Schoenbrunn Healthcare

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records, review of facility policies and procedures, staff and resident observations and interviews, the facility failed to ensure the privacy of Resident #3 during incontinence care. This affected one resident (#3) of one resident reviewed for incontinence care. The facility census was 86. Findings include:Review of the medical record for Resident #3 revealed admission to the facility on [DATE] with diagnoses including lung disease, heart failure, diabetes, anxiety, gastric reflux, high blood pressure, arthritis, and a bleed of the gastric system. Further review of the medical record revealed a quarterly minimum data set (MDS) assessment was completed on 01/14/26. The MDS assessment revealed Resident #3 was cognitively intact and was dependent on staff with personal hygiene, toileting, bathing, dressing, transfer and mobility. The MDS assessment also indicated Resident #3 was always incontinent of both bowel and bladder.Observation on 03/25/26 at 8:58 A.M. of incontinence care of Resident #3 revealed certified nurse's aide (CNA) #137 gathering appropriate supplies and entering the double occupancy room of Resident #3 and closing the door. Resident #3's roommate was present in the room sitting in his wheelchair. There was an undrawn privacy curtain located in the middle of the room dividing the space. CNA #137 began providing incontinence care of Resident #3 without pulling the privacy curtain to ensure the privacy of Resident #3. Resident #3 was laying in his bed and CNA #137 removed his adult brief exposing his genital area for cleaning then had Resident #3 roll to his left side toward the wall exposing his buttocks to his roommate while she continued to clean Resident #3 buttocks. The privacy curtain was not used at anytime during the care provided by CNA #137.Interview on 03/25/26 at 9:04 A.M. with Resident #3 revealed sometimes the CNAs forget to pull the curtain during incontinence care and it sometimes bothers him that he is exposed to his roommate when he is in the room. CNA #137 was present for interview with Resident #3 and acknowledged she did not pull the privacy curtain for Resident #3 and immediately apologized to him.Review of the facility policy undated and titled Resident Rights, revealed residents have the right to privacy and confidentiality. Further review revealed personal privacy to include personal care.This deficiency represents an incidental finding of non-compliance investigated under Master Complaint Number 2800638.

Based on personnel record review, observation and interview, the facility failed to employ a qualified director of food and nutrition services (Dietary Manager) and educate dietary aides. This affected all 86 residents in the facility. The facility census was 86.Findings include: Interview on 03/23/26 at 9:43 A.M. with the Administrator revealed they have a company called Health Care Services Group (HCSG) that started as a contract company to run the kitchen. The facility uses their employees and conduct oversight.Review of personnel credentials revealed Dietary Manager #217 did not have the qualifications to be a Dietary Manager. She was not certified and her degrees were not in the areas to qualify her for the position, despite her years of working in a kitchen. Interview on 03/23/26 at 11:02 A.M. with Dietary Manager #217 revealed she had been employed by the facility as a cook. When HSCG was contracted they hired the kitchen employees the facility had employed.Interview on 03/24/26 at 4:13 P.M. with Dietary Manager #217 revealed HCSG took over running the kitchen on 10/20/25. Dietary Manager #217 was promoted to manage the kitchen on 12/01/25. She revealed [NAME] #100 was the credentialed Dietary Manager and stepped down when the contract company took over due to the complexity of the computer system. [NAME] #100 informed HCSG she was stepping down as the Dietary Manager at the beginning of November and recommended Dietary Manager #217, who was a Cook, to take over. She informed HCSG at that time Dietary Manager #217 was not credentialed. They informed the facility they would pay for Dietary Manager #217 to take the classes to receive credentials as a Certified Dietary Manager. Dietary Manager #217 verified she had not started classes. She speculated the new company might be waiting to see if she would be able to handle the position before putting money into her training.This deficiency represents non-compliance investigated under Complaint Number 2701233.

Based on observation, test tray, and interview, the facility failed to ensure food was prepared by methods that conserve nutritive value, flavor, and appearance. This had the potential to affect all 86 residents in the facility.Findings include:1.Observation of the lunch meal on 03/23/26 revealed the Lifebridge Unit was the last hall to be served. The dining cart with trays arrived at 1:15 P.M. Observation and interviews related to the meal appearance and palatability revealed on 03/26/26 at 1:25 P.M. Resident #78 was sitting on the side of the bed eating his lunch. The resident appeared to have two bowls of pasta salad on his tray that he was eating with a fork. The surveyor commented related to the pasta salad and Resident #78 revealed the bowls were chicken noodle soup not pasta salad. There was not any broth in either bowl of chicken noodle soup. The resident was eating it with a spoon. The resident indicated he requested two bowls of chicken noodle soup daily for lunch. When asked if they ever have broth he indicated sometimes, they do but usually he has to eat the soup with a fork. Interview and observations on 03/23/26 at 1:40 P.M. with Certified Nurse Aide (CNA) #111 verified Resident #78 received two bowls of chicken noodle soup that did not contain broth.2.Observation of the dinner tray line on 03/23/26 at 5:28 P.M. revealed broccoli was being served in a bowl. The broccoli appeared to not be holding it's shape. At 5:54 P.M. the broccoli was served into a bowl to be tested. The broccoli did not hold shape. The texture was mushy and watery.Interview on 03/23/26 at 6:04 P.M. with [NAME] #106 verified the broccoli always gets mushy. He indicated he cooks it on the stovetop in a tin on low. 3. Observation on 03/24/26 at 1:16 P.M. of Resident #78's lunch meal revealed he had two bowls of pasta on his tray. He was eating them with a fork. Interview on 03/24/26 at 1:16 P.M. with the resident verified the bowls were supposed to contain his chicken noodle soup. One bowl had no visible broth, and the second bowl had a small amount of liquid on the bottom. Dietary Manager #217 was present during the observation and interview. She asked the resident if he would rather have a flat noodle verses the spring noodle and he said yes. She included the spring noodles must be soaking up the broth. Observation of the tin of soup in the kitchen on 03/24/26 at 1:18 P.M. revealed it was dry at the bottom when the noodles were pushed aside. There was no broth in the soup at all. The tin appeared as a tin of noodles with carrots.Dietary Manager #217 was present during the observation. She verified there was not broth in the tin of soup in the kitchen.This deficiency represents non-compliance investigated under Master Complaint Number 2800638, Complaint Numbers 2701233, 2661187.

Based on menu review and interview, the facility failed to ensure appealing options of similar nutritive value were available to residents who chose not to eat food that was initially served or who requested a different meal choice. This had the potential to affect all 86 residents in the facility. The facility census was 86.Findings include:Interview on 03/23/26 at 11:02 A.M. with Dietary Manager #217 revealed the kitchen needed major plumbing work where the cement floor was removed in areas to access broken pipes in the kitchen and dry storage. They had no use of the kitchen during 19 days of replacing the pipes and re-cementing the floor. An alternative menu was approved by corporate to be able to serve meals from the dining room using roasters, crockpots, microwave, griddle, and a waffle maker. Between 02/26/26 and 03/16/26 meals were made out of the dining room and were not cooked in the kitchen. There was only one choice for each meal. There were no second option and the only substitutes available were a peanut butter and jelly sandwich and a deli sandwich. Interview on 03/23/26 at 1:28 P.M. with Resident #72 revealed there are no second options or substitute items. He does not get to order. They just give him what they want and he doesn't like the peas and carrots and rice he had on his plate.Interview and observation on 03/23/26 at 1:33 P.M. with Resident #78 revealed his meal ticket included he wanted chocolate milk, which was not served on his tray,Interview and observation on 03/23/26 at 1:35 P.M. with Resident #48 revealed she does not order. She is just served whatever they give her. Her preference was to get two percent milk, cranberry juice and fruit punch on her tray. She only was served the fruit punch.Interview and observation on 03/23/26 at 1:42 P.M. with Resident #71 during the lunch meal revealed when the kitchen was down, she was served burnt pizza with no other option. She indicated even when she tells them what she wants she doesn't usually get it. Her ticket indicated she was to receive ice for every meal which was not delivered on her tray. She was also to receive fruit punch per her lunch ticket which was not delivered on her lunch tray.Interview on 03/25/26 at 2:36 P.M. with Dietary Manager #217 verified they did not have a second meal of similar nutritional value available during the kitchen shut down. Further verified, they are training new kitchen dietary aides and with the kitchen in the dining room and just moving back to the kitchen on 03/18/26 she had not given them the time they need for training for their duties including the tray line.This deficiency represents non-compliance investigated under Master Complaint Number 2800638, Complaint Numbers 2789794, 2661187.

Based on record review, observation and interview, the facility failed to ensure adaptive equipment was available as ordered. This affected one resident (#49) of six residents reviewed who were ordered adaptive equipment for meals. The facility census was 86.Findings include:Review of Resident #49's medical record revealed a 09/20/23 admission with diagnoses including hypertensive urgency, renal dialysis, glaucoma, and legally blind.Review of the quarterly 01/13/26 Minimum Data Set (MDS) Assessment revealed he was independent for daily decision making and required set up for meals. Physician orders included a renal diet, regular texture, thin consistency, double protein no orange juice, no bananas, no potatoes, 1800 milliliter fluid restriction with blue scoop bowl and plate guard for renal failure.Observation of the supper tray line on 03/23/26 at 5:28 P.M. revealed the meal was cheeseburger on a bun, broccoli, tater tots, and pineapple tidbits.The ticket for Resident #49 included he was to have a blue scoop bowl and a plate guard. The tray only had a plate guard.Interview on 03/23/26 at 5:40 P.M. with Dietary Aide #107 revealed she did not have any blue scoop plates. She included there used to be about 10 and now they can not find any. Dietary Manager #217 included she went to the room and floor and could not find any. She included she is having the Administrator buy some.Observation of the lunch tray line on 03/24/26 revealed the first tray was plated at 11:36 A.M. At 11:58 A.M. it was revealed there were no scoop bowls for Resident #49's meal. The lunch meal was smothered chicken thigh, whole kernel corn, oven brown potatoes, cornbread and sliced pears. Interview on 03/24/26 at 11:58 A.M. with [NAME] #104 revealed they had three of them (scoop bowls) and now they can not find any.Interview on 03/25/26 at 9:35 A.M. with [NAME] #104 revealed they still had not found or obtained any blue scoop bowls.Interview on 03/25/26 at 9:43 A.M. with Dietary Manager #217 revealed scoop bowls were ordered 03/23/26 and were due to be delivered 03/26/26.This deficiency represents an incidental finding of non-compliance investigated under Master Complaint Number 2800638.

Based on observation, interview, record review, and policy review, the facility failed to store, prepare and serve food under sanitary conditions. This had the potential to affect all the residents in the facility. The facility census was 86.Findings include: 1.Observation of the kitchen on 03/23/26 at 2:40 P.M. revealed the large garbage can in the kitchen near the prep table and three compartment sink did not have a lid covering. On 03/23/26 observation at 5:12 P.M. revealed the trash was piled above the top of the large garbage cans. Dietary Aide #105 was placing pineapple in cups and covering them with saran wrap on the prep table by the trash can.Observation of the kitchen on 03/24/26 at 11:08 A.M. revealed the trash can by the prep table did not have a lid. There were large cans piled high over the top of the trash can. At 1:17 P.M. the trash was still over flowing the top of the garbage can without a lid. Interview 03/24/26 at 1:20 P.M. with Dietary Manager #217 verified the garbage can was not covered with a lid.2. Observation of the supper tray line on 03/23/26 at 5:12 P.M. revealed tray line temperatures were taken. There was no observation of the temperature of the milk being obtained. At 5:46 P.M. the surveyor asked for the milk to be tested when placed on a tray. The milk was 40 degrees Fahrenheit.Observation of the kitchen on 03/24/26 at 11:08 A.M. revealed there were five cups of milk poured and dated 03/24/26 on the three compartment sink with the milk gallon next to them. At 11:29 A.M. when the tray line began the glasses of milk were placed on a tray in the milk chest by Dietary Manager #217.At 11:50 A.M. a glass of milk was removed from the milk chest and placed on a tray. The surveyor asked for a temperature reading of the milk. The temperature was 46.9 degrees Fahrenheit. On 03/24/26 at 11:52 A.M. [NAME] # 104 verified the temperature of the milk was not obtained before the tray line started. The milk was above the 41 degree guideline for refrigeration.Review of the food temperature logs for March 2026 revealed there were 71 meals served. There was not a milk temperature reading for 47 of the 71 meals. Interview on 03/24/26 at 1:22 P.M. with Dietary Manager #217 verified the milk temperatures were not consistently monitored.Review of the facility's Record of Food Temperatures policy revised 2022 included potentially hazardous cold food temperatures will be kept at or below 41 degrees Fahrenheit. Food temperatures will be verified using a thermometer which is both clean, sanitized and calibrated to ensure accuracy.3. Observation of the kitchen milk chest on 03/23/26 at 2:53 P.M. revealed the thermometer read 40 degrees. There were eight cartons of 1% milk with a use by date of 03/23/26 in the milk chest.Observation of the milk chest on 03/24/26 at 1:22 P.M. revealed there were six cartons of 1 percent milk in the milk chest.Interview on 03/24/26 at 1:22 P.M. with [NAME] #104 revealed she used two of the milk cartons for trays on 03/24/26 not realizing the use by date was 03/23/26. The milk was served to Resident #21.This deficiency represents non-compliance investigated under Master Complaint Number 2800638, and Complaint Numbers 2789794, 2701233, and 2661187.

Based on medical record review and interview the facility failed to ensure medications for the treatment of respiratory illness were implemented timely and administered per orders and failed to ensure diagnostic testing results were timely available. This affected one (Resident #1) of one residents reviewed for respiratory care. The facility census was 76.Findings include: Medical record review revealed Resident #1 was admitted to the facility 06/29/23 with diagnoses including pneumonia, chronic respiratory failure with hypoxia, and diabetes. Review of Resident #1's chest x-ray results dated 06/30/25 revealed the resident had some opacities representing penumonitis. A computed tomography (CT) was recommended (of the chest).Review of Resident #1' s plan of care revealed two pneumonia plans of care were initiated on 07/02/25 however no interventions were initiated. Review of Resident #1's nurse practitioner note dated 07/03/25 revealed the resident had respiratory failure with hypoxia. New orders to schedule CT scan. Review of Resident #1's medical record revealed on 07/03/25 a CT was ordered for pneumonia and the CT scan was completed on 07/11/25. Review of Resident #1's physician note dated 07/08/25 revealed the resident had acute respiratory failure with minimal improvement. New orders to start Prednisone 20 milligrams (mg) daily for five days. Review of the physician orders July 2025 revealed the Prednisone 20 mg daily for five days was not entered until 07/09/25.Review of Resident #1's Medication Administration Record (MAR) for July 2025 revealed the Prednisone was not started until 07/10/25, two days after it was ordered, and the resident was only administered four doses of five ordered. The CT results were completed on 07/21/25 and showed the resident had right lower lobe pneumonia, multifocal bronchitis and probable subacute, age undetermined thoracic vertebra compression fracture.Further review of Resident #1's physician orders revealed on 07/22/25 Rocephin (antibiotic) one gram (gm) intramuscularly once daily for seven days for pneumonia was ordered.Review of Resident #1's MAR for July 2025 revealed the Rocephin was not administered on 07/22/25 or 07/23/25 due to the medication was not available. The resident only received six doses from 07/24/25 to 07/29/25 and then it was discontinued. There was no documented evidence a new order was written to extend one more additional day to ensure the resident received seven days/doses of the Rocephin. Review of Resident #1's progress note dated 07/24/25 revealed the initial dose of Rocephin was administered left gluteal area. Interview on 07/31/25 at 9:50 A.M., with the Infection Preventionist (IP)/Assistant Director of Nursing (ADON) #115 confirmed Resident #1's Prednisone was ordered on 07/08/25 and not started until 07/10/25 and the resident only received four of the five doses ordered. The IP/ADON also confirmed Resident #1 had a CT done on 07/11/25, however the results were not completed and sent to the facility until 07/21/25. The IP/ADON confirmed the resident was ordered Rocephin on 07/22/25 and it was not started until 07/24/25 due to it being not available. Further interview revealed the facility only administered six days/doses of the medication (from 07/24/25 through 07/29/25) and then it was discontinued and not extended despite the delay with initiating the medication. Once the omitted dose was brought to the facility's attention through this interview, the IP/ADON got the order extended one additional day. Lastly, it was confirmed there were no care planned interventions related to the resident's pneumonia.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the medical record, interview with staff and policy review, the facility failed to ensure fall interventions were in place for Resident #12. This affected one resident (Resident #12) of five reviewed for accidents.Findings include: Review of the medical record revealed Resident #12 was admitted to the facility on [DATE]. Diagnoses included atherosclerotic heart disease, severe protein calorie malnutrition, malignant neoplasm of the prostate, depression, peripheral vascular disease, adult failure to thrive, history of falling, transient ischemic attack, fracture of the fifth metatarsal of the left hand, emphysema, dementia, and hypertension.Review of the plan of care dated 11/01/24 revealed Resident #12 had a potential for falls related to history of falls, cachexia, and unsteady gait. Interventions did not include wearing hipsters. Review of the Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #12 had moderately impaired cognition and had one fall with injury. Review of the physician ' s orders revealed Resident #12 had an order for hipsters (protective hip pads) on at all times, remove every shift to check skin integrity dated 07/02/25. Observation on 07/28/25 at 9:15 A.M. and 10:58 A.M. revealed Resident #12 was in bed on his back with the sheet pulled down to expose his incontinence brief. He did not have his ordered hipsters on while in bed. An interview on 07/28/25 at 11:11 A.M. with Certified Nursing Assistant (CNA) #223 verified Resident #12 did not have his ordered hipsters on in bed. Review of the undated facility policy titled, Fall Management, revealed the facility would identify each resident who was at risk for falls and would develop a plan of are and implement interventions to manage falls, The facility would provide an environment that was free from potential hazards.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure residents had a comprehensive treatment plan in place for the use of hand splints to improve or maintain mobility. This affected one (Resident #60) of one residents reviewed for mobility. The census was 76. Findings include: Review of Resident #60 ' s medical record revealed the resident was admitted on [DATE] with diagnosis including multiple sclerosis, marasmic kwashiorkor, hypertension, major depressive disorder, and obstructive and reflux uropathy. Review of Resident #60 ' s Annual Minimum Data Set (MDS) dated [DATE] revealed no restorative days or minutes for splint or brace assistance, no impairment to the resident's upper extremities.Review of Resident #60 ' s physician orders revealed a resting wrist/hand splint to the left hand once daily for up to four hours on dayshift dated 04/25/25. Review of Resident#60 ' s care plans did not identify a resting hand splint.Review of Review of Resident #60's medication administration records and treatment administration records from July 2025 revealed no documentation the left resting hand splint was applied as ordered.Interview on 07/31/25 at 2:15 P.M. with Director of Nursing (DON) verified the resting hand splint is a nursing order and staff should be putting it on and verified staff has not been signing off on administration.Observation on 07/31/25 at 2:34 P.M. with therapy #152 revealed Resident #60's left wrist was contracted with no resting hand splint in place. Therapy stated they initiate the splint and then nursing takes over after that.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interview, and policy review the facility failed to ensure residents who required staff assistance with activities of daily living received showers per schedule and preferences. This affected two (Resident #4 and #46) of two residents reviewed for shower preferences. Findings include: 1. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with diagnoses of peripheral vascular disease, above left knee ambulation, heart failure, chronic obstructive pulmonary disease, chronic kidney disease, non-pressure ulcers, neuromuscular dysfunctional bladder, diabetes, legally blind, and chronic pain. Review of Resident #4 ' s orders dated 07/2025 revealed on 05/28/25 the resident was ordered showers on Monday, Wednesday, and Fridays per the resident ' s preference. Document refusals in the progress notes. Review of Resident #4 ' s Activity of Daily Living (ADL) care plan dated 05/02/16 and revised on 06/18/2020 revealed the resident required extensive assist of one staff member with bathing/showering three times weekly on Sunday, Tuesday and Thursday dayshift and as necessary. Review of Resident #4 ' s right to make lifestyle changes plan of care dated 05/11/16 and revised 04/23/21 revealed the resident preferred showers. Review of Resident #4 ' s significant change minimum data set (MDS) dated [DATE] revealed it was very important for the resident to choose type important is it to you to choose between a tub bath, shower, bed bath, or sponge bath. Review of Resident #4 ' s quarterly MDS dated [DATE] revealed no evidence the resident had rejected care. Review of the Resident #4 ' s bathing documentation dated 07/01/25 to 07/31/25 revealed no evidence that the resident had received a shower in the last 31 days. There was no documentation the resident had refused a shower. Review of Resident #4 ' s progress notes dated 07/01/25 to 07/31/25 revealed no documented evidence that the resident had refused a shower. Review of Resident #4's hospice note dated 05/02/25 revealed the resident would be seen twice a week for bed baths. The resident was dependent on staff for activities of daily living. Interview on 07/29/25 at 10:20 A.M., with Resident #4 revealed she had only received bed baths lately and she preferred to have a shower. Interview on 07/31/25 at 11:00 A.M., with Medical Record Clerk (MRC) #112 confirmed in the last 30 days Resident #4 was not provided with a shower per the resident's preference, orders and plan of care. The MRC reported currently she had Resident #4 on the shower schedule for Monday and Fridays, due to the resident being under hospice services and the hospice aides only come twice a week on Monday and Fridays. The MRC reported she would talk to the resident and hospice to work out a schedule to meet the resident preference for showers. 2. Medical record review revealed Resident #46 was admitted to the facility on [DATE] with diagnoses including ends stage renal disease, diabetes, legally blind, difficulty walking, weakness, and history of falls. Review of the annual modification MDS dated [DATE] revealed it was very important important is it to you to choose between a tub bath, shower, bed bath, or sponge bath. Review of quarterly MDS dated [DATE] revealed no evidence of the refusal of care and the resident required partial to moderate assistance with showering. Review of Resident #46's activity of daily living plan of care initiated 01/20/25 and revised 02/26/25 revealed the resident required partial/moderate assistance with bathing. Review of Resident #46's preference plan of care dated 01/04/23 revealed the resident would participate in choosing a bathing schedule that meets my preference and needs. Review of progress notes dated 07/01/25 to 07/31/25 revealed no evidence the resident refused showers. Review of resident's shower documentation (paper and electronic medical records) dated 07/2025 revealed the resident did not get a shower on 07/06/35, 07/20/25 and 07/27/25 Interview on 07/28/2025 at 2:53 P.M. with Resident #46 revealed his shower days were Tuesday, Thursday, and Sundays, however the doesn't get them three times a week and the staff forgets about him. Interview on 08/04/25 at 8:26 A.M., with MRC #112 confirmed it may have been her fault the resident didn't receive showers on Sundays in July 2025 because she only had the resident on the shower schedule for Tuesday and Thursday. MRC #112 confirmed there was no documented evidence the resident had received a shower on Sunday in July on 07/06/25, 07/20/25 and 07/27/25. The MRC confirmed she did not have access to the plan of care to update the resident's shower preferences. Review of the facility's policy and procedure dated 2024 revealed it was the facility's practice of this facility to assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues as per current standards of practice. Resident would be provided showers as per request or as per facility schedule protocols and based up resident safety.

Based on interview and record review the facility failed to ensure antibiotic use was appropriate according to antibiotic stewardship protocols. This affected one resident (Resident #74) of three residents reviewed for antibiotics use. Facility census was 76.Findings include: Record review revealed Resident #74 an admission date of 06/22/22 with diagnosis including type II diabetes, neuralgia and neuritis, depression, anxiety and dementia.Review of the annual minimum data set (MDS) completed 04/14/25 revealed the resident had intact cognition and was frequently incontinent of urine and always incontinent of bowel.Review of the physician orders revealed a urinalysis with culture and sensitivity due to an elevated white blood cell count dated 07/17/25. The report returned on 07/21/25 with results showing 60,000-70,000 colony forming units per milliliter (cfu/ml) Escherichia Coli (E Coli) bacteria, 60-70,000 cfu/ml proteus mirabilis bacteria with possible extended-spectrum beta lactimase (ESBL). The resident started Tobramycin (antibiotic) solution 100 milligrams (mg) intramuscularly (IM) every 12 hours for seven days. Further review of the medical record revealed the McGeer Criteria (Fever or chills, new or worsening urgency, frequency, suprapubic pain, gross hematuria (blood in the urine), or dysuria (painful urination) and no more than two species of bacteria in the urine with a cfu/ml of 100,000 or greater) for Infection Surveillance Checklist-V 4 form dated 07/17/25 revealed Resident #74 did not meet criteria for antibiotic usage. The nurse practitioner was notified Resident #74 did not meet criteria; however the antibiotic was not discontinued.Interview on 08/04/25 at 2:00 P.M. with the Assistant Director Nursing (ADON) confirmed Resident #74 did not meet criteria for antibiotic usage however, the resident continued to receive the antibiotic ordered. Review of facility policy titled Antibiotic Stewardship Program revealed laboratory testing shall be in accordance with the current standards of practice. The facility uses the (CDC ' s NIISN Surveillance definitions, updated McGeer criteria, or other surveillance tool) to define infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, interview, and policy review the facility failed to ensure infection control practices were maintained during wound care, dining, incontinence care, and medication administration. This had the potential to affect all 78 resident residing in the facility. Based on medical record review, observation, interview, and policy review the facility failed to ensure infection control practices were maintained during wound care, dining service, incontinence care, and medication administration. This affected Resident #3, #4, #9, #40, #43, #51 and #63 but had the potential to affect all 76 residents residing in the facility.
Findings include:
1. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with diagnoses of peripheral vascular disease, above left knee ambulation, heart failure, chronic obstructive pulmonary disease, chronic kidney disease, non-pressure ulcers, neuromuscular dysfunctional bladder, diabetes, legally blind, and chronic pain.
Review of Resident #4's orders dated 07/2025 revealed enhanced barrier precautions with high contact resident care activity.
Review of Resident #4's wound care orders dated 07/2025 revealed cleanse right lateral foot with normal saline, pat dry, apply medihoney, collagen and calcium alginate, and cover with abdominal pad, and wrap with kerlix Tuesday, Thursday, and Saturday. The right posterior ankle order included to cleanse with normal saline, apply skin prep, cover with abdominal pad and wrap with kerlix Tuesday, Thursday, and Saturday.
An. observation and interview on 07/29/25 at 10:00 A.M., revealed Licensed Practical Nurse (LPN) #122 and Wound Nurse Practitioner (WNP) #250 were observed in Resident #4's room without gowns applied while performing wound care and assessing Resident #4's wound on her right foot. LPN #122 removed the old dressing from Resident #4's right foot without evidence of a gown on. The LPN confirmed the old dressing had a scant amount of brown drainage. The WNP measured the resident's wound without a gown and reported the resident had two open areas on her right foot. The outer foot wound measured 3.2 centimeters (cm) by 0.9 cm by 0.2 cm and was treated with medihoney and alginate and the ankle was 1.1 cm by 0.2 and depth was undetermined and treated with skin prep. LPN #122 confirmed Resident #4 was on enhanced barrier precautions (EBP) because the resident had a catheter. The LPN was not aware she was required to wear a gown during wound care. The LPN confirmed the sign on the resident door indicated the resident was on EBP and provider and staff were required to wear gloves and gowns with high contract resident care activities including wound care (any skin opening requiring a dressing). There was no evidence of gowns in the cart outside the door. LPN #122 looked for gowns on the unit and could not find gowns and reported she would have to leave the unit to try to find gowns.
Further observation of the room revealed there were clothing and blankets pilled on the two isolation trash bins inside the resident's room and the bins were not located near the exit door.
Interview on 07/29/25 at 10:12 A.M., with the Director of Nursing (DON) confirmed Resident #4 was on EBP for wounds and urinary foley catheter. The DON confirmed staff were required to wear gowns and gloves when providing wound care.
Observation and interview on 07/29/25 at 11:23 A.M., with Infection Preventionist (IP) #115 of Resident #4's room revealed there were no gowns in the protective personal equipment (PPE) cart outside the room and the isolation trash bins in the resident rooms were not located near the exit door and the bins were covered with clean clothing and blankets. The IP removed the clothing items and opened the bins, and the used PPE was in bins without a biohazard bag in-place. The IP confirmed there were no gowns readily available, the isolation trash bins were not located near the exit door, the isolation trash bins should not be covered with clothing and blankets and the bins should have red biohazard bags inside to contain the used PPE. The IP confirmed the WNP and LPN #122 should have been wearing gowns during wound care.
Review of Enhanced Barrier Precautions policy and procedure dated 2025 revealed it was the facility policy to implement enhanced barrier precautions (EBP) for the prevention of transmission of multi-drug-resistant organisms (MDRO). EBP refers to an infection control intervention designed to reduce the transmission of multidrug-resistant organisms that employs targeted gown, and gloves use during high contact resident activities.
An order for EBP will be obtained for resident with any of the following: Wounds and/or indwelling medical device even if the resident was not known to be infected or colonized with a MDRO.
Implementation of EBP include ensuring gowns and gloves are available immediately near or outside the resident ' s room. Personal protective equipment is only necessary when performing high-contact care activities and may not need to be done prior to entering the resident ' s room. Position the trash cans inside the resident ' s room and near the exit for discarding PPE after removal, prior to exiting the room. The Infection Preventionist will incorporate periodic monitoring and assessment of adherence to determine the need for additional training and education. Provide education to residents and visitors. High-contacts residents ' care activities include wound care (any skin opening requiring a dressing).
2. Review of the medical record revealed Resident #40 was admitted to the facility on [DATE]. Diagnoses included dementia, anxiety disorder, hypertension, glaucoma, major depressive disorder, delusional disorders and bipolar disorder.
Review of the Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #40 had severely impaired cognition and was always incontinent of bladder and bowel.
Observation of incontinence care for Resident #40 on 07/30/25 at 2:40 P.M. revealed Certified Nursing Assistant (CNA) #105 went into the adjoining bathroom and placed the clean washcloths directly into the sink to get them wet. CNA #105 then proceeded to apply liquid soap on to them, while they were lying in the sink. She took the washcloths out of the sink and began to provide perineal care to Resident #40 with the washcloths she had lying in the sink.
An interview on 07/30/25 at 2:55 P.M. with CNA #105 verified she had not sanitized or cleaned the sink prior to placing the clean washcloths for perineal care for Resident #40 directly into the sink. She stated she did not have a basin to place them in.
Review of the undated facility policy titled, Perineal Care, revealed it was the practice of the facility to provide perineal care to all incontinent resident during routine bath and as needed in order to promote cleanliness and comfort, prevent infections to the extent possible and to prevent and assess for skin breakdown. Step two indicated for the basin method to gather a basin and fill it no more than three-fourth the way up with warm water and the second method was the disposable cleaning cloth method, which the CNA did not use.
3. Observation on 07/28/25 at 12:35 P.M. revealed Certified Nursing Assistant (CNA) #141 went into the room of Resident #3 to deliver the lunch meal tray. She moved the over-the-bed table in front of the resident after placing the meal tray on to the over-the-bed table. She proceeded to go out into the hallway to the meal cart and get another meal tray off the meal cart for Resident #28 without washing her hands. She placed the meal tray on the over-the-bed table and then picked up his dinner roll with her bare hands and broke it in half and was going to butter it. The surveyor intervened. CNA #141 then went to get another roll off the meal cart and took it back into Resident #28 and butter it without touching it. She placed his over-the-bed table in front of him, went out of the room, retrieved another tray off the meal cart and took it the room of Resident #9 without washing her hands.
An interview on 07/28/25 at 12:45 P.M. with CNA #141 verified she had not washed her hands while passing meals trays and touching resident items.
4. Review of medical record for Resident #43 revealed an admission date of 07/26/25 with diagnosis including methicillin resistant staphylococcus aureus infection, type II diabetes, anxiety disorder and hypertension.
Observation on 07/28/25 at 8:30 A.M. of Resident #43's room revealed an isolation cart outside of room near the doorway. Upon entering the room, two red isolation bins were observed inside the room near the door.
Interview on 07/28/25 at 8:30 A.M. with LPN#209 verified Resident #43 was on contact isolation and no signage was placed at the doorway.
Review of facility policy titled Transmission-Based (Isolation) Precautions revealed Signage that includes instructions for use of specific PPE will be placed in a conspicuous location outside of the residents room, wing, or facility-wide. Additionally, either the CDC category of transmission-based precautions (e.g. contact, droplet, or airborne) or instructions to see the nurse before entering will be included in the signage.
5. Medication administration observation was made on 07/29/25 at 8:29 A.M. with RN #246. RN #246 was observed to prepare Resident #51's medications, entered Resident #51's room, administered oral medications and applied gloves. RN #246 then applied a lidocaine topical patch to Resident #51's back. Upon leaving the room, RN #246 removed her gloves and went to the medication cart, signed off the administered medications and prepared oral medications for Resident #63 without performing hand hygiene. RN #246 entered Resident #63's room, administered oral medications, applied new gloves, administered insulin, and applied a lidocaine topical patch to Resident #63's back. Upon leaving the room, RN #246 removed her gloves and went to the medication cart to sign off medications. She did not perform hand hygiene.
Interview on 07/29/25 at 8:35 A.M. with RN #246 verified she did not perform hand hygiene between the medication administrations with Resident #51 and resident #63.
Review of facility policy titled Medication Administration revealed wash hands using facility protocol and product before and after medication administration with each Resident.
Review of the undated facility policy titled, Hand Hygiene, revealed the staff would perform hand hygiene procedures to prevent the spread of infection to other personnel, residents and visitors.

Based on observation, interview, review of dishwasher temperature log, review of manufacture guidelines, and policy review the facility failed to ensure the dishwasher and three compartment sink were in proper working order to prevent the potential spread of food borne pathogens. This had the potential to affect all 76 residents residing in the facility. Findings include: Observation on 07/30/25 at 9:34 A.M., of the three compartment sink with Dietary Manger #199 and [NAME] #216 revealed the sink was leaking and water was noted running down the hoses and faucet into the second compartment of the sink (rinse water). There was sediment observed in the water. The Dietary Manger #199 confirmed the sink was used for items that could not be ran through the dishwasher. [NAME] #216 was washing the blender in the sink, preparing for the next pureed food item. The Dietary Manger confirmed findings during observation. Observation on 07/30/25 at 10:14 A.M., of the dishwasher with Dietary Manger #199 revealed the label indicated the dishwasher was a hot temperature dishwasher. The Dietary Manger confirmed the dishwasher was high temperature and the label indicated the wash cycle was 155-160 degrees Fahrenheit and rinse was 180-195 degrees Fahrenheit to disinfect the dishes. The first observation the wash was 110 degrees Fahrenheit and rinse was 186 degrees Fahrenheit. The second and third observation revealed the same temperatures. Review of the daily dishwasher temperature logs dated 07/27/25 to 07/30/25 with the Dietary Manger #199 revealed on 07/27/25 the dishwasher temperature in the A.M. was 183 degrees Fahrenheit for the wash and 132 Fahrenheit for the rinse and P.M. was 178 Fahrenheit Fahrenheit for the wash and 160 Fahrenheit for the rinse. On 07/28/25 the A.M. wash was 132 Fahrenheit, and rinse was 170 Fahrenheit and the P.M. wash was 173 Fahrenheit, and the rinse was 181 Fahrenheit. On 07/29/25 the A.M. wash was 180 Fahrenheit, and the rinse was 130 Fahrenheit and the P.M. the wash was 170 Fahrenheit and the rinse 184 Fahrenheit. On 07/30/25 the A.M. wash 130 Fahrenheit and the rinse was 170 Fahrenheit. The Dietary Manger confirmed findings during the review of the log. Interview on 07/30/25 at 10:14 A.M. and 10:39 A.M., with the Dietary Manger #199 confirmed the wash should be 155-160 degrees F and the rinse should be 180-195. The Dietary Manger confirmed she was not aware the dishwasher temperatures were not meeting recommendations. There had been issues with the water pressure and last night the Maintenance Director had cleaned the filters in the dishwasher and three compartment sinks. The Dietary Manger confirmed staff had been using regular dining ware, however she would have staff use disposable dining ware until the sink and dishwasher were fixed.Interview and observation on 07/30/25 at 10:24 A.M., with Maintenance Director (MD) confirmed she had cleaned the filters in the three compartments sink last night due to there being no water pressure. The MD confirmed the sink was leaking and there was sediment in the rinse water. The MD confirmed she was not aware the dishwasher temperatures were not meeting the recommended temperatures. Review of the facility's policy and procedures manual titled Dishwashing undated revealed the dish machine temperatures are logged at each of meal on the dish machine temperature log. Minimum temperatures, as required by the manufacturer are wash 150-160 F and rinse 180-195. Staff should check the dish machine gauges throughout the cycle to assure properly temperatures for sanitation. A three-compartment sink is set up with wash, rinse, and sanitizing. Employees are trained in proper manual dishwashing procedures. Review of the owner ' s manual for the dishwasher the wash temperature must be 155 minimum. The rinse temp must be 180 minimum. NOTE: Rinse water temperature must be observed during the rinse cycle.

Based on observation, staff interview and review of facility policy the facility failed to dispose of expired medications and/or unlabeled medications. The had the potential to affect all 76 residents residing in the facility. Findings include: Observation on 07/30/25 at 7:49 A.M. of the second floor medication storage room revealed the following expired medications:Two Incruse Ellipta inhalers 6.25 micrograms (mcg) in a sealed foil package, removed from box with expiration dates of 10/24 and 02/25. No label attached.Lovenox 100 milligrams/milliliter (mg/ml) injection with an expiration date of 05/25. No label attached Cipro 400 mg 2 mg/ml intravenous (IV) kit with a dispensed date of 03/14/19 and a discard after 04/18/25 date.Acetylcysteine 20% 200 mg/ml 23 vials with an expiration date of 5/2025.Interview on 07/30/25 at 7:55 A.M. with Registered Nurse (RN) #246 verified the medications were expired and stored in the medication room. Review of facility policy titled Medication Storage revealed unused medications: The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are destroyed in accordance with our Destruction of Unused Drugs policy.

Based on record review, facility policy review and interview, the facility failed to implement a comprehensive resident centered treatment plan to manage residents receiving hemodialysis. This affected one (Resident #39) of one residents reviewed for dialysis. The facility census was 76.Findings include: Review of the medical record for Resident #39 revealed an admission date of 07/02/25 with diagnosis including c-diff infection, end stage renal disease, type II diabetes, chronic obstructive pulmonary disease, atrial fibrillation, chronic systolic heart failure, and malignant neoplasm of prostate. Review of the physician orders revealed to weigh the resident before each hemodialysis treatment and after each hemodialysis treatment on Mon/Wed/ Friday and check for bruit (sound heard over an arteriovenous fistula, used for dialysis access, that indicates good bloodflow) and thrill (the pulsation felt over an arteriovenous fistula that indicates good bloodflow) to left arm fistula. The residents dialysis dates in July 2025 were as follows: 07/02/25, 07/04/25, 07/07/25, 07/09/25, 07/11/25. 07/14/25, 07/16/25, 07/18/25, 07/21/25, 07/23/25, 07/25/ 07/28/25, and 07/30/25.Review of the July 2025 Dialysis Monitoring and Communication Forms revealed incomplete/missing forms for the month of July 2025: 07/04/25, 07/07/25, 07/11/25, 07/18/25, 07/23/25 and 07/25/25.Review of medical record revealed the following weights:07/30/25 05:35 214.3 pounds (lbs.)07/28/25 13:35 207.7 lbs.07/28/25 06:18 218.6 lbs.07/25/25 10:44 202.84 lbs.07/25/25 05:11 215.2 lbs.07/23/25 16:16 204.4 lbs.07/21/25 10:56 204.6 lbs.07/21/25 05:48 221.6 lbs.07/18/25 16:53 205.8 lbs.07/18/25 05:49 217.0 lbs.07/16/25 11:44 216.0 lbs.07/16/25 05:53 216.8 lbs.07/14/25 11:02 209.0 lbs.07/14/25 05:53 220.4 lbs.07/11/25 06:03 221.2 lbs.07/09/25 18:38 211.8 lbs.07/09/25 17:08 211.0 lbs.07/09/25 05:43 219.6 lbs.07/07/25 16:58 211.0 lbs.07/07/25 05:13 217.2 lbs.07/04/25 04:57 217.8 lbs.There was no evidence of fistula monitoring as ordered. Interview on 07/31/25 at 11:07 A.M. with the Director of Nursing (DON) verified the missing dialysis communications forms including the weights and documentation checking the fistula.Review of facility policy titled Hemodialysis revealed the facility will assure that each resident receives care and services for the provision of hemodialysis consistent with professional standards of practice. This will include:The ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility. Ongoing assessment and oversight of the residents before, during and after dialysis treatments. The nurse will monitor and document the status of the residents access site upon return from the dialysis treatment to observe for bleeding or other complications.

Based on record review, interview and facility policy review, the facility failed to develop a comprehensive plan of care for pain management. This affected one (Resident #38) of two residents reviewed for pain management. Facility census was 76.Findings include: Review of Resident #38 ' s medical record revealed an admission date of 05/16/25 with diagnosis including chronic systolic heart failure, type 2 diabetes, atrial fibrillation, chronic obstructed pulmonary disease, and hypertension.Review of the 05/28/25 5-day Minimum Data Set (MDS) Assessment revealed the resident received as needed pain medications and had intact cognition.Review of Resident #38 ' s physician orders revealed orders for Norco 5/325 milligrams (mg) every 6 hours as needed and Tylenol 650 mg every 6 hours as needed. Interview on 07/28/25 at 4:08 P.M. with Resident #38 revealed he always has pain and it is somewhat controlled.Further review of the medical record revealed no evidence of a pain care plan.Interview on 07/30/25 at 1:01 P.M. with MDS Nurse #104 verified there was not a comprehensive pain plan of care developed for Resident #38. Review of facility policy titled Comprehensive Care Plans revealed The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of the medical record, interviews with staff, review of the facility policy, the facility failed to ensure treatment orders were received for burns to Resident #27's thighs and failed to comprehensively assess a skin tear to Resident #45's leg. This affected two residents (Resident #27 and #45) of five residents reviewed for accidents.Findings include: 1. Review of the medical record revealed Resident #27 was admitted to the facility on [DATE]. Diagnoses included heart failure, atherosclerotic heart disease, dysphagia, extended spectrum beta lactamase resistance, glaucoma, retention of urine, osteoarthritis, hypothyroidism, major depressive disorder, generalized anxiety disorder and hypertension. Review of the Significant Change Minimum Data Set assessment dated [DATE] revealed Resident #27 had moderately impaired cognition.Observation of incontinence care with Certified Nursing Assistant (CNA) #144 and 224 on 07/30/25 at 1:36 P.M. revealed Resident #27 had two large blisters to both her right and left inner thighs. CNA #224 left the room to get Registered Nurse (RN #183) to look at them.Observation of the blisters on 07/30/25 at 1:43 P.M. with RN #183 revealed Resident #27 had large blisters to both of her right and left inner thighs. RN #183 stated she had spilled soup on herself yesterday.Review of the nurse's note dated 07/29/25 at 4:39 P.M. revealed Resident #27 was in the chair for lunch and spilled soup on her lap. The nursing assistant responded, immediately pulled clothing way, and placed cold cloths on the abdominal area. The area was slightly pink. A reassessment was completed and no indications of redness or burning were noted. There was no documentation the physician, hospice or the responsible party was notified.Review of the nurse's note dated 07/30/25 at 2:14 P.M. revealed Resident #27 was noted to have blisters to the bilateral inner thighs from spilling soup on self yesterday. The blisters were intact at this time. Resident #27 was educated on the importance of keeping blisters intact to prevent infection. An interview on 07/30/25 at 3:35 P.M. with RN #183 verified no treatment order was written for the blisters to both inner thighs of Resident #27.Review of the nurse ' s note dated 07/30/25 at 3:43 P.M. revealed hospice was notified of the burn. The physician was okay with covering the blisters with Tegaderm (clear protective film) to protect it.Review of the physician ' s orders revealed Resident #27 had an order to apply Tegaderm to the left and right thigh burn sites, leave in place for seven days then remove or remove if no longer clean or intact, and check site every shift dated 07/30/25.2. Review of the medical record revealed Resident #45 was admitted to the facility on [DATE]. Diagnoses included pain due to internal orthopedic prosthetic device in the left hip and knee, osteoarthritis, dementia, anxiety disorder, cataracts, and weakness.Review of the Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #45 had moderately impaired cognition.Observation on 07/28/25 at 11:25 A.M. revealed Resident #45 had an undated dressing to her right lower leg. An interview at this time Resident #45 stated the aide threw her into bed after she told her she did not want to go to bed. She stated she hit her shin on the bedrail and got a skin tear. She stated Her Aide came in and asked her what had happened to her leg, she told her what happen then she went and got the nurse. She stated the nurse came back and put a dressing on it. She stated she does not know her name, but it happened couple weeks ago. She stated she did not know anyone ' s name.Review of the physician ' s orders revealed Resident #45 had an order to clean the right lower leg with normal saline, apply xeroform, four by four, wrap in Kerlix (medical cling wrap), change daily every evening shift and as needed dated 07/14/25 at 11:45 A.M. written by Licensed Practical Nurse (LPN) #122.Review of the nurse ' s notes revealed no documentation of a skin tear, physician notification, or responsible party notification.An interview on 07/30/25 at 2:00 P.M. with the Assistant Director of Nursing (ADON) revealed the nursing assistant was getting the resident out of bed, bumped her leg on the bed and the resident got a skin tear. She verified there was no investigation, assessment, family or physician notification or documentation of the skin care in the medical record. She stated she did not know who the nursing assistant was who transferred her. She stated she has been having problems getting the nurses to document information in the medical record. An interview on 07/31/25 at 8:15 A.M. with the Director of Nursing (DON) stated she spoke to Resident #45 yesterday and the resident stated she did not believe the nursing assistant had malicious intent, but she transferred her too fast after she told her to go slow and caused a skin tear. The DON stated there were black knobs on the bed and that was what she caught her leg on. She stated Resident #45 thinks the staff were always going too fast with her. She stated the nursing assistant was Certified Nursing Assistant (CNA) #149. She stated the nurse was Registered Nurse (RN) #162. The DON stated the day shift nurse was told by the day shift aide Resident #45 had a dressing to her leg. The day shift nurse had to write an order because there was not one written. She stated she was made aware of the skin tear when she got to work on 07/14/25. She stated they did not do an investigation because Resident #45 never said the nursing assistant threw her in bed she just said she went too fast. She verified the nurse had not written an order, documented, assessed, filled out an incident report or notified the family or physician.An interview on 07/31/25 at 10:25 A.M. with LPN #122 stated she has been working as the wound nurse while the wound nurse was off on medical leave. She stated she only worked Monday and Tuesday. She stated she had a message from RN #238 to look at the skin tear of Resident #45, so she looked at it on 07/14/25. She stated it had a dressing on it. She stated she does not know what happen she just wrote an order for a treatment. She verified at this time there was no order written but it did have a dressing on it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of the medical record, interview with staff and review of facility policy, the facility failed to ensure the call light was within reach of Resident #26. This affected one resident (Resident #26) of one reviewed for accommodation of need. Findings include: Review of the medical record revealed Resident #26 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, rhabdomyolysis, paroxysmal tachycardia, anxiety disorders, hypertension, major depressive disorder with psychotic symptoms, and muscle weakness. Review of the plan of care dated 08/18/20 revealed Resident #26 was at a risk for falls related to deconditioning, gait and balance problems, and psychoactive drug use. Interventions included to be sure the call light for Resident #26 was within reach and encourage resident to use it for assistance as needed.Review of the Annual Minimum Data Set assessment dated [DATE] revealed Resident #26 had moderately impaired cognition and was dependent for all Activities of Daily Living. Observation on 07/28/25 at 11:18 A.M. revealed Resident #26 was up in the tilt in space wheelchair by the left side of the bed, however her call light was still attached to the left grab bar out of reach, behind her tilt in space wheelchair. This was verified with Certified Nursing Assistant (CNA) #141 on 07/28/25 at 11:20 A.M.Review of the undated facility policy titled, Call Lights: Accessibility and Timely Response, revealed the purpose of the policy was to assure the facility was adequately equipped with a call light at each resident ' s bedside, toilet, and bathing facility to allow residents to call for assistance. Staff would ensure the call light was within reach of each resident and secured as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the medical record, and interview with staff, the facility failed to ensure the responsible party, physician and hospice were notified when Resident #27 spilled soup on herself causing a burn and when Resident #45 received a skin tear. This affected two residents (Resident #27 and #45) of five residents reviewed for accidents. Findings include:1. Review of the medical record revealed Resident #27 was admitted to the facility on [DATE]. Diagnoses included heart failure, atherosclerotic heart disease, dysphagia, extended spectrum beta lactamase resistance, glaucoma, retention of urine, osteoarthritis, hypothyroidism, major depressive disorder, generalized anxiety disorder and hypertension. Review of the Significant Change Minimum Data Set assessment dated [DATE] revealed Resident #27 had moderately impaired cognition.Observation of incontinence care with Certified Nursing Assistant (CNA) #144 and #224 on 07/30/25 at 1:36 P.M. revealed Resident #27 had two large blisters to both her right and left inner thighs. CNA #224 left to get Registered Nurse (RN #183) to look at them. Observation of blisters on 07/30/25 at 1:43 P.M. with RN #183 revealed Resident #27 had large blisters to both of her right and left inner thighs. RN #183 stated she had spilled soup on herself yesterday.Review of the nurse's note dated 07/29/25 at 4:39 P.M. revealed Resident #27 was in the chair for lunch and spilled soup on her lap. The nursing assistant responded, immediately pulled clothing way, and placed cold cloths on the abdominal area. The area was slightly pink. A reassessment was completed and no indications of redness or burning were noted. (There was no documentation the physician, hospice or the responsible party was notified.)Review of the nurse's note dated 07/30/25 at 2: 14 P.M. revealed Resident #27 was noted to have blisters to the bilateral inner thighs from spilling soup on self yesterday. The blisters were intact at this time. Resident was educated the importance of keeping blisters intact to prevent infection (There was no documentation the physician, hospice or the responsible party was notified.)An interview on 07/30/25 at 3:35 P.M. with RN #183 verified the physician, responsible party or hospice were not notified of the burns to the bilateral inner thighs of Resident #27. She stated she would update them.Review of the nurse's note dated 07/30/25 at 3:43 P.M. revealed hospice was notified of burn. The physician was okay with covering blisters with Tegaderm to protect it.Review of the nurse's note dated 07/30/25 at 6:57 P.M. revealed the Power of Attorney was notified on the resident's status.Review of the undated facility policy titled, Notification of Change, revealed the purpose of the policy was to assure the facility promptly informed the resident, consult the resident's physician, and notified the resident's representative when there was a change requiring notification. Circumstances requiring notification included accidents resulting in injury or potential to require a physician's interventions.2. Review of the medical record revealed Resident #45 was admitted to the facility on [DATE]. Diagnoses included pain due to internal orthopedic prosthetic device in the left hip and knee, osteoarthritis, dementia, anxiety disorder, cataracts, and weakness.Review of the Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #45 had moderately impaired cognition.Observation on 07/28/25 at 11:25 A.M. revealed Resident #45 had an undated dressing to her right lower leg. An interview at this time Resident #45 stated the aide threw her into bed after she told her she did not want to go to bed. She stated she hit her shin on the bedrail and got a skin tear. She stated Her Aide came in and asked her what had happened to her leg, she told her what happen then she went and got the nurse. She stated the nurse came back and put a dressing on it. She stated she does not know her name, but it happened couple weeks ago. She stated she did not know anyone's name.Review of the physician's orders revealed Resident #45 had an order to clean the right lower leg with normal saline, apply xeroform, four by four, wrap in Kerlex, change daily every evening shift and as needed dated 07/14/25 at 11:45 A.M. written by Licensed Practical Nurse #122Further review of the medical record revealed no documentation of a skin tear, physician notification, or responsible party notification.An interview on 07/30/25 at 2:00 P.M. with the Assistant Director of Nursing (ADON) revealed the nursing assistant was getting the resident out of bed, bumped her leg on the bed and the resident got a skin tear. She verified there was no investigation, assessment, family or physician notification or documentation of the skin care in the medical record. She stated she did not know who the nursing assistant was who transferred her. She stated she has been having problems getting the nurses to document information in the medical record.An interview on 07/31/25 at 8:15 A.M. with the Director of Nursing (DON) stated she spoke to Resident #45 yesterday and the resident stated she did not believe the nursing assistant had malicious intent, but she transferred her too fast after she told her to go slow and caused a skin tear. The DON stated there were black knobs on the bed and that was what she caught her leg on. She stated Resident #45 thinks the staff were always going too fast with her. She stated the nursing assistant was Certified Nursing Assistant (CNA) #149. She stated the nurse was Registered Nurse (RN) #162. The DON stated the day shift nurse was told by the day shift aide Resident #45 had a dressing to her leg. The day shift nurse had to write an order because there was not one written. She stated she was made aware of the skin tear when she got to work on 07/14/25. She verified the nurse had not written an order, documented, assessed, filled out an incident report or notified the family or physician.An interview on 07/31/25 at 10:25 A.M. with Licensed Practical Nurse (LPN) #122 stated she has been working as the wound nurse while the wound nurse was off on leave. She stated she only worked Monday and Tuesday. She stated she had a message from RN #238 to look at the skin tear of Resident #45, so she looked at it on 07/14/25. She stated it had a dressing on it. She stated she does not know what happened she just wrote an order for a treatment. She verified at this time there was no order written but it did have a dressing on it.Review of the undated facility policy titled, Notification of Change, revealed the purpose of the policy was to assure the facility promptly informed the resident, consult the resident's physician, and notified the resident's representative when there was a change requiring notification. Circumstances requiring notification included accidents resulting in injury or potential to require a physician's interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interviews, review of information located on Medscape.com, and policy review the facility failed to ensure a resident had an appropriate justification for the use of an antipsychotic medication and also failed to ensure residents had stop dates for antianxiety medications. This affected four (Resident #2, #8, #5 and #35) out of five reviewed for unnecessary medication review. Findings include: 1. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including dementia, anxiety, and depression.
Review of Resident #2 's medication administration records (MAR) and orders dated 04/25/25 to 07/22/25 revealed Resident #2 was administered Seroquel (antipsychotic)12.5 milligrams (mg) at bedtime for dementia.
Further review of Resident #2's MAR and orders dated 04/24/25 to 07/22/25 revealed no documented evidence the resident was ordered or administered any other medication to treat anxiety, depression, or dementia.
Review of Resident #2 ' s psych note dated 05/29/25 revealed the resident was stable with no behaviors noted. The plan was to continue Seroquel 12.5 mg at night for dementia. There was no documented evidence why Seroquel was determined appropriate to treat the resident ' s dementia.
Review of Resident #2 ' s pharmacy reviews dated 05/25/25 and 06/22/25 no evidence any irregularities were noted with the Seroquel.
Review of Resident #2's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was receiving an antipsychotic daily and no gradual reduction was attempted.
Review of Medscape information (current) revealed the indication for use was schizophrenia, bipolar, major depression, and off-label use for alcohol dependence and insomnia. There was no evidence Seroquel was indicated to use for dementia.
Interview on 07/31/25 at 11:32 A.M., with the Director of Nursing (DON) confirmed the resident returned from a short hospital stay (04/15/25-04/25/25) with an order for Seroquel 12.5 mg. The facility continued the order for Seroquel from 04/25/25 to 07/22/25 for dementia, which the DON confirmed dementia was not an appropriate indication of use for Seroquel. The DON reported psych had discontinued the Seroquel on 07/22/25 due to the resident was not having any behaviors.
Review of the facility ' s policy and procedure titled Use of Psychotropic Medication dated 2025 revealed the policy ensures that residents only receive psychotropic medications when other non-pharmacological medication are clinically contraindicated. Additionally, these medication should only be used to treat the resident medical symptoms and not used for the discipline or staff convenience, which would deem a chemical restraint.
Adequate for indication for use refers to the identified, documented clinical rationale for administering a medication that is based upon an assessment of the resident ' s condition and therapeutic goals and after any other treatments have been deemed clinically contraindicated. For psychotropic medication, without documentation in the record explaining that the practitioner had determined that other treatments have been deemed clinically contraindicated the indication of use was inadequate. Also, adequate indication for use means that the medication administered is consistent with manufacture ' s recommendation and/or clinical practice guidelines, clinical standards of practice, medication references, clinical studies, or evidence-based review of articles that are published in medical and/or pharmacy journals.
The resident medical record shall include evaluation and the rationale for chosen treatment options. This includes any indicated documentation of rationale for prescribing psychotropic medication or switching from one type of psychotropic medication, specifically an antipsychotic medication, to another category of psychotropic medication.
2. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE]. Diagnoses intercranial injury, vascular dementia, pseudobulbar affect, traumatic brain injury, major depression disorder, hypertension, mood disorder, hypothyroidism, right ankle contractures, frontotemporal neurocognitive disorder, generalized anxiety disorder, impulse disorders, hemiplegia and cerebral infarctions affecting the right side.
Review of the physician's orders revealed Resident #8 had an order for Ativan 0.5 milligrams (anti-anxiety medication) two times daily for restlessness/anxiety and 0.5 milligrams every 12 hours as needed for restlessness dated 01/20/21. Further review revealed no documentation of a stop dated for the as needed Ativan for Resident #8.
Review of the Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #8 had severely impaired cognition and received an antipsychotic and an antianxiety.
An interview on 07/29/25 at 2:00 P.M. with the Director of Nursing (DON) revealed all as needed psychotropic were only used for 14 days after being ordered for 14 more days then the order was written to continue. She confirmed there was no stop dated for the as needed Ativan.
3. Review of the medical record revealed Resident #35 was admitted to the facility on [DATE]. Diagnoses included subarachnoid hemorrhage, dementia, protein calorie malnutrition, falls, osteoporosis, neoplasm of the right breast, anxiety disorder, hypertension, head contusion, depression, reduced mobility and weakness.
Review of the physician's orders revealed Resident #35 had an order for Ativan 0.5 milligrams (anti-anxiety medication) every four hours as needed for anxiety dated 04/14/25. Further review of the medical record revealed no documentation of a stop dated for the as needed Ativan for Resident #35.
Review of the psychiatric progress note dated 06/05/25 revealed the plan was to continue with current psychotropic medication; give Ativan 0.5 milligrams when getting ready for bed and Ativan 0.5 milligrams every four hours as needed for anxiety. The rationale was due to the resident's current psychiatric status and history of instability a gradual dose reduction (GDR) was clinically contraindicated unless otherwise noted.
An interview on 07/29/25 at 2:00 P.M. with the Director of Nursing (DON) revealed all as needed psychotropic were only used for 14 days after being ordered for 14 more days then the order was written to continue. She confirmed there was no stop dated for the as needed Ativan.
4. Review of Resident #5's medical record revealed an admission date of 05/15/25 with diagnosis including chronic obstructive pulmonary disease, type 2 diabetes, chronic respiratory failure, anxiety disorder, and major depressive disorder.
Review of the 06/06/25 admission Minimum Data Set (MDS) Assessment revealed the resident has intact cognition.
Physician orders included: Ativan 0.5 milligrams (mg) every 8 hours as needed for dyspnea or anxiety dated 06/12/25. There was not a 14 day stop for the as needed controlled medication. The medication should have been discontinued 06/28/25.
Interview on 07/30/25 at 11:19 A.M. with Director of Nursing (DON) verified the antianxiety medication did not have a 14 day stop as required.
Review of the undated facility policy titled, Use of Psychotropic Medications, revealed the policy was to ensure the residents only received psychotropic medications when other nonpharmacological interventions were clinically contraindicated. Additionally, these medications should only be used to treat the resident ' s medical symptoms and not used for discipline or staff convenience. Step 16 indicated psychotropic medications used on an as needed basis must have a diagnosed specific condition and indications for the as needed use documented in the resident ' s medical record and was subject to limitations. As needed orders for psychotropic medication, excluding anti-psychotics should be limited to no more than 14 days, unless the attending physician or prescribing practitioner believed it was appropriate to extend the order beyond the 14 days. The medical record should include documentation from the physician or prescriber for the rational for the extended time period and indicated a specific duration.

Based on record review, and interview, the facility failed to ensure a Level II Preadmission Screening and Resident Review (PASARR) was completed with a new psychiatric diagnosis. This affected one (Resident #34) of two residents reviewed for PASARR. The census was 76.Findings include: Review of Resident #34 ' s medical record revealed an admission date of 07/15/22 with diagnosis including vascular dementia, hypertension, anxiety disorder, and paranoid personality disorder. Review revealed the last PASARR submitted for the resident dated 07/08/22 did not indicate Resident #34 had a personality disorder.Record review revealed on 05/30/23 Resident #34 had a diagnosis of paranoid personality disorder added to his list of diagnoses.Review revealed there was no evidence of a subsequent PASARR submission, for a Level II consideration, to the state agency that included the new psychiatric diagnosis.Interview 07/26/25 at 1:10 P.M. with social services #213 verified there was not a PASARR submitted to the state agency for Level II consideration after the addition of the paranoid personality disorder diagnosis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, review of activity calendars and interview, the facility failed to ensure an individualized activity program was developed based on resident preferences. This affected one (Residents #28) of three residents reviewed for activities.
Findings include:
Review of Resident #28's medical record revealed diagnoses including chronic obstructive pulmonary disease (COPD), anxiety order, depression with psychotic symptoms, dementia with mood disturbance and difficulty walking. A physician order dated 02/03/21 indicated Resident #28 was to be transferred with a mechanical lift. A plan of care initiated 08/17/20 indicated Resident #28 would remain active and social. Interventions included providing an activity calendar in Resident #28's room, talking about what was taking place, listening to interests, reminding Resident #28 of activities, making Resident #28 feel welcome, and monitoring for changes in needs. The interventions indicated Resident #28 liked to watch television (all kinds of news and talk shows), take naps throughout the day and speak with her son.
An Activities Interest Data Collection Tool dated 11/20/24 indicated Resident #28 preferred to spend her time with others. Resident #28 preferred to participate in group activities. Naps were part of Resident #28's daily activity routine. Community activity interests included voting, children/youth, shopping, entertainment, and restaurant. Creative activities interests included crafts, listening to music, television, and movies. Educational/cognitive interests included news, discussion, and reminiscing. Social interests included humor, talking/conversing, and live music/entertainment. Miscellaneous interests included animals/pets. Resident #28's work experience/occupation was a waitress. Resident #28 responded to questions.
A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #28 was able to make herself understood, was able to understand others and had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15.
Review of the March 2025 activity participation log revealed active participation with room visits, new updates/trivia/discussion, reminiscing daily between 03/01/25 and 03/25/25. The log indicated Resident #28 observed television/radio and reading daily between 03/01/25 and 03/25/25. The log revealed Resident #28 passively participated in chronicles, religion, and parties/socials daily between 03/01/25 and 03/25/25. Resident #28 passively participated in games/puzzles on 03/07/25.
No activity participation logs were available for April 2025 or May 2025. On 06/06/25, staff documented Resident #28 had her nails done by activities. On 06/11/25, Resident #28 had documentation of an activity of reminiscing and obtaining her shopping order.
Review of the April 2025 activity calendar revealed on Sundays Chronicle packets were distributed, one on one visits were scheduled, and church was scheduled at 2:00 P.M. On Mondays one activity was provided twice (once on two different units) and dining room. The first Tuesday of the month chronicles, puzzles and calendars were distributed in the morning then one other activity on two different units. The second Tuesday of the month Walmart shopping was scheduled with a resident led activity in the afternoon. The other three Tuesdays revealed one activity was scheduled twice (once on two different units). Every Wednesday one activity was scheduled twice a day on different units and dining was listed as the only other activity. Thursday scheduled activities revealed the first two Thursdays one activity (besides dining) was scheduled twice a day on different units. The third Thursday revealed activities of ordering in food and music entertainment. The fourth Thursday revealed an outing at the Senior Center was scheduled with a resident led activity in the afternoon. The first through third Friday had one activity scheduled twice (on different units) with the second Friday indicating instead of dining room there was a resident lunch outing. The fourth Friday had one activity in the morning and resident council in the afternoon. On Saturdays Bingo was scheduled twice (on different units) with the only exception being a community Easter egg hunt on 04/12/25 in the morning with Bingo scheduled in the afternoon only.
The May 2025 calendar revealed 19 days in which there was only one activity (with the exception of dining) scheduled twice a day. Sundays was the only days with more than two activities scheduled (with the exception of dining being counted as an activity). Sunday activity schedules included providing daily chronicle packets, providing 1:1's and church.
Observation of Resident #28 on 06/30/25 at 9:03 A.M. revealed she was sitting in her bed eating breakfast. The television was playing. Subsequent observations on 06/30/25 at 10:58 A.M. and 12:40 P.M. revealed Resident #28 was in bed with her eyes closed. The television was playing. On 06/30/35 at 3:48 P.M., Resident #28 was observed in bed with the head of the bed raised. From the doorway it appeared Resident #28 might have been watching television but did not answer the door to permit entry. On 07/01/25 at 7:57 A.M. and 11:01 A.M., Resident #28 was observed lying in bed with her eyes closed. The television was playing.
During an interview on 06/30/25 at 2:25 P.M., Activity Assistant #106 stated she sometimes tried to provide one on one activities for Resident #28 but she was sleeping most of the time and she did not attempt to wake her. Activity Assistant #106 indicated as far as she knew if residents were sleeping, she was not supposed to wake them to ask if they wanted to go to activities.
On 07/01/25 at 10:40 A.M., Activity Coordinator #110 stated she had began employment in the middle of May 2025. Activity Coordinator #110 stated when she first started she noted there were only two activities scheduled per day with the morning activity being repeated in the afternoon on many days. Activity Coordinator #110 stated she was still working on getting to know the residents. Her focus had been on improving the group activities offered with input of resident council. Activity Coordinator #110 stated she was unable to find any activity participation logs between April 2025 to May 2025. Activity Coordinator #110 stated the Daily Chronicles referred to on the activity calendars were only provided to those residents who wanted them (print about 25). Each resident received an activity calendar that was posted in their rooms (observed on multiple occasions and in multiple rooms posted on bathroom doors not visible from beds or some stationary chairs). Activity Coordinator #110 stated activity staff made rounds about 30 minutes before activities to invite/gather residents.
On 07/01/25 at 12:05 P.M., the Director of Nursing (DON) and Activity Director #110 were informed of concerns related to a lack of individual preference-related activities. Both the DON and Activity Director #110 indicated Resident #28 did not come out of her room except entertainers like an Elvis impersonator. Although staff had identified this, there had been no re-evaluation to determine if Resident #28 would benefit from a change in her activity plan. Activity Director #11 verified she had been unable to locate any activity participation logs for Resident #28 for April 2025 or May 2025. The month of June 2025, two activities of one on one visits were documented.
On 07/01/25 at 12:26 P.M., Resident #28 was observed sitting in bed. The television was playing but Resident #28 did not appear to be watching it. Interview with Resident #28 revealed she would be interested in group activities if she knew what activity was occurring, stating she needed reminders. Resident #28 reported she would like to attend activities including crafts and socialization opportunities. Resident #28 was interested in activities with music but was unsure if she wanted to listen to music in the room by herself.
This deficiency represents non-compliance investigated under Complaint Number OH00164293.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure complete medical records were maintained in regard to activity participation and medication administration. This affected four (Residents #28, #30, #78 and #79) of four residents reviewed.
Findings include:
1. Review of Resident #28's medical record revealed diagnoses including chronic obstructive pulmonary disease (COPD), anxiety order, depression with psychotic symptoms, dementia with mood disturbance and difficulty walking. A physician order dated 02/03/21 indicated Resident #28 was to be transferred with a mechanical lift. A plan of care initiated 08/17/20 indicated Resident #28 would remain active and social. Interventions included providing an activity calendar in Resident #28's room, talking about what was taking place, listening to interests, reminding Resident #28 of activities, making Resident #28 feel welcome, and monitoring for changes in needs. The interventions indicated Resident #28 liked to watch television (all kinds of news and talk shows), take naps throughout the day and speak with her son.
An Activities Interest Data Collection Tool dated 11/20/24 indicated Resident #28 preferred to spend her time with others. Resident #28 preferred to participate in group activities. Naps were part of Resident #28's daily activity routine. Community activity interests included voting, children/youth, shopping, entertainment, and restaurant. Creative activities interests included crafts, listening to music, television, and movies. Educational/cognitive interests included news, discussion, and reminiscing. Social interests included humor, talking/conversing, and live music/entertainment. Miscellaneous interests included animals/pets. Resident #28's work experience/occupation was a waitress. Resident #28 responded to questions.
A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #28 was able to make herself understood, was able to understand others and had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15.
No activity participation logs were available for April 2025 or May 2025. On 06/06/25, staff documented Resident #28 had her nails done by activities. On 06/11/25, Resident #28 had documentation of an activity of reminiscing and obtaining her shopping order. The activities documented in June 2025 were not part of the medical record.
On 07/01/25 at 12:05 P.M., Activity Director #110 verified there were no activity participation records documented in the medical record since March 2025.
2. Review of Resident #30's medical record revealed diagnoses including congestive heart failure (CHF), post-traumatic stress disorder, schizoaffective disorder, depression, anxiety disorder, bipolar disorder, and intellectual disabilities. Review of an activities interest data collection tool dated 06/20/24 revealed Resident #30 preferred to spend time with others. Resident #30 wished to participate in independent and group activities. Interests included shopping, restaurant, crafts, television, cards, bingo, word games/trivia, word puzzles, jigsaw puzzles, walking, humor, talking/conversing, and animals/pets. Baptist religion was recorded on the assessment. A plan of care initiated 06/20/24 revealed Resident #30 would remain social and active with interventions to remind Resident #30 of activities, providing an activity calendar in her room, offering encouragement to go to activities and monitoring for change in needs. There was no documentation found in the medical record of activity participation since 03/25/25.
On 07/01/25 at 12:05 P.M., Activity Director #110 verified there was no activity participation records documented in the medical record since March 2025. There were some notes written down in a notebook for activities in June which were not part of the medical record.
3. Review of Resident #78's medical record revealed diagnoses included left hip osteoarthritis, artificial left hip joint, heart failure, morbid obesity, malignant neoplasm of the prostate, cellulitis of the right lower extremity, depression, idiopathic aseptic necrosis of the right femur, cataract, chronic kidney disease, and arthritis of multiple sites. A care plan initiated 06/09/25 indicated Resident #78 had feelings of sadness, anxiety, uneasiness, and depression characterized by ineffective coping, low self esteem, insomnia and withdrawal from care/activities related to relocation. Interventions included encouraging Resident #78 to attend group activities and to participate in the pet therapy program when available.
An admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #78 was able to make himself understood, was able to understand others, and was cognitively intact. The MDS indicated Resident #78 reported it was somewhat important for him to have reading material, listen to music, be around animals, keep up with the news, do things with groups of people, do favorite activities, go outside to get fresh air when weather was good, and to participate in religious services or practices.
On 07/01/25 at 12:05 P.M., Activity Director #110 verified there was no activity participation records available for Resident #78 although she knew he had been provided one on one activities.
4. Review of the initial submission of Facility Reported Incident (FRI) #260537 revealed Resident #79 made allegations Registered Nurse (RN) #150 had substituted her pain pills with a different pill and was taking the pain medications herself.
Review of Resident #79's medical record revealed an admission/5 day MDS assessment dated [DATE] which indicated Resident #79 was able to make herself understood, was able to understand others, and was cognitively intact. Resident #79 denied pain over the prior five days. Resident #79 had a physician order for oxycodone 10 milligrams (mg) every eight hours as necessary for pain.
The following discrepancies between the May 2025 Medication Administration Record (MAR) and controlled substance administration record were verified with the Director of Nursing (DON) on 07/01/25 between 9:55 A.M. and 10:14 A.M.:
On 05/02/25 at 5:00 A.M. and 9:00 P.M. staff signed for the withdraw of oxycodone from the narcotic supply. However, administration was not documented on the MAR.
On 05/08/25 at 10:00 P.M., staff signed a dose of oxycodone out of the narcotic supply. Administration was not documented on the MAR.
On 05/10/25 a dose of oxycodone was removed from the supply at 6:00 A.M., 9:05 A.M. and 5:15 P.M. according to the controlled substance accountability record. The MAR indicated the first dose administered on 05/10/25 was at 11:59 A.M. with another dose administered at 5:14 P.M. The DON stated she assumed the dose withdrawn at 6:00 A.M. was given then but not documented on the MAR. Because the 6:00 A.M. dose was not documented she assumed a dose was given at 9:05 A.M. when withdrawn but it was documented late in the MAR at 11:59 A.M. (instead of at the time of administration) then a dose was given at 5:14 P.M. as indicated on the MAR.
On 05/15/25 at 8:00 A.M., an oxycodone tablet was signed off on the controlled substance accountability sheet but not recorded on the MAR. The next dose was signed as administered at 1:13 P.M. which was closer than the ordered every eight hours.
On 05/20/25 a dose of oxycodone was removed from the supply but not documented on the MAR as administered.
Interview on 07/01/25 between 9:55 A.M. and 10:14 A.M. the DON stated she believed the discrepancies were documentation errors. One of nurses who did not document administration had worked seven days straight.
This deficiency is an incidental finding discovered during the complaint investigation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, medical record review, review of a facility self-reported incident (SRI) and investigation, staff interview and review of facility policy, the facility failed to ensure allegations of staff to resident abuse were reported timely. This affected one resident (#03) of three residents reviewed for abuse. The facility census was 65.
Findings include:
Review of the medical record revealed Resident #03 was admitted on [DATE] with diagnoses that included acute and chronic respiratory failure with hypoxia, myocardial infarction, anxiety disorder and major depressive disorder.
Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/09/24, revealed Resident #03 was cognitively intact.
Review of SRI #252690, dated 10/06/24, revealed Resident #03 alleged that on 09/30/24, State Tested Nursing Assistant (STNA #174) was angry and punched a nearby wall. The SRI stated although the alleged incident occurred on 09/30/24, the Administrator was not notified until 10/06/24 at approximately 6:13 A.M. The allegation indicated STNA #174 became frustrated in Resident #03's room and punched/hit the wall.
Review of a facility investigation written statement, completed by STNA #100 and dated 10/09/24, revealed around 09/30/24, STNA #174 and STNA #100 were putting Resident #03 to bed. STNA #174 was frustrated about something and punched the wall in Resident #03's room. STNA #174 had been getting frustrated easily lately. At times, the nurses would get STNA #100 when they needed something so STNA #174 did not get upset. STNA #100 asked STNA #174 if he had been going to counseling lately and taking antianxiety medications. STNA #100 stated STNA #174's actions startled her and Resident #03. Three or five days later, Resident #64 (Resident #03's spouse) asked STNA #100 if she heard about the incident with STNA #174. Resident #64 stated Resident #03 was fearful because of the incident.
Review of an undated written statement, completed by STNA #174, revealed on 09/30/24 it was a rough day and due to last minute appointments, therapy, call lights going off and demands, STNA #174 got frustrated and snapped. STNA #174 slapped the wall and yelled out comments, which STNA #174 realized scared Resident #03.
Interview on 10/18/24 at 10:44 A.M. with Resident #03 revealed on 09/30/24, there was an incident in which STNA #174 hit the wall above her head and stated, you [explicative] people. Resident #03 stated STNA #100 reported the incident to a nurse and stated the nurse would talk to STNA #174. During the interview with Resident #03, her husband, Resident #64, entered the room. Resident #64 stated he resided in another room and was not aware of the incident with STNA #174 until STNA #181 told him about it. Resident #64 stated he went to the nurse to make sure it was reported, and the nurse stated the incident could not be reported until Monday because the Administrator was not in the facility on the weekend. Resident #03 revealed none of the nurses came to ask her about what happened with STNA #174.
Interview on 10/18/24 at 11:06 A.M. with LPN #214 verified she saw STNA #174 get upset at the nurses station. LPN #214 stated STNA #174 got frustrated when there was any change or a lot of residents needed assistance. LPN #214 denied STNA #100 reported any concerns with STNA #174 and Resident #03 until the end of the week.
Interview on 10/18/24 at 11:20 A.M. with the Administrator verified he was not notified of the incident on 09/30/24 until the morning of 10/06/24. The Administrator stated STNA #100 wrote a statement indicating she did not report the incident because she did not feel abuse occurred.
Review of the undated facility policy titled Abuse, Neglect and Exploitation revealed the facility will have written procedures that include reporting of all alleged violations to the Administrator, state agency, and all other required agencies within specified timeframe's. Reporting requirements included immediately, but not later than two hours after the allegation was made if the events that cause the allegation involve abuse or result in serious bodily injury or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

Based on medical record review, review of a facility self-reported incident (SRI) and investigation, review of a personnel records, review of staff schedules and time punches, facility policy review and interviews, the facility failed to ensure Resident #03 was free from an incident of staff to resident abuse which included intimidation, verbal and emotional abuse.
Actual psychosocial harm occurred on 09/30/24 to Resident #03 when State Tested Nursing Assistant (STNA) #174, while providing care for the resident, yelled, used profanity and punched/hit the wall above the resident's bed. Resident #03 believed STNA #174's actions were directed toward her. Following the incident, STNA #174 worked additional shifts, providing care for Resident #03, before he was suspended on 10/06/24, and subsequently terminated. Resident #03 reported being fearful, afraid of retaliation and not wanting to eat or do anything as a result of the incident. This affected one resident (#03) of three residents reviewed for abuse. The facility census was 65.
Findings include:
Review of Resident #03's medical record revealed an admission date of 05/05/23. Diagnoses included acute and chronic respiratory failure with hypoxia, myocardial infarction, anxiety disorder and major depressive disorder.
Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/09/24, revealed Resident #3 was cognitively intact.
Review of the facility SRI, tracking number 252690 dated 10/06/24, revealed on 09/30/24 Resident #03 alleged that a staff person (STNA #174) was angry and punched a nearby wall. On Sunday, 10/06/24, at approximately 6:13 A.M., the Administrator was notified by a facility nurse that STNA #174 became frustrated in Resident #03's room and punched/hit the wall. Although this incident took place on 09/30/24 at 10:10 A.M. it was not reported to facility management until 10/06/24.
Review of a facility investigation written statement, completed by STNA #100 and dated 10/09/24, revealed around 09/30/24, STNA #174 and STNA #100 were putting Resident #03 to bed. STNA #174 was frustrated about something and punched the wall in Resident #03's room. STNA #174 had been getting frustrated easily lately. At times, the nurses would get STNA #100 when they needed something so STNA #174 did not get upset. STNA #100 asked STNA #174 if he had been going to counseling lately and taking antianxiety medications. STNA #100 stated STNA #174's actions startled her and Resident #03. Three or five days later, Resident #64 (Resident #03's spouse) asked STNA #100 if she heard about the incident with STNA #174. Resident #64 stated Resident #03 was fearful because of the incident.
Review of a facility investigation written statements, completed by STNA #114 and STNA #152, revealed they had witnessed STNA #174 express frustration and anger in front of residents and staff. Review of an undated written statement, completed by STNA #181, revealed on 09/27/24, STNA #181 asked STNA #174 to help put a resident in bed using a mechanical lift. STNA #174 got angry and started punching the shower book and throwing things.
Review of an undated written statement, completed by STNA #174, revealed on 09/30/24 it was a rough day and due to last minute appointments, therapy, call lights going off and demands, STNA #174 got frustrated and snapped. STNA #174 slapped the wall and yelled out comments, which STNA #174 realized scared Resident #03.
Interview on 10/18/24 at 10:44 A.M. with Resident #03 revealed on 09/30/24, she had her call light on and STNA #174 came in the room. Resident #03 stated STNA #174 hit the wall above her head and stated, you [explicative] people. Resident #03 stated STNA #100 reported the incident to a nurse and stated the nurse would talk to STNA #174. During the interview with Resident #03, her husband, Resident #64, entered the room. Resident #64 stated he resided in another room and was not aware of the incident with STNA #174 until STNA #181 told him about it. Resident #64 stated he went to the nurse to make sure it was reported, and the nurse stated the incident could not be reported until Monday because the Administrator was not in the facility on the weekend. Resident #03 and Resident #64 stated STNA #174 continued to work after the incident. Resident #03 confirmed STNA #174 was assigned to provide care for her following the incident and stated he kept telling her it was okay; he had just been frustrated with her. Resident #03 stated she told LPN #202 she was afraid of retaliation by STNA #174. Additionally, Resident #03 stated she was upset and did not want to eat or do anything for three days following the incident. Resident #03 revealed none of the nurses came to ask her about what happened with STNA #174.
Interview on 10/18/24 at 10:48 A.M. with STNA #181 revealed she did not witness the incident with STNA #174 (and Resident #03) but had heard about it. STNA #181 stated STNA #174 was upset prior to going to Resident #03's room and had been throwing binders at the nurse's station. STNA #181 stated LPN #214 witnessed STNA #174 getting upset. STNA #181 stated she thought STNA #100 reported witnessing STNA #174 punch the wall in Resident #03's room.
Interview on 10/18/24 at 11:06 A.M. with LPN #214 verified she witnessed STNA #174 upset at the nurse's station on 09/30/24. LPN #214 stated STNA #174 got frustrated when there was any change or if a lot of residents needed assistance. LPN #214 denied STNA #100 reported any concerns with STNA #174 and Resident #03 until the end of the week.
Interview on 10/18/24 at 11:20 A.M. with the Administrator verified he was not notified about the incident with STNA #174 and Resident #03 until the morning of 10/06/24. The Administrator stated STNA #100 wrote a statement that it was not reported because she did not feel abuse occurred.
Review of STNA #174's personnel file revealed a hire date of 02/27/19. STNA #174 was terminated on 10/10/24 due to creating a hostile work environment for co-workers on numerous occasions and had been witnessed expressing frustrations with aggressive, and at times, threatening behavior. On or around 09/30/24, STNA #174 punched/slapped a wall in a resident's room. As a result of the seriousness and frequency of his actions, termination was deemed appropriate and necessary.
Review of the staff schedule and time punches revealed STNA #174 worked on 09/30/24 from 5:53 A.M. to 2:05 P.M., 10/01/24 from 5:53 A.M. to 2:00 P.M., 10/02/24 from 5:53 A.M. to 2:10 P.M., 10/03/24 from 5:53 A.M. to 2:02 P.M., 10/05/24 from 5:53 A.M. to 2:09 P.M. and 10/06/24 from 5:53 A.M. to 6:33 A.M.
Review of the undated facility policy titled Abuse, Neglect and Exploitation revealed abuse was defined as willful infliction of injury, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Possible indicators of abuse included, but were not limited to, resident, staff, or family report of abuse, psychological abuse of a resident observed and sudden or unexplained changes in behaviors and/or activities such as fear of a person or place, or feelings of guilt or shame. The facility would make efforts to ensure all residents were protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples included, but were not limited to, responding immediately to protect the alleged victim and integrity of the investigation and providing emotional support and counseling to the resident during and after the investigation as needed.
This was an incidental finding discovered during the complaint investigation.

Based on review of the facility self-report incident (SRI) and investigation, staff interview and review of facility policy, the facility failed to prevent misappropriation of resident medication. This affected 13 residents (#1, #5, #14, #20, #25, #28, #29, #70, #71, #72, #73, #74 and #75) of 13 residents reviewed for misappropriation. The facility census was 65.
Findings include:
Review of SRI #252381, dated 09/27/24, revealed local law enforcement notified the facility that during the search of a facility employee's vehicle, medication packages with residents' names were found. The employee was identified as Licensed Practical Nurse (LPN) #211. Residents #1, #5, #14, #20, #25, #28, #29, #70, #71, #72, #73, #74, and #75 were identified in the SRI as the residents with medications found in LPN #211's vehicle.
Review of the facility investigation revealed a total of 70 medication packages for Residents #1, #5, #14, #20, #25, #28, #29, #70, #71, #72, #73, #74, and #75 were found in LPN #211's car. The medications included 22 packages of Mirtazapine, 23 packages of Metoprolol, one package of Hydralazine, four packages of Buspar (to treat anxiety), one package of Trazodone (antidepressant), six packages of Lasix (diuretic), one package of Celexa (antidepressant), seven packages of tizanidine (muscle relaxant), one package of Zoloft (antidepressant) and four packages of Seroquel. The medications were dated from 09/29/23 through 08/01/24. All medication packages were unopened, except for two packages of Metoprolol for Resident #5, and each package contained one pill.
Interview on 10/18/24 at 8:30 A.M. with the Administrator verified medications were found in LPN #211's car but none of the medications were controlled medications. The Administrator stated LPN #211 was acting erratic at a local airport. The police were called and LPN #211 was taken to the hospital for further evaluation and treatment. LPN #211's family retrieved her car and discovered the medication packages in the center console. The family contacted the police about the medication and the police contacted the facility. The Administrator stated as far as he knew, LPN #211 was still receiving inpatient treatment.
Interview on 10/18/24 at 9:15 A.M. with Police Officer (PO) #500 revealed he opened the case related to the medications in LPN #211's car. PO #500 stated LPN #211's family brought the car to the police station after discovering the medications. PO #500 verified all the medications were still in the unopened packages except for the two packages of Resident #5's Metoprolol. PO #500 stated he had not been able to interview LPN #211 because she was still receiving treatment and the physicians did not want her to be interviewed yet.
Interview on 10/18/24 at 10:22 A.M. with the Director of Nursing (DON) verified the police brought the packages of medications to the facility and only two packages (Resident #5's metoprolol) were opened. The DON stated the medications were checked against the medication administration record (MAR). Some of the medications had been discontinued, some were from when residents were out of the facility, and some were marked as administered. The DON was unable to determine if any residents actually missed medications related to the incident.
Review of the undated facility policy titled Abuse, Neglect, and Exploitation revealed misappropriation of resident property was defined as the deliberate misplacement, exploitation or wrongful use of a resident's belongings without the resident's consent.
This deficiency represents non-compliance investigated under Complaint Number OH00158618.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, policy review and interview, the facility failed to ensure proper gloving and hand washing was completed during incontinence care. This affected one resident (#26) observed for incontinence care. The facility identified 41 incontinent residents. The census was 73.
Findings include:
Medical record review revealed Resident #26 was admitted on [DATE] with diagnoses including dementia, obstructive and reflux uropathy and functional incontinence.
On 09/16/24 between 2:00 P.M. and 2:05 P.M., observation of Resident #26's incontinence care revealed State Tested Nurse Aide (STNA) #144 and Housekeeping Aide #155 gathered supplies, washed their hands and applied gloves. Resident #26's incontinence product was removed and observed to be urine soaked. STNA #144 cleansed and rinsed the perineal area, rolled the resident on her right side and cleansed and rinsed the anus and buttocks. STNA #144 placed a clean incontinence product on the resident, adjusted the resident's gown, call light and bed linens while wearing the same soiled gloves worn for incontinence care. STNA #144 gathered her soiled supplies and then removed her gloves. STNA #144 walked the soiled supplies down the hallway to the shower room, placed them in a bin for laundry and went to the sink and washed her hands.
On 09/16/24 at 2:05 P.M., interview with STNA #144 verified she had not changed her gloves during incontinence care or adjusting the resident's gown, call light or bed linens, and did not wash her hands prior to leaving the resident's room stating she hadn't given it a thought.
Review of the policy: Hand Hygiene (dated 2024) revealed all staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. The use of gloves does not replace hand hygiene and if your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves.
Review of the policy: Perineal Care (dated 2023) revealed to cleanse buttocks and anus, front to back; vagina to anus in females, scrotum to anus in males, using a separate washcloth or wipes. Thoroughly dry and re-position resident in supine position. Change gloves if soiled and continue with perineal care. Once resident was cleansed, reposition as desired and cover resident. Remove gloves and discard. Perform hand hygiene, ensure call light is within reach and replace all equipment used.
This deficiency represents incidental findings of non-compliance investigated under Complaint Number OH00156997.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, policy review and interview, the facility failed to develop a discharge plan of care. This affected one resident (#75) of four sampled residents. The facility census was 73.
Findings include:
Closed medical record review revealed Resident #75 was admitted on [DATE] with diagnoses including cerebral infarction, diabetes mellitus type-1, tracheostomy and anoxic brain injury. Resident #75 was discharged from the facility on 08/14/24.
Review of the electronic mail correspondence (dated 07/12/24) between Resident #75's power of attorney and Social Service Designee (SSD) #177 revealed additional information was needed from a home care provider of products/services regarding any and all orders being placed that SSD #177 had placed.
Review of the quarterly Minimum Data Set 3.0 (MDS) assessment (dated 07/31/24) revealed Resident #75 was moderately impaired for daily decision-making and had no active discharge planning or referrals made regarding discharge for the resident.
Review of the Nursing Note dated 08/14/24 revealed Resident #75 was discharged from facility with her significant other, supplies and medications.
Review of the record revealed no evidence of a discharge plan of care.
On 09/16/24 at 2:49 P.M., interview with Social Service Designee (SSD) #177 revealed Resident #75 was admitted in April (2024) and upon admission the plan was to discharge back to the community. The resident and her power of attorney had decided to return to North Carolina and SSD #177 began working on setting up supplies and equipment in North Carolina. SSD #177 verified she had been speaking with providers trying to set things up and provided emails sent including one dated 07/12/24. SSD #117 verified she did not develop a discharge plan of care for Resident #75 because she was afraid she would forget to update it. SSD #177 stated she normally does one upon admission but it was undecided as to the resident's discharge plans at that time. SSD #177 verified she had been working on discharge plans for about a month prior to Resident #75's discharge, had not developed a discharge plan of care and the MDS assessment dated [DATE] was not accurate for discharge planning.
Review of the policy: Discharge Planning Process (dated 2023) revealed the facility was to develop and implement an effective discharge planning process that focused on the resident's discharge goals. The expected goals and outcomes regarding discharge was to be determined upon admission, routinely with the comprehensive assessment and as needed. Subsequent assessment information and discharge goals were to be included in the resident's comprehensive plan of care. If discharge to community is a goal, an active discharge care plan will be implemented an will involve the interdisciplinary team, including the resident and/or representative.
This deficiency represents incidental findings of non-compliance investigated under Complaint Number OH00156997.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure comprehensive care plans were revised with resident preferences. This affected one resident (#75) of four sampled residents. The census was 73.
Findings include:
Closed medical record review revealed Resident #75 was admitted on [DATE] with diagnoses including cerebral infarction, diabetes mellitus type-1, tracheostomy and anoxic brain injury. Resident #75 was discharged from the facility on 08/14/24.
Review of the admission Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #75 was cognitively intact for daily decision-making and frequently incontinent of urine and bowel.
Review of the care plan: Preferences (initiated 04/11/24 and revised 08/09/24) revealed Resident #75 had the right to make lifestyle choices as evidenced by preferring to appear more masculine and desiring to grow a beard. Resident #75 also preferred to be addressed as they/them pronouns during stay and keep the room warmer regardless of outside temperature. Interventions included staff would assist the resident with preferences as able.
On 09/16/24 at 1:29 P.M., interview with the Director of Nursing (DON) revealed the facility had a male agency State Tested Nursing Aide (STNA) #502 who worked on 05/30/24 and provided care to the resident on the nightshift. No concerns from the resident was voiced at that time regarding the care provided. The DON stated the facility was later notified by Resident #75's power of attorney that the resident did not want male caregivers. It was not until that time the facility became aware that Resident #75 did not want male caregivers, and all male staff were removed from the unit as not to provide care to the resident.
On 09/16/24 at 3:10 P.M., interview with the DON verified the resident's preference care plan had not been revised to reflect she did not want male caregivers providing care.
This deficiency represents incidental findings of non-compliance investigated under Complaint Number OH00156997.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed record review, policy review and interview, the facility failed to ensure tracheotomy care was completed as ordered. This affected two residents (#64, #75) reviewed for tracheostomy care. The facility identified no residents currently in the facility with a tracheostomy. The census was 73.
Findings include:
1. Closed medical record review revealed Resident #64 was admitted on [DATE] with diagnoses including cerebral infarction, epilepsy, acute tracheitis without obstruction, hypertension and acute kidney failure. Resident #64 was discharged from the facility on 09/13/24.
Review of the admission Minimum Data Set 3.0 assessment (MDS) (dated 07/16/24) revealed the resident received oxygen, suctioning and tracheostomy care.
Review of the electronic Physician Orders (dated 07/09/24) revealed tracheostomy care was to be completed every shift, aerosol and cool mist was to be changed weekly, oxygen tubing and set up was to be changed weekly, and 35% trach collar 5 liters of oxygen via cool mist was to be checked every shift.
Review of the Treatment Records (dated July, August and September 2024) revealed the following:
a. Tracheostomy care was not completed as ordered on 07/17/24, 08/05/24, 08/14/24 and 09/05/24.
b. Aerosol/cool mist and oxygen tubing/set up was not changed as ordered on 07/17/24.
Review of the care plan: Tracheostomy (dated 07/15/24) revealed the resident was able to do his own tracheostomy care with partial assist of staff and providing equipment. There were no interventions regarding changing or cleaning of equipment.
2. Closed medical record review revealed Resident #75 was admitted on [DATE] with diagnoses including cerebral infarction, diabetes mellitus type-1, tracheostomy and anoxic brain injury. Resident #75 was discharged from the facility on 08/14/24.
Review of the quarterly MDS assessment (dated 07/31/24) revealed Resident #75 was moderately impaired for daily decision-making, received oxygen, suctioning and tracheostomy care.
Review of the electronic Physician Orders 04/08/24 revealed tracheostomy care was to be completed every shift, aerosol and cool mist was to be changed weekly, oxygen tubing and set up was to be changed weekly.
Review of the Treatment Records (dated June and July 2024) revealed the following:
a. Aerosol/cool mist and oxygen tubing/set up was not changed as ordered on 06/10/24 or 06/26/24.
b. Disposable respiratory equipment was not changed on 06/10/24.
c. Daily tracheostomy care was not completed on 07/10/24, 07/11/24 or 07/17/24.
Review of the care plan: Tracheostomy related to complications of CVA (cerebral vascular accident) (dated 04/26/24) revealed no interventions regarding cleaning of equipment or daily care.
Review of the policy: Tracheostomy Care (dated 2023) revealed the facility will ensure that residents who need respiratory care, including tracheostomy care and tracheal suctioning, is provided such care consistent with professional standards of practice, the comprehensive person-centered care plan and resident goals and preferences. Tracheostomy care was also to be provided according to the physician's orders and general considerations included to provide tracheostomy care at least twice daily.
On 09/16/24 at 3:21 P.M., interview with the Director of Nursing verified there was no evidence Resident #64 and #75's tracheostomy and respiratory orders were completed as ordered as indicated above.
This deficiency represents non-compliance investigated under Complaint Number OH00156997.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, policy review and interviews the facility failed to ensure Resident #64 received comprehensive and individualized care to prevent/treat constipation. This affected one resident (Resident #64) of two residents reviewed for bowel and bladder management. The census was 72.
Findings included:
Review of the medical record revealed Resident #64 was admitted to the facility on [DATE]. Diagnoses included respiratory failure, chronic obstructive pulmonary disease, alpha-1-antitrypsin deficiency, emphysema, anxiety disorder, protein-calorie malnutrition, dehydration, constipation (06/28/23) and hypertension.
Review of the plan of care dated 07/05/23 revealed Resident #64 had bowel incontinence related to side effects of medication. She had no incontinence pattern identified on the three-day bowel and bladder tracker. Interventions included to observe for a pattern of incontinence and initiate toileting schedule if indicated, provide a bedpan or bedside commode, provide loose fitting and easy to remove clothing, provide peri care after each incontinent episode and inspect her skin for irritation.
The resident did not have a care plan related to constipation.
Review of the physician's order dated 07/12/23 revealed Resident #64 had an order to give prune juice for constipation. The order did not specify when to give the prune juice or how often.
Review of the Bowel and Bladder assessment dated [DATE] revealed Resident #64 was continent of bowel.
Further review of the medical record revealed the resident was hospitalized from [DATE] through 12/27/23 after having difficulty breathing and the resident requested to be evaluated in the emergency room. Upon the resident's return, the resident began to experience lack of bowel movements and complaints of abdominal pain.
Review of the physician's order dated 12/27/23 revealed Resident #64 had an order to give milk of magnesia (MOM) 30 milliliters (ml) once daily per bowel protocol if no bowel movement (BM) in three consecutive days; give a bisacodyl suppository (laxative) 10 milligrams (mg) one daily at bedtime if no bowel movement eight hours after MOM administration.
Review of the physician's order dated 12/28/23 revealed Resident #64 had an order to give Colace (stool softener) 100 mg every 24 hours as needed for constipation.
Review of the Significant Change Minimum Data Set assessment dated [DATE] revealed Resident #64 had intact cognition. She was occasionally incontinent of bladder, always continent of bowel, and required partial assistance with transfers and toileting.
Review of the nursing assistant documentation for resident bowel movement tracking from 12/27/23 to 01/14/24 revealed the resident had a small bowel movement on 12/28/23 and no BM documented from 12/29/23 to 01/12/24. Resident #64 had two medium and one small bowel movements on 01/13/24.
Review of the Medication Administration Record (MAR) for January 2024 revealed Resident #64 was given Colace 100 mg on 01/02/24 and 01/07/24 but the medication was ineffective.
Review of the progress notes dated 01/08/24 at 4:41 P.M. revealed Resident #64 refused medication for constipation despite education of risks and benefits. Her abdomen was non-distended with hypoactive bowel sounds. (The progress note did not indicate what medication for constipation Resident #64 refused).
Review of the progress note dated 01/12/24 at 3:35 P.M. revealed hospice was called in regards to Resident #64 not having a BM and refusing to take any oral medication to help alleviate it.
Review of the progress notes dated 01/12/24 at 4:00 P.M. revealed Resident #64 was having trouble moving her bowels. She was stating to the nursing assistants she just wants the BM to fall out and not have to worry about going. She was offered Colace and refused stating she just wanted a little orange colored pill (bisacodyl).
Review of the physician's order dated 01/12/24 revealed Resident #64 had an order to give bisacodyl five or 10 mg tablet once daily as needed for constipation.
Review of the January Medication Administration Record (MAR) revealed the resident was administered bisacodyl on 01/12/24, which was ineffective, a bisacodyl 10 mg suppository on 01/13/24 and 01/15/24 which were effective.
On 02/13/24 at 8:00 A.M. an interview with Resident #64 revealed she had been having trouble with constipation because the nurse (Licensed Practical Nurse #156) would not give her a Dulcolax (bisacodyl) pill when she asked for one. The resident stated she told the nurse she was having severe abdominal pain because she had not had a bowel movement since she had returned from the hospital, she was not sure how many days it had been. She stated the nurse brought in her MOM but she told the nurse she did not want it because it did not work for her. She stated the nurse just mumbled something to her, went out of the room, and never tried to give her anything else. She stated she got upset and called for the nurse to come back in her room. She stated she asked the nurse what she said, and the nurse told her they had a bowel protocol they must follow for constipation, and they could not just give her a bisacodyl. The resident stated she knew the MOM was not going to work fast enough so she did not want it and they would not give her anything else. She stated they had not done anything for a couple days and she was having severe abdominal pain. She stated she only refused the MOM but it was the only laxative the nurse offered.
On 02/14/24 at 3:20 P.M. an interview with Regional Compliance Nurse #200 confirmed there was no documentation of Resident #64 having a BM from 12/29/23 to 01/12/24.
Multiple attempts to reach LPN #156 were unsuccessful.
Review of the facility policy titled, Bowel Management and Treatment, dated 04/03/17 revealed the purpose was to achieve control of bowel evacuation on a routine basis which may be indicated by an independent or assisted stool every two to three days to avoid constipation and prevent skin irritation.
Residents who have not had a movement for three consecutive days would have the following protocol initiated unless the resident had individual orders specific to bowel management.
1. The initial nurse receiving the Point Click Care Alert for the lack of bowel movement in three days would begin the following bowel protocol for the residents:
a. Assess for bowel sounds.
b. Administer 30 milliliters of milk of magnesia.
c. If the resident refused the MOM, the nurse would notify the attending physician and document such on the MAR and nurse's notes.
d. Documents on the MAR and in the nurse's notes when the resident had a BM and then the resident would be placed on a modified promotional bowel regimen.
2. The Medication nurse on the next shift would check the list upon beginning her shift and the following would be performed.
a. Assess for bowel sounds.
b. If the resident does not have a BM on the prior shift, after receiving MOM, the nurse would administer a suppository per the physician's orders.
c. If the resident refused the suppository, the nurse would notify the attending physician and document such on the MAR and nurse's notes.
d. Documents on the MAR and in the nurse's notes when the resident had a BM and then the resident would be placed on the modified promotional bowel regimen.
3. The medication nurse for the third consecutive/next shift would check the list at the start of her shift and the following would be performed.
a. Assess bowel sounds.
b. If the resident does not have a BM in the prior shift, after receiving the suppository, he nurse would administer an enema per physician's order.
c. If the resident refused the enema, the nurse would notify the attending physician and document such on the MAR and nurse's notes.
d. Documents on the MAR and in the nurse's notes when the resident had a BM and then the resident would be placed on the modified promotional bowel regimen.
e. If the resident does not have a BM within one hour of receiving the enema, notify the attending physician for further instruction and document such in the MAR and in the nurse's notes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to ensure comprehensive assessments were accurate. This affected two of two residents (Residents #28 and #64) reviewed for hospice services. The facility census was 72.
Findings include:
1. Review of Resident #28's medical record revealed an admission date of 03/22/19 with diagnosis that included chronic kidney disease, hypertension and anxiety. Further review of the medical record revealed on 01/12/24 the resident was placed under hospice services. Review of the Minimum Data Set (MDS) 3.0 significant change assessment with a reference date of 01/12/24 indicated the resident was receiving hospice services. Further review of the MDS assessment revealed no evidence of a life expectancy of six months or less.
Review of Resident #28's hospice certification revealed the hospice physician indicated the resident had a life expectancy of six months or less.
On 02/15/24 at 8:20 A.M., interview with Registered Nurse (RN) #153 verified the significant MDS did not identify a life expectancy of six months or less as stated by the hospice physician in Resident #28's hospice certification.
2. Review of the medical record revealed Resident #64 was admitted to the facility on [DATE]. Diagnoses included respiratory failure, chronic obstructive pulmonary disease, alpha-1-antitypsin deficiency, emphysema, protein-calorie malnutrition, constipation (06/28/23) and hypertension.
Review of the physician's orders dated 12/28/23 revealed the resident was placed under hospice services.
Review of the significant change Minimum Data Set assessment dated [DATE] revealed Resident #64 had intact cognition. She received hosice services however, her assessment indicated she did not have a prognosis of less than six months.
On 02/14/24 at 4:41 P.M. an interview with Registered Nurse #153 revealed she had completed a significant change Minimum Data Set assessment for Resident #64 due to her receiving hospice care. The RN verified the MDS did not indicate the resident had a life expectancy of less than six months despite the physician signed hospice certification.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and policy review the facility failed to accurately obtain and document resident weights. This affected one (Resident #20) of four residents reviewed for nutritional services. The facility census was 72.
Findings include:
Review of Resident #20's medical record revealed an admission date of 11/21/23 with diagnoses that included non-displaced fracture of right great toe, chronic obstructive pulmonary disease, diabetes mellitus, congestive heart failure and hypertension.
Review of Resident #20's weights revealed a weight of 242 pounds upon admission on [DATE], 213.5 pounds on 11/28/23 (loss of 28.5 pounds in three days), 214.6 pounds on 12/11/23, 228 pounds on 01/15/24 (gain of 13.4 pounds in 34 days), 214.4 pounds on 01/30/24 (loss of 13.6 pounds in 15 days) and 237.0 pounds on 02/02/24 (gain of 22.6 pounds in three days). No evidence of any attempted re-weights to check for accuracy were noted. Weights were obtained by varying methods (sitting, standing, wheelchair and lift scale) and by various staff members.
Review of nutritional notes revealed on 02/01/24 concerns related to possible weight error of 228 pounds on 01/15/24. A nutritional note on 01/18/24 indicated weekly weights were discontinued due to resident's request and refusal. Refusal of weights documented in nutritional notes on 01/06/24, 12/28/23 and 12/23/23.
On 02/15/24 at 9:10 A.M. interview with Registered Dietician (RD) #201 verified there were concerns with accuracy of weights and no attempted re-weighs occurred to ensure accuracy.
On 02/15/24 at 9:55 A.M. interview with the Director of Nursing revealed the facility does not use consistent staff for obtaining weights, but use different staff and scales to obtain weights.
Review of the undated facility policy Weight Monitoring revealed no information related to obtaining re-weighs for significant changes in weights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the medical record and interview with staff the facility failed to ensure Resident #10, #37 and #49 had physician ordered adaptive equipment for meals. This affected three residents (Resident #10, #37 and #49) of six residents reviewed for nutrition. The census was 72.
Findings included:
1. Review of the medical record revealed Resident #49 was admitted to the facility on [DATE]. Diagnoses included dysphagia, acute respiratory failure, proteins-calorie malnutrition, dementia, weakness, cerebral infarction, and paraplegia.
Review of the physician's orders revealed Resident #49 had an order for a plate guard (a metal food bumper that clips onto a plate and makes scooping food onto utensils easier), dated 08/15/22.
Observation on 02/13/24 at 8:15 A.M. revealed Resident #49 was in the atrium eating her breakfast. Her plate guard was not on her plate but was lying on the table. An interview at this time with State Tested Nursing Assistant (STNA) #100 stated she did not know why it was not on the resident's plate but she applied the plate guard to the resident's plate. Interview with Resident #49 revealed she had not removed the plate guard from her plate.
2. Review of the medical record revealed Resident #37 was admitted to the facility on [DATE]. Diagnoses included Parkinson's disease, dysphagia, dementia, diabetes, protein-calorie malnutrition, adult failure to thrive, and transient cerebral ischemic attack.
Review of the physician's orders revealed Resident #37 had an order for a regular diet with a plate guard and grey weighted silverware dated 02/23/23.
Observation on 02/13/24 at 5:20 P.M. revealed Resident #37 was sitting in her room eating her dinner meal. She did not have her plate guard on her plate but it was sitting off to the side, on the table.
On 02/13/24 at 5:27 P.M. an interview with Licensed Practical Nurse (LPN) #164 confirmed Resident #37 did not have her plate guard on her plate as ordered.
3. Review of the medial record revealed Resident #10 was admitted to the facility on [DATE]. Diagnoses included end stage renal disease, diabetes, dependent on renal dialysis, legally blind, anxiety disorder, and glaucoma.
Review of the physician's orders revealed Resident #10 had an order for a plate guard for all meals dated 09/20/23.
Observation on 02/13/24 at 5:25 P.M. revealed a nursing assistant delivered the meal tray to Resident #10 and she had not placed the plate guard on his plate. She sat it off to the side with his lid to his plate. She did not ask him if he wanted the plate guard on or off his plate.
On 02/13/24 at 5:28 P.M. an interview with Licensed Practical Nurse (LPN) #164 confirmed the nursing assistant had not placed the plate guard on the plate of Resident #10. She stated he was blind and needed it on his plate. She also verified she had not asked him if he wanted it on his plate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, medical record review, observation and staff interview, the facility failed to ensure hospital discharge medications were followed and medications provided as ordered. This affected one resident (#37) of three residents reviewed for medications upon discharge from the hospital. The facility census was 74.
Findings include:
Interview with Resident #37 on 09/26/23 at 9:20 A.M. revealed she had recently returned to the facility after admission to the hospital. She indicated she was prescribed Norco (opioid pain medication) and had an order upon discharge from the hospital that should have been provided upon admission to the facility. Resident #37 indicated she had not received the Norco when requested and staff alerted her she did not have any to administer. Resident #37 stated she was provided other pain relief medications, but the Norco would work better.
Review of Resident #37's medical record revealed an admission date of 06/06/23 with admission diagnoses that included diabetes mellitus with diabetic neuropathy, bipolar disorder and cerebrovascular accident.
Review of Resident #37's Minimum Data Set (MDS) 3.0 quarterly assessment with a reference date of 09/18/23 indicated Resident #37 had an intact cognition.
Further review of the medical record revealed on 09/06/23 Resident #37 was transferred and directly admitted to the hospital due to increasing behaviors. On 09/11/23 Resident #37 was discharged from the hospital back to the facility. Review of the discharge summary and medication list revealed Resident #37 was ordered Norco 5/325 milligrams (mg) one every 12 hours as needed for pain.
Review of Resident #37's physician's orders revealed upon readmission on [DATE] an order for Norco 5/325 one every 12 hours as needed for pain. Review of the Medication Administration Record (MAR) revealed Norco orders in place as ordered by the physician. The MAR showed no evidence of any Norco administration for Resident #37 after readmission to the facility.
Observation and interview with Licensed Practical Nurse (LPN) #85 on 09/26/23 at 12:10 P.M. revealed Resident #37 does not have any Norco available as nursing staff felt the resident did not need the medication because her pain was adequately controlled with other pain relief medication prior to her hospital admission and readmission to the facility. LPN #85 stated Resident #37 has requested the Norco, but staff advised the resident it is not available. LPN #85 verified staff did not contact physician to clarify the need for Norco upon readmission to the facility.
Further review of the medical record revealed no documentation from nursing staff to the physician notifying and seeking clarification of the hospital discharge orders for the use Norco.
Interview with the Director of Nursing on 09/26/23 at 1:15 P.M. verified staff failed to notify the physician of Resident #37's Norco orders upon readmission and seek clarification for ordering and also failed to obtain and administer the medication to Resident #37 upon request.
This deficiency represents non-compliance investigated under Complaint Number OH00146397.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure residents who required staff assistance with activities of daily living received timely and adequate nail care to promote proper hygiene. This affected five residents (#26, #44, #45, #56 and #367) of five residents reviewed for activities of daily living.
Findings include:
1. Review of Resident #26's medical record revealed a 09/11/20 admission with diagnoses including age related debility, vascular dementia with behavioral disturbance, non traumatic intracerebral hemorrhage, hemiplegia and hemiparesis following cerebral infarction.
Review of the Activities of Daily Living (ADL) plan of care, dated 09/14/20 revealed the resident had an ADL self-care performance deficit related to generalized weakness, physical debility, hemiplegia/hemiparesis and confusion. Interventions included check nail length, trim and clean on bath day and as necessary.
Review of the 10/12/22 quarterly Minimum Data Set (MDS) 3.0 assessment revealed the resident was severely impaired for daily decision making, had difficulty focusing and other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds). The assessment revealed the resident required extensive assistance from two staff for bed mobility and transfers, did not walk and required extensive assistance from one staff for personal hygiene. The resident was totally dependent on one staff for bathing.
On 03/21/22 at 11:17 A.M. Resident #26 was observed in the dining room sitting in a high back wheelchair. Observation of the resident's fingernails revealed the nails on both hands were dirty with brown debris under the nail beds.
On 03/22/22 at 2:01 P.M. the resident's nails remained with brown debris under the nail beds. The fingernails on the resident's left hand were long.
Review of the Personal Care Bathing policy, revised 11/2020 revealed nails were to be checked daily during the bathing process for cleanliness and trimmed every week and/or as needed usually after shower.
On 03/22/22 at 2:07 P.M. interview with Registered Nurse (RN) #143 verified the resident's fingernails had brown debris under his nail beds and the fingernails on his left hand were long. She said the resident was dependent for care and the fingernails were to be cleaned and trimmed on shower days and as needed.
2. Review of Resident #44's medical record revealed a 12/29/20 admission with diagnoses including schizoaffective disorder, muscle weakness, paraplegia and acute respiratory failure with hypoxia.
Review of the Activities of Daily Living (ADL) plan of care, dated 12/31/20 revealed the resident had an ADL self-care performance deficit related to generalized weakness and paresthesia. Interventions included check nail length, trim and clean on bath day and as necessary.
Review of the 02/04/22 quarterly MDS 3.0 assessment revealed the resident was severely impaired for daily decision making, required extensive assistance from two staff for bed mobility and transfers and extensive assistance from one staff for personal hygiene. Interventions included check nail length, trim and clean on bath day and as necessary.
On 03/21/22 at 1:39 P.M. observation of Resident #44 revealed the resident's fingernails were longer with some debris under the nail beds. On 03/22/22 at 2:03 P.M. the resident's fingernails remained long with brown debris under the nail beds.
On 03/22/22 at 2:06 P.M. interview with RN #143 verified the resident's long fingernails with some brown debris under the nail beds that should have been cut and cleaned after her shower.
3. Review of Resident #45's medical record revealed a 03/16/21 admission with diagnoses including Parkinson's disease, dementia with behavioral disturbance and psychotic disorder with delusions.
Review of the Activities of Daily Living (ADL) plan of care, dated 03/17/21 revealed the resident had an ADL self-care performance deficit related to generalized weakness and pain in the right shoulder. Interventions included check nail length, trim and clean on bath day and as necessary.
Review of the 02/05/22 quarterly MDS 3.0 assessment revealed the resident was moderately impaired for daily decision making, had behavior or feeling down and required extensive assistance from two staff for bed mobility and transfers and required extensive assistance from one staff for personal hygiene.
On 03/21/22 at 2:11 P.M. observation of Resident #45's fingernails revealed they were longer. On 03/22/22 at 2:08 P.M. observation revealed the resident's nails remained long.
On 03/22/22 at 2:09 P.M. interview with RN #143 verified Resident #45, who was dependent for ADL care, had long fingernails and would need staff to trim them for her.
On 03/23/22 at 10:28 A.M. Resident #45's nails were observed to remain long.
4, Review of Resident #56's medical record revealed a 07/20/21 admission with diagnoses including dementia with behavioral disturbance, and schizoaffective disorder.
Review of the Activities of Daily Living (ADL) plan of care, dated 07/21/21 revealed the resident had an ADL self-care performance deficit related to aggressive behavior, confusion, dementia and impaired balance. Interventions included check nail length, trim and clean on bath day and as necessary.
Review of the 12/24/21 quarterly MDS 3.0 assessment revealed the resident was moderately impaired for daily decision making, required extensive assistance from two staff for bed mobility and transfers and extensive assistance from one staff for personal hygiene.
On 03/21/22 at 10:35 A.M. observation of Resident #56 revealed the resident's fingernails were dirty and long.
On 03/22/22 at 2:05 P.M. Resident #56's nails remained long and dirty and the right index finger was broken and jagged.
On 03/22/22 at 2:05 P.M. interview with RN #143 verified Resident #56, who was dependent for ADL care had long dirty fingernails, and the right index fingernail was broken and jagged.
5. Review of Resident #367's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including muscle weakness, difficulty in walking and heart failure.
Review of Resident #367's baseline care plan form, dated 03/18/22 revealed interventions included checking the resident's nail length, trimming as well as cleaning the nails on bath days and as necessary.
Review of Resident #367's nursing admission assessment form, dated 03/18/22 revealed the resident was oriented to time and place and she required one person to assist with grooming.
On 03/21/22 at 9:43 A.M. Resident #367 was observed with long fingernails with brown matter under them. On 03/22/22 at 3:02 P.M. and 03/23/22 at 8:31 A.M. the resident was again observed with long fingernails with brown matter under them.
On 03/23/22 at 7:44 A.M. interview with State Tested Nursing Assistant (STNA) #156 verified Resident #367 was dependent on ADL care. The STNA revealed the resident had received a bed bath the evening of 03/22/22. She also verified Resident #367 had received A.M. care at 6:00 A.M. on 03/23/22 which consisted of face washing, underarm washing, perineal (peri) care with brief change, teeth brushing and hair combing.
On 03/23/22 at 10:15 A.M. Resident #367 was observed with long fingernails with brown matter under them. The Director of Nursing (DON) was present and verified the resident's nails were long with a brown matter under them.
Review of the Shower Schedule form dated 03/13/22 to 03/24/22 revealed Resident #367 had been bathed on 03/21/22 and 03/22/22.
Review of the facility policy titled Progressive Quality Care - Personal Care/Bathing, revised 10/2020 revealed resident nails were to be checked daily during the bathing process for cleanliness and trimmed every week and/or as needed usually after the shower.

Based on observation and staff and resident interview the facility failed to maintain resident over bed tables, window blinds and wheelchairs in good repair and failed to ensure the main shower room on the second floor was free of storage for optimal resident use. This had the potential to affect 16 residents (#9, #19, #20, #23, #29, #33, #38, #48, #59, #64, #65 #366, #367, #368, #369 and #370) who resided on the second floor and five residents (#4, #5, #7, #26 and #51) who resided on the first floor Gardenway unit. The facility census was 66.
Findings include:
1. On 03/21/22 at 8:42 A.M. interview with Resident #65 revealed concerns the shower room was full of stuff. The resident indicated she had a hard time getting showers with one aide taking her into the shower. The resident revealed there was a ramp going up into and down from the shower and it was scary coming down the ramp from the shower.
On 03/22/22 at 2:41 P.M. observation of the second floor lower shower room revealed there was storage in the room. There were 10 cartons of facemasks, five boxes of eight ounce cold packs, three shower chairs, two over the toilet commodes, a large plastic yellow trash can, a sit to stand mechanical lift, an eyewash station and three tables. One table was at the bottom of the ramp and had a needle box on it. The items being stored in the shower room made it more difficult to maneuver a wheelchair in, up the ramp to the shower and back down out of the shower room.
On 03/22/22 at 2:52 P.M. interview with the Administrator and Maintenance (MD) #152 verified the shower room did have storage in it. The Administrator and MD #152 revealed they had not been using the shower for a while and when they started to use it again the items were not removed.
The facility identified Resident #9, #19, #20, #23, #29, #33, #38, #48, #59, #64, #65, #366, #367, #368, #369 and #370 who resided on the second floor who could access/use this shower room.
2. On 03/22/22 between 2:12 P.M. and 2:52 P.M. the following environmental concerns were identified:
Resident #26's over bed table top was rough and delaminating on all four sides.
Resident #5's over bed table top was damaged on all four sides.
Resident #7's window blind had six consecutive slats broken off on the right side, and one on the left side of the blind.
Resident #4's wheelchair arms both had the vinyl worn off.
Resident #51's right wheelchair arm had the black vinyl peeling off and the resident's over bed table top was bubbled, cracked and delaminating.
On 03/22/22 at 2:52 P.M. interview with the Administrator and Maintenance (MD) #152 verified the above residents' had damaged over bed tables that could cause skin tears, damaged wheelchair arms and broken blinds.
The Administrator provided the following information: On 01/04/22 the facility ordered six deluxe over bed tables from Allstate but more than what came in needed replaced. In December 2020 five or six over bed tables were bought. The Administrator revealed the tables just didn't last.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #48's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including heart failure, diabetes and adult failure to thrive.
Review of Resident #48's Minimum Data Set (MDS) 3.0 assessment, dated 02/11/22 revealed the resident had intact cognition and was admitted with an unstageable (unable to determine stage) pressure wound due to coverage of the wound bed by slough and/or eschar (a dry dark scab or falling away of dead skin).
Review of Resident #48's physician's orders revealed a treatment order, dated 03/01/22 for Dakin's (1/4 strength) solution apply to coccyx topically every shift for wound care. Pack with Dakin's soaked gauze as wet to moist dressing, cover with abdominal (ABD) pad and secure with silicone tape. Change twice daily and as needed.
On 03/21/22 at 9:48 A.M. Registered Nurse (RN) Wound Nurse #97 was observed completing Resident #48's coccyx pressure ulcer wound care. RN Wound Nurse #97 washed her hands, put on her gloves, removed the coccyx soiled dressing dated 03/20/22, measured the coccyx pressure wound with a paper measuring tape and cleaned the coccyx pressure wound with normal saline wound wash. RN Wound Nurse #97 then removed her gloves, washed her hands, put on new gloves, placed 1/4 strength Dakins solution (antiseptic solution) onto gauze and placed the gauze into the wound. RN Wound Nurse #97 then covered the wound with an abdominal dressing and taped the dressing in place.
On 03/21/22 at 10:03 A.M. interview with RN Wound Nurse #97 confirmed she should have removed her gloves after she removed the soiled dressing and prior to cleansing the wound as per the infection control guidelines in the facility dressing change policy as well as best practice guidelines.
Review of the Dressing Change - Clean policy, revised 10/2017 revealed to wash and dry your hands thoroughly, apply clean gloves and loosen tape, remove the soiled dressing, pull the glove over the dressing and discard into the plastic or biohazard bag, wash your hands thoroughly, replace gloves, cleanse the wound, use dry gauze to pat the wound dry, apply the ordered treatment and secure it with tape.
Based on observation, record review, Centers for Disease Control (CDC) guidance, facility policy and procedure review and interview, the facility failed to ensure contaminated N95 masks were stored and discarded appropriately following care of residents in droplet isolation precautions and failed to ensure infection control guidelines were maintained when completing Resident #48's pressure ulcer wound care to prevent the spread of infection including COVID-19. This affected one resident (#48) of one resident reviewed for pressure ulcer wound care, one resident (#366) of one resident reviewed for droplet isolation precautions and had the potential to affect all 16 residents (#9, #19, #20, #23, #29, #33, #38, #48, #59, #64, #65, #366, #367, #368, #369 and #370) who resided on the second floor. The facility census was 66.
Findings include:
1. Review of Resident #366's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease with acute exacerbation, unstable angina, and acute respiratory failure with hypoxia.
Review of Resident #366's baseline care plan, dated 03/16/22 revealed interventions included the resident was to remain in droplet isolation precautions to prevent the spread of COVID-19 infection and staff were to wear appropriate personal protective equipment (PPE) per the facility policy.
On 03/21/22 at 9:11 A.M. observation and subsequent interview revealed State Tested Nursing Assistant (STNA) #159 was outside of Resident #366's room. Signage on the door revealed the resident was in droplet isolation precautions. The resident was ordered droplet isolation precautions to rule out COVID-19 because the resident was a new admission to the facility. The STNA stated she entered Resident #366's room and had applied (donned) an N95 mask and then placed a surgical mask over it. STNA #159 reported each staff member had their own N95 masks based on fit testing results. She proceeded to remove the N95 mask from the right pocket of her scrub top. She reported she was allowed to wear the same N95 mask for a total of five shifts prior to discarding the mask.
On 03/21/22 at 9:15 A.M. observation revealed the facility had a DisCide Ultra disinfecting towelette container which was the disinfectant used to kill COVID-19.
On 03/21/22 at 12:35 A.M. STNA #156 was observed to enter Resident #366's room after she applied (donned) an N95 mask. The STNA placed a surgical mask over her N95 mask. She donned goggles, a disposable gown and gloves, provided care to Resident #366 and then exited the room with only her N95 mask in place. STNA #156 sanitized her hands, removed her N95 mask and donned a new surgical mask. She walked to the nurse's station on the unit carrying the contaminated N95 mask and goggles in her right hand. She placed her N95 mask and goggles in a brown paper bag located on a stand next to the clean linen cart. There were twenty-six other paper bags located on the shelf and those bags appeared crumbled, some were dated, some were not. STNA #156 did not clean her goggles prior to placing the goggles and contaminated N95 respirator mask in the brown paper bag.
On 03/21/22 at 12:54 P.M. an interview with STNA #156 verified she did not clean her goggles with the DisCide Ultra disinfecting towelette prior to placing the goggles in her assigned brown paper bag for storage.
On 03/22/22 at 10:10 A.M. an interview with Infection Preventionist (IP) #105 verified the facility re-used N95 masks for up to five shifts. She reported one mask could be worn for an entire shift and staff members were to use a rotating system to allow the N95 masks to sit unused for 72 hours. IP #105 verified she had not directed the staff to discard their N95 masks after they had applied or removed them for a total of five times. She had directed the staff to wear the N95 masks on a rotating basis for a total of five shifts. IP #105 verified her directions were against the facility policy for reuse of N95 masks. There was no evidence the facility was in crisis or contingency capacity for N95 mask use.
On 03/22/22 at 1:19 P.M. observation and subsequent interview with IP #105 revealed 27 brown paper bags containing used N95 masks at the second floor nurse's station were located on a storage cart. Some of the brown bags had no writing on the outside, some brown bags had a staff members names written on them, some brown bags had dates written on them and some of the brown bags were left open. IP #105 verified the second floor had two nurses and two STNAs currently working on the floor. Therefore, only four brown paper bags should have been on the cart. IP #105 also verified open brown bags with used N95 masks in them were next to clean linens and could potentially contaminate the clean linens for use by residents on the second floor .
The facility undated policy titled Recommended Guidance for Extended Use and Limited Reuse of N95 Filtering Facepiece Respirators in Healthcare Settings revealed if no manufacturer guidance was available, preliminary data suggested limiting the number of reuses to no more than five uses per device to ensure adequate safety. This policy also revealed the use of N95 respirator masks for respiratory protection programs.
The facility policy titled Isolation - Categories of Transmission-Based Precautions, revised 10/2018 revealed droplet precautions were implemented when there was an individual with documented or suspected infection with a microorganism transmitted by droplets such as COVID-19.
Review of the Centers for Disease Control and Prevention COVID-19 guidelines, updated 09/16/21 revealed as of 05/2021, the supply and availability of NIOSH-approved respirators had increased significantly over the last several months. Healthcare facilities should not be using crisis capacity strategies at this time and should promptly resume conventional practices. Respirators that were previously used and decontaminated should not be stored. Crisis capacity strategies that were not commensurate with United States (U.S.) standards of care but may need to be considered during periods of known N95 respirator shortages.
Review of the CDC Infection Control Guidance, updated 02/02/22 revealed if an N95 respirator mask was used as personal protective equipment (PPE) during care of a resident with COVID-19, during a surgical procedure or during care of a patient on droplet precautions, they should be removed and discarded after the patient care encounter and a new one donned.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure Resident #367 received the appropriate consistency of food in a form designed to meet the resident's needs. This affected one resident (#367) and had the potential to affect nine additional residents (#5, #17, #23, #25, #26, #27, #30, #51 and #60) who were to receive a mechanical soft diet. The facility census was 66.
Findings include:
Review of Resident #367's medical record revealed the resident was admitted to the facility on [DATE] heart failure, difficulty in walking and muscle weakness.
Review of Resident #367's care plan, dated 03/18/22 revealed to provide diet as ordered and to report choking or difficulty chewing with the charge nurse.
Review of Resident #367's medical record revealed an order, dated 03/19/22 for a regular diet with mechanical soft texture (food items) and thin liquid consistency.
On 03/21/22 at 12:38 P.M. observation Resident #367's lunch tray revealed the resident was served whole kernel corn, mashed potatoes, a ground up hotdog including the bun and chocolate ice cream. Further observation revealed the resident had consumed 76 to 100 percent of the meal including the whole kernel corn.
On 03/21/22 at 12:38 A.M. interview with Licensed Practical Nurse (LPN) #161 confirmed Resident #367, who was ordered a mechanical soft textured diet was served whole kernel corn for the lunch meal.
On 03/22/22 at 8:58 A.M. interview with Dietary Supervisors (DS) #161 verified whole kernel corn was not considered a mechanical soft food item when served alone and should only be provided to residents on a mechanical soft diet if mixed into a soup or casserole. DS #161 verified Resident #367 should not have received whole kernel corn for the lunch meal on 03/21/22 and indicated the resident should have been served cooked carrots instead.
The facility identified ten residents, Resident #5, #17, #23, #25, #26, #27, #30, #51, #60 and #367 who were to receive a mechanical soft diet.
Review of the Mechanical Soft Diet from the Innovations Services Diet Manual, dated 07/19 revealed the mechanical soft diet consisted of foods that were in an easy to chew form. The goal of the mechanical soft diet was to improve or maintain the resident's nutritional status and provide a safe feeding.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure new Preadmission Screening and Resident Reviews (PASARR) were completed following the identification of new mental health diagnoses for residents. This affected two residents (#5 and #44) of two residents reviewed for PASRR Level II services.
Findings include:
1. Review of Resident #5's medical record revealed the resident was admitted to the facility on [DATE]. Resident #5 had diagnoses including symbolic dysfunction, unspecified psychosis not due to a substance of known physiological condition, major depressive disorder, hallucinations, unspecified dementia without behavioral disturbance, and generalized anxiety disorder.
Record review revealed a 12/06/19 admission Preadmission Screening and Resident Review (PASARR). The PASARR included a diagnosis of unspecified psychosis and a diagnosis of dementia. The determination included no indication of serious mental illness.
Record review revealed on 07/02/20 a diagnosis of schizoaffective disorders was added and on 04/04/21 a diagnosis of unspecified dementia with behavioral disturbance was added.
Review of the 03/08/22 quarterly Minimum Data Set (MDS) 3.0 assessment revealed the resident was severely impaired for daily decision making, with difficulty focusing, delusions and wandering.
There was no evidence a new PASARR was submitted for consideration which included the new mental health diagnoses for Resident #5.
Review of the facility PASARR level of Care (LOC) policy, dated 05/31/16 revealed the facility would refer to the attachment with this policy published by Ohio Department of Health (ODH) to help determine when a PASARR or level of care (LOC) needed to be completed.
Review of the Ohio Administrative Code Rule 5160-3-15.2 resident review requirements for individuals residing in nursing facilities revealed to complete the review if there was subsequent evidence of possible, but previously unrecognized or unreported, serious mental illness or developmental disability.
On 03/22/22 at 4:58 P.M. interview with the Administrator verified the facility did not submit a new PASARR for consideration when Resident #5 had a new diagnosis of mental illness.
2. Review of Resident #44's medical record revealed an admission date of 12/29/20. The resident had diagnoses including symbolic dysfunctions, acute respiratory failure with hypoxia, dysphagia, and unspecified protein-calorie malnutrition.
Review of the 01/21/21 PASARR revealed the resident had no documented diagnoses of dementia, Alzheimer's disease or other organic mental disorder. The PASARR revealed the resident had no diagnoses of any mental disorder.
On 03/04/21 a diagnosis of anxiety disorder was added, on 04/12/21 a diagnosis of unspecified dementia without behavioral disturbance was added, on 04/20/21 a diagnosis of schizoaffective disorder was added and on 08/05/21 a diagnosis of major depressive disorder was added.
Review of the facility PASARR level of Care (LOC) policy, dated 05/31/16 revealed the facility would refer to the attachment with this policy published by Ohio Department of Health (ODH) to help determine when a PASARR or level of care (LOC) needed to be completed.
Review of the Ohio Administrative Code Rule 5160-3-15.2 resident review requirements for individuals residing in nursing facilities revealed to complete the review if there was subsequent evidence of possible, but previously unrecognized or unreported, serious mental illness or developmental disability.
On 03/22/22 at 11:49 A.M. interview with the Administrator verified a new PASARR was not completed following the new mental health diagnoses for Resident #44.