opened on 05/16/24 at 12:00 P.M. and completed on 05/23/24 at 11:25 A.M. after the resident was discharged .
Review of the falls assessment for Resident #300 revealed the assessment was opened on 05/17/24 and completed on 05/23/24 by RN #804.
Interview on 07/10/24 at 12:59 P.M. with RN #804 verified she was the Director of Nursing (DON) for a sister facility and helping at this facility due to having an Intern DON at the facility. RN #804 verified the assessments were not documented as completed until after Resident #300 had left the facility.
Interview on 07/10/24 at 3:05 P.M. with the Corporate RN #800 stated the facility did not have a policy regarding the documentation or completion of the admission assessments.
Interview on 07/11/24 at 11:37 P.M. with the Administrator verified the admission assessments were completed/locked after Resident #300 was discharge and further verified that it was the expectation of the facility to have the admission assessments (bowel and bladder assessment, Braden assessment, fall assessment, pain assessment, dental assessment and elopement assessment) completed on the day of admission.
This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on observation, staff interview, record review, the facility failed to ensure food items were stored in a sanitary manner. This had the potential to affect 59 of 59 residents who receive their meals from the kitchen, the facility identified two residents (#25 and #31) that received no food by mouth. The facility census was 61.
Findings include:
Observation of the kitchen on 07/03/24 at 7:45 A.M. revealed the reach in refrigerator in the kitchen was 60 degrees Fahrenheit. A package of ham, a package of hamburgers and a package of hotdog's were located in the refrigerator. There was also a gray fuzzy substance on the line that went from the ceiling to the steam table and there was a gray fuzzy on the ceiling vent located directly above the onions in the dry storage room. There were also three flies sitting on the line that went from the ceiling to the steam table in the kitchen.
Interview with Dietary Supervisor (DS) #110 on 07/03/24 at 7:45 A.M. verified the reach in refrigerator was 60 degrees Fahrenheit and there was a package of ham, a package of hamburgers and a package of hotdog's located in the refrigerator. DS #110 stated the refrigerator had been broken approximately one week. DS #110 also verified there was a gray fuzzy substance on the line that went from the ceiling to the steam table and there was a gray fuzzy on the ceiling vent located directly above the onions in the dry storage room. DS #110 confirmed there were three flies sitting on the line that went from the ceiling to the steam table in the kitchen.
Review of the facility's preventing foodborne illness policy dated 05/01/22 revealed food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized. The policy stated federal standards require that refrigerated food be stored below 41 degrees Fahrenheit.
This deficiency represents non-compliance investigated under Complaint Number OH00155177.

Based on observation, staff interview, review of the facility menu and spreadsheet and policy review, the facility failed to ensure menus were followed. This had the potential to affect 59 of 59 residents who receive their meals from the kitchen, the facility identified two residents (#25 and #31) that received no food by mouth. The facility census was 61.
Findings include:
Review of the menu dated 07/03/24 revealed oatmeal or cold cereal, cheesy scrambled eggs, a sausage patty, assorted toast, whole milk or two percent milk and coffee or tea were to be served for breakfast.
Review of the undated menu spreadsheet revealed regular diets were to receive six ounces of oatmeal, two ounces of cheesy scrambled eggs, and one slice of toast for breakfast, mechanical soft diets were to receive six ounces of oatmeal, two ounces of cheesy scrambled eggs, and one slice of toast for breakfast and pureed diets were to receive six ounces of pureed oatmeal, two ounces of pureed cheesy scrambled eggs, and two ounces of pureed toast for breakfast.
Observation of the kitchen on 07/03/24 at 7:38 A.M. revealed [NAME] #65 took the temperature of the food on the tray line. The oatmeal was 160 degrees Fahrenheit, the ham was 145 degrees Fahrenheit, the mechanical ham was 180 degrees Fahrenheit, the pureed sausage was 160 degrees Fahrenheit, and the scrambled eggs were 140 degrees Fahrenheit. [NAME] #65 was observed to serve regular diets six ounces of oatmeal, one slice of ham and one slice of toast, mechanical soft diets six ounces of oatmeal, two ounces of mechanical ham and one slice of toast and pureed diets six ounces of oatmeal, four ounces of pureed scrambled eggs and four ounces of pureed sausage.
Interview with [NAME] #65 on 07/03/24 at 7:38 A.M. verified regular diets were served six ounces of oatmeal, one slice of ham and one slice of toast, and mechanical soft diets were served six ounces of oatmeal, two ounces of mechanical ham and one slice of toast. [NAME] #65 verified regular and mechanical soft diets did not receive cheesy scrambled eggs per the menu spreadsheet and the facility did not provide regular or mechanical soft diets a substitution for the cheesy scrambled eggs. [NAME] #65 also verified pureed diets received six ounces of oatmeal, four ounces of pureed scrambled eggs and four ounces of pureed sausage and pureed diets did not receive pureed bread per the menu spreadsheet. [NAME] #65 stated that ham was provided to residents that received regular and mechanical soft diets as a substitution for sausage because the facility was out of sausage.
Review of the nutritional services policy dated 05/01/22 revealed food portion sizes will be reviewed by the dietician on an as needed basis to ensure nutritional needs are met.
This deficiency represents non-compliance investigated under Complaint Number OH00155177.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility's Self-Reported Incident (SRI), review of the facility policy, and staff interview, the facility failed to report resident-to-resident physical abuse to the State Survey Agency, the Ohio Department of Health. This affected two (Residents #1 and #2) of four residents reviewed for abuse. The facility census was 55.
Findings include:
Record review for Resident #1 revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic kidney disease, dementia, depression, anxiety, and psychotic disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had impaired cognition.
Review of Resident #1's progress notes dated 01/27/24 at 7:42 P.M. revealed Resident #1 walked past Resident #3's room and while standing in the hallway, Resident #3 struck Resident #1 in the mouth causing an abrasion to her lip. Resident #1 was assessed by the nurse and the resident's family representative was notified.
Record review for Resident #3 revealed the resident was admitted to the facility on [DATE]. Diagnoses included dementia, altered mental status, and schizoaffective disorder. Review of the MDS assessment dated [DATE] revealed Resident #3 had impaired cognition.
Review of Resident #3's progress notes dated 01/27/24 at 5:50 P.M. revealed Resident #3 was observed striking another resident, Resident #1, when the other resident walked by the room. Resident #3 was placed into one-to-one monitoring. On 01/27/24 at 8:25 P.M., Resident #3 was transferred to the hospital for a geriatric psychiatric evaluation.
Review of the facility's Self-Reported Incident (SRI) from 01/27/24 to 01/28/24 revealed there was no SRI initiated for the resident-to-resident physical abuse between Residents #1 and #3 on 01/27/24.
Interview on 02/29/23 at 2:22 P.M. with the Administrator, Director of Nursing (DON), and Corporate Administrator #500 revealed on 01/27/24, it was reported by the nurse on duty Resident #3 had struck Resident #1 in the face when she approached his door. Per the Administrator, a full investigation into the incident was completed, the residents were separated immediately, assessed for injuries, the families were notified, the physicians were notified, and the police came and made a report. The Administrator stated she could not substantiate abuse due to the cognition of both residents. The Administrator verified the facility did not submit an SRI to the State Survey Agency, Ohio Department of Health per policy and regulation. The Administrator verified the incident between Resident #3 and Resident #1 was a resident-to-resident allegation of abuse that was not reported to the State Survey Agency.
Review of the facility policy titled 'Abuse Prevention,' dated 08/20/21, revealed all incidents of abuse will be reported to the State agencies in a timely manner.
This deficiency represents non-compliance investigated under Complaint Number OH00151084.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of the facility policy, the facility failed to notify the physician and resident representative of the resident's severe weight losses. This affected two (Residents #200 and #500) of six residents reviewed for weight loss. The facility census was 54.
Finding:
1. Closed record review for Resident #200 revealed an admission date of 12/09/22. Diagnoses included diabetes mellitus type two, tracheostomy, stage four decubitus ulcer (Full thickness tissue loss with exposed bone, tendon or muscle), systemic cerebral vascular accident, dysphagia, quadriplegia, and gastrostomy tube.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #200 was cognitively impaired and no behaviors or rejection of care. Resident #200 received 51% or more total calories though tube feeding, had a five percent weight loss, and was not on a physician prescribed weight-loss regimen. Resident #200 was at a high risk for pressure ulcers with one stage four pressure ulcer upon admission.
Review of Resident #200's weights revealed a monthly mechanical lift weight on 08/04/23 of 143.6 pounds (lbs.) and 10/05/23 a mechanical lift weight of 134.2 lbs. (A 9.4 weight loss in two months; 7% weight loss) There was no weight recorded for the month of September 2023. The medical record was silent for notification to the physician and resident representative regarding Resident #200's severe weight loss on 10/05/23.
Interview on 12/11/23 at 10:30 A.M. with Dietitian #619 verified the facility did not obtain Resident #200's weight for September 2023. Dietitian #619 verified Resident #200 had a seven percent weight loss from August to October 2023. Dietitian #619 stated Resident #200 should have been placed on weekly weights and was unable to locate any weekly weights for October and November 2023.
Interview on 12/11/23 at 11:00 A.M. with the Administrator verified the physician and resident representative were not notified of Resident #200's weight loss on 10/05/23.
2. Closed record review for Resident #500 revealed an admission date of 07/26/23. Diagnoses included restlessness leg syndrome, anxiety, depression, osteoarthritis, diabetes, chronic lower leg wound, sepsis, urinary tract infection, and acute metabolic encephalopathy.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #500 impaired cognition, had no behaviors, and had no rejection of care.
Review of the Resident #500's monthly weight record revealed Resident #500 was weighed on 08/10/23 of 166.4 pounds (lbs.) and 09/08/23 of 150.8 lbs., indicating a nine percent severe weight loss in thirty days. There were no weights recorded for the months of October and November 2023. The medical record was silent for notification to the physician and resident representative for Resident #500's significant weight loss for the month of September 2023 and the facility's inability to obtain Resident #500's weight for October and November 2023.
Interview on 12/11/23 at 11:00 A.M. with the Administrator verified verified the physician and resident representative were not notified of Resident #500's weight loss on 09/08/23.
Review of the facility policy titled Weight Management dated 05/01/22, revealed the nursing assistants weighs residents within 24 hours of admission to the facility then weekly for four weeks and monthly thereafter. A significant weight changes are indicated by any of the following: three percent in fourteen days, five percent in thirty days and seven in a half percent in ninety days.
Review of the facility policy titled Change in Condition Monitoring, dated 05/01/22, revealed the facility shall promptly notify the resident, attending physician and representative of changes in the resident's medical condition and or status.
This was an incidental finding during the course of the complaint investigation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of the Medline guidance, the facility failed to provide the care and services for a resident's peripherally inserted central catheter (PICC). This affected one (Resident #200) of three residents reviewed for intravenous (IV) therapy. The facility census was 54.
Findings include:
Closed record review of Resident #200 revealed an admission date of 12/09/22. Diagnoses included moyamoya, tracheostomy, systemic inflammatory response syndrome, cerebral vascular accident, neurogenic bladder, and quadriplegia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #200 had impaired cognition, had no behaviors, or no rejection of care.
Review of the physician orders dated 11/14/23 revealed Resident #200 received a new order for an intravenous antibiotic Meropenem one gram three times a day for urinary tract infection. The antibiotic was to be administered through a Peripherally Inserted Central Catheter (PICC) which was placed on 11/14/23. The physician orders were silent for orders for care of the PICC line dressing or maintain patency of the line before medication or after medication administered from 11/14/23 to 11/27/23. On 11/27/23, an order for intravenous Meropenem one gram every eight hours for infection was to be administered until 12/31/23. On 11/28/23, there was a physician's order for saline flush intravenous solution use 10 milliliter (ml) intravenously as needed for flush.
Review of Resident #200's plan of care was silent for the PICC line that was placed on 11/14/23 and the treatment for a urinary tract infection.
Review of the November and December 2023 medication administered record revealed no documented utilization of the as needed saline flush for the PICC line.
Interview on 12/12/23 at 9:30 A.M. with Registered Nurse (RN) #622 verified no documented utilization of the saline flush or PICC line care performed, or there was no order for PICC line dressing change in the November or December 2023 medication administration record. RN #622 stated the PICC line dressing change should be performed, flushing of PICC line before and after medication and caps or care of the line should be evaluated or performed as standard practice. RN #622 verified Resident #200's plan of care was not updated when the PICC line was inserted for the treatment of an infection on 11/14/23) and a plan of care should have been in place for the care of the intravenous line and urinary tract infection.
Interview on 12/12/23 at 9:40 A.M with the Administrator stated the facility did not have specific policy for plan of care or PICC lines.
Review of Medline medical encyclopedia guidance for PICC line catheter revealed you need to rinse out the catheter after every use. This was called flushing. Flushing helps keep the catheter clean from intermixing medications and prevents blood clots from blocking the catheter. Care of the PICC line includes changing the caps at the end of your catheter (called the claves) when you change your dressing and after blood is drawn.
This deficiency represents non-compliance investigated under Complaint Number OH00148901.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of facility policy, the faciltiy failed to assess pressure ulcers on a weekly basis to include wound measurments and description of the wounds. This affected two (Residents #30 and #37) of four residents reviewed for pressure ulcers. The facility identified four (Residents #29, #30, #37, and #39) with pressure ulcers. The facility's census was 51.
Findings include:
1. Review of the medical record for Resident #30 revealed an admission date of 12/09/22. Diagnoses included neuromuscular dysfunction of bladder, gastroesophageal reflux disease, type II diabetes mellitus, seizures, major depressive disorder, and pressure ulcer of the sacral region (stage IV).
Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #30 had impaired cognition. The resident required total assistance for all activities of daily living (ADLs), except bed mobility in which the resident required extensive assistance. The assessment indicated Resident #30 had a Stage IV pressure ulcer upon admission.
Review of the admission assessment dated [DATE] for revealed Resident #30 had an area to the sacrum measuring 2 by 2 (measurement unit not identified on the assessment), with tunneling (wound has progressed to form pathways underneath the surface of the skin).
Review of the pressure ulcer risk assessment dated [DATE] revealed Resident #30 was at high risk for the development of pressure ulcers.
Review of the plan of care dated 12/29/22 revealed Resident #30 was at risk for skin breakdown related to medical condition. Interventions included body audits as scheduled and as needed, low air loss mattress, and turning and repositioning every two hours.
Review of the weekly skin assessments from 12/09/22 through 02/03/23 revealed the facility identified Resident #30 had a pressure ulcer to the scarum area, however the assessments did not include wound measurements or descriptions of the pressure ulcer.
Further review of the medical record revealed Resident #30 went to a wound clinic once a month for review of the pressure ulcer. The facility provided wound clinic documentation from Resident #30's visits on 11/16/22, 12/14/22, and 01/11/23. The wound clinic documentation included extensive notes and measurements regarding the wound to the sacrum. With each visit, the wound to the sacrum appeared to stay stable related to measurements and descriptions provided.
Interview on 02/08/23 at 2:18 P.M. with the Director of Nursing (DON) confirmed Resident #30 went to the wound clinic once monthly for treatment and assessment of the wound to her sacrum. The DON verified the facility staff was completing treatments to the wound as ordered by the clinic but was not assessing the wound regularly to include measurements or any changes in condition. The DON verified lack of documentation of wound measurements and wound descriptions in the residents medical record.
2. Review of the medical record for Resident #37 revealed an admission date of 01/18/22 with a hospitalization from 12/03/22 through 12/10/22. Diagnoses included vitamin D deficiency, major depressive disorder, vascular dementia, type 2 diabetes mellitus, and peripheral vascular disease.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #37 had intact cognition. The resident required total assistance from staff for toileting, locomotion on/off unit, and transfers. Resident #37 required extensive assistance from staff for bed mobility, dressing, eating, and personal hygiene. The assessment indicated the resident had one unstageable pressure ulcer upon admission.
Review of the admission assessment dated [DATE] for Resident #37 revealed the resident had many skin issues but had one pressure area to the left buttocks. No measurements were noted in the assessment.
Review of the pressure ulcer risk assessment for Resident #37 dated 01/19/22 revealed the resident was at a very high risk for the development of pressure ulcers.
Further review of the medical record revealed Resident #37 had a pressure ulcer to the coccyx being noted on 03/30/22. The facility would send the resident to the wound clinic monthly to review the pressure ulcer to the coccyx and other skin concerns.
Review of the plan of care dated 09/26/22 revealed Resident #37 had a longstanding pressure ulcer to the coccyx. Interventions included body audits as scheduled and as needed, low air loss mattress with bolsters, and maintaining wound vac to pressure ulcer as ordered.
Review of the weekly skin assessments from 03/30/22 through 02/03/23 revealed the facility identified Resident #37 had a pressure ulcer to the coccyx area, however the assessments did not include wound measurements or descriptions of the pressure ulcer.
Further review of the medical record revealed Resident #37 went to a wound clinic once a month for review of the pressure ulcer. The facility provided documentation from the wound clinic visits from March 2022 through February 2023. The wound clinic had extensive notes and measurements regarding the wound to the coccyx. With each visit, the wound to the coccyx appeared to stay stable but required a wound vac as a treatment in December 2022.
Review of the physician orders for Resident #37 from March 2022 through February 2023 revealed orders for the treatment to the wound on the coccyx. Orders matched recommendations given by the wound clinic. Review of the Treatment Administration Record (TAR) from March 2022 through February 2023 for Resident #37 revealed facility staff documented treatments as completed.
Interview on 02/08/23 at 2:20 P.M. with the Director of Nursing (DON) confirmed Resident #37 went to the wound clinic once monthly for treatment and assessment of the wound to his coccyx. The DON verified facility staff was completing treatments to the wound as ordered by the clinic but was not assessing the wound regularly to include measurements or any changes in condition.
Review of the facility policy titled, Skin and Wound Care Program, dated 05/30/22 revealed the facility failed to follow their policy of monitoring the incidence and severity of pressure ulcers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview, the facility failed to ensure an ordered orthotic therapeutic device was applied to assist with a resident's contracture. This affected one (Resident #49) observed for application of therapeutic devices. The facility identified 25 residents with contractures. The facility's census was 51.
Findings include:
Review of Resident #49's medical record revealed the resident was re-admitted to the facility on [DATE]. Diagnoses included traumatic brain injury, anoxic brain damage, fracture of the thoracic vertebra, traumatic subdural hemorrhage, quadriplegia, tracheostomy, gastrostomy, and persistent vegetive state.
Review of Resident #49's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had impaired cognition related to his persistent vegetive state. Resident #49 was totally dependent on staff with all areas of activities of daily living (ADLs).
Review of Resident #49's physician orders revealed an order dated 11/09/22 for staff to place right hand roll orthotic during the daytime shift, times six hours as tolerated for contraction management.
Review of the Treatment Administration Record (TAR) for Resident #49 revealed the facility failed to apply the orthotic device to the right hand on 02/01/22 and 02/02/22.
Observation on 02/06/23 at 10:40 A.M. revealed Resident #49 did not have the orthotic device in his right hand.
Observations on 02/07/23 at 9:53 A.M. and 2:07 P.M. revealed Resident #49 did not have the orthotic device in his right hand.
Interview on 02/07/23 at 2:07 P.M. with Registered Nurse (RN) #192 verified Resident #49 did not have his orthotic device in his contracted right hand as ordered. RN #49 stated she cannot say why the orthotic device was not placed and stated, We can put the orthotic device on him if you want? Additionally, RN #192 confirmed Resident #49's TAR was not signed off as providing the orthotic device on 02/01/23 and 02/02/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to provide supervision and failed to implement interventions for a resident who smoked. This affected one (Resident #45) of five residents identified to smoke. The facility's census was 51.
Findings include
Medical record review for Resident #45 revealed an admission date of 06/11/21. Diagnoses included encephalopathy, seizures, polyarthritis, alcohol abuse, anxiety disorder, essential primary hypertension, pseudobulbar affect, major depressive disorder, alcohol abuse with alcohol induced psychotic disorder, and dementia.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #45 had severely impaired cognition. Resident #45 required extensive assistance from staff with bed mobility, transfers, dressing, locomotion on the unit, and toilet use. Resident #45 required limited assistance from staff with personal hygiene and eating.
Review of Resident #45's most recent care plan revealed interventions and goals in place for smoking, with a target date of 03/22/23. Interventions included immediately notify nurse/administrator if resident was observed smoking unsupervised while in facility, remind visitors/resident to return cigarettes/lighters when returning from being out of the facility, staff to light cigarettes for resident during supervised smoking, provide and review a copy of the smoking policy and smoking schedule, and resident to smoke while supervised in the designated area.
Review of Resident #45's smoking assessment dated [DATE] revealed Resident #45 required supervision during smoke breaks, was not able to light his own cigarette, and required the use of a smoking apron.
Observation on 02/07/23 at 10:30 A.M. revealed Resident #45 was seated in the smoking room, alone, smoking a lit cigarette. Resident #45 was not wearing an apron, and no staff was present in the room or in the near vicinity to provide supervision. Subsequent interview with State Tested Nurse Aide (STNA) #168 verified Resident #45 required assistance with smoking and required a smoking apron. STNA #168 verified Resident #45 was seated in the designated smoking room, alone, with no supervision and no smoking apron applied. Resident #45 was smoking a lit cigarette. STNA #168 reported a staff member would have had to provide Resident #45 with the lit cigarette and left him alone because residents do not have access to smoking materials.
Interview on 02/07/23 at 10:53 A.M. with the Administrator confirmed Resident #45 required supervision while smoking. The Administrator was unaware how Resident #45 ended up in the smoking room, smoking with no supervision or no smoking apron applied. The Administrator further reported she was unaware how Resident #45 could have gotten his cigarette lit.
Interview on 02/07/23 at 11:30 A.M. with the Director of Nursing (DON) confirmed the facility identified STNA #169 as the aide who gave Resident #45 his cigarette, lit the cigarette, and left Resident #45 unsupervised to smoke on 02/07/23 at 10:30 A.M. The DON further confirmed STNA #169 did not utilize a smoking apron for Resident #45.
Review of the facility policy titled, Resident Smoking Policy, dated 01/20/23 revealed all tobacco products, matches, and lighters will be locked and stored at the nurse's stations and will be provided as needed. No resident shall be permitted to smoke unsupervised unless assessed as being independent.

Based on observations, staff interviews, and review of the facility policy, the facility failed to ensure proper storage of medications by ensuring expired medications were not being used. This affected six residents (#2, #4, #7, #15, #34, #155) who facility identified as receiving the expired medications from two medication carts and a medication storage room in the facility. The facility census was 51.
Findings include:
Observations and interviews on 01/07/23 from 10:20 A.M. to 11:00 A.M. of two facility medication carts (200 and 300 halls) and one medication storage room (200/300 halls) with Licensed Practical Nurse (LPN) #140 and Registered Nurse (RN) #192 revealed the following over the counter (OTC) expired medications: Certavite multivitamins expired 01/2023, Gerilanta expired 12/2022, and Claritin 10 milligrams (mg) expired 09/2022. LPN #140 and RN #192 confirmed the outdated medications were in the medication carts and the medication storage room.
Review of the facility policy titled, Medication Storage, undated, revealed the facility failed to implement the policy. Medication with a preservative expires on the manufacture's expiration date unless otherwise indicated on the manufacturer's package insert.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and review of facility policies, the facility failed to maintain appropriate infection control techniques during tracheostomy (trach) care. This affected one resident (#49) of the two residents identified by the facility as requiring tracheostomy care. The facility also failed to utilize proper hand hygiene during wound care. This affected one Resident (#49) of the four residents identified with wounds and requiring dressing changes. The facility census was 51.
Findings include:
1. Review of Resident #49's medical record revealed resident was readmitted to the facility on [DATE]. His diagnoses included, but not limited to, diffuse traumatic brain injury (TBI), anoxic brain damage, fracture of the thoracic vertebra, traumatic subdural hemorrhage, quadriplegia, trach dependent, and gastrostomy.
Review of Resident #49's most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed resident had impaired cognition. Further review of the MDS assessment revealed Resident #49 was totally dependent on staff with all areas of activities of daily living (ADLs).
Review of the physician's orders dated 02/02/23 for Resident #49, revealed resident was ordered to be suctioned as needed (PRN) via Yankuer (tool used to suction oropharyngeal secretions in order to prevent aspiration) or a 14 French suction catheter, trach care to be completed every night shift every three days and a trach tie holder changed every seven days.
Review of the nurse's progress notes dated 02/03/23 for Resident #49, revealed trach care was given and residents inner cannula was changed without issues.
Observation of trach care on 02/08/23 at 10:55 A.M. for Resident #49 revealed Licensed Practical Nurse (LPN) #179 removed the old stoma dressing on Resident #49's tracheostomy. Continued observations revealed LPN #179 washed his hands as resident appeared to be comfortable with his oxygen saturation being above 95 percent (%) (normal 96-100 %) and the resident had no signs of respiratory distress noted. Observations revealed LPN #179 opened the sterile trach kit and donned the sterile gloves from the kit. LPN #179 used his right hand (dominant hand) to grab sterile supplies from the trach kit and cleansed around resident's tracheostomy. Continued observations revealed LPN #179 used his contaminated gloved right hand to retrieve the new inner cannula from the kit and placed the new inner cannula into Resident #49's tracheostomy.
Interview on 02/08/23 at 11:15 A.M. with LPN #179 confirmed he donned the sterile gloves, cleaned around Resident #49's stoma opening with his right hand then picked up the new sterile inner cannula and placed it in Resident #49's tracheostomy.
Review of the facility document titled Competency Check Off for Tracheostomy Care, dated 01/24/21, revealed staff were to follow infection control procedures, as appropriate and tracheostomy care was a sterile procedure not a clean procedure, and follow sterile procedure when placing gloves on.
2. Review of Resident #49's medical record revealed resident was readmitted to the facility on [DATE]. His diagnoses included, but not limited to, diffuse TBI, anoxic brain damage, fracture of the thoracic vertebra, traumatic subdural hemorrhage, quadriplegia, trach dependent, and gastrostomy.
Review of Resident #49's most recent MDS 3.0 assessment dated [DATE], revealed resident had impaired cognition. Further review of the MDS assessment revealed Resident #49 was totally dependent on staff with all areas of ADLs.
Review of the physician's orders dated 12/08/22 for Resident #49's revealed resident was ordered to have the open area on his right outer ankle cleansed with non-sterile saline, Mesalt (impregnated gauze for heavy wound drainage) applied, two by two (2 x 2) gauze applied, and island dressing (bordered gauze dressing for wounds with light to moderate drainage) applied every day on night shift.
Review of the nurse's progress notes dated 02/08/23 for Resident #49, revealed resident had a treatment to his right outer right ankle. Notes indicated resident had a superficial, open area and no drainage or signs or symptoms of infection were noted.
Observation on 02/08/23 at 11:10 A.M. of wound care for Resident #49, revealed LPN #179 washed his hands, applied gloves, and provided privacy for the treatment. Continued observations revealed LPN #179 removed the soiled dressing from the right outer ankle of the resident and changed gloves without cleansing his hands with hand sanitizer or soap and water. Continued observations revealed LPN #179 cleansed the wound with normal saline and applied the new dressing as ordered.
Interview on 02/08/23 at 11:15 A.M. with LPN #179 confirmed he removed the soiled dressing, changed his gloves without cleansing his hands and completed the wound care to resident #49's outer ankle.
Review of the facility policy titled, Infection Prevention Policy and Procedure, dated 10/2019, revealed hand hygiene prevents spread of pathogens such as bacteria and viruses which causes infections. Pathogens can contaminate hands of staff during direct contact with residents or contact with contaminated equipment and environmental surfaces. Failure to clean contaminated hands can result in spread of pathogens to residents, staff, and environmental surfaces. Employee must wash their hands 10 to 15 seconds using antimicrobial or non- antimicrobial soap. Before and after direct contact with residents, when hands are visibly dirty or soiled with blood or other body fluids, after contact with blood, body fluids, secretions, mucous materials or non- intact ski, after removing gloves, before eating and after using restroom, before donning sterile gloves, before preparing and handling medications, before handling clean or soiled dressings, and after contact with resident intact skin.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of facility policy, the facility failed to respond to an acute change in condition, including an elevated temperature for Resident #49 in a timely manner. Actual harm occurred on 01/27/23 when Resident #49, who was in a persistent vegetative state and dependent on staff for all activity of daily living care, was transferred to hospital and admitted for treatment of pneumonia requiring intravenous (IV) antibiotics. The resident had been initially assessed to have an elevated temperature on 01/25/23 of 101.3 with no evidence of physician notification, comprehensive assessment or treatment. The resident was hospitalized until 02/02/23. The facility's census was 51.
Findings include:
Review of Resident #49's medical record revealed the resident was readmitted to the facility on [DATE]. Diagnoses included, diffuse traumatic brain injury, anoxic brain damage, fracture of the thoracic vertebra, traumatic subdural hemorrhage, quadriplegia, tracheostomy, gastrostomy, and persistent vegetive state.
Review of Resident #49's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had impaired cognition related to his persistent vegetive state. Further review revealed Resident #49 was totally dependent on staff with all areas of activities of daily living (ADLs).
Review of Resident #49's progress note dated 01/14/23 revealed the resident was discharged to the hospital from the nursing facility related to a fever. On 01/14/23 the progress notes confirmed Resident #49 was admitted to the hospital with the diagnosis of systemic inflammatory response syndrome (SIMS). Resident #49 returned to the facility on [DATE].
Review of Resident #49's vital signs history revealed on 01/25/23 at 5:38 P.M., Resident #49's body temperature was elevated at 101.3 degrees Fahrenheit (F). On 01/26/23 at 2:37 P.M., Resident #49's body temperature was elevated at 101.9 F. On 01/27/23 at 7:45 A.M., Resident #49's body temperature was elevated at 101.3 F. On 01/27/23 at 9:54 A.M. Resident #49's body temperature was elevated at 99.8 F. On 01/27/23 at 2:45 P.M., Resident #49's body temperature was elevated at 104.0 degrees F. (Normal body temperature 97 to 99 degrees F)
Further review of the nursing progress notes from 01/25/23 to 01/27/23 revealed no documentation the physician was notified of elevated temperatures on 01/25/23 or 01/26/23. The physician was not notified until 01/27/23 when abnormal labs were received.
Further review of Resident #49's progress notes revealed on 01/27/23 at 2:45 P.M. the facility obtained an order for 325 milligrams (mg) of Acetaminophen, give two tablets via percutaneous endoscopic gastrostomy (PEG) tube every six hours as needed for temperature. At 3:18 P.M., the physician was notified of lab work indicating Resident #49 had an elevated white blood cell (WBC) count and Resident #49 also had a temperature of 104 degrees. On 01/27/23 at 11:11 P.M. the hospital was contacted and notified the facility Resident #49 was admitted to the hospital with a diagnosis of pneumonia.
Review of the Medication Administration Record (MAR) for Resident #49 revealed on 01/27/23 at 2:45 P.M. the resident was administered Acetaminophen via PEG tube for a body temperature of 104.
Review of the hospital documentation revealed Resident #49 was admitted to the hospital on [DATE] with health-care associated pneumonia. Resident #49 required intravenous (IV) antibiotics.
Review of Resident #49's progress notes revealed the resident returned to the facility from the hospital on [DATE].
Interview on 02/07/23 at 3:03 P.M. with the Director of Nursing (DON) confirmed Resident #49 experienced a change of condition of an elevated temperature on 01/25/23 and 01/26/23. The DON verified the facility failed to notify the physician of this change of condition and fever on 01/25/23 and 01/26/23. The physician was not notified until later in the day on 01/27/23 after Resident #49's temperature reached 104.0. The DON further verified Resident #49 required hospitalization.
Review of the facility policy titled, Change in Condition, dated 05/30/22 revealed the Charge Nurse will notify the resident's Attending Physician or On-Call Physician where there has been a significant change in the resident's physical/mental/or emotional condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, staff interviews, and review of facility policy, the facility failed to provide activities to residents residing in the facility's Memory Care Unit (MCU). This affected three (Residents #25, #35, and #41) of three residents reviewed for activities. The facility's census was 51.
Findings included:
1. Review of Resident #25's medical records, revealed resident was admitted to the facility on [DATE] with a diagnosis of dementia without behavioral disturbances, cerebrovascular disease, psychotic disorder with delusions due to known physiological condition, diabetes, hypertension, and diverticulosis of intestine.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 had extensive cognitive impairment. His functional status is listed as extensive one to two person assist to totally dependent on staff for activities of daily living.
Review of the care plan dated 07/30/21 revealed Resident #25's daily activity could be affected by admission, auditory deficits, cognitive deficit, decreased vision and general physical decline. Interventions included one on one (1:1) to be done three times a week by activity staff. Schedule activities to allow for limited energy, offer structured activity for intellectual stimulation, modify programs/goals as needed, encourage socialization with others with common interests, and assist resident to and from activities.
2. Review of Resident #35's medical record revealed resident was admitted to the facility on [DATE] with a diagnosis of dementia, psychotic disorder with delusions, depressive and anxiety disorders, Alzheimer's Disease, chronic kidney disease, and diverticulosis of the intestine.
Review of the quarterly MDS dated [DATE] revealed Resident #35 had severe cognitive impairment. Her functional status is listed as extensive one person assists for all activities of daily living.
Review of the care plan dated 08/29/22 revealed Resident #35's daily activity could be affected by admission, auditory deficits, and cognitive deficit. Interventions included assist to and from activities, offer structured activity for intellectual stimulation, provide calendar of events, and divide tasks into segments allowing resident to work at own pace.
3. Review of Resident #41's medical record revealed resident was admitted to the facility on [DATE] with a diagnosis of dementia with behaviors, diabetes, cerebral infarction, hyperlipidemia, hypothyroidism, hypertension, repeated falls, and depression.
Review of the MDS dated [DATE] revealed Resident #41 had extensive cognitive impairment. His functional status is listed as extensive one to two person assist for all activities of daily living except eating and he is a supervise set up only.
Review of the care plan dated 12/13/22 revealed a plan in place for Resident's #41's daily activity could be affected by admission, cognitive deficit. Resident enjoyed the outdoors and talking to people. Interventions included assist to and from activities, assist with radio/television programs as needed, divide tasks into segments allowing resident to work at own pace, encourage feedback regarding activity schedule/calendar, encourage participation, and encourage socialization with others with common interests.
Numerous observations on 02/06/23 and 02/07/23 at various times throughout the annual survey revealed MCU residents were sitting in front of a television with no activities and/or treatment and services for dementia being completed. Residents #25, #35, and #41 were not observed participating in any activities throughout the survey.
Interview with the Activities Director #195 on 02/07/23 at 2:00 P.M. confirmed she was short an activity aide, therefore, activities for the MCU were not being completed. Activities Director #195 indicated the higher functioning residents on the MCU would attend the general activities in the common area.
Review of the February 2023 activities calendar revealed no activities scheduled for the MCU.
Review of the facility policy titled, Resident Rights, undated revealed residents have the right to maintain their highest practicable well-being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of facility policy, the facility failed to notify the physician of Resident #49's elevated temperature for two days. This affected one (Resident #49) of three residents reviewed for physician notification. The facility's census was 51.
Findings include:
Review of Resident #49's medical record revealed he was re-admitted to the facility on [DATE]. Diagnoses included, diffuse traumatic brain injury, anoxic brain damage, fracture of the thoracic vertebra, traumatic subdural hemorrhage, quadriplegia, tracheostomy, gastrostomy, and persistent vegetive state.
Review of Resident #49's the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he had impaired cognition related to his persistent vegetive state. Further review revealed Resident #49 was totally dependent on staff with all areas of activities of daily living (ADLs).
Review of Resident #49's vital signs history revealed on 01/25/23 at 5:38 P.M., Resident #49's body temperature was 101.3. On 01/26/23 at 2:37 P.M., Resident #49's body temperature was 101.9. On 01/27/23 at 7:45 A.M., Resident #49's body temperature was 101.3. On 01/27/23 at 9:54 A.M. Resident #49's body temperature was 99.8. On 01/27/23 at 2:45 P.M., Resident #49's body temperature was 104.0 degrees.
Review of Resident #49's nursing progress notes from 01/25/23 to 01/27/23 revealed no documentation the physician was notified of elevated temperatures on 01/25/23 and 01/26/23. The physician was not notified until 01/27/23 when abnormal labs were received. Resident #49 was hospitalized on [DATE] and diagnosed with pneumonia.
Review of the progress note dated 01/27/23 at 2:45 P.M. the facility obtained an order for 325 milligrams (mg) of Acetaminophen, give two tablets via percutaneous endoscopic gastrostomy (PEG) tube every six hours as needed for temperature. Further review revealed on 01/27/23 at 3:16 P.M. the physician was made aware of lab work indicating Resident #49 had an elevated white blood cell (WBC) count and Resident #49 had a temperature of 104 degrees.
Interview on 02/07/23 at 3:03 P.M. with the Director of Nursing (DON) confirmed Resident #49 experienced a change of condition on 01/25/23. The DON verified the facility failed to notify the physician of this change of condition and fever on 01/25/23 or 01/26/23. The physician was not notified until later in the day on 01/27/23 after Resident #49's temperature reached 104 degrees.
Review of the facility policy titled, Change in Condition, dated 05/30/22 revealed the Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been a significant change in the resident's physical/mental/or emotional condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview, the facility failed to develop and/or implement each resident's plan of care related to contracture management, diabetes management and insulin use, use of an anti-platelet medication, and for medications used to managed inappropriate behaviors. This affected four (#04, #07, #52, and #63) of 20 residents' whose care plans were reviewed. The census was 66 residents.
Findings include:
1. Review of the medical record revealed Resident #04 was admitted to the facility on [DATE]. Diagnoses included multiple sclerosis, anxiety disorder, major depressive disorder, hypertension, and dysphagia.
The facility completed a quarterly minimum data set (MDS) assessment of Resident #04's cognitive and physical functional status dated 09/02/19. The resident was identified as having moderate cognitive deficits, and being dependent on one to two staff person for all of her activities of daily living. The resident was assessed as having functional limitations in her range of motion to both of her upper and lower extremities.
Review of Resident #04's current physician's orders revealed an order on 12/03/19 as follows: may use bilateral palm pillow orthotic twice a day for up to four hours (personal caregiver may do) as tolerated
Review of nursing progress notes revealed an entry by Licensed Practical Nurse (LPN) #15 on 12/03/19. LPN #15 documented Occupational Therapy (OT) clarified to staff to don the resident with the bilateral palm pillows from 9:00 A.M. through 1:00 P.M., and 3:00 P.M. through 7:00 P.M. Daily skin check and range of motion to be completed.
Review of Resident #04's current plan of care through 12/12/19 revealed a plan of to address the resident's problem/need related to bilateral contractures of her hand and feet. The goal was for the resident to be comfortable and have relief through the next review. The new interventions relating to the application of the palm pillows daily had not been added as of 12/09/19.
On 12/10/19 at 10:16 A.M., LPN #11 was asked to view Resident #04's hands, with the resident's permission. Resident #4 smiled and stated yes. The resident was observed with severe contractures of the wrist and hands, with her fingers directed downward, and her fingernails were very long. There were no palm pillows/protectors evident. LPN #11 did not voice awareness that the palm pillows were supposed to be in place at that time, but did note the resident's fingernails were long.
On 12/10/19 at 12:51 P.M., State Tested Nurse Aide (STNA) #36 who was caring for Resident #04 at that time was asked if the resident every wore any protective devices to her hands, like palm protectors or palm pillows. STNA #36 stated that the resident did not wear any devices in her hands, that she was never told anything about any devices for the resident. She shared that she had taken care of the resident at a previous facility where the resident did have something for her hands/palms. STNA #36 was then asked to view the resident's hands with permission from the resident. Resident #4 gave permission, and STNA #36 gloved and showed this surveyor the resident's hands. The nurse aide affirmed the resident did not have any palm pillows present, and there was white matter in her palms and at the base of her thumb. Resident #04 was asked at that time if she had been wearing any thing in her hands that morning, and the resident stated no.
Review of the care card (Kardex) sheet for Resident #04 revealed an entry at the bottom written in pencil regarding the palm pillows. The penciled in entry was not dated, and did not specify a wearing schedule. The entry only specified that the resident may use bilateral palm pillow orthotic twice daily up to four hours, and personal caregiver may apply. The Kardex entry did not specify if it was four hours total daily, or four hours at wearing interval, or the specified hours to be worn.
An interview was conducted with Resident #04's personal caregiver on 12/10/19 at 6:06 P.M. The personal caregiver explained she or another caregiver was with the resident about 8 hours a day, seven days a week. She stated the resident did have palm pillows but they were too large, they slide off. The caregiver shared that the resident either needed a smaller version, or Velcro needed to be added to make the palm pillows smaller. She then pointed to instructions regarding the palm pillows taped to the wall in the resident room, stating that it was just posted this past week. The posted scheduled specified the resident was to wear the palm pillows from 9:00 A.M. through 1:00 P.M., and 3:00 P.M. through 7:00 P.M.
An interview was conducted with Certified Occupational Therapy Aide (COTA) # 89 on 12/11/19 at 11:42 A.M. regarding Resident #04's palm pillows. She affirmed the resident was discharged from OT on 12/02/19, and was supposed to be wearing the palm pillows twice a day for up to four hours each time.
2. Resident #52 was admitted to the facility on [DATE] with diagnoses including heart failure, dysphagia, protein calorie malnutrition, coronary atherosclerosis due to calcified coronary lesion, hyperglycermia, and hypertension.
The facility completed a quarterly MDS assessment of the resident's cognitive status dated 11/04/19. The resident was assessed as having moderate cognitive impairment, but was alert to himself, place, time, and situation on interview on 12/09/19.
Review of Resident #52's current physician's order revealed the resident had an order to receive 75 milligrams (mg)of Clopidagrel daily, a medication to inhibit platelet aggregation.
Review of Resident #52's comprehensive plan of care failed to reveal a plan of care to address the resident's potential or current problems/needs related to the use of the anti-platelet medication.
During interview with Resident #52 on 12/09/19 at 1:15 P.M. the resident expressed concerns regarding a few red circular bruised areas on both arms. The resident indicated he noticed it a few weeks ago and also shared that he had fallen recently.
An interview was conducted with LPN #15 on 12/11/19 at 10:23 A.M. regarding Resident #52's concerns about the red areas/bruising on his arms. She reported the resident had a fall, and also had blood work recently. LPN #15 stated the resident was on a medication, and named an anticoagulant medication not an anti-platelet medication, and that it took a long time for his bruises to resolve.
An interview was conducted with MDS nurse, Registered Nurse (RN) #05 on 12/11/19 at 4:34 P.M. regarding the lack of a plan of care for Resident #52's use of an anti-platelet medication. RN #05 reviewed the resident's care plan and affirmed there was no care plan to address the potential problems/needs related to the resident's use of the anti-platelet medication and it should have been care planned.
3. Resident #63 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus type 2, psychotic disorder with delusions, mood disorder, hypertension, major depressive disorder, and age related osteoporosis.
The facility completed a comprehensive assessment of Resident #63's cognitive and physical functional status on 11/15/19. The 11/15/19 assessment identified the resident as having short and long term memory problems, inattention, disorganized thinking, and requiring the physical assistance of at least one staff person to complete all activities of daily living.
Review of Resident #63's current physician's orders, and November and December 2019, medication administration record revealed the resident was receiving short acting Novolog insulin four times daily as needed per sliding scale, and long acting Levimir insulin each morning.
Review of Resident #63's comprehensive plan of care failed to reveal any care plan regarding the resident's problems/needs related to use of insulin subsequent to her diagnoses of diabetes mellitus.
On 12/02/19 RN #125 made an entry into Resident #63's progress notes. RN #125 noted a new physician order to change the Levemir to morning dosing to 100 units a day, and to add a sliding scale at bedtime of Novolog related to type 2 diabetes mellitus, and to fax the blood sugars next Monday.
An interview was conducted with LPN #15 on 12/12/19 at 12:47 P.M. regarding Resident #63's new insulin orders. She reported the resident did received short acting insulin as needed per sliding scale with meals and at bedtime, and long acting insulin also. She shared the resident's physician recently changed the long acting insulin Levemir from evening to morning as the resident's morning blood sugar was running low.
On 12/11/19 at 2:10 P.M. MDS nurse, RN #05 was asked to review Resident #63's plan of care for any care plan which addressed the resident's use of insulin and diabetes management. RN #05 reviewed the care plan and affirmed no care plan had been developed related to the resident's need for insulin and management of her diabetes.
4. Review of Resident #07's medical record revealed an admission date of 09/17/15 with diagnoses including dementia with behavioral disturbance, major depressive disorder and anxiety disorder.
Review of Resident #07's MDS dated [DATE] revealed the resident required supervision for bed mobility and transfer. The resident required extensive one-person assistance for dressing, personal hygiene and toileting. The resident was independent with eating. The resident had no identified behaviors.
Review of Resident #07's plan of care dated 09/05/19 revealed no focus or interventions related to inappropriate sexual behaviors or for the use of the medication Medroxyprogesterone (Provera).
Review of Resident #07's physician order dated 09/17/15 revealed Medroxyprogesterone Acetate 10 milligram (mg)tablet. Give one tablet by mouth one time a day for sexually inappropriate behavior.
Review of the Resident #07's physician progress note dated 11/14/19 identified the resident remained on Provera 10 mg for sexually inappropriate behaviors. Physician's progress note was silent for any recent reported sexual behavior.
Interview on 12/12/19 at 1:22 P.M. with MDS RN #05 confirmed she had not included interventions for the Provera or for the sexually inappropriate behavior. RN #05 confirmed she was not aware of any sexual behaviors in the past year.
Interview on 12/12/19 at 1:33 P.M. with LPN #01 revealed having knowledge of the resident. LPN #01 denied Resident #07 had any sexually inappropriate behaviors in the past year.
Interview on 12/12/19 at 3:40 P.M. with the Director of Nursing (DON) denied the facility was monitoring Resident #07 for sexual behaviors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to ensure a resident was monitored for sexual behaviors related to the use of medication. This affected one (Resident #07) of six residents reviewed for unnecessary medications. The facility census was 66.
Findings include:
Review of Resident #07's medical record revealed an admission date of 09/17/15 with diagnoses including dementia with behavioral disturbance, major depressive disorder and anxiety disorder.
Review of Resident #07's Minimum Data Set (MDS) dated [DATE] revealed the resident required supervision for bed mobility and transfer. The resident required extensive one-person assistance for dressing, personal hygiene and toileting. The resident was independent with eating. Resident #07's had no identified behaviors.
Review of Resident #07's plan of care dated 09/05/19 revealed no focus or interventions related to inappropriate sexual behaviors or the medication Medroxyprogesterone (Provera).
Review of Resident #07's physician order dated 09/17/15 revealed Medroxyprogesterone Acetate 10 milligram (mg) tablet. Give one tablet by mouth one time a day for sexually inappropriate behavior.
Review of the Resident #07's Physician progress note dated 11/14/19 identified the resident remained on Provera 10 mg for sexually inappropriate behaviors. Physician's progress note was silent for any recent reported sexual behavior.
Interview on 12/12/19 at 1:22 P.M. with MDS Registered Nurse (RN) #05 confirmed she had not included interventions for the Provera or for the sexually inappropriate behavior. RN #05 confirmed she was not aware of any sexual behaviors in the past year.
Interview on 12/12/19 at 1:33 P.M. with Licensed Practical Nurse (LPN) # 01 revealed having knowledge of the resident. LPN #01 denied Resident #7 had any sexually inappropriate behaviors in the past year.
Interview on 12/12/19 at 3:40 P.M. with the Director of Nursing (DON) denied the facility was monitoring Resident #07 for the sexual behaviors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview, the facility failed to ensure that a resident with a limited range of motion received appropriate treatment to prevent further decreases in range of motion and to improve comfort. This involved one (Resident #04) of three residents reviewed for positioning/mobility.
Findings include:
Review of the medical record revealed Resident #04 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, anxiety disorder, major depressive disorder, hypertension, and dysphagia.
The facility completed a quarterly minimum data set (MDS) assessment of Resident #04's cognitive and physical functional status dated 09/02/19. The resident was identified as having moderate cognitive deficits, and being dependent on one to two staff person for all of her activities of daily living. The resident was assessed as having functional limitations in her range of motion to both of her upper and lower extremities.
Review of Resident #04's current physician's orders revealed an order on 12/03/19 as follows: may use bilateral palm pillow orthotic twice a day for up to four hours (personal caregiver may do) as tolerated
Review of nursing progress notes revealed an entry by Licensed Practical Nurse (LPN) #15 on 12/03/19. LPN #15 documented that Occupational Therapy (OT) clarified to staff to don the resident with the bilateral palm pillows from 9:00 A.M. through 1:00 P.M., and 3:00 P.M. through 7:00 P.M. Daily skin checked and range of motion to be completed.
Review of Resident #04's current plan of care through 12/12/19 revealed a plan to address the resident's problem/need related to bilateral contractures of her hand and feet. The goal was for the resident to be comfortable and have relief through the next review 12/12/19. The new interventions related to the application of the palm pillows daily had not been added as of 12/09/19.
On 12/10/19 at 10:16 A.M. LPN #11 was asked to view Resident #04's hands, with the resident's permission. Resident #04 smiled and stated yes. The resident was observed with severe contractures of the wrist and hands, with her fingers directed downward, and her fingernails were very long. There were no palm pillows/protectors evident. LPN #11 did not voice awareness that the palm pillows were supposed to be in place at that time, but did note the resident's fingernails were long.
On 12/10/19 at 12:51 P.M. State Tested Nurse Aide (STNA) #36 who was caring for Resident #04 at that time was asked if the resident every wore any protective devices to her hands, like palm protectors or palm pillows. STNA #36 stated that the resident did not wear any devices in her hands, that she was never told anything about any devices for the resident. She shared that she had taken care of the resident at a previous facility where the resident did have something for her hands/palms. STNA #36 was then asked to view the resident's hands with permission from the resident. Resident #04 gave permission, and STNA #36 gloved and showed this surveyor the residents hands. The nurse aide affirmed the resident did not have any palm pillows present, and there was white matter in her palms and at the base of her thumb. Resident #04 was asked at that time if she had been wearing any thing in her hands that morning, and the resident stated no.
Review of the care card ([NAME]) sheet for Resident #04 revealed an entry at the bottom written in pencil regarding the palm pillows. The penciled in entry was not dated, and did not specify a wearing schedule. The entry only specified that the resident may use bilateral palm pillow orthotic twice daily up to four hours, and personal caregiver may apply. The [NAME] entry did not specify if it was four hours total daily, or four hours at wearing interval, or the specified hours to be worn.
An interview was conducted with Resident #04's personal caregiver on 1210/19 at 6:06 P.M. The personal caregiver explained she or another caregiver was with the resident about eight hours a day, seven days a week. She stated the resident did have palm pillows but they were too large, and they slide off. The caregiver shared that the resident either needed a smaller version, or Velcro needed to be added to make the palm pillows smaller. She then pointed to instructions regarding the palm pillows taped to the wall in the resident room, stating that it was just posted this past week. The posted scheduled specified the resident was to wear the palm pillows from 9:00 A.M. through 1:00 P.M., and 3:00 P.M. through 7:00 P.M.
An interview was conducted with Certified Occupational Therapy Aide (COTA) #89 on 12/11/19 at 11:42 A.M. regarding Resident #04's palm pillows. She affirmed the resident was discharged from OT on 12/02/19, and was supposed to be wearing the palm pillows twice a day for up to four hours each time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and representative/family interview and staff interview, the facility failed to ensure that one resident received treatment and care to maintain proper and comfortable positioning while in a wheel chair. This affected one (Resident #16) of three residents reviewed for positioning/mobility.
Findings include:
Review of the medical record revealed Resident #16 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, moderate protein calorie malnutrition (PCM), dementia with behavioral disturbance, anxiety disorder, repeated falls, dysphagia, and bilateral hearing loss. The resident was admitted to in-facility hospice services on 11/15/19 with an admitting diagnoses of PCM.
The facility completed an admission minimum data set (MDS) assessment of the resident's cognitive and physical functional status on 09/18/19. The 09/18/19 assessment identified the resident as having short and long term memory problems with severely impaired cognitive skills, and requiring limited to extensive assistance by one to two staff persons to completed all activities of daily living. The resident utilized a wheel chair propelled by others for mobility.
Review of Resident #16's physician's orders revealed an order date 11/12/19 for the resident to utilize a high back tilt-in-space wheel chair with a lap tray at all times. The order specified for the lap tray to be removed for 10-15 minutes ever two hours, and the resident must be supervised during that time.
While there was an assessment evident for Resident #16's use of the lap tray in an existing wheel chair on 10/18/19. There was no re-assessment evident in the medical record prior regarding the use of the new high back tilt-in-space wheel chair with lap tray ordered on 11/12/19 related to the resident's positioning and comfort in the new wheel chair.
Resident #16 was observed passively attending an activity in the large activity room on 12/09/19 at 9:47 A.M. The resident was seated in a high back wheel chair with a padded lap tray and foot rests. The resident did not keep her feet in the foot rests, and her feet were dangling underneath the chair and her toes barely touched the floor. Resident #16 was wearing non-skid socks.
On 12/09/19 at 1:47 P.M. an interview was conducted with Resident #16's representative/family member. The family member was questioned about the high back wheel chair and lap tray, and was asked if the resident was comfortable in the chair. The family member shared that the resident's feet dangle somewhat in the chair, and that they barely touched the floor, and to him that would probably be uncomfortable.
ON 12/10/19 at 4:34 P.M. Resident #16 was observed up in the common area near the 200/300 nursing station in the high back wheel chair with the lap tray in place. The residents knees hung down from the wheel chair seat which had pads, and her ankle extended, with only her toes touching the floor. The resident was not able to propel the chair on her own, and was not able to answer questions regarding her comfort at that time due to her advanced dementia. Resident #16 remained up in the wheel chair near the nursing station until at least 6:09 P.M. with her feet dangling under the chair and toes pointed downward.
On 12/11/9 at 11:30 A.M. Certified Occupational Therapy Assistant (COTA) #89 was asked to check to see if Resident #16 had received any OT evaluation or treatment for wheel chair management/positioning. She reported that she had not, and potentially was not referred to OT as she was receiving hospice care, and the chair was most likely ordered by nursing or hospice. COTA #89 was then asked to observe the resident with this surveyor, and asked about the fit of the wheel chair related to the resident's comfort and positioning. She affirmed the residents feet dangled while in the chair, and did not fully touch the floor, and that the resident did not keep her feet in the foot rests. COTA #89 was questioned regarding potential negative consequences from the poor positioning, and affirmed it could potentially result in flexion contractures of the knee, and lead to foot drop.
An interview was conducted with the Director of Nursing (DON) on 12/11/19 at 5:45 P.M. regarding Resident #16's positioning, and the resident was observed with the DON. The DON affirmed the resident's feet did not touch the floor and that she would not use the foot rests. She also affirmed there was no assessment evident in the medical record of the resident's positioning/comfort in the high back wheel chair.
On 12/11/19 at 5:59 P.M. a nurse documented in Resident #16's nursing progress noted that there was a new order received from the hospice provider for the resident to have a foot cradle to the wheel chair for leg/foot positioning.